Carlyle Guerra de Macedo
Director, PAHO
5 October 1991

FORUM -  PANEL "HEALTH FOR DEVELOPMENT"

COLEGIO MEDICO DE PERU

(Lima, Peru)

Mr. Minister, Mr. Coordinator, Representative of the Pan American Health Organization in Peru,
distinguished speakers, panelists, and participants in this Forum on "Health for Development": 

Allow me first to reiterate how very pleased I am to be with you on this beautiful day in Lima and to
express my satisfaction and appreciation for your invitation to attend the final session of this meeting.  Since
today is the day that Peru sets aside to acknowledge the contribution of medicine, and since just a few hours
ago I was the recipient of a great honor for which I am deeply moved, I would like to begin my remarks by
paying heartfelt tribute to the health care workers of this country.

Faced with the overwhelming difficulties brought on by one of the most profound crises in the history of
this country and one of the most daunting health emergencies that has ever occurred in our Region, the health
sector and the health workers of Peru have shown the ability to respond positively and successfully, forging a
body of experience and knowledge that has made it possible for other countries in the Region of the Americas,
also later struck by the cholera epidemic, to contend with this epidemic and reduce its impact on the health of
their people and on the economic and social activities of their countries.  It is truly a measure of greatness that
the health workers of Peru have made themselves available to their sister countries, sharing their experience
and knowledge with unwavering commitment and solidarity.

In the name of the Pan American Health Organization and on behalf of the other countries of the
Americas, I would like to take this opportunity to pay a well-deserved tribute to our Peruvian colleagues who
have so diligently carried out their arduous task.

I would also like to commend the various institutions of this nation which, notwithstanding their different
ideological, political, and social inclinations, have joined forces in order to overcome the crisis.  This effort
reflects not only their understanding of the gravity of the situation that the country is facing but also their will to
find the best solutions and make the best decisions, as difficult as this has sometimes been, in order to
surmount the nation's problems. 

This grasp of the situation led naturally to the formation of the present working group and the
organization of this Forum on "Health for Development."

I have read your agenda, and shortly before the opening of this session I was informed of what
transpired during the panels on each of the various topics:  "Social Policies for Development," "Impact of the
Structural Adjustment on Health," "Health Policy," and finally, "Health for Development."  Given the cogency of
the debates and the qualifications of the speakers, panelists, and participants who are gathered here today, I
am certain that the conclusions reached will be of great value for the decisions to be made by the Governments
and the various sectors of society on this subject.  This leads me to wonder about the advisability of being the
last to speak and attempting to do so without having participated in the preceding sessions.  Although there is
certainly the risk that I will repeat what has already been said, what gives me greatest pause is the thought that
my remarks might draw attention away from the excellent discussions that have already been held here.  My
comments should therefore be taken simply as reflections--sometimes general, sometimes specific and
selective--on certain considerations related to the broad theme of "Health in Development" or "Health for
Development."

My remarks will center around four concerns:  first, the type of development that is needed in Peru and
in Latin America; second, the contribution that health can make toward this development, and the conditions
that are required in order for it to make such a contribution; third, an issue that goes hand-in-hand with the first
two, namely the close connection between the State, society, and health in the context of reciprocal and
complementary responsibilities; and finally, and also closely related, the political dimension of this entire
process.

Peru and all of Latin America are still reeling from the effects of the most profound economic crisis in
their history.  We can no longer simply speak of a lost decade in referring to the economic situation of the
eighties, since we are continuing to grapple with the negative and sometimes counterproductive effects of
solutions that were fashioned during that decade and which continue to be the hallmark of the economic
policies of most of the Governments.  Perhaps the most significant and devastating repercussion of this crisis
has been the tremendous blow to our productive capacity, or in other words the destruction of the incipient
infrastructure that we had managed to develop up to that time.  You may perhaps think it is an exaggeration to
speak of "destruction," but we must certainly agree that we have been thwarted in our efforts to modernize and
rebuild this infrastructure.  By way of illustration, suffice it to point out the extent to which investment, which
determines present and future capacity for production, has declined since the onset of the crisis.  In 1981 the
Latin American economies were able to save and invest an average of about 24% of their gross domestic
product.  But by 1990 this percentage had dropped to an average of less than 13%, and in some countries it
had plummeted to 8% or lower.  It is not surprising, then, that in decisions regarding the distribution of limited
resources for investment, the social sectors, especially the health sector, have been the most adversely
affected.  The results are readily apparent:  the network of hospitals run by the public institutions that are most
representative of the Ministries of Health and the social security institutions are laboring under such enormous
constraints that they are on the verge of collapse; the capacity to recruit and maintain a qualified workforce and
to offer adequate working conditions has been seriously eroded; and credibility, hope, and faith are increasingly
shaken.

The crisis is not yet over.  It has simply moved on to a new stage.  Nevertheless, we have the
opportunity to rekindle the economic growth that we enjoyed before, and we are getting started in this process. 
But we do so in a world that is profoundly different from the one we were living in when the crisis began,
especially for those us who are poor.  The Cold War has ended.  No longer are we haunted by the spectre of
nuclear destruction--or at least this threat has been greatly reduced.  No longer do nations, social groups, and
even families need to be divided by this artificial and rhetorical barrier created by ideology.

But this new post-Cold War world has yet to resolve some of the gravest conflicts that continue to
affect humankind, countries, societies, and individuals themselves--graver still, perhaps, than the threat of
nuclear war.  I would like to mention four of them, since I consider these to be particularly important for
determining what kind of development we need.

First, while ideological differences and the East-West conflict may have been resolved, regionalist,
nationalist, and especially religious and ethnic fervor is on the rise.  The presence of this regionalism,
nationalism, and ethnocentrism has already been confirmed in the post-Cold War period, for example by the
Persian Gulf war, the regional conflicts in the Balkans, and the threat of many other conflicts in Eastern Europe. 
And there are other conflicts elsewhere that also pose a threat to peace and solidarity, which are essential and
universal conditions for progress. 

Second is the gap between rich and poor, another enormous conflict that the world has been unable to
overcome.  It is unbelievable, and it is absolutely unacceptable, at the end of this century, during which we
humans have learned to utilize science and technology to harness nature and put it to our service, that we
continue to increase our capacity for destruction and limit our capacity for creation.  And it is equally
unacceptable that three-fourths of humankind continue to live in poverty, and almost half of these people in
abject poverty.  The gap between rich and poor, between powerful and weak, may ultimately prove to be the
greatest threat to the stability and progress of nations.  The new international order that is being fashioned on
the basis of large blocs of power has yet to enlist the forces liberated from the East-West conflict and the arms
race to establish a new type of dialogue and cooperation between North and South, between developed and
underdeveloped countries (because we cannot use, even euphemistically, the expression "developing"
countries) so as to build the solid bases of support needed in order to preserve the stability of the universe.

Third, humankind's capacity to dominate nature has been wielded without respect for the finite
resources that have taken millennia to form.  Immoderate consumerism, unbridled materialism, and the license
to destroy, even in the process of producing, have become enormous risk factors that threaten to overwhelm
our planet and bring an end to life itself.  Pollution, the depletion of nonrenewable resources, and many other
expressions of environmental deterioration are manifestations of this enormous conflict that we have yet to
resolve.

We in this poorer part of the world are sometimes accused of arriving late at the banquet of modern
production and industrialization, and it is said that through our poverty we are destroying and contaminating the
earth's remaining natural reserves--and this is true.  But the powerful nations forget who it was that first
destroyed our natural heritage and overlook the fact that any damage we are now doing represents only a
fraction of the devastation that is being wrought on the environment, the common heritage of humankind.  The
environment is a resource that should be utilized for development intended to benefit human beings, but we
cannot forget that it is also the insurance policy that must secure the future of generations to come.

The fourth conflict, the development and consequences of which offer both extraordinary possibilities
and extraordinary risks for our countries, is the new economic order that is being forged at the global level.  The
major economic powers have joined forces, recognizing that, despite their size, their domestic markets are not
sufficient to sustain the new forms of production and the efficient use of science and technology that
development requires.  The "Europe of the Twelve," which will probably soon become the "Europe of the
Thirty," North America, and the Pacific Rim, constitute large economic blocs whose power and influence will
shape the immediate future of the universe.  The competition between them, coupled with the increasingly
rapid evolution of science, offer opportunities for the poor, but they also present a tremendous challenge for
which we are not prepared.  How can we confront the competition of such powers as Europe, the United States
of America, and Japan?  Can we, the underdeveloped nations of the world, and Latin America in particular, with
the divisive forces that undermine our unity, establish the conditions needed for a regional movement that will
lay the groundwork for a sustained process of negotiation and for real and effective integration of our countries
into the new world order?

It is in this context that we must face the great challenge to Latin America and to Peru--the challenge
of development.  But we must not repeat the mistakes of the past.  Minister Yamamoto has already alluded to
the failures that the Governments have experienced up to now in the promotion of development, and with good
reason.  Even during periods of accelerated growth, which in many cases were considered true economic
miracles (the development that we achieved during the 1970s is an example), we were not capable of resolving
the problems of poverty.  On the contrary, they have persisted despite economic growth, and paradoxically
there has even been an increase in the number of people and sometimes the proportion of the population living
in poverty.  The development we need and should seek requires the establishment of basic conditions that will
permit the recovery of economic growth.  We need to stabilize our economies.  Macroeconomic adjustments
are required in order to hold down spiraling prices, reorder our foreign relations, control fiscal imbalances, and
create healthy conditions for sustained production with high levels of output.

But, though I agree that this need is undeniable, I believe that we need to look closely at what kind of
adjustment and stabilization policy is to be implemented, and especially at who will pay the price for this
adjustment. 

In a context of such unequal social organization, historical experience suggests that the poorest and
weakest among us will be called on to pay most if not all the cost of these stabilization policies.  There is no
technical or scientific reason for this.  Rather, the reasons are purely political. 

The development that we need must enlist the productive capacity that we seek to recover in the
service of something that transcends productive activity.  Economics is not the end that justifies the means in
organized societies.   Nor is production the end result that justifies the existence of the States.  Production is
essentially a means that should be employed toward the end of improving the well-being of the people, which is
society's raison d'Þtre.  Although this ethical--indeed logical--principle of social activity is not disputed, in
practice it is not applied.  We must recognize, moreover, that this will not come about simply through the play of
market forces.  Purposeful action, positive resolve, and effective decisions will be required, and these are
possible only through states and governments that act as conduits for the expression of social consensus.

If this end is to be achieved, there must be an act of political commitment on the part of the institution
that societies have created to represent their collective will:  the State.  Adjustment policies can never be
structural, in the strict sense of the word, if they are not accompanied by political measures aimed at turning
production into a tool that will contribute to the well-being of all, and this well-being includes good health. 

The development that we seek necessitates strengthening the exercise of democracy.  This does not
just mean periodic consultation of the population through the election of leaders and authorities--which is
important and necessary, but not sufficient.  Rather, democracy must become the lifestyle of a society, an
integral part of the day-to-day life of every citizen, every community, every social group.

This profound concept of representative and participatory democracy calls for sincere commitments of
an ethical nature.  Well-being cannot exist without individual freedom, but at the same time each person's
freedom must be limited in order to allow the exercise of freedom by others, thus protecting the rights and
responsibilities of all.  The establishment of conditions of social coexistence that make it possible to guarantee
respect for the individual and the human rights of every person and every citizen, and the supreme exercise of
this freedom with collective respect for the freedom of all, is one of the basic requirements for the existence of a
true democracy.

Participatory democracy therefore requires the creation and redistribution of the most limited and
inequitably distributed resource in our societies, namely power.  Of all the commodities--in the broad sense of
the word--possessed by humankind, power is the one that is most concentrated in the fewest hands.  This
highly regressive distribution of power has long been justified on the basis of concepts of social equity and
justice, but these concepts have never become realities in the everyday lives of our nations.  The powerful,
through the setting of policies, the implementation of laws, and the generation of projects and programs, have
created a situation wherein those who have the most receive the most, while those who have the least pay the
greatest cost.

An absolute requirement for the exercise of democracy and for this new development that we seek is
therefore a transfer of power to those who for generations and centuries have been denied access to it.  Of the
instruments that can be used to this end, I would point out that information is one of the most effective.

The development that we need requires that we be integrated into the new order that is being created
in the world, and this integration must be effective and efficient.  The preferred mechanisms for accomplishing
this are trade and competition, and I have already alluded to the difficulties we face in competing.  However, it
must be pointed out that the greatest obstacle to our integration into the new world order is the lack of control in
our countries over scientific and technological knowledge in all fields of social endeavor.

Hegemony in the production and appropriation of technological knowledge and development means
that these commodities, too, are concentrated in a few hands, and they are thus instruments of global power. 
Our countries have neglected science and technology, and our current difficulties have exacerbated this
situation of neglect.  We spend little on science and technology and even less on utilization of the knowledge
that we do acquire or generate.  Shortsightedness on the part of leaders and the pressure of immediate needs
have led us to overlook the true magnitude of the problem.

Another requirement for our effective insertion is Regional integration:  separate we are weak, but
united we can win the right to participate and also to decide.  For reasons that have already been mentioned, if
the countries of the Region continue to turn their backs on one another and persist in always looking to the
North in search of the solution to our problems, we will continue to resign ourselves to our inability to assume
responsibility for our development.  It has never been true that one nation could achieve development on behalf
of another, and no one is going to do so for us.  If we continue to rely on the kindness, the charity, or the
solidarity of the countries that are currently in positions of power, disregarding what we might be able to
accomplish if we pooled our efforts, we will never be able to take our rightful place in the new order.  Only
together, with the support of our people and our nations, our countries and our societies, can we create a core
of power that will earn us the respect and consideration we deserve, allow us to be accepted as equals, and
give us the opportunity to have a say in the construction of this new world order and thus be capable of building
our own future.

Viewed from this perspective, Regional integration ceases to be merely an ideal, a dream, or a utopia
bequeathed to us by the founders of our countries:  it becomes one of the most important strategies for our
development.  Unfortunately, it is also a need that is still very far from becoming a reality.

Development cannot be the result of short-term measures, nor is it a matter of simply taking advantage
of factors that happen to be favorable at a given moment, such as trade relations with other countries; the
availability of easy credit, which we used to have and which plunged us into our current problems; or the ideas
or even the accomplishments of our leaders, who are transitory.  On the contrary, development must be based
on conditions that ensure sustainability and continuity--allowing, of course, for the variations that occur as
social processes evolve.

There are five factors, among many others, that are essential for ensuring sustainability and continuity
in the development that we seek for Latin America.  First, the construction of new or renewed institutions, in the
broadest social and political sense of the word:  the establishment of a political-legal framework that will ensure
full exercise of the rule of law; the administration of justice and the establishment of rules of social organization
that will protect all of us; the creation of educational, cultural, and scientific institutions; the formation of an
institutional framework for a civil society that will allow the equitable distribution of power and the capacity to
exercise it, including the democratization of political parties; and the strengthening and full exercise of the
people's right to representation in congresses and other institutions within the political society.  These are but
examples of the many institutions that we need to reassess, reform, or create in order to ensure the conditions
of sustainability and continuity that are needed for development.  Second, we need to create a culture of
development, built on the foundation of the common cultural heritage that enriches our people, which we
frequently underestimate.  It is no longer a question of simply recovering the cultural features that define our
identity, but of drawing on that identity to create conditions that will favor work, productivity, competition, and
the exercise of social and individual ethics--in sum, the exercise of power and democracy.  Education is the
most powerful instrument for the development of this culture.  The third requirement is the protection and
intelligent use of the environment.  Fourth is the mastery of science and technology, and fifth is the training of
appropriate human resources for the process of development that we seek.  This last requirement will in one
way or another determine our success in establishing all the other conditions.

It is in this context, taking into account these considerations and characteristics, that we must place
our discussions about the new State, its reorganization, and its relationship to society, rejecting out of hand any
proposal that casts the State either as a supreme master, an ever-present "colossus," or as a woefully
inefficient monster, responsible for all the evils that currently aggrieve us--an image that we must minimize or
do away with altogether.

The State is necessary.  I do not believe that the development we are discussing calls for its
elimination.  However, it does need to be redefined.  We need a State that is much more active, more
expeditious, more efficient--a State that is not governed by the interests of a few.  We need a State that
regulates the performance of institutions, that ensures normal development of the democratic process and
respect for the rights of individuals and the social groups, that will support the development process which we
decide on and will become an instrument of social solidarity and affirmation.

But the State cannot exist outside the society it represents, and this means that society will have to be
redefined as well.  It will have to be strengthened through the assimilation of all its members who have
heretofore remained on the fringes of national life.  A civil society, committed to full participation in the
democratic process, will be the counterpart that will uphold a strong, effective, and dynamic State, free of
prepotency and abuse.  It is through a balanced interaction between the functions of civil society and those of
the State or political society that we will be able to achieve the development to which we aspire.  While we
cannot accept an entity that attempts to control the generation of ideas, or an all-powerful State that squelches
individual freedom and creativity, neither should we subscribe to the Kantian conception of a minimal State that
is responsible only for the fulfillment of marginal functions.

Health can be an excellent route toward implementation of the development sought.  I do not believe it
necessary to repeat what I am sure has already been discussed here regarding the contribution of health to
production and productivity.  However, there is one element in this equation that I have seldom heard
mentioned by economists or sociologists.  Aggregate productivity in any social system, and by extension in any
economic system, depends on a variable that is difficult to quantify but is undoubtedly important, and that is the
extent to which the population feels linked to this economic or social system--in other words, how favorable
society's attitude is toward the system in question.  If the population is excluded from the benefits of production,
it will not have a positive attitude toward participation in the productive process.  The population's level of
psychosocial disposition toward the economic system is in direct proportion to its degree of satisfaction with the
benefits it derives from the effort it invests in overall production.  Among these benefits, health is one of the
most important from the social standpoint.  The enjoyment of good health not only helps to improve the
productive capacity of the worker but also contributes to the generation of an important and favorable process
of his or her integration into society and the workplace.

Without a doubt, health also contributes, or can contribute, to a strengthening of the democratic
process.  It may even serve as a catalyst for processes of social organization, spurring participation by the
entire community. 

Health can likewise contribute to the process of Regional integration.  Similarity of problems and
concurrence on the solutions proposed can and should be the articulating instrument that binds together the
isolated efforts of individuals, institutions, and governments into a body of Regional interventions that contribute
to the process of integration.

Health can be, as we have already shown in Central America, a bridge for dialogue and
understanding, a bridge for peace and development.  Health can contribute to the formation of culture.  Health
is inextricably linked to the conservation and rational use of natural resources, the protection and use of the
environment.  Health is both the subject and the object of scientific and technological development. 

For all these reasons, health is a powerful instrument for bringing about the development that we need,
and it is also a central component of well-being.

But in order for health to play these roles and make all these contributions, it is essential that current
health practices and the models of health service organization and operation undergo a profound and extensive
transformation.  I am certain that during the past few days you have discussed the characteristics of this
process, and the Minister has mentioned some of the changes that the health system in Peru is attempting to
introduce.  I would therefore just like to point out that in this process of transformation, in order for health to be
an integral part of development and contribute effectively and efficiently to its achievement, several extremely
important principles, values, or strategies must be borne in mind.  These are the principles of equity,
universality, and comprehensiveness in health care, all of which are closely interrelated.  There can be no
equity without universality, nor can there be equity and universality without access to all the services
necessary, in a structure that is complementary and functionally integrated.  Equally important are the
principles of effectiveness and efficiency, not because effectiveness and efficiency are ends in and of
themselves, but because they are necessary conditions for achieving equity and universality in a situation of
scarcity.  Another principle that must be considered is that of participation, by which I mean participation in the
broadest sense of the word, but especially in decision-making processes.  In order to facilitate this participation,
increase effectiveness and efficiency, and create a suitable framework for the exercise or application of the
principles of equity and universality, it will be necessary to establish new forms of organization founded on a
balanced process of decentralization and the strengthening of local administration.  For it is at the local level
that one finds expression of all the ways in which human beings interact with the environment that sustains
them and the services that provide for them.  It is here that the relationship between services and population is
transformed into an undertaking of mutual responsibility, through which it is possible to establish responsibility
for the health and life of all--children, mothers, young people, and the elderly, both male and female.  It is at this
level that it is essential to create conditions that will allow the exercise of local power in the administration or,
and in decisions relating to, health. 

This brings us back to the relationship between State, society, and health.  A great deal of time has
already gone by.  There have been and continue to be many offers and promises, such as the suggestion that
through generalized privatization we will be able to correct the deficiencies and inefficiencies of the State and
overcome the problems we have encountered in the administration of health resources.  Myths and illusions
coexist with our utopic idea that, because health has to do with life and is of vital importance to everyone, it will
always be approached with benevolence, dedication, and commitment.  When these utopias, myths, and
illusions come up against the realities of everyday life, we will no doubt learn many things.

With the indulgence of those who might not agree with me, I would like to conclude with the following
thought.  If the process of development is assumed to be at the service of well-being, if health is viewed as
essentially a product of the public domain which results from this process and to which the laws of the market
are only marginally applicable, and if it is considered the responsibility of the State to create the conditions
required in order to ensure well-being, then it becomes impossible to conceive of a State that reneges on its
responsibility to provide the conditions and means which will ensure health for all with equity, universality,
comprehensiveness, effectiveness and efficiency, and the committed participation of everyone concerned.

I am not talking about State control in the conventional sense of the word.  Rather, I am referring to the
State's political and institutional responsibility to mobilize all the resources of society toward active, effective,
and articulated participation by the public and private sectors, by individuals, families, and by communities in
order to make health what we believe it should be.

Ladies and gentlemen, you are all aware that this process is of enormous significance.  It is not simply
a question of political will on the part of the State, much less the government--although this is necessary;
rather, what is needed is the creation of mechanisms through which decisions can be the result of a truly
democratic exercise of the real power in our societies and not merely the exercise of institutional power.  It is a
question of ensuring that these objectives, principles, and values are accepted and incorporated into political
practice in the broadest sense of the term--political practice with effective participation by all, a new exercise of
power.

Achieving these ideals will mean a transfer of power; it will mean creating power for those who have
never had any, rather than extending the privileges of those who are already powerful, among whom we must
include ourselves.  Let us use our privileges on behalf of those who have never had them.                                                             






















CUBA





TABLE OF CONTENTS


General Characteristics

The Tobacco Industry
     Agriculture
     Manufacturing and Export
     Marketing

Tobacco Consumption
     Prevalence of Smoking in Adults
     Prevalence of Smoking in Adolescents
     Other Tobacco Consumption
     Attitudes, Knowledge, and Opinions about Smoking

Smoking and Health

Activities for the Prevention and Control of Tobacco Consumption

     Executive Structure and Policies
     Legislation
     School-based Education
     Public Information Campaigns

Summary and Conclusions

References



GENERAL CHARACTERISTICS

     Cuba is an archipelago in the Caribbean Sea located at the entrance to the Gulf of
Mexico.  Its area of 111,000 km2 is home to 10 million inhabitants--a population that has
some of the most favorable health indicators in the Americas.  In 1988, infant mortality
was 11.9 per 1,000 live births, down from 38 in 1965, while during this same period total
fertility declined from 4.4 to 1.9 and life expectancy at birth increased from 67 to 76 years
(Table 1) (World Bank 1990).  In addition, health and social services are among the most
widely available in the Americas, with one physician for every 333 residents, and a
literacy rate of nearly 100 percent (PAHO 1990).

TABLE 1

     Like the other countries in the Americas, Cuba has suffered from the effects of the
economic crisis of the 1980s, and hard cash reserves and personal income have been
declining in recent years.  Cuban agricultural products, including tobacco, have been
finding fewer markets as a result of the political changes being experienced by the
nation's chief trading partners:  the Soviet Union and the countries of Eastern Europe. 
Cuba has been one of the major producers and exporters of tobacco in Latin America,
ranking second only to Brazil.  As one of the country'sprimary crops, tobacco imbues the national cultural heritage, and themes about its
cultivation and use pervade the music, folklore, and other traditions (Suárez-Lugo 1988). 
At the same time, however, Cuba has recognized the health consequences of the nation's
high per capita consumption of tobacco and has embarked on an extensive control
program that is strongly backed by its national leadership and makes use of its
well-organized health system, which includes appropriate disease surveillance and
monitoring of the population's lifestyle and consumption habits.


THE TOBACCO INDUSTRY

Agriculture

     Cuba is the number two producer of tobacco in Latin America, after Brazil.  It is
one of the country's traditional crops and used to rank among its chief economic assets,
being exceeded only by sugar as a source of foreign exchange.  Even today tobacco
production still continues to be an important factor in the Cuban economy.

     The cooperative and rural sectors account for 78 percent of all tobacco-growing in
Cuba, while 22 percent is in the hands of the State.

    Production has fluctuated over the years, with variations caused, inter alia, by
adverse climatic conditions, pests, and diseases--for example, blue mould, which was a
problem in 1980.

     In 1988 a total of 56,700 hectares were planted in tobacco, or the equivalent of 1.6
percent of Cuba's total agricultural land area (Cuba 1988).  Fifteen thousand persons
were engaged in tobacco-growing, representing 3.1 of all workers in the agricultural
sector (Chapman 1990).  Approximately 40,000 MT of dried leaf tobacco have been
produced annually since 1983.

Manufacturing and Export

     Tobacco production is concentrated in rural tobacco-growing areas, and it is
largely a manual process.  There are 97 factories for processing tobacco and 6 for making
cigarettes, all of which belong to 23 companies which together form the Unión de
Empresas del Tabaco (consortium of tobacco companies).

     The outlook for tobacco production will depend on the situation in domestic and
foreign markets, where consumption has been declining since 1985.

     Although actual exports of leaf tobacco and cigarettes, in terms of quantity, were
lower during this last decade, the valueof these exports showed an increase because of prices abroad.  Cuba earns abound
US$90 million annually from exports, which means that tobacco still constitutes a major
line in the national economy.

     Most of the production is for domestic consumption, especially in the case of
cigarettes as opposed to other tobacco products.

Marketing

     Since 1960, all advertising of consumer products, including tobacco, has been
banned, and since 1970 cigarettes packs have been imprinted with the warning FUMAR
DA‘A SU SALUD [SMOKING IS HAZARDOUS TO YOUR HEALTH] (Varona-Pérez,
1990).

     The Ministry of the Agriculture has an agency that is responsible for analyzing the
chemical composition of all brands and types of cigarettes.  The tar content of unfiltered
dark-tobacco cigarettes--precisely the kind that is most popular in Cuba--is greater than
for any other kind of cigarette, which adds to the potential hazard of smoking as a risk to
health.

     Tobacco is marketed in Cuba in two ways:  on the rationed market, where the price
is kept low, and on the open market, where they are high.  Cigarettes are dispensed in
packs of 20.

    Under the rationing program, since 1971 individuals born before 1 January 1956
have been allowed four packs of cigarettes a month at a price of 30 cents.

     On the open market the prices are high, with a view to discouraging consumption,
principally among young people.  The light cigarette costs 1.80 pesos and the dark
cigarette between 1.60 and 2.0 pesos.

     Taking the extremes into account, the average price of a cigarette in 1990 was
1.21 pesos.  During the period 1973-1990 the average official price increased by
approximately 30 percent, which is consistent with the strategy of using price as a means
of regulating consumption.

     In 1989 the average monthly wage in Cuba was 188 pesos, and statistics provided
by the Instituto Cubano de Investigaciones y Orientación de la Demanda Interna (Cuban
Institute for Research and Guidance on Internal Demand--ICIODI) show that expenditures
on cigarettes and tobacco in the last decade have ranged between 8 and 12 percent
(Cuba 1988).

     It is forbidden to sell cigarettes to minors under the age of 16, in health centers and
educational institutions, and in recreational centers for children and young people.

    Loose cigarettes have only been sold in the Province of Matanzas, and this
practice was eliminated at the end of 1990 (Caraballoso & Suárez 1988).


TOBACCO CONSUMPTION

     From 1959 until 1970, cigarettes and other tobacco products were sold at low
prices on a totally open market and were distributed gratis to specific sectors
(sugarcane-cutters, etc), as a result of which consumption steadily increased, reaching its
peak in 1967-1968.

     The rationing of tobacco manufactures was instituted in 1971 in order to keep
prices down and guarantee quotas.  This rationing, which is still being imposed, has had
the effect of discouraging consumption.

     In August 1972 the open sale of these products was reintroduced, but at prices
ranging from 1.60 to 2.00 pesos per pack for dark cigarettes, 2.40 pesos for light
cigarettes, and 0.68 pesos for a cigar, while at the same time the quotas were maintained.

    Marketing at these prices led to a substantial rise in the average price of cigarettes
and cigars, amounting to yet another measure which helped to discourage consumption.

     After the initial impact of the open sale of cigarettes and cigars at these high
prices, by 1985 total per capita consumption had settled down to between 2,500 and
2,800 cigarettes a year with a slightly declining trend (Table 2).

TABLE 2

     Starting that year, when the campaign to discourage tobacco use got under way,
consumption began to decline more sharply, falling to levels below the range just
indicated.

Prevalence of Smoking in Adults

     The first national survey on the prevalence of smoking was carried out by the
Ministry of the Interior in 1978.  In 1980, 1984, and 1988 the ICIODI--the specialized
agency responsible for studying the consumption habits of the population, conducted
national surveys using representative sampling techniques--which is why comparative
analyses of prevalence are always based on these statistics.  In all these surveys the
"current smoker" was defined as a person who was smoking on a daily basis at the time
the survey was carried out.

    In 1989 a national survey was conducted on the consumption of alcoholic
beverages which also yielded data on the prevalence of smoking.  A new national survey
was conducted in 1990, but its results had not been fully processed when information was
requested for the present report.

     In 1980, Cuba had a total of 3,192,203 smokers over the age of 17, or 52.9 percent
of the population in that age group.  By 1988 this prevalence had declined to 40.1
percent, and in 1989 it fell to 37.4 percent.  This means that during the decade
1980-1990, despite a growth in population, Cuba saw a decline of 15.5 percent in the
prevalence of smoking, or an annual average of 1.5 percent (Table 3).

TABLE 3 (Figure 1)

     In 1988 the prevalence of smoking in the population aged 17 or over was 53.7
percent in men and 28.3 percent in women (Table 4).  This distribution is shifting,
however, with an increase in the proportion of women who smoke and a reduction in that
of men.

TABLE 4

     Prevalence is highest is the 30-49 age group (Table 5), and it is slightly higher in
rural areas than in cities (42.1 versus 39.3 percent, respectively).

TABLE 5

     Although there are no major differences in prevalence according to educational
level, it can be seen that a larger number of smokers is found among the population with
the least amount of schooling (Table 6).

TABLE 6

     In terms of occupation, prevalence is highest among agricultural and industrial
workers, with larger numbers of smokers being found in rural areas.  Next in decreasing
order are service workers, retirees, and administrative and clerical personnel.  Prevalence
is high among physicans:  3 out of every 10 are smokers (Table 7).

TABLE 7

     Prevalence is higher in the provinces where tobacco is grown--Sancti Spíritus,
Cienfuegos, and Pinar del Río--and the rates among women are highest in the city of
Havana.  The first phenomenon corresponds to a cultural tradition and the second to
greater incorporation of women in social life.

     Both the prevalence and consumption of tobacco have been declining trend in
recent years.

Prevalence of Smoking in Adolescents

     According to a survey conducted in 1988, 95 percent of the smokers in Cuba
began to smoke before the age of 30, and of these, 58.5 percent started between the
ages of 13 and 16 (Varona-Pérez, 1990).

     As a result of these findings--very similar in fact to the results obtained in previous
surveys--it was considered to be of interest to compare the information obtained in
households with that that elicited from adolescents interviewed outside the home setting.

     Thus, a national survey conducted among 1,847 students aged 13-17 using a
self-administered questionnaire (ICIODI 1988) revealed a prevalence of tobacco use of
5.7 percent (8.1 percent for males and 2.9 percent for females), whereas in a household
survey carried out in 1988 the responses of adults speaking on behalf of their adolescent
children indicated a prevalence of only 2.8 percent for males and 0.6 for females. 
Obviously the parents of these adolescents were underestimating the extent to which their
children were smoking.

Other Tobacco Consumption

     Most tobacco in Cuba is consumed in the form of cigarettes.  In 1988, only 8.5
percent of smokers aged 17 or over smoked cigars, 1.8 percent smoked both cigarettes
and cigars, and 1 percent of the population reported that they use other types of
tobacco--meaning, basically, that they smoked a pipe or chewed tobacco.

     Cigar-smoking accounts for 15.4 percent of the tobacco consumed in Cuba, and
chewing tobacco accounts for only 0.5 percent.

Attitudes, Knowledge, and Opinions about Smoking

     In view of the fact that tobacco prevention and control activities had gotten under
way in the late 1980s, the 1988 ICIODI survey asked questions about knowledge and
attitudes towards smoking.  Of the total population, 97 percent considered themselves
"well informed" about the hazards of smoking, and smokers and nonsmokers did not differ
in their response to this question.  Ninety percent of the respondents had received
smoking-related information from television, 80 percent from the radio, and 61 percent
from the print media (ICIODI 1988), indicating that the tobacco prevention and control
program hadsucceeded in raising public awareness about the health consequences of smoking.  The
respondents were in agreement with policies that restrict smoking in public places, and
almost all (98 percent) supported the newly legislated bans on smoking in enclosed
spaces.  At the same time, however, most of them (76 percent) also felt that the
regulations were not strict enough to make an impact on smoking behavior, given the fact
that there is widespread noncompliance (ICIODI 1988).


SMOKING AND HEALTH

     Cuba's statistics on mortality are among the most accurate figures in the Americas. 
In 1988, underreporting was estimated to be only 1.5 percent, and only 0.2 percent of all
deaths were classified as "symptoms and ill-defined conditions" (PAHO 1990). 

     Noncommunicable chronic diseases are the leading cause of death in Cuba in the
15-49 and 50-64 age groups.  Cardiovascular diseases and cancer rank first and second,
respectively, in the population aged 50-64.  The most frequent cause of cancer death in
Cuba is lung cancer (an overall age-adjusted rate of 16.2 per 100,000 population in
1988), with a higher rate for men (23.5 per 100,000 population) than women (8.7 per
100,000) (PAHO 1990).  Among the countries of the Americas, Cuba's age-adjustedmortality rate for lung cancer is surpassed only in the United States and Canada.  During
the period 1983-1988, age-adjusted mortality for lung cancer increased slightly among
men (Table 5), and age-specific mortality for this type of cancer increased dramatically
with age in both sexes.

     In Cuba, the consumption of unfiltered dark-tobacco cigarettes and cigars is more
common than in other countries of the Americas.  In light of Cuba's excessive death rates
from lung cancer, Joly et al. conducted a hospital-based study of 826 patients and
controls to determine the relationship between risk for lung cancer and consumption of
these types of tobacco (Joly 1983).  The relative risks (RR) for lung cancer among
cigarette-smokers was 7.3 for women and 4.1 for men.  The RR was higher for dark
tobacco users than for light tobacco users (RR of 8.6 vs. 4.6 for women and 14.3 vs. 11.2
for men).  Cigar-smokers had a much lower risk for lung cancer (RR = 4.0) than those
who smoked only cigarettes.  However, those who smoked both cigars and cigarettes had
a higher RR than those who smoked only cigarettes (15.0 vs. 14.1).  Based on the RR
estimates in this Cuban study, Joly also estimated that 91 percent of male lung cancer
deaths and 66 percent of female lung cancer deaths were attributable to smoking, even
when other variables such as environmental exposure, occupation, and other risk factors
were considered.  Thus, in 1988, 2,647 lung cancer deaths in Cuba were caused by
smoking.

    In addition to lung cancer, evidence of the disease impact of smoking in Cuba can
be observed during the period 1983-1988 for selected cardiovascular diseases.  The
age-adjusted death rate for ischemic heart disease increased for both men and women
during this period.  However, age-adjusted mortality from cerebrovascular diseases and
from cancers of the lip, oral cavity, and throat remained stable for both men and women. 
These diseases may have other contributing risk factors such as arterial hypertension and
excess consumption of alcohol, the prevalence of which has decreased in Cuba.


ACTIVITIES FOR THE PREVENTION AND CONTROL OF TOBACCO CONSUMPTION

Executive Structure and Policies

     In Cuba, all activities for the prevention and control of tobacco consumption are
carried out within a government framework, and the Government has officially recognized
that tobacco has been an important factor in the emergence of noncommunicable chronic
diseases in the Cuban population (Suárez Lugo 1988).  Anti-smoking actions were
already being undertaken in the 1960s--including a ban on the advertising of tobacco
products, the inclusion of a health warning on cigarette packs, and various educational
activities on the part of healthprofessionals.  In 1976, the Ministry of Public Health created the National Commission on
Health Promotion with the stated objectives of reducing sedentary lifestyle, obesity, and
smoking.  In 1986, a national working group (Grupo de Trabajo Nacional--GTN) was
established with a view to launching an anti-smoking campaign.   A national program to
reduce tobacco consumption was organized in 1987, and the anti-smoking campaign is
an integral part of this program.

     The GTN includes representatives from 15 different government agencies:  the
ministries of health, education, higher education, culture, agriculture, commerce, and
transportation; institutes concerned with radio, television, sports, physical education,
recreation, and aeronautics; the union of communist youth; the Organización de Pioneros
José Martí (José Martí Organization of Pioneers); and the ICIODI, which acts as general
coordinator.  At least 100 persons participate in this group, which does not have its own
budget but rather draws on resources from the participating institutions.  The GTN has
established units at the provincial level in an effort to regionalize its activities.

Legislation

     The anti-smoking campaign relies primarily on public education through the mass
media.  Recently there has been an increase in legislative action.  Early tobacco-related
legislation focused on fire prevention through bans on smoking in the vicinity of flammable
or explosive substances (Decree No. 41 1988).  It is now also forbidden to smoke in
airplanes (Resolution DJ 26/88 1988), urban public transportation, and certain other
public spaces (Law No. 60 1987), as well as in education and health establishments
(Rodríguez-Palacios 1988).  Concern over noncompliance with these restrictions has led
the GTN to redraft the existing regulations.  The new version would ban smoking in
meeting places, health centers, educational facilities, sport centers, public offices, and all
public transportation facilities, including terminals (Varona-Pérez 1990).  The bill also calls
on political leaders to oversee compliance with the regulations and to impose fines on
offenders.  The proceeds of these fines would be turned over to the GTN to invest in the
anti-smoking campaign.

     Cuba has some restrictions on the sale of cigarettes (Varona-Pérez 1990). 
Cigarette sales are prohibited in health centers, schools, and other places where children
and youth are found in groups.  By decree, the Ministry of Commerce prohibits the sale of
cigarettes to persons under the age of 16.

School-based Education

     In 1989 work began on the development of an anti-smoking education program for
children and adolescents to be implemented both in and outside the schools.

     The Program is being assessed in terms both of its effectiveness and the feasibility
of introducing it in the national education system.

     Also in 1989 a process was initiated to help people give up smoking.  It is being
applied primarily in the community at the level of the family, which is the basic unit in the
primary health care system.  In addition, physicians are provided with information for
helping their patients to give up the habit, and other therapeutic methods are being used
as well.  This undertaking is still in the experimental stage.

Public Information Campaigns

     Public information campaigns are the main component of anti-smoking activities in
Cuba.  These campaigns educate the public about the health hazards of smoking; raise
public awareness of nonsmokers' rights to breathe clean air; and encourage parents,
teachers, and government officials to set an example by giving up the habit.

    Several subcampaigns are targeted at specific groups such as individuals who
want to quit; smoking in families; physicians and other influential figures such as teachers
and athletes; adolescents and young people; and passive smokers.  Another
subcampaign emphasizes the economic effects of smoking on family income.  The
vehicles employed have included the mass media, posters, bumper stickers, and tee
shirts bearing the message: "En vez de humo, llénese de vida" (Breathe life, not smoke!).

     The first two years of the anti-smoking campaign have focused on education.  So
far, few resources have been available to help people give up smoking.  The survey
mentioned earlier revealed that both smokers and nonsmokers are well informed about
the health consequences of the habit.  Pharmacological aids and a few clinical programs
are available on a sporadic and limited basis.  In addition, the GTN is working on other
solutions based on available resources, and it is trying to get support from international
agencies.

     In 1988 Fidel Castro, maximum leader of the Nation, received an award from the
World Health Organization on the occasion of its worldwide "No-Tobacco Day" in
recognition of the Cuban Government's commitment to fight smoking and give priority to
the nation's health.


SUMMARY AND CONCLUSIONS

     Tobacco cultivation has played an important role in the Cuban economy and
culture.  Cuba has been the second largest producer and exporter of tobacco in Latin
America, and per capita consumption of tobacco by Cubans is the highest in the
Hemisphere.  During the period 1986-1989 Cubans consumed 2,315 billion cigarettes a
year.  This excess consumption has caused lung cancer to become one of the leading
causes of cancer-related mortality in Cuba, with more than 2,600 deaths from lung cancer
attributable to smoking each year.

     The Government and its leadership have recognized the heavy toll that smoking
takes both on health and on the well-being of a struggling economy.

     The educational efforts that have been undertaken so far,  and the interest shown
by the State in improving the health indicators of the population have helped to maintain
the steadily declining trend in tobacco consumption which began in 1985.

     Despite the decline, however, the prevalence of smoking has increased among
both women and young adults.  In addition, Cubans continue to start smoking at an early
age, although in1988 only 5.7 percent of the the adolescent population reported that they were smokers.

     Legal actions are being stepped up under the program with a view to banning
smoking in public places.  Physicians, who have an improtant role not only as
opinion-makers but also as counselors to their patients who smoke, are actively involved
in the anti-smoking campaign.

     The GTN considers that it is essential to provide effective support for smokers who
want to give up the habit.

     Cuba truly has political commitment, and this is a key aspect in the country's
efforts toward health promotion.

     Another positive aspect of the Program is that it is being implemented by a
multidisciplinary and multisectoral group whose action is nationwide.

     Based on the presented in this review, the following conclusions may be drawn:

1.   Tobacco production and consumption are deeply rooted in the Cuban culture, a
     fact that is reflected in the high prevalence of smoking.  The high level of tobaccoconsumption is not so much a product of marketing as it is of strongly entrenched
     national custom.  Since 1960 there has been no advertising of tobacco products.

2.   Cuba has the third highest death rate from lung cancer in the Americas, and
     mortality from this form of cancer is increasing for both men and women.  There
     are more than 2,600 lung cancer deaths attributable to smoking each year. 
     Mortality from ischemic heart disease is also increasing.  Cardiovascular and
     neoplastic diseases are the leading causes of death in Cuban adults.

3.   The Cuban Government has recognized the need to prevent and control tobacco
     use among its citizens.  Cuba's data systems have provided the necessary
     information for implementing a national tobacco prevention and control program. 
     The effects of this program are measured by such indicators as consumption,
     prevalence, mortality, and the results of knowledge and attitude surveys.

4.   Interventions against tobacco consumption have included public information using
     the mass media, school-based education, legislation, and a public commitment on
     the part of the Government's leadership to control tobacco consumption.  Studies
     have shown that knowledge about thehealth consequences of smoking appears to be universal but services are needed
     in order to help people who want to give up the habit.

5.   The prevalence of smoking declined during the 1980s by 15.5 percent.  Young
     people continued to get "hooked" on tobacco, and prevalence of the habit
     increased among adults aged 30-49 years as well as among women.  Per capita
     cigarette and tobacco consumption fell by 46.7 percent between 1974 and 1989. 
     However, even with these reductions, the prevalence and consumption of tobacco
     continue to be high in the Cuban population, and it is necessary to keep working
     intensively under the program initiated in 1986.REFERENCES


AGRO-ECONOMIC SERVICES LTD. AND TABACOSMOS LTD.  The employment, tax
revenue and wealth that the tobacco industry creates. 1987.sr

CENTRO LATINOAMERICANO DE DEMOGRAFIA.  Boletín Demográfico. Santiago,
Chile: CELADE, Año XXIII, No 45., January 1990.sr

CHAPMAN S, LENG WW. Tobacco Control in the Third World--A Resource Atlas.
International Organization of Consumers Unions, Penang, Malaysia, 1990.

HEDGES M. Trail of phony Winstons leads to Noriega, Cuba. The Washington Times,
July 5, 1990, page A3.

JOLY, O.G., LUBIN, J.H., CARABALLOSO, M.  Dark tobacco andlung cancer in Cuba. 
Journal of the National Cancer Institute 70(6):1033--1039, June 1983.sr

MASIRONI R, ROTHWELL K. Tendences et effets du tabagisme dans le monde.  Rapp.
Trimest. Statist. Sanit. Mond. 41:228-241, 1988.

ORGANIZACION PANAMERICANA DE LA SALUD.  Las Condiciones deSalud en las
Américas, 1981--1984. Washington D.C.:Organización Panamericana de la Salud,
Oficina Sanitaria Panamericana, Oficina Regional de la Organización Mundial de la
Salud, Publicación Científica No. 500, 1986.sr

ORGANIZACION PANAMERICANA DE LA SALUD. Las Condiciones de Salud en las
Américas. Washington D.C.: Organización Panamericana de la Salud, Oficina Sanitaria
Panamericana, Oficina Regional de la Organización Mundial de la Salud, Publicación
Científica No. 524, 1990.sr

PAN AMERICAN HEALTH ORGANIZATION. Informe Preliminar, Taller Sobre
Tabaquismo y Salud, Region Mesoamérica, Ciudad de Guatemala, 11 de octubre 1988.

RODRIGUEZ-PALACIOS, E.  Estudio Sobre Aspectos Legales del
Hábito de Fumar. Instituto Cubano de Investigaciones y Orientación de la Demanda
Interna, La Habana 1988
(mimeograph).sr

SUAREZ-LUGO, N. Actividades Anti-Tabáquicas en Cuba, La Habana 1988
(mimeograph).sr

UNITED NATIONS DEVELOPMENT PROGRAMME.  Human Development Report 1990. 
New York: Oxford University Press, 1990.sr

U.S. DEPARTMENT OF AGRICULTURE. Foreign Agricultural Service. Latin American
and Caribbean Tobacco Production and Consumption (unpublished tabulations), April
1990.

VARONA-PEREZ, P.  Informe Sobre Tabaquismo, Cuba, 1990 (unpublished data).

WORLD BANK. World Development Report 1990. New York: Oxford University Press,
1990.


REPORT ON THE PROGRAM FOR THE CONTROL OF 
ACUTE RESPIRATORY INFECTIONS, 1991


1.INTRODUCTION

  The 1988-1989 biennium represented an important period of transition in the advancement of the ARI
Program inasmuch as the Guidelines for Case Management were revised, appropriate administrative
instruments for the National ARI Programs were developed, and a clear set of research priorities was
established.  In turn, coordination meetings were held between WHO and UNICEF for the purpose of
unifying the lines of action in support of the countries, and seeing that ARI control measures achieve the
most rapid possible reduction in childhood mortality. 


  During the 1987-90 quadrennium, a series of activities was carried out which were relevant to the
organization of ARI control activities at the level of local health services, where care is provided for ARI
cases. 


  During the eight years since the creation of the WHO Program for the Control of ARI, the Region of
the Americas has been engaged in intense activity.  With the support of PAHO/WHO, UNICEF, and AID,
many countries have implemented the first recommendations on ARI case management in the health
services.  Thus, at the end of 1989, the Region of the Americas was home to most of the countries that had
ARI control programs in execution. 


  Although the advances achieved have been indicated, numerous difficulties still persist with the
implementation of the proposed strategies, the regular provision of supplies, the periodic supervision of the
health services, and the overall evaluation of the activities.  For this reason, although no impact on mortality
was expected over the short term, the delay in achieving national coverage through effective
implementation of the control strategies has postponed even more the possibility of seeing the programs'
success in terms of a reduction in the number of serious cases of ARI resulting in death.


  During 1990 a Regional Project for the implementation of ARI control measures in the countries of the
Americas was drawn up whose fundamental objective was to accelerate implementation of the National
ARI Programs and to establish clear targets for the short, medium, and long term that would make it
possible to gauge the progress made. 


  With the goal of helping to reduce mortality from ARI in the countries of the Americas and achieve
more effective coordination among the various agencies that support the efforts made by the countries; and
in order to take advantage of the experience that the Expanded Program on Immunization and the Program
on Control of Diarrheal Diseases have gained in channelling international resources for optimal impact on
infant mortality, the Agenda of the ARI Component is proposed in the Interagency Coordinating Committee
of the Maternal and Child Health Program, with representatives from PAHO/WHO, UNICEF, AID, and
other agencies.


2.PLANNING

    a. Regional Program

Among the Regional-level planning activities in the Region of the Americas, the following
are of note: 

  RESOLUTION APPROVED BY THE REGIONAL BODIES

  The XXXV Meeting of the PAHO Directing Council and the XLIII Meeting of the WHO Regional
Committee approved a regional analysis of the resolution, along with other actions by the 44th World
Health Assembly of interest to the Regional Committee.  These include Chapter 2 (WHO Resolution 44.7),
"Control of Acute Respiratory Infections," which says, in summary:

  In the Region of the Americas, acute respiratory infections remain a significant cause of infant and
  preschool mortality.  In 4 countries of the Region it is the second cause of infant mortality, in 14 the
  third, and in 6 more the fourth or fifth.  For preschoolers, it is the most frequent cause of mortality in
  one country, the second in 7, and the third in nine more.  Furthermore, it is estimated that children under
  the age of 5 suffer five to seven episodes annually.


  The program to control acute respiratory infections was begun in the Region of the Americas in 1983. 
  The principal objectives of the Program have been to reduce the impact of acute respiratory infections
  and to prevent complications, including from the incorrect use of antibiotics.


  THE PAN AMERICAN SANITARY CONFERENCE
  AND THE EXECUTIVE COMMITTEE OF PAHO

  At its Eighth Plenary Session, the XXXV Meeting of the PAHO Directing Council, held on 26
September 1991, approved:

  Resolution XVI, on maternal and child health and family planning, which takes the control of ARI into
account and urges the Governments:

  To promote at the central, regional, and local levels in their countries the decisions and commitments
  of the Summit, and to call upon the public and private sectors to join in attaining the national goals on
  behalf of women and children;

  To help devise a methodology for better estimating the costs of the maternal and child health and family
  planning programs in the nineties, which will facilitate the design of financial strategies and the
  mobilization of resources. 

  To strengthen the establishment and consolidation of interagency coordination mechanisms for maternal
  and child health, through a committee to be headed by a government employee with decision-
  making authority;

  To continue developing their epidemiological surveillance systems and data bases for improved
  monitoring and evaluation of programs.


  SUBREGIONAL AGREEMENTS

   The ARI control component actively participates in the maternal and child health activities of all the
subregional initiatives, such as those in the Andean area, Central America and Panama, and the Caribbean.


  INTERAGENCY COORDINATING COMMITTEE

  In order to support the implementation of ARI control measures at the Regional level in the context of
comprehensive care of the child in the local health services, and based on a recommendation by the World
Summit for Children regarding the preparation of national operational plans and the establishment of
Interagency Coordinating Committees for maternal and child health activities, strong ties were forged with
UNICEF and AID so that instruments could be created that would make these plans workable.


  As a result, in the name of the three agencies (PAHO/WHO, UNICEF, and AID), a document has been
published as the "Plan of Action for the Implementation of ARI Control Programs - the ARI Component
of the Interagency Coordinating Committee on Maternal and Child Health," which is in the process of being
established in the countries of the Region.



  OTHER CONCEPTUAL FRAMEWORKS

  For the period covering 1991-1995, PAHO's Regional Program on ARI has adopted the targets
proposed at the "Bangkok Reaffirmation" with regard to the first of the program objectives, setting the goal
for 1995 of a 30% reduction in deaths from respiratory infections in children under 5 as compared with the
1990 levels.  Keeping in mind the effectiveness of the strategy of standardized ARI case management, as
well as the situation of the countries in the Region of the Americas, the Program has established the
following targets:


  In accordance with the Plan of Action for implementation of the World Declaration on the Survival,
  Protection, and Development of Children in the 1990s, adopted by the World Summit for Children held
  at United Nations Headquarters in New York on 30 September 1990, all governments were urged to
  prepare, by the end of 1991, national action programs aimed at fulfilling the commitments contained
  in the Declaration.
 

  Each country needs to establish appropriate mechanisms for collecting, analyzing, and publishing, on
  a regular and timely basis, all data needed to monitor the relevant social indicators of children's well-
  being, such as death rates in newborns, in children under 1 year of age, and in children under 5 years
  of age.


  We can advance more rapidly toward the targets approved in the Declaration of the World Summit for
  Children and in this Plan of Action, and we will be in a much better position to solve many other
  important problems suffered by children and their families if research and development activities are
  increased.


  All Regional institutions, including Regional political and economic organizations, are asked to include
  an examination of the Declaration and this Plan of Action in the program for their meetings, even at the
  highest political level, with a view to setting up collaboration agreements for their implementation and
  ongoing supervision.


  b.Programming of the National ARI Programs


  DESCRIPTION OF ACTIVITIES BY COUNTRY


  ARGENTINA

  Several of the country's provinces (Tucuman, La Rioja, Santa Fe, Entre Ríos, Paraná, and Córdoba)
have offered supervisory skills courses, based on the PAHO/WHO models, and are preparing their
provincial operational plans for the development of ARI control activities at the level of the services.  The
training unit at the Children's Hospital of Santa Fe has begun the training process for the province's Area
V, and nearly 300 persons have been trained.  In December 1991, the first area will be evaluated, and
programming will be carried out in the other areas of the province.  Since the program activities have been
in operation for almost a year, some very important achievements can be seen; for example, a reduction in
the amounts of antibiotics used to treat ARI cases (nearly 60% of the cases treated).


  For the coming year the plan is to consolidate the process of program implementation, to encourage the
central level to perform monitoring and supervision in the provinces and to promote standards in the
departments of pediatrics at schools of medicine, and to support the establishment of more than one training
unit in ARI treatment in Buenos Aires.

  
  The Emilio Coni National Institute of Epidemiology in Santa Fe supports the dissemination of technical
documents and supervision, and monitoring at the national level.  As a WHO Collaborating Center in
tuberculosis and respiratory diseases, it supports the Regional effort by collecting epidemiological
information on the countries, setting up the ARI data base, and analyzing information for the national
programs.


  BELIZE

  The country has prepared its operational plan and, with PAHO support, held its first ARI training skills
course for physicians and nurses.  After the national standards were revised, control measures were initiated
at the level of the health services.


  BOLIVIA

  With the support of UNICEF and AID, the country has developed a series of instruments, including
standards, training modules, flip charts, posters, radio spots, and videotapes on ARI. 


  In July 1991 a course was given on the organization of ARI control measures, with participation by
representatives from all of the country's departments. 

  PAHO, in conjunction with the WHO Global Program on ARI, is committed under the UNICEF/NY
initiative to carry out a variety of clinical-etiological, epidemiological, and ethnographic research on ARI
control, in cooperation with the Division of International Health at the Johns Hopkins University.  We
believe that the results of these studies can have a favorable impact on Program development.  The country
has revised its standards based on the updated recommendations of PAHO/WHO.


  BRAZIL

  ARI control is currently coordinated by CORSAMI, the National Coordination of Maternal and Child
Health, in Brasilia.


  The standards have been revised and are to be published on a timely basis by the Ministry as part of the
publication "Manual da CrianÛa."  Some areas of the country are being given high priority.  For example,
while the infant mortality rate in the state of SØo Paulo is approximately 35/1000 live births, in the
Northeast it is estimated at 135/1000 live births, with around 1/3 of these deaths being caused by
pneumonia.  ARI control is being formally implemented in the states of Pará, Rio Grande do Sul, and SØo
Paulo.


  In August 1991, a course on the organization of ARI control was given for the country's southern and
southeastern states, and in September 1991 it was offered for the northern and western central states.  The
course for the northeastern states will be in February of 1992.


  The training units are in operation (in Pará and Rio Grande do Sul) and have trained close to 500 people
using the PAHO/WHO modules.  For the next year, the goal is to promote the establishment of at least two
more units, in Ceará and Bahía.


  Three axes of Program development are being programmed for establishment in the North (Pará), the
Northeast (Ceará), and the South (Rio Grande do Sul).


  THE CARIBBEAN

  In May 1991, a joint CDD/ARI meeting was held in Jamaica with participants from all the countries
in the area.  At this meeting, the technical guidelines were revised with the help of representatives from
university departments, while several countries programmed supervisory skills courses, using the
PAHO/WHO modules in English.


  During the year the collection of epidemiological data from the countries in the area was promoted-
-especially with regard to mortality from pneumonias and influenza--so that the profile and its
accompanying trend could be prepared.  In addition, there has been continued delivery of technical
documents and information on ARI published in English.  For 1992, technical advisory services have been
programmed to evaluate the Program's advances in the countries of the area.  This is in order to follow up
on the encouragement offered during the Third Regional Course on the Organization of the ARI Program,
which was held in Barbados for the countries of the English-speaking Caribbean. 

  
  COLOMBIA

  All of the country's 35 departments and territories have implemented activities, although they differ
in terms of quality and coverage.  Some activities of the health promoters and monitors in the community
are in need of evaluation.  Various documents have been published.  The country has adopted the WHO and
Ministry of Health guidelines and has implemented 7 ARI treatment training units aimed at upholding the
quality of training and preserving its practical aspects.  In 1992, 3 additional units will be implemented. 
Several departments of pediatrics at schools of medicine in the country are including modules on
"Management of the child with an acute respiratory infection" in the regular classes for their degree courses.



  Several localities in the country (Monteria, Santander, and Armenia) have begun to develop community
respiratory infection units in order to expand coverage, based on the success experienced with community
oral rehabilitation units).  A CDD/ARI workshop is being programmed for the coming year to evaluate the
activities carried out by the country's divisions of health and programming/1992.  In addition, a workshop
has been programmed to evaluate the ARI training units, since in 1992 there will be 10 units in the country
as a whole.

  ECUADOR

  The country has revised its national standards and was in the process of conducting training courses by
region between November and December 1991.


  HAITI

  ARI control has been formally established as a Ministry program, with a national director.  Support was
provided for an operational study on KAPs in ARI at the community level, and an attempt is being made
to encourage the country to offer ARI supervisory skills courses.  WHO has programmed support for
clinical-etiological research on numerous risk factors.  Although the country has an APO in CDD/ARI
(currently in the Dominican Republic), the Program has not been able to move forward given the current
situation. 


  GUATEMALA

  In July 1991, support was provided for preparation of the operational plan for ARI control in the context
of comprehensive child health care.  The national standards need to be revised, and there are plans to
support a national course on the organization of the Program to be held during the coming year.

  HONDURAS

  The country has developed an effective social communication plan with the support of AED/PRITECH. 
The standards were reviewed and found to be of good quality.  For the coming year, the country's targets
are to train personnel and to implement the standards in the local health services.


  NICARAGUA

  The national standards at both the outpatient and the hospital levels have been published, and conform
to the recommendations of PAHO/WHO.  Standards have also been prepared for the hospital level. 
Through WHO, a US$420,000 contribution was received from Finland in support of the 1990-
1992 ARI Program.  The project envisions country-wide implementation of the Program, drug procurement,
supervision, monitoring, the production of educational materials, social communication, and annual
evaluation.

  At the moment, the region that has shown the most progress is León, with its implementation of
activities at the level of the services, and establishment of a training unit in ARI treatment which is doing
good work. 


  PANAMA

  The Program is being implemented on a country-wide basis.  The standards have been revised in
accordance with the technical guidelines recommended by PAHO/WHO, and in August 1991, support was
provided for preparation of the national operational plan for ARI control.  A national course on the
organization of the ARI Program is programmed for the first four-month period of 1992.


  MEXICO

  The country has set up a national experts' group to provide technical support to the Program.  Five
training centers have been set up in the states of Tabasco, Zacatecas, Guanajuato, Chihuahua, and Mexico
to improve the quality of training in ARI treatment, and a social communication plan has been developed. 
The country has revised and published its standards.  A national course was given on the organization of
the ARI Program, with the participation of representatives from all the states as well as other national health
institutions.


  The regional training centers also support the monitoring and supervision of ARI control measures.


  PARAGUAY

  The country has standards, modules and training, and a flip chart (including a version in Guaraní). 
Activities have been underway in some regions of the country since 1986, with the support of PAHO,
UNICEF, and GTZ.  The standards have been revised and a national course on the organization of the ARI
Program is programmed for December 1991, utilizing the PAHO/WHO module on "Management of the
Child with an Acute Respiratory Infection" and evaluation of the national operational plan.


  PERU

  In 1985 the country began to prepare its standards, training materials, and operational plan.  The
implementation of the "Three-Year Plan to Reduce Mortality" gave new momentum to the Program, with
priority given to training, drug procurement, and participation by promoters in both preventive and curative
activities in the community.  The country's situation has prevented the activities from progressing further;
however, two training units have been created.  At a joint workshop between the pediatrics departments at
the country's schools of medicine and CDD, the standards were presented and well received.  In November
1991, a national course was given on the organization of the ARI Program.  The PAHO Representative
Office has a CDD consultant who also supports the ARI component.  Support is provided for the
preparation of the national operational plan; and standards, clinical charts, and a programming manual have
been published. 


  DOMINICAN REPUBLIC

   The country has prepared its standards, which have already been approved and published.  Acute
respiratory infections are integrated into the national plan for child survival, which has strong political
support at the Ministry level.  During the year, support was provided for training health personnel in Herrera
(near Santo Domingo), so that ARI control measures could be implemented by NGOs active in the area,
with support and monitoring by the Ministry of Health. 


  Support was provided for preparation of the national operational plan, and in November 1991 a national
course was given on the organization of the ARI Program. 


  VENEZUELA

  With technical support from PAHO, the country was able to prepare a manual on standards, which was
published by UNICEF, in addition to a flip chart and other instructional materials.  During the year the
national standards were revised, and a national course was given on the organization of the ARI Program,
with the participation of representatives from all of the states in the country.  Currently, the national
operational plan is being prepared, and arrangements are being made to procure drugs for the entire country. 
The country has an APO to support the CDD/ARI programs.  A technical advisory commission for the
Program was established at the national level.  For the coming year, the plan is to support publication of
the standards, promote an evaluation of progress in the states of Aragua, Zulia, and Mérida, and support
implementation of at least one ARI treatment training unit. 


  c.Consultant/staff visits to collaborate in the discussion
    and design of the technical guidelines and plans of operation.

  January   Colombia    Dr. Y. Benguigui, PAHO
Dr. A. Cattaneo, WHO

  February  Argentina Dr. Y. Benguigui, PAHO

  March     Suriname    Dr. G. Baldew, PAHO

  March     Belize    Dr. A. Flores, STC/ARG

  April     Guatemala   Dr. R. Armengol, STC/VEN

  June      Panama      Dr. R. Armengol, STC/VEN

  Sept.     El Salvador Dr. C. Jauregui, STC/COL

  Nov.      Paraguay    Dr. C. Jauregui, STC/COL



2.OPERATIONS

  a.Status of implementation of Program activities

  The ARI Control Program is being implemented at the national level in 7 countries of the Region
(Colombia, the Caribbean, Guatemala, Panama, Paraguay, Mexico, and Uruguay).  In 11 other countries
(Argentina, Belize, Bolivia, Brazil, Costa Rica, Ecuador, Honduras, Peru, the Dominican Republic,
Nicaragua, and Venezuela), ARI control activities are being carried out in the local health services in
specific areas of states, provinces, and departments, and have progressed to varying degrees without
achieving national coverage.


  In the Region to date, 27 countries have named a national coordinator in charge of the ARI program. 
Sixteen countries have prepared a national plan for the ARI program, and 17 countries have revised their
ARI control standards in accordance with the recommendations of PAHO/WHO, while 5 others (Costa
Rica, Cuba, Guatemala, Haiti, and Suriname) are expected to revise their standards during 1992.


  b.Coordination with other programs

  In the Region of the Americas, the ARI Control Program is part of Comprehensive Child Health Care. 
This can be seen in the fact that, of 27 countries in which the Program has been evaluated, 23 include ARI
Control under their division of maternal and child health. 


  The CDD and ARI programs carry out some activities jointly, such as supervisory skills courses and
seminars held in conjunction with schools of medicine and nursing.


  In conjunction with the Expanded Program on Immunization, there has been collaboration to introduce
the guidelines on diagnosis and treatment of ARI (mainly pneumonias in children) for the manual on
treating the complications and intercurrence of measles in children.


  In conjunction with INCAP (the Institute of Nutrition of Central America and Panama), it has been
possible to coordinate the distribution of 16,000 copies of the bulletin "Noticias sobre IRA" ["ARI News"]
to all the countries of the Central American Isthmus (in June and December of 1991). The INCAP
consultants in the countries of Central America have collaborated to promote ARI control measures, and
there is an ongoing exchange of the research on ARI control that is being carried out by INCAP.
  

  In conjunction with the Regional Office of UNICEF, various activities have been coordinated, such as
"Noticias sobre ARI," as well as UNICEF financing for the regional and national courses on the
organization of the ARI Program.  At the level of the national offices, UNICEF is supporting publication
of the national standards and other training materials in ARI control, prepared with PAHO technical
support.  The document on the ICC/ARI is being published jointly. 


  In conjunction with the Emilio Coni National Institute of Epidemiology in Santa Fe, Argentina, various
coordinated activities have been carried out.  A data bank on the ARI Program has been set up in the
information sector of the Institute, and follow-up is being conducted on those who have attended the
regional and national courses on the organization of the ARI Program.

  There has been close collaboration with other NGOs in promoting the Program, including Foster Parents
Plan International, ADRA International, the International Child Health Foundation, AED/PRITECH, and
the Fundación Santa Fé of Bogota.


  A vigorous exchange has been maintained with the REACH Project in order to involve that institution
in providing support for the national ARI control programs.


  In conjunction with USAID, the document on ICC/ARI was revised and an agreement reached on its
joint publication (PAHO/WHO, UNICEF, and AID).


  In conjunction with universities, schools of medicine, schools of nursing, and national public health
courses in various countries of Latin America, efforts have been made to coordinate joint research activities,
to promote the implementation of training units, and to include material on ARI control in the regular
curriculum for degree courses. 

  
  Coordination with the Programs on Essential Drugs is considered a priority activity.  All consultants
assigned to support the preparation of the national ARI plans have been sensitized to the importance of
getting these programs involved from the time that the Program is in its planning phase.  However, the
availability of essential drugs, including antibiotics, to the Program continues to be a problem in various
countries.


  For example, in countries such as Argentina, Brazil, Colombia, Mexico, and Venezuela, drug
procurement is a mechanism that is completely decentralized from the central level and left in the hands
of departments, states or provinces.  The complicating factor is that each such political unit in these
countries has its own policy and list of essential drugs, which do not necessarily undergo the same level of
control as they would under the Ministry of Health.  This situation has helped to stimulate the preparation
of state or departmental operational plans, with the essential drug sectors involved in the process, so that
drugs for ARI could be included.  In the particular case of Brazil, aside from the fact that the states are
totally decentralized from the central level of the Ministry of Health, a process of municipalization has been
underway, accompanied by the decentralization of activities to the municipal secretariats of health, which
at the same time have their own procurement policies and lists of essential drugs.  The priority in all these
cases is for Cotrimoxazole to be included in the standardized lists of essential drugs.


  In the case of Argentina, which recently adopted the WHO standards, every province selects its
antibiotic of first choice.  The province of Santa Fe has selected Ampicillin, for example.  What is
interesting is that the province has a chemical pharmaceutical supply that responds to demand.


  Other countries such as Brazil, Mexico and Venezuela, which have state chemical pharmaceutical
suppliers, respond in part to the respective demand.


  Some countries have special plans set up by the governmental authorities with special funds-
-generally derived from specific taxes on cigarettes and alcoholic beverages--for programs on special drugs;
this is the case in Colombia, Peru, and Ecuador (NEGRAME 5).


  c.Summary of the activities of the National Programs

  Annex 1 contains a summary highlighting the most important aspects of the execution of the national
ARI programs in the Region.


3.TRAINING

  a.Regional intercountry workshops and seminars

    No workshops or seminars were held during 1990.

  b.Intercountry courses on Program administration

    See Annex II.

  c.National courses and seminars

    Five national workshops or seminars on ARI control were held in Chile, Suriname, Belize, and
    Ecuador.  The principal objective was to provide training on the standards which have been updated
    in accordance with the recommendations of PAHO/WHO (see Annex III).


  d.National courses on the administration of the ARI Program

    Five national courses on the organization of the ARI Program were given in Bolivia, Brazil (Belém
    and Rio de Janeiro), Peru, and the Dominican Republic (see Annex IV).


  e.Training courses for supervisors at the central level

    During the year numerous country meetings were held, involving 2,887 participants from 5
    countries (Argentina, Brazil, Nicaragua, Mexico, and Peru).  These courses lasted for 2-
    4 days and were attended by an average of 20-40 persons per course.  In all of them, the basic
    material utilized was the module on "Management of the Child with an Acute Respiratory
    Infection."


  f.Establishment and activities of the ARI training units

    Fifteen ARI treatment training units were established in 1990, and that number increased to 20 in
    1991.  The units are located in Argentina (2), Brazil (2), Colombia (7), El Salvador (1), Nicaragua
    (1), Mexico (5) and Peru (2).  Of these, 17 have been in operation during the year, and 3 (2 in Peru
    and 1 in Argentina) will begin systematic execution of training activities in 1992.  These units are
    not uniform in terms of structure and function; on the contrary, each has its own characteristics that
    reflect the operational circumstances of its location.  What they do have in common is their
    utilization of the standards, their teaching of the clinical module for case management, and the
    priority they give to practical training in the clinical management of ARI cases (see Annex VI).

    The units in operation carried out 78 training activities, averaging 4-5 days in duration, in which
    843 technicians were trained to work at the local health care level (see Annex VII).


  g.Collaboration with undergraduate and graduate schools of sciences for teaching on ARI

    Support was provided to hold CDD/ARI workshops for representatives from pediatrics departments
    and schools of medicine, and educators from schools of nursing.  In March, there was a CDD/ARI
    workshop in Paramaribo, Suriname; in April, there was one in Ciudad Juárez, Mexico, with the
    participation of representatives from the border states of the United States and Mexico; in April,
    a CDD/ARI workshop was held in Montego Bay, Jamaica, for representatives from the countries
    of the English-speaking Caribbean; and in July, there was a CDD/ARI teaching workshop in Buenos
    Aires, Argentina.  Support was provided to pediatrics departments in various countries (Argentina,
    Colombia, Mexico, Peru, Uruguay, and Venezuela) so that they could introduce aspects of ARI
    control into their regular departmental curriculum. 

    Contacts were made with ASCOFAME (Latin American Advisory Services for Schools of
    Medicine) and ALAPE (the Latin American Association of Pediatrics, an association of all the
    national pediatrics societies) in order to strengthen contacts with practicing pediatricians and
    educators regarding the dissemination and incorporation of WHO's proposed standards for the
    diagnosis and treatment of ARI. 

    In this particular case, the large numbers of physicians in general and pediatricians in particular who
    are active in the first-level health care network in education and referral, and their resultant great
    importance to ARI case management in the Region, has intensified participation in national and
    Regional congresses and forums for the dissemination of ARI standards.  The Regional Adviser or
    consultants have taken part in the following events:


    ·  The Pediatric Symposium of Uruguay, held in Tacuarembo, Uruguay, in May 1991; attended
       by Dr. Antonio José Alves de Cunha, STC/BRA. 

    ·  The Brazilian Congress on Pediatric Pneumology, held in Campinhas, SØo Paulo, in May;
       attended by Dr. Gustavo Aristizabal Duque, STC/Colombia.

    ·  The Argentinean Congress on Pediatrics, covering topics from Rio Hondo, Santiago del Estero,
       in May; attended by Dr. Yehuda Benguigui, PAHO.

    ·  The Colombian Congress on Pediatric Pneumology, held in Medellín, Colombia, in June 1991;
       attended by Dr. Herminio Hernández, STC/Peru.

    ·  The Subregional Meeting on Maternal and Child Health in the Andean Area, in August;
       attended by Dr. Eduardo Zegarra, STC/BOL.

    ·  The International Course of Honduras, held in Tegucigalpa, Honduras, in September; attended
       by Dr. Gerardo Cabrera Meza, STC/GUT.

    ·  The Latin American Congress on Pediatrics, held in Asunción, Paraguay, in October; attended
       by Dr. Yehuda Benguigui, PAHO.

    ·  The Brazilian Congress on Pediatrics, held in Porto Alegre, Rio Grande do Sul, Brasil, in
       October 1991; attended by Dr. Yehuda Benguigui, PAHO.

    ·  Colombian Congress on Pediatrics, held in Cali, Colombia, in November; attended by Dr.
       Yehuda Benguigui, PAHO.

  At all these events, control of acute respiratory infections was an official topic. 

  h.Production of educational material:

    The modules for the ARI Program Managers' Training Course, which were translated into Spanish
    and Portuguese last year, were corrected, revised, and reprinted during 1991, to meet the demand
    generated by the national courses.  

    The modules for the Supervisory Skills Course, especially the module on "Management of the Child
    with an Acute Respiratory Infection," were revised in accordance with the new corrections made
    by the Global Program, and reprinted in Spanish and Portuguese.  In February 1992, they will be
    available as part of the PALTEX series for wide distribution in conjunction with schools of
    medicine and nursing.  The module for the Clinical Course Instructor has also been translated into
    Spanish and Portuguese. 

    The charts "Treatment of the Child with Cough or Difficult Breathing" and "Treatment of the Child
    with an Ear Problem or Sore Throat" were revised and reprinted in Spanish and Portuguese. 

    The module on "Management of the Child with an Acute Respiratory Infection" and the contents
    of the clinical charts have been translated into Dutch and are in the process of being printed for use
    in Suriname (see Annex VIII).

  i.Dissemination of ARI material from WHO

    One of the important activities of the Regional Program has been the production and dissemination
    of technical material.  The translation, adaptation, and publication of WHO technical materials are
    given priority when these materials are considered to be a fundamental support for the training
    process. 

    Various countries have adopted and published the module on "Care of the Child with an Acute
    Respiratory Infection" and the clinical charts; they include Argentina, Chile, Colombia, Mexico,
    Paraguay, and Peru.


  At the Regional level, the following materials have been prepared and distributed (see Annex IX):


  · "ARI News" in Spanish ("Noticias sobre IRA"), Nos. 16-17, June 1991.  40,000 copies were
    printed, of which 8,000 were distributed in Central America by INCAP.  Nos. 17-18 have already
    gone to press, for publication in December 1991.

  · PALTEX No. 15 from the series for mid-level technicians and auxiliary personnel. "Tratamiento
    del niño con infeccion respiratoria aguda" ["Treatment of the Child with an Acute Respiratory
    Infection"] will be replaced by the module "Atención del niño con IRA ["Management of the Child
    with an Acute Respiratory Infection."]  There will be an initial printing of 7,000 copies, which are
    expected to be distributed in December 1991 and January 1992. 

  · PALTEX No. 17 from the series for health program directors.  "Infecciones Respiratorias Agudas:
    Guía para la planificación, ejecución y evaluación de las actividades de control dentro de la atención
    primaria de salud" ["Acute Respiratory Infections:  A Guide for the planning, execution, and
    evaluation of control measures as part of primary health care"] will be replaced by the document
    "Infecciones Respiratorias Agudas, en las Américas: Magnitud, tendencia y avances en el control"
    ["Acute Respiratory Infections in the Americas:  Magnitude, trends, and advances in control"]. 
    3,000 copies will be printed, with distribution planned for the first four-month period of 1992. 

  · The charts "Atención del Niño con Tos o Dificultad para Respirar" ["Management of the Child with
    Cough or Difficult Breathing"] and "Atención del Niño con Problemas de Oído y Garganta"
    ["Management of the Child with an Ear Problem or Sore Throat"].  The English version is being
    promoted in the Caribbean.  1,000 copies have been printed in Spanish and Portuguese and are being
    used as models for reproduction at the level of the countries of Latin America.

  · The document "Plan de Acción para la Instrumentación de Programas de Control de las IRA -
     Componente IRA del Comité de Coordinación Interagencial," ["Plan of Action for the
    Implementation of ARI Control Programs - the ARI Component of the Interagency Coordinating
    Committee on Maternal and Child Health"].  2,000 copies were published in a joint effort by
    PAHO/WHO, UNICEF, and AID.

  · Various WHO technical documents, which were translated, adapted, printed, and distributed,
    especially those related to the updated PAHO/WHO guidelines for the classification and treatment
    of ARI.  The English originals were disseminated in the countries of the English-speaking
    Caribbean. 

  · "Los antibióticos en el tratamiento de las infecciones respiratorias agudas en niños menores de 5
    años," ["Antibiotics in the treatment of acute respiratory infections in children under the age of 5
    years"], PNSP/91-01.

  · "Perfil nacional del Programa de Control de las infecciones respiratorias agudas," ["National Profile
    of the Program for the Control of Acute Respiratory Infections"], HPM/ARI/03/91.

  · "Medidas de resultados en estudios prospectivos de la Diarrea e Infecciones Respiratorias de la
    niñez - como seleccionarlas y usarlas," ["Measurements of Results in Prospective Studies of
    Diarrhea and Respiratory Infections in Children - how to select and use them"], PNSP/91-03.

  · "Vigilancia de la resistencia de streptococcus pneumoniae y Haemophilus influenzae a los Agentes
    Antimicrobianos," ["Surveillance of Antimicrobial Resistance of Streptococcus pneumoniae and
    Haemophilus influenzae"], HPM/ARI/06-91.

  · Report of the Sixth Meeting of the Technical Advisory Group on ARI (HPM/ARI/07/91).

  · "Guía del Instructor Clínico de IRA" [Guidelines for the ARI Clinical Instructor] (PNSP/90-
    02(S) Vol.VI.

  · "Guía del Instructor Clínico de IRA" (PNSP/90-02(P) Vol.VI.

  · "Infecciones Respiratorias Agudas IRA" [Acute Respiratory Infections, ARI"] (WHO/ARI/90.17).

  · "Informe del Programa IRA de la OMS" ["Report of the WHO ARI Program"] (HPM/ARI/08/91).

  · "Bases técnicas para el manejo de casos de neumonía en niños en el primer nivel de atención de
    acuerdo a las recomendaciones de la OMS," ["Technical bases for case management of pneumonias
    in children at first-level health facilities according to the recommendations of WHO"]
    (HPM/ARI/09-91)


  j.Consultant/staff visits for training

    In order to attend 13 training events held at the country level during the year, consultants made 19
    trips.  These events ranged from CDD/ARI workshops with pediatrics educators (4); national
    courses on case management (3); national courses on the organization of the Program (3); and
    technical support for the national ATUs (2) (see Annex X).


  k.Other activities

    The Interagency Coordinating Committee on the ARI component was formed, through an agreement
    by PAHO/WHO, UNICEF, and AID.  The three organizations will be promoting establishment of
    the ICC/Maternal and Child Health at the country level, including activities under the specific
    heading of the ARI component. 

    In conjunction with the government of Holland, arrangements are being made to free up sufficient
    reserves to continue publication of the International Bulletin "Noticias sobre IRA;" 40,000 issues
    would be printed on a twice-yearly basis. 

    Ties are being maintained with AHRTAG, in London, England, for preparation of the regional
    publication of "ARI News" in English.  Close technical collaboration continues with the Emilio
    Coni National Institute of Epidemiology in Santa Fe, Argentina, for implementation of the Regional
    data bank on ARI epidemiology, as well as follow-up on the contributions of regional, subregional,
    and national courses on the organization of the ARI Program.

    In conjunction with ALAPE, orientation is being provided on the role of the ARI component in the
    scientific and technical activities, forums, and research monitored by that association, as well as on
    including ARI as a topic at all the conventions programmed for the future.


4.COMMUNICATION

  Ethnographic studies and surveys of knowledge, attitudes, and practices in the Region are being carried
out in the Region directly through the Global Program, with the participation of health establishments and
national technical institutes in Mexico, Bolivia, and Brazil.  In the case of Bolivia, UNICEF is taking part,
and there is also a contract with the Johns Hopkins School of Medicine.  We believe that the results can be
useful in the future to the countries where these studies are being carried out, and that the modules (and
findings) will be helpful to other countries as well.  In this particular case, we are recommending more
extensive Regional participation in these activities, which would include obtaining advance knowledge of
the type of work to be carried out, as well as keeping tabs on the results of the activities or visits completed. 


  The production of communications materials by the countries can be seen in Annex VIII.


  In view of the fact that most of the countries in the Region are still carrying out phases 1 and 2 of their
ARI control activities, the development and production of training materials has not been given high
priority.  We believe that during the next two years this is an activity that will merit special attention and
probably receive good support, given that UNICEF has demonstrated that it is going to be more actively
promoting the ARI program in the Region.


5.MONITORING, EVALUATION, AND SURVEILLANCE

  a.Administration of the information system for collecting information on the programs.

    The countries have responded well in completing their forms for the National Profile of the ARI
    Program, although in some cases the information has been of poor quality and the answers delayed. 

    The forms covered the following aspects: 

  · The scientific, technical, and operational quality of the standards (this last essentially having to do
    with the possibility of implementation at the local level). 

  · The extent of dissemination and the training of health personnel to apply the standards.

  · Mechanisms for the supervision of health personnel (it is a good idea to include the possibility of
    carrying out indirect supervision at the regional or central level, given that not all countries have
    sufficient resources for direct supervision).

  · The existence of a plan for phased implementation of the control measures by region, in accordance
    with previously established priorities.

  · Sectoral and intersectoral coordination in the Program; the sectors that participate (public, private,
    social welfare).

  · The organization of an effective system for case referral to the different levels of complexity based
    on the severity of symptoms.

  · The existence of an organized system for anticipating supply needs in the health services that help
    to provide care for children with ARI.

  · The organization of supervision and evaluation of the Program activities.

  · The existence of an information system that makes it possible to supervise and evaluate progress
    in the Program.

  The responses to the survey covering 1991 can be important to gaining a more complete picture of the
status of the national programs.

  In addition, the data base has been consolidated at the Regional level with the support of the National
Institute of Epidemiology in Santa Fe, Argentina.  The first product has been the publication "IRA en las
Américas" ["ARI in the Americas"] which provides a broad analytical perspective on the status of ARI in
the Region, in the subregions, and in each country.


  b.Evaluation, efforts, and results

    In view of the fact that most of the countries have only recently prepared their operational plans and
    begun to carry out activities in their health services based on the updated WHO recommendations,
    it is too soon to present any reliable findings on the program's impact.  We believe that for the 1992-
    1993 biennium, especially after technical instruments that address this area have been developed
    and made available, this could be one of the priority tasks to be pursued in the Region.

    The two countries chosen for more careful monitoring and impact assessment
--Colombia and Nicaragua--have faced operational difficulties that have made these activities impossible. 
(Colombia has undergone a year of successive changes in government accompanied by adjustments in the
technical team, while Nicaragua has experienced delays in its implementation of the Program, which draws
upon the ARI Project supported by FINNIDA through WHO).

    However, some examples of positive results can be seen in the evaluations carried out in Chile and
    the province of Santa Fe, Argentina (see item d).


  c.Consultant/staff visits for purposes of evaluation

    The following visits were made for the purpose of evaluating ARI control activities: 

    ·  Valparaiso, Chile; participation in the Seminar for Evaluation of the National ARI Program, in
       April 1991.  Dr. Yehuda Benguigui, PAHO, and Dr. Alberto Marches, STC/ARG, attended.

    ·  Santa Fe, Argentina; participation in the Workshop for Evaluation of the ARI Program in the
       Province of Santa Fe, in December.  Dr. Yehuda Benguigui, PAHO, and Dr. Jaqueline Hargons,
       STC/Chile, attended.


  d.Examples of the Program's achievements

    In the Province of Santa Fe, Argentina, the ARI Control Program was first carried out in Health
    Region V of the province, which has a population of 580,000. 

    Although the indicators place this among the high priority areas for implementation of the ARI
    Program (the infant mortality rate is 8.5/1000 live births), we feel that it is a good example because
    its activities have been very systematically implemented in accordance with the proposed
    guidelines, and both the process and some aspects of its operation have shown promising results
    (Annex XI-1).

    Medical notes dating from the time of the Program's inception were examined to find the proportion
    of consultations for ARI in which treatment was not specified.  They showed that in January 1991,
    when activities began, the proportion was 83.5%; while as a result of training, supervision, and
    systematic monitoring, in October 1991, only 21.4% of the notes failed to record the treatment
    administered for cases of ARI in children under 5 (Annex XI-2).

    When the Program began, the proportion of consultations for ARI in which the cases were treated
    with antibiotics was 51.6% of the total cases--in January 1991--while in the last month evaluated-
    -October 1991--that figure had already dropped to 39.3% (see Annex XI-3).

    In the specific case of the Sayago Hospital, antibiotic prescriptions for ARI cases dropped from
    64.9% in March 1991 to 27.3% in October 1991 (see Annex XI-4).

    It was also possible to analyze the cost of antibiotic treatment per case of ARI served in relation to
    the proposed target of reducing antibiotic use to a maximum of 30% of ARI cases.  In the same
    health districts, those health establishments reaching the target were compared with those in which
    antibiotic treatment continued to be used in more than 30% of ARI cases.  One example shows the
    cost of treatment in the centers that reached the target as being 10% of the cost in health centers that
    treated more than 30% of cases of ARI with antibiotics (see Annex XI-5).


6.PROSPECTS FOR WORK DURING THE COMING YEAR

  Looking toward 1992, the prospects are good for keeping up momentum in the Program and reorienting
it toward the execution of activities at the operational level, the revision of standards, the improvement of
training (training units), the preparation of national operational plans, and the establishment of effective
interagency coordination through the ICCs that will be set up in the countries.

  The plan is to place greater emphasis on the execution of ARI control activities at the level of the health
services by doing the following: 

  · Consolidating the updated PAHO/WHO guidelines for the diagnosis and treatment of ARI in all
    the countries of the Region.

  · Providing advisory services in the preparation of national operational plans for ARI control,
    including all components, such as training, monitoring, supervision, and the supply of inputs and
    drugs, all in the context of Comprehensive Child Health Care. 

  · Supporting the national courses given on the Organization of the ARI Program; and, at the
    departmental (or state or provincial) level, promoting the ARI supervisory skills courses. 

  · Evaluating the progress of the country programs, using the following indicators:  the number of
    health services with programmed and standardized ARI activities; the quality of the services; and
    the mortality trends per cause in children under 5.

  · Maintaining cooperation with the Regional office of UNICEF and encouraging the World office
    of UNICEF, as well as USAID, to incorporate ARI into their cooperation programs, including
    through the Interagency Coordination Committees. 

  · Promoting training activities in conjunction with educators in the pediatrics departments at schools
    of medicine and nursing; an effort will be made to carry out these activities in conjunction with
    CDD.

  · Promoting evaluation at the level of the local health services and measurement of the impact of the
    control measures.

  · Implementing training units for the treatment of acute respiratory infections in referral hospitals,
    in order to train the technical team, medical students, and nursing and auxiliary personnel.  To the
    extent possible, these units will be implemented jointly with the CDD Program.

  · Strengthening the health education and community activities in coordination with the training
    process.

  · Carrying out, in 1992-93, an evaluation of the Program's impact:  reduction in mortality from
    pneumonia, reduction in the use of antibiotics for cases of virus, and changes in the profile of
    hospital discharges for cases of ARI.




















ANNEXES






















ANNEX I


       STATUS OF ACTIVITIES FOR THE CONTROL OF ACUTE RESPIRATORY
INFECTIONS IN THE COUNTRIES OF THE AMERICAS, 1991


COUNTRY

APPOINTMENT OF NATIONAL DIRECTOR

AREA UNDER WHICH THE PROGRAM IS FOUND

NATIONAL OPERATIONAL PLAN (*)

STANDARDS FOR CASE MANAGEMENT
1ST ED.
REV. ED. (*)

FLIPCHART

TRAINING UNITS

STAFF TRAINING MODULE

SELF-INSTRUCTIONAL GUIDE FOR HEALTH CENTERS

NATIONAL COURSE ON ORG. OF ARI PROG.

INITIATION OF SUPERVISORY SKILLS COURSES

IMPLEMENTATION BEGUN
    **
ARG --   YES  NO   YESYES  --   YES     YES  YES
BAH --   NO   NO   NO NO   --   --   --   --
BLZ YES  YES  NO   NO NO   --   YES     YES  YES
BOL YES  YES  YES  YESYES  YES  YES     --   --
BRA YES  YES  NO   YESYES  YES  YES     YES  YES       
CHI YES  YES  YES  NO YES  YES  YES     YES  YES
COL YES  YES  YES  YESYES  --   YES     YES  YES
COR --   NO   NO   YESNO   --   --   --   YES
CUB --   NO   NO   NO --   --   --   --   --
DOR YES  YES  NO   NO --   YES  YES     YES  YES
ECU YES  YES  YES  NO YES  --   YES     YES  YES
ELS YES  YES  NO   YESYES  --   --   --   --
GUT YES  NO   YES  NO YES  YES  --   --   YES
HAI --   NO   NO   NO NO   --   --   --   --
HON YES  YES  YES  NO YES  --   --   --   YES
JAM --   --   NO   NO NO   --   --   YES  --
MEX YES  YES  YES  YESYES  YES  YES     YES  YES
NIC YES  YES  NO   YESYES  --   YES     YES  YES
PAN YES  YES  YES  NO YES  YES  --   --   YES
PAR YES  YES  YES  NO YES  YES  YES     YES  YES
PER --   YES  YES  YESYES  YES  YES     YES  YES
SAL --   --   --   NO NO   --   --   --   --
SAV --   NO   NO   NO NO   --   --   --   --
SUR --   NO   NO   NO NO   --   --   --   --
URU YES  YES  NO   NO NO   YES  YES     YES  YES
VEN YES  YES  YES  NO NO   --   YES     YES  YES
VIB --   --   --   -- NO   --   --   --   --

* In accordance with the updated PAHO/WHO guidelines.

**Provincial operational plans.
ANNEX II

SUBREGIONAL OR INTERCOUNTRY WORKSHOP
ON THE CONTROL OF ARI, 1991

PLACE                   MONTH        NO.               NO.
COUNTRIES   PARTICIPANTS

CIUDAD JUAREZ, MEXICO APRIL (A) 2         32

MONTEGO BAY, JAMAICA    MAY (B)    8         28


A.Workshop with educators from the border states of Mexico and the United States, organized by the El
  Paso Office, El Paso, Texas.

B.Workshop on CDD/ARI with representatives of educational institutions and Ministries of Health in the
  countries of the English-speaking Caribbean.
ANNEX III

NATIONAL WORKSHOPS OR SEMINARS, 1991


PLACE                   MONTH           NO.
PARTICIPANTS

VALPARAISO, CHILE (A) JANUARY      34

PARAMARIBO, SURINAME (B)MARCH        26

BELIZE CITY, BELIZE (C)MARCH         28

QUITO, ECUADOR (D)    NOVEMBER       30

GUAYAQUIL, ECUADOR (D)  NOVEMBER        32


A.National seminar with the participation of representatives from 15 provinces in the country, to respond
  to the updated guidelines on ARI control. 

B.CDD/ARI seminar with central- and mid-level health personnel, representatives of educational
  institutions, and some local-level personnel.

C.Workshop with physicians and nurses from local-level health services.

D.National seminars on the standards for case management as well as operational concerns for mid-
  level personnel from the country's various departments.
ANNEX IV

NATIONAL ARI PROGRAM MANAGERS COURSES, 1991


PLACE                      MONTH        NO.                    NO.
PARTICIPANTS      PROVINCES
(A)

COCHABAMBA, BOLIVIA (B)    JULY      36           15

RIO DE JANEIRO, BRAZIL (C)AUGUST     28            7

BELEM, BRAZIL (D)       SEPTEMBER    32            9

LIMA, PERU (E)          NOVEMBER     34           18

SANTO DOMINGO, DOM. REP. (E)NOVEMBER 37           12


A.States or departments.

B.Course on the organization of the ARI Program carried out at the same time as other activities related
  to child health.

C.Course on the organization of the ARI Program for the southern and southeastern states of Brazil.

D.Same course for the northern and western central states of Brazil.

E.National course on the ARI Program.


NOTE:The courses given in Rio de Janeiro, Lima, and Santo Domingo were preceded by training for the
    national facilitators.
ANNEX V

ARI TRAINING COURSES FOR MID-LEVEL SUPERVISORS
HELD IN 1991

COUNTRY            NO. PARTICIPANTS  COMMENTS

ARGENTINA (A)         1,115        3-DAY COURSE

BRAZIL (B)              792        2-DAY COURSE

NICARAGUA (C)           120        3-DAY COURSE

MEXICO (D)              680        4-DAY COURSE

PERU (E)                180        3-DAY COURSE


A.Training courses given in the provinces of Neuque, Córdoba, Salta, Jujuy, S. Luis, and Entre Ríos.

B.Courses given in the states of Rio Grande do Sul and Brasilia, Distrito Federal.

C.Training carried out in the areas provided for under the ARI project financed by FINNIDA.

D.Training carried out in the 5 states that serve as headquarters for the regional training centers.

E.Courses given in the priority areas for Program implementation.
ANNEX VI

ARI TREATMENT TRAINING UNITS, 1991


COUNTRY       NO. OF UNITS COMMENTS

ARGENTINA       2       SANTA FE AND BUENOS AIRES

BRAZIL          2       BELEM, PARA, AND PORTO ALEGRE,
RIO GRANDE DO SUL

COLOMBIA           7       BOGOTA (2), ARMENIA, BUCARAGAMANGA
MEDELLIN, MANIZALES, AND CARTAGENA

EL SALVADOR        1       B. BLOOM HOSPITAL, SAN SALVADOR

NICARAGUA       1       LEON

MEXICO          5       MEXICO CITY, TABASCO, CHIHUAHUA,
GUANAJUATO, AND ZACATECAS

PERU            2       LIMA (INSTITUTO NACIONAL DEL NI‘O
AND CAYETANO HEREDIA HOSPITAL)


  TOTAL           20
ANNEX VII

TRAINING IN ATUS, 1991


COUNTRY       NO. OF UNITS NO. OF TRAINING   NO. OF
EVENTS            PARTICIPANTS

ARGENTINA      2            8              84

BRAZIL         2           14             147

COLOMBIA         7            22             231

EL SALVADOR      1             6              56

NICARAGUA      1           (A)          (A)

MEXICO         5           28             325

PERU           2           (B)          (B)


  TOTAL         20            78             843



A.Information unavailable.

B.The units will become operative in 1992.
ANNEX VIII

PRODUCTION OF LOCAL TRAINING MATERIALS, 1991


TYPE OF MATERIAL                PLACE

POSTERS ON CHILD CARE           BOLIVIA, COLOMBIA, MEXICO,
(FOR MOTHERS)                 PARAGUAY, CHILE, AND PERU

SLIDES ON TREATMENT             COLOMBIA, CHILE, AND MEXICO

VIDEO ON TREATMENT AND HOME CARE   CHILE, BOLIVIA, PERU, AND MEXICO

INSTRUCTION PAMPHLETS FOR MOTHERS  BOLIVIA, COLOMBIA, MEXICO,
AND THE COMMUNITY                  ARGENTINA, CHILE, AND PERU

NATIONAL REPRODUCTION AND       ARGENTINA, CHILE, COLOMBIA,
ADAPTATION OF WHO TRAINING MODULESMEXICO, PARAGUAY, AND SURINAME

ANNEX IX

DISSEMINATION OF WHO/ARI MATERIALS, 1991


ANNEX X

CONSULTANT/STAFF VISITS FOR TRAINING PURPOSES


PLACE                   MONTH      STAFF  CONSULTANT   TOTAL

VALPARAISO, CHILE (B) JANUARY   -     2        2

PARAMARIBO, SURINAME (A)MARCH     1      -          1

BELIZE CITY, BELIZE (B)MARCH      -      1          1

CIUDAD JUAREZ, MEXICO (A)APRIL  -     1        1

MONTEGO BAY, JAMAICA (A)MAY     -     2        2

TACUAREMBO, URUGUAY (B) MAY       -      1          1

COCHABAMBA, BOLIVIA (C) JULY      -      3          3

BUENOS AIRES, ARGENTINA
(A)                JULY      -      1       1

TEGUCIGALPA, HONDURAS (B)SEPT.    -      1          1

LIMA, PERU (C)        NOV.      1     1        2

SANTO DOMINGO, DOM. REP.
(C)                NOV.      -      2       2

MEDELLIN, COLOMBIA (D)  NOV.      -      1          1

TABASCO, GUANAJUATO,
MEXICO (D)            NOV.      -     1        1


TOTAL                             2     17         19



A.CDD/ARI workshop with school of pediatrics.

B.National course on ARI case management, using the clinical module.

C.National ARI Program Manager's Course.

D.Support for the training activities of the national ATUs.
ANNEX XI-1


5TH HEALTH DISTRICT, SANTA FE PROVINCE, ARGENTINA






ILLITERACY
ANNEX XI-2

PROPORTION OF CONSULTATIONS FOR ARI IN
       WHICH TREATMENT WAS NOT SPECIFIED.  5TH HEALTH DISTRICT.
JANUARY-OCTOBER 1991

PERCENTAGE


















JAN FEB  MAR  APR  MAY  JUNJUL  AUG     SEPT OCT
ANNEX XI-3

PROPORTION OF CONSULTATIONS FOR ARI TREATED WITH
ANTIBIOTICS.  5TH HEALTH DISTRICT.
JANUARY-OCTOBER 1991.


PERCENTAGE


















JAN FEB  MAR  APR  MAY  JUNJUL  AUG     SEPT OCT
ANNEX XI-4


PROPORTION OF CONSULTATIONS FOR ARI TREATED WITH
ANTIBIOTICS.  SAYAGO HOSPITAL.
JANUARY-OCTOBER 1991.


PERCENTAGE


















JAN FEB  MAR  APR  MAY  JUNJUL  AUG     SEPT OCT
ANNEX XI-5

COST OF ANTIBIOTICS PER ARI CASE SERVED IN
THE HEALTH SERVICES, IN TERMS OF
FULFILLMENT OF THE PROPOSED TARGET.


COST IN DOLLARS


       HEALTH CENTERS WITH <30% ANTIBIOTIC USE

       HEALTH CENTERS WITH >30% ANTIBIOTIC USE









TOTAL  ITURR. PSYCHIAT. PROTOM. CHILDREN'SSANTO     SAYAGO
TOME

 
FEPPEN
PAN AMERICAN FEDERATION OF NURSING PROFESSIONALS

DECLARATION OF CARTAGENA, 1991

     The I Iberian-American Meeting and VIII Pan American Congress
of Nursing, held from 4 to 7 June 1991 in Cartagena (Colombia),
hereby declare the following:

1.   The member countries of FEPPEN and the Consejo General de
     Colegios de Diplomáticos en Enfermería of Spain resolve and
     agree to establish mechanisms for ongoing cooperation and
     assistance to promote the development of the nursing
     profession.

2.   We agree to work together to strengthen professional nursing
     associations at the international level and in our respective
     countries.

3.   The organizations entering into this agreement will undertake
     periodic evaluations of national and international experiences
     in the political, social and economic domains, placing
     particular emphasis on health, with a view to contributing to
     the improvement of living and working conditions for our
     peoples.

4.   We will endeavor to promote national, subregional, and
     international events aimed at advancing conceptual and
     practical studies that will provide orientation for the
     development of comprehensive health care models, as a means
     of participating in the formulation of health policies for our
     peoples.

5.   We agree to collaborate in the development of scientific
     research and techniques in a variety of health-related areas
     as means of contributing to the orientation and participation
     of our colleagues in efforts to enhance the quality of their
     activities undertaken in the name of public health and social
     security institutions in our respective nations.

6.   We will promote the granting of loans and assistance through
     direct advisory services, technical or expert missions,
     individuals, and financial cooperation, all with a view to
     strengthening our professional associations, increasing the
     prestige of the profession, enhancing our knowledge,
     protecting our rights, and enabling us to work more
     effectively to improve the health of our peoples.



     Cartagena, 7 June 1991



LINES OF RESEARCH

1.   NURSING LEADERSHIP:

     In order for Latin American nursing to participate in the
     implementation of health policy in the Region there must be
     a critical analysis of the role that the profession has
     historically played in the following areas:  decision-making,
     policy implementation, and efforts aimed at modifying health
     conditions in the communities while addressing the limitations
     and utilizing the advantages of our social responsibility as
     a profession.

     We consider it important to expand the term "leadership" to
     encompass a broader interpretation that includes participation
     by the profession in the economic, political, and social
     sectors.

     SUBTOPICS:

     Political participation of nursing professionals at the
     national decision-making level.

     - Recognition by society
     - At the decision-making level
     - At the operational level

2.   BIOLOGICAL AND/OR SOCIAL MODELS OF NURSING CARE 

     Methodological proposals for the implementation of local
     health systems:

     It is important to bear in mind that the formulation of
     governmental policy in regard to health care and health
     maintenance is not an exclusively technical activity, nor does
     it imply competition between individual professionals who
     specialize in the area of public health.
     
     It is political, social, and economic reality that determines
     health conditions in the countries of the Region.  Thus, in
     the process of health policy formulation it is essential to
     take into account the context in which health problems occur. 
     This involves:
     
     - Evaluating the effectiveness of health policies in the
     context of the new local health system model, looking
     especially at the operational level and its capacity to solve
     the problems it is called on to address, as well as any
     negative reactions that have been identified since the policy
     was announced.
     
     - Examining the relationship between health policy--especially
     in terms of its conceptual structure--and prevailing medical
     practice so as to identify contradictions and obstacles, as
     well as areas of agreement, with a view to effectively
     implementing the policy. 
     
     - Studying the evolution of health policy at the country level
     in order to better understand the social dynamics,
     effectiveness, and efficiency in each country.

     - Gaining an increased understanding of the internal
     determinants that lead to the adoption of health policies that
     are oriented toward local health systems.  At the political,
     economic, and social level there is a tendency among decision-
     makers, when it comes to justifying their decisions, to adhere
     strictly to technical and administrative criteria, although
     there may be strong pressures of other kinds.  In order to
     complete the analysis of decision-making processes, this
     dynamic must also be studied at the regional and local level
     within the countries. 

     It is essential that research related to health and community
     participation look more closely at the processes that lead to
     changes in governmental policy.  Growing importance is being
     attached to the strategic role of the community in the
     solution of its own health problems, and there is increased
     understanding of the need to promote this commitment through
     programs that emphasize self-management and self-reliance at
     the community level.  It is necessary to objectively study the
     capacity of communities to articulate the proposed models and
     thereby generate proposals that will bring about changes in
     their complex realities in terms of health, disease, and
     death.  In order to accomplish this, it will be necessary to:

     - Establish a conceptual framework that takes into account
     community participation and the implementation strategies
     generated at the institutional and/or community level, whether
     formal or informal in nature. 

     - Carry out studies at the national, regional and/or local
     level with a view to gaining a better understanding of the
     significance of health problems for the various communities,
     taking into account the economic, social, and resulting
     cultural diversity that exists between and within the
     countries of Latin America.

     The lines of research should seek to encourage community
     participation through the promotion of joint efforts and
     better understanding by both technical personnel and the
     community of the complexities inherent in the phenomena of
     health and disease.

     There should also be research into phenomena such as the
     relationship between violence and health problems in a given
     population. 


     SUBTOPICS:

     - Profile of the nurse's role in the interdisciplinary team
     
     - Interdisciplinary integration
     
     - Community participation
     
     - Functional integration



3.   RELATIONSHIP BETWEEN WORK AND HEALTH:

     An analysis of the work that health professionals do in the
     broader context of the social history of the sciences and
     professions will help them to appreciate the historical
     development of the health professions and also to enlist their
     technical capacity so that their work will have an impact on
     health.  It is important to bear in mind that their
     occupational risk factors involve aspects related to the
     workplace (macro and micro) which should be analyzed from the
     perspective of health care workers not as the providers of
     care but as the recipients thereof.

     SUBTOPICS:
     
     - Conceptual aspects of the relationship between work and
       health
     
     - International regulations (ILO)
     
     - National regulations
     
     - Identification of occupational risk factors
     
     a) General risk factors
     
     b) Specific risk factors for health care workers
        Role of nursing in occupational health

4.   REGULATION OF NURSING:  ETHICAL AND LEGAL ASPECTS

     In the framework of the biological sciences, the field of
     bioethics deals with a broad range of issues, from problems
     related to values that arise in all the health professions to
     regulation, liberal interpretation, and the philosophical and
     moral framework of those who are responsible for decisions
     relating to health, life, and death.

     Over the last few decades of this century there has been a
     shift in the relationship between patients and the health
     team.  The patient now approaches the relationship with
     autonomy, while the health team is concerned with the
     principle of justice and what will benefit society.  The
     health professional should study ways of articulating these
     two approaches.  

     At the same time, it is important to consider the issues of
     macroethics and examine the right of peoples to health.

     SUBTOPICS;
     
     - Equity
     
     - Regulation in nursing
     
     - Liberal interpretation
     
     - Right of peoples to health



5.   NEW APPROACH TO THE FORMATION OF HUMAN RESOURCES IN NURSING

     Research on health manpower should be approached from the
     standpoint of labor relations in the context of the political
     and social factors that affect the professions.

     This will facilitate an understanding of the historical
     processes underlying the implementation of health policies by
     the countries, which in turn will enable the nursing
     profession to act on and through these policies and thus
     participate actively as a profession in the policies of the
     country.  Efforts in this regard should include:

     -Discussing once again, at the academic as well as political
     and administrative level, the relationship between health
     professionals and the socioeconomic, political, and cultural
     structure in which they work, and what their role is, or
     should be, in this context.

     -Redefining the interaction between the university--as the
     developer of human resources and producer of knowledge--and
     the State in response to the health-disease problem in the
     population.  This may entail the establishment of relations
     that involve the provision of critical advisory services and
     the discussion and implementation of decisions.

     -Developing a critical approach to the analysis of models for
     health manpower development, taking into account the role that
     health professionals are called on to play in the community,
     the relationship between theory and practice in the process
     of manpower development, the overall concept of health-
     disease as a historical process and a sociocultural reality,
     and the role of the social sciences and the connections that
     they imply.


     SUBTOPICS 

     - Prospective analysis

     - Teaching-service integration

     - Strengthening of the interdisciplinary approach in health
     care delivery

     - Retention of nursing personnel


METHODOLOGY

     - Utilization of personnel













    MATERNAL MORTALITY IN LATIN AMERICA AND THE CARIBBEAN


























César A. Chelala












CONTENTS



Introduction                                           

The Social Status of Women                             

Diagnosis of the Situation                             

Trends in Maternal Mortality                 

Risk Factors                                           

The Causes of Maternal Mortality                       

Strategies                                             

General Strategies                                     

Specific Strategies                                    

Future Outlook                                         

Bibliography                                           




    MATERNAL MORTALITY IN LATIN AMERICA AND THE CARIBBEAN

INTRODUCTION

The death of a woman from causes associated with pregnancy or
delivery is always a tragedy.  When that death could have been
prevented, the tragedy is infinitely greater.  Yet this
scenario is one that is played out with disturbing frequency
in the Region of the Americas, where at least 28,000 pregnant
women die each year (8).

To put this figure into perspective, keeping in mind the high
rates of underreporting as well as population increases, it
is as if every year a mid-sized city were to vanish from the
face of the earth.  If these figures are projected through the
year 2,000, it would be as if the city of Cartagena, Colombia,
were to be wiped out by an explosive and deadly plague. 

Given the role that mothers play not only in their own
families but also in the communities in which they live, these
deaths cast an ominous shadow over our entire society.  Their
importance, therefore, far outweighs what can be expressed in
mere numbers. 

Maternal mortality in the Americas has two fundamental
characteristics:

     -    it is preventable in a great many cases; and
     -    it occurs predominantly among certain groups of
women and social classes.

Regarding the first characteristic, it is estimated that from
90% to 95% of maternal deaths are preventable using the
knowledge and technology that is available today.  With
respect to the second, the women who are most seriously
affected are those from the lowest socioeconomic strata, those
living in rural areas far away from hospital centers, and
those who for other reasons have limited access to health
services.  Whatever strategies are used to combat this problem
will first need to take these two characteristics into
account.


THE SOCIAL STATUS OF WOMEN 

The problem of maternal mortality cannot be looked at in
isolation from the role that women play in the societies in
which they live.

The women of Latin America and the Caribbean experience
serious disadvantages in their environment, as evidenced by
their more limited access to social, job-related, and
educational opportunities in comparison with men.

Women are the victims of an uneven distribution of resources
and responsibilities, which is legitimized by customs and
ancestral traditions.  Traditionally, women have had limited
access to and control of productive resources, such as land,
while at the same time the gender-based division of labor has
allocated to them the most onerous and the worst-paid tasks. 

To these circumstances can be added the negative impact that
urbanization and industrial development have had on the status
of women.  Since the mid-1950s there has been increased
migration of the rural populations in Latin America and the
Caribbean to urban areas in their own and neighboring
countries or to the United States (7).

This rapid urbanization is taking place in a situation in
which health services are ill prepared to receive the added
influx of people, which only serves to magnify the gaps.  It
has been estimated that more than 130 million people in Latin
America and the Caribbean are without access to either rural
or urban health services. 

With regard to the impact of industrial development, a number
of modern textile industries have stopped manufacturing
homespun textiles and other handiwork, tasks at which many
women have traditionally been employed.  Women are thus forced
to compete at a disadvantage to men in industrial work, or
else to participate in the informal economy, with the often
meager rewards that it offers.  In general, women are not
proportionately represented in different types of jobs, but
rather tend to have the lower-paying ones (5,6).

It is important not to overlook the negative impact of having
to work a double shift inside and outside of the home. 
Overwork, a factor whose influence on health is generally
given little importance, is having an unquestionable effect
on women's health and well-being.  Fatigue and the attendant
physical and mental stress put women at greater risk of
becoming ill. 

In the area of formal education as well, women are at a
disadvantage in comparison with men.  Their school attendance
is conditioned by the belief, especially prevalent in rural
areas, that women's true place is in the home, where often
from an early age girls are expected to help their mothers
with the housework and the care of their younger siblings (7). 
Studies conducted in various countries show that there is an
inverse correlation between years of education of the mother
and maternal mortality.  It has been found that the more years
of schooling the mothers have had, the fewer children they
bear (23).

All these factors are important because they perpetuate
situations of inequality and discrimination, and because they
have a more or less direct impact on maternal mortality.  The
variety and complexity of these factors makes it clear that
the problem of maternal mortality is not going to be solved
by implementing medical and health programs alone.  There is
going to have to be a sustained and multifaceted campaign
against the multiple causes that give rise to this situation
of social discrimination (20).


DIAGNOSIS OF THE SITUATION 

Although maternal death rates have declined in various
countries of the Americas over the past two decades, they are
still very high in most countries of Latin America and the
Caribbean.  These rates are high not only in comparison with
the rates in industrialized countries such as the United
States and Canada but even when compared with rates in other
countries in the Region such as Costa Rica and Cuba.  It is
therefore important, from the standpoint of planning
strategies to control maternal mortality, to analyze the
reasons for the differences found between countries that have
similar levels of development.

In the Region as a whole, despite the lack of strictly
comparable figures, it can be seen that the highest rates are
as much as 120 times greater than the lowest ones.  For
example, while the maternal death rate for Canada in 1987 was
estimated at 4 deaths per 100,000 live births, the rates for
Paraguay, Peru, and Bolivia were 270, 303, and 480,
respectively.  It is interesting to note that the low maternal
death rate in Canada occurred in a country with a system of
universal coverage that gives the entire population equal
access to health services (8).

Several factors may account for these sizable differences
between the maternal death rates.  One that has been
repeatedly emphasized relates to the quality, accessibility,
and degree of coverage of prenatal services and delivery care. 
As a rule, there is a direct correlation between the
availability of adequate prenatal monitoring services and
institutional delivery with low rates of maternal mortality.

However, some of the countries in the Region, such as
Argentina, Panama, Uruguay, and Jamaica, which have a high
percentage of institutional deliveries, still show relatively
high rates of maternal mortality.  This suggests the
possibility that there are still serious deficiencies in the
quality, coverage, and timeliness of care in their health
services.

These situations highlight the need for systematic and
generalized surveillance of the quality of these services in
order to find out which factors are most important in terms
of increasing their efficiency and accessibility.  From this
perspective, maternal mortality is an important indicator of
accessibility and coverage, as well as quality of care in
these services.

The figures on maternal mortality need to be examined in the
context of the high proportion of women of reproductive age
in the total population.  It is estimated that women aged 15
to 49 currently represent 25% of the total population in the
Region's developing and industrialized countries, while the
population of both sexes aged 0 to 14 comes to 39% in the
developing countries as compared with 22% in the
industrialized countries.  As a result, taking into account
the higher fertility rates in developing countries, it is
estimated that the number of future deliveries will be much
greater in the developing countries than in the industrialized
ones in the coming years (1).

If current trends continue unchanged, this higher number of
deliveries that is expected will be reflected in a
considerable increase in maternal deaths.  However, if the
levels of preventable maternal deaths are reduced across the
board to a point where they are on a par with countries such
as Chile, Cuba, and Costa Rica, that number will decrease
markedly.  This savings in lives would have an immeasurable
impact on the demographic structure and well-being of the
population (1).


TRENDS IN MATERNAL MORTALITY

The measurement of maternal mortality in developing countries
suffers from various defects in relation to conspicuous
underreporting, which in some of the developing countries is
estimated to be more than 70% (8).

Important causes of underreporting are the shortage of
adequate systems of vital statistics and the fact that many
deaths occur outside the hospital setting, particularly in
rural areas that are located far away from urban centers.  It
is also significant that many of these deaths are from
abortion, which is illegal in most countries of the Region. 
For these reasons, the data obtained on maternal mortality are
often incomplete and of doubtful reliability.  Nevertheless,
it is estimated that maternal mortality has seen a general
decline in most countries of the Americas (1).

It is important to note that similar improvements are showing
up in countries with different levels of economic development,
which suggests that these improvements are being determined
by the quantity of resources as well as the quality of health
services and their accessibility to different social strata. 
This also highlights the need to assess which strategies are
of proven effectiveness in providing care for pregnant women,
so that they can be used in countries where such strategies
have not yet been implemented.

RISK FACTORS

Not all mothers are at equal risk of illness or death.  It is
now known that numerous occupational, environmental, and
biological factors can make some women more susceptible than
others to developing serious or fatal complications that
affect themselves or their fetus either during pregnancy or
during and after delivery.  Knowledge about these factors and
the implementation of measures to minimize or eliminate them
will be of unquestionable importance as an approach to
prevention (9,10).

One very workable approach is to group the risk factors for
the mother or fetus into four main categories (10):

- preexisting risks;
- preexisting diseases;
- risks originating during pregnancy; and
- risks originating during delivery.

Preexisting risks include extreme ages (under 18 or over 35),
parity (the first delivery and any coming after the fifth pose
the greatest risk), short intervals between pregnancies (less
than 2 years), poverty, illiteracy, poor hygiene, and
residence in marginal urban areas or rural areas with
inadequate health services.  Added to these factors are small
stature (less than 140 cm) and malnutrition or obesity in the
mother.

Preexisting diseases have a clear impact on the course of
pregnancy and delivery, with consequences that can be serious
for both mother and fetus.  These include: sexually
transmitted diseases, tuberculosis, AIDS (acquired
immunodeficiency syndrome), chronic infections, diabetes,
hypertension, and diseases of the heart and kidneys. 
Structural abnormalities in the mother and a history of
obstetric difficulties and fetal loss are also important.

Risks originating during pregnancy include anemia; diabetes;
infections; low or excessive weight gain; multiple pregnancies
or problems with fetal presentation; abuse of alcohol, drugs,
and tobacco; exposure to radiation; and occupational risks.

Risks originating during delivery include problems of fetal
presentation, septicemia, risks associated with anesthesia,
hemorrhage during labor, premature delivery and prolonged
delivery, and premature rupture of the membranes.  To these,
it is important to add postpartum risks, in particular
hemorrhage and infection.

All these risk factors call for proper prenatal care and
special care during delivery in order to reduce mortality and
morbidity in the mother and her child.  Such care does not end
with the birth, however, but extends beyond it, so that
mothers--especially those with a history of complications--
are kept under close observation during at least the first
hours after delivery to guard against the possible occurrence
of hemorrhage and infection.


THE CAUSES OF MATERNAL MORTALITY

The causes of maternal mortality are numerous and not always
strictly speaking biological in nature; rather, they are
related to a wide range of conditions.  In many cases they
have an unfortunate common denominator:  these causes strike
disproportionately high numbers of pregnant women living at
a distance from places where they can receive adequate care
and in situations of extreme poverty.  As a result, any
attempt to reduce the high maternal death rates presupposes
finding measures to control the most frequent medical causes,
in conjunction with a political commitment to distribute
resources on a more just and equitable basis.  It is also
essential to keep in mind that these medical causes are often
complicated by logistical problems related to transportation
or caused by deficiencies in the health services (9).

Although there are various ways of classifying maternal
deaths, they may be broken down into two main categories:

- direct obstetric causes; and
- indirect obstetric causes. 

An analysis of direct obstetric causes resulting from
complications of pregnancy and delivery shows that in the
developing countries the most frequent causes are induced
abortion, hemorrhage, infections, obstructed delivery, and
eclampsia, their relative importance varying from one country
to another.

Indirect obstetric causes include all the concomitant
diseases, such as anemias, malaria, hepatitis, and
tuberculosis, that can be aggravated by pregnancy and
delivery.

To these causes may be added, in the developing countries,
conditions created or aggravated by situations of extreme
poverty. In addition, in many cases pregnant women are placed
at risk by a weakened physical state and by a lack of or
insufficient prenatal care, which they resort to infrequently
or too late. 

Inadequate nutrition, intestinal parasitic diseases, various
infections, and excessive physical labor work together to
produce a high percentage of anemic and undernourished women. 
Under these conditions, pregnancies, especially when they are
frequent and closely spaced, are the cause of added physical
and psychological stress which can lead to the maternal
exhaustion syndrome.  Pregnant women in this situation who
give birth, and then, without having completely recovered, get
pregnant again, increase their possibilities of having
premature and low-birthweight children.  This creates a
vicious cycle with a marked negative impact on the health and
well-being of mothers and their children.

Of all the causes of maternal death, induced abortion, which
is illegal in most countries of Latin America and the
Caribbean, is the one that is most widely underreported.  It
is precisely because it is illegal that, especially in the
case of women of limited means, abortion ends up being
performed either by the patients themselves or else by
inexperienced persons, in many cases without the appropriate
asepsis.

Induced abortion, which is largely used as a method of
fertility regulation, is on the increase in many Latin
American countries, despite serious legal, social, and
religious restrictions.  Induced abortion is assumed to be one
of the leading causes of death in women between the ages of
15 and 49 in Latin America (8,9).

Although the real figures are unknown, it is estimated that
in Mexico at least 800,000 procedures are performed annually;
in Colombia that number is 280,000; and in Argentina one out
of every four pregnancies ends in abortion (6).  It is
estimated that in Latin America as a whole about 5,000,000
abortions are performed each year, suggesting that there are
around 500 abortions to every 1,000 live births (11).  Induced
abortion is currently one of the most serious and destructive
problems facing the Region (12).

The risks associated with induced abortion depend on a number
of variables, including the following: 

-    the method used;
-    the technical competence of the person performing the
     abortion;
-    the stage of pregnancy when it is performed; 
-    the age and health status of the pregnant woman; and
-    the availability and quality of medical care.

When abortions are performed at inappropriate times and under
inadequate conditions--especially during advanced stages of
pregnancy--the incidence of complications is very high.  Of
these, the most common are pelvic infections and hemorrhage,
which are important causes of mortality.  Other commonly
occurring complications are trauma of the pelvic organs,
uterine perforations, and injury to the bladder and
intestines.

In addition to the above complications, it is important to
mention those originating from specific methods used to induce
abortion.  These methods range from the introduction of
chemical substances into the cervix, which produce burns and
hemorrhage, to the ingestion of toxic substances that injure
the fetus and the mother, sometimes without ending in
abortion.

The true figures for mortality from abortion are unknown,
since many cases occur outside the hospital setting; however,
it is estimated that there may be as many as 1,000 deaths for
every 100,000 procedures carried out.  In some cases mortality
from abortion may be responsible for up to half of all
maternal deaths (8,11).

A study carried out in Chile showed that induced abortions and
their complications decreased when the coverage and quality
of family planning programs improved (11).  If this
observation were to be repeated in other countries, it would
highlight the usefulness of one of the most obvious preventive
measures for resolving this serious problem.

In addition to the physical and psychological consequences of
abortion for the pregnant women themselves, there is the
sizable drain on the resources of the health services, which
are forced to deal with the complications that commonly
result.  It is estimated that in Latin America from 10% to 30%
of the beds in obstetric and gynecologic services are occupied
by women suffering from the effects of this procedure (9).

It has been said that abortion is not so much an option as it
is a response to the lack of any real options from both the
health and the economic, social, and educational perspectives
(12).  It is impossible to think at all seriously about this
issue and continue to be an impassive observer of situations
such as these which pose such tremendous risks, especially to
women who have no access to safe interventions and who are the
victims of arbitrary and unfair sexual standards.

An analysis of other causes of maternal mortality reveals that
basic strategies of action are needed to control them.  Among
these causes, hemorrhage, whether originating before the
birth, after delivery, or as a consequence of abortion, is an
important factor in mortality (1,4).

In this case not only medical factors but also those related
to the quality of services and the possibility of obtaining
a blood supply, as well as rapid and timely treatment, are
crucial in preventing fatal outcomes.  After its onset, this
complication does not permit delays or mistakes.  Hence the
importance of timely detection of pregnant women who are at
greatest risk of hemorrhage, as well as preparedness for
referring them to the appropriate care level if necessary.

This complication in turn underscores the need to be familiar
with the previous history of a pregnant woman, since
multiparous women, women with a history of postpartum
hemorrhage or women with pronounced anemia before pregnancy
constitute special risk groups.  The frequent occurrence of
hemorrhage and the importance of timely detection highlight
the need to train lay midwives and health workers to detect
the warning signs of increased risk and to determine any
immediate need for referral to more appropriate levels of
care.

Infections are another important cause of maternal mortality. 
When they occur, early detection and timely treatment are
effective weapons.  Important sources of infection are the
entry of germs into the genital tract because of inadequate
hygiene or the use of nonsterilized instruments during
delivery (23).  Two predisposing conditions for this type of
complication which need to be given special attention are
premature rupture of the membranes and the retention of
portions of the placenta, especially when the delivery occurs
far away from a hospital center (4).

Rupture of the membranes without delivery occurring within 24
hours frequently produces both maternal and fetal infections. 
There are various ways of fighting these infections, some of
which can be used by non-professional personnel.  The
participation of such adequately trained personnel is becoming
an increasingly important strategy for dealing with common
health problems which for various reasons do not receive
timely professional attention (13,21).

Other situations in which the collaboration of such personnel
is critical include the detection of high-risk pregnant women
(women with a history of multiple deliveries and those who are
small in stature or who are experiencing the onset of delivery
with the fetus in an unusual presentation) and cases of
obstructed delivery, many of which require cesarean section. 

This operation is not totally risk-free, however, since death
can occur from septicemia or problems related to the
anesthesia, although this happens in only a very small
proportion of cases.  The usefulness of this procedure makes
it essential to consider giving not only obstetrical surgeons
but also general practitioners the appropriate training to
perform it.  Nevertheless, it is important to point out that
the procedure has been abused in certain countries.  Brazil,
for example, currently has one of the highest cesarean rates
in the world.  In a study done in that country between 1982
and 1986, it was found that 27.9% of the women were sterilized
during the course of the procedure.  If cesarean sections
continue to increase at the same rate, it is estimated that
in the year 2000 almost two-thirds of all babies will be born
by cesarean section, imposing a considerable economic burden
on the health services (22).  

Preeclampsia in a pregnant woman can lead to a serious array
of symptoms, including convulsions, which are referred to as
eclampsia.  This is a common and serious complication of
pregnancy which can have a fatal outcome in at least 5% of
cases (9)--hence the importance of prenatal monitoring in
order to detect such early symptoms as arterial hypertension,
edema, or notable weight gain. 

Eclampsia is more common in developing countries because of
the nutritional status of pregnant women and the presence of
untreated diseases, among other reasons.  The higher frequency
of death from eclampsia in unprotected populations is largely
due to their lack of access to and appropriate use of health
services.

The causes of maternal mortality mentioned thus far stand out
because of their frequency, and also because they can be
targeted by control strategies that are designed to prevent
them or reduce their occurrence. 

Often maternal mortality is the end result of poor
reproductive health and processes leading to progressive
weakening of the organism as a result of decades of
undernutrition and misery.  These processes can begin before
birth, continue during childhood and adolescence, and still
be going on later in the life of a pregnant women.  They
encompass a broad spectrum of challenges, including persistent
vitamin and mineral deficiencies, problems resulting from
pregnancy at an advanced age, multiple pregnancies, and
pregnancies with excessively short or excessively long
intervals between them.

The above-mentioned risk factors for disease or death should
not cause us to forget the important impact that health
services can have on the health and well-being of mothers. 
When these services are accessible, efficient, and actually
utilized by those who need them, they can help to prevent
fatal outcome in a high proportion of cases.

Inadequate treatment of complications, lack of prenatal care,
shortage of trained personnel and critical supplies, and
inaccessibility of pregnancy and delivery care services are
important causes of maternal death that are associated with
health services delivery.

Studies carried out in developing countries show that between
11% and 47% of maternal deaths are due to inadequate treatment
of complications of pregnancy and delivery (2).  This type of
situation is related in part to the difficult circumstances
under which physicians and nurses must perform their jobs,
especially in peripheral and rural areas that lack adequate
infrastructure.  The problem is especially significant in view
of the fact that the interval between the onset of certain
complications and death is only a few hours.

The lack of adequately trained staff at the different levels
of pregnancy and delivery care continues to be a significant
problem in many countries of Latin America and the Caribbean,
where professionals tend to be concentrated in the most
affluent urban areas.  Coupled with this factor is the
shortage of essential supplies such as blood and antibiotics,
as well as difficulties with transportation and communication,
all of which further complicate an already serious situation.

The accessibility of health services determines their level
of utilization and in part their effectiveness.  Maternal
death rates increase in proportion to the difficulty of
gaining access to services.  Improving the quality and
increasing the accessibility of these services should be a
priority for the health authorities in the different
countries.


STRATEGIES

In the picture of maternal health in Latin America and the
Caribbean, while flawed in some respects, there is
nevertheless room for optimism.  Although there are numerous
causes of mortality, the rates are generally concentrated in
a few of the most common ones, which makes it possible to plan
basic strategies to control them. 

Maternal health is affected by medical and biological as well
as economic and cultural factors.  Only when these are acted
upon as a whole can any significant reduction be expected in
maternal death rates.  Maternal mortality is a significant
indicator not only of the accessibility, coverage, and quality
of health services but also of social development.  Moreover,
the lower the women's socioeconomic status, the higher the
indexes of maternal mortality.  In this sense, maternal
mortality is one of the indicators that shows the most sizable
disparities between countries at different levels of
development (9).


GENERAL STRATEGIES

Given the numerous factors that produce maternal mortality,
strategies aimed at reducing it must encompass, in addition
to specific health sector actions, measures which are
coordinated with other sectors that deal with this important
problem.

The improvement of levels of health must be considered an
integral part of socioeconomic development in the Region.  It
therefore depends on an effective campaign against illiteracy,
unemployment, and economic and social inequality.  It also
entails the updating of existing legislation to clearly
stipulate that women are entitled to appropriate care for
their sexual and reproductive health. 

These legal measures must also eliminate sanctions against
abortion and emphasize instead the development of
comprehensive programs of universally accessible fertility
regulation for those who desire it, providing information on
the safest and most effective methods.  

If these strategies for action are to be effective, they must
not be imposed vertically.  On the contrary, although the
political commitment at the central level is undeniably
important, these strategies must be based on joint action by
political and social leaders working together with
representatives of grass-roots community organizations and
women's groups who will thus be empowered to become actors in
their own development and well-being.

The importance of organizing concurrent activities in order
to strengthen their effectiveness needs to be stressed.   The
health training of personnel must go hand-in-hand with the
opportunity to put this new knowledge to work.  Training in
how to handle new techniques or equipment must be accompanied
by the actual provision of these techniques or devices so that
new knowledge and capabilities for their effective use can be
cultivated. 

Strategies should be planned so that they are flexible enough
to adapt to local circumstances, respecting the values,
customs, and beliefs of the communities they are directed
toward.  In this way it will be possible to establish the
guidelines for action that are needed in order to
significantly improve the health levels of mothers, entire
families, and the community.

Mothers clearly have an important role to play in this
process. They are an essential resource for the effective
planning of programs to deal with the curative aspects of
health, as well as disease prevention and health promotion. 
No one can do a better job than they can when it comes to
identifying their own needs and those of their families and
communities.  And no one can take their place when it comes
to participating actively in the implementation and evaluation
of programs to improve their health.

The social strides that women have made in Latin America and
the Caribbean have come more from their active participation
and their struggle to win their rights than from understanding
and initiative on the part of the national leaders.  Thus it
is crucial that women be well informed so that they can take
an active part in the planning of health sector actions and
at the same time serve as catalysts for the economic and
social policies that shape their lives. 


SPECIFIC STRATEGIES

In addition to the general actions discussed above, there are
specific strategies which should include the following
measures:

-    education in sexual and reproductive health with popular
     participation;
-    use of the risk approach;
-    organization of health services by levels of care; 
-    personnel training;
-    improvement of basic supplies for prenatal and delivery
     care; and
-    development of projects based on operations research.  

The implementation of these measures will improve the quality
and effectiveness of the health services.  These actions need
to be based on epidemiological and evaluative studies of the
most common causes of maternal mortality in the different
countries, as well as on experiences gained to date with
measures for disease prevention and health promotion.

Education in sexual and reproductive health with popular
participation

Sexual and reproductive health education with active
participation by the people is one of the basic strategies for
combating high indexes of maternal mortality.  Social
participation involving adolescents of both sexes is of
undeniable importance, especially in view of the serious
consequences of premature pregnancy or pregnancy in women
suffering from poor health.  In the specific case of
adolescent pregnancy, it is now recognized that programs and
services for adolescent boys need to be included, given that
their motivations, behavior, and attitudes are as important
as those of adolescent girls when it comes to solving these
problems (14, 15).

Sexual and reproductive health education with active
participation by the people is one of the basic strategies for
increasing awareness in youth regarding certain sexual
behaviors that pose special risks.  To varying degrees, the
Latin American countries have experienced an increase in the
number of adolescent pregnancies (14,15).  This fact, coupled
with the increase in certain diseases such as AIDS, makes it
imperative for the health and the education sectors to join
forces in an effort to educate children and young people about
the behaviors that will help them avoid harmful health effects
and to give them a basic understanding of human reproduction.

Use of the risk approach

The risk approach recognizes that not all individuals or human
groups are equally susceptible to disease.  Based on this
assumption, the risk approach is used as a methodological
tool.  This makes it possible to perform an evaluative
analysis of a specific situation in order to achieve maximum
utilization of the available resources by focusing them on the
most unprotected groups.

From this perspective, the risk-based strategy plays a
fundamental role in the development of primary health care,
and its use can be decisive in obtaining a marked reduction
in maternal mortality.

Risk factors are not only physical and biological.  They also
include factors associated with the family, socioeconomic, and
cultural environment.  Thus they tend to be found in the most
neglected and unprotected human groups.  Moreover, the armed
conflicts that are devastating a number of the countries are
posing an added risk for a significant portion of the
population (16,17,18).

The more risk factors that a pregnant woman faces, the greater
her chances of having a pregnancy with an unfavorable
evolution.  Pregnant women belonging to marginal social
classes and those with litle schooling, ages that place them
at the extremes of the reproductive years, and a history of
multiple pregnancies and previous pathologies constitute high-
risk groups (1).

From the standpoint of maternal morbidity and mortality, use
of the risk approach makes it possible to detect pregnant
women who are more likely to develop complications and have
an unfavorabel evolution so that the available health care
resources can be focused on them in order to minimize damage
to maternal health.  The risk approach strategy applied in
accordance with these concepts is an important tool for
optimizing resources and fostering equity.

Organization and delivery of health services by levels of care

The fact that limited resources are available for the health
sector in Latin America and the Caribbean means that these
resources must be rationalized in order to extend coverage and
improve the efficiency and effectiveness of health services.

The organization of health services by levels of care makes
it possible to comply with this basic principle, and it is in
line with a logical approach to grouping and utilizing
existing resources by levels according to the needs to be met. 
This means evaluating health care needs and making a correct
assessment of the resources available so that they can be
adapted to those needs (19).

The levels of care are equivalent to functional combinations
of services wherein the different levels are stratified
according to their technological capacity to resolve problems. 
Basic levels perform simple actions and more complex levels
handle those that are more technologically complex. 

Thus the organization of services according to levels of care
paves the way for an approach that integrates activities aimed
at strengthening operational capacity.  It also makes it
possible to improve the flow of resources so that they are
optimally utilized, as well as to reformulate the delivery of
benefits so that new types of health care can develop that
will contribute effectively to the extension of coverage (19).

Personnel training

The training of health personnel is of crucial importance to
the adequate operation of health care programs for pregnant
women.  This training should cover health personnel at all
levels, including lay midwives as well as the popular health
promoters, representatives, or directors who are becoming
increasingly important in the Region (13).

Lay midwives are often the first or only health workers that
pregnant women come into contact with.  Providing these women
with training, educational supervision, and support is of
fundamental importance if they are to do their work as
effectively as possible. 

Part of this training has to be directed toward teaching these
workers basic techniques that they can use to treat commonly
occurring conditions, as well as to detect risk factors and
serious complications that require immediate referral.

This training for health personnel should be supplemented by
health education for pregnant women and the communities in
which they live.  The health of women, mothers, and children
is an excellent point of entry for gaining community
participation, which is an essential component of any health
strategy (20).

There is no doubt that it is important to integrate the
concepts of fertility regulation into training, which should
be free of charge and accessible to all.  Family planning,
which has been called the first line of defense against
induced abortion, is one of the most important preventive
measures available for reducing maternal death rates. 

The importance of fertility regulation using the risk approach
goes beyond its impact on the health of mothers.  It is a
fundamental human right which puts women on the path toward
more egalitarian social and economic participation. 

Improvement of basic supplies for prenatal and delivery care

The lack of essential supplies and adequate prenatal
monitoring contribute significantly to maternal mortality.

Among the critical supplies needed in order to deal with the
most common problems, it is important to include oxytocic
drugs (which contract the uterus and the blood vessels),
antibiotics, and blood reserves, as well as supplies for
administering anesthesia and performing cesarean sections.

Oxytocic drugs are very useful in dealing with cases of
uterine atonia, one of the most frequent causes of postpartum
hemorrhage.  The use of antibiotics helps to prevent
infectious processes, especially in cases of cesarean section
following prolonged delivery with rupture of the membranes. 
In cases of serious hemorrhage, when blood for transfusions
is unavailable, some crystalloid solutions can serve as
emergency replacements.

Prenatal monitoring is one of the most effective interventions
available for the prevention of maternal morbidity and
mortality.  In addition to overseeing the evolution of the
pregnant woman, this process makes it possible to detect
hypertension during pregnancy and to treat it before it can
evolve into eclampsia and lead to the death of the pregnant
woman.  It should also be noted that adequate prenatal care
makes it possible to teach basic concepts of health and
hygiene to the pregnant woman, as well as to treat preexisting
diseases.

The higher a woman's level of education, the greater the
possibility that she will seek out prenatal care and receive
delivery care from trained medical personnel.  These findings
were highlighted at the World Conference on Education for All
held in Thailand in March 1990.

Development of projects based on operations research 

The measures discussed above will be much more effective if
they are preceded or accompanied by research projects whose
fundamental aim is: 

-    to determine the prevalence of the different causes of
     maternal morbidity and mortality in each country through
     a national system of epidemiological surveillance;
-    to evaluate the current status of the health services,
     the quality of supplies, and the effectiveness of the
     treatments in use;
-    to determine the possibility of using technologies that
     are adapted to the different situations; and
-    to study the social determinants of behavior.

The findings of this research will make it possible to more
effectively plan specific activities aimed at overcoming the
most serious and common problems.  Improved health and well-
being for mothers will be the logical outcome (2). 

FUTURE OUTLOOK

Maternal mortality is currently one of the most serious health
problems in Latin America and the Caribbean.  It is estimated
that in the developing countries between one-fourth and one-
third of all deaths in women of reproductive age can be
attributed to maternal causes (9).  Although it is not
possible to calculate the exact cost of maternal deaths, it
is clear that their impact is significant in terms of their
legacy of family breakdown, orphaned children, and probable
increase in infant mortality.  Research on those costs is
being carried out in the Region, measuring such parameters as
orphaned of children and consequent rates of school dropout.

There will continue to be significantly high numbers of
maternal deaths unless a far-reaching set of measures can be
enlisted to bring these numbers down. 

Such measures should reflect a decision on the part of
political and health authorities and leaders to give priority
to the problem.  This decision will have to be accompanied by
the work and the efforts of grass-roots community
organizations, which will have to help identify the problems
most urgently in need of solution and to plan the most
appropriate strategies for dealing with them. 

Maternal mortality should not be looked at in isolation but
rather as an integral part of a much broader and more complex
problem.  Responsibility for these high indexes goes beyond
the level of the individual.  The solution rests on the
shoulders of society as a whole.  Special attention needs to
be directed toward the poorest sectors of the population, and
among these, toward the young girls and adult women who suffer
the most from poverty. 

Our chances for success will depend on the capacity of all the
sectors that are involved in this difficult social problem to
generate participatory actions.  This will lead to the
development of meaningful political decisions and a genuinely
democratic commitment on the part of the Region's leaders. 
Their response to this challenge will reflect the spirit of
justice and equity of the societies in which we live. 

BIBLIOGRAPHY


1.   Organización Panamericana de la Salud.  Documento de
     Referencia sobre Estudio y Prevención de la Mortalidad
     Materna.  1986.

2.   Maternal Mortality:  Helping Women Off the Road to Death. 
     WHO Chronicle, 40(5)175-183, 1986.

3.   Maine, D., Rosenfield, A., Wallace, M., Kimball, A.M.,
     Kwast, B., Papiernik, E., and White, S.  Prevention of
     Maternal Deaths in Developing Countries:  Program Options
     and Practical Considerations.  Background paper prepared
     for the International "Safe Motherhood" Conference,
     Nairobi, 1987.

4.   Winikoff, B., Carignan, C., Bernardik, E., and Semeraro,
     P.  Medical Services to Save Mothers' Lives.  Feasible
     Approaches to Reducing Maternal Mortality.   The
     Population Council, 1986.

5.   Harrison, Paul.  Inside the Third World.  Penguin Books,
     Great Britain, 1984.

6.   "Latin American Women: One Myth - Many Realities".  NACLA
     Report on the Americas, vol. XIV, no. 5, Sept-Oct, 1980.

7.   Chaney, E.M.  Women of the World.  Latin America and the
     Caribbean.  U.S. Department of Commerce.  Bureau of the
     Census, 1984.

8.   Pan American Health Organization.  Regional Plan of
     Action for the Reduction of Maternal Mortality in the
     Americas. 1990.

9.   Royston, E. and Armstrong, S., ed.  Preventing Maternal
     Deaths.  WHO, Geneva, 1989.

10.  Omram, A.R., Martin, J., and Hamza, B.  High Risk Mothers
     and Newborns.  OTT Publishers, THUN, Switzerland, 1987.

11.  Pregnancy Termination.  Complications of Abortion in
     Developing Countries.  Population Reports, Series F, No.
     7, July 1980.

12.  Gómez Gómez, E.  Perfil epidemiológico de la salud de la
     mujer en la Región de las Américas.  Organización
     Panamericana de la Salud, 1990.

13.  Chelala, C.A. "Correos de la Salud" en Bolivia.  Salud
     Mundial.  December 1988.

14.  Chelala, C.A.  Embarazo de las adolescentes en las
     Américas.  Salud Mundial.  June 1988.

15.  Chelala, C.A.  Embarazo de las adolescentes en Nueva
     York.  Salud Mundial.  April-May 1990.

16.  Chelala, C.A.  Central America:  The Cost of War.  The
     Lancet, vol. 335, 153-154, Jan. 20, 1990.

17.  Chelala, C.A.  La population dans la maré des conflits. 
     Le Monde Diplomatique, August 1989.

18.  Chelala, C.A. "Central America:  A Slough of Despond." 
     Wall Street Journal, January 5, 1989.

19.  Castellanos Robayo, J.  "Aplicación funcional del
     concepto de niveles de atención".   Working document
     prepared for Meeting on Organization and Delivery of
     Health Services by Care Levels.   Pan American Health
     Organization, Washington, 1983.

20.  Chelala, C.A.  La salud materna:  Un perenne desafío. 
     Pan American Health Organization, 1991.












PAN AMERICAN HEALTH ORGANIZATION
REGIONAL PROGRAM OF ESSENTIAL DRUGS















RATIONAL USE OF DRUGS

SUBREGIONAL PROJECT FOR CENTRAL AMERICA AND PANAMA




















January 1992






CONTENTS


Page

1.    TITLE                                                                  
      1

2.    BACKGROUND                                                             
      1

3.    CURRENT SITUATION                                                      
      3

4.    OBJECTIVE                                                              
      5

      4.1  OVERALL OBJECTIVE                                                 
      5
      4.2  SPECIFIC OBJECTIVES                                               
      5

5.    DESCRIPTION                                                            
      6

6.    STRATEGIES                                                             
      9

7.    FINANCING                                                              
      10

8.    PLAN OF OPERATION, BY COMPONENT                                        
      12

      - ACTIVITIES
      - EXPECTED OUTCOMES
      - DISTRIBUTION OF RESOURCES







LIST OF TABLES


Page


1.    






1.    TITLE

      RATIONAL USE OF DRUGS

2.    BACKGROUND1

      In 1984 the Central American countries undertook a joint effort to find
solutions to critical health problems with a view to supporting the process
of pacification and democratization in the area.  The outcome of this
initiative was a plan for addressing health priorities in Central America and
Panama entitled "Health, a Bridge to Peace."  The plan identified seven
priority areas for the promotion and development of strategies aimed at
tackling the most urgent health problems that are affecting the well-being of
the population.  One of these areas was drugs.

      As part of this exercise, the most serious problems in the area of
drugs--a key component in the primary care strategy--were identified.  These
problems were:

   -  Chronic shortages of critical drugs in both public and private health
      care services.

   -  Frequent shortages of drugs in the marketing chain affecting the
      population in general.

   -  Limited access by those sectors of the population most in need,  which
      have been steadily growing as a result of the socioeconomic crisis.

   -  Variable quality of the drugs available on the market in terms of
      standards for production, storage, distribution, and dispensing.

   -  Limited capacity of national authorities to exercise quality control
      and assurance.

   -  Scarcity of personnel trained in the application of risk-benefit
      assessment and cost-effectiveness criteria to make decisions about drug
      treatment schemes.

   -  Limited decision-making capacity for the solution of problems at the
      central, local, or institutional levels.

      Traditional analysis of this situation has attributed the foregoing
difficulties to the inability of governments to allocate sufficient resources
to the health sector, and specifically to the procurement of drugs.  However,
the measures that have been taken--namely approval of extrabudgetary national
funds for emergency purchases (usually at the national level), requests for
donations from developed countries or cooperation institutions, and mass
purchasing of drugs through bilateral project resources--have proved to be
largely ineffective, even in the short term.

      A deeper analysis of the situation prevailing at that time shows that
the dramatic situation with respect to drugs was basically due toweak policies in this area, which were often incompatible with general health
policies, given the failure to clearly identify objectives vis-Õ-vis national
realities.  A detailed analysis revealed, in addition, that the crisis in
this area was directly related to inadequate programming of national needs
and inappropriate procurement and distribution processes, which have
undermined rational use of the scarce financial resources available, held
back the development of reliable and timely administrative and technical and
scientific information systems, reduced national and subregional
self-sufficiency in production, perpetuated inadequate systems for the
registration and quality control of drugs, and prevented the develpment of
standards and mechanisms for assessing the degree to which a rational
approach is being applied to the drug use.

      Another aspect that came to light in most of the countries in the area
was the small critical mass of experts available to lead the processes of
change and carry out the activities that need to be undertaken on an urgent
basis.  Indeed, the only sectors with groups of national technicians that
demonstrated a certain amount of cohesion and readiness to focus their
knowledge and experience on problem areas of mutual concern were the
pharmaceutical industry and the private marketing sector, while in other
strategic areas such as selection and registration, pharmaceutical services,
quality control and assurance, education, and therapeutic updating there were
serious gaps.

      In addition, a lack of carryover was noted between teaching
institutions and the health care services.  The schools of pharmacy and
medicine tended to be isolated from the health sector and have little
knowledge and experience, with few multiplier agents available and ready to
assume a decisive role in training the qualified resources needed by the
health sector.

      Given this evidence that the solutions being tried were not very
effective, if the states had kept on with the same action programs they had
been following thus far, they would have quickly found themselves in a
permanent state of crisis.  It was in this context that the Ministers of
Health decided to seek strategies which would make it possible to correct the
original causes and develop lasting solutions.  The strategies selected were
based on the principles of PAHO's Regional Program on Essential Drugs.  They
involved five main components:

      -      Strengthening of the quality regulation and assurance of
pharmaceutical products

      -      Development of supply systems

      -      Establishment of an Essential Drugs Revolving Fund

      -      Formulation of pharmaceutical policies

      -      Promotion of national and regional drug production

     Accordingly, the Governments, in collaboration with PAHO, prepared
various proposals for cooperation based on the above components.  Financial
support was obtained for six projects, thus making it possible to establish
the bases for comprehensive development in the area of drugs.  These projects
were:

      -      Drug supply and quality (USA)

      -      Development of national pharmaceutical policies and the rational
use of drugs (France)

      -      Capitalization of a revolving fund for drug purchases (Holland)

      -      Development of pharmaceutical services (Sweden)

      -      Production of essential drugs (Norway)

      -      Support to the essential drugs program in Nicaragua (Finland)

      In each project, the plan of action included specific activities tarted
at some of the critical elements identified by the countries of the
subregion, with emphasis on those of greatest interest to the Governments and
donor agencies.


3.    CURRENT SITUATION1,2

      The Ministers of Health, responding to a mandate from the Presidents of
the Central American countries set forth in the "Declaration of Montelimar,"
agreed to prepare a second phase of the Plan of Priority Health Needs of
Central America in order to provide continuity following on the achievements
of the first phase and to implement activities that would make it possible to
resolve some of the remaining problems.  This proposal was confirmed at the
VI Special Meeting of the Health Sector of Central America (RESSCA) (1990),
in proposals presented at the III Conference of Madrid (May 1991), and in the
Final Declaration of the VII RESSCA (August 1991).

      In the resolutions approved under the Health Initiative of Central
America, four priority areas were identified for national and regional
projects:  Health Infrastructure, Health Promotion and Disease Control,
Attention for Special Groups, and Health and the Environment.  Projects on
drugs, along with others, come under the priority area of Health
Infrastructure.

      The need to respond specifically to the advances achieved in the area
of drugs under the subregional projects has required the inclusion of
indicators as part of the projects' activities which, when systematically
applied, would monitor progress and identify weak points that need to be
strengthened.  Although these indicators have not yet been applied, from a
review of the current situation it is reasonable to say that, despite theefforts to date, the projects have failed to solve the existing problems.

      Although the degree of progress varies from one country in the
subregion to another, in general it has been slow.  The effects of the crisis
still persist, especially the shortage of essential drugs and the lack of
access by large sectors of the population.  Nor have the Governments been
able to stop using stop-gap measures to resolve these problems; so far,
situational solutions tend to predominate over those of a more rational and
strategic nature.

      Studies have confirmed, on the one hand, a failure to make rational use
of the financial resources intended for the purchase of drugs, and, on the
other, indiscriminate prescribing and dispensing, which translates into false
expectations, unnecessary expenditure, and, in some cases, iatrogenec
consequences.  The first of these situations stems from the extremely low
level of local participation, coupled with highly centralized programming
which fails to respond to the population's morbidity profile, often
aggravated by the persistence of inadequate systems for the management of
inventory, distribution, and dispensing of drugs.  The second situation is
directly related to the capacity of teaching institutions and services to
develop and update manpower, and it is exacerbated by attitudes on the part
of health personnel and the patients themselves toward drugs.

      The response to these situations will clearly involve providing
continuity for actions already initiated and under way under other projects. 
It is too soon to look for the needed structural modifications and changes in
attitude on the part of the political and technical actors involved.  The
structural modifications usually depend on events and actions that go beyond
the scope of this area--events and actions that are taking place in other
sectors of national and international activity in response to different
concerns--and the speed of response does not always coincide with the social
needs of the health sector.

      The changes in attitude, in turn, respond only to educational
processes, which never give instantaneous results, especially when the actors
and the disciplines they represent are as numerous and varied as those
involved in the area of drugs and when the population itself represents a mix
of different traditions, interests, objectives, and cultural values.

      In light of all these circumstances, it is essential to continue to
carry out actions aimed at improving the rational use of drugs, which can be
done by strengthening activities in projects already under way, initiating
others that are more specific, expanding the coverage and quality of the drug
component in health care services, evaluating drug treatment regimens on an
ongoing basis, and strengthening the decision-making capacity of the services
and their personnel.


4.   OBJECTIVES

4.1Overall Objective

      To promote the rational use of drugs by ensuring that they are of
      optimum quality, effective, and safe; maximizing their availability to
      the entire population; and strengthening measures to ensure that they
      are correctly prescribed, dispensed, administered, and consumed.

4.2Specific Objectives

   -  To promote the definition and implementation of drug policies that are
      compatible with overall health policies and which respond strategically
      to national and subregional needs and priorities.

   -  To review and adapt legislation and pharmaceutical regulation in terms
      of the registration, importation, and marketing of drugs at the
      national level, and to standardize them at the subregional level to the
      extent that this will help to strengthen the sector.

   -  To intensify efforts to modify the behavior of personnel who prescribe,
      dispense, and manage the supply of drugs by further streamlining the
      availability and prescribing thereof in public and private
      institutions.

   -  To increase the effectiveness and efficiency of national, regional, and
      local pharmaceutical services within the context of local health
      systems, including public and private institutions, and to assist in
      strengthening the capacity of institutions to take decisions in the
      solution of their own health problems.

   -  To improve educational capacity at the national and subregional level
      in order to provide adequate training and updating of personnel
      involved in the management of drugs, with emphasis on teaching-service
      integration in schools of pharmacy, medicine, and nursing, on the one
      hand, and in service-providing institutions, on the other, including:

      (a)  Improving the basic formation of professionals in medicine in terms
of the pharmacological and therapeutic aspects of health care;

      (b)  Evaluating the pharmacy curriculum and adapting the
teaching-learning process through a strategic approach that will
bring it into alignment with modern professional performance and
with current and future national and subregional needs; and

      (c)  Improving knowledge about drugs on the part of auxiliary personnel
involved in therapeutic care through the design and development of
training and updating programs.

  -  To promote a responsible attitude on the part of patients and the
      community toward health care at the individual and collective level by
      improving their knowledge about the use of drugs.

   -  To promote coordination between the different programs and projects
      being carried out in the subregion either directly or indirectly
      related to drugs by promoting a coherent and uniform conceptualization
      of the problems and their solutions, independently of their sources of
      financing.


5.    DESCRIPTION

      It is proposed to develop the "Rational Use of Drugs" project in four
components, three of them technical in nature and one dealing with
coordination and management of the project.  The first three combine areas
and activities that affect the use of drugs by determining the degree to
which they are being rationally used.  The project's conceptualization is
based on the fact that the rational use of drugs is not an objective that can
be ascribed to a given time and space or achieved at a specific moment.  On
the contrary, it is an ongoing practice that involves all the actors engaged
in the management of drugs, and it needs to be evaluated on a regular basis.

      One of the most important factors in designing this project was its
correlation with other projects being carried out in Central America in the
area of drugs, which are being coordinated with the cooperation of the Pan
American Health Organization's Regional Program on Essential Drugs.  Thus,
with due consideration for the interests of the recipient countries and the
recommendations of donor agencies, an effort was made to complement existing
activities, prevent duplication, and avoid undertaking activities that were
already adequately supported by other projects.  In this vein, activities
dealing with drug production and quality assurance for marketing, even though
these factors have a strong bearing on the rational of use of drugs, are not
included in the present project because they are supported by other projects
in the subregion.

      In general, this project picks up on activities already being carried
out in the area under other projects and is designed to enable them to make
greater progress.  In addition, it emphasizes programs and activities aimed
at analyzing and correcting the causes that lead to problems impeding the
rational use of drugs and thus tries to offer a  permanent response to the
problem rather than haphazard or temporary "fixes."  Most of the activities
attempt to bring about changes in attitude toward the problem of drugs by
raising awareness and providing training for health personnel and the users
themselves that will enable them to better understand, analyze, make
decisions, and evaluate the problem.  Thus is it hoped not only to make a
greater impact in terms of attaining of the objectives proposed under the
project but also to help ensure that the activities and effects of the
project will continue even after it has concluded.

     Consideration has also been given to the need to integrate the
activities being carried out under other projects which are not specific to
this area but which have a direct or indirect bearing on the work of the drug
programs and, consequently, on national policies in this area both from the
conceptual standpoint and in terms of rational drug use.  Especially
important are activities being carried out by nongovernmental agencies,
unions, and private companies in indigenous communities, among refugees, and
in rural areas, as well as those being developed in teaching institutions. 
The general idea is that activities being carried out under other projects
can be complemented or strengthened by those planned under the present
project as long as conceptually they do not generate any confusion or
distortion.  With this in mind, the project's activities are concentrated in
national agencies that are concerned with the problem of rational drug use
and in institutions with a more specific focus, such as hospitals.

      Another criterion considered was the need to strengthen institutions in
subregional terms in order to train the multiplier agents needed for
continuing education and for updating programs in specific areas related to
drugs.  At the national level, the emphasis will be in-service training,
especially cooperation and teaching-service integration.  This difference in
the focus of training at the national and subregional levels is based on the
fact that neither the time nor the resources envisaged for the financing of
the project would be sufficient to strengthen all the areas in each of the
countries where training is needed.  Nor is a broad overall application
feasible, given the lack of physical capacity and specialized human resources
the countries.  As a result, the project only attempts to lay down the bases
so that at the subregional level there will be adequate capacity to train and
update specialized personnel who will then be in a position to improve the
quality of health care in the respspective countries.

      With regard to the development of services in general and
pharmaceutical services in particular, the project provides for a gamut of
activities ranging from the basic, which include preparation and dispensing
of the therapeutic formulary, to others of greater complexity such as the
systematic evaluation of intrainstitutional prescribing practices with a view
to rationalizing and improving the utilization of drugs.  Not all activities
relating to modern pharmaceutical services are included, however.  This
decision was taken because, on the one hand, the resources of the project
itself are limited and, on the other, national capacity and the current level
of development of pharmaceutical services, as well as the factors that affect
the drug situation both internally and externally, including the health
sector, vary significantly from one country to another within the subregion. 
Acordingly, it was necessary to program activities that would be carried out
in only some of the countries and at the same time other activities that
would apply to the subregion in general.

      An important part of the project is that most of the activities are
directed as much toward the public as the private sector, based on theawareness that most of the factors which bear on the rational use of drugs
affect both of these sectors and that only a broad overall strategy would
make it possible to achieve significant results--a strategy that would have
to include the review, adaptation, and harmonization of laws and regulations
giverning the pharmaceutical area as well as those focusing on basic
education.

      The project also envisages activities that will make it possible to
help raise the level of awareness of consumers themselves at both the
individual and collective levels (patients and communities) of their
corresponsibility for caring for their health by improving their level of
knowledge about medication.  With these activities it is hoped to achieve
more rational self-medication, better compliance with prescribed treatments,
and a reduction in the health complications caused by errors in this regard.

      Each of the three technical components comprises a set of specific
activities of varying number the development of which will make it possible
to achieve the results proposed for the particular component.  However,
because of differences between the countries of the subregion in the degree
of development achieved in specific areas of the project, not all the
activities will be carried out in each and every country of the subregion,
even though they are subregional in nature; rather, they will be carried out
if and as they are feasible in each specific country.

      The estimated duration of the project is three years, which will make
it possible to lay a foundation for systematizing execution of the activities
programmed and facilitating their continuity once the project is completed. 
It is necessary to note, however, that some of the results cannot be achieved
within the project period; they will only be achieved later, as a result of
the same activities being carried out routinely over a longer time.

      Finally, with due consideration for the final evaluation of the
project, it was also felt important to include within each component an
initial, interim, and final assessment of progress achieved vis-Õ-vis a given
baseline in each of the areas covered.  These exercises will be conducted
within the grantee agencies, institutions, or organizational units.  The same
indicators will be applied for the initial, interim, and final assessments,
based on a scheme or protocol agreed upon by all the countries and units
carrying out the same activities within a given component.  The indicators to
be used will be determined based on the results of a study which, as noted
elsewhere in this document, is currently being carried out and is in its
final stages.  Thus it will be possible to have a timely initial evaluation
and readily compare results or degrees of accomplishment under the project in
different countries.


6.   STRATEGIES

6.1   Sectoral Coordination

      In this project, coordination is important both between the public and
private sectors and between the service and productive sectors.  It is
planned to establish mechanisms that will permit the participation of the
sectors mentioned not only in executing the project but also in helping to
ensure that such participation becomes permanent.

      Another type of coordination that is important for the project is that
to be established between the central and local levels in terms of common
standards and managerial oversight for the programs within a given country. 
The main idea is to make implementation of the activities viable by
facilitating comparative studies, evaluations, and consequently the
implementation of solutions.  Common standards will be proposed at the
subregional level only after benefits have been maximized at the national
level.

6.2   Institutional Strengthening

      It is also important for the institutions, whether health care
providers or teaching institutions, to achieve an organizational and
functional level of development that will enable them to ensure quality and
continuity in the fulfillment of their mission.  Another important aspect is
the integration of service and educational institutions in programs of common
interest to both, which can be expected to improve the quality of the
teaching-learning process.

6.3   Training

      Through this strategy an attempt will be made to improve and strengthen
the management capacity of the services in normative terms, from both the
therapeutic and managerial perspective, and at the same time, in educational
terms, to promote training at the subregional level of multiplier agents in
the countries.

      This strategy also includes education about drugs for patients and
communities to make them more aware of their responsibility in terms of
management and appropriate consumption.

6.4   Multidisciplinary Integration

      Development of actions with the participation of the different actors
involved in the management of drugs will permit a comprehensive approach to
the problem in which every person has a contribution to make from the
perspective of his/her area or specialization.  The project's activities call
for the participation of medical, pharmaceutical, and nursing personnel,
social communicators, administrative assistants, lawmakers, and inspectors,
depending on the needs and realities of each country.

6.5  Operations Research

      The importance of implementing a strategy for operational analysis
stems basically from the need to assess progress and achievements resulting
from execution of the project itself.  It will be applied to areas and
aspects as required, giving priority to the presentation and implementation
of proposals for the solution of problems related to the particular
characteristics of the Central American countries.


7.    FINANCING

      The financial resources needed in order to carry out the project are
estimated at US$1,444,360.00, of which, pursuant to an internal resolution of
the Pan American Health Organization, 13% is for support costs.  The balance
of $1,256,593.00 is for financing the project's activities.

      Of the amount indicated, 74% is for financing the technical components
and the remaining 26% is for project coordination and management. 
Approximately 50% of the financing under the coordination component will be
shared through contributions from other drug projects being carried out in
the subregion.  Table 1 shows the distribution of resources by component and
year of project execution.  The even distribution of the budget over the
three years of the project largely reflects its continuity vis-Õ-vis other
initiatives currently under way and also the existing management capacity in
the countries, taking into account the activities under their own projects.

      An important aspect from the standpoint of financing is the
participation of each of the grantee countries in the development of
activities.  Unfortunately, owing to problems in the availability,
accessibility, and reliability of information, which vary from one country to
another, this is not reflected in the tables presented.  However, the
man-hours of regular staff at teaching and service institutions to be
involved in execution of the project at the different levels--central,
regional, and local--as well as the provision of needed materials and inputs,
including drugs, are obviously the major co-contribution to be made by the
countries.

      The breakdown of resources by elements of expenditure and year of
execution is detailed in Tables 2 and 3, which reflect the strategies to be
applied in carrying out the project.  These elements include:

      (a)  Short-term consultants and temporary advisors (element 040).  This
category represents 10% of the resources.  It includes the
contracting of international experts who will participate in the
project, to be selected on the basis of their particular experience
and the level of development and nature of the activities. 
Whenever possible, professional resources from countries of the
Central American subregion itself will be mobilized, thus
facilitating the strengthening of the subregion.

     (b)  Local contracts (element 390).  This element deals specifically
with the mobilization of national resources within each country and
represents 24% of the total budget.  Development of the various
activities planned requires the participation of personnel from
outside the public sector whose participation will lead to the
systematization of activities within the operating capacity of the
grantee institutions.  In addition, the cost of activities
involving participation of the private sector, when so required,
will be covered under this element.

      (c)  Supplies (element 550).  This element, which corresponds to 10% of
the total budget, will cover the cost of the publications
envisaged, in particular teaching materials and reports of research
and other studies to be conducted under the project, as well as the
dissemination thereof.  This will maximize the utilization of
educational tools in terms of dissemination and accessibility and
it will also facilitate the implementation of similar activities in
the various countries of the subregion.  This element will also
cover the purchase of needed materials such as teaching equipment
(mainly for the education component), the acquisition of computer
equipment to facilitate the implementation of automated systems for
inventory control as provided for in Component 2, and bibliographic
support geared to the development of information services on drugs.

      (d)  Fellowships (element 810).  This heading covers the cost of
personnel participation in training activities away the workplace,
as provided for in Components 2 and 3 and represents 9% of the
budget.

      (e)  Courses, meetings, and seminars (element 820).  Basic education,
updating, and in-service training of both professionals and workers
in general is an important part of the project and one on which
many of its activities are based.  Thus, 29% of the total budget
has been set aside under this heading.

      (f)  Salaries and travel (elements AAA and 230).  Element AAA is
intended to cover the cost of personnel responsible for project
coordination and follow-up, which is being shared with other
projects currently under way in the subregion.  Thus the figure
given represents only half the amount needed for this activity. 
Sixteen percent of the total budget will be allotted for this item,
while 2% is for mobilization of the subregional coordinator as well
as regular PAHO staff to support the activities.  In this case,
too, the costs are being shared with other projects.


8.   PLAN OF OPERATION, BY COMPONENT

Component 1:  Legislation and Regulation

      This component is considered the point of access for promoting the
rational use of drugs.  Indeed, it is through this area that national
policies are made regarding the pharmacological criteria and requirements
that bring drugs together for registration and consequent marketing in the
country, as well as the criteria that govern the advertising of these
products.  The project includes activities dealing with the evaluation and
updating of legislation on the registration of generic drugs and the
importation and marketing of pharmaceutical products.  Decisions in these
areas will make it possible to prevent the marketing of drugs of doubtful
therapeutic effectiveness, irrational drug combinations, or products that are
unnecessary according to the national profile of morbidity and mortality.

      It also includes the design and implementation of a system for the
national dissemination of regulatory decisions, which currently does not
exist.  Such a system will make it possible to keep prescribers and
dispensers up to date on pertinent official decisions and the bases therefor. 
Since this information will come directly from the source that originates it,
its objectivity is guaranteed.  These activities will be accompanied by
review and regulation of the advertising of drugs at the national level,
which will clearly have an impact on the rational use of drugs, inasmuch as
emphasis will be on disseminating objective information and on controlling
and minimizing the effects of advertising campaigns that promote the use of
drugs and contribute to their irrational consumption.  This information
system, once established and satisfactorily under way, will be extended to
the subregional level in order promote the exchange of information among the
countries in the area.

      Finally, the project will foster, insofar as possible and feasible,
common understanding with regard to the various issues covered by the
component, which will contribute to the movement toward Central American
integration to which the countries of the area and their institutions are
committed.  This effort will only be promoted when, on the basis of due
analysis and feasibility, it is deemed to represent benefits for the
countries of the area and contribute to strengthening the sector in the
subregion.


Activities

1.1   Adaptation of pertinent legislation

   1.1.1  Compilation of legislation on:
(a) Registration of drugs,
(b) Importation/donation,
(c) Marketing:  channels and accessibility,
(d) Prescribing and dispensing, and
(e) Promotion and publicity

  1.1.2  Analysis and proposals for updating legislation on each aspect
studied

   1.1.3  Implementation of proposal(s)

1.2Subregional harmonization of:

   (a) Pharmacological criteria and requirements for drug registration,
   (b) Criteria for importation and marketing,
   (c) Registration of generic drugs, and
   (d) Standards for advertising.

   1.2.1  Comparative study of each of the aspects selected by the Central
American countries
   1.2.2  Presentation and discussion of a proposal for harmonization on each
aspect studied
   1.2.3  Subregional agreement on the subject

1.3Development of an information system on regulatory decisions

   1.3.1  Design of the system:  definition of the instrument of
dissemination, unit or responsible agency, channels and methods of
dissemination, feedback to be provided by the system
   1.3.2  Implementation of the system:  pilot testing, evaluation, and
adjustment.
   1.3.3  Expansion of the system at the national level
   1.3.4  Creation of mechanisms for exchanging information at the subregional
level

1.4Initial evaluation of progress and/or impact of the component

   1.4.1  Preparation of a report on the current situation (prior to the
project)
   1.4.2  Development of the final evaluation


Expected Outcomes

1. Summary prepared of existing legislation on drugs at the national level.

2. Proposal developed for the upgrading of national legislation on the
   different matters studied.

3. Proposal developed for the harmonization of pharmacological criteria and
   requirements for the registration of drugs at the subregional level.

4. Proposal developed for subregional harmonization and/or a document
   prepared that reviews criteria for importation and marketing in each of
   the Central American countries.

5. Proposal developed for subregional harmonization and/or a document
   prepared that reviews standards for advertising in each of the Central
   American countries.

6.Proposal developed for subregional harmonization and/or national proposals
   developed for the simplified registration of generic products.

7. Definition and implementation of an information system on regulatory
   decisions at the national level.

8. Documents prepared for initial and final assessment of the component.


Distribution of Resources

   (Include Table 4)


Component 2:  Development of Services

      This component is designed to strengthen institutions that provide
health care services and to give viability to professional pharmaceutical
practice as an indispensable aspect of service quality.  It includes the
development and strengthening of hospital pharmaceutical services as well as
the organization and coordination of such services among the institutions in
a given local health system.  It also envisages, at the institutional level,
the systematization of activities for analyzing prescribing practices and
reporting adverse reactions to drugs, which without doubt will lay the
foundation for drug monitoring programs that go beyond the scope of the
present project.

      The first two activities of the component, development of hospital
pharmaceutical services and evaluation of drug utilization, can be
implemented through a systemic strategy because they are interdependent and
interrelated to an increasingly complex degree.  When both activities are
implemented in the same hospital institution they can be systematized and it
is reasonable to expect the pharmaceutical services to be more highly
developed and comprehensive--thus having a more effective impact on the
quality of health care services in terms of drug treatment.  Otherwise, if
they are carried out partially in different hospitals or in only some of a
hospital's clinical units, there is less opportunity to take advantage of the
comprehensive nature of pharmaceutical services and as a result their effect
will be fragmented.  However, even if they are only implemented in part,
benefit will be gained from having laid the foundation for future expansion
to the rest of the hospital, since they can still be systematized after the
project is completed.  Selection of the modality to be implemented will
differ from one country to another, since it depends on factors beyond the
scope of the project.

      One of the factors of greatest importance in this regard is the
availability of adequate human resources.  The development of modern
pharmaceutical services requires the active presence of professional
pharmacologists in institutions and hospitals.  It is also necessary that
such professionals be duly trained and available in sufficient number, which
is not always possible for the institutions or the countries.  Insome countries of the subregion there is a shortage of pharmaceutical
professionals in both the public and private sectors, while others simply do
not have enough active or trained professionals to extend pharmaceutical
services beyond pilot services to the entire institution or to ensure that
such services are more fully developed.

      Another factor that also affects the development of pharmaceutical
services is economic in nature:  the lack or insufficiency of resources to
finance the initial cost and maintenance of the services.  Also, there are
such labor-related factors as the absence of policies regarding job security,
adequate remuneration, and other incentives to reduce the staff turnover
currently being experienced in public institutions, which cuts severely into
efforts to provide in-service training for the workforce and makes it
difficult to recruit the personnel needed.

      In view of the foregoing factors, and in light of the expected outcomes
of the project, it was considered necessary to prepare a development plan for
activities relating to management of the pharmacy unit in each institution
where the project is being carried out.  This plan be form part of the
initial assessment of the component and will cover all the activities to be
carried out during the project period.

      One of the activities envisaged is the development of drug information
services.  These services will be aimed at solving problems relating to the
use of drugs at the institutional level, which means that needs for
information at that level must be identified.  In addition, it will support
such activities as the evaluation of prescribing practices and the
dissemination of bulletins on the subject.  It should be emphasized that
these services will not constitute national information centers but rather
will be supported by centers already existing at the national level.

      Studies on drug utilization, and in particular on the evaluation of
prescribing practices at the institutional level, imply the development of
educational activities such as courses, seminars, and workshops on the
clinical pharmacology and pharmacotherapy of specific groups of drugs in
order to ensure that they are more rationally used and to make it possible to
modify prescribing patterns if necessary.  This outcome will be achieved by
targeting the medical professionals.

      Another activity included in this component is the development of
pharmaceutical services at the local level.  Its most important objective is
to manage coordination of the specific activities in the pharmaceutical area
between the various institutions that make up the local system, including
both the public and the private sectors.  The activities and the type of
coordination required will be defined in terms of the characteristics of each
local system while at the same time leaving open the possibility to develop
standards that apply on a general basis.  The most important characteristics
relating to this activity include:  the predominant interinstitutional and
intrasectoral relationship in the country, the degree of dependency of the
local levels on the intermediateand/or central levels, the type of private institutions operating locally in
the pharmaceutical area, and the availability and interest of unions and
other organized groups at the local and national levels.

      The project also envisages activities relating to the provision of
information and education for patients as actors and users responsible for
the utilization of drugs, the role of these patients as members of specific
risk groups, and the role that organized or unorganized communities play in
this regard.  Its principal objective in this regard is to design educational
programs that are tailored to the cultural characteristics, to develop an
epidemiological profile or identify the principal groups at risk and
determine the educational level of the population, and to implement such
programs through strategies in which they can be systematized.

      Finally, the evaluation activity within this component, in both its
previous and final stages, will attempt to measure the results obtained in
such areas as expenditures on drugs and rational prescribing practices in the
units or institutions where the project is being carried out.


Activities

2.1   Development of hospital pharmaceutical services
      
   2.1.1 Preparation and dissemination of the therapeutic formulary

-  Creation of a Committee on Pharmacy and Treatment
-  Development of the list of basic drugs    
-  Development of the therapeutic formulary
   
   2.1.2 Design and development of a management plan for the pharmacy unit

   2.1.3 Systematization of supply at the institutional level

-  Programming and prioritization of needs
-  Review and updating of standards for procurement and storage
-  Inventory control
-  Distribution systems, with emphasis on combined doses

   2.1.4 Development of drug information services

-  Identification of the needs for information on drugs at the
institutional level
-  Training
-  Design of the institutional program, relationship to the national
information center
-  Provision of bibliographic material
-  Implementation and evaluation of the service
   
2.2Evaluation of the utilization of drugs
    
   2.2.1 Systematization of programs to evaluate intrainstitutional
prescribing practices.  This activity requires full development of
subactivities 2.1.1, 2.1.3, and 2.1.4.

-  Training of responsible professional staff
-  Design and implementation of a system for the evaluationof drug
treatment schemes
-  Systematization of analysis               

   2.2.2 Studies on drug utilization

-  Training in research methodology
-  Studies of treatment groups and/or drugs
-  Analysis and discussion of outcomes

   2.2.3 Systematization of reports of adverse reactions to drugs used in the
system (RAM)

-  Design of the system:  format, reporting procedure, levels
involved
-  Systematization of analysis and assessment of progress

2.3.Development of local pharmaceutical services

   2.3.1 Diagnosis of local pharmaceutical services and proposals for
development.  Determination of the degree of administrative
decentralization at the local level and of standardization at the
central level, as well as the levels of interinstitutional
coordination, including the distribution network in the public and
private sectors and the interrelationship between them.
   
   2.3.2 Development of a methodology for the local programming of needs, and
coordination of decision-making with regard to supply at the
responsible levels.

   2.3.3 Design and implementation of an inventory control system for
institutions in the local system, to be harmonized with the
management information system.
   
   2.3.4 Analysis of the marketing and dispensing systems at the national
level, including the private sector, based on a common protocol
agreed upon by the countries.

2.4Development of information and education services for patients and the
   community

   2.4.1 Research on needs in the area of education:  educational level of the
community, degree of literacy, idiomatic and cultural constraints,
and proposal for a mass communication strategy, toinclude the print media, radio, talks in schools, organized
community associations, and others (through national
universities).

   2.4.2 Identification of high-risk groups on the basis of local morbidity
and mortality by age groups, sex, and specific health conditions.
   
   2.4.3 Identification of the products most widely used in self-medication
(natural, drugs).

   2.4.4 Design and implementation of programs for the provision of
individualized information via labels, information provided at the
time the drug is dispensed, package inserts, and selected
pharmacological groups (through service institutions).

   2.4.5 Development of educational materials and implementation of selected
methodologies (through national universities).

2.5Evaluation of the component, initial evaluation and assessment of impact
   or progress.

   2.5.1 Design of a common evaluation protocol (indicators and methods) and
development of an initial pre-project diagnosis.

   2.5.2 Final evaluation of the component.


Expected Outcomes

 1.Pharmaceutical services being provided in selected institutions at the
   national level.

 2.Institutionalization of Committees on Pharmacy and Treatment.

 3.Implementation a systematic individualized dispensing service in at least
   one hospital in each country.

 4.Studies on the utilization of specific groups of drugs at the
   institutional and local levels.

 5.Implementation of programs for the systematic evaluation of drug treatment
   in at least one hospital at the national level (optional in each country).

 6.Evaluation of prescribing practices at the level of institutions and
   selected local systems.

 7.Design and implementation of a proposal for local programming and
   distribution of drugs in at least one local health system at the national
   level.

 8.Design and implementation of a system for the monitoring of drug
   management at the local level in at least one local health system at the
   national level.

 9.Completion of an analytical study of systems for marketing and dispensing
   drugs at the subregional level.

10.Design, implementation, and evaluation of educational programs for
   specific risk groups.

11.Prepapration of educational material about the products most widely
   consumed in self-medication.

12.Evaluation of the component.    


   Distribution of Resources

   (Include Tables 5.1, 5.2, 5.3, 5.4, and 5.5)



Component 3:  Education

      Basic professional formation and updating, as well as the education and
training of personnel involved in the management of drugs, from prescribers
to dispensers, are decisive factors in the rational use of drugs. 
Accordingly, the project includes activities in this area for both the public
and the private sectors.

      One of the activities envisaged is the introduction or strengthening,
depending on the case, of the concepts of essential drugs and the rational
use of drugs as part of the basic formation of professionals in medicine,
pharmacy, and nursing.  This activity includes a review of academic programs
in pharmacology, clinical pharmacology, and/or pharmacotherapy.  The names as
well as the content of these programs will vary in the different professions
cited and even betweeen different schools within a single profession.  For
this reason, and because it is desired to include studies on drug therapy for
patients, all the possible variants are mentioned.  The review will focus on
building the concept of essential drugs and the practice of rational drug use
into the teaching-learning process.

      By the same token, the project also includes a review and adaptation of
basic curricula for forming the professions cited above.  Since much of the
responsibility for the rational use of drugs rests with the act of
prescribing, and since the medical professional is the person who officially
and most often performs this act, the project includes participation in
curriculum reform for medical studies, to be undertaken in the context of
other projects, with a view to supporting the needed changes in the
teaching-learning process that have been noted in the paragraph above.

     The foregoing notwithstanding, the project also includes significant
support for revision and adaptation of the pharmacy curriculum in view of the
fact that this profession requires a comprehensive overhaul in order to meet
the demands of present-day society--a process not currently supported by any
other project in the area.  It should be pointed out that this is not only a
Central American reality but a regional one, as revealed in the analysis of
pharmaceutical education carried out in 1990 under the auspices of PAHO.

      In addition, in view of the fact that the prescribing and dispensing of
drugs in many health institutions in the different countries comes under the
responsibility of auxiliary nursing personnel, health promoters, or pharmacy
auxiliaries, the project also plans to develop educational activities aimed
at improving the level of knowledge of such personnel so that their
participation in this area will be more effective.

      The project also includes, following a needs and feasibility study, the
systematization of training activities in specific areas of continuing
education, plus training designed to promote the needed integration of
teaching and service.  Of special importance is training dealing with
clinical pharmacology and drug treatment for selected groups, with a view to
promoting a reorientation of prescribing patterns through the more rational
use of drugs.  This activity is closely tied in with the utilization studies
and the evaluation of prescribing practices at the institutional level under
Component 2 of the project.

      It is important to point out that the activities under this component
are directed not only toward personnel who work in the public sector but
also, insofar as they focus on the teaching institutions, toward the private
sector, not only because they involve the basic formation of the individual
but also, in many cases, because such personnel participate in both sectors
and because the programs will also include professionals who are exclusively
engaged in private practice.  This process will emphasize the involvement of
unions in the process as strengtheners and multiplier agents.


Activities

3.1   Basic Professional Formation

      3.1.1  Dissemination of the concept of essential drugs in schools of
medicine, pharmacy, and nursing.

      3.1.2  Strengthening of the teaching-learning process (curriculum and
objective content) relating to pharmacotherapy in schools of
medicine, pharmacy, and nursing.

      3.1.3  Participation in the process of curriculum reform in medical
education being undertaken by other projects in the area.

     3.1.4  Review of the curricula for pharmacy programs using a strategic
approach with emphasis on teaching-service integration.

3.2   Systematization of programs for continuing professional education in
      selected areas

      -  Identification of the teaching and service institution(s)
      -  Training of teaching personnel
      -  Adaptation of teaching material (if necessary)
      -  Programming and development of educational activities

      At the subregional level (under agreements between teaching and service
      institutions):

      3.2.1  Clinical pharmacology
      3.2.2  Administration of the hospital pharmacy

      At the national level (under agreements between teaching and service
      institutions):

      3.2.4  Drug treatment for selected groups
      3.2.5  Administration of the hospital pharmacy     

3.3   Development of programs for updating health workers in the area of drug
      education (under teaching institutions)

      3.3.1  Identification and evaluation of the training and educational
needs of health workers involved in the management of drugs in
public and private sector establishments in the local system.

      3.3.2  Development of teaching materials and selection of an educational
strategy and methodology.

      3.3.3  Implementation of the educational methodology and systematic
evaluation thereof.

3.4   Initial-interim-final impact assessment of the component

      3.4.1  Preparation of the initial report prior to execution of
activities under the project.
      
      3.4.2  Final evaluation of the component.


Expected outcomes

1.    Proposal developed for reform of the pharmacy curriculum.

2.    Work under way on a proposal for the reform of pharmacy studies in at
      least one school of pharmacy at the subregional level.

3.   Curriculum review under way and the respective proposals developed for
      improving the courses in pharmacology, and/or pharmacotherapy in at
      least one school of medicine, two schools of pharmacy, and one school
      of nursing.

4.    Three activities under way in each country for disseminating the
      concept of essential drugs at the national level.

5.    Teaching resources trained to give courses in specific drug-related
      areas at the subregional level.

6.    In-service training programs under way pursuant to agreements between
      teaching institutions and service providers in at least two
      institutions at the national level.

7.    Teaching materials prepared for health workers on the subject of drugs.

8.    Component evaluated.


Distribution of Resources

      (Include Tables 6.1, 6.2, 6.3, and 6.4)


Component 4:  Project Coordination and Management

      The annual plans of work presented in this proposal will be reviewed
and tailored for implementation at the national and subregional levels in
annual subregional meetings of national representatives designated by the
Governments.  This plan will be developed in every country under the
supervision of intersectoral committees coordinated by national
representatives or focal points, and support will be provided for contracting
national and international experts as needed.

      At the subregional level the technical and administrative coordination
of the plan agreed upon will be carried out through the subregional manager,
and it will be implemented in concert with other projects under way in the
subregion in the area of drugs.

      PAHO's Regional Drug Program will continue to cooperate with the
projects under way and will incorporate support for this new project in its
plans of work.

      The assessments envisaged for the components of the project will be
carried out utilizing a common protocol for the countries in which the
activities are being carried out.  Preferably they will be performed by
external personnel.  These assessments will be conducted without detriment to
the final evaluation of the project, which will be undertaken jointly with
the donor agency based on a profile prepared by mutual agreement.


Activities

4.1   Coordination and regional and subregional support

      4.1.1  Subregional coordination
      4.1.2  Secretarial and administrative support

4.2   National coordination

      4.2.1  Subregional meetings


Distribution of Resources

      (Include Table 7)

ENDNOTES


1Plan for Priority Health Needs in Central America and Panama [published in
Spanish as "Evaluación del Plan de Necesidades Prioritarias de Salud para
Centroamérica y Panamá," PNSP/90-17].

2VII Special Meeting of the Health Sector of Central America (RESSCA).  Final
Report.  Guatemala, August 1991.

 

ACUTE RESPIRATORY INFECTIONS


During the 1994-1995 biennium priority will be placed on the development of two
components of ARI control:  activities at the local health service level and research.


HEALTH SERVICES


The Program has focused initially on the development and distribution of technical standards
and materials that will help the countries to establish national ARI control programs within the
primary health care system, including training courses for national program coordinators, standards
of case management, a treatment manual for physicians and supervisors, technical outlines,
audiovisual aids, and bibliographies.  In addition, steps have been taken to establish ARI training
units (ATUs) to provide clinical training in the treatment of ARI in the developing countries. 
Methodologies are being developed for the monitoring and evaluation of both the Regional Program
and the national programs.  Efforts in this connection include the preparation of manuals for surveys
on morbidity from ARI, practices that are followed in the home for the treatment of patients, and
clinical practices in health facilities.  Another important aspect of case management is the
surveillance of drug resistance of the principal bacterial agents that cause pneumonia.  A manual
containing recommended surveillance procedures is currently being developed.


Work will continue on the development of ARI control activities at the local health service
level through:

-            Consolidation of the updated PAHO/WHO guidelines for the diagnosis and treatment
of ARI in all the countries of the Region.

-            Advice on the preparation of national operational plans for ARI control, including all
the components--training, monitoring, supervision, and provision of supplies and
drugs--in the context of the comprehensive health care for children.

-            Support for national courses in the organization of ARI programs and courses at the
state or provincial level in supervisory abilities in ARI control.

-            Promotion of training activities with educators in the pediatrics departments of schools
of medicine and nursing.  This will be a joint effort carried out in collaboration with the
Program on CDD.


RESEARCH


The research component is intended to strengthen the scientific bases of the Program and
determine the best means of applying available knowledge and implementing control strategies at
the country level.  Research priorities to be promoted during the biennium include:  (i) clinical
research to determine the most reliable signs and symptoms for the diagnosis of pneumonia and
other serious cases of sepsis of bacterial origin during the first months of life, as well as to identify
better criteria for the diagnosis of pneumonia in infants and children; (ii) behavioral research to
determine the knowledge, attitudes, and practices of families in relation to the recognition of
pneumonia, the decision to seek outside help, home treatment of ARI, and adherence to the
recommended treatment regimen; (iii) health systems research to evaluate the cost and
effectiveness of the case management strategy when it is applied in selected national ARI programs,
with a view to evaluating drug use in ARI control programs and defining effective communication
strategies to promote early recognition of pneumonia; and (iv) research on disease prevention,
particularly field tests in the developing countries to determine the effectiveness of new vaccines
against the principal bacterial agents that cause pneumonia in infants and young children.



ACTIVITIES TO BE CARRIED OUT DURING THE 1994-1995 BIENNIUM                                                                               


i.           Support for the countries in the preparation and later follow-up of the implementation
of a National Plan for the ARI Control Program, with special emphasis on evaluation
of the epidemiological impact and the process.

ii.          Incorporation of ARI control activities into the existing health structures of every
country.

iii.         Integration of pharmacists, practitioners of traditional medicine, and other segments
of society into the Program so that, in coordination with the public sector, they can
participate in the execution of activities under the ARI Control Program.

iv.          Strengthening of the coordination of National ARI Control Programs with pediatrics
societies, clinical and public health physicians, and schools of medicine and nursing
with a view to disseminating the standard case management strategy as well as
general information about the Control Program and encouraging the incorporation
thereof into curricula for the formation of health personnel.

v.           Provision of theoretical and practical training for all categories of health workers at
the first level in standard management of ARI cases in children, as well as in the
development of supervisory skills and the organization of national control programs
in all the countries of the Region of the Americas.

vi.          An effort will also be made to extend training in standard ARI case management to
health personnel in the private sector and social security institutions, as well as to the
NGOs that carry out activities in the countries.  Activities to train community health
workers will be initiated once the health workers in the public and private sectors have
received their training.

vii.         The Plans of Action should firmly support self-sufficiency in the procurement of
antimicrobial agents and other supplies for standardized case management in the
countries, as well as the coordination of National ARI Control Programs with the
National Program on Essential Drugs.

viii.        The communication component is crucial to the success of the National ARI Control
Program, since it will play a key role in the education of mothers and other persons
who care for children in regard to home treatment of children with ARI.  In this
connection, it will be important to carry out research on the knowledge, beliefs, and
practices of families with regard to ARI, as well as to develop, test, and evaluate
communication materials.




DECREE I NUMBER 1811 of August 6 1990.

By the which there is regulated partially Law 10 of 1990, in regard
to the health services delivery to the indigenous communities.

THE CHAIRMAN OF THE REPUBLIC OF COLOMBIA

in use of its constitutional and legal faculties, especially the
conferred by article 120 of the political Constitution;

C Or N S I D And R To N D Or;

That in accordance with law 10 of 1990, health is a public service
to whose provision have right all the inhabitants of the national
territory;

That it inhabits in Colombia a grown number of indigenous
communities of different ethnic origin and in very varied
circumstances of economic, social and cultural origin but that
require a constant and effective health services delivery;

That Colombia has subscribed to and ratified various agreements and
declarations of international character; that it commits its
responsibility, not only in the protection of life and of the
physical goods of these communities, but in the set of its cultural
heritage of leagues, forms of social and economic organization,
tradition mítica and religious, technical of work, education and
other specifications of a model of life;

That the fulfillment of the responsibilities indicated, not only
that determines the success of the health programs that are provided
to such communities, but the applicability and full effect, among
the members of the indigenous communities, of the rights and
fundamental garantias in the Universal Declaration of the Human
Rights, signed and ratified by Colombia, especially of those to
which refer the articles // 1, 3 and 18 of said Declaration.

That within the set of the values of the indigenous cultures,
knowledge and skills own of its traditional medicine have done
contributions of high interest to the prevention and cure of certain
diseases, and continue fulfilling a fundamental role both in health
of the referred communities and in the supervivecia and the
development of its community life.

That law 10 of 1990 establishes as principle for the provision of
the health public service, the right of the community to participate
in the processes of diagnosis, formulation and preparation of plans
and program and projects, decision-making, administration and
management, related to the health services.

That the reasons indicated concur as a whole, to justify and to
apply the desirability and need for seeking, in the cumlimiento of
all the plans and health actions that are going to be carried out
among the indigenous communities, a solid alliance between these
last and institutional medicine, that promotes and favors permanent
forms of dialogue and that supports the autonomia of the communities
in the design, realization // and control of the health programs.





D And C R And T To;



ARTICLE FIRST - The health services delivery to the       indigenous
communities of the country will be fulfilled
hereinafter subject to the provisions of the present
Decree.

ARTICLE SEGUNO.  -   Everything programs, in general, every health
action that is planned to advance in indigenous
communities should be previously agreed upon
with them and approved by the respective
cabildos of authorities that perform the
internal government of the same.

PARAGRAPH .-    For the purpose of guaranteeing decisions basically
in own mechanisms of community discución and
decision-making and to devote the sufficient time to
the analyses and preliminary discuciones to such
agreements.  To the discuciones, the traditional
authorities can, invite to the indigenous
organizations or any another person that sees fit.

ARTICLE tercero.-    The formulation and execution of health
programs in the indigenous communities, should
consult and take advantage of the reflections,
works and studies carried out in this matter
and define methodologies in order to increase
and purify the experience in said field.

ARTICLE cuarto.-     The Ministry of Health, Bureaus        
Sectional and Local Health, in whose
jurisdiction exist indigenous communities, will
do agreements with the Schools of Health
Sciences, so that these orient programs or
contents of formation aimed at providing
professionals and socially aware technicians
and trained for the work with indigenous
communities.

     So much in the design and in the execution of such programs of
formation, one should guarantee a broad participation to the
indigenous communities.


ARTICLE quinto.-     Hereinafter the selection and the work of
thehealth promoters in the indigenous
communities will be submitted to the following
general standards;

a>   The selection of the promoter will be done by the interested
community and will be ratified by the traditional authority of the
group.  The position, the training and the functions of every
promoter, will be defined in accordance with the community, taking
into account the needs of this and the characteristics of the
candidate.

b>   The Sectional and Local Health Bureaus will provide the means
necessary for the fulfillment of the functions of the promoter. 
Similarly, they will define and they will adopt a model of education
of the promoter and a system of frequent and regular contacts that
make it possible to support and to improve its actions and
knowledge.  In the fulfillment of these last responsibilities there
will be had as a purpose of priority interest the establishment of
an adequate network of radio- communication.

c>   The health promoters of the indigenous communities will have
the character of permanent speakers among the communities the the
Sectional and Local Health Bureaus for the execution of the actions
and programs agreed upon.

d>   The cabildos or captains or, in general, the own traditional
authorities of the communities, in coordination with the sectional
and local health respective agencies, will perform surveillance and
the control on the progress of the health programs, both in the
fulfillment of the promoter and in the use of the resources destined
to such programs.

e>   The too much small indigenous communities, in order to justify
the creation of a position of promoter, that for special cultural
reasons, linguísticas or of asilamiento, cannot enjoy the services
of the most nearby promoter, can demand-obtain from the Sectional or
Local Health Bureaus the training of one of its members as
volunteer, whose I work will be governed by the same standards that
in this // decree govern for the promoter.  They cannot the
Sectional or Local Health Bureaus, so pretext of the provisions in
this literal, avoiding the due coverage of the wage to the
indigenous promoters, nor the responsibility of creation of the
positions of promoters when the conditions and needs thus demand it.


ARTICLE sexto.- The health services delivery for theindigenous communities will be free.   It does not exclude that
which the communities, in harmony with its cultural tradition, can
covenant against benefits to the received services, but in such
case, happinesses against benefits will have to be represented in
commitments or actions decided by the community itself and oriented
to carry out works of community interest that facilitate the success
of the health programs.


ARTICLE septimo.-    With the purpose to fulfill to the previous
article and to give application to the ordered
in article 19 of law 51 of 1967, the Ministry
of Health, with the collaboration of the
Sectional and Local Health and indigenous
Bureaus the communities themselves, will study
and will adopt formulas adapted in order to
expand the resources that demands the
fulfillment of such commitments.

ARTICLE octavo.-      The Ministry of Health will create a group of
attention in health made up of staff members
with experience in this field, with dedication
exclusive and with the following functions;

a>   To define the general policies for the health services delivery
in communities indígenas,con arrangement to the provisions of this
decree.

b>   To centralize and to disseminate the reflections and
experiences in the health services delivery to indigenous
communities.

c>   To advise the Sectional and Local Health Bureaus for the
adequate provision of such services.

g>   To design special solutions of epidemiological information that
make it possible to establish the state of mortality of the
communities.

h>   To coordinate with the Division of Indigenous Matters of the
Ministry of Government and with the other state entities that have
responsibilities with indigenous communities, the formulation of
health policies and of development, in order to guarantee a coherent
and effective action of the State in the indigenous communities.

f>   To promote research on conditions and mechanisms of dialogue
between the indigenous communities, their health systems and
institutional medicine.

ARTICLE noveno.-     The health agencies of sectional direction inwhose jurisdiction exist indigenous communities, integrated a group,
or designated a staff member for the fulfillment of the following
functions:




a) To assume the responsibility of the adaptation and execution of
the general policies for the provision of the health services of the
indigenous communities.

b) To coordinate and to supervise the health services delivery to
the indigenous communities, by the `Municipios` and Institutions of
their area of influence, asi how to coordinate, with the regional
office of the Division of Indigenous Matters of the Ministry of
Government and other state entities, the adequate provision of
services in the department, intendancy or commissary. 
(clarification these two last denominations were changed according
to the new political constitution of the Pais reformed in 1991.)


c) To coordinate with the provider institutions of services of the
respective `Municipio`, the attention to patients from the
indigenous communities in accordance with the provisions of the
present decree.

TRANSITORY PARAGRAPH.  In those places where there has not been
satisfied the agency of local direction, or that this could not
assume the functions assigned in the previous article, the Sectional
Bureau, in development of the prinicipio of solidarity, will assume
them.

ARTICLE TENTH-PRIMERO.-/The relationships among the indigenous
communities and the agencies of sectional and local direction,
regulated by articles 9 and 10 of the present decree will be carried
out without detriment to the right of the communities to form part
of the agencies of community participation of the health system.

ARTICLE TENTH SEGUNDO.-/The present decree governs beginning in the
date of its publication.


PUBLIQUESE AND CUMPLASE 6 AGO 1990

MINISTER OF GOVERNMENT.

MINISTER OF HEALTH.
     







PAN AMERICAN HEALTH ORGANIZATION

REGIONAL PROGRAM ON WOMEN, HEALTH, AND DEVELOPMENT











FINAL REPORT OF THE RAPPORTEUR

LATIN AMERICAN WORKING GROUP ON
"WOMEN, HEALTH, AND SELF-CARE"












6-8 November 1991
Cali, Colombia





 CONTENTS

Page



INTRODUCTION                                                1


1.   PARTICIPANTS:  WHO WAS INVITED?                   2


2.   METHODOLOGY: HOW WAS THE MEETING CARRIED OUT?     3


3.   DISCUSSIONS OF THE WORKING GROUPS:                     9
WHAT CONCEPTS WERE PROPOSED?  


4.   THE SOCIALIZATION                                      11
     OF SELF-CARE:  WHAT WERE THE PRINCIPAL
     METHODOLOGICAL PROPOSALS?                    


5.   HEALTH POLICIES:  WHAT COMMENTS WERE              12
     MADE ON POLICIES SPECIFICALLY RELATED TO WOMEN'S
     HEALTH AND SELF-CARE?                                  

6.   GENERAL RECOMMENDATIONS                                13

     6.1  The Concept of Self-care                          13

     6.2  The Content and Priorities of                14
Self-care                                    

     6.3  The Socialization of Self-                   15
care as a Health Practice                         

     6.4  The Role of State Institutions               16
and Nongovernmental Organizations       

7.   CLOSING PLENARY SESSION AND REMARKS BY THE MINISTER16
     OF HEALTH OF COLOMBIA                        

8.   ANNEXES                                                24

     8.1. Convocation                                       24

     8.2. List of Participants                         25

INTRODUCTION

      During 1991, the PAHO Program on Women, Health, and
Development promoted a number of scientific and cultural activities
in the Region aimed at dissemination, study, discussion, and
analysis, especially on topics pertaining to the health of women. 
In general, all these activities employed gender studies as their
theoretical referent, enriching the discussions in the consultative
groups, seminars, workshops, and conferences held throughout the
year in Latin America.

     In particular, the Working Group which met in Cali, Colombia,
from 6-8 November 1991 on the subject of "Women, Health, and Self-
care" brought new dimensions to the concept of self-care, and
contributed to rethinking the meaning of health based on the
knowledge and feelings of the women and men consulted.

     The meeting was enriched by the diverse origins of the
participants.  Those present included poets, artists, painters,
community representatives, communicators, sociologists,
psychologists, sexologists, public health specialists, nurses,
physicians, educators, anthropologists, demographers, social
workers, and lawyers--a group of women and men from 14 countries of
the Americas.  They worked in a joyful setting, surrounded by
nature, a setting which contributed greatly to fostering the various
working dynamics in which participation, creativity, and
companionship created a solid foundation for intellectual activity
and attainment of the goals projected by the Organization.

     The central theme of the gathering--"self-care in women's
health"--was set forth in a crucial discussion dealing with theories
of development, social participation, social medicine, and gender. 
In recent years these theories have incorporated new concepts that
give priority to the subject of women.  Such themes as women's
historically marginalized position in economic, social, cultural,
and political terms; their exclusion from public life and from the
locus of power and decision-making; their maternal function, which
takes on overwhelming dimensions and is turned into the object of a
medical practice concerned mainly with biology; their image of
submission, weakness, fragility, and subordination gave the Working
Group ample subject for debate and for an analysis of the various
phenomena that circumscribe, limit, and restrict the lives of women.

     In light of current theories that have opened a dialogue about
human development, about democratic participation within civilian
society, and about the concept of health from a perspective which
values the right of women to their own lives and to make decisions
on both public and private matters, the proposed study of self-
care had special implications.  It meant, first of all, the opening
of a field of study that can strengthen efforts to achieve new
sociocultural dimensions in women's health.  Secondly, it implied
steps to reformulate the concept of self-care (traditionally
directed toward the short-term management of health problems,
usually related to surgery or chronic diseases) by valuing the
woman's self-determination, self-esteem, and autonomy, making her
the actor in a primary plan of intervention and decision-making. 
Third, it implied an effort to maximize the social and human
development of women in light of demands for their rights and
liberation, their differences as a gender group, and their full
participation in the protection of their own health.


1. PARTICIPANTS:  WHO WAS INVITED?


     As mentioned previously, this event, facilitated by PAHO's
Program on Women, Health, and Development, fit within the
comprehensive Work Plan developed in 1991.  In particular, the
subject of self-care required an approach that would articulate it
to the discussions of gender.  There was a need for fresh views and
opinions, as well as renewed challenges and commitments tied to
paradigms that assert principles of equality, democracy, and dignity
among human beings.

     The convocation was issued to women and men who, in one way or
another, have promoted in their home regions efforts related to
development on a human scale, social participation, and social
medicine; to members of women's movements; to representatives of
international organizations, state agencies, and nongovernmental
organizations; to experts in the mass communications media; to
persons involved in alternative forms of health care; to feminist
spokespersons; to artists who explore the subject of women in their
art; and to government officials responsible for defining policies
related to women's health and implementing programs of service.

     In particular, Colombia's Minister of Health Camilo González
Posso enriched the discussions with his frank, informal, open, and
spontaneous remarks.

     The following excerpt from the Minister's statements is of
special note:

Self-care in women's health has a social and cultural
dimension.  It is not simply an individual matter, as one
might assume; it does not mean that each woman takes
responsibility for her own health, but rather that
responsibility lies in the hands of a social movement of
men and women, under the leadership of women, in support
of women's health.  It relies on the family, on self-
management, and on self-determination; it is a movement,
it is a force that is unleashed for the purpose of
transforming a history of oppression, of inequality, and
of privileges nurtured by "machismo," among other things,
and grounded in a diverse array of structures ...

When we talk about leadership, we are referring to the
social recognition of these structures and also of the
distribution of power in society.  A thesis I think it
important to point out is that the formation of that
social force, of that social movement and that new
leadership of women, can be a crucial component of a new
policy.  I believe that it is work for an
interdisciplinary team of women and men attempting to
reformulate policies regarding women.

     The foregoing political points and the reflections generated in
the working groups comprised a rich body of theoretical material
that, jointly with the proposals for intervention aimed at health
protection and the use of self-care measures, could in the near
future become part of the Action Plan of PAHO's Program on Women,
Health, and Development in the Region of the Americas.


2.   METHODOLOGY:  HOW WAS THE MEETING CARRIED OUT?


     The gathering employed the "working group" modality.  It was
believed that this framework would facilitate collective
participation based on the diverse disciplines, experience,
knowledge, and views of the participants.  It drew in the subjective
aspects, sensitivity, and personal histories of those present. 
Health was not considered solely in rational terms, but also in
relation to feelings, the complexity of human beings, and the
specific experience of women.  Expression of feeling took place
through music, poetry, and the recovery of words describing
tenderness, love, desires, and emotions.

     The musical and poetic interludes created playful moments which
were supremely enriching and which helped to express the cultural
diversity of Latin America as represented by the participants at the
meeting.  The theme of self-care came out especially strongly in
those songs and verses which, like the following, were written by
the male participants from Cuba, Bolivia, and Colombia:
From all the countries            From all the countries   
They've come to speak         Good people have come
About self-care               All have experience
They cannot be silent.             To speak to this theme.

For three days running             After all the discussions
Everyone on this hill         About self-care
Has worked most seriously     The male contingent
Imagine how the hormones feel      Has been quite transformed

Talking about the concept     Self-care, self-esteem
Opinions were aired                And self-affirmation
It's sure that our hearts     Self-consciousness, self-pride
Are moved by self-care.            And self-transformation.

Each group always had         Would it not be better
Someone to serve as reporter       To change the term self-care
What onerous work!                 So that its rich meaning
Applause is in order.         Will not be so limited?

When I hear so many women speakThis group of women
about self-care               Is a bouquet of flowers
My heart leaps                     Self-care became
When they pass by my side.    a waterfall of love

Self-care, self-esteem             They call us machista
Concept and definition             Sexist and sly
For these three days          Can't they see
What impressive discussion!        Through to our hearts?

Women are the majority here        We men also have
We men are few                     Emotions and sweetness
Thanks to self-care                Affection, warmth, feelings
Our energies were spared.     Love, passion, and tenderness.

     Reflections on the human body and recognition of its vitality
and need for care also contributed to creating an atmosphere of
affectionate, spontaneous, and informal relations.  One of the
female participants who supervised the practice of self-massage
said:  "The recovery, improvement, and well-being of our bodies are
among the rights of women.  Care of our physical and mental health
must be based on a collective questioning of what is happening to us
and why ... With exercise and with an adequate combination of rest
and silence, the body is strengthened, metabolizes food, resists,
grows, achieves balance, transforms itself, is reborn, is liberated,
and is revitalized."

     The recognition of physical affection, movement, rest, and food
as essential to the harmony of the body was an important reflection
that contributed to understanding the meaning of health and the need
for self-care.  In response to the interest in learning about
practices and exercises for relaxation and pain relief, those
persons who wished to do so programmed extra meetings that became
occasions for learning, closeness, dialogue, and enjoyment through
the practice of self-massage and relaxation.

     The methodology was characterized by the variety of techniques
brought to bear on the different subjects and discussions.  At the
start of the meeting the mood was set by the presentation of a film
on the life of the famous Mexican painter Frida Khalo.  This woman,
who from infancy was marked by pain and by physical limitations due
to an incurable disease, led her life as a painter (she is
recognized today as a leading Mexican cultural figure) focused on
the subject of her own body, which became the "axis of her pictorial
universe."  Her life was a story of political commitments, of love
relationships charged with affection and animosity; she lived every
minute of her existence intensely.  Frida was a woman who faced
constant doubts, conflicts, and contradictions.  One of the
participants at the meeting, a painter and student of the life of
Khalo, commented:


Frida strived for physiological nakedness: feeling
herself, seeing herself, painting herself, fixing herself
in order to accept, love, and cure herself of the rigid
embrace of the corsets, crutches, and canes ... Face to
face with the harsh reality of her tragedy, she dressed
up in the finest traditional clothing of Mexican folk
culture, and in doing so, banished the image of her weak
and shriveled leg.  She adorned herself with pieces of
antique jewelry ... little by little, in the hours she
passed before the mirror, she transformed herself into a
work of art reflecting the various regions and cultures
of Mexico ... Feeling herself the maker of her own
history, as painful as it was ... she becomes color,
owner of her name, vibrating space and although she was
ill, she succeeded in breaking through the walls and
transformed her pain into an all-embracing tolerance of
her different states of health.


     From the standpoint of methodological process, to have started
off the meeting with a film on the real life of a woman like Frida
made it possible to create an atmosphere open to the world of
sensations; it created channels for analysis, discussion, and
reflection on the complex realities involved in human existence.  

     It became possible to rethink the concept of health, using
referents which differ from the rigid scientific theories that blur
the complex world that envelopes a person at her different moments,
in her feelings, in her illnesses, and in her personal realizations.

     Accordingly, the Working Group became increasingly immersed in
the discussion of various matters that bear on women's lives:

     ·    The sensitivity, expressiveness, vitality, and
emotionality rooted in the condition of "being female,"
and socialized through cultural practices that liberate
the woman from her bonds or which, alternatively,
restrict and oppress her.
     
     ·    The sociopolitical events that define a large part of her
options as a social being.

     ·    Romantic relationships carried out amid conflicts,
emotional battles, and choices.

     ·    Experiences linked to alcoholism, smoking, and use of
tranquilizers.

     ·    Pain and feelings of loneliness and abandonment arising
from the loss of loved ones.

     ·    Suffering from disease and its effects on women's bodily
integrity, on their psyches, and on their daily lives.

     ·    Sexuality and its manifestations in terms of the
expressiveness and unique nature of the female being. 
Her need for affection and her various forms of
expression in response to eroticism, sensuality, and
tenderness.

     Together, these reflections provided new angles from which to
rethink the concept of self-care.  The methodology unquestionably
contributed to achieving a collective participation rich with
meaning, solidarity, and commitment.  Various thoughts expressed by
participants reflect the level of dialogue and of sensitivity
attained in the encounter:  "This meeting is taking place in a
different kind of environment, and with a different methodology as
well."  One wonders: what created this environment?  We can say that
in this particular case, several things happened:
 
     First.  It was not an open and unrestricted meeting.  The
people who were invited had prior knowledge of the convocation. It
was not expected that they would prepare papers, nor that an expert
would present his or her work.  The important thing was to have
invited individuals with a commitment to the issue, from different
angles.  It was obvious that these were persons who lived their
work, and lived it with great intensity.  That is, their
professional activities were not only professional, but were linked
to the struggle for women's rights and thus to the validation of
women.  Such persons obviously gave a particular direction to the
meeting.  This was in fact foreseen in designing the methodology,
with successful results since it ensured that the preparations were
not in vain.  These were persons who not only worked in promotion,
but also worked to shake things up, and who had great capacity to be
moved and changed themselves.  These characteristics ensured that
the human input into the workshop rendered it a special event.  An
example was the recital which took place on the second night of the
encounter, featuring poems such as:


My house, my body
I touch you with my hands
soiled by contact
with contradictions.
I come from the night,
I was an accomplice to its lies.
From the bridge I have seen
many dreams drift away, lost 
in the haze of cigarette smoke.
The city was a woman
with red lips and a faded dress
and a clenched heart
after weeping.
My house, my body
the door does not open from within.
The blood trembles still,
while I loosen my sandals
and cast off my clothes.
I want to reach you
stripped of words,
inhabited by silences,
so that you recognize me
and I can then return to you
to my
house
my body

Meisy Correa
Colombian Poet



     Second.  The film presented was well chosen, among other
things because it took into account the particular
characteristics of the audience.  That is, the film touched a
sensitive nerve in people:  it was the story of a woman who
moves in a political world, who is committed to her people,
who is an incredibly emotional person, a person who feels,
who is touched, who is hurt by things, who expresses, who
approaches what she does with great vitality; who lived with
pain in a certain way and who found herself in that pain in
order to create artistic works of great interest.  This
window on the life of Frida Khalo, we might say, in some ways
revealed an image that connected to those present at the
meeting; she was not a strange figure.  She evoked for us
memories of lived images and of ways of seeing the world.  In
this sense the film was a narrative that in some ways
mirrored the situation of those present.  As a result, it
clearly uncovered and unleashed a great deal of
expressiveness in the meeting.  From this perspective the
film was successful; not because it was important to begin
with a film, or because it would be interesting to begin with
an audiovisual, but because in this case, the subject of
Frida Khalo reflected feelings and experiences of the women
and men who were at the meeting.  It touched us; and touching
us, it uncoiled springs within us.  As a consequence the
meeting had, from the outset, an atmosphere of great
expressiveness.

     We begin to express ourselves--after seeing the film--
from different perspectives:  about what we felt, about what
we lived.  From the beginning, therefore, sensitive nerves
were touched which resulted in richer and more creative work
sessions.  The film was a message for many of the women: 
women who are searching, women involved in very specific
work, who are creating, who have moments of solidarity. 
There were identities and images that reflected their own
commitment.  This transformed the nature of the encounter and
acted upon the emotions of the people present.  They began to
speak from their own emotions rather than in purely rational
terms.

     Third.  "We believe it was a good thing that the working
group was kept constant.  The continuity of participants
throughout the meeting made it possible to work from a common
base, familiarize ourselves with the language, and get to
know one another.  In a small working group each person
begins to live the experience of the other.  For example, the
presence of a person whose work was of a very intense nature
helped one of the groups to keep its feet on the ground-
-she always offered very concrete empirical observations,
corresponding to real situations, which helped us avoid
remaining in a purely speculative mode."

     Fourth.  "Another extremely important element was the
subject of self-care.  The document of reference for the
meeting outlined a framework that departed from the theme of
bodily self-care and women's hygiene.  The document treated
the subject within a much broader context, within a social
and political context.  This tied in with the themes of the
film.  The subject of self-care when raised in this way, when
understood like this, broke with a simple approach, giving
the term a different meaning than it traditionally has.  In
other words, the title no longer matched the script.  It was
very important to begin to see self-care from a completely
liberating perspective, from which, upon reflection, people
began to look at ways of achieving a utopia."

     Fifth.  "A thought which came to me, from a masculine
point of view, was that the framework for this concept is
also valid for men.  To conceive of self-care in terms of a
liberating struggle is to regain a bit of life and to reunite
a divided humankind.  It is the cry of a new humanism, which
is a meaningful idea for all downtrodden groups who in some
way have suffered a slight to their humanity."
 
     Sixth.  "There were languages other than the spoken word. 
There was a great deal of syntony that manifested itself in
emotion, in the belief in one another, in the recognition of
who each person was.  There was a substratum and a wavelength
for non-verbal communication.  

     The importance of this type of communication, from the
rational perspective, was that it evoked other things; it
brought to the surface elements that verbal communication
does not touch because they are considered vulgar or
irrelevant or non-professional, but through this language,
many ideas about self-care emerged and were then taken up at
the rational level.  In other words, emotion and affection
were very important because they reinforced commitment,
enabling people to see one another in different ways; the
symbolic language fostered tolerance.  In one way or another
it highlighted the human elements that often pass unperceived
and weakened in the theoretical reflections carried out in
traditional meetings.  The recognition of love and the
affectionate interpersonal relations were a key aspect of
this encounter on self-care."

     Seventh.  "Another important element was the success in
going beyond speech-making.  Participation was very frank and
open; the methodology made it possible for people to open up
and express themselves.  The exercises on relaxation were
very important.  Dealing with the language of the body in
societies that are not comfortable with bodily contact
clearly produced a series of quite unusual sensations; to
recognize the significance of touching oneself, the
importance of showing affection toward oneself, gave rise to
very special reflections and experiences for those present at
the meeting."     


3.   DISCUSSIONS OF THE WORKING GROUPS:  WHAT CONCEPTS WERE
     PROPOSED?

Self-care is the practice that enables
the woman to realize her dreams

Gustavo I. De Roux
     

     All the groups began by broadly analyzing the historical
subordination of women, using the theory of gender as their
base.  They were in agreement with the concept that
oppression based on gender does not originate in biological,
social, or cultural differences, but with the concept of
these differences as inequality.  It was pointed out that
such differences in and of themselves do not constitute
inequalities, and that it is not a question of attempting to
ignore differences, but rather of treating what is different
according to its specific and unique nature. 
 
     The participants also discussed power relationships,
which have caused differences between the sexes to serve as a
basis for a treatment of women characterized by inequality,
oppression, subordination, and injustice.  There was
particular emphasis on the situation of subordination and its
destructive effects on the woman's personal ego, which has
led her to turn herself into a socially diminished being, to
fulfill stereotyped functions and roles, and to be defined as
a person basically tied to domestic life and excluded from
public life.  She is conceived of in terms of service "to
others" and not to herself, leading to the neglect of her own 
needs, interests, and motivations.

     The early discussions also included an historical
analysis on the evolution of the concept of self-care. 
Traditionally this concept has been propounded by organicist
and biologicist currents which have interpreted self-care as
consisting of practical measures for the control of
dysfunctions associated with chronic illnesses or surgery. 
It was judged that approaches of this kind derived from
atomist and reductionist ideas about disease and about
disorders that affect the individual and the world around
her.  The working group, opening the discussion from a
different theoretical base, considered self-care to be a
polyvalent category tied to conceptions of an ethical-
philosophical nature, which have as their axis the active
intervention of the person in all aspects of his or her life,
body, and health; as such it is a social, individual, and
collective phenomenon.  From this perspective self-care
manifests itself in daily behavior and practices that are
employed at various moments in a person's life.  In the
discussions self-care was also considered as a political
concept, to the extent that it broadly questions both the
power relations in the society and the relationships between
men and women, especially within health institutions, where
"medical knowledge" is accorded higher status than "popular
knowledge" and the ancestral knowledge women have about their
bodies and illnesses.  Self-care is also a political question
because it requires the State to formulate proposals that
recognize the theory of gender as a basis for justifying
activities related to women's health, as well as for
negotiating and demanding their rights to a dignified and
healthy life.  

     Self-care was conceived, in turn, as a strategy that
permits the woman to take possession of her own body and to
become aware of it; to become the maker of her own destiny. 
In this sense self-care is more than a mandate from the
health institutions and or a "duty" associated with maternal
functions; it must be seen as an internal process, the core
of which is love and respect of one's self.  Self-care is a
point which is reached via processes of self-discovery and
self-building that allow the woman to get in touch with
herself and to reverse the "feminine" mode of "living for
others."

     Yet another aspect of self-care is constituted by
decision-making and self-determination at the individual
level, which contributes to the development of specific and
consistent practices with postulates rooted in the theory of
gender.  Self-care also was conceived in the twin dimensions
of the individual and the collective, two poles that are
inextricably linked and that give feedback to each other in
various ways.  At the individual level it permits a
reaffirmation of the feminine ego; the individual cannot be
reduced to her physiology; the individual implies a holistic
conception of the human species.  At the collective level it
depends on the recognition and knowledge that the woman
herself has of actions that promote her health.

     From this perspective self-care can be formulated as a
public policy, which involves shared responsibility between
the individual and institutions; it cannot, in fact, be
understood as an individualistic attitude, nor as an approach
that relieves the State of its responsibilities and duties
regarding public health.  Neither is self-care to be
understood as a set of directives that mandate standardized
practices without room for differences among women.  It
begins with recognition of the diversity in socioeconomic
relations, in cultural patterns, in ethnic origins, and in
religious beliefs.

     Self-care does not imply that one must "do things alone"
without help from anyone.  It is not an invitation to
autonomism, nor to self-reliance.  It favors shared
management and collaborative efforts between communities and
the institutions.  In this regard it demands that health
officials, both men and women, understand and care for health
based on a conception of gender; this involves the need to
define processes for the resocialization of officials about
health concepts and practices, so that they come to view
women's health in the context of women's specificity as a
human group, with a shared identity and history.


4.   THE SOCIALIZATION OF SELF-CARE:  WHAT WERE THE PRINCIPAL
     METHODOLOGICAL PROPOSALS?

     The groups departed from the premise that their method
should be articulated to a theoretical conception.  From this
standpoint, the methodology takes shape in a pedagogical
development of the theoretical propositions.

     In order to deal with the methodological structures in
self-care, the first question must address the historical
location in space and time of the women who are involved as
subjects of the process.  Another aspect to consider is their
participation in the delineation of policies, programs, and
plans, based on the specifics and needs they themselves have
identified, in accordance with their ethnicity, religion,
culture, and social group.  (For example, to promote:  a) the
involvement of adolescent mothers in defining measures
related to early pregnancy; b) the participation of alcoholic
women in rehabilitation activities; c) the contribution of
indigenous women to the determination of policies on sex
education).

     It follows that the content of the programs must not be
imposed by institutions in a top-down process.  Rather, there
must be recognition of the traditional practices and
knowledge of self-care on the part of women and their
initiatives, so that policies and programs in women's health
become a democratic synthesis of diverse types of knowledge
and the participation of various sectors of women.

     The groups gave special recognition to the methodological
modalities of socialization that are based on and appeal to
artistic sensitivity, that promote learning through games,
that recognize the importance of acquiring knowledge through
pleasure, enjoyment, and fun.  Moreover, methods of teaching
about self-care must be based on the recognition of pluralism
in which every social sector of women deserves care
appropriate to their particular ways of becoming ill, the
specific risks associated with their activities, and the
different characteristics of each age group.  The
identification of the many differences between various groups
of women makes it possible to recognize their risk profiles. 
These determinations contribute to the formulation of
specific methodologies appropriate to the specific
circumstances and needs of different women.

     Health education dealing with self-care must also "de-
hospitalize" itself.  One must take a look at the
opportunities for collective mobilization, with a view to
creating settings for the socialization of self-care
practices that favor health promotion and the saving of
lives.  It is necessary to reclaim the streets, the parks,
the churches, the community centers, the stores, and the
washrooms as places where self-care practices are
disseminated.




5.   HEALTH POLICIES: WHAT COMMENTS WERE MADE ON POLICIES
     SPECIFICALLY RELATED TO WOMEN'S HEALTH AND SELF-CARE?  

     The groups agreed that the formulation of general and
specific policies related to women's health must take into
account various levels:  first, a conceptual and ethical
level; second, a programming and instrumental level; and
third, a normative level that leads to comprehensive
development that promotes processes of transformation and
social change.

     In regard to policies on women's health and self-care,
the team consulted raised several considerations that, in one
way or another, reaffirm the theoretical and methodological
discussions summarized above.  Of particular note were the
following:

a) The development of policies, programs, targets,
and services must be supported by processes that
lead to self-knowledge and self-esteem on the part
of women.

b) Responsibility on the part of institutions will
be oriented toward accompanying, supporting, and
promoting decision-making in relation to the events
that affect women's health at the individual and
collective levels.  This means that responsibility
lies both with civic society and with the State.

c) Recognition that the various acts related to
health bring together multiple forms of knowledge
and power that can intersect and reinforce each
other through democratic relationships of mutual
respect.

d) Political directives based on self-care should
take into account that the concept of self-care goes
beyond a normative and homogenizing prescription. 
It also transcends the notion of health education as
merely a way of providing information.  Linear
relations do not necessarily exist between
information and attitudinal changes.  That women
have information is not sufficient to ensure that
they care for themselves.  It is not merely a
problem of lack of information.  What is needed is
for the processes of health education to promote the
dismantling of gender stereotypes:  the "living for
others" and the neglect of oneself in terms of care
and attention to health.

e) The State cannot delegate the social obligations
and functions that pertain to it, as arbiter of the
distribution of services and resources for society. 
It cannot delegate its duty to protect the interests
of all persons and in particular of the most
vulnerable social sectors.


6.   GENERAL RECOMMENDATIONS

6.1  Based on the Concept of Self-care

     The concept of self-care was widely discussed in all the
groups, during the working sessions and in the plenary
meetings.  Among the reflections expressed on the subject the
following are of  special note:  The concept of self-care had
its origin and developed an institutional character within
the traditional health services.  As reconsidered in this
meeting, it was understood from the perspective of political
demands, from a liberating perspective focused on rebuilding
a human society that has been damaged by the relationships
between men and women and by the class relations that have
affected women especially.  The term self-care appears
diminished, when placed in the social and political context
that leads to this new conceptualization.

     Self-care is linked to the search for identity and
autonomy; it must be concerned with the general well-being of
women and not reduced exclusively to physical health.  Self-
care can be placed within the framework of self-
determination; it becomes a social need and not merely a
concern of the individual; it transcends and projects itself
in a dialectical relationship toward and from the
collectivity.  Self-care must be understood as a social
behavior; it is a process and a permanent structure that
develops throughout life.  The idea of self-care should be
rooted in an attitude of preservation of the human condition,
that permits the woman to be in charge of herself.  A new
concept of self-care questions the grounding of the feminine
identity in service to others and proposes an ethic of self-
love; it also requires, as point of departure, a process of
self-discovery, of consciousness-raising, of building self-
esteem as well as relations of mutual respect and legitimacy. 
"Self-care is a synonym for the right to happiness ... it
means discovering for oneself the right to live well."

6.2  The Content and Priorities of Self-care

     When considered in the context of the foregoing
proposals, self-care takes on multiple dimensions of a
social, political, and ethical nature.  Self-care cannot be
rooted in a practice which is detached from a frame of
reference, one which takes into account the new directions of
the democracy under construction and the new relationships
between the State and civic society.
     
     Who are we, where are we, how do we relate to each other? 
These are the questions that must be asked before we can talk
about the content of self-care.  That content cannot be
dictated "from above;" it must be derived from specific
situations, from a recognition of the concrete needs of women
in particular.  One cannot bring completed programs to
communities or to women and impose these programs on them in
a top-down process.  One must work horizontally, bringing in
all the sectors.  The specificities must be identified, but
also the similarities within the differences.  Different
criteria should be applied to individuals who differ in their
sex, their physiological make-up, their area of residence,
their identity, their roles, and the stereotypes that have
defined them.  The way in which women become ill and deal
with illness is different.  Their psycho-emotional
development is also different.  Other differences have to do
with the socioeconomic status of women, risks, periods of
life, ethnic groups.  One cannot speak in a generic way about
the content of self-care; neither can one standardize the
risks for all women; it is necessary to establish different
profiles for each group.

     It is also important to keep in mind that it is not a
question of "defining" a way of doing things for women to
learn.  Nor is it a matter of introducing artificial
methodologies, transplanted from elsewhere, in order to "do"
self-care.  Rather, one needs to start from practices in
daily use, from the way women do things, from the things they
are already doing.

     Women's traditional practices and expertise in self-
care and the initiatives taken by women themselves should be
recognized and valued; these should be the points of
departure for the design of programs, in such a way as to
consider them a synthesis of popular knowledge without
overestimating their value.


6.3. The Socialization of Self-care as a Health Practice

     In the final plenary the participants were in accordance
with the proposal presented by one of the groups that placed
special emphasis on the most desirable modalities for
disseminating the conception and practices of self-care. 
This group believed that the socialization of content should
proceed in several directions, taking into account both macro
and micro levels of intervention.  At the macro level, it is
necessary that public policies be defined comprehensively and
interrelated intersectorally, on the basis of gender.  At the
micro level efforts should be directed to the strengthening
and support of organizations that favor social participation.

     In the area of socialization, the methods of
disseminating content related to self-care should include
three forms of circulation:

     a)   Divulgation, as a way of circulating content to all
levels of a society.  Divulgation requires processes
in which messages are expressed in a universal
language and can reach a majority of the population. 
It entails processes of information and
communication which are interpersonal but also
collective.

     b)   Diffusion through the mass media, including the
press, the radio, and television, which are aimed at
broad audiences.

     c)   Dissemination directed toward specialized audiences:
in this case, officials at decision-making levels
who are familiar with the field of study.  The
purpose in this case is usually oriented toward
decision-making.  The level of dissemination is
important in projects of self-care in terms of
sensitizing personnel at all levels and deciding on
policies and actions to follow.

6.4. On the role of state institutions and nongovernmental
organizations:
 
      The groups concluded that these entities should promote
the mobilization of diverse groups of women and health
workers around:  a) the definition of public policies which
are integrated intersectorally, in both the short and long
term, and which have as their foundation the role of gender
in self-care actions; b) the design of strategies and
programs that emphasize the need for sensitizing diverse
groups of women and health workers regarding self-care; c)
incentives for the production of audiovisual materials on
self-care (primers, videotapes, radio dramas, films) for
dissemination and diffusion in treatment centers, educational
facilities, community centers, and cultural centers, among
others; d) the compilation of experiences of nongovernmental
organizations with projects involving women in order to
evaluate them and suggest, on this basis, methodologies that
can avoid faulty actions in the socialization of self-care;
e) the interrelationship of programs and projects with
agencies that have been concerned with the subject of women,
such as PAHO, UNESCO, and UNICEF; f) the development of
programs of self-care within Local Health Systems and the
subsequent drawing up of recommendations on self-care in
women's health.


7.   CLOSING PLENARY SESSION AND REMARKS BY THE MINISTER OF
     HEALTH OF COLOMBIA, CAMILO GONZALEZ POSSO

Women should have special rights as a consequence of
their difference, on the one hand, but they also
merit special rights as a result of their historical
oppression.  Only to the extent that power
structures are modified, can one achieve equality of
opportunities in a context of equal rights.
 
-- Camilo González
Posso 

     The problem of self-care in women's health, I believe,
can have a cultural and social dimension.  That is, it is not
a matter for the individual alone, as might seem to be the
case; it is not the responsibility of each woman for her own
health; rather, it is the responsibility of a social movement
composed of men and women, headed by women, concerned with
women's health.

     Self-care belongs to the same family as self-management
and self-determination; it is a movement, a force that is
unleashed in order to transform a history of oppression, of
inequality, and of privilege sustained by "machismo," among
other things, and based on a diverse set of structures.  In
our country, as in many countries of Latin America, there
exists a great paradox:  the role of women in society, in
matters related to health, is one of leadership, leadership
in daily life and at the micro level; however, the apparent
paradox is that while women exercise leadership in the
family, in the community, in the neighborhood, on the
sidewalks, they do not enjoy the same participation in terms
of leadership in the society as a whole.  When we talk about
leadership we are referring to the social status of different
social sectors and also to the distribution of power in
society.  A striking conclusion, I believe, is that the
formation of this social force, of this social movement and
this new leadership of women, is an important component of a
new politics.  In this study group on women, I see very
important characteristics:  work by an interdisciplinary team
of men and women making an effort to reformulate a policy
regarding women.  I believe that the method itself is
something significant for us, and for me in particular, very
illustrative and encouraging, that we can make a leap forward
as have all the revolutions that have shaken humankind, after
the sexual revolution and the technological revolution and
all those to come.  I thank those who have chosen this
country and this city as a venue for this important exchange.

Following are some of the questions asked by the participants
after the Minister's remarks.

     Question:   I'm very pleased to hear these views from the
Minister of Health of Colombia, because it is not often that
one finds high government officials who have clear ideas
about equity and about the State's responsibility, as well as
the weight society's responsibility.  I think it is very
important to have this sensitization regarding these problems
at the governing levels of society, because one of the things
that our working group saw very clearly was the need to have
public policies that are differentiated in relation to the
criterion of gender to which you have just referred.

     Do you not believe that when there is a divorce between
the economic policies that governments undertake and their
social policies, a substantial number of social programs are
doomed to failure?


Response:   I believe this is a great problem at the crucial
moment that Latin America is experiencing as it confronts the
crisis of  what were the established systems of social
organization, developed principally in the 18th and 19th
centuries.  We still live in the world of 18th century
utopias; what is certain is that the crisis of the socialist
bloc countries has placed us in a situation where the magic
words are "market," free enterprise, and the idea that the
development of business and competition will resolve both
economic problems and social problems simultaneously.  Part
of the theoretical basis of perestroika is the transition to
a socialist market economy, but a market economy nonetheless;
this is also part of the neoliberal creed, whether leading to
neoconservative or typically neoliberal conclusions.  The
concept of human development, or what others have called
development on a human scale, has been posited as an
alternative to neoliberalism; I think that is a promising
path, but it is still a search for new policies and new
utopias.  Utopias which are viable and necessary, but which
have great difficulty when it comes to defining governmental
policies.  The most immediate experiment which the world is
currently experiencing is that which is termed neoliberalism;
it is the market and freedom of the market in which social
progress is to result from economic growth.  It is a new
developmentalist position as I see it; from a theoretical
point of view I believe that a policy requires a social
vision that is in harmony with the economic conception.  One
cannot have an economic policy based simply on the promotion
of free competition in the interest of the monopolies and at
the same time have a policy that favors employment.  I
believe in the thesis that "small is beautiful"; however, I
think that the risk of remaining at that level, without
looking at the larger forces that control the small, can lead
to increasing inequality.  As an alternative to neoliberalism
we have proposed an economic conception based on solidarity
and democracy, and we are seeking to flesh this out with
content in different fields.

     There exists a path that goes against many of the
dominant world trends, and I think it is a very complex
struggle in which we are losing ground on some counts, but
that we have to attempt it.


Question:   You describe an objective reality; you suggest
that economic development, which in the long term tends
toward neoliberalism, is going to have an impact on social
services, which are an obligation of governments.  When that
happens, what are we going to do with the people?
 
Response:   In Colombia we have a policy of economic openness
and a macroeconomic management whose orientation is,
basically, neoliberal.  But the panorama is neither
homogeneous nor rigid; there are contradictions and openings
or opportunities to do other things, informed by a social
concept of development.  We are, for example, seeking a
transformation of the social security systems, one which
would guarantee an expansion according to the well-known
criteria of universality, solidarity, and decentralization,
with a view to covering the entire population.  We have
calculated, for example, what would be required in order to
guarantee health coverage to the six million families that
make up Colombian society and adding the resources of the
official health subsector; these calculations show us that if
we organize ourselves differently, we can achieve health
insurance with total coverage that we could begin to
implement next year.  That assumes that it is possible to
provide health coverage to the entire family and to overcome
the resistance of sectors that are merely thinking, amidst
this situation of inequality, of how they can benefit with
small health companies.  I believe, therefore, that one
cannot make progress with a fatalistic approach; one cannot
say, well, we have had the "law of the jungle" for a decade
and therefore it's not possible to develop concrete programs. 
I believe that we can indeed move forward with a great many
initiatives; some of those immediate initiatives may be
simply symbols of resistance, of organization, but they have
value, even as short-term initiatives.  In Colombia there
exists something very difficult to evaluate: these are the
Community Care Homes [Hogares de Bienestar], and although
they have not satisfied the social need for the protection of
children, nor the needs of preschool children for appropriate
educational content, they have nonetheless created a social
infrastructure of power, which increases the bargaining power
of the community and of mothers and women in particular.  I
think this example illustrates the kind of thing that can be
done in the future.  On the other hand, the inherent
contradictions within neoliberal policy show that there are
many areas of work also based within the communities that can
go far toward resolving social problems partially, and giving
greater bargaining power to civic society, led by women.  As
a result of these processes I have written a work entitled
"The Urban Neighborhood Dwellers," in which I analyze the
experience of women's leadership in the communities with
specific reference to the Community Care Homes.  I believe
firmly in these "micro" experiences; although we cannot
elevate them to a model of social organization for the
protection of infants and preschool children, they are
nonetheless very important supporting elements.  So we do not
have to wait until another alternative emerges at the end of
the decade; I believe that it's possible right now to carry
out actions aimed at resistance, at organization, and at
solving problems.

Question:  We are wondering how one might create, within the
Ministry of Health or the Ministry of Development, a type of
educational program for male health workers.


Response:  I believe that effort must begin with the
recognition of the great difficulties presented by the
dictatorship of the doctors.  Women make up an ever-
increasing proportion of health professionals and physicians;
but within the health institutions there exists a
relationship of domination that is very marked:  the
relationship of domination between the male head doctors,
specialists, and others, and the health personnel, such as
nurses and nurses' aides.  Here we have an extremely
difficult situation that bears on the transformation of the
health institutions; we need a new ethic, a new understanding
of social behavior on the part of health professionals.  This
should begin with the hospitals which remain, notwithstanding
the programs aimed at prevention, general barracks of
disease.

     I believe that experiments with educational programs in
the health sector, such as the ones being developed in Cali,
can provide support for the planning of other projects.  It
is a difficult problem in the health sector, as in the
society as a whole, but we must confront it.  One of our
interests for next year is indeed the planning of programs
like the one carried out in Cali in the health sector: 
education on the problem of gender in women's health, on the
role of women in regard to the health of the population and
the specific problems of women.  We are going to work on
this.

Question:  We are talking about launching, within this new
and alternative conceptual framework of women's self-care, a
new discussion.  This conceptualization is supposed to
translate into practice, both individual and collective,
which is emancipating in nature and leads toward development;
it goes beyond the term self-care to encompass a force that
can be articulated both to efforts toward development on a
human scale and to those concerned with the development of
women.  We have discussed strategies for promoting this idea
of a force and articulating it to public policies, and for
opening a dialogue between the State, civic society, women's
organizations, and in particular, governments at the local
and national levels.  My specific question, then, is:  In
your capacity as Minister of Health of Colombia, and as a
Minister who is involved with the Latin American community
and participates on behalf of one of the Member States of the
Organization, what suggestions can you give us regarding
orientation or guidelines that would enable us to promote the
idea of a force, of a process of mobilization, of political
support in order to introduce self-care as a dynamic
throughout Latin America?


Response:  I have a very great responsibility because I sit
on the Program Committee of the World Health Organization,
where I am called upon to decide, among other things, matters
relevant to women and women's health.  The director of the
World Health Organization himself made important statements
during the last Assembly.  In Colombia we are at a point of
departure, at the point of breaking with previous models
which focused on providing assistance, in order to move
toward a new concept.  There is a problem of tactics that, as
I see it, produces a broader transformation.  To formulate a
policy which is a bit more general on women and health, or to
choose a central idea, an entire line of action, raises the
whole debate regarding the need to develop a policy on women
and health or on health for women and to enunciate it in
terms of the concept of self-care.  The practice of
approaching governments to design a policy on health for
women, and at the same time a policy on women for health, is
capitalizable.  It is essential that governments formulate
and commit themselves to enunciate, program, and pay the
costs of special policies in this area.  In this regard one
can seek the details, the emphasis, and the ideas, including
the idea of self-care.  These must be translated into
specific projects and programs; in this way a policy of self-
care in women's health will find its niche as an approach. 
Now, I keep thinking that here we have a preexisting problem,
one that is political in nature.  These ideas will be
developed to the extent that there is effective mobilization
of those persons who are directly involved; the potential for
a movement of women in support of health and in support of
their own health, in Latin America as in Colombia, is
immense.

     There is potential here, even from the point of view of
professionals.  If we take the sum of the 15,000 physicians,
22,000 nurses, 30,000 nurses' aides, 12,000 midwives, and
50,000 mothers of the Community Care Homes, along with those
groups which are organized or can potentially be organized
with local and national outreach, we find that Colombia has
almost 400,000 leaders who work in women's health.

     A mobilization with concrete goals of transformation, of
institutional action regarding health, would have, I believe,
impressive possibilities for social transformation, bearing
little resemblance to any other social movement.  A general
movement of women, involving women who are leaders in their
communities or within the health institutions, can play the
crucial vitalizing role.  I want to repeat that when it comes
to formulating programs, when it comes to developing
alternatives that are technically sound, socially viable, and
economically feasible, an indispensable element for producing
a true transformation is the mobilization of women.  I
believe that this is the most important meaning of self-
care and that in this process there is no substitute for the
leadership of women.

Question:   I want to take advantage of your remarks in
describing this situation, in recognizing this reality, by
suggesting that we discuss the possibility of holding a
meeting that would convoke women's organizations within the
framework you have suggested.  What possibilities would there
be for Colombia, for example, to take a leading role?  In
this regard, how would you view such a convocation?

Response:   I can tell you first of all that if an
institutional or non-institutional group of persons or of
women's organizations presents such an initiative, they will
find a willing ear in the governmental agencies.  They will
find complete support not only within the Ministry of Health
but also in other government agencies, because there is a
recognition of these problems; the political situation at the
moment is very favorable.  But leadership is needed for this
project and the Minister of Health cannot provide it; I
cannot put myself at the head of a such a convocation because
it would not be effective; if it were effective I would do
it.  If I could lead this potential force which is the
women's movement, I would do so.
 
Question:  How would you see it if out of this meeting
emerged a proposal from the participating countries based on
this idea?

Response:   I believe such a proposal would have to be
presented not only to Colombia but internationally, and
involving the governing levels of PAHO.  That is, generate a
process within the countries that you represent.

Question:  Returning again to the analysis regarding the
leadership of women that is taking place in the health
sector, we have indeed been working at the political level,
but it is a very "micro" kind of politics.  It has made an
impact nonetheless by defining that leadership with regard to
the health services.  But leadership in terms of designing
policies--that we have not had.  We are the ones who carry
out the policies that men, working within the health sector,
have headed.  I believe this is an analysis that we must
engage in; that we, as women who have been working for a long
time in the field of women's health, must raise these
questions and be able to enter into dialogue on them.  Right
now the Ministries of Health--it is an historical trend--
have few women in governing positions defining policies on
women's health.  How many women?

     It seems to me that the program of policies on women's
health should have specific directives regarding the health
of women; it is possible to capitalize women's health and
women in health; they are very manageable politically and we
can capitalize to our benefit or against.  I think that the
new restructuring of the National Health System should open
up opportunities with respect to women.  In the past we had
an opportunity to speak about Women, Health, and Development;
however, they gave us back a program on reproductive health
and we found ourselves once again concerned with biological
reproduction.

     Another observation I want to make is that when economic
adjustment is undertaken, in fact, the sole concern is with
the economic production that has existed and with material
production for the market; there is the assumption that human
development takes place alongside economic development in a
parallel process.  Is it clear that there is an economic
opening that will lead us to social development?  Past
experience has demonstrated that this economic development
comes at a very high social cost.  There are schools that
carry out this adjustment with a human face and they call it
Development with a Human Face.  I insist that this adjustment
with a human face has a woman's face and that woman's face
must be evident in all the sectors, at all levels, in all
settings.  When one speaks of solidarity, of an economic
policy based on solidarity, that is striking to me, because
we women stand in solidarity, but it is a solidarity that
does not transcend the private and the small.  Women soon
will assume greatness, but greatness with a very large
responsibility; they do not limit their solidarity, but it is
a solidarity that we as women, sitting here right now, want
and seek in order to bring about true social development.  My
observations and questions are not for us to answer now, but
to think about.

Response:   Within the Ministry of Health of Colombia we have
a matriarchy; at present both the General Secretary and the
General Director of Planning are women, and all the governing
bodies of the Ministry are to a large extent made up of
women.  The most important submanagements are directed by
women, so that there really is a representativity; if we
total all the submanagements, we could say that more than 60
percent of the submanagements in the Ministry of Health are
directed by women.  This reflects a reality of professional
development, of professional and technical capacity in our
country on the part of women.  There are also efforts under
way to have this subject debated in the universities, in the
different schools of medicine, and in the schools related to
health.  So if we are behind, it is in the very conception of
health that is molded within the complex of institutions; in
this country health is viewed basically in terms of disease. 
Thirty years ago discussion began at the international level
about prevention and promotion in the health field.  In
Colombia the reality is that we talk about promotion and
about prevention, but what we practice is curative medicine. 
Ninety percent of the country's health budget is devoted to
hospitals; the main thing is to cure.  Not only is there
inconsistency with respect to a new conception of women from
the standpoint of gender, but also in regard to the problem
of health as a whole.  There exists a contradiction, and we
have to take advantage of that contradiction in order to
bring about change.

     One can speak of a feasible and fruitful process of
concentration, of the articulation of efforts and initiatives
that translate democratically into a comprehensive
alternative for women's health.  It is necessary to bring
about, promote, and demand a real opening, a revaluation, a
cultural leap on the part of personnel working in health at
the central, regional, local, and international levels.  In
the programs, in the diagnoses and interventions regarding
women's health we must keep in mind the differences between
the sexes, although it may appear superfluous.  If we do not
begin with this understanding of gender we will not discover
the real health problems of women; we would continue
addressing only the problems associated with maternal
mortality, for example.  So we must investigate and ask the
right questions in order to stamp out the manifestations of
sexual and domestic violence, the suffering that women bear
in their daily lives, both private and public.

8.  ANNEXES

 8.1.     Annex:  CONVOCATION FOR THE WORKING GROUP ON "WOMEN,
HEALTH, AND SELF-CARE"


     The Pan American Health Organization, through its
Regional Program on Women, Health, and Development, in
fulfillment of the strategic orientations and programming
priorities for the quadrennium 1991-1994, joins in launching
the proposal for "self-care in women's health" as an
alternative that favors the human development of women.

     This formulation translates into a policy of intervention
on the part of the health institutions aimed at offering
options and facilitating decision-making by women in matters
that pertain to their lives and the promotion of their
health.

     The Pan American Health Organization invites
professionals of diverse disciplines coming from different
Latin American countries and the United States of America to
participate in the Working Group on "Women, Health, and Self-
Care" that will meet in the city of Cali, Colombia from 6 -
 8 November, 1991.


OBJECTIVES


·    To propose, using the gender-specific approach, possible
     reconceptualizations of "self-care in women's health,"
     based on criteria that promote interventions in aspects
     of their lives and different social roles:  citizenship,
     identity, and self-esteem, among others.

·    To suggest alternative methodological modalities and
     evaluation methods that can help to socialize and
     disseminate "self-care in women's health" as an
     individual and collective practice in terms of promotion,
     prevention, and human development.  In this regard, to
     recommend approaches that facilitate the socialization of
     these practices among health personnel and women
     themselves.

·    To suggest criteria for thematic areas, priority groups
     of women, and social settings toward which actions can be
     geared, in the short and medium term, in accordance with
     the reconceptualizations established for "self-care in
     women's health."





RESULTS

      It is expected that the working group on "Women, Health,
and Self-care" will prepare a document containing a set of
proposals, remarks, and recommendations in regard to:

·    The reconceptualization of "self-care in women's health"
     using a gender-specific approach.


·    The methodological modalities that contribute to
     socializing and disseminating self-care as an individual
     and collective practice by women.


·    Guidelines for introducing this practice and body of
     knowledge among health personnel.


·    Thematic lines and the priority groups of women,
     institutions, and social organizations which are
     sensitive or susceptible to promoting measures aimed at
     self-care in women's health.
8.2.Annex: PARTICIPANTS IN THE WORKING SESSION ON WOMEN,
     HEALTH, AND SELF-CARE 


LEONOR BARRIOS LEAL
Secretaría de Salud Silos 3
Coordinadora participación social NAP
Residencia : Carrera 33A No. 12B-98  Apto. 401D;  
Tel. Res. 346144  Trabajo: 809293
Cali - Colombia

MIRYAM CRUZ OLAVE
Secretaría de Salud del Valle
Directora Sección Materno Infantil Salud de la Mujer, el Niño
y Adolescente
Gobernación del Valle  piso 11,   Tel. 811727
Residencia: Calle 13A  No. 76-21  Tel. 306679
Cali - Colombia

DORA CARDACI
Universidad Autónoma Metropolitana Xochimilco
Jefa del Area de Investigación en Educación y Salud
Apartado postal 23-181, Tel. 594-7833   Ext. 227
Residencia: Acuario 28-6  Col Prado Churubusco Mexico 13,
D.F.
FAX : (52-5) 6711621



MARIA SOLEDAD RIVERA MARTINEZ
Universidad Católica de Chile
Prof. asociada, Jefe Depto. Enfermería Salud Mental y
Siquiatría
Campus San Joaquín Unv. Católica-Vicuña  Mackenna 4686.
55211765
Anexo  3631
Casilla 6177  Correo 2 (Universidad)
FAX : (562)  5525407
Residencia : Alicante 910-Santiago de Chile; Tel. 2085447

GLORIA TEJADA PARDO
Instituto de Salud Popular
Av. Arenales 1080 Of. 302 -  Tel. 715526
Lima - Perú

MARTHA LUCIA URIBE DE LOS RIOS
Casa de la Mujer
Carrera 18  No.59-60  - Tel. 2482469    A.A.  36151
Residencia:  Calle 138 Bis A  No. 25-57; A.A. 241284  
Santa fé de Bogotá - Colombia

LUZ AMPARO PINZON
4447 P   ST. NW
Washington D.C. 20007
Tel. (202) 333 33 64

GUENTCY ARMENTA
Institución: Diferentes grupos familiares e intstitucional
Tel.  3414872
Residencia : Carrera 4A No.26B-24
A.A.  37703
Santa fé de Bogotá - Colombia

ANA LORENA CAMACHO DE LA O.
OPS de Costa Rica y Colectivo Paneha Carrasco San José
Tel. 333013 -  215755
A.A.  952  Heredia -  FAX : 333013  - A.A. 7-3200 San José
Costa Rica

AURA MARINA HERRERA ALVIZURES
Ministerio de Salud Pública
Centro de Salud Morazan El Progreso - Tel. 041166
Residencia :  16 Av. 1195 211
Guatemala

NELLY MENESES V.
Silos 3  NAP 8 Diego Lalinde
Carrera 12 E  No. 50-18  Villacolombia - Tel 411518 - 411911
Residencia: Ave, 7a.A   No. 20-73
Cali - Colombia

MONSERRAT MU‘OZ
Ministerio de Salud
Calle 55  No. 10-32  Bloque  B P.3  Of.306  -  
Tel. 2113846  -  2179900  Ext. 327
Residencia: Transv.  78  No. 7-79  Apto. 518  A.A. 16563
FAX : 2113846
Santafé de Bogotá - Colombia 

SOFIA VILLALTA DELGADO
Secretaría Nacional de la Familia  - Tel. 712505
Clínica : Edif. Villatoro-Barriere  BLvd  Tutumichapa 
Urb. La Esperanza San Salvador
Tel.  263284 - 264190
FAx : 710950
El Salvador

B. CECILIA ZAPATA
Department of Maternal & Child Health School of Public Health
CB # 7400  401  Rosenaw Hall
University of North Carolina at Chapel Hill
Chapel Hill,  N.C. 27500-7400 -  Tel. 919-966-3807
Residencia:  2137B Old Oxford Rd. Chapel Hill, NC 27514 
Tel. 919-929-6859   FAX: 9199667141
USA



CONSTANZA COLLAZOS VIDAL
CIMDER
Carrera 4B  No. 36-00  P.2 - Tel. 564505
Residencia:  Tel. 520307  - A.A.  3708 - FAX :562575
Cali - Colombia

ENRIQUETA DAVIS VILLALBA
Universidad de Panamá
Ciudad Universitaria - Tel.23-9279
Residencia:  Panamá, Panamá- Tel. 61-3245 - A.A. 9256
FAX : 64-5525
Panamá, Panamá

DOLORES ORTIZ
OPS
Los Cedros 269  - Tel.409200
Residencia: 452333
Lima - Perú

HUGO A. PINTO CARRAZANA
Postgrado Salud Pública UMSA Fac. Medicina
Universidad Mayor San Andrés La Paz 
Tel.,  35-65-90/91-95  int. 42
Residencia: Bolognia C.  No. 2-196
La Paz - Bolivia


MARIA CLARA TOVAR
Universidad del Valle
A.A. 20557  - Tel. 564514-564485
Residencia: 396804
Cali - Colombia

MARA VIVEROS V.
Inst. Francés de Estudios Andinos  IFEA - Univ. Externado de
Colombia
Calle 4 No. 42-110  (El Lido) Cali
Residencia: Carrera 16 No. 32-83  (802)  A.A. 54918
Tel.  2225737  -  FAX : 2225787
Santa fé de Bogotá - Colombia

NELSY ARIAS C.
CIMDER  Centro de Investigaciones Multidisciplinarias en
Desarrollo Carrera 4B No. 36-00  P. 2  Univalle San Fernando
Tel. 564505 - 562575
Residencia : Calle 7A  No. 56-136  - Tel. 531148 - A.A. 3708
FAX : 562575  
Cali - Colombia




JORGE LEONARDO CONTRERAS P.
Universidad del Valle 
Depto. de Medicina Social   
Residencia : Transv. 3  No. 4-43 San Fernando
Tel.  522067
Cali - Colombia

SANDRA ECHEVARRIA LOPEZ
Fundación para el Desarrollo de la Educación en Salud
(FUNDESCO)
Carrera 13  No. 19-29  - Tel. 443000 - 443001 - 443002
Residencia : Villa Ximena Etapa 2  Manzana 2  Casa #10
Armenia - Quindio - Colombia

LUZ DEL CARMEN IRIGOYEN MORENO
Ministerio de Salud Pública y Asistencia Social 
Calle Arce 827-S.S, .  El Salvador, C.A; Tel 21-09-90
Residencia: 12 Ave. nte. 1719-col  La Rabida, S.S. 
El Salvador CA -  Tel.  25-87-40 ; FAX: telex 20704 MSPASSal.
El Salvador

ANA MARIA OCAMPO MEJIA
Secretaría de Salud 
Carrera 19  Calle 20  P.7 ; Tel. 832318
Residencia: calle 52  No. 21-36 ; Tel. 845084;
FAX : 968-842311
Manizales - Colombia

RAYEN QUIROGA MARTINEZ
Humanisis, un Programa de Desarrollo a Escala Humana INTEC
Av. Los Próceres-Galá  Santo Domingo; Tel. (809) 567-
9271(x226)
Residencia:  Av. México 87-A Apto. C-301  El Vergel
Tel. (809) 565-6278; FAX:  (809)566-3200 - A.A. 342-9
Santo Domingo, RD.

EDNA ROLAND
Geledés Instituto da Mulher Negra
Praca Carlos Gomes 67- 7o and.  CJ M; 
Tel. (55-11) 35-3869 / 36-9901
Residencia: Rva Jorge Utsumi 40 Villa Sonia 05519 Sao Paulo
Tel (55-11) 843-6190
Brasil

LIGIA DEL ROSARIO ALTAMIRANO GOMEZ
Centro Mujer y Familia
Entrada Repto San Juan 2 1/2  al sur; 75088
Managua - Nicaragua

YOLANDA ARANGO
Universidad del Valle San Fernando; Tel 564532
Residencia : Carrera 35A  No. 3-85; Tel. 563775
A.A. 2188 ; FAX: 569472
Cali - Colombia

ARGELIA LONDO‘O VELEZ
Universidad de Antioquia
Depto de Sociologia - Fac. Ciencias Sociales
Tel. 2630011  Ext. 260
Residencia: Tel. 2579848 - A.A. 50983
Medellín - Colombia

BALTAZAR MEJIA
Universidad del Valle San Fernando; Tel. 561151
Residencia: Calle 2B oeste No. 24B-46  Apto. 703 
Tel 582478
Cali - Colombia

LUCRECIA MESA
Centro de Apoyo a la Mujer y al Infante -CAMI-
Calle 3 No. 23B-80   Tel. 568481 -569472
Residencia: Calle 12B  No. 59-31 Bloque 9 Apto. 501
Tel. 308156   FAX: 569472
Cali - Colombia

MIGUEL SOSA MARIN
23 y  N-Minsap-Vededo Plaza. Ciudad Habana
Tel. 32-41-30
Residencia: Tel. 403410 ; FAX: 334525
Cuba


ELIZABETH  SAFAR GANAHL
Instituto de Investigaciones de la Comunicación - Universidad
Central de Venezuela
Centro Comercial los Chaguaramos P.3;  Tel. 662-2751 / 662-
2761
Residencia:  P.O. Box 47-421  :ps Chaguaramos 1041A 
Tel. 772032
Caracas - Venezuela

EUNICE SANTOS ACEVEDO
Ministerio de Salud
Calle 72  No. 10-03  P.5  Tel. 2486110
Residencia:  Calle 73  No. 0-87  Tel. 2352366
Santa fé de Bogotá - Colombia

GUSTAVO DE ROUX
Universidad del Valle Melendez; Tel. 392399
Residencia:  Carrera 35 No. 4A-36 ;  A.A.  5802
FAX : 562575
Cali - Colombia

OLGA OSORIO
Fundación Alternativas para la Comunidad -FUNDALCO-
Residencia: Calle 12B  No. 59-31  Unidad Residencial Puente
Palma
Bloque 10  Apto. 401 ; Tel. 300115
Cali - Colombia

MEISY CORREA
Calle 3A  No. 36-80
Tel.  569485
Cali - Colombia

INOCENCIA ORELLANA
Consejo Nacional de la Cultura -CONAC-
Dirección General Sectorial de Proyectos  Teatro Teresa
Carreño planta baja  - Tel. 5749122  Ext. 509/510
Residencia: Apdo. 4438 Caracas 1010A
Venezuela

EDDA QUIROS RODRIGUEZ
Ministerio de Salud 
Departamento Salud Mental
Tel. 335066 - 260295
San José - Costa Rica

MARGARITA ROSA TIRADO
Calle 26B No. 4-23  Tel. 967-452297   91-2820249
Residencia: Carrera 13A No. 1A-47  Parque Fundadores
Armenia - Quindio

ESTELA MARIA SOCH BATA
Jefatura de Area de Salud
Centro de Salud Totonicapan - Tel. 0661334
Residencia:  8a. Calle 4-11 zona 4
Totonicapan - Guatemala

GLORIA VELASCO GONZALEZ
Carrera 33B  No. 31-45
A.A. 2886
Cali - Colombia

REBECA DE LOS RIOS
OPS / OMS
525 23rd  Street N.W.
Washington D.C.  20037 - Tel. (202) 8613405
USA

MARIA TERESA ARIZABALETA DE GARCIA
Centro de Apoyo a la Mujer Maltratada de la Unión de
Ciudadanas
de Colombia
Presidente U.C.C.
Calle 8 No. 9-36  Tel. 807817 - 807686 - 811887
Cali - Colombia

ESMERALDA BURBANO
Residente Salud Internacional OPS/OMS
CIMDER - UNIVALLE  A.A. 3708  - Tel. 564505 -392273
Cali - Colombia

















ACKNOWLEDGMENT
TO

THE WORKERS IN THE PROGRAM
FOR PREVENTION AND CONTROL OF 
MALARIA


THE COORDINATED PUBLIC HEALTH
SERVICES OF CAMPECHE

THE SECRETARY OF PUBLIC HEALTH
OF THE STATE OF TABASCO

THE BUREAU FOR PREVENTION AND CONTROL
OF VECTOR-BORNE DISEASES



INDEX






SUMMARY 

I.   INTRODUCTION

II.  BACKGROUND 

III. METHOD

     1.  Variables

     2.  Techniques for Collecting Information

IV.  SITUATION OF THE SANITARY INFRASTRUCTURE AND OF MALARIA AT
     THE NATIONAL LEVEL AND IN THE STATES OF TABASCO AND CAMPECHE

V.   RESULTS 

     1.   Organization of the Program:  Decentralization and
Integration 

     2.   Financing of the Health Services and the Malaria
Program

     2.1  Acquisition of Supplies for the Malaria Program

     3.   Sanitary Infrastructure 

     3.1  Personnel of the Malaria Prevention and Control Program

     4.   The Relationship between API and Malaria Program
Workers.  The Operating Capacity of the Malaria Program

     5.   Intra- and Intersectoral Coordination 

     6.   Social Participation for the Control of Malaria

     7.   Malaria Program Information 

     8.   Training Malaria Workers 

     9.   Malaria Union 

VI.  DISCUSSION AND CONCLUSIONS 

VII. REFERENCES AND BIBLIOGRAPHY


INDEX OF TABLES AND FIGURES


TABLES

1.   Indexes of Physical and Human Resources at the Primary
     Health Care Level for the Population with No Social Security
     Coverage, for the Country, Campeche, and Tabasco, for 1989

2.   Mexico.  Malaria Indexes.  1986-1990

3.   Campeche and Tabasco.  API, ABER, and IHS.  1986-1990

4.   Expenditure per capita.  Health Services and Malaria
     Program.  Campeche and Tabasco.  1986-1990

5.   Index of Workers in the Malaria Program, for the Country,
     Campeche, and Tabasco.  1986-1990

6.   Ratio of Other Workers to Specialized Workers in the Malaria
     Program, for the Country, Campeche, and Tabasco.  1986-1990

7.   API and Index of Malaria Program Workers, for Escárcega,
     Campeche, and Tenosique, Tabasco.  1986-1990 


FIGURES

1.   Campeche.  Malaria Diagnoses, by Source.  1986-1990

2.   Tabasco.  Malaria Diagnoses, by Source.  1986-1990

3.   API and Malaria Program Workers in Two Jurisdictions with
     High Incidence, in Campeche and Tabasco.  1986-1990

4.   Campeche and Tabasco.  Malaria Diagnoses in First
     Consultations.  1986-1990





ABBREVIATIONS



PHC.  Primary health care. 

DPCETV.   Bureau for Prevention and Control of Vector-borne
Diseases.

IMSS.  Mexican Social Security Institute.

IMSS-SOLIDARIDAD (formerly IMSS-COPLAMAR).  Program of Care for
Marginal Areas.

SSA.  Ministry of Health.

SCSP.  Coordinated Public Health Services of the states.

SCSPC.  Coordinated Public Health Services of the state of
Campeche.

SST.  Secretariat of Public Health of the state of Tabasco.



     The Integration of the Malaria Control Program into the
        Health Services:  The Impact on its Organization
and Operation

SUMMARY

The process of integrating the malaria program into the health
services was analyzed to learn the impact on its organization and
operation as a part of the health services.  For this a case
study was carried out in two states in Mexico - Campeche and
Tabasco - with a high incidence of malaria during the period from
1986 to 1990.  The selected states form similar units
ecologically and sociodemographically, with differences at the
level of the organization of the health services; Tabasco's
health services are decentralized and those of Campeche are
centralized.

The broadening of the program and its integration into the
decentralized health services would hypothetically bring the
decision-making closer to the places where the health problems
are generated, would increase the efficiency of the utilization
of the resources, adapting them to local conditions, and would
favor the integration of the malaria workers, so that they would
be come a part of primary health care services.  This process
would depend on the characteristics of the financing and of the
infrastructure of the services.

The results show that the state of Tabasco has a bigger health
infrastructure and more financing than Campeche (in a ratio of
pesos per capita of 10:1).  The state government contributes more
than 50% of the financing, which has permitted the contracting of
personnel and/or acquisition of supplies to provide continuity to
public health actions, including the control of malaria.  At the
organizational level, the decentralization of the health services
meant the integration of the institutions for the care of the
population that had no social security (SSA, previously IMSS-
COPLAMAR) into the Secretariat of Public Health of the state of
Tabasco; that step eliminated the problems of duplication and
increased the coverage.  Intersectoral coordination is the
responsibility of the municipal presidents who are considered the
local health authorities.

The financing of the malaria program comes from the federal
government; in this regard it continues to be centralized, with
state program chiefs and decentralized units having a certain
degree of autonomy to administer and to carry out the
interventions approved at the national level.  Its distribution
represents a logic of equity in relation to the sizes of the
populations in the malarious areas in each of the states.

However, in Tabasco the malaria control program is part of the
jurisdictional health program and its activities are coordinated
by the chiefs of the sanitary jurisdictions.  The health services
and the voluntary collaborators have assumed responsibility for
the diagnosis and treatment of cases and the malaria program
carries out the activities directed mainly against the vector. 
The participation of the voluntary collaborators is not
exclusively for the program or for the health services; these
individuals act in an integrated fashion in the different social
development activities in the community.

In this situation Tabasco has achieved a greater reduction of the
incidence of malaria than Campeche.  One of the sanitary
jurisdictions with the greatest incidence - Tenosique, Tabasco -
saw its API go from 38.4 per 1,000 population in 1986 to 2.7 in
1990.  In that year the increase in the number of workers in the
malaria program in these jurisdictions of Tabasco was only
slightly related to the frequency of the disease.

The situation is different in Campeche, which presents low ratios
of health services infrastructure to overall population, serious
problems in coordination and financing, and little linkage of the
health services with the malaria program.  However, a reduction
in the incidence of the disease has been achieved even in those
jurisdictions with a higher incidence; the API for Escárcega,
Campeche, decreased from 91.3 per 1,000 inhabitants in 1986 to
13.9 in 1990.  For this purpose there should have been twice as
many workers in the program in Campeche as in Tabasco.  The
malaria program has maintained an exclusive network of community
support that has assumed responsibility for the diagnosis and
treatment of more than 50% of cases throughout the period
analyzed.  The operation of this network depends on the malaria
program for supplies for diagnosis and treatment, with little
connection with the limited permanent health services.

It has been concluded that the decentralized organization and the
availability of infrastructure and financing for the health
services of Tabasco made the functional integration of the
malaria program into the services possible, along with the
control of the disease.  The low incidence figures achieved begin
to show the limits of the efficiency of the interventions
provided by the program and the health services for the continued
reduction of incidence.  Under current conditions intersectoral
participation is required to ensure the maintenance of what has
been achieved.




I.   INTRODUCTION

The malaria program represents one of the paradigms of social
response to the problems of health and disease in Latin America. 
The identification and analysis of the determinants of the
disease in the different social groups and the organization of
the antimalaria services have represented a new way of dealing
with public health problems since the 1950s.  The antimalaria
practice affected the forms of organization of the health
services in the way that the sanitary priorities have been
handled up to the present time - 1991 - with vertical,
centralized programs, intended to protect efficiency.

The application of the malaria program at the world level
generated forms of understanding and response to the public
health problems that it has not been possible to reverse. 
Currently, 21 countries in Latin America maintain active programs
for control of malaria and the population in malarious areas is
estimated at 278,600 million inhabitants (PAHO/WHO, 1991).

In 1976 changes were proposed in the eradication strategy in the
campaign against malaria, oriented toward a "flexible strategy"
(PAHO/WHO, 1985) for the following reasons, among others:  the
progressive deterioration of the malaria situation in extensive
areas of the Americas, a significant reduction in the
international financial contributions, and an increase in the
costs of maintaining a program of that type in America, which
went from $US34.7 million in 1960 to $US136.9 million in 1980
(PAHO/WHO, 1982).

In 1985 a recommendation was made to redefine the objectives of
the program on the basis of the stratification of malaria.  The
suggestion was made to "sectorize and decentralize" the
antimalaria activities in accordance with the infrastructure of
the health services.  In addition, it was suggested that it might
be possible for the program to constitute a point of departure
for the implementation of the strategy of primary health care
(PAHO/WHO, 1985).

Decentralization and the integration of the program into the
health services would hypothetically place the decision-making
closer to the places where the health problems are generated,
would increase the efficiency of the utilization of available
resources, and would favor the assignment of the workers in the
program in accordance with the local problems, strengthening the
health services.  In this way, the integration of the program
into the services would mean the transfer of responsibilities for
the administration, programming, execution, and control of the
antimalaria activities to the health services.

The broadening and integration of the malaria program into the
health services attempts to provide new responses to the quasi-
secular epidemiological problem of malaria in light of the new
ecological, sociopolitical, economic, and health scenarios in the
countries of Latin America.

The governments of the region began the incorporation of the
malaria programs into the health services in the middle of the
1980s, following different modalities.  The level of integration,
the development of activities, and the epidemiological impact
have been different in each of the countries and within their
malarious areas (PAHO/WHO, 1991).

In 1984 Mexico integrated the malaria program into the health
services.  The simultaneous interaction of many factors of
various kinds in the determination of the malaria problem in
Mexico, as in other countries, makes it necessary to analyze the
participation of the health services in the control of the
problem.  The experience developed in Mexico over more than five
years can contribute to the achievement of a better understanding
of the response to such a complex problem.

The results of this work represent the situation only in the
states of Tabasco and Campeche for the period from 1986 to 1990. 
The elements that were analyzed are related to the process of the
integration of the program into the health services, to the
financing of the services and of the program, to the situation of
the health infrastructure, to social participation, to the
training of the workers, and to the situation of union
representation of the malaria workers in the face of the
integration of their representatives into the health services.

It was considered important to analyze the situation at the level
of the microregions with high incidences of malaria.  There, the
amalgamation of the factors that can favor the process of
integration could be evaluated, along with the specific
participation of each of the actors in the control of the
problem.

II.  BACKGROUND

Decentralization:  A Health Policy in the 1980s

During the 1980s decentralization of government functions was
promoted as one of the mechanisms to increase efficiency and to
reduce the costs of the bureaucratic apparatus, as well as to
reorder local relationships with the center both for the units of
government and for the various social actors.  Decentralization
was defined as the transfer of the authority for planning,
decision-making, or administration from the central government to
its organizations in the field, local administrative units,
semiautonomous and semipublic organizations, and local
governments or nongovernmental agencies, (Rondinelli and Cheema,
1983).

Decentralization was proposed in a period of grave economic and
political crisis in the Region of the Americas in order to
respond to problems of various kinds that directly and negatively
affected the operation of the public institutions, particularly
those in the fields of education and health.  Centralized
organization was pointed out as one of their principal problems
in the achievement of functional efficiency, rationality, equity,
and quality.  Noted among other expressions of centralism were
the fragmentation and lack of coordination of the institutions in
the provision of health services.

In several countries in Latin America, programs for
decentralization of the health services were proposed from
various perspectives and with different conditions for
organization and social participation.  Among them were
Argentina, Honduras, Brazil, Chile, Mexico, Peru, and Panama. 
All agreed that decentralization was related to the search for
new forms for providing health services under schemes that
supported different ways out of the crisis (CLAD, PAHO, 1986).

Mexico:  Decentralization of the Health Services

In the middle of the 1980s Mexico initiated a process of
decentralization of the Ministry of Health (SSA) and the Program
of Care for Marginal Areas (formerly IMSS-COPLAMAR, now IMSS-
SOLIDARIDAD), which provide health care services for the
population that does not have social security.  The social
security institutions did not participate, nor did those
semipublic companies, such as Mexican Petroleums, that have
medical services for their workers.

Of the 32 states that constitute the Mexican republic, only 14
(43%) participated in the decentralization.  In these states the
total of their health care resources for the population not
covered by social security amounted to 50% of the SSA units at
the first and second levels of care and nationally, 27% of the
units at the first level and 31% of the hospitals in the IMSS-
COPLAMAR program.  The governments of the states took charge of
the administration and direction of the decentralized health
services.

In the period from 1982 to 1986, with full decentralization the
national budget for health was reduced by 47.1% in constant
pesos although the financial contribution of the state
governments to expenditures on health went from 5% in 1982 to
17.5% in 1987, on the average.  In addition, the
epidemiological problem of malaria was manifested in a rising
trend in the numbers of cases from the beginning of the 1980s (in
1982 there were 49,993 cases) and there was a rapid increase
(from 85,501 to 116,016 cases) between 1984 and 1985.

In this context the malaria program was broadened and integrated
into the health services in Mexico.

The present work had as its goal the determination of the
organizational characteristics of the malaria programs with
respect to the health services, the participation of the health
services in the control of malaria, and the sources and
distribution of the financing for the health services and the
malaria program during the period from 1986 to 1990.

III.  METHOD

A cross-sectional retrospective case study in the states of
Tabasco and Campeche, located in the southeast region of Mexico
along the Atlantic coast, was carried out.  The analysis covered
the period from 1986 to 1990, which corresponds to the
decentralization stage of the health services for the population
that was not covered by social security and to the integration of
the malaria program into the health services.

The states of Campeche and Tabasco were selected for two
principal reasons:  a) during the 1980s both states remained
among the 10 with the highest incidence of malaria in the country
and beginning in 1986 they were considered to have priority for
the malaria program (Sánchez Rosado, 1985), b) because Tabasco
decentralized the health services and formed a Secretariat of
Public Health for the state of Tabasco (SST), unlike Campeche
which kept its administration and financing dependent on the
federal (central) government through the Coordinated Public
Health Services of the states (SCSP).

In addition, there are characteristics that both states share,
mainly their areas with a high incidence of malaria - the selva
region, which borders on Guatemala and comprises the sanitary
jurisdictions of Tenosique and Balancan in Tabasco and Escárcega
in Campeche.  Chewing gum, rice, and sugarcane are produced
there; there is extensive and intensive exploitation of wood; and
cattle are raised (Jhabvala, F.; M. Tokeshi, 1990), (INEGI,
1991), (Rivera A., 1988).  Population densities are low and
there are international migratory movements between Guatemala and
Mexico and migratory movements among the southeastern states
(Chiapas, Quintana Roo, Yucatan, Tabasco, and Campeche) that are
considered at high risk for malaria (INEGI, 1991), (SCSP
Campeche, 1990), (Beltran J., 1988), (SST, 1989).  From 1980
to 1990 oil exploitation increased in Tabasco.  In addition, the
areas devoted to extensive livestock raising, which had replaced
crop production, previously important for that area, were
expanded (Beltran J., 1988).

This made it possible to form a quasi-experimental model of
similar units, where the difference for the analysis is located
at the administrative and organizational levels of the health
services.  Decentralization of the health services would
hypothetically bring the decision-making closer to the level of
the local units and the adaptation of the sanitary infrastructure
closer to the local and regional epidemiological problems.  In
this regard the analysis of the control of malaria as a regional
epidemiological problem made it possible to address two
interrelated aspects:  the participation of the health services
in the solution of a regional problem and the integration of a
vertical program into a decentralized system of health care.

The analysis was carried out at the operating and organizational
levels of the state and of the sanitary jurisdictions, technical
and administrative units of the health services.  The state of
Tabasco has made its political and administrative regionalization
territorially uniform.  Thus the sanitary jurisdictions coincide
territorially with the 17 municipalities, with the electoral
districts, and with the regions for purposes of investment by the
federal government.  This type of political and administrative
organization is different in the state of Campeche, where the
four sanitary jurisdictions do not coincide with the eight
municipalities or with other established regions.

III.1. Variables

For this research the financing and the infrastructure of the
health services were taken as the independent variables and the
organization and operation of the health services and of the
malaria control program in each of the states as the dependent
variables.

Infrastructure, in the context of the health services and the
malaria program, was taken to mean the human resources, the
primary health care units, and the specific supplies for the
control of malaria.  The human resources were divided into
functional categories according to their jobs in the health
services and/or in the control of malaria, specifically.

Financing was taken to mean the quantity of money utilized by the
health services and/or the malaria program in each of the states. 
The relationship between centralization and decentralization was
analyzed in terms of the monetary contributions of the sources of
financing, as well as the actors that intervene in the decision-
making for their distribution and control (Ashford, 1979).

The variable organization refers in this research to the flow of
responsibilities for decision-making.  Thus an analysis was made
of the participation of the social actors in the decision-making
process and in the execution of the activities (Fremont, E., and
J. Rosenzweig, 1979) at the national, state, jurisdictional,
and municipal levels in each of the states.

In the analysis, the variable operation as it is applied to the
health services for the population not covered by social security
and to the malaria program consisted of the process of the
execution of activities.  Selected for this purpose were some of
the activities that are considered to be in the malaria control
program and that are registered continuously by the health
services and/or the malaria program.

III.2. Techniques for Collecting Information

Primary qualitative information was collected through
semistructured interviews with staff members in the government
and in the health services; and secondary quantitative
information was derived from the information systems of the
health services and the malaria program.

a) Qualitative information:  Semistructured interviews were
carried out in November 1991 with the staff members from the
health services responsible for the population not covered by
social security and with those from the malaria program at the
national, state, and jurisdictional levels, as well as with the
municipal presidents.  The purpose was to understand the
organization of the health services and/or of the malaria program
with respect to the financial participation of the federal,
state, and municipal governments; the processes of intra- and
intersectoral coordination; and social participation in the
control of malaria.

A total of 18 staff members with equivalent managerial and
operational responsibilities were interviewed in both states. 
These were carried out by an interviewer and were transcribed
with a word processor immediately afterwards.  The interviews
lasted an average of 30 minutes.  The period over which the
interviews were conducted coincided with municipal electoral
processes in both states.

The interviewees had an average of 15 years experience working in
the health services and in the malaria program.  The municipal
presidents were at the ends of their terms of service (in the
last two months).

b) Quantitative information:  Secondary information corresponding
to the period from 1986 to 1990 was collected from the statistics
offices of the health services and of the malaria program at the
jurisdictional level in both entities.  Information on financing
and infrastructure (human and material resources) in the health
services and in the malaria program was collected, as well as
data on the diagnostic and spraying activities.  With this
information, indicators of the efficiency of the program and/or
of the health services for the control of malaria were
constructed.  For this research efficiency was taken to mean the
use of the smallest quantity of resources to carry out an
activity and obtain a specific effect (St. Martín H. and Pastor
Aranda, 1984).  The analysis of efficiency makes sense in this
research to the extent that the activities are studied in
connection with their contribution to the control of malaria.

This was a global approximation, which did not pretend to be an
analysis of cost per unit of activity.  In any case the
activities are included as a summary of the set of processes
generated for the control of malaria.  The antimalaria activities
also include the results from interactions between the population
and the health services.

The information available for the analysis of the financing was
concentrated at the national and state levels, which limited the
analysis to the level of the local units.

The interviews with SSA staff members made it possible to acquire
information on the process of integration in depth; however, they
limited the exploration of aspects of coordination and social
participation which could not be observed at the same depth.

The financial analysis, in current pesos, did not allow
exploration of the trend in operational expenditures (wages are
not included) in the malaria program.  The study covered the per
capita distribution of the funds in malarious areas of the states
analyzed.


IV.  THE SITUATION OF THE SANITARY INFRASTRUCTURE AND OF
     MALARIA AT THE NATIONAL LEVEL AND IN THE STATES OF
     TABASCO AND CAMPECHE

The characteristics of the sanitary infrastructure at the
national level and in the states of Campeche and Tabasco are an
indication of the regional heterogeneity of the country.  The
indexes for care of the population with no social security
coverage in the state of Campeche in 1989 were below the averages
for the country and for the state of Tabasco (see Table 1).




Below, in Table 2, the behavior of the malaria indexes at the
national level for the period from 1986 to 1990 is presented. 
During this period a decreasing trend in the API is observed,
with the figures for the ABER remaining the same and those for
spraying increasing.  Thus extensive exploration of case-finding
for malaria, as well as of spraying, is assured.

In 1990 the malaria situation in Mexico changed substantially.  A
reduction of approximately 58% in the number of cases was
observed with respect to 1989; this figure is similar to that
observed in 1981 when the increasing trend in malaria was
reversed (SSA-DGE, 1991).  This reduction has been attributed
to the stratification of the malaria problem and to the
utilization of the Program for Intensive Simultaneous Actions
(PAIS) beginning in the second half of 1989 in the localities
with bigger problems.  The actions included household spraying
with residual insecticides (DDT, bendiocarb, and fenitrothion),
spatial spraying around residences with malathion, radical
curative treatment (scheme of five days of chloroquine), combined
treatment (monthly doses of chloroquine and primaquine combined),
and antilarval chemical spraying (fenthion and temephos) (SSA,
DGE, 1990).




At the level of the states analyzed, there is a marked increase
in spraying, as well as in case-finding.  The API presents a
decreasing trend during the period studied (see Table 3).



V.  RESULTS

V.1. Organization of the Program:  Decentralization and
     Integration

One of the principal theses at the national level to explain the
resurgence of the malaria problem in Mexico associates the
disasters in the malaria situation and the situation in the
program with the transfer of a responsibility to the health
services without training them to deal with the problem (DPCETV-
N1).

In this process there was a redefinition of responsibilities
among the national agencies that would formulate the strategies
to be followed for the control of malaria and the health services
as implementers of the guidelines.  Among the functions that were
assumed by the Bureau for Prevention and Control of Vector-borne
Diseases (DPCETV) at the national level were:  the management of
the financial resources and their allocation to the entities with
a problem, standardization, advisory services, and evaluation of
malaria control at the national level.  The health services in
each of the states organized an office for the prevention and
control of vector-borne diseases, which covers leishmaniasis,
dengue, onchocerciasis, and rabies, in addition to malaria; these
offices are responsible for arranging and carrying out the
actions envisaged in the program, which is prepared at the state
level and which must be evaluated and approved by the DPCETV
(DPCETV-N1, 1991) (see Annex 1).

The relationship of the DPCETV with the state offices for the
prevention and control of vector-borne diseases and zoonoses
varies according to whether the health services are decentralized
or not.  In Tabasco, the state office aggregates the information
that is produced in the sanitary jurisdictions, evaluates the
completion of the program activities, detects the administrative
problems that relate to the availability of resources at the
level of the sanitary jurisdictions, and supports the field
activities, when this is requested by the sanitary jurisdiction. 
In Campeche the state office works as a center for programming
activities, managing resources and supervising and evaluating at
the level of the sanitary jurisdiction; it works directly with
the malaria group.

The sanitary jurisdictions in Tabasco function as coordinators of
the antimalaria actions, which are considered as part of the
jurisdictional health program (Jurisdicción Sanitaria,
Tenosique, 1991).  In these programs the evolution of the
demand for health services by the population is analyzed and the
control of malaria forms part of the profiles of health care
provided by the health services.  The public and private health
institutions and the municipal government participate in the
formulation of the jurisdictional health program, which is
constituted in a basic document for the definition of
responsibilities and coordination in the development of
activities for health.  The state of Tabasco formulated its state
health law in 1985; in it the municipal presidents are considered
to be the local health officials, with the power to administer
the health services and formulate and develop municipal health
programs (Periódico Oficial, 1985).

The situation is different in Campeche, where the sanitary
jurisdictions are regional offices of the SCSP in Campeche, which
in turn are the state offices of the Ministry of Health at the
national level.  In this case, the linkage of the sanitary
jurisdiction with the rest of the health institutions and with
the municipal authorities depends on the interpersonal
relationships that the chief of the jurisdiction has or can
develop (SCSP-C3), (SCSP-C4).

This definition of responsibilities for the control of malaria
involving the DPCETV and the health services produces a scheme of
administrative deconcentration, more than decentralization.  Thus
specific administrative functions and resources are transferred
to the state officials of the program, along with a degree of
autonomy, for the purpose of increasing administrative
efficiency.  Similarly, this deconcentration permits the central
government to transfer financial resources directly, without
encountering possible redistributive policies of the governments
or the state services.

In summary, the state office for prevention and control of
vector-borne diseases works as a decentralized office, a regional
representation of the DPCETV, which is responsible for the
execution of the antimalaria actions, among others.


V.2. Financing of the Health Services and the Malaria
     Program

The decentralization of the health services in Tabasco involved
the participation of the state government and more than half of
the health budget was utilized during the period studied (see
Table 4).  The ratio of the per capita expenditure on health in
Tabasco to that of Campeche was approximately 10:1.  For every 10
pesos that were spent on health services in Tabasco one peso was
spent in Campeche.



In addition, greater flexibility was achieved in the
administration of the federal financial contribution for the
health services.  This contribution is not received "labeled" by
expenditure category but it cannot be applied to the purchase of
durable goods or to wages.  Also, since the federal contribution
is received in the month of March or April each year, a mechanism
of financing - a "credit bridge" - has been generated between the
SST and the government of the state of Tabasco in order to cover
the immediate needs in the first months of the year, avoiding
paralysis of the activities.  This procedure expresses the
political will of the state government in support of health (SST-
T1, 1991) and the SST administrative team has experienced two
six-year periods with the bureaucratic structures of the federal
and state budget offices.


Thus, the financing necessary for providing continuity to the
program actions is ensured; in the case of malaria the increase
in the incidence is associated with specific months in the year. 
In addition, the acquisition of supplies, the contracting of
personnel to strengthen the activities, and the overall financing
of the health services are ensured.  Since 1989, payment was also
decentralized; under this system the Secretariat of Health of the
state of Tabasco (SST) has been able to contract personnel
without the need for central authorization.

The financing of the malaria program has continued to be through
the federal (central) government both before and after the
decentralization of the health services.  The wages of the
permanent workers in the malaria program continue to come from
the federal government.

In the entities studied - the states of Campeche and Tabasco, the
financing received for the malaria program from the federal
government is proportional to the number of inhabitants in the
malarious areas.  Quantitatively, there are no differences
between the states (see Table 4).

In 1990, the state government of Tabasco began to participate in
the financing of operating costs, supplies, and wages for the
malaria program.  Its contribution to the budget was equivalent
to 15% of the federal contribution.  This has made financial
resources more readily available; they have been used to respond
to outbreaks and/or for contracting temporary personnel and 
purchasing additional supplies, vehicles, and other materials for
the operation of the program.

The method of programming and budgeting for the malaria program -
 the calculation of the number and type of activities to be
carried out in a specific time and the needs for staff, supplies,
and financing - is being applied to other programs in the SST. 
Once a year budgeting workshops are held at the level of the
sanitary jurisdiction, supported by each of the program chiefs
(SST-T1, 1991).

Thus Tabasco has, for 1989, a primary health care network whose
indicators are above the national average for the population not
covered by social security (see Table 1).

In Campeche the administrative and financial situation of the
SCSP is qualified as "unbearable" (SCSPC-C1, 1991).  The needs
are budgeted in Campeche and in Mexico City the financial ceiling
is fixed, with allocations to programs, categories, and line
items.  In general, the amount of financing that is received is
less than that requested (SCSPC-C1, 1991).

In 1989-1990 the malaria program had additional financial support
to contract temporary personnel in the periods when the problem
was acute.  However, the schedule was not met because the money
was received three months late for what was programmed (SCSPC-
C2).

In the state of Campeche the direct financing of the malaria
program constitutes a protective measure against redistributive
pressures stemming from the enormous needs of the state SCSP. 
However, it can be a selective factor for attention to a disease
that should be taken care of as a part of the profile of the
demand for services by the population.  Thus the budget for the
program in the state represents a significant quantity in
comparison to the health services budget (see Table 4).  This
financial scheme is also followed for the programs for family
planning and immunization; with a degree of regularity they
receive financial support which is allotted for exclusive
application to their activities.

This financial centralization, with a certain amount of
independence for the health services, has allowed the DPCETV to
increase the number of permanent employees, mainly sprayers and
entomologists, to hire temporary personnel, and to have supplies
to carry out the activities in the states with higher incidence.

V.2.1     Acquisition of Supplies for the Malaria Program

The acquisition of supplies for the states with coordinated
services (not decentralized) is carried out at the central level. 
The DPCETV functions as an adviser for purchases, which are made
under the guidance of the Ministry of the Treasury (DPCETV-N1,
1991).

In Tabasco the purchase of medical supplies was centralized; only
10% of the purchases could be made locally.  With
decentralization the entire budget was transferred to the state
level for administration.  Currently, there is competitive
bidding for consolidated purchases organized by the federal
government; at the state level what to purchase, how much, and
when are decided in accordance with a purchasing schedule which
in the case of the malaria program is well defined.  The federal
government decides from whom to buy and negotiates the best price
with the suppliers (SST-T1, 1991).

In Campeche the situation that is presented corresponds to an
image that is the opposite of that described for Tabasco. 
Although the Campeche SCSP prepare a proposal for the acquisition
of supplies, frequently what is received does not match the
request in quantity or quality or in the time of receipt
specified for its utilization (SCSPC-C2).  At the level of the
sanitary jurisdictions there is a formal purchasing committee
that is supposed to meet each time that there is a purchase that
exceeds 11 million pesos (approximately $US3,500).  However,
since the purchasing power of the sanitary jurisdiction does not
exceed two million pesos in six months, this committee does not
function (SCSPC-C4).  In addition, the mechanisms for the
control of this situation are practically impossible to operate,
since once the supplies are shipped, the SCSP would have to pay
for transportation for the return of the materials that because
of their quality or quantity or the time of their delivery might
not be useful.  In addition, a series of accounting and
administrative transactions would be required that would
aggravate the already reduced availability of supplies for health
in the SCSP in Campeche.

In order to avoid some of the problems mentioned, the DPCETV
assumes, for the central purchasing network, responsibility for
control of the quality, quantity, and timeliness of arrival of
the supplies for the program.  In this way, at the level of the
sanitary jurisdictions the supplies necessary for the malaria
program are made available (SST-J1, 1991; SCSPC-C2, 1991). 
Tabasco is doubly favored with this mechanism whenever it can
obtain additional supplies by direct purchase through the Tabasco
Secretariat of Health with the support of the DPCETV.

In addition, in Campeche there are no permanent supports for
timely distribution and storage in the sanitary jurisdictions,
since for the most part appropriate installations and a
transportation network are lacking; thus every program has to
obtain its resources from the state warehouse (SCSPC-C3).

V.3. Sanitary Infrastructure

The work of the physicians and nurses in the PHC units for the
control of malaria is concentrated on the diagnosis and treatment
of malaria symptoms and the promotion of preventive activities. 
In both states it has been established that in the regions of
higher incidence anyone who arrives at a PHC unit with all the
symptoms of malaria has a blood sample taken and complete
treatment is initiated immediately, without waiting for the
results from the sample (SST-T2), (SCSPC-C5).  This has been
reflected in the numbers of cases diagnosed (with verification by
examination of a blood sample) by the health services, which have
increased percentagewise in both states (see Figures 1 and 2).

V.3.1.    Personnel of the Malaria Prevention and
Control Program

At the national level the profiles of the various workers that
participate in malaria control have been redefined.  All are
considered "health" workers (DPCETV-N1, 1991).  The recognized
hierarchy consists of chief of the health district, the chief of
the health sector, the chief of the health brigade, and the
health technician (sprayer, evaluator).  They work in the field
in brigades in the spraying of houses and larvae and the
promotion of the reporting of cases and as entomologists.

Under this organizational structure there are, as of 1990, 3,321
workers in the malaria program at the national level, of which
3.6% are in the state of Campeche and 4.9% in Tabasco.



















However
, the
index
of
workers
per
100,000
populat
ion was
always
greater
in
Campech
e than
in Tabasco during the period studied (see Table 5).


This form of work in the new organizational structure has a
significant organizational influence in the campaign for
eradication.

In the malaria program there is a group of workers that can be
considered as specializing in particular tasks and that account
for most of the service provided by the program, namely, the
microscopists, sprayers, and entomologists.  There is another
group of workers that can be considered as providing logistical
and administrative support, which in this research we call "other
workers."  The ratio of other workers to those that specialize
has decreased at the national level during the period analyzed,
from 1.95 (1986) to 0.63 (1990).  This reduction is due to the
increase in sprayers during the last year analyzed (see Table 6).



In Campeche the ratio of "other workers" to specialized workers
was 1.24 in 1990 (SCSP-Campeche, 1990).  The values of this
ratio relate to the integration into the SCSPC; part of the
program staff was assigned to their places of residence; others
were retired; and those remaining were placed in the labor
category.  Thus Campeche continued to have many generals and few
soldiers (SCSPC-C5, 1991).  In this state the size of the staff
is considered inadequate to achieve continuity of action in
accordance with the epidemiological needs (SCSP-Campeche,
1990).  Thus more sprayers, microscopists, and personnel were
requested for collective treatments in 1990 (SCSP-Campeche,
1990).  However, the ratio of workers to population is a lot
larger in Campeche than at the national level and in Tabasco, and
what is observed is an inverse proportion of the specialized
group assigned to the program (see Table 6).

Thus in Campeche the broadening and integration of the malaria
program signified the disintegration of the program and the
dispersion of the workers (SCSPC-C6, 1991).  However, the
organization is kept separate from the health services; its
participation in the activities of these health services, such as
vaccination, is considered by the workers of the program as
outside their purview, diverting resources, and to a certain
extent, interfering with achieving the targets (SCSPC-P1),
(SCSPC-P2).

In Tabasco the program has been strengthened with workers
assigned principally to the activities directed against the
vector.  There are twice as many specialized workers in the
malaria program (microscopists, entomologists, and sprayers) as
other workers throughout the period studied, which is the
opposite of what occurs in Campeche.  To a certain extent this
can be attributed to the fact that all of the logistical and
administrative support is part of the operation of the sanitary
jurisdiction, which means that personnel from the program are not
needed for these tasks.  In addition, the PHC units have assumed
the responsibility for diagnosis and treatment of the cases -
tasks frequently carried out in Campeche by personnel in the
program (see Tables 5 and 6).

V.4. The Relationship between API and Malaria Workers.  The
     Operating Capacity of the Malaria Program

Analysis of the distribution of malaria program workers in the
sanitary jurisdictions with higher incidence in both states, in
Escárcega, Campeche, and Tenosique, Tabasco, yields a picture
that is similar to that found at the state level.  Escárcega,
Campeche, had a higher index of workers to population than
Tenosique, Tabasco, throughout the period analyzed.  However, in
Escárcega the index of workers decreases, with respect to what
occurs at the state level (see Tables 6 and 7).  In Tenosique
this index increases, while it remains unchanged at the state
level.  This shows that in Tabasco the distribution of the
program personnel is related to the incidence of the problem,
strengthening those areas with a higher API (see Table 7 and
Figure 3).




















For these sanitary jurisdictions, there is an inverse
relationship between the index of workers in the malaria program
and the behavior of the API in the period analyzed.  In 1986
Escárcega had an index of workers that was twice as high and API
figures that were more than double the corresponding figures for
Tenosique.  Both sanitary jurisdictions have succeeded in
reducing the API figures.  However, in 1990 Escárcega employed
twice as many workers as Tenosique in 1987 to achieve the API
figures that the latter sanitary jurisdiction presented that year
(see Table 7).



In 1988 Tenosique, Tabasco, had an API value of 4.6 and the index
of workers in the malaria program increased in the two following
years.  In 1990 Tenosique achieved an API value that was
sufficiently low - 2.79 - and in spite of the increase in the
number of workers, the incidence did not decrease more rapidly
(Figure 3).  Therefore, it is thought that the operating capacity
of the program interventions are reaching the optimal limit of
their efficiency/effectiveness relationship, where an increase in
the number of activities per resource and per unit population has
little effect on the frequency of the disease.

In addition, the operational costs of the malaria program and of
the installed infrastructure have to be considered.  Solely for
emphasis:  in 1986, as a generator of a demand for health
services malaria was responsible for 3.44 and 1.07 of every 100
initial consultations in the PHC units in Campeche and Tabasco,
respectively.  By 1990, these figures had decreased to 0.80 and
0.06, respectively (see Figure 4).




















In
Tabas
co,
it should be noted, four lines of human resources exist to
address the epidemiological problems at the level of the sanitary
jurisdictions; those related to malaria control would be:  a) the
personnel (physicians and nurses) assigned to the PHC units,
whose principal function is the diagnosis and treatment of cases;
b) the personnel in the malaria program, which can be assigned to
the sanitary jurisdictions with the greatest problems, whose
principal function is to carry out activities against the vector
and to provide support for case diagnosis and treatment through
active search; c) the personnel contracted temporarily to
strengthen the malaria program team in killing larvae in specific
months and in household spraying in localities with high
incidence; and d) units of the Mobile Medical Services, which in
outbreaks can strengthen the above lines by moving to the
communities to support diagnosis and/or to apply collective
treatments.  This same organization has been used in dealing with
other problems, such as cholera.  Thus a team is available to
respond rapidly to acute problems and to strengthen the daily
activities of the health services.

V.5. Intra- and Intersectoral Coordination

At the central level, the DPCETV has promoted coordination
agreements with the health institutions and with the Ministries
of National Defense, the Navy, Ecology, and Mexican Petroleums to
support the operational strengthening of the malaria control
program.  There is collaboration with the Autonomous National
University of Mexico in aspects of research and support has been
provided by the Pan American Health Organization for supplies and
training.  However, these efforts are expressed differently in
the various states of the country.

In Campeche no local, private, or governmental organization has
supported the development of antimalaria activities (SCSPC-C1,
1991).  Since 1983 there has been an agreement with the Mexican
Social Security Institute (IMSS) for the execution of the program
for prevention and control of malaria in the state of Campeche. 
It is renewed annually without integration of changes or current
needs (SCSPC-C1, 1991), since the areas of responsibility, that
is, the locations of the health care units of the IMSS, are
already set.  In 1990 the Campeche SCSP invited the municipal
presidents to a meeting to gain their support for health.  Some
sent their representatives but most did not go (SCSPC-C1, 1991). 
The municipal presidents occasionally support the destruction of
mosquito breeding places, but their participation is irregular. 
Formal agreements have been established with 21 public and
private agencies for participation in the control of malaria but
permanent supports for the actions of the malaria program have
not been set up (SCSPC-Campeche, 1990).

In Tabasco, where the sanitary jurisdictions coincide
territorially with the municipalities, this is considered to be a
matter for the advisory team of the municipal government (SST-
J1, 1991), (SST-P1, 1991), although it is not a formal part of
the municipal cabinet.  The sanitary jurisdiction presents its
demands in two ways:  directly to the municipality, where some
activities are analyzed and budgeted as a part of the municipal
government plan, and through the secretary of health to the
governor of the state, who in turn communicates with the
municipal governments to provide support.

The municipal governments have in their budgets a category
devoted to health, through which the financial support remains
constant (SST-P1, 1991).  Additional support through the
provision of personnel, maintenance, or development of the
infrastructure for health care is being provided in several
municipalities.  In the case of the municipality of Tenosique, in
1991 it contributed specialized material and labor for the
construction of 19 convalescent homes, located for the most part
in the area bordering on Guatemala.  Community participation,
"tequio," consisted of support in the form of labor for the
construction.  This participation of the municipalities and the
community is still not taken into account by the Tabasco
Secretariat of Health and thus in the analysis of the annual
budget the municipal and community contributions for the
operation of the health services do not appear.  This is known at
the state level, but it is considered that underestimating the
participation is "not much" (SST-T1, 1991).

Although at the state level there are agreements with other
sectors, it is the municipal presidents and their representatives
in the localities - municipal agents - who promote intra- and
intersectoral coordination to strengthen health care in Tabasco. 
At the municipal level there is a health committee made up of all
the institutions in the sector (SST-J1, 1991), for the purpose
of coordinating the public health programs and activities at the
local level.

Campeche presents great difficulties for coordination.  With
respect to care in the marginal areas, the IMSS-SOLIDARIDAD
(formerly IMSS-COPLAMAR) does not have any supporting
relationship with the Campeche SCSP health programs.  They are
reluctant to provide information, even on vaccination, which is a
priority program at the national level; there is still no
agreement to carry out the activities (SCSPC-C1, 1991).  This
isolation is attributed to the vertical pattern of operation of
the IMSS-SOLIDARIDAD.  Its units take blood samples and receive
the samples collected by the voluntary collaborators for analysis
in the IMSS laboratory.  When the blood sample is positive, the
Campeche SCSP is informed so that it can provide the treatment
and the epidemiological study is carried out, if appropriate. 
Receipt of this information is, on occasion, delayed up to two
months.  The IMSS sets goals for its units and its workers go out
into the communities - a responsibility of the SCSP - in search
of those with fevers in order to reach their goals.  Later they
go the SCSP and find that the population had been analyzed
recently by the IMSS.  These actions result in duplication of
actions, loss of resources, and a low quality of health care for
the community.  However, the most remote communities - those that
have communications problems - are not visited by the IMSS or by
the SCSP or by the malaria program (SCSPC-C1, 1991).

In 1991, a new division of responsibilities was proposed between
the SCSP of Campeche and the IMSS; however, the high rate of
rotation of the administrative and technical teams of the SCSP
has not permitted implementation of these agreements.  During the
last six-year period six administrators in the Campeche SCSP were
changed.  In 1991 the governor was changed and the entire state
cabinet was removed, including the chief of the Campeche SCSP,
although he is not part of the state government unit.

This lack of stability of the technical and administrative team
is one of the determinants of the form of operation of the
Campeche SCSP, which, in general, is translated into the absence
of interinstitutional coordination and a lack of continuity and
timeliness in the health actions.

However, during 1989 meetings on interstate coordination for
malaria control were held; members of the malaria programs and
the health services of the states of Tabasco, Yucatan, Quintana-
Roo, and Campeche participated.  The epidemiological situation
with respect to malaria in each of the states was described and
agreements were achieved on coordinated interventions in the
neighboring regions.  An informative bulletin entitled "The
Malaria Situation at the Level of the Peninsula" was produced. 
However, the meetings were suspended in 1990 without any
explanation (SCSP-C2, 1991).  In addition, agreements were
reached with Guatemala and Belize for coordination of border
actions.  Of all of these agreements, progress was made only with
Belize, with which joint antimalaria activities have been carried
out.

V.6. Social Participation for the Control of Malaria

This concept, at the levels of the health services and the
malaria program, is translated, in the states analyzed, into
voluntary collaborators and begins to make sense primarily in the
rural communities.

The malaria program, since its formation in the 1950s, has
promoted social participation at the local level for the control
and the elimination of the problem.  The specific functions were: 
collaboration in the diagnosis of cases, taking blood samples,
promoting household spraying, and supporting the program's rural
brigades with food, transportation, and housing.  In this regard,
broad experiences were gained; they included the participation of
the rural teachers, one of the organized groups that provided
greater support to the program for the execution of its
activities.

Now the picture has changed.  Many governmental and
nongovernmental agencies in the rural and urban areas of Mexico,
under the premise of achieving "community participation" in their
projects, have formed committees with various purposes: 
agricultural development, communication, education, religion, and
health, among others.  In the case of the health services, in
some Mexican states committees have been formed by health
institutions and by programs.  In this case one can find
committees in IMSS-SOLIDARIDAD, the SSA, and in the programs for
the extension of coverage, family planning, vaccinations, and
malaria, among others.

In Tabasco this situation has been analyzed.  The network of
collaborating volunteers in the malaria program was integrated
into the health services at the beginning of the decentralization
(1985) and forms part of the community committees, supporting not
only the operation of the health services but the whole set of
actions for social development.  In this way they do not
represent institutions or specific programs.  However, in the
regions with higher incidence of malaria in Tabasco, the program
has considered that a specific speaker that prioritizes the
antimalaria actions in the community is required (SST-J1,
1991).

Community participation for malaria control is quantified by the
program as the number of cases diagnosed as malaria by the
voluntary collaborators and is identified as "passive search." 
These diagnoses plus those made by the health services
represented 75% of the national total in 1990.

In Campeche there is the perception that the communities have
ceased to cooperate, that they rent the animals at 50,000 pesos
per day (approximately $US16) (SCSPC-C5, 1991).  This hampers
the workers' mobility, especially out to the most remote
communities.  At present the treatment is left in the hands of
the voluntary collaborators (SCSPC-C5, 1991), who form the
community network for support of the malaria program.  The cases
diagnosed by the voluntary collaborators represented more than
50% of the annual total in the period analyzed (see Figure 1).

It is possible that the material support of the malaria workers
by the rural communities has decreased; however, what is
important is their direct contribution for the control of
malaria, through the diagnosis and treatment of cases, among
other aspects not quantified by the program.  It is necessary to
consider the poverty in which the greatest part of the rural
groups in Mexico are found; their income in the best of cases
does not exceed the official minimum wage, which in 1990 was
11,000.00 Mexican pesos per day ($US4.00, approximately).  Under
these conditions, community participation is not only a
philanthropic function, but also collective support for survival. 
In both cases analyzed, the rural groups represent approximately
a third of the population; their actions for the control of
malaria are of primary importance in the region bordering on
Guatemala, where there are no permanent health services.

The provision of supplies to the voluntary collaborators in
Campeche for the control of malaria depends on the malaria
program.  The strengthening or weakening of the program directly
affects the participation of these collaborators, since they have
little connection with the limited existing health services in
the region.

In the state of Campeche, the level of control that has been
achieved in malaria can be attributed principally to the
operation of the network of voluntary collaborators for the
diagnosis and treatment of cases, to the actions against the
vector (fumigation), and to the diagnosis and treatment provided
by the program; these diagnoses - those of the collaborators and
those of the program - represented 58.34% of the total number of
cases in 1990.  The actions of the health services can be
considered to have been complementary to those of the program and
of the voluntary collaborators (see Figure 1).

The situation is different in Tabasco, where the health services
have assumed and continued activities for control.  The
collaborators have permanent resources in the health care units
and have succeeded in stabilizing their ties with them.  Although
the malaria program does not rely on collaborators exclusively,
the diagnosis of cases by voluntary collaborators has been
continued (see Figure 2).

Community participation for social development actions is an
unquestionable fact.  The problems with its continuity stem from: 
the lack of permanence and continuity of the actions; the lack of
relations that are characterized by respect and equity in the
face of the social and needs and political problems of the
communities; and the lack of recognition of the experiences of
the community which has to deal with an unending list of
institutions, programs, and community officials, without its
well-being and development appearing as a consequence.

In this regard, it is important to emphasize the changes in the
forms of the relationship between institutions and the population
promoted in Tabasco:  the formation of committees that are
representative of the community, not of institutions;
intersectoral coordination by the local authorities; integration
of health into the municipal social development programs; and the
establishment of permanent ties between the community and the
health services.  Thus there is in Tabasco a network of social
participation oriented toward the regional problems - the control
of malaria, among others.

V.7. Malaria Program Information

Quantum:  Numbers:  when, how many, and for what?
In Mexico, the health services seek to function with a State
System of Basic Information (SEIB), integrating the information
generated by the health programs as a whole.

In the case of malaria, the data on the incidence of the problem
and the blood samples analyzed are incorporated into SEIB.  In
addition, the weekly case information should be sent to Mexico
City as part of the data on the diseases for which reporting is
mandatory, for publication.

For their part, the DPCETV and the malaria program in each of the
states require information on personnel, materials, and supplies,
in addition to the epidemiological analysis and the productivity
of the human resources, to program their activities at the local
level.  This is valued differently by the health services and by
the malaria program.  For the former there is no justification
for having a table of information that systematizes the huge
volume of information generated by the program (SCSPC-C2,
1991), and thus having personnel dedicated to that task.  On
the other hand, the preparation of the malaria operating program
and the evaluation of its activities requires the utilization of
information that is not found in the SEIB, through which the
malaria program continues to produce its information "as before",
without achieving systematization and utilization under current
conditions.

In the case of Campeche, which does not have sufficient resources
to process the information generated in the sanitary
jurisdictions, there is a perception of oversupply and
saturation.  The processing is carried out with a degree of
jurisdictional disaggregation, in total numbers of activities in
the program.  The chiefs of the sanitary jurisdictions make
little use of the information and in general are unaware of the
epidemiological situation of malaria, in terms of the evolution
of the number of cases in the previous two weeks.

The information that is processed is utilized very little by the
health services, since their operation has little relationship to
the form of work of the malaria program.  It has mappings,
regionalizations, stratifications, case and API trends, and
productivity per resource, per week, per month, and per year. 
All of that great effort to analyze and systematize is not valued
and utilized except by the program itself.

There exist marked differences in Tabasco, where the sanitary
jurisdiction analyzes the purpose of the program and the disease
situation as a part of its functioning.  In this regard, the
preparation of maps and censuses at the community level, carried
out by the malaria program, has contributed to the integration
the jurisdictional health program, bringing it closer to the
local situations.  In addition, at the state level, there are
personnel specialized in the manual processing of the
information, since there is no computer equipment for these
purposes.

Another important point, related to the information found in
research, was that the population figures for the malarious areas
(reported by the malaria programs) are higher than those for the
total population (reported by the health services), in both
locations.  The differences constitute one sixth of the
population, on the average, depending on the jurisdiction or
state and the source consulted (SSA, 1986-1990;  SSP, 1990; 
Malaria Program, 1991).  These differences are so important
that they can modify the APIs as well as the other indexes and
indicators used.  However, it is not the purpose of this research
to pursue this point.

With respect to the conditions of the resources that Tabasco has,
there could be further investigation of the production,
processing, availability, and timely use of the information for
the central operation of the health services:  epidemiological
surveillance.  The information system must be assessed in
relation to the purposes of the health services and of the
malaria program, to the epidemiological situation, particularly
of malaria, and to the living conditions of the population, in
order to orient the decision-making at the local level.

This situation is relevant since another significant hypothesis
to explain the reintroduction of malaria was the lack of
functioning epidemiological surveillance (DPCETV-N1, 1991).

V.8. Training Malaria Workers

The training activities for the malaria program have as their
principal objective the strengthening of the knowledge of methods
and procedures for the prevention and control of malaria (DGMP,
1991).  Those involved in the program participate in training
programs in accordance with the activities that they carry out
for malaria control.  At the national level, a series of events
directed primarily toward those participating in the program is
scheduled.  The course Epidemiology and Malaria Control is for
the state epidemiologists in the health services and the state
officials in the malaria program; Medical Entomology for
entomologists; Management of Insecticides and Equipment
Maintenance for district chiefs and health technicians
(sprayers); and Management of Malaria for state, jurisdictional,
and district epidemiologists (SSA, DGMP, DPCETV, OPS, 1991). 
The courses given at the local level on updating operating
techniques in the program are presented by those responsible for
the program at the level of the sanitary jurisdiction.  The
training has a practical orientation (DPCETV-N1, 1991).  There
is no participation by the universities in any of these courses.

This fragmentation of the training of the workers makes it
difficult to reshape the team that works in malaria control and
to understand the levels of participation of each of the health
workers and the limits of their control of the problem; in
addition, the vertical structure of the knowledge and the
interventions is strengthened.  In addition, the advances in the
field of continuing education indicate that what is important is
not the knowledge or ideas or "correct" behavior true to the
expected pattern but the creation of the capacity to detect the
real problems and to look for original, creative solutions for
them (Haddad; Roshke; Davini, 1990).  In this regard, the
training has to be considered as an element for the development
and maintenance of what is achieved by the health services and in
the program, in controlling the malaria.

In the states analyzed, the training situation presents marked
differences.  In Tabasco training has been considered a valuable
resource for achieving functional interaction and integration of
the malaria workers with those of the health services.  The
training forms part of the activities for personnel development
at the level of the sanitary jurisdiction and is carried out
continuously.  The problems that are analyzed and the techniques
that are taught are related to the morbidity and mortality
profile of the sanitary jurisdiction or to emerging problems,
such as cholera.  The workers in the malaria program analyze
other epidemiological problems that require their participation,
such as diarrhea, diseases preventable by vaccination, and
rabies, among others, which on principle are considered "alien"
to the malaria program (SST-J1, 1991).

In Campeche, the SCSP at the state and jurisdictional levels have
had no analysis of training needs thus far (1991) (SCSPC-C3,
1991).  However, there are training activities for the
temporary personnel that are contracted for three months twice a
year by the malaria program; these individuals, mainly sprayers,
are trained in the techniques of spraying.  Similarly, training
is provided to the medical interns in social services, who are
changed every year.  Thus far no activities have been developed
for training the permanent personnel of the health services.

These two groups of temporary employees in the health services
have been constituted with the principal objective of training,
in both entities.  In the case of the interns, they are bombarded
with information by those responsible for the various programs,
each of whom considers his program the most important.  In 1991
the priority for training was cholera; the previous year it was
measles; and in 1989 it was malaria in specific regions (SST-T2,
1991).

However, the characteristics of the training in the malaria
program have succeeded in revitalizing the operating team in the
states and in the sanitary jurisdictions; there is a demand by
the workers to participate in some of these courses.  In
addition, the relationship between the training of personnel and
increasing the operating capacity of the program should be
analyzed but that is a question that remains outside the scope of
this work.

V.9. Malaria Union

With the integration of the malaria program into the health
services at the end of 1984, the workers belonging to the 16
local unions in the National Commission for the Eradication of
Malaria (CNEP) carried out a series of work stoppages to demand
wage improvements, per diem, and material resources to continue
their activities and, primarily, to maintain the central
structure of the program.  Approximately 4,000 workers were
integrated into the health services (SSA, 1987).  The most
qualified personnel were taken by social security (IMSS) and the
rest were assigned where they requested in an attempt to avoid a
labor conflict.  The 16 local unions succeeded in conserving
their autonomy in relation to the National Union of Workers in
the Ministry of Health.  Currently (1991), the malaria workers in
Tabasco and Campeche, some no longer part of the program,
continue to be incorporated and to elect representatives of the
Malaria Union (SCSPC-C6).

Among the points that were negotiated was the arrangement by
which no worker could be transferred to another entity or outside
the region of his work assignment, which has direct consequences
for the organization and operation of the program.  In the
principal cities of the state of Campeche - Campeche and del
Carmen, which have a low incidence of malaria and a greater
infrastructure of PHC services in the state - part of the malaria
program personnel is devoted to the treatment of cases, with the
justification that surveillance of the completion of the
treatment is required (SCSPC-C2, 1991).  This situation
contrasts with what occurs in the selva regions, with their high
incidence of malaria and less infrastructure for health services,
where the voluntary collaborators assume this responsibility.

In the state of Tabasco the personnel of the program are
coordinated by the sanitary jurisdiction, which does not have
specific administrators for the program at the local level.  Its
actions are planned in the jurisdictional health program in
accordance with the specific needs that are presented in the
localities (Tenosique Sanitary Jurisdiction, 1991).  Although
there is a local malaria union, the management of the sanitary
jurisdiction imposes a regional structure on the work teams in
the field, which assume their responsibilities and interact with
the physicians and nurses in the PHC units.

VI.  DISCUSSION AND CONCLUSIONS

The behavior of malaria in the 1980s in Mexico can be associated
directly with changes in the organizational and financial
strategies and with the incorporation of other actors in the
approach to the problem.

The rapid increase in the number of the cases of malaria between
1984 and 1985 was directly associated with the broadening and
integration of the program into the health services.  However,
other factors, such as the reduction in the financing of the
health services and the malaria program in the same period, have
to be considered in explaining the problem (Leyva, 1990).  In
addition, during the 1980s the quality of the living conditions
of most Mexicans declined.  It was estimated that in 1987, 41.3
million Mexicans, 50.8% of the total population, lived under
conditions of poverty and extreme poverty.  This means that their
needs for food, housing, education, and health, among others,
were not met (PRONASOL, 1990).  Of the ten states in the
country with the highest indexes of poverty and extreme poverty,
seven (Oaxaca, Chiapas, Guerrero, Puebla, Michoacan, Veracruz,
and Tabasco) were considered to have priority in the malaria
program in 1990, due to the high incidence of malaria (SSA-DGE,  
1991).  At present it is estimated that there are millions in
extreme poverty distributed over the entire country, although
they are concentrated in the southern states, among which are
Guerrero, Oaxaca, Chiapas, and Campeche; all of them are found
within the 10 states with the highest rates of malaria in the
country for the entire decade.

In summary, in order to explain the increase in the incidence of
malaria in Mexico in the 1980s, consideration must be given to
the changes at the level of the organization, the underfinancing
of the health services and the program, and the deterioration of
the living conditions of broad social groups, each factor with
different explanatory weights.

Thus the decentralization of the health services was part of the
response to the underfinancing.  However, Tabasco, in addition to
assigning financial resources to the health services and
organizing the services in accordance with local needs and
conditions, incorporated the malaria program as a part of the
general restructuring that was carried out in organizing the
Secretariat of Public Health of the state of Tabasco.  At the
operating level, the goal was to make the jurisdictional
directors more professional and by 1990 all had masters degrees
in public health.  In selecting the chief of the jurisdiction,
technical capability has priority over political pressures.  This
has led to the existence of a stable cadre of professionals that
provide continuity to the health programs in Tabasco.

In this regard, the malaria program has found technical,
administrative, and financial support which has enabled it to
have the human and material resources needed for its operation. 
The impact achieved in the control of malaria forms part of the
results of the responses to the problems of health and disease in
the region.  Among these results are the control of canine and
human rabies and the absence of cases of poliomyelitis since 1988
(SST, 1990).

It should also be pointed out that the lack of coordination and
the underfinancing of the health services in Campeche are not
attributable to the individuals that were in charge at the time,
but these are part of the political and administrative schemes
that have been noted in various analyses (SSA, 1988), (IDB,
1988).  In addition, decentralization is not only a technical
design problem to increase the functional efficiency of socially
neutral institutions, but it includes important questions related
to power and the distribution of resources among the social
groups (Collins, 1989).  In this regard, the problem is to find
the logic that would explain the continuation of inefficient
systems under conditions of economic crisis.

The characterization of the organizational situation of the
malaria programs, prepared by López Antuñano (1991),
contributes to the systematization of the forms of organization
in the framework of the relationships between the center and the
communities.  He points out that there is no totally
decentralized integrated program, just as there is no totally
centralized vertical program.  In this regard, it is important to
explore the determinants of these organizational forms adopted by
the malaria programs and the health services.

In the state of Campeche the control of the problem can be
attributed to the revitalization of the malaria program.  Its
interventions and the reestablishment of the community support
network were the principal axes of the control, although the
health services provided a growing contribution in the diagnosis
and treatment of cases in the last year analyzed.  The
problematic situation being experienced by the health services
has made permanent interaction between the program and the health
services difficult.

The network of primary health care services in the state of
Tabasco has strengthened the interventions of the malaria program
in those localities with the highest incidence.  However, the
problem of maintaining the gains will relate to the incorporation
of other sectors of the society in affecting the risk factors
relating to the disease and to the improvement of the living
conditions of the affected populations.  And the latter is not
only the responsibility of the health services, but also of the
political, economic, and social interests that, as a part of
national development, are prioritized in the region.  In this
regard, among the principal interests in the region are extensive
livestock-raising and the wood industry which have generated
ecological damage and conditions propitious for the reproduction
of the vector.  The concrete proposals to deal with these complex
problems should not come from the imagination but from specific
analyses in which the interested parties participate.  It is not
a matter of finishing with the cows nor should there be an
attempt to finish with the plants or to continue to increase the
use of insecticides (DDT), which during the period analyzed was
tripled (the national average went from 7.4 to 20.6 kg/100,000
inhabitants in malarious areas) (DPCETV, 1991), along with the
risk that their use involves for health of the population (FASE,
1990).

The interest of the community for the control of the problem has
been expressed in its direct participation in the diagnosis and
treatment of cases in both locations.  However, this should not
be limited to practices in medical care, but the analyses of the
conditions that facilitate the continuation and reproduction of
the disease should be incorporated.  In this regard, it has been
reaffirmed that continuing education can contribute to the
detection of the real problems and the search for their creative
original solutions (Haddad; Roshke; Davini, 1990).  It is
thought that a new definition of the responsibilities for the
control of malaria should be sought, based on an analysis of the
risk.

In the future, the control of malaria has to be considered,
basically, through mechanisms that favor the timely utilization
of the health services by the population, intersectoral
participation in dealing with the risk factors as a part of the
measures for social development, and the definition,
implementation, and material support of the functions of
epidemiological surveillance in the health services.

The information system generated by the malaria program has
proven its operational validity in programming and budgeting for
the activities at the local level; in Tabasco it is being applied
to other programs.  However, it needs to be evaluated and adapted
as a useful instrument for the analysis of the epidemiological
situation of the population, including the living conditions of
the affected social groups.  Otherwise, the inertia in the
measurement of malaria can lead to overloading the information
system.

The characteristics of the infrastructure, financing, and
technical capability evinced by the health services in the state
of Tabasco can constitute the best scenario to develop this
proposal.

VII. REFERENCES AND BIBLIOGRAPHY
Figure 1
CAMPECHE.  MALARIA DIAGNOSES, BY SOURCE.  1986-1990
YEAR
ACTIVE SEARCH     VOLUNTARY COLLAB.     SS
SOURCE:  SCSPC.  MALARIA PROGRAM, 1991.
----------------------------------------------------------------
-
Figure 2
       TABASCO.  MALARIA DIAGNOSES, BY SOURCE.  1986-1990
YEAR
ACTIVE SEARCH     VOLUNTARY COLLAB.     SS
SOURCE:  SST.  MALARIA PROGRAM, 1991.
----------------------------------------------------------------
-                           Figure 3
API* AND MALARIA PROGRAM WORKERS**
IN TWO JURISDICTIONS WITH HIGH INCIDENCE,
IN CAMPECHE AND TABASCO.  1986-1990
YEAR
WORKERS, ESCARCEGA       WORKERS, TENOSIQUE
API, ESCARCEGA           API, TENOSIQUE
*    Per 1,000 population
**   Per 10,000 population
SOURCES:  SCSPC.  Malaria Program, 1991.
SST.  Malaria Program, 199.
----------------------------------------------------------------

Figure 4
CAMPECHE AND TABASCO.
      MALARIA DIAGNOSES* IN FIRST CONSULTATIONS.  1986-1990
YEAR
     Campeche        Tabasco
*    Per 100 consultations
SOURCES:  SCSPC.  Malaria Program, 1991.
SST.  Malaria Program, 199.
ANNEX 1

MALARIA
ORGANIZATIONAL CHART OF THE PROGRAM
1991

MINISTRY OF HEALTH
UNDERSECRETARY OF HEALTH SERVICES
OTHER ORGANISMS               Leads the program.
Advice and technical          Coordinates interinstitutional
assistance                         group
Analyzes epidemiological situation
Evaluates completion of activities
Promotes technical and
administrative support

CHIEF ADMINISTRATIVE OFFICERS
Support for:
Financing
Acquisitions and supplies
Personnel relations

OFFICE OF PREVENTIVE MEDICINE
Sets standards, supervises, advises, evaluates, promotes
training, promotes studies, promotes coordination, and manages
resources

OTHER OFFICES
Supports for:
Information
Epidemiological surveillance
Social participation
International coordination

HEALTH SERVICES IN THE STATES
Adapt standards, plan activities, formalize coordination, and
control the development of the program

HEALTH JURISDICTION
Programs actions, manages resources, diagnoses parasitemia,
conducts entomological and epidemiological studies, supervises
the work, and evaluates what was programmed

OPERATING UNIT
Promotes notification, antimalaria education, and basic
sanitation; searches for those with fevers; administers drugs;
and applies insecticides






TROPICAL DISEASES AND SOCIOECONOMIC DEVELOPMENT:
THE CASE OF MALARIA IN COLOMBIA1



Elssy Bonilla, Ph.D.
Penelope Rodríguez



BACKGROUND


      This paper summarizes the results of a study financed by the World
Health Organization on the socioeconomic impact of malaria in a Colombian
community.2

      The study is part of a long-term research effort that began in early
1980 and has sought to provide a comprehensive view of the problem taking
into account its different components, together with its qualitative and
quantitative dimensions.

      The tropical diseases that predominate in the developing regions are
related to the socioeconomic conditions in these countries and to the
standard of living of the population, and they exist almost exclusively
among groups living in poverty.  Traditionally, the biomedical approach
involved a definition of the problem of tropical diseases based on the
interaction between the vector, the parasite, and the host, with priority
frequently being given to isolated diagnosis and treatment in the social
surroundings of the disease.

      Recognition of the relationship between tropical diseases and the
living conditions of the affected populations, together with the
impossibility of eradicating the problem using conventional biomedical
measures, gave rise to creation of the Special Program for Research and
Training on Tropical Diseases (TDR) of the World Health Organization (WHO). 
In the first document published by the program, Mahler and Morse (1976)
pointed out that many millions of people who live in tropical regions are
outside the main currents of socioeconomic progress, victims of the
tremendous burden of diseases and their difficult economic conditions. 
Thus they do not have freedom to choose a better future.  Health and
development are inextricably linked, and any strategy to improve this
situation must be based on recognition of this fact.3

      The increasing certainty that tropical diseases were the result of
the living conditions of populations with endemic diseases fact led the TDR
to promote a socioeconomic research program aimed at seeking a more
comprehensive and structural diagnosis of the problem that would lead to
the design of more appropriate and effective control strategies that did
not lose sight of the relationship between development and disease.

      This approach was not in any way designed to disregard the central
role of medicine and other related sciences in overcoming the problems of
tropical diseases.  What was really being questioned was the incomplete
picture that was being gained from this perspective.  Also, attention was
being called to the need to move towards an interdisciplinary approach that
would pave the way toward understanding the concept of health as a social
product.

      This is the context of the research outlined below.  One of the most
valuable lessons from this experience has been the conceptualization of the
disease in terms of its different social, economic, psychological, and
biomedical dimensions, which imply an interdisciplinary view of the problem
and a methodological approach that has made it possible to grasp its impact
both qualitatively and quantitatively.


OBJECTIVES

      The principal objectives of the study were:

   -  To develop a broad conceptual framework that would make it possible
      to analyze response to malaria at the level of the household taking
      into account the value of losses measured in terms of time, monetary
      income, consumption of labor and, in addition, aspects having to do
      with the maximization of well-being in the household.

   -  To design methodological tools that would make it possible to
      measure the impact of malaria on the household taking into account
      the toll on health, the impact on social relationships and free
      time, and the effects on the production of goods for market and for
      the household.

   -  To study in detail the way in which households define and perceive
      their malaria problem.

   -  To undertake a comparative analysis of the way households from
      different socioeconomic strata responded to the disease.


THE MODEL OF SOCIOECONOMIC IMPACT

      The model for studying the impact of malaria on households was
designed taking into account both Popkin's revised version (1980) of the
theory of the new household economy and the microeconomic models of farming
households.4

      Specification of the model in effect requires information on a set
of variables relating to the patient and his household in order to gain an
understanding of the way the different members of the household have to
reorganize their available time in order to replace and care for the person
who is incapacitated.  Also, an appropriate indicator should be created for
quantifying the different effects--both those related to production for
market and self-consumption and those involving production for the
household and productive consumption.

      In the model presented in Figure 1, the individuals and the
household are variables for calculating the losses suffered on account of
malaria, which, when assessed in termms of individual productivity, are
equivalent to the total economic losses of the household.  In this model,
the impact of the disease is determined taking into account the time lost
due to the patient's incapacity and to the care given and the compensatory
work required on the part of other members of the household.

      The impact of the time lost on the productivity of the domestic unit
will depend on the characteristics of the patient, the members of the
household who replace and take care of him or her, and the conditions in
the household.  The negative consequences for productivity can be measured
by considering such effects on productive market activities, non-productive
activities, and productive consumption.  The household also experiences a
direct monetary loss on account of medical expenditures and treatments
related to the disease.  The sum of these effects constitutes the total
economic loss to the household.


Figure 1: Model of the impact of malaria

[LEFT TO RIGHT, ROW BY ROW]

Time lost due to incapacity
Economic loss in terms of productive market activities

Incidence of malaria
Time lost due to care given
Reduced productivity
Economic loss, non-productive market activities
Total economic loss or total loss of household income

Time lost in replacing incpacitated family member
Economic loss in toll taken of production

Expenditure for diagnosis and treatment


     The losses are estimated assuming that the patient has less time
available because of incapacity, that the person who cares for him or her
is  sacrificing time in order to do so, and the person who replaces him or
her compensates partly or fully for the time lost by the patient but at a
cost equivalent to the value of the activities that the person replacing
him no longer performs.

      Incapacity is the time that elapses between the appearance of
symptoms and the patient's resumption of his or her daily work.  Care is
calculated in terms of the time spent by different members of the household
in caring for the patient.  Replacement corresponds to the time invested by
other members of the household to carry out those activities suspended by
the incapacitated patient.  Incapacity, care, and replacement depend on who
the patient is in the family and the specific conditions for coping with
the disease.  Care and replacement usually mean a longer workday for the
individuals who assume these tasks.

      With regard to replacement, the impact model assumes that if the
activity that the patient no longer performs is totally compensated in
number of hours by another individual, the economic loss in terms of that
activity will be determined by the difference in value between the
productivity of the patient and that of the substitute.  If the
productivity of the latter is greater than that of the patient, instead of
a loss, the value of the replaced activity will be increased.  Naturally,
less time will be devoted to another activity in the household, which is
assessed in terms of the productivity of the person acting as the
replacement.

THE MODEL OF PSYCHOSOCIAL IMPACT

      The total impact of malaria includes not only the quantitative
aspects indicated, but also the qualitative effects on all the activities
performed by the different members of the household.  This means that it is
necessary to determine other aspects related to the way in which the
household values its different members and their responsibilities. 
Moreover, it is necessary to study perceptions and knowledge about the
disease and attitudes toward its disruption of the functioning and
activities carried out by the household as a whole.

      It is expected that the net economic impact of the disease will vary
depending to the perception of the disease and its effects.  If the
negative effects are not evaluated, then it will be difficult to conduct
activities aimed at preventing it or reducing its consequences.

      Some researchers (Andreano and Helminiak, 1988) have stressed the
need to recognize the role played by psycho-affective variables in
assessing the socioeconomic impact of the disease.5  However, given the
difficulty inherent in the quantification of these phenomena and the
absence of interdisciplinary studies, these aspects have been omitted in
the economic research presented by the authors.  Specifically, reference is
made to the importance of understanding the disease's impact on what they
consder to be the toll taken, or consumption, of health.  Included in this
conceptual category are both the aspects directly related to the perception
of the pain and suffering associated with the disease, symptoms, and
follow-ups, and those pertaining to reduced well-being in terms of
premature mortality, physical incapacity, the stigma attached to certain
diseases, and the grief of patients' relatives and friends (Figure 2).



       Figure 2.  Perception of the toll on health imposed by malaria

[LEFT TO RIGHT]

General conception of health
Percpetion of suffering associated with the disease
Perception of the toll on health
Overall conception of disease
Perception of reduced well-being
THE AREA COVERED BY THE STUDY AND THE SAMPLE

      This research was carried out between August 1987 and March 1989 in
the community of La Tola, a population of 3,000 inhabitants living on the
Colombian Pacific coast in the north of Nariño Department on the banks of
the Nariño River.  It is located 5 m above sea level, and the average
temperature is 28o C, and the area has 5,000 to 10,000 mm of rainfall
annually (see enclosed map).

      La Tola was chosen for the study because of its high rate of P.
falciparum infections.  In September 1986 a high rate of malaria cases
began to be recorded in the community, and as of January 1987 approximately
48% of the population was ill and according to the report of the Malaria
Eradication Service (MES) on its visit at that time, 92% had P. falciparum
infections.

      A more comprehensive indication of the prevalence of malaria in La
Tola is provided by the registers of positive cases relative to the total
number of samples taken during the two years of the study.  In the five
visits conducted between August 1987 and March 1989, the MES took 1,255
blood samples, of which 215, or 71.1%, were positive.  The largest
percentdge of cases corresponded to P. falciparum (68.8%).

      The analysis of the socioeconomic effects of malaria was continued
through careful monitoring of one-third of the 211 positive cases of
malaria identified by the MES by serological examination.  The sample was
made up of 67 patients from 54 households.  The patients were identified by
the MES through active and passive case-finding, and the selection of cases
was made by direct sampling, taking into account the sex, age, and
occupation of the patients.  The same criteria were followed for the
selection of 10 groups that were interviewed regarding the qualitative
analysis of psychosocial effects.  In the selection, preference was given
to the patients identified during the initial days of each visit, in order
to be able to observe precision the processes of disease and recovery more
precisely during the field visits.


RESULTS

Economic Loss: Description and Quantification

      The principal findings related to the description and quantification
of the effects of the disease are presented taking into account the
attitude of household members toward malaria; the monetary and nonmonetary
economic loss with respect to all the activities of the household, and
economic loss in terms of total household income.

      Attitude of household members toward the disease.  According to the
results, most of the patients (67%) had falciparum malaria, which caused a
significant average loss of time per household.

      All the ways in which the patients made use of their time were
changed (Table 1).  Free time was most affected, since, with the uncertain
conditions of the labor market in La Tola, people had more hours during
which no work was being done6.  Even so, time lost due to inability to work
in the regular market was 27 hours (3.5 workdays); to perform domestic
activity, 19 hours (2.5 workdays); and to study, 24 hours (3 days).


Table 1.  Hours of incapacity, by use of time

----------------------------------------------------------------
TOTAL               AVERAGE HOURS
ACTIVITY                HOURS*       %   ATTRIBUTABLE TO THE
DISEASE

----------------------------------------------------------------

Market              1,222       22.5           26.7
Domestic              821       17.0           19.0
Study                 579       11.5           24.0
Free                2,389       49.0           35.6
Total               4,911      100.0
----------------------------------------------------------------
Source: Bonilla et al., op.cit, 1991, p. 175.

*Total hours of incapacity of the 67 patients seen in follow-up visits.


      Seventy-five percent of the patients received care during their
period of incapacity.  This work was done basically by women (94%), who in
78% of the cases, in addition to performing domestic tasks, engaged in
market activities as a secondary occupation or in study as a principal
occupation, depending on their age.

      The productivity of the persons who took care of the patients
averaged $153.20, which was higher than the productivity of the patients,
at $119.7  This meant that the persons who took on the care had a higher
productivity than the patients, and as a result, this activity is very
costly to the household.  Taking into account all the activities of the
persons who care for the patient, an average of 5 hours of market time, 4
hours of domestic work, 9 hours of study time, and 4 hours of free time
were sacrificed.

      Only 14 of the 67 patients were replaced in their work.  The
majority of those who served as replacements were women (64%), whose
principal occupation was either domestic work (50%) or study (22%).

      The average productivity of the persons who replaced the patients
was $90.60--that is, lower than that of the patient.  In order to replace
the patient, an average of 3.5 hours of market time, 11.2 hours of study
time, and 20 hours of free time were sacrificed.

      Measurement of the Loss.  Measurement of the loss took into account
time, monetary loss due to treatment, and total economic loss for the
household.

      - Lost time.  According to Table 2, the average total loss to the
households of the patients was 83 hours.  On average, they lost 43 hours of
free time, 18 of market time, 12 hours of activity time, and 10 of study
time.  The total time lost corresponded to the activities carried out in
free time (49%), to market activities (25%), to domestic activities (13%),
and the same proportion for study.


Table 2.  Total loss of time attributable to disease


----------------------------------------------------------------
Average
Activity               time attributed to disease     %
of total loss
----------------------------------------------------------------
Market                         18                    25
Domestic                       12                    13
Study                          10                    13
Free time                      43                    49
Total                          83                   100
----------------------------------------------------------------
Source:  Bonilla et al, op.cit., 1991, p. 147.

      - Monetary loss attributable to treatment.  Direct monetary
expenditure relating to treatment of the disease was paid for by 32% of the
patients and ranged from $20 to $5,000, or an average of $711.  If it is
considered that at the time of the study the minimum daily wage was $1,000
and that economic conditions were uncertain, the amount paid by the patient
is quite high.  Since the diagnosis and the antimalarial drug are provided
free of charge by the MES, these expenditures corresponded to
hospitalization, transportation, and non-malarial drugs used during
treatment or later on during recovery (in some cases self-prescribed, but
usually prescribed and sold "informally").  On average, the cost assumed by
the MES per patient in La Tola was $400.8  Although supposedly the patient
does not have any expenditures related to treatment because the services of
the MES are free, the data showed that the individual covered more than
half of the necessary costs in La Tola in order to be cured.

      - Total economic loss for the household.  This heading includes both
the cost of treatment and the categories corresponding to the estimated
monetary value of time lost in the household for different reasons.  On
average, the La Tola households that had a malaria patient during the
period of the study lost $12,508.  When this category is broken down by
activity, it was observed that in terms of productive free time, an average
of $6,940 was lost, with market activities and specific expenditures due to
malaria accounting for $3,864; domestic activity, $1,227; and study, $475. 
In terms of total economic loss, 49% corresponded to free time activities,
30% to market activity, 11% to domestic activity, and 10% to study (Table
3). 


Table 3.  Total economic loss


----------------------------------------------------------------
ACTIVITY                        AVERAGE LOSS          %
($)
----------------------------------------------------------------
Market plus monetary loss
attributable to treatment          3,864            30.0%

Loss (domestic)                    1,227            11.0%

Loss (study)                         475            10.0%

Loss (free time)                   6,940            49.0%

Loss (total)                      12,508           100.0%
----------------------------------------------------------------
Source: Bonilla et al., op. cit., 1991, p. 149.


      Total household income and economic loss.  Theoretically, to measure
total household income one must consider all the time devoted by its
members over the age of 7 to production and consumption.  This assumes that
the household generates a profit not only from the goods that it acquires
on the market but also from those that it produces directly and which
depend decisively on the available "healthy" time in the household.

      To estimate the distribution of household time taking into account
all the tasks performed by the different members, a value was assigned to
the different activities regardless of whether or not they generate
monetary income, since they were all considered to help maximize the
benefits derived from the utilization of time, which is the resource that
is most available in communities like La Tola.



Table 4.  Total household income, by activity (monthly average)

----------------------------------------------------------------
ACTIVITIES              $          %*      %         %
----------------------------------------------------------------
Market                58,625     66.27    57.60     24.0
Domestic              29,838     33.73    29.30     12.0
School-related        13,322     -----    13.10      6.0
Relaxation           145,259     -----    -----     58.0
----------------------------------------------------------------
Source: Bonilla et al., op.cit., 1991, p. 150.

*     The second column shows the breakdown between market and domestic
      activities only; the third, between the first two plus
      school-related activities; and the fourth, between all four
      activities.


      Table 4 shows that market activity corresponds to 24% of total
household income ($58,625), domestic work, 12% ($29,838); school activity,
6% ($13,322); and free time invested in community support activities,
recreation, and relaxation, 58% ($145,259).  Again, it is pointed out that
if only market activities are taken into account in communities such as La
Tola in developing countries, the impact of the disease on household
operations is significantly underestimated.


Regression Analysis: Explanation of the Loss

      Once the actual magnitude of the disease's impact is quantified, the
next step was to identify the factors involved in the economic loss using
estimates from the econometric model.

      Loss of time attributable to incapacity.  Two factors, namely the
days elapsed between the onset of symptoms and the diagnosis, coupled with
the patient's position in the household (position in the family), account
at a 95% level of significance for the time that the patient lost on
account of malaria for each of the different activities.

      Time lost by the household according to activity.  The greatest loss
of time of the household in terms of market activity occurred when the
patient was head of the household, at a level of significance of 98%.  This
loss was significantly greater (99%) in households with higher per capita
income.  It is possible that the heads of household are more likely to have
a paying job, and in this regard the disease significantly reduced market
activity.

      The time lost in terms of domestic activity was significantly
greater (97%) when the patient was a woman.  This included the time lost
due to her inability to do domestic work and the time she devoted to caring
for other patients in the household.

      The time lost in terms of school-related activity was explained at a
significance level of 99% in terms of age, and 95% in terms of sex. 
Students had greater losses of time not only because of their incapacity
but also because of the time that they spent caring for other patients
(relationship of significance - 99%).  This result is not surprising, since
schoolchildren, especially girls, help householdmakers regularly with this
work.

      The loss attributable to the disease in terms of free time in the
household was directly related (level of significance - 99%) to the number
of days elapsed between the onset of symptoms and the diagnosis and to the
hours spent in caring for and replacing the patient.  This time is a very
important resource for offsetting the time lost for other reasons and
constitutes a permanent reserve that enables the household to reorganize
its work and efficiently meet the needs inherent in caring for and
replacing the patient.

      The days elapsed between the onset of symptoms and the diagnosis and
the time spent caring for the patient account, at a level of significance
of 95%, for the total loss of household time attributable to malaria. 
Household time as a whole was affected by the duration of the patient's
incapacity and by the cost of caring for him or her.

      Economic loss for the household, by activity.  The monetary economic
loss in market activities is directly linked to the position of the patient
in the family and to household income (level of significance - 99%).

      The greatest economic loss attributable to the reduction of domestic
activity occurred when the persons who did this work were incapacitated and
partially replaced by others who had less productivity than theirs, usually
students.  In other words, the loss on account of domestic work is
significant (99%), although the patient who does the work is replaced.

      The economic loss in school activity is related to age.  The greater
the number of patients of school age (between ages 7 and 20), the greater
the economic loss in this area.

      The economic loss attributable to sacrifice of free time is directly
and significantly associated with the patient's position in the family and
with who it is who replaces the patient.  Because of the market conditions
in the area, heads of household reported greater available free time. 
Since the productivity of the head is greater, the household experiences a
greater economic loss in terms of free time when he or she becomes ill. 
Given the fact that almost all replacement activities draw upon a person's
free time, the sacrifice of this time also increases the economic loss.

      Of all the losses that have just been estimated, the total economic
loss for the household was greatest when the patient was the head of the
household, when the patient received care, and when the households had
higher levels of monthly per capita income.  Households with higher levels
of per capita income reported a greater economic loss both in terms of the
amount of monetary loss in market employment and because they could devote
more time to achieving a satisfactory level of recovery and pay more for
treatment of the disease.


Psychological and Social Cost

      For a qualitative viewpoint, the La Tola study analyzed the
perception of the disease's impact based on information provided from
direct or indirect experience with malaria, and interviews were conducted
individuals who developed malaria during the period of the study or who had
been indirectly affected by the disease.

      The most significant findings make it possible to draw the following
conclusions with regard to perceptions about the effects of malaria:

- The impact of the disease is felt at three levels:  from the economic
point of view, in terms of its socio-affective dimension, and strictly
speaking in a physical sense.  In the first case, the economic impact was
perceived most clearly when the patient was the head of household and was
identified as the principal breadwinner, which is consistent with the
definition of roles and the division of labor existing in most Colombian
households, particularly in rural areas.  This division assigns the
instrumental role to men, since they are given the task of meeting the
economic and material needs of the family.  For this reason, it can be seen
that these aspects were adversely affected when the head of the household
became ill.

      The emotional effects, which include such feelings as concern,
anguish, and fear of the disease, were felt most directly when the patients
were women, who in social terms have the affective role in the household. 
The cost of suspension of domestic work was felt through the negative
impact on the emotional and vital tranquillity of the home; it was not
economic, given the fact that there is no clear perception of the "monetary
value" of the work in the household done by the woman.  In considering this
emotional cost, although the members recognized the inconveniences that
malaria causes for the homemaker when she develops the disease, they
emphasized the burden that the other healthy members had to assume in order
to get the domestic chores done.

- Although the people had a clear perception of the symptoms of malaria,
its implications, and the effects of the disease, the diagnosis was usually
not made early, whether because of lack of medical resources in the
community, a desire to avoid the cost of medication, or the practice of
"elimination by trial and error," a method which tends to be followed when
symptoms appear.  For these reasons, the diagnosis was delayed, which adds
to the period of incapacity, thereby increasing the direct expenditures
occasioned by the disease.

- Because of the severity of the symptoms, the affected individuals are
almost always incapacitated.  The onset and duration of incapacity depend
also on cultural factors associated with the position of the patient in the
family.  In other words, not all members of the household are incapacitated
according to a pattern determined solely by the seriousness of the disease. 
The possibility of being incapacitated and postponing activities depends on
the characteristics of the patient and the way in which the different
effects are viewed with respect to the economic and emotional well-being of
the family.  In the study, it was the woman who postponed the decision to
be incapacitated for a longer time.  Hence her infection reached critical
levels, which forced her to rest for a longer time, thereby increasing the
negative impact on the household.  The behavior of the woman helps us to
understand the differences in the disabilities caused by malaria on men and
women and the variations in the ratio of the impact, depending on whether
the patient is the husband or the wife.


CONCLUSIONS

      The principal findings from the analyses conducted on the basis of
the qualitative and quantitative information made it possible to arrive at
the following conclusions:

- Malaria had economic implications that were clearly felt by the affected
individuals.  It should be remembered that most of patients had falciparum
malaria, which causes very severe symptoms and hence significant losses in
household time due to incapacity and the need to care for and replace the
patient.

- Patients were incapacitated for an average of one week, which affected
all the time available in the household for carrying out the various
members' activities.

- Care for persons with malaria wa0 very expensive.  Two-thirds of the
incapacitated individuals were looked after by women, who, on average, had
higher productivity than the patients.  Moreover, the persons who provided
care or serve as replacements were forced to reorganize their daily
schedule and significantly cut into their free time.

- One-third of the total monetary loss corresponded to payments to the
physician and for treatment, while the other two-thirds corresponded to
time lost due to incapacity, care, and replacement.  In other words, the
household underwent a significant loss in terms of available time. 
Although traditionally the analysis of the effects of the disease takes
into account market time, in this research it was confirmed that in La Tola
the income corresponding to these activities did not even represent half
the total income of the household.  In fact, in the assignment of a value
to each of the activities carried out by the members of the household, the
income from market activities corresponded to only 24% of total income. 
This suggests that if the impact of the disease is measured considering
only market activities (as has been done in traditional analyses), it
prevents consideration of the real loss incurred by households in
communities such as La Tola.

- The existence of a case of malaria in the household also affected the
psychosocial well-being of individual members and the emotional
tranquillity of families.  According to the results of the qualitative
analysis, both the individuals affected by the disease and the close family
members felt these effects, expressed in the form of such feelings as
anguish, fear, and concern over their inability to fulfill the obligations
of the household and their uncertainty over how the symptoms would develop.

- The incapacity inherent in the disease has serious effects on the
well-being of households.  As was observed in the qualitative and
quantitative analyses, incapacity does not manifest itself the same way in
all households.  On the contrary, it is different because it is based on a
decision that depends on the sex and the age of the patient, his or her
position in the household, his or her occupation, and the possibility of
being cared for and replaced.  The duration of the incapacity is related to
the time that is allowed to elapse between the onset of symptoms and the
diagnosis.  According to the quantitative analysis, the shorter this
period, the shorter the duration of the incapacity.

- The qualitative information made it possible to understand that the
timely effort to obtain medical treatment did not depend solely on the
presence of health personnel in the area.  Although people were able to
correctly identify the symptoms of malaria, clinical diagnosis was
postponed until other causes are ruled out "empirically" in order to avoid
incurring any monetary costs that were not absolutely necessary.  This
approach, as might be expected, can have a negative impact on people's
well-being when it leads to delayed diagnosis, which adds to the period of
incapacity and hence to expenditures associated with the disease.

- The patient's position in the household is another pertinent variable in
understanding different behavior patterns that influence the decision not
to be incapacitated.  As was observed in the model of estimated impact, the
household experienced the greatest loss of time due to incapacity and in
terms of domestic activities when the patient was the female homemaker. 
According to the perception and opinion of the persons interviewed, this
may be understood in terms of the importance of domestic work to household
well-being, the way in which the health of women is assessed, and the
implications of their illness.  In rural areas, domestic chores usually
cannot be postponed and, as a result, the woman puts off her decision to be
incapacitated, which serves to intensify the symptoms and extend the
patient's period of recovery.  All the members of the household, including
the woman, think that when she becomes ill it is more important to preserve
the well-being of the household than to provide her with adequate and
timely care.  The loss of household time in domestic activities is
explained both by the incapacity of the woman and by the time she spends
caring for other patients, which, according to the data analyzed, involves
a high cost for the household.

- When the patient was the head of the household, the greatest reported
loss of time was in market activities and the greatest loss in monetary
terms was for with such activities.  This is due to the fact that most
heads of households are men who engage primarily in market activities and
who, in La Tola and in the rest of the country, mostly participate in the
labor market and receive a higher income than women who do similar work. 
The care of this patient also adds to the economic loss of the household
because the person who looks after him must suspend her activities in order
to care for him not only because he is man of the house but also because
the different members of the household view his incapacity as creating a
greater monetary loss and do not have any idea of the meaning and cost of
the other losses.

- Malaria caused economic and psychosocial losses in all the households in
which any of their members contracted the disease.  Both the qualitative
and the quantitative findings indicated that the impact, measured in terms
of incapacity and the demands for care and replacement, varied according to
the characteristics of the patient.  The position in the household, age,
education, and sex are all factors that define and guide the dynamics of
the response to the effects of the disease in terms of substituting the
work of the patients who are incapacitated or of responding to needs for
attention and care.

- In summary, the economic loss model designed to observe the disease's
impact in terms of time and money made it possible to assess in detail the
different components of the economic cost of the disease.  Application of
the model shows the importance of time as the principal resource available
to communities in which endemic diseases such as tropical diseases
predominate.  Measurement of the disease's impact in terms of the use of
the total time on the different activities of persons makes it possible,
first, to identify the total loss in this area and, second, to assess it in
monetary terms.  The economic loss model that pinpoints the consequences of
the disease in terms of time is very well suited to assessing the impact of
malaria in disadvantaged communities in developing countries.  In the case
of La Tola, the members of the community also viewed the negative effects
of the disease in terms of the time that they lost in their different
activities, and they adopted methods of care and replacement in an effort
to address the problem so as to reduce the negative effects of the disease
on the well-being of the household.  Thus time is a unit of reference and
measurement that is shared by communities and investigators and which
facilitates better communication in understanding the losses caused by the
disease.


ENDNOTES

 1Paper prepared for the Inter-regional Meeting on Malaria in the Americas
(Brasília, 26-30 April 1992).  Elssy Bonilla is an investigator at the
Center for Economic Development Studies (CEDE), Department of Economics,
University of the Andes. Bogotá, Colombia.  She coordinates the area of
health and development.  Penelope Rodríguez is also an investigator at the
same institution.

 2The complete study was published in Elssy Bonilla et al., Health and
Development: Socioeconomic Aspects of Malaria in Colombia, Bogotá: Plaza y
Janés, 1991.

 3H. Mahler and B. Morse, "Preface," Position Paper on Research and Major
Tropical Diseases, 1976, TDR/WB/WHO/76.4.

 4B. Popkin, "A Household Framework for Examining the Social and Economic
Consequences of Tropical Diseases," paper presented at the Scientific
Working Group on Social and Economic Research on Tropical Diseases, Geneva:
UNDP/World Bank/WHO, 1980 (mimeo).

 5R. Andreano and T. Helminiak, "Economics Health and Tropical Diseases: A
review," in A. Herrin and P. Rosenfield (eds), Economics Health and
Tropical Diseases, Manila: University of Philippines, School of Economics,
1988.

6Although free time disguises time unemployed, it was very difficult to
handle these categories separately because, in the community, periods of
work and rest are not defined in terms of hours alone but more in terms of
periods, with intense and low levels of activity that influence the
distribution of work, as for example during the felling of trees and the
transportation of wood.  Because this has been and continues to be a very
important activity in the work history of the community, this is the point
of reference that organizes the distribution of the times of rest and work
according to productive cycles rather than days.  The summer and rainy
seasons therefore have considerable bearing on the conception of the
distribution of work and recreation time.

 7The exchange rate at the time was $295.80 to the US dollar.

 8This includes only the cost of laboratory supplies and drugs for
treatment (1988 prices).

ACUTE RESPIRATORY INFECTIONS

       REGIONAL PROJECT TO EXPEDITE THE ACHIEVEMENT OF THE TARGETS
OF THE WORLD SUMMIT FOR CHILDREN 
IN THE COUNTRIES OF THE AMERICAS, 1992-1994


1.         INTRODUCTION

Description of the problem

At present, acute respiratory infections (ARI) are one of
the leading causes of disease and death in children under 5 in 
developing countries.

The extent of mortality due to ARI in children can be
clearly appreciated in the analysis of the figures for pneumonia-
related deaths, which is the principal cause of death due to ARI:

-          More than 7,000 deaths per day of children under 5 due
to pneumonia in developing countries, and almost 10,000
if neonatal deaths are included, with pneumonia being
one of the leading causes.

-          Approximately 45 million children under 5 will die
during the 1990s in developing countries if current
mortality rates are maintained.

In addition to the problem that they pose in terms of
causing death, ARI also constitute one of the principal causes of
disease and complications that affect the health of children:

-          Many problems in child development and learning are
caused by hypoacusis or subsequent deafness due to 
otitis media.

Acute respiratory infections are also one of the principal
reasons for pediatric visits to health services.  Therefore, they
represent a major component of the operation of these services. 
Many of these visits are not properly handled, either because the
level of seriousness is not detected or because the child is
overmedicated, basically with antibiotics, thereby encouraging an
increase in bacterial resistance and the cost of care.

Control Situation

The control of ARI in children became a maximum priority
area from early 1980, when countries approved the inclusion of
ARI in the 17 disease prevention and control programs of the
World Health Organization.  Since that time, countless activities
relating to the study, research, and application of strategies
have been conducted, which enabled the preparation of instruments
and methodologies suited to addressing the problem.

In the past year, which coincides with the beginning of the
final decade of the 20th century, two events of major importance
have supported and strengthened the efforts undertaken:

-          The world declaration on the survival, protection, and
development of the child, arising from the World Summit
on Matters relating to Children, held at the United
Nations in November 1990, which included the reduction
of ARI-related mortality as one of the six targets
proposed by developing countries, within the section on
infant health.

-          The convening of the International Consultation Meeting
on the Control of ARI, held in Washington, D.C. in
December 1991, organized by PAHO/WHO, UNICEF, and UNDP,
which brought together representatives of AID and other
international agencies, experts, and specialists from
most countries of the world.  This meeting permitted
analysis of the recent progress made with respect to
the control of ARI and the declaration on interagency
commitment to assist with implementation processes in
developing countries.

Current prospects

Given the fact that in the Region of the Americas, ARI
control activities have already been included to a large extent
in the comprehensive health care services of the child, most
recent international events have contributed and will contribute
to expediting the processes of development, in anticipation of
the achievement of concrete results in terms of impact.

The specific areas of programming established by PAHO/WHO
and UNICEF to support the countries in attaining the targets of
the Summit constitute the principal areas of emphasis for
achieving the implementation of ARI control activities.  They
are:

-          extension of the health infrastructure.

-          assistance in developing action plans in areas of high
priority.

-          training.

-          operational research.

-          communication.

The process of preparing action plans for the attainment of
the targets, which is currently being developed by the countries
of the Americas, will also contribute to strengthening the plans
of operation for the control of ARI in the countries with their
components relating to training, provision of supplies,
communication, supervision, monitoring, and evaluation.


2.         GOALS AND OBJECTIVES OF THE PROJECT

The ultimate goal of the project is to improve the health of
children in the Region of the Americas through the control of one
of the principal causes of disease and death, namely pneumonia,
and through the proper management of ARI.

The objective of the project is to expedite and strengthen
the implementation of the standard case management strategy of
ARI in children under 5.

The targets proposed for 1995 are:

-          To provide 80% of the population under 5 with access to
standard case treatment of ARI.

-          To use standard case treatment in more than 80% of
cases.

-          To expedite the rate of reduction of mortality due to
pneumonia in children under 5.  This involves achieving
30% in 1996 compared to 1990 values.

Through the development of this project, and in accordance
with the foregoing points, the possibility will exist for other
achievements such as:

-          The preparation of plans of operation by country that
design the sequence of implementation of ARI control
measures.

-          The improvement of comprehensive child care through
increased immunization coverage (measles, whooping
cough, diphtheria, tuberculosis) and education of the
mother regarding care of the child with ARI in the
home.

-          Greater organizational, planning, monitoring, and
evaluation skills of health personnel.

-          Improved capacity and ability for supervising health
personnel.

-          Better routine information systems and analysis of the
information that they produce.

3.         STRATEGY

The principal strategy suggested for the achievement of the
objectives proposed is standard case treatment and immunization
against measles, whooping cough, and diphtheria.

Standard case treatment includes the criteria for diagnosis
and treatment of cases of ARI that permit the early
identification of children who require treatment in a hospital,
who can be treated on an outpatient basis with antibiotics, and
those who only require care in the home without antibiotics
(Annex).

Standard treatment also includes educational material for
mothers and other persons responsible for the care of the child
in order to have proper treatment and care in the home.

The following strategies are being proposed with a view to
the effective implementation of standard case management of ARI:

In order to expedite the impact of the plan, in the first
two years, actions will be focused on countries with infant
mortality rates over 40 per 1,000 live births, that is, those
that account for 95.2% of the deaths due to pneumonia and
influenza in the Region.  Therefore, a 20% reduction in the
number of such deaths in these countries represents a 28.6%
reduction in the deaths linked to pneumonia and influenza that
were recorded on the entire continent.

Table 1 presents the countries grouped according to their
estimated mortality rate.

In the countries included in Group B, although the infant
mortality rate is less than 40 per 1,000 live births, ARI is
still a significant health problem due to the occurrence of many
deaths that could be avoided through increased access and use of
standard case management, the existence of excessive and improper
use of antibiotics and other medication, and the high prevalence
of ARI complications in children.

Profound regional differences exist in some countries
included in Group B (such as Venezuela, Argentina, and Chile),
which justify the implementation of control programs.

Therefore, these countries will constitute the second
priority in terms of the plan.
TABLE 1
COUNTRIES OF THE AMERICAS GROUPED ACCORDING TO THEIR
ESTIMATED RATE OF INFANT MORTALITY
1985-1990


GROUP A
RATE OF INFANT
MORTALITY > 40GROUP B
RATE OF INFANT 
MORTALITY BETWEEN          20 AND 40   
GROUP C
RATE OF INFANT        MORTALITY > 20

BOLIVIAANTIGUA AND BARBUDABARBADOSBRAZILARGENTINACOSTA
RICACOLOMBIABAHAMASCUBADOMINICABELIZEGRENADADOMINICAN
REPUBLICCHILEJAMAICAECUADOR GUYANAEL
SALVADORPANAMAGUATEMALASURINAMHAITITRINIDAD AND
TOBAGOHONDURASURUGUAYMEXICOVENEZUELANICARAGUAPARAGUAYPERUST.
CHRISTOPHER AND NEVIS



4.         PREPARATION OF PLANS OF OPERATION BY
COUNTRY FOR THE GRADUAL IMPLEMENTATION OF THE
ARI CONTROL PROGRAM

PAHO/WHO prepared an outline for the preparation of plans of
operation for the control of ARI that provided details on the
situation in the country, the objectives and targets, the
activities to be conducted, and follow-up mechanisms, together
with the resources needed for their execution.

The preparation of plans of operation by country will make
available all the elements necessary for determining the impact
of the actions to be conducted and the instruments for the
follow-up and evaluation of the proposed targets.  In turn, it
will enable a detailed budget to be prepared in order to
determine the financial resources necessary for the
implementation of the regional project.

In the case of countries that have already prepared plans of
operation that are in different stages of execution, their review
will permit the evaluation of the progress made and the need for
adjustment.


5.         PREPARATION OF PLANS OF OPERATION BY COUNTRY

As indicated earlier, some of the countries of the Americas
have already prepared plans of operation.  These plans are in
different stages of execution.  At times, numerous difficulties
have been involved in their implementation.

In order to harmonize the available plans and to adjust them
to the current situation, the following activities will be
conducted:

1.         A meeting to evaluate ARI control programs in the
countries.

Based on the plans of operation prepared, the
activities conducted and the results obtained will be
evaluated.  At the meeting, the problems faced will be
identified and the necessary adjustments will be
proposed.

2.         Training of local officials responsible for the control
of ARI in organizing activities and preparing plans of
operation.

Although most of the local officials responsible for
the control of ARI have already been trained in matters
relating to organization, those who have not yet taken
the course will be trained.

3.         Support and advisory services for the countries in the
preparation of plans of operation.

Support and extensive technical advisory services will
be provided to the countries in the preparation or
adjustment of plans of operation.  These plans will
constitute the basis for the implementation of control
activities and for the follow-up and monitoring of
activities and results.

Plans of operation will conform to the models proposed
by PAHO/WHO, including aspects related to the practical
implementation of the control component of ARI in    
health services.


6.         IMPLEMENTATION OF PLANS OF OPERATION

The activities to be conducted with a view to implementing
plans of operation will be the primary responsibility of local
officials and health services.  However, in order to guarantee
the effectiveness of the implementation process, which, as
mentioned earlier, constitutes the critical point, countries will
be assisted in the following areas:

1.         Plans of operation provide for three different courses
to be held:

a.         A national course on the organization of
activities related to the control of ARI.

It will be geared towards regional, state,
departmental, or provincial officials responsible
for preparing plans of operation for their area.

b.         Course on supervisory skills

It will be geared towards persons responsible for
the supervision of activities at the national and
regional levels.

c.         Course on ARI case management.

It will be geared towards the health personnel
responsible for the evaluation and treatment of
children with ARI.  Depending on the country,
these courses can be subdivided according to the
category of personnel to be trained.

Assistance will be provided to countries to offer courses on
organization and supervisory skills.  The assistance will consist
of:

-          financing for the course
-          forwarding of materials for the course
-          participation of facilitators and foreign advisers to
assist with the course

Assistance with case management courses will be provided
through:

-          financial assistance and supplies to the training units
for the treatment of ARI.

-          assistance with course material.

2.         Supplies

The application of the strategy of standard case
treatment requires availability of the following
supplies:

-          Antibiotics for the treatment of pneumonia.
Outpatient:  cotrimoxazol, amoxicillin,
ampicillin, and procaine penicillin.

Hospital:  crystalline penicillin, gentamicin, and
chloramphenicol.

-          Antibiotics for the treatment of streptococcic
pharyngitis.  Benzathine benzylpenicillin,
amoxicillin, ampicillin.

-          Antibiotics for the treatment of otitis: 
cotrimoxazol, amoxicillin, ampicillin.

-          Bronchodilators:  salbutamol (for oral spraying).
Subcutaneous epinephrine.

-          Antithermic:  paracetamol.

-          Timers.

-          Case management posters on: "Caring for the child
with cough or difficult breathing" and "Caring for
the child with a hearing problem or sore throat."

-          Forms for recording information.

The project provides for assistance to the countries in
purchasing the aforementioned supplies.
 
3.         Communication

During the first phase of implementation, the countries
will conduct interpersonal communication activities and
will use the mass media only after achieving proper
coverage in order to avoid creating expectations in the
population in areas that still do not have the
personnel to provide standard case treatment.

Therefore, communication activities that will be
included in plans of operation will be:

-          Preparation of materials for interpersonal
communication.

-          Development of interpersonal communications
activities:  talks, meetings, etc.

Assistance will be provided to countries in the following
areas of the communications component:

-          Preparation and printing of educational materials.

-          Evaluation and test of materials and methods of
communication.

-          Design of specific communication plans.

4.         Supervision

Plans of operation will require a strong component
involving the supervision of activities in order to
guarantee the effective application of standard case
management by health personnel.

To this end, they will provide for two methods of
supervision:

-          Indirect supervision:  through periodic
information systems based on actual interviews at
health meetings.

-          Direct supervision:  through visits to the health
services using the manual on visits.

Assistance to countries with this component will be of great
importance, since, by and large, they do not have systems of
routine supervision.  For this reason, the areas of assistance
with this component will be:

-          Advisory services and technical support in the design
and preparation of systems of indirect supervision
(including definition of indicators, design of
formulation, mechanisms of information flows, and
methodologies for analysis of results and feedback at
the local level).

-          Advisory services and technical support for the design,
testing, and analysis of the findings based on the
manuals of supervision.

-          Participation in direct supervision visits.

5.         Monitoring and Evaluation

The monitoring and evaluation component will also be
strongly emphasized in plans of operation since it will
constitute the key for the acquisition of data to
analyze the results obtained in the execution of the
plan and the findings regarding the impact of the
execution of activities.

Monitoring and evaluation will involve:

-          The process of implementation of plans of operation: 
progress in the activities programmed.

-          The achievement of the sub-targets and targets proposed
in the plan:  progress made.

As in the case of supervision, strong support will be
provided to the countries in the development of this component,
based on the following activities:

-          Advisory services and technical support in designing
systems to monitor activities and targets.

-          Design and testing of evaluation methodologies of plans
of operation.

-          Financial support for the evaluation of plans of
operation.

-          Participation in the processes of evaluation and
national and regional evaluation meetings.7.FOLLOW-UP OF THE PROJECT AND RESEARCH ON THE OPERATIONAL
ASPECTS OF THE EXECUTION OF ACTIVITIES

In addition to providing direct assistance for the actual
implementation of plans of operation, global activities will be
conducted at the regional level in order to support and monitor
the progress of the project.  These activities will consist of:

1.         Meetings of ARI Consultants

The development of the foregoing activities will
require a solid group of consultants to support the
different countries in the implementation of the plan
at the regional level, in the consolidation and
analysis of information, and in the preparation of
technical documents and instruments.

At the moment, PAHO has a group of consultants who
cover the technical and operational aspects of the
control activities of ARI.  In order to harmonize
criteria and update the progress of regional
activities, coordination meetings of consultants will
be held and documents and technical information on the
ARI control program will be periodically distributed.

2.         Regional communication activities

At the regional level, a system of dissemination of
information on the control of ARI will be maintained
for persons involved in the activities outlined in the
plans of operation.  This includes the preparation,
printing, and distribution of the newsletter "ARI News"
and the printing and distribution of other technical
documents on the problem, its control, and the results
obtained from the application of the strategy of
standard case treatment.

3.         Monitoring of activities

The current system of surveillance at the regional
level will be strengthened with a view to monitoring,
on an ongoing basis, activities and results.  The
preparation of reports and newsletters for the
countries, which contain the results of the monitoring,
will provide feedback on a continuous basis from local
officials.

To this end, the following activities will be conducted:

-          Updating and using the current regional ARI data base
to include indicators of operation of the national
programs.

-          Periodic preparation of reports and comments on plans
of operation and the results of their implementation.

-          Periodic meetings to analyze, review, and evaluate the
information from the countries.

4.         Research on Operations

It is particularly important to analyze some aspects of
the application of the strategy of standard treatment
in relation to the manner in which they operate in
health services and in the evaluation of achievements.

At the regional level, assistance will be provided for
the design and application of research on operations on
these aspects in related areas, in order to obtain
results and recommendations that facilitate
implementation at the country level.


8.         IMPLEMENTATION OF THE PROJECT

Coordination Structure

Coordination will be a key element of the project, since the
implementation of control programs will require the development
of regional and national activities.  A basic two-level
coordination structure is being proposed (regional and national).

The ARI Regional Adviser of PAHO and the Regional Primary
Care Adviser of UNICEF will be responsible for coordination at
the regional level.

With regard to coordination at the country level, three
regional consultants with subregional duties will be assigned to
intercountry activities related to the control of ARI, structured
according to the scheme presented in Table II.

These consultants will coordinate with PAHO and UNICEF
representatives in the country and with the national authorities. 
The ICC will play a very important support role in the
coordination structure in the country.


TABLE II

ORGANIZATIONAL STRUCTURE OF THE PROJECT FOR MONITORING
ARI CONTROL ACTIVITIES IN THE AMERICAS 

*          Countries in which a subregional consultant will be
stationed.

NOTE:                The countries included in Group A are listed
because they require the highest priority in terms
of the implementation of control measures.

9.         TECHNICAL COORDINATION AT THE REGIONAL LEVEL

-          PAHO/WASHINGTON, D.C.

The regional ARI program will coordinate all activities
related to the implementation of control measures in each
country, ranging from its active participation in assistance and
advisory services provided to the national authorities in
preparing plans of operation, to coordinating their
implementation once the mechanisms for their financing have been
approved and established.  All the reports and requirements for
assistance from the countries will be processed through the PAHO
field offices in the country and will be sent to the regional ARI
program (HPM/ARI), which will coordinate coverage of these needs
with the other PAHO units.  This aspect is critical in order to
ensure a consistent and coordinated effort in terms of regional
activities and the optimum utilization of resources at the
regional level.

Technical cooperation in all the areas of operation of the
program will be available through PAHO to the countries, which
will coordinate this cooperation and provide it based on needs.

In addition to country and subregional personnel, additional
personnel will be available.  These persons will provide
assistance in the areas relating to epidemiology, clinical
matters, the information media, administration, and financial
management.  This assistance will also include bacteriologists to
assist with studies on bacterial resistance and assistance in the
establishment of a central surveillance laboratory.



TECHNICAL GROUP OF CONSULTANTS

The existing and expanded group of ARI consultants will
assist with the effort to implement control programs.  This group
is made up of experts in the field of ARI and control programs.

The role of the group will be to provide advice and
assistance at the regional and country levels with respect to the
technical components of the program, the annual review of
strategies to achieve the targets of access and use, the
identification of research needs, the review of the progress of
studies underway, protocols, and results.  The group will meet
once a year to review the progress of the program and the
problems encountered.  Its conclusions and recommendations will
be included in the Annual Report, which will be distributed
throughout the Region by the ARI program of PAHO.



INTERAGENCY COORDINATING COMMITTEE FOR THE CONTROL OF ARI
(ICC/ARI)

The project will be presented at the meeting of the
Interagency Coordinating Committee in order to establish regional
and national lines of support with other agencies, with a view to
improving and strengthening the expected results.

A brief progress report on the project will be presented at
annual ICC meetings, together with results obtained and the
critical areas in which the regional or national ICC could
provide assistance.


INTERCOUNTRY ADVISERS

Three intercountry advisers will be selected.  They will be
stationed in Guatemala (to assist with implementation efforts in
the countries of Central America), Bolivia (to fulfill the same 
function in the Andean countries), and Mexico (to assist this
country and the Caribbean).  These advisers will work closely
with the national program in the country in which they are
stationed and will provide, in addition, permanent technical
assistance to the rest of the countries.  They will prepare
periodic progress reports, which will be sent to the regional
PAHO office through the national field offices.

Their function will include coordination with the national
ICC/ARI and the country offices of UNICEF.


COORDINATION AT THE NATIONAL LEVEL

The person responsible for the national ARI control program
will be the focal point of all efforts, since he will be
responsible for the preparation and execution of the plans of
operation for the control of ARI, and will be assisted by the
ICC/ARI and international advisers provided by PAHO/WHO.  The
countries will make a commitment to assigning a full-time
official to this position, which will ensure that a sustained
effort is made to implement gradually the control measures until
the proposed level of coverage is attained.

PAHO field offices will be the channel of communication
between the national program and regional activities.  In turn,
they will provide assistance with technical matters through
maternity and infancy consultants in order to achieve the
effective implementation of the control program.  They will serve
as the support structure for subregional advisers and other
consultants that visit the country in connection with specific
matters.

The needs of the program and periodic progress reports on
activities will be channeled through field offices.

The national ICC/ARI and UNICEF local field offices will
provide support during all stages of implementation of this
project, ranging from their active participation in the
preparation of plans of operation to ongoing assistance to carry
out the timetable of activities set.  In turn, they will assist
the national program in identifying problems and establishing
support mechanisms for acquiring resources.


10.        NECESSARY RESOURCES


The resources needed for the execution of the project will
be allocated to paying for the national and regional activities
listed in point 8.  Details are provided in the section
pertaining to the budget (point 11).  In addition to these,
permanent resources will be required in the personnel category,
which will facilitate coordination and the execution of the
proposed activities for the implementation of the regional
project.



PERMANENT AND TEMPORARY TECHNICAL SUPPORT PERSONNEL

Periodic assistance will be required at the regional level
to conduct the activities outlined in this project, which will be
contracted or requested periodically and will be adapted, insofar
as possible, to the development of the activities involved.

The equivalent of a full-time consultant for 10 months is
being considered in order to:

-          Participate in periodic joint reviews (government, donor
agencies, and PAHO) of the use of extrabudgetary funds for
the project.

-          Coordinate, from an administrative point of view, with the
Personnel, Budget, and Finance units and, based on needs,
with other units in order to work jointly in all aspects
related to ordering supplies and equipment.

-          Process the appointments of consultants and advisers and
make travel arrangements.  Assist in the preparation of
contracts for personnel services and their administrative
processing.

-          Collaborate with other units, within PAHO, to achieve
effective coordination of project activities and the
appropriate use of resources.

Consultants are needed in three countries (Andean Area,
Central America, and Mexico and the Spanish-speaking Caribbean).


Duties and responsibilities:

 -         To encourage the implementation of the strategy of standard
case treatment of ARI with a view to using it in the health
services of the countries and the implementation of plans of
operation for the establishment of national control
programs.

-          To participate actively in the advisory services of the
authorities of the countries in preparing the plans of
operation for the control of ARI within the health system
and in establishing more efficient coordination mechanisms
with different areas of the Ministry of Health and other
ministries, and with UNICEF and the national ICC/ARI.

-          To assist countries with their responsibilities in the
following areas of technical cooperation:  preparation of
training materials, establishment of training courses,
maintenance of a continuous and adequate system of supplies
to the health services, indirect and direct supervision of
the application of the strategy of standard case treatment
of ARI, and monitoring, evaluation, and identification of
the needs related to research on epidemiology and
operations.

-          To assist the countries in organizing and coordinating with
other areas with a view to having an effective mechanism for
obtaining information on mortality and morbidity due to
pneumonia and information relating to operations.

-          To assist, at the regional level, in the design and
execution of the protocols for the monitoring and evaluation
of the implementation of control activities and in the
methodology of evaluation in order to verify the fulfillment
of the targets of the project.

-          To collaborate and coordinate with national and
international organizations in the optimum use of the
technical, administrative, and economic resources available
in the Region of the Americas in order to achieve the
targets proposed by the project.

Necessary qualifications:

-          University degree in the area of health, with a post-
graduate degree in public health or epidemiology.

-          At least five years of experience in ARI control programs at
the national level in a developing country.  At least one
year of experience in advisory services relating to the
implementation of ARI control programs at the international
level.

-          Excellent knowledge of Spanish (for the position in
Bolivia), of Spanish and English (for the position in
Guatemala), and Portuguese and Spanish (for the position in
Mexico).



11.        TIMETABLE


During the first quarter of 1992, approval of the present
project will be reviewed, analyzed, and evaluated, so that
specific activities can be started at the beginning of the second
six-month period of 1992.

Beginning on that date, specific activities will be
conducted in each country with a view to implementing gradually
the ARI control program, based on PAHO/WHO guidelines.

Regional activities will be conducted based on the elements
outlined in this project.  During the second year of execution, a
global review of the project will be done (including, in
particular, financial aspects) and an evaluation of the
achievement of targets, for the purpose of making the necessary
adjustments.  This review is independent of any changes to be
made as a result of the ongoing monitoring of the implementation
of proposed activities.

In July 1994, a global evaluation will be conducted for the
purpose of determining whether complications have arisen with the
activities envisaged, whether the targets programmed were
achieved, and to prepare a new project for the following period.

The tasks to be conducted during the first year are listed
below.  From now on, only brief mention will be made of the tasks
that are repeated, with new activities being included.  Persons
responsible for execution of the activities listed were described
in item 8.


1992

i.           Structure of the coordination system.

ii.          Preparation and/or review of the plans of operation for the
ARI control program in the countries that comprise Group A
(some countries already have plans of operation prepared
with the assistance of PAHO/WHO consultants, which will be
reviewed, updated, and adapted, if necessary, to the
features of this project, in particular the aspects related
to targets for access and use of the standard case
treatment proposed in the present document).

iii.         Approval of plans of operation by country.

iv.          Implementation of plans of operation (during the first
year, standard case treatment will be introduced with a
view to providing access to 30% of the population).  The
global activities to be carried out by the programs are
listed, since the detailed timetable of each will be
established in the respective plans of operation:

-        Training of regional officials regarding organization
of the ARI control program.

-        Training of health personnel in the application of
standard case treatment and supervisory skills.

-        Continuous provision of medication to the health
services that have trained personnel.

-        Bi-monthly indirect supervision of the records sent by
the health services.  Direct supervision, on a
quarterly basis, of the application of standard case
treatment by health services.

-        Monitoring of the progress of the program, with special
emphasis on training health personnel in the
application of standard case treatment and the
availability of supplies in the health services.

-        Identification of needs pertaining to research on
epidemiology and operations so that activities are
fully developed.

-        National evaluation of the program at the end of the
first year of work.

v.           Preparation and circulation among the countries of
communication materials for education of the community in
health services (face-to-face methods).

vi.          Distribution of the newsletter "ARI News" among the health
personnel that participate in the project in the countries,
which will include a special chapter on its features.

vii.         Regional evaluation of the progress of the project in the
countries, including the administrative aspects of fund
management and efficiency of their use in achieving the
proposed objectives.

viii.        Meeting of ARI consultants to analyze country reports on
specific problems identified with respect to the
implementation of plans of operation, design of solutions,
and evaluation of research needs identified in the
countries.

ix.          ICC/ARI meeting to analyze national reports on the progress
of plans of operation in the countries, the project at the
regional level, and the TAG report pertaining to this
subject.

x.           Evaluation meeting with persons responsible for ARI control
programs being conducted.


1992-1994

Beginning in 1992, national activities will be focused on
the extension of the standard treatment of cases with a view to
providing access to:

-          60% of the population in 1994.



To this end, the activities outlined in points iv. to x.
will be conducted.

In addition to these activities will be the ones arising
from the periodic evaluation of the progress of the project
outlined in points vii. to x.  These will include research on
epidemiology and operations, based on the conclusions reached at
the meetings of consultants and the ICC/ARI, which, as indicated
in point 8, will be budgeted for based on the respective designs.


12.        BUDGET


The funds needed for the project will be provided so that
the proposed regional and national activities can be carried out,
as listed in point 8.  Based on this, the costs of implementing
the regional ARI program are estimated in Table III.


Table IV indicates the available PAHO/WHO resources that
will be used in the Region to assist with the control component
of ARI within the context of comprehensive health care for the
child.                                                                          TABLE III

ESTIMATED BUDGET FOR THE IMPLEMENTATION OF THE
REGIONAL PROJECT FOR THE CONTROL OF ARI
IN THOUSANDS OF DOLLARS


CATEGORY19921993TOTAL
A. PERSONNEL
-   STC Consultant to provide regional
       assistance (Washington)                                            5050100-Consultant (Andean Area)9696192-Consultant (Central America)9696192-Consultant (Mexico and the Spanish-speaking
       Caribbean)                                                         9696192            
SUBTOTAL338338676B. MEETINGS
-   Meetings of Consultants of technical 
       groups (1 per year)                                                 
20
20
40-    Evaluation meetings of CPARI [Control Program of
ARI]6060-Evaluation meetings of TUTARI [Training Units for the
Treatment
       of ARI] (1 per year)                                               202040              SUBTOTAL40120140C.  DISSEMINATION OF INFORMATION
-   Maintenance of the data base on epidemiology and operations
 
5
5
10-    Circulation of information on ARI336 
SUBTOTAL8816D.  COMMUNICATION

-   Development, production, circulation, and
       evaluation of educational material (15 countries)

50

30

80                  SUBTOTAL503080E.  RESEARCH ON OPERATIONS IN THE
COMMUNITY202040F.  PROVISION OF
SUPPLIES
-   Antibiotics
60
60
120-    Timers202040SUBTOTAL
8080160                                                      TOTAL5365961,132



TABLE IV

BUDGET OF THE ACTIVITIES OF THE ARI PROGRAM OF PAHO, 1992/93

(IN THOUSANDS OF DOLLARS)


CATEGORY                                                                                                                                               
19921993TOTAL
Regional Adviser                                                         120120240Support Personnel6060120National Courses on Organization of CPARI120100220Regional Evaluation Meeting with ARI Coordinating
Nationals                                                                 40--40Assistance with Courses on ARI Supervisory Skills203050Assistance to TUTARI6060120Production, editing, and publication of modules and other
training instruments                                                     180160340Publication of News on ARI202040Editing and publication of technical documents and
scientific reference material                                             8080160Assistance to the countries in developing training and 
circulation material                                                     100120220Direct technical advisory services to the countries in the
implementation and monitoring of CPARI.                                  140140280Administrative expenditures (mail, telephone, fax, etc.).203050ARI project in Nicaragua supported by FINNIDA.240---240TOTAL1,2009202,120




















Provisional Agenda Item 7                       SPP18/6 (Eng)
4 May 1992
ORIGINAL:  SPANISH 



REGIONAL PLAN FOR INVESTMENT IN HEALTH AND THE ENVIRONMENT


        On various occasions during recent years the Governing Bodies of PAHO
   have discussed the implications of the economic crisis for health and the
   relationship between health and development.  The outbreak and spread of the
   cholera epidemic in the Americas has made all the more apparent the poverty,
   underdevelopment, and inadequate living conditions that prevail in the countries
   of the Region.

        In response to these conditions in general and the epidemic in particular, the
   Director of PAHO, through the Country Representations, the PAHO Centers, and
   a special interprogram task force, launched an effort to provide urgent support to
   the countries in order to combat the spread of cholera and limit its impact on the
   countries affected.  This effort included a special conference, held at PAHO
   Headquarters in December, which brought together cooperation agencies and
   organizations for the purpose of analyzing proposals for assistance during the
   emergency phase. 

        At the same time, the Director alerted the Governing Bodies to the need to
   initiate an unprecedented long-term (12 years) effort to bring about a recovery in
   the social sector, particularly in the area of health in the broadest sense of the term. 
   Informed of the general strategy proposed by the Organization to address the
   problem, the XXXV Meeting of the Directing Council of PAHO/WHO approved
   Resolution XVII, in which it requests the Director "to prepare, in close
   collaboration with the Member Countries and other cooperation agencies, a long-
   term plan of investment in health and the environment for meeting the
   infrastructural requirements in those areas" (Annex I).

        The Director of PAHO personally initiated conversations with the President
   of the Inter-American Development Bank and the Regional Vice President for
   Latin America and the Caribbean of the World Bank, who agreed to cooperate in
   developing the plan under the leadership of PAHO/WHO.  The document that
   follows describes the proposal that has been developed to identify and mobilize
   resources for rectifying problems and fostering the development of infrastructure
   in the areas of health and the environment. This proposal was presented by the
   Director to the managers of the various PAHO programs and units at a special
   session held in December 1991.  The Director thereafter designated a special
   working group, which followed up on the conversations with the World Bank and
   IDB and prepared the outline for a background paper (Annex II).

        The Subcommittee is asked to express its opinion in regard to this important
   line of action for PAHO, which must articulate and coordinate a strong initiative
   of promotion and mobilization in order to support social as well as economic
   development starting with efforts aimed at addressing health needs.















        "I cannot guarantee that this proposal will be implemented, but I do
        want to underscore the importance of the effort we will put forth to
        make it viable.  Even if we are only partially successful, we will have
        made a tremendous contribution to the health and well-being of our
        people during the next decade, but above all we will have helped to
        secure the future of our societies."










Dr. Carlyle Guerra de Macedo
Director, PAHO/WHO
6 December 1991
Meeting of Managers of PAHO/WHO
REGIONAL PLAN FOR INVESTMENT IN HEALTH AND THE ENVIRONMENT



   PAHO/WHO strategy in response to the cholera epidemic in the Region is being
constructed on the basis of two central ideas:  first, the importance of cholera in itself
as a disease and the need to combat its spread or limit its impact when it does strike
a particular country and, second, recognition that cholera is basically the expression
of a situation of underdevelopment, poverty, marginalization, and insufficient
development of environmental and health services infrastructure, just as it is a
reflection of the living conditions, educational levels, and degree of participation by
individuals, families, and communities in our countries.

   In adopting this strategy, the Organization has divided the possible action into two
phases.  The first phase is aimed at fighting the cholera epidemic directly, specifically
by preventing the spread of the disease or, in the event that it proves impossible to
prevent the introduction or spread of cholera in a particular country, by limiting its
impact on all areas-- the health of the people, economic and social activity,
international trade, etc.  Efforts are currently focused on the implementation of, or
attempts to implement, this emergency phase in all the countries.  It comprises several
components.  We are concentrating our attention on epidemiological surveillance,
improvement of technological and laboratory capacity, sanitary conditions for patients,
water quality, and, on an immediate, urgent, and critical basis, the treatment of waste. 
Attention is also being given to problems in the areas of education, information,
community mobilization, and research, including the testing of possible vaccines.  All
these activities are aimed at combating the disease directly and limiting its impact. 

   We have estimated that the emergency phase in our Region will last approximately
three years--1991, 1992, and 1993--and we are working under the assumption that we
will be unable to prevent the spread of cholera to most, if not to all, the Latin
American countries and several of the Caribbean countries as well.  I believe that the
steps that have been taken thus far have vastly reduced the proportions of the
epidemic, which could have been, and might yet be, catastrophic in the Region.

   However, we would be doing very little if we were to limit ourselves to simply
fighting the epidemic.  I believe that we have the obligation to propose measures that
will get to the underlying causes of the epidemic, and it is for this reason that the
Organization has included a second phase in its strategy. This second phase has been
designated the Phase of Investment in the Infrastructure of Health and the
Environment.  Our proposal seeks to measure the gap that has developed between
needs, on the one hand, and accomplishments and available resources in the health
sector, on the other, and to propose a long-term initiative aimed at narrowing this gap. 
The initial proposal is for 12 years, which would take us into the early years of the
next century. 


   Our initial estimates put the total cost of this gap at around $US200 billion.  Of this
amount, approximately $130 billion corresponds to environmental infrastructure-
-in particular water and sanitation--while some $60 billion corresponds to health
services infrastructure.  The concept of infrastructure as it is being used here is fairly
broad.  It is not confined to physical infrastructure; it goes on to encompass the
capacity for effective organization, management, and operation.  The figure of $200
billion may seem surprisingly high.  Indeed, in this period of continuing economic
crisis, it may seem inconceivable that anyone would dare to propose making an
investment of $200 billion in Latin America and the Caribbean over the next 12 years. 
It is not so much the magnitude or the quantity of the needs that is surprising.  In fact,
meeting these needs may very well call for more than $200 billion.  But the first
impression, the initial reaction is that this is an impossible, completely unrealistic
figure--that it does not even warrant consideration.  It is precisely this way of thinking
that I want to address.  I believe that, in order to take advantage of the sociopolitical
opportunity that has arisen out of the cholera epidemic, we must look at the whole
picture, and when we examine the situation a little more closely, we will see that $200
billion is not as utopian or absurd a figure as it may seem.

   We have proposed four major ways of financing the $200 billion required for
investment.  The first is mobilization of the resources available in each country--
even though to suggest that there are national resources to be mobilized in countries
that are in crisis might, too, seem surprising.  At the onset of the crisis in the 1980s,
the countries of Latin America had an aggregate savings and gross investment capacity
of about 23% to 25% of each nation's gross domestic product.  That was the situation
from 1979 to 1981.  The crisis of the 1980s, in addition to all its other manifestations,
has had one consequence that is sometimes not even mentioned but which I believe
is the most serious as an expression of the gravity of the crisis--namely, the reduction
in the capacity for savings and investment to about half what it had been before the
crisis.  At present, savings and investment are hovering at around 12% of gross
domestic product, although the exact figure varies from country to country.  If the
economic situation and the period of stagnation and recession continue unchanged, we
cannot truly hope to recover previous levels of investment or, consequently, allocate
resources for any type of investment whatsoever, especially one as large as what we
are talking about.  But this is where our first assumption comes in--namely, that
productive economic growth will resume, or is in the process of resuming, and that
this resumption will begin next year and continue through the end of this decade into
the early years of the next century.  Assuming this, it is perfectly feasible and not even
particularly ambitious to expect an aggregate economic growth of around 3% per year. 
This is equivalent to a rate of only 1.2% or 1% in real terms because, allowing for
population growth, the increase in per capita income would be only 1% or 1.2% per
year during the period in question.  But with a 3% annual growth it should be possible-
-although this needs to be examined more fully--to rapidly increase savings and
therefore gross investment to levels of between 18% and 20% per year. 


   In these circumstances, our proposal is that 1.5% to 2% of the gross domestic
product be allocated for investment in health and the environment.  This would
represent approximately 10% of the savings capacity of the Latin American
economies.  This is neither unrealistic nor particularly ambitious.  On the contrary, it
is actually quite cautious.  And if this can be done, it will represent nearly $140 billion
over the period we are considering.  But I am playing with numbers. Obviously at this
stage we have to play with numbers in order to form an initial impression of the
feasibility of a macro-proposal of such magnitude.  But these are reasonable numbers;
they are not absurd.  Seventy percent could be financed through the mechanism just
described.  Nevertheless, while it is easy to state this in terms of numbers, we must not
overlook the amount of effort that will be required in order to make this proposal a
reality:  economic, financial, and fiscal policies will have to be defined to provide for
the allocation of these resources in each of our societies, because the central
governments should not be expected to single-handedly come up with the entire $140
billion.  This is a point that I want to stress.  We are not proposing that the
Governments alone invest $140 billion over the next 12 years.  Rather, the investment
must come from the societies and economies as a whole, including all levels of
Government as well as other economic and social actors, particularly the private
sector.

   The second major financing mechanism would be the mobilization of external
resources, which would come under three broad headings.  Under the first heading, a
large portion--we have suggested 20% of the official multilateral or bilateral financial
flows that go to Latin America--would be channeled into investment in health and the
environment over the next 12 years.  Currently, despite the crisis and worldwide
competition for these resources, Latin America is receiving between $US12 and
$US14 billion in financial resources from official sources, whether bilateral or
multilateral, primarily through the Inter-American Development Bank and the World
Bank.  Between them, these two organizations are responsible for more than $10
billion of the financial flows into Latin America.  Thus, in potential terms, at least, the
resources are available.

   If it were possible to allocate 20% of these financial flows for investment in health
and the environment, in 12 years at least $30 billion would have been invested for this
purpose.  There are many obstacles standing in the way of this, but they are not related
to the availability of resources.  Rather, they are obstacles in terms of political will and
the capacity to develop and effectively negotiate projects and proposals. 

   By way of illustration, at a meeting I attended yesterday at the World Bank to
discuss this matter, the Regional Vice President for Latin America and the Caribbean
told us that the World Bank's policy for the next two years--although there is no
reason to suppose that the policy will not be extended beyond this period--will be to
apply 25% of the funds provided through the Bank to what they call "human
resources," which in essence means human development.  The concept of human
resources is understood to encompass the population as a whole.  To this it is
necessary to add the amounts the Bank applies to investment in sanitation
infrastructure, since these sums are not included under the heading of human
development.  Hence, it is not absurd to think that it would be possible to attain the
figure of 20% that we are proposing for investment in health and the environment.  In
recent years the Bank has been allocating substantially less than this--less than 10%,
closer to 9%, in fact--for investment in these two areas.  But it has been doing so
mainly because there has been a failure to promote acceptable investment
opportunities.

   As far as the Inter-American Development Bank is concerned, in recent years it has
been applying around 14% of its lending portfolio to activities that could be
considered the equivalent of investments in health and the environment.  The
challenge, then, is to increase this amount from 14% to 20%--and in this connection
the seventh increase in the authorized capital stock of the Inter-American
Development Bank will work to our advantage.  This will require the establishment
of a policy that is valid, though it may not be fully attained, whereby at least 20% of
the Bank's total resources would have to go to the social sectors.  Add to this the water
and sanitation sectors, which are not classified under this heading, and we would not
be far from the numbers that we are talking about.

   The second source of external financing--which it appears we initially
overestimated--is the possibility of using debt conversion operations to finance
investments in health and the environment.  Environment here is used not just in the
strictly "green" sense of the term--in other words, the preservation of natural
resources--but is understood to mean the improvement of environmental conditions
in the broad sense, which would necessarily include water supply, sanitation, the
avoidance and prevention of soil and air pollution, and waste management in general. 
According to our estimates, notwithstanding our overestimation of the potential of this
source of financing, initially it should be possible to mobilize about $1 billion a year
for investment in health and the environment, taking into account the size of the debt
of the Latin American and Caribbean countries, which currently amounts to $440
billion. 

   Finally, if all of the foregoing takes place, an additional $10 billion to $15 billion
would still need to be raised, and this could be sought through donations or other
operations.

   In saying all this, I hope to make it plain that we are not talking about something
that is entirely outside the realm of possibility.  We may never succeed in doing it, but
if we can at least succeed in developing a viable proposal along these lines and then
go on to implement at least half of it, we will have taken an extraordinary step toward
solving problems that have plagued our peoples for generations and centuries. 

   Where do we stand at this point?  I have initiated contacts with agencies that might
become involved.  We have managed to obtain the recognition and at least the stated
support of the presidents of the countries of the Region for this idea, so we have the
initial political backing needed.  We intend to establish immediately--during this
month--a working group within the Organization specifically for the purpose of
studying these proposals in depth and spelling them out in a more precise
macroeconomic formula, in terms of epidemiology, etc.  We intend to work primarily
with the two Banks, but we also plan to involve other agencies in these studies, such
as the United Nations Development Program and the Economic Commission for Latin
America and the Caribbean.  If we make good progress in this endeavor, we will create
a kind of alliance involving all these institutions.  Thus there would be support for the
establishment of a program which, even if it were not a formal program in bureaucratic
terms, would be a de facto program that would serve to orient the activities of all these
institutions.  In conjunction with these activities, which are to be carried out at the
Regional level, there need to be concrete activities at the level of the countries.  The
Regionwide studies that we are carrying out must be accompanied by the analysis and
development of proposals within each country, because ultimately, when all is said
and done, it is at the country level that action must be taken.

   We intend to begin gathering information through each Representation with a view
to diagnosing needs and, even more important, creating a sort of "idea bank" for
investment, so that once we are ready to support national efforts on a large scale we
will have at our disposal the initial information with which to begin.





Excerpted from the presentation made by
Dr. Carlyle Guerra de Macedo
at an internal PAHO meeting held in
Washington, D.C., on 6 December 1991.
NOT REVIEWED BY THE AUTHOR.

E0091.fin



PAN AMERICAN HEALTH ORGANIZATION

SUBREGIONAL PROGRAM ON "ENVIRONMENT AND HEALTH
IN THE CENTRAL AMERICAN ISTHMUS" (MASICA)

PROJECT ON WATER RESOURCES CONSERVATION 
AND DRINKING WATER QUALITY SURVEILLANCE
IN CENTRAL AMERICA

OBSERVATIONS FOR SIDA


I.   Background of the project under consideration

     The Project on Water Resources Conservation and Drinking
Water Quality Surveillance came about in the context of the basic
strategy of the "Environment and Health in the Central American
Isthmus" Program (MASICA), which attempts to combat transmission
of the principal diseases of the region through activities
directed toward preventing environmental alteration in order to
reestablish the original condition of natural resources and
restore the ecological equilibrium, whose deterioration has
created conditions favorable to the proliferation of diseases. 
Deteriorated environmental resources serve at the same time as
reservoirs and physical vehicles of transmission of the principal
pathogens.  Water in particular is one of those elements which is
principally involved in the causal relationship of its
contamination and the diseases that follow in its wake when one
is exposed to contact with or ingests it.  It is calculated that
more than 80% of all the diseases in the region stem from this
condition of resource contamination and deterioration, a
sufficient reason in itself to deal on a priority basis with
preserving its quality.


II.  The IDWSSD, the ADD, and the sociopolitical situation

     The efforts made during the International Drinking Water
Supply and Sanitation Decade (IDWSSD) from 1980 to 1990 collided
with the worsening of the economic and social conditions in the
region and with aggravation of its political and military
conflicts in such a way that to date most Central Americans lack
a safe supply of drinking water, and changes in current and
potential sources of supply are becoming greater every day.

     The three most affected countries are Guatemala, Nicaragua,
and El Salvador, where the effects of the conflicts mentioned
have also been most intense; but the entire region, perhaps with
the sole exception of Costa Rica, has deficient indicators in
basic sanitation related to high rates of morbidity and mortality
due to acute diarrheal diseases (ADD), among which cholera stands
out because of its new development and virulence.  Up to 14
February 1992 it had affected 8,236 Central Americans, of whom a
total of 134 have died.  It is important to note that in the
first 45 days of the year alone there were sizable new epidemic
outbreaks in Guatemala and El Salvador, with 1,124 and 948 cases,
respectively, which in itself indicates that this disease has
taken root endemically in the region.

     The attached reference document, "Drinking Water Supply in
Central America" (Jenkins, J. Global Forum, Oslo, September
1991), provides a more complete panorama of the regional
situation in basic sanitation and its links with the social
problems of the last decade.

     
III. The project's consultations

     During the consultations carried out throughout 1990 by the
Ministries of Health and drinking water supply agencies of the
countries of the Isthmus to prepare the seven MASICA projects,
there was a consensus that the Pan American Health Organization
(PAHO/WHO) was the agency best suited to gear its activities
toward preserving the quality of water resources, which are
essential for ensuring the health of the Central American
population.  The activities of the IDWSSD dealt more with supply
matters, and very little was done to ensure water quality and
protection of current and potential sources for human
consumption.  Although supply and water quality matters should be
managed inseparably, the truth is that investments and efforts in
Central America have focused for the most part on the first
aspect.

     Throughout the preparation of the Water Resources Project,
more than ten specialists from the Organization and its
specialized centers--the Pan American Center of Human Ecology and
Health (ECO/PAHO) and the Pan American Center for Sanitary
Engineering and Environmental Sciences (CEPIS/PAHO)--
participated.  The final document has been presented to countless
organizations and subregional jurisdictions which work in related
fields and those with which MASICA keeps in frequent
communication.  Among them are the Central American Commission on
the Environment and Development (CCAD), the senior environmental
coordination agency in Central America, which was created by the
five presidents of the Isthmus and with which the Organization
has signed an Agreement of Cooperation for carrying out the
MASICA projects (January 1991); the Committee on Drinking Water
of the Region (CAPRE), made up of the managers of the drinking
water supply agencies in Central America; the Inter-American
Sanitary and Environmental Engineering Association (AIDIS); the
Central American Institute for Research on Industrial Technology
(ICAITI), which belongs to the Central American governments; the
Network of Nongovernmental Environmental Organizations for the
Sustainable Development of Central America (NETWORKS-C.A.), the
strongest confederation of environmental NGOs in the region; the
International Union for the Conservation of Nature (UICN); the
Regional School of Sanitary Engineering (ERIS), in Guatemala; the
Master's Degree Program in Environmental Engineering of the
National University of Engineering of Nicaragua; PINUD, UNEP,
UNICEF, FAO, and many others among those from which support has
been received, not mention bilateral agencies such as SIDA,
NORAD, DANIDA, FINNIDA, AID/ROCAP, and the Government of Italy.

     In the agreements concluded at the last meeting of CCAD,
held in Belize from 19 to 21 February 1992, support was also
reiterated for the MASICA/PAHO Program (XIII).

     Such on-going contacts with the agencies that work in the
drinking water sector are a good beginning for regional
coordination of the activities included in the different subject
areas of the water quality project.


IV.  Later developments

     The water resources project drawn up by MASICA responds to
the demands of the Ministries of Health and drinking water supply
agencies.  It is aimed at dealing with an aspect frequently
forgotten in efforts to improve basic sanitation, has a basically
preventive and integrative approach, and falls within the context
of the decentralization of local health systems.  Few doubt that
by improving water quality and ensuring itsCentral America:  Social Indicators
Related to Basic Sanitation and Health*

GUAELSHONNICCORPANFrank unemployment
(% of EAP), 1989
10.0
24.0
10.0
26.6
3.8
n/aOverall poverty, 1985
Thousands of persons
6,726
4,169
3,422
2,212
746
840Per-capita external
debt, 1989 (dollars)
317
355
654
2,021
1,530
2,321Life expectancy at
birth, 1985-90
62.0
62.2
64.0
62.3
74.7
72.1Mortality, 1985-908.98.48.18.04.05.2Infant mortality, 1985-
9058.757.468.461.719.422.7Gastrointestinal diseases as
a percentage of total deaths,
circa 1980

41.5

9.9

16.9

13.6

n/a

n/aPercentage of urban population
with potable water, 1985
72.0
68.0
47.0
76.0
100.0
100.0Percentage of rural population
with potable water, 1985
14.0
40.0
45.0
11.0
83.0
64.0Percentage of urban population
with sewerage, 1985
41.0
82.0
24.0
35.0
99.0
99.0Military effectives, 198551,60051,25023,00062,00019,800n/aMilitary expenditures as
per-
centage of total budget, 1985
15.5
21.4
6.5
22.5
n/a
n/a
*IICA/FLACSO.  Centroamérica en Cifras.  San José, Costa Rica,
1991.


integrity through the mechanisms of monitoring its quality and
epidemiological surveillance, most of the acute diarrheal
diseases, including cholera, will also be prevented.  This has
been recognized by the Ministers of Health of Central America
who, at the VII Meeting of the Health Sector of Central America
(VII RESSCA), declared the following in their Resolution I-7: 
"To recommend that mobilization of support for the projects of
the MASICA Program which have great potential for helping control
the cholera epidemic, especially the `Water Resources
Conservation and Surveillance of Drinking Water Quality' and
`Management and Control of Solid Wastes and their Effects on
Health and the Environment' projects be intensified."

     In the same vein, the II Symposium on Water and the
Environment held at Managua, Nicaragua, on 26 February 1992, said
in item 11 of its Act of Agreements:  "To support the `Water
Resources Conservation and Surveillance of Drinking Water
Quality' project presented by MASICA/PAHO since it is aimed at
contributing significantly to solving the problem related to the
protection and conservation of water resources and with the
health of the population.

     In the context of MASICA, several of its seven projects have
a relationship with that of water presented here.  Among them are
that dealing with pesticides, which cause contamination of
current and potential sources of drinking water; that dealing
with industrial contamination, which is also responsible for
deterioration of resources; that dealing with environmental
education, which covers household handling of water and standards
of community and personal hygiene, and that on evaluation of
environmental and health impacts of development works, a
methodology intended to prevent the negative consequences of
development and to achieve a self-sustaining process.  Thus are
the different MASICA/PAHO projects closely linked.     


V.   Favorable conditions created by MASICA

     With the implementation of MASICA/PAHO's project on
institutional strengthening, institutional conditions have begun
to be laid for carrying out the other projects.  Information
about current environmental legislation and diagnosis of the
situation of water analysis laboratories, needs in technical and
professional formation, and the status of environmental
information systems, which it has been possible to determine
through the execution of different activities of the
institutional strengthening project will allow adaptation and
more precise programming of the activities which will be carried
out in the project on water resources conservation and potable
water quality surveillance.  The contacts established by
MASICA/PAHO in the seven Central American countries and
relationships with regional organizations are also positive in
facilitating the coordination so necessary for the success of the
project at both the national and regional levels.


VI.  Administration of the project

     It is useful to note that through the institutional
strengthening project of MASICA/PAHO a scheme of administration
has been enhanced which has proven its usefulness.  This scheme
is based on the concept of strengthening the national and
regional agencies charged with environmental management above any
other consideration and increasing their executive and technical
capacity to intervene in protecting the environment.  The
Organization (PAHO/WHO) provides the technical advisory services
required through its offices (Country Representations) in each of
the seven countries and places at the disposal of the ministries
and agencies charged with the execution of the projects its
administrative, logistical, and information support facilities. 
It is hoped that the water resources project will also follow
this plan.

     In every country there is a staff member who has been
designated by its government to assume the functions of focal
point of every MASICA/PAHO project.  He bears the principal
responsibility for carrying out the project.  The focal point is
aided by an advisory group comprised of representatives of the
agencies that have some responsibility for carrying out the
activities programmed in the project.  The focal point also
serves as coordinator of the advisory group.

     The PAHO/WHO Country Representatives' offices have officials
known as Country Engineers, usually sanitary or environmental
engineers, who exercise responsibility for generating and
orienting required technical assistance and promoting interagency
institutional coordination to carry out the activities of the
project.  In certain cases where it has been necessary, a Liaison
and Follow-up Technician (TEAS) has been contracted through the
project who provides assistance to the focal point, establishes
liaisons required between agencies, and provides follow-up to the
execution of programmed activities.  All the agencies noted have
their own terms of reference.  In matters of technical assistance
the Project has the support of ECO/PAHO and CEPIS/PAHO, in
addition to the Environmental Health Program (HPE) located in
Washington, D.C., which is responsible for all of MASICA.

     In the case of the water resources project which concerns
us, it will be necessary for the national authorities to
designate a focal point, define the agencies which are
responsible for carrying out the project in each country, and
convene them to form the advisory group in each country.   It
will also be necessary to contract the project's coordinator
according to the terms of reference which have been prepared for
this purpose, and to locate him at the headquarters of MASICA in
San José, Costa Rica.  It will be necessary to define in what
countries it is necessary to contract the Liaison and Follow-
up Technician.

     Although the project is regional in character, it is based
on activities which will be carried out in each of the countries,
and as a result interagency institutional coordination at the
national level will be  decisive.  It is hoped that the
commercial nature of the drinking water supply and sanitation
agencies and their internal organization will facilitate the
project's execution, as will the existence of CAPRE, which
PAHO/WHO has supported from its beginnings.  In addition, MASICA
has a presence in the principal environmental forums of Central
America, a modest infrastructure at its headquarters, and a
logistical support network in the countries.  All of these are
conditions promoting effective and efficient execution of the
project.

     
VII. Observations of the MASICA/PAHO Coordinator's Office on the
     observations of the water section of SIDA's Division of
     Infrastructure on the Project:  Water Resources Conservation
     and Potable Water Quality Surveillance in Central America.

     San José, Costa Rica, February 1992.


1.   SIDA

     Control and improvement of water quality in the region is
very important.

     MASICA/PAHO
     
     Agrees completely with the observation.  All the experts who
analyze the data on water quality and its relationships with
epidemiological records of morbidity and mortality in the Region
assign the highest priority to its surveillance and control.


2.   SIDA

     The project's proposal focuses mainly on curative aspects. 
Greater emphasis should be placed on preventive aspects, as well
as on concrete preventive measures.

     MASICA/PAHO

     This observation requires detailed comment.  The purpose of
the project was to emphasize preventive aspects, to seen in the
General Objectives.  Is aspired to reduce the incidence of
waterborne diseases not  through curative means such as oral
rehydration or the mass use of antibiotherapy, but instead by
ensuring a safe supply of water by means of conservation
activities, improving the quality of resources (see General
Objective 6.1), and strengthening surveillance and control
activities (General Objective 6.2).

     Indeed, curative activities are limited to Subject Area 4
(Epidemiological Surveillance and Primary Health Care), which
accounts for only 12% of the budget of the project.  But Specific
Objective 4.2 applies even here:  "To identify waterborne
diseases and population groups with the greatest degree of
susceptibility to them in order to carry out preventive
activities and activities to reduce health risks."

     The bulk of the activities which can be called preventive
are in Subject Area 5 (Surveillance and Monitoring of Sources and
Drinking Water Quality), which in fact is the strongest in the
project, accounting for 27.9% of the total budget and
constituting the backbone of the project.  In the Justification
of the Area, it is established clearly that ...  "drinking water
supply and basic sanitation are considered essential in the
preventive health approach" (page 33).  Further on in the same
text it is noted that:  "The ultimate end that is pursued by the
measures and activities proposed in this subject area is the
advance protection of population ..." (page 34). Finally,
Specific Objective 5.1 again establishes the preventive character
of the Subject Area.

     The second budgetary allocation in order of magnitude is for
Training of Human Resources, with 19.1% of the total of the
project's budget.   Training is basically oriented to preventive
matters to prevent, or if that is not possible to remedy, cases
of polluted water for human consumption.

     The Subject Area of Conducting Applied Research and Use of
Appropriate Technologies has received 13.7% of the total budget. 
Here again, the activities in this area are essentially
preventive.

     From the previous figures and statements we believe that
preventive aspects predominate over curative ones in the project. 
However, if SIDA considers that preventive measures should be
strengthened still more, the MASICA/PAHO Coordinator's office is
prepared to make appropriate adjustments before initiating the
project.

     
3.   SIDA

     The relationships and ties between this project and other
projects within the sector in the Region are not completely
analyzed (projects with others donors, UNICEF, etc.).  A list of
projects planned and in execution could be useful to avoid
duplicated activities.  Such a list would help facilitate
coordination with other projects.

     MASICA/PAHO

     The observation has validity in regard to the need to have
an updated and detailed list of the projects planned and in
execution related to water supply and the control of drinking
water quality in the countries of the Region.  This project is
oriented toward increasing surveillance and control capacity and
not toward increasing service coverage, an activity which is
better suited to financial agencies.  The project was so
conceived and oriented before the arrival of cholera.  Today this
approach has been one of the elements of greatest usefulness in
mitigating this epidemic.  PAHO participates in the collaborative
committee of the region in achieving effective coordination and
preventing or reducing to the minimum the duplication of
activities.  Activities are also coordinated with UNICEF, the
Committee of Drinking Water for the Region (CAPRE), the Central
American Commission on the Environment and Development (CCAD),
the Inter-American Association of Sanitary and Environmental
Engineering (AIDIS), and bilateral cooperation agencies such as
AID/ROCAP so that the project is informed about and maintains
contacts with the principal initiatives that are carried out in
this sector.  This information could be systematized in a list
before initiating the project in question.
 

4.   SIDA

     The role and the capacity of PAHO in the planning and
execution of the project are not clearly defined.

     MASICA/PAHO

     PAHO/WHO has played the principal role in matters of
technical assistance in the field of drinking water supply and
sanitation in the Americas.  The Environmental Health Program of
the Organization (HPE), with the support of the sanitary
engineers assigned to the countries and the team of professionals
of various specialties located at the Pan American Center of
Human Ecology and Health (ECO), in Mexico, and the Pan American
Center for Sanitary Engineering and Environmental Sciences
(CEPIS), in Peru, has provided continuous support in the
planning, design, execution, operation, maintenance,
optimization, and administration of infrastructure works and to
the agencies responsible for these basic services.

     Technical assistance has ranged from collaboration with
universities and training centers in all the countries of the
Region to the assignment of experts to collaborate in solving
particular problems of relative complexity.  During the last
decade PAHO/WHO has acted as the international cooperation
organization responsible for the follow-up and evaluation of the
progress made in the IDWSSD.

     In good measure the installed capacity and the experience
accumulated by the Organization was made available in formulating
the project.  Similarly, there was a process of previous
consultation, through the collection of the information available
on the seven countries, with the participation of local
professionals of recognized experience in the field of drinking
water and sanitation.  This list of professionals who
participated in compiling basic information and formulating the
project in the countries is available.

     The structure designed to carry out the project envisages a
level of responsibility of the PAHO/WHO Country Engineers, with
broad participation by the agencies with greatest responsibility,
which are members of the Support Group of the focal point of the
project.  The Regional Coordinator's office of the Program, the
Technical Coordinator's office of the project, and the
Coordination of the Environmental Health Program (HPE) will
provide guidance and technical and administrative orientation to
achieve efficiency and effectiveness during the execution of the
project.

     
5.   SIDA

     The possibility of integrating the project in the different
national organizations has not been discussed.

     MASICA

     As a set of PAHO projects integrated among themselves, the
MASICA program has a central purpose, which is that of
establishing a system of duly articulated and coordinated
environmental management in the seven countries of the Central
American isthmus.   In this regard, the water resources project
has initiated a process of consultation and research meetings
which contributes to effective integration with the agencies
having greatest responsibility for achieving the purposes,
objectives, and targets of the project.  These tasks are
currently carried out as a part of the institutional
strengthening project and as one of the priority activities of
the Regional Coordination of MASICA.

     The role of the different agencies involved in carrying out
the water resources project is defined in the advisory groups
which will be formed in each country, and in general includes the
following agencies:

     ´    National drinking water supply and sanitation agency.

     ´    Municipalities or agency which groups municipalities
charged with supply.

     ´    Ministry of Health.

     ´    Ministry of Natural Resources and/or Environment.

     ´    National Commission on the Environment and Development.

     ´    NGOs, community groups, women's organizations,
professional associations, etc.

     ´    Water resources research centers.

     ´    Universities.

     ´    Ministry of Education.

     ´    Institute of territorial studies or similar agency.
     

6.   SIDA

     The provision and capacity of national organizations to
cover the costs of operation and maintenance in the short and
long term has not been discussed.

     MASICA/PAHO

     The process of providing water and sanitation services has
passed through several stages, among which the following are
noted:

     7.1  Carrying out infrastructure works to increase coverage.

     7.2  Investigating, carrying out, and utilizing technologies
appropriate to the economic social, and cultural
reality of our countries.

     7.3  Improving the administrative and financial management
of water and sanitation agencies and companies.

     7.4  Developing systems of surveillance and control of human
drinking water quality.

     7.5  Conceiving the water resource comprehensively so that
the various users are also responsible for conservation
and rational use of resources.

     The purposes of the project are related to the five points
noted, and it has greatest responsibility for points 4 and 5. 
The arrival of cholera helped to show the high priority that
should be placed on surveillance and control of the quality of
the water delivered to the population.  Consequently, the
governments have observed the growing need for assigning
resources for the operation and maintenance of the programs of
surveillance and control.

     The project plans to establish a system of surveillance and
control which provides reliable and timely information on
drinking water quality and current and potential sources of
supply to support the process of rational management of resources
and preventive measures that can be taken in case of alteration
or contamination phenomena.  The network of properly equipped
laboratories with trained staff members will be indispensable
resources which the project plans to deliver to the respective
countries as its initial contribution to carrying out continuing
activities.

     In order to ensure a commitment by national organizations to
cover the costs of operation and maintenance as counterpart funds
of the project in the medium and long term, the signing of an
Agreement of Cooperation between PAHO/WHO and the national
drinking water supply agencies, encompassing all the commitments
required by the water resources project, is proposed.


7.   SIDA

     The purposes of the project cover a great number of
subareas, and it should be considered if the activities could be
concentrated in the future.  The option for execution should be
investigated.

     MASICA/PAHO

     The observation is pertinent, and it is thought desirable to
concentrate the subject areas and the different activities in the
phase of annual programming for the execution of the project.

     
8.   SIDA

     The need for developing specific designs adapted to the
particulars of the countries is not discussed.

     MASICA/PAHO

     Subject Area I, on Planning of Policies, recognizes this
principle, which is necessary for "defining general policies that
guarantee uniformity of criteria, purposes, and objectives in
each country" (page 19).

     Section IV, in describing the nature and magnitude of the
problem, also presents figures which support the need for carry
out particular plans and activities in each country (page 9).

     As noted above, although the project has a regional
character, its execution should be based on the activities
carried out in each of the countries, where the particulars of
the institutional development, level of training of human
resources, existing infrastructure, degree of social
organization, and cultural particulars should be taken into
account.

     PAHO/WHO has in operation a system of programming and
evaluation of projects that facilitates this task of
individualizing the planning of the activities in each country,
adapting it to their particular circumstances, as occurs at
present in the institutional strengthening project in MASICA. 
Each country carries out a Four-Month Plan of Work (PTC) in which
the set of activities to be carried out in the next four months
in each of the Subject Areas is programmed.  This programming
exercise, which is carried out three times a year, is very
important because the focal point, the Country Engineer
(PAHO/WHO,) and in some cases the representatives of the most
important agencies of the advisory group participate in its
preparation.  It is thus ensured that programming is adjusted to
local circumstances in each country.  The PTCs of all the
countries are reviewed and harmonized with the availability of
resources and local execution capacity by the MASICA Regional
Coordinator's office and the Technical Coordinator of the
project.  Evaluations are also made in each country at the end of
every PTC and are sent to the Program Coordinator's office.  The
Organization's DAP and DEC units continue to be the principal
interlocutors with donors.


9.   SIDA

     The proposals formulated do not contain an explicit
justification for the mass utilization of consultants for the
execution of the project.

     MASICA/PAHO

     The lack of an organized and systematic activity for
achieving surveillance and control of drinking water quality
requires strong initial technical assistance which can enhance
national capacities, which will be the ones that in the end will
bear the responsibility for leading a permanent surveillance and
control program.  However, the project will seek to utilize
qualified and experienced resources available in their own
countries as the principal resource for the consultantships
required.  This involves carrying out a process of negotiations
with qualified personnel who have a real option of being
assimilated into the project in the countries of the Region.

     
10.  SIDA

     The "Social Participation" Subject Area could be integrated
into other Subject Areas.  In addition, this area is rather vague
and has no clearly defined strategies for its implementation.

     MASICA/PAHO

     The observation is valid.  This area could be concentrated
in other areas and so improve the specific objectives which are
pursued.  It is clear that there is a marked interest in
consolidating broad participation of other actors, in addition to
the traditional ones, in solving the control, surveillance, and
certification of the quality of drinking water and its sources. 
This applies in particular to community participation, women,
social communicators, and young people, as well as NGOs and other
organizations with other interests compatible with health and
water resources conservation.  Achieving this purpose requires a
specific program of organization and training.

     It is necessary to mention that the MASICA project on
institutional strengthening is carrying out research in all the
Central American countries on mechanisms and strategies for
promote the social participation specified in environmental
improvement projects that are for their own benefit.  In the
first four-month period of 1992 national workshops on
consultation on this subject are programmed in all the countries
which it is hoped can contribute ideas to other MASICA projects
and especially to the water resources project which concerns us.

MASICA/PAHO COORDINATOR'S OFFICE

San José, Costa Rica, February 1992

Such thinking inspired several events during the decade of the 1980s which
pointed up the desirability and timeliness of incorporating the issue of
"Democracy and Health" into the dynamics of the legislatures in the Americas.

This phenomenon carries singular importance, since the legislative sphere,
where conflicting groups and interests converge and validate one another,
provides fertile ground for the examination of health issues and the
formulation of new social policies to contend with the crisis.  The
authoritarian state tends, by its very nature, to formulate restrictive
legislation, which emphasizes national security at the internal level and
leads to isolation and seclusion at the international level.  The
constitutional state, on the other hand, attaches special importance to
distributive legislation, oriented toward social welfare and the achievement
of equity, while in regard to external relations it emphasizes integration
and cooperation with the countries that are its counterparts.


   PAHO/WHO is postulating the improvement of health as one of the objectives
of economic and social development, with a view to reducing the inequalities
in health conditions and in access to health services among the different
social segments of its Member Countries.  The XXIII Pan American Sanitary
Conference, held in September 1990, adopted this position when it approved
the Strategic Orientations and Program Priorities for PAHO during the
Quadrennium 1991-1994.  Among other targets that it establishes for the
quadrennium, this document calls on the countries and the Secretariat to
endeavor to improve the relative priority assigned to health on their
political agendas and in decision-making for the allocation of resources,
both at the national and international level.  The thrust of this objective
is to restore the social visibility and political relevance of health in the
societies and Governments of the Americas.  To this end, it is essential to
promote the active involvement of the social and political actors who are
most influential and have the greatest decision-making capacity in efforts to
solve health problems and to safeguard the achievements in this area to date.

   Among other measures, it is considered essential for the Organization to
work more closely with the legislatures of the Region to promote the growing
interest in health within the respective countries, as well as to support
them in carrying out their legislative and control functions in this area. 
Health is considered to be one of the most propitious areas for achieving
agreement on the objectives of equity, democratic consolidation, and Regional
integration.  This is the rationale behind PAHO/WHO's promotion of the
Project "Democracy and Health."  The legislatures have a key role to play in
the Project inasmuch as they are regaining the central position in the
political life of the Region that they had temporarily lost during periods of
recess, cloture, or dissolution.  This reactivation of the legislatures
implies an effort to recover lost time, notably through constitutional
reforms, sectoral reorganization, and the updating of sanitary
codes--measures that have been taken recently by several countries of the
Region.

   For many countries this new presence of the legislature has signified a
move away from a tradition of strong primacy of the executive branch toward
an acceptance of the equalizing role of the legislative branch in the
formulation of policies, the allocation of resources, or management of the
state apparatus.  More important still, the legislature provides a forum for
negotiation and cooperation between the various interest groups involved in
the health sector and in health issues.  It is precisely through the power
and effectiveness of the democratic system that it is possible to turn this
negotiation and cooperation into clear-cut action mediated and regulated by
those who represent the interests of the people as a whole.  Thus, the
legislature plays an important role in the definition of health policies,
especially when there is a need to reorder health care, rechannel financing
for it, or regulate the actions of those who produce health inputs and
services.  Moreover, it provides a favorable environment for making health
more than merely a sectoral concern and for strengthening its links with
other levels of political and socioeconomic development.  To accomplish these
tasks, the legislative branch will require technical information and advice,
in addition to exchange and cooperation between legislatures, in order to
enable it respond more expeditiously and effectively to the social demands
that it is called upon to meet.













Provisional Agenda Item 9                             SPP18/8 (Eng.)
1992
Original:  Spanish















DEMOCRACY AND HEALTH:

PAHO/WHO COOPERATION WITH THE LEGISLATURES OF THE AMERICAS 































PAHO/WHO COOPERATION WITH THE LEGISLATURES OF THE AMERICAS


1.    Background

      Several factors have contributed to the evolution of the Project on
"Democracy and Health" since the beginning of the 1990s.  From a
socioeconomic perspective, opportunities have arisen to offset some of the
negative effects of the crisis of the 1980s--the so-called "lost decade" --on
social development in the Americas, especially its impact on health. 
Aggravated by the economic adjustment policies adopted by many countries in
response to the crisis, these effects have been manifested in growing
inequity between the different strata of American societies in terms of the
risks for disease and death and access to health services.

      The Region's legislatures have different roles depending on whether the
governments are of the presidential type (which are the norm in Latin America
and the United States) or the parliamentary type (which prevail in the
English-speaking Caribbean and Canada).  From the political standpoint, the
trend toward democracy that has been gaining momentum in the last decade,
most notably in Latin America, has generated favorable conditions for
involving the legislatures as counterparts in the PAHO/WHO cooperation
endeavor.  With the revitalization of democracy, legislatures are gradually
assuming the central role in the Region's political life which they had
temporarily lost during periods of recess, cloture, or dissolution.  This
reactivation of the legislature has brought with it an effort to make up for
lost time, as witnessed by the recent constitutional reforms and initiatives
to reorganize the sector or update the health codes in several countries of
the Region.  Also, the return of rule of law and of democratic regimes has
created a propitious climate for legislation aimed at achieving equity
internally and, externally, at fostering integration and cooperation between
the countries of the Region.

      For many countries, this change has meant that the legislature has come
to share functions with the executive power which were once the exclusive
responsibility of the latter, such as making policy and allocating funds for
the health sector or regulating the production of goods and services.  Even
more important, since the legislature constitutes a setting in which
different interest groups come together and affirm their position on issues
that affect health, they have been able to negotiate and forge new health
policies that address the crisis.  The strength of the democratic regime lies
precisely in its capacity to turn this process of negotiation and agreement
into a transparent and mediated effort that involves the participation of
those who represent the interests of the entire nation.  At the same time,
the legislature also provides a uniquely privileged setting in which to
encourage and evaluate the contributions being made by institutions in the
health sector and other areas of socioeconomic and political development
toward progress in health.

     In the context of the Organization, the countries of the Americas have
recognized that health is not only a basic component of development but also
one of its objectives.  PAHO/WHO is postulating the improvement of health
with a view to reducing inequalities in the state of health and the access to
health services enjoyed by the different segments of society in its member
countries.  Inasmuch as it is influenced by political, social, and economic
determinants, health should not be the exclusive province of the health
sector; rather, it requires participation by society as a whole and by the
various entities of the State.  This position was endorsed in September 1990
by the XXIII Pan American Sanitary Conference through its approval of the
Strategic Orientations and Program Priorities for the Pan American Health
Organization during the Quadrennium 1991-1994.  Subsequently, the Executive
Committee of PAHO/WHO, at its 107th Meeting in July 1991, approved a set of
targets for the implementation of these SOPP, which for the countries are
indicative and for the secretariat are normative.  During this period the
countries and the secretariat are committed to improving the relative
position of health both on the various political agendas and in the
decision-making process for the allocation of resources.  In order for this
to happen, it will be necessary for health to regain its social visibility
and political relevance in the life of societies and in the endeavor of
governments and their legislatures in the Region.

      The Organization's first step in support of this initiative was to
establish the Health Legislation Project (HLE) under its program for Health
Policies Development (HSP) for the purpose of managing information and
providing relevant technical cooperation.  As part of this undertaking, work
got under way to produce the LEYES data base, which is developing an index of
national health legislation enacted by the countries of Latin America and the
Caribbean since 1978.  The data base is being made available to the
Ministries of Health, the legislatures, and academic institutions throughout
the Region on the compact disk (LILACS/CD-ROM) produced by the Latin American
and Caribbean Center on Health Sciences Information (BIREME).  Its structure
parallels that of the Index to Latin American Legislation developed by the
Hispanic Law Division of the United States Library of the Congress.  Work on
compiling the legislation in the Caribbean countries is being carried out
under an agreement between PAHO/WHO and the Law School of the University of
the West Indies (UWI).

      This data base, which is more current and complete than similar
collections in other areas of WHO, will enable our member countries to access
the body of comparable legislation on health for the entire Region, which in
turn will serve as an incentive and as a source of information for updating
health legislation in the respective national contexts.  At the same time,
efforts are being made to encourage the compilation of health legislation at
the subnational level utilizing the same methodology as that employed by
LEYES, as in the case of the agreement with the Centro de Estudos e Pesquisas
de Direito Sanitário [Center for Study and Research on Health Law] at the
University of Sao Paulo.  This agreement providesfor assembling and incorporating into the data base health legislation at the
national, state, and municipal level with a view to bringing it into
conformity with the provisions of Brazil's new Constitution enacted in 1988.


2.    Objectives

      The Project on "Democracy and Health" was initiated in 1990 under a
cooperation agreement between PAHO/WHO and the Organization of American
States (OAS), on the basis of which four subregional meetings of lawmakers
were held.  In addition to seeking to establish closer relations between
PAHO/WHO, the OAS, and the legislatures of Latin America and the Caribbean,
these meetings had the following objectives:

      a)  To contribute to the consolidation of democracy through greater
equity in the area of health;

      b)  To strengthen the role of the legislature in dealing with health
issues;

      c)  To promote greater knowledge and information on the health situation
among legislators as members of the Hemisphere's political
leadership; and

      d)  To identify the challenges and priorities for health with a view to
orienting future actions in the legislative area, including
technical technical cooperation.

      With regard to this last objective, the project has undertaken to
involve the legislatures in the technical cooperation process at the
Regional, subregional, and national level in coordination with the respective
national authorities and with the support of other international agencies. 
This cooperation is intended to reach out progressively to encompass
legislative bodies at the national, provincial or state, and municipal
levels.

      Some of the previous experiences of PAHO/WHO, such as its activities
related to the peace-making process and the Plan for Priority Health Needs in
Central America and Panama, have provided useful background for proposing
these objectives to the legislatures of the Americas.  These experiences have
suggested that health constitutes one of the most propitious areas for
pursuit of the aims of equitable development, consolidation of democracy, and
regional integration.  Moreover, they illustrate the need to strengthen
cooperation between the legislatures and other entities of the State as well
as to promote closer ties with other legislative powers in the Region with a
view to implementing a process of "advocacy for health."

      In each of the countries, it will be necessary to stimulate thelegislature's interest in the health of the people and to support it in
fulfilling its role in this area as one of the powers of the State.  In order
to meet this commitment, the legislative power will need to have access to
information and technical advisory services so that it can respond more
readily and effectively to the demands of society which it has to address. 
Accordingly, PAHO/WHO has promoted the Project on "Democracy and Health" for
the purpose of fostering cooperation between traditional
counterparts--particularly the Ministries of Health--and the corresponding
legislatures.

3.    Evolution of the Project on "Democracy and Health"

3.1.  First stage:  Subregional Meetings of Legislators in 1990

      The first stage of the project began with the following subregional
meetings, the sites and dates of which are indicated below, together with the
number of lawmakers in attendance:

      -   First meeting:  Tegucigalpa, Honduras, 28-30 May, attended by 21
lawmakers from Belize, Costa Rica, El Salvador, Guatemala, Honduras,
Nicaragua, and Panama.

      -   Second meeting:  Caracas, Venezuela, 18-21 June, attended by 24
legislators from Bolivia, Colombia, Cuba, the Dominican Republic,
Ecuador, Mexico, Peru, and Venezuela.

      -   Third meeting:  Kingston, Jamaica, 22-24 October, attended by 35
lawmakers from Antigua and Barbuda, Aruba, Bahamas, Dominica,
Grenada, Guyana, Jamaica, Netherlands Antilles, St. Kitts and Nevis,
Saint Lucia, Saint Vincent and the Grenadines, Suriname, and
Trinidad and Tobago.

      -   Fourth meeting:  Santiago and Valparaiso, Chile, 7-9 November,
attended by 28 legislators from Argentina, Brazil, Chile, Paraguay,
and Uruguay.

      The meetings brought together a total of 108 lawmakers from both
legislative chambers (in the case of countries with bicameral legislatures)
with recognized interest and a relevant background in social and health
policies.  Two to five lawmakers were invited from each country in order to
ensure that each delegation had a politically pluralistic composition. 
Participation by women legislators was strongly encouraged.  Each of the
meetings was opened by the Head of State of the host country, or his
representative, and included the participation of a number of distinguished
leaders, such as the Ministers of Health and other government authorities. 
The Central American meeting was held in conjunction with a special meeting
of Ministers of Health of the subregion.  Three of the meetings were held, at
least in part, on the premises of the host legislature.

     The Director of PAHO/WHO participated in three of the meetings and the
Assistant Director in one, presenting the Organization's position on this
initiative and the manner in which it will be carried out.  The OAS was
represented at the meetings alternately by the Secretary General, the
Assistant Secretary General, and the Secretary for Economic and Social
Affairs.  The PWRs participated by providing support for the respective
national delegations, as did the OAS Representatives in the host countries. 
A team of staff from the two organizations served as the technical
secretariat for the four meetings.  Thanks to excellent press coverage, the
public in the host countries was able to gain an idea of the significance of
the event and its implications for the future.

      The sessions of the meeting were devoted to an examination of issues
bearing on the relationship between democracy and health, including:

      -   The role of the legislature in the area of health;

      -   Crises, adjustment policies, and their impact on health;

      -   Financing problems in health systems development;

      -   Women, health, and development;

      -   Technical cooperation:  priorities and future outlook.

      As background for the meetings, reference documents were prepared on
the respective topics of the agenda taking into account suggestions received
from different units of PAHO/WHO and the OAS.  In addition, various
publications produced by the sponsoring organizations were made available to
the participants.  The documentation was sent to the delegations in advance
in order to allow them sufficient time to prepare their contributions to the
discussions, which resulted in well-structured interventions and a productive
discussion of the proposed agenda.  At these meetings the participating
lawmakers agreed on a series of points which have gone on to provide the
basis for formal declarations and have served to orient interaction between
PAHO/WHO and the national legislatures in the respects cited.

      In economic terms, the lawmakers focused on the negative impact that
the crisis, the external debt, and the economic adjustment programs has been
having on the Region, especially in the social and health areas.  There was
also recognition of the need to seek mechanisms capable of responding to the
situation and, with this objective in mind, of integrating the resources and
the efforts being made by welfare agencies, social security institutions, and
private health services.

      In addition, they reaffirmed the need to consolidate the processes of
democratization and peace-making in order effectively guarantee that the
entire population has increasingly better access to health.  The most
important manifestation of this process has been the constitutionalreforms that guarantee the right to health and define the responsibility of
society and the State in this area.  The lawmakers also recognized the
importance of complementing the work of the executive and legislative
branches in order to ensure more effective and efficient normative action in
the area of health, and of giving the legislatures more latitude in the
exercise of their rightful control over this process.

      The legislature was recognized to be a basic arena for the attainment
of equity, particularly in light of its role in setting policy on fiscal and
budgetary matters.  Moreover, emphasis was placed on the need to encourage
regional integration as a means of responding to pressing problems in the
countries of the Region and presenting a common front in the global system of
international relations.

      With regard to women, attention was called to the importance of their
participation in the development process, given the fundamental role of women
in society.  The legislators also affirmed the need to make the utmost use of
women's capacity in the promotion, protection, and recovery of health, as
well as in the prevention of disease.  It was agreed, therefore, that women
need to be included in the development and implementation of health policies
both as beneficiaries and as promoters thereof.

      Finally, it was recognized that there is a need to promote cooperation
between the legislatures of the Region in health matters, as well as to enter
into agreements and promote the participation of their members in events
where social and health issues are debated.  In addition, the legislators
asked PAHO/WHO and the OAS to establish lines of cooperation in the area of
health, stressing the need to update health legislation through an approach
that combines the principles outlined above.  It was also emphasized that in
order to attain these objectives it would be indispensable to have mechanisms
that would not only facilitate the dissemination of knowledge in the area of
health legislation but would also provide lawmakers with access to the
training needed in order to address the challenge of health management at the
legislative level.

      In this connection it was recognized that the legislative
infrastructure is quite limited, making it difficult for the legislatures to
adequately fulfill the functions that have been consigned to them in the
prevailing Regional situation.  However, as yet there has been little
interaction between legislators, health authorities, and international
agencies in the area of health, and there is no clear awareness of the
possibilities for reciprocal cooperation.  The subregional meetings enabled
these parties to become better acquainted with one another and to establish
ties that will lead to greater utilization of the potential of all concerned.

3.2   Second stage:  Establishment of Direct Cooperation with the
      Legislatures in 1991

     The subregional meetings have generated a series of tacit commitments
for technical cooperation between the legislatures and the sponsoring
organizations.  For PAHO/WHO, these commitments have resulted in a line of
work to be implemented during the second year of the project which will
involve various activities that take into account both the political and the
technical dimensions of the legislatures, as described in this section.

3.2.1 Technical cooperation agreements between PAHO/WHO and the legislatures

      The need manifested by the lawmakers for access to information and
training in the management of health issues led PAHO/WHO to sign a technical
cooperation agreement this year with several of the legislatures in the
Region.  This first stage will include the legislatures of Argentina,
Barbados, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador,
Guatemala, Haiti, Honduras, Jamaica, Mexico, Paraguay, Peru, Saint Lucia,
Trinidad and Tobago, Uruguay, and Venezuela.  Cuba was added later at the
request of that country's Ministry of Health.  The agreement, which has been
finalized in consultation with the pertinent national authorities, covers the
following components:

      a)  Provision of the technology required for use of the LILACS/CD-ROM,
including, in addition to periodic delivery of the compact disk, a
microcomputer with a printer and a CD-ROM reader.  This technology
permits access to the data bases of Latin American and Caribbean
literature in the health sciences (LILACS), human ecology (ECO),
environmental sanitation (REPIDISCA), and health legislation
(LEYES), all of them produced by BIREME;

      b)  Subscription to the publications of the Organization that are
considered relevant for the development of health-related
legislation; and

      c)  Opportunity for the legislatures to participate in the Regional
initiatives promoted by the Organization, as well as in cooperation
activities at the country level under agreements concluded with the
respective national authorities.

      The agreement also provides for the designation of an official from the
legislative branch who will take responsibility for coordinating cooperation
and providing information on the draft legislation currently  under
discussion, as well as on the composition and activities of the health
commissions.  This information, in turn, will be placed at the disposal of
other legislatures through a special data base that should become available
during 1992.  As this report was being prepared, 18 legislatures had already
accepted the Organization's offer of cooperation, received the equipment and
documents that were sent, and designated the respective focal points to
coordinate efforts in this area.  In several ofthese countries there have been ceremonies to mark the formal signing of the
agreement, with the participation of the respective Ministers of Health and
other national authorities.  In some cases, the Director of PAHO/WHO was also
present or special ceremonies were held in connection with the event.  To
facilitate implementation of the agreements, training courses are being
organized on the use of CD-ROM technology.  These courses, to be given by
BIREME, will benefit not only the personnel in the legislatures but also
personnel in the Ministries of Health who may need the relevant training.1

      The project has generated a series of requests for advisory services to
aid in the updating of health legislation.  These requests have generally
been addressed through two complementary modalities, both of these in
consultation with the corresponding technical program.  The first involves
providing information about comparable legislation on the subject, which has
been organized into "working compendia" based on the structure of the LEYES
data base.  Worthy of mention in this regard are the initiatives to update
legislation on controlling the use of tobacco, in collaboration with the
Program for Health Promotion (HPA), and the study on the implications for
health of the Treaty of Asunción, which created the Common Market of the
Southern Cone (MERCOSUR).  The implementation of this agreement will
necessitate harmonizing various aspects of the health legislation of the
signatory countries.  The second modality involves providing advisory
missions to the health commissions of the legislatures.  Noteworthy among
these have been missions on updating the sanitary code of the Dominican
Republic and the codes on mental health in Colombia, Ecuador, and Panama.2 
Mention should also be made of the participation offered by PAHO/WHO in
drafting the Health Law of Bolivia, commissioned by the legislature of that
country at the initiative of the Ministry of Public Health and Social
Welfare.

      The PWRs are gradually enlisting the legislatures, especially their
health commissions, as counterparts in the cooperation provided by PAHO/WHO
in the countries.  At the same time, a number of Regional programs, such as
those on environmental health, communicable diseases, maternal and child
health, and health promotion, are getting legislators involved in the
cooperation activities that they are promoting.  The Director has been
regularly including the legislatures in the contacts that he makes during
official visits to the countries.  Similarly, in their missions to the
countries, HSP personnel have met with the health commissions of the
legislatures in Argentina, Brazil, Costa Rica, Peru, Uruguay, and Venezuela
as follow-up on the activities carried out in connection with the Project on
"Democracy and Health."  A meeting was recently held in Lima with lawmakers
from the health commissions of Ecuador, Peru, and Venezuela with a view to
identifying areas of common interest for the harmonization and updating of
health legislation in the countries of that subregion.  This meeting sought
to create an opportunity for supranational coordination and debate in order
to lay the groundwork for establishing a Health Commission under the Andean
Parliament in the near future.

     These activities have served to confirm the keen interest of the
legislatures in PAHO/WHO cooperation, as well as to coordinate the delivery
of cooperation in response to specific requests from lawmakers in connection
with projects that they are promoting in their respective countries. 
Moreover, the positive response to this cooperation has not come from the
legislatures alone.  Several of the Ministers of Health have expressed their
satisfaction with this PAHO/WHO initiative, which is helping to bring about
smoother interaction between the Ministers and their respective legislatures
as well as increased consideration of health matters in the legislative
arena.  In addition, legislators have been included in national delegations
that have come to PAHO/WHO Headquarters, notably during the last meeting of
the Directing Council.

3.2.2 First Meeting of Legislators of the Southern Cone

The First Meeting of Legislators of the Southern Cone brought
together representatives from the signatory countries of the Treaty of
Asunción, namely Argentina, Brazil, Paraguay, and Uruguay, as well as a
delegation from Chile.  The meeting was held in Brasília from 29 to 31 July
1991 in parallel with a meeting of Ministers of Health of the same countries. 
PAHO/WHO's contribution to this the meeting of lawmakers included the
preparation of a document on the incongruities and gaps in the health
legislation of the participating countries that might hamper or impede
execution of the Treaty.  The areas analyzed during the meeting were: 
quality control of food, drugs, equipment, and medical devices; environmental
protection; industrial promotion, protection, development, and integration;
social security systems; the health of workers, and the rights of children. 
Following the same approach used for the subregional meetings in 1990, the
background material on these subjects was sent in advance to the lawmakers,
who had the support of the corresponding PWRs in reviewing the information
and preparing their respective contributions.

      In the course of the meeting the lawmakers expressed concern over the
possibility that, with the consolidation of MERCOSUR, economic problems might
displace those of social concern.  They also agreed on the need for the
integration process engendered by the "Treaty of Asunción" to revitalize the
system of participatory democracy and guarantee protection of the environment
and the preservation of natural resources.  In this connection, it was agreed
that, of all the issues under discussion, environmental protection was the
one in which there was the most pressing need for integrated action on the
part of all the participating countries.  With regard to the quality control
of food, drugs, and medical devices, attention focused on the need to
reconcile trends toward deregulation with the need to protect consumers, as
well as the importance of adopting international standards such as the Codex
Alimentarius.

      The legislators concurred in recognizing the right to health as an
integral part of democracy and a condition for the exercise of citizenship. 
Workers' health was stressed as an indispensable element for achieving
comprehensive development, and a detailed account was given ofthe crisis currently affecting the social security systems and the need to
propose appropriate measures to reform and modernize them.  Finally, at the
request of the Director of PAHO/WHO, the delegates agreed on the importance
of setting "legislative agendas" in health, with a view to furthering the
integration process engendered by the Treaty of Asunción.  To this end, the
legislators of Argentina and Paraguay requested advisory services from
PAHO/WHO in order to reformulate the legislation applicable to the subjects
covered by the treaty.  In particular, the Paraguayan delegation asked for
cooperation from the Organization in determining the treatment to be given to
health in the National Constitution that is soon to be drawn up.

3.2.3     Activities with regional and subregional legislative organizations

     i.   European Parliament3

      Also in July, a working meeting was held with the members of the
Commission for Latin America of the European Parliament at the time of their
visit to the Andean Parliament.  The visit of the Europeans was coordinated
by the Representation of the European Economic Community in Lima, and it was
PAHO/WHO's responsibility to arrange for the inclusion of health on the
meeting's agenda.  The objective of this gathering was to define possible
lines of cooperation between the American and European parliaments with a
view to strengthening the Project on "Democracy and Health" in the following
areas:

      a)  Political support from the European Parliament for the resolutions
passed by the American legislatures on health-related issues, in
regard to both their legislative and their control functions;

      b)  Support for interparliamentary projects and cooperation activities
promoted by PAHO/WHO in the countries; and

      c)  Participation of the European Parliament in the Inter-American
Parliamentary Conference.

    ii.   Latin American Parliament4

      The Organization has proposed to the Latin American Parliament, or
"Parlatino," that an Inter-American Parliamentary Conference be organized in
order to define a Regional agenda for the legislatures in the area of health. 
This Conference, to be held in 1993, would be attended by representatives
from all the legislatures of the Region, in addition to a delegation from the
European Parliament.

      At the same time, together with the Brazilian Group and the
"Parlatino's" Commission on the Environment, ECLAC, and the UNDP, PAHO/WHO is
proposing a Regional Meeting of Legislators on the Environment, Health, and
Development, to be held next April in Sao Paulo.  The aim of thismeeting is to promote the participation of the Region's legislators in the
United Nations Conference on the Environment and Development (ECO-92), as
well as in the implementation of its recommendations in the respective
countries.  PAHO/WHO cooperation for this initiative is being coordinated
through the Environmental Health Program (HPE) and the PAHO/WHO
Representation in Brazil.

      It should be noted that at present the Latin American Parliament is
organized into the following commissions:  Political Affairs, Economic and
Social Affairs, Cultural and Educational Affairs, Legal Affairs, the
Environment, and Science and Technology.  Until recently, health matters were
included on the agenda of the Commission on Social Affairs.  However, at its
last Conference, held in Cartagena on 31 July to 3 August 1991, the
Parliament created a Commission on Health, Labor, and Social Security.  This
commission, which will be responsible, inter alia, for promoting the
Conference proposed by PAHO/WHO, will be formally established at a meeting
scheduled for March 1992 in Havana.

   iii.   Meeting with the Andean Parliament5

      The Andean Parliament has manifested its interest in supporting the
Project on "Democracy and Health" through the establishment of a line of
direct cooperation with the legislatures in the Andean countries in the area
of health.  PAHO/WHO is working jointly with the secretariat of the Andean
Parliament to ensure that health will be included on the agenda of its IX
Conference, to be held in September 1992, and to promote the possibility of
its being the central theme of the X Conference.  This body was created in
1979 and ratified five years later under a treaty signed by Bolivia,
Colombia, Ecuador, Peru, and Venezuela.  For the time being, the Andean
Parliament has an indicative role with regard to budgetary matters and serves
as a political forum for discussion and amalgamation of ideas, thereby
helping to strengthen regional integration.  At its last meeting, this
subregional Parliament examined the Initiative for the Americas proposed by
the President of the United States.  Also, it will serve as a very important
forum for the implementation of agreements in the area of health that are
being negotiated within the framework of Andean integration.


4.    Outlook for the Future:  Legislative Agendas at the Regional,
      Subregional, and National Level

      The process generated by the subregional meetings on "Democracy and
Health" and the cementing of cooperation with the legislatures augur well for
the future.  It is anticipated that there will be opportunities for action
that will transcend the national framework and have an impact at the
subregional and Regional levels as well.

      In the first place, the subregional and regional integration processes
call for uniform normative support that will not only validatebut also facilitate them.  This is the rationale behind the promotion of
"health agendas" to guide the legislatures in the harmonization of their
respective national laws.  For this purpose, PAHO/WHO, through its Regional
programs and PWRs, is seeking to identify gaps in legislation and will urge
the legislatures of the Region to address them.

      At the same time, the Organization intends to step up technical
cooperation with the national legislatures through implementation of the
agreements signed in 1991.  This cooperation will be provided through the
PWRs within the framework of the annual programs of work agreed upon with the
respective national authorities, to be supplemented, if necessary, by
contributions from the regional programs.  It is also hoped that new
agreements will be signed in 1992 that will involve the legislatures of other
countries, namely:  Antigua and Barbuda, Bahamas, Belize, Dominica, Dominican
Republic, Grenada, Guyana, Nicaragua, Panama, St. Kitts and Nevis, Saint
Lucia, Saint Vincent and the Grenadines, and Suriname.

      At the supranational level, there are opportunities for diverse types
of action, including:

      a)  Support for promptly naming members to the recently created the
Commission on Health, Labor, and Social Security of the Latin
American Parliament so that it will serve as a springboard for
promoting the establishment of "health agendas" at the national,
subregional, and Regional levels;

      b)  Continued support for coordination efforts with the Andean countries
for the creation of a Health Commission under the Andean Parliament
and for increased initiatives by the Parliament in this area;

      c)  Initiation of contacts aimed at spurring action by the Central
American Parliament, established at a meeting in Guatemala in late
October 1990, on health issues;

      d)  Involvement of the Commonwealth Parliamentary Association6--or the
future Caribbean Parliament--in this program of activities;

      e)  Follow-up on the possible creation of a MERCOSUR Parliament with a
view to ensuring that health issues are on the agenda of this body;

      f)  Support for the meetings convened by the legislatures to examine and
debate health issues with representatives of the legislative bodies
of the member countries.  In this regard, the efforts of PAHO/WHO
will be focused on preparations for the Meeting on Environment,
Health, and Development within the framework of ECO-92 and the
Inter-American Parliamentary Conference to be held in 1993.


5.   Conclusion:  A Preliminary Evaluation

      Although it is still early for a formal evaluation of the Project on
"Democracy and Health," a number of achievements are already pointing to the
usefulness and timeliness of this initiative.  These developments include:

5.1   Incorporation of New Counterparts in the Activities of PAHO/WHO

      With the Project on "Democracy and Health," the Organization has opened
up new areas of action and identified new interlocutors, which are
reinforcing its work from the political perspective at the national,
subregional, and regional levels.  At the same time, the legislatures have
become new and important allies in promoting the improvement of health as one
of the objectives of economic and social development.  As its relationship
develops with the legislatures, PAHO/WHO will be concentrating its
cooperation on the health problems of highest priority for the Region.

5.2   Identification of Cooperation Initiatives Under Way

      Through execution of the Project on "Democracy and Health," it has been
possible to identify a number of cooperation initiatives generated by the
legislatures themselves or by their regional bodies.  This fact has enabled
PAHO/WHO to select, among the cooperation initiatives that are being proposed
to it, those that best correpond to the Organization's mandates and
priorities.  The opportunities for cooperation provided by initiatives such
as the upcoming Meeting of Legislators on the Environment, Health, and
Development and the Inter-American Parliamentary Conference on Health in
1993, will serve to consolidate the health agendas with which the
legislatures of the Region will be working.

5.3   Increased Demand for Technical Cooperation

      Since its initial contacts with the legislatures, the Organization has
been experiencing a growing demand in different areas related to the
development of legislation on health.  This trend is owed, inter alia, to a
better understanding within the legislatures of the strategies and
possibilities for cooperation with PAHO/WHO, as well as to the experience
that the Organization is accumulating in the area of health legislation. 
During 1992, efforts will focus on the participation of lawmakers in meetings
organized by the regional prorgrams of PAHO/WHO, with a view to promoting
increased understanding and greater interest on the part of lawmakers in the
chief health problems of the Region.

5.4   Strengthening of Cooperation between the Executive and the Legislative
      Branches in the Area of Health

      The Project on "Democracy and Health" has helped to open up new
channels of communication between the executive and legislative brancheswhich will lead to a better understanding of the viewpoints and priorities of
each of these bodies in the area of health.  Several of the PAHO/WHO
Representations have promoted activities involving lawmakers and executive
officials, which have had positive effects on the management of health issues
in the corresponding countries.  One result of this may well be a
reinvigorated debate on health issues and possibly even a shortening of the
time that the legislative process takes in acting on proposals of interest
for health.  A data base to be implemented in 1992 will make it possible to
accompany the action of legislatures in the area of health and in this way to
assess the project's impact in this regard.

      Finally, it should be recalled that the possibilities offered by
historic moments are not likely to be repeated.  Thus, everything would
indicate that the times in which we are currently living afford perspectives
which it would not be wise to overlook.  The strengthening of the democratic
process has an unquestioned impact on the generation of adequate conditions
for resurgence of the issue of health as a human right in political
discourse.  But the democratic process, although it is important for
attainment of this objective, is not enough.  A population which through
health has gained the possibility of access to economic and social
development is a fundamental element in safeguarding the democratic process
itself.
ENDNOTES


     1During the programming of the agreement, other initiatives were
identified involving automation of the legislatures so that they can have
access to information needed for the fulfillment of their functions, which
are receiving support from international development agencies.  These
initiatives and that of PAHO/WHO are mutually complementary.

     2The activities of these two countries are a result of the reform process
generated by the Declaration of Caracas, adopted at the Regional Conference
on the Restructuring of Psychiatric Care (Caracas, Venezuela, 11-14 November
1990), which was promoted by the Program for Health Promotion (HPA).

     3The European Parliament is composed of 12 member countries from the
European Community, elected by direct vote.  The representatives are
organized into commissions according to their area of interest.  There are
two types:  the issue-oriented commissions, which examine social, economic,
and international affairs, among other areas, and the regional commissions,
which maintain relations with the different subregions (Asia, Africa, South
America, Central America, etc.).

     4The Latin American Parliament, created in 1964, is composed of 23 Latin
American legislatures.  It has a Governing Board, a Regular Conference of
Members, and several working commissions.  Despite its long existence, it is
only in recent years, beginning in 1987, that the "Parlatino" has begun to be
institutionalized with the establishment of a headquarters and a General
Executive Secretariat and adoption of its first statutes.

     5Established by the Treaty of Lima, the Andean Parliament comprises the
legislatures of the countries of the Andean Group and meets several times a
year in regular and special sessions.  Its Governing Commission is composed
of five members, with a president and a vice president.

     6An organization headquartered in London which brings together the
parliaments of the British Commonwealth.







[TRANSLATION IDENTIFIED AS      EOO97.FIN 
 
AGREEMENT BETWEEN
THE GOVERNMENT OF _________ AND
      THE PAN AMERICAN HEALTH ORGANIZATION /WORLD HEALTH
ORGANIZATION
FOR THE EXECUTION OF THE
SUB-REGIONAL PROJECT FOR
       STRENGTHENING AND DEVELOPMENT OF THE ENGINEERING
      AND MAINTENANCE SERVICES FOR HEALTH ESTABLISHMENTS
IN CENTRAL AMERICA, PANAMA AND BELIZE -
SECOND PHASE


      Between the Government of _______ (hereinafter the
"Government"), through the Ministry of Health, represented by
its incumbent, Dr. ___________________, and the Pan American
Health Organization /World Health Organization (hereinafter
"PAHO/WHO"), represented by the Director of the Pan American
Sanitary Bureau, Dr. Carlyle Guerra de Macedo, the present
Agreement is entered into for the execution of the second
phase of the Sub-regional Project for Strengthening and
Development of the Engineering and Maintenance Services for
Health Establishments in Central America, Panama and Belize
(hereinafter the "Project"), subject to the following
Whereas's and clauses:

WHEREAS:

      On 29 November 1990 the Ministry of Development and
Cooperation of Holland (hereinafter "Holland") and PAHO/WHO
entered into a second General Agreement by which Holland
agreed to con- tribute the total of Dlf 4,235,805 for the
execution of the second phase of the Project, according to
the terms and the timetable for disbursements established in
said General Agreement, which is attached hereto as Annex A;

      On 9 May 1988, PAHO/WHO and the Government of _______
entered into an Agreement for the implementation in _______
of the first phase of the Project pursuant to a sub-regional
strategy of cooperation in health sponsored by the Government
of Holland;

      31 December 1989 was the expiration date of said Agree-
ment between the Government of _______ and PAHO/WHO for the
implementation of the first phase of the Project, and there-
fore it is necessary to enter into a new Agreement that
permits the Parties to continue with the second phase of the
Project, also sponsored by the Government of Holland.

      On 21 August 1984, the Government of ______ and PAHO/WHO
entered into a Basic Agreement on Institutional Relations and
Privileges and Immunities, which constitutes sufficient legal
basis for the formulation, execution and implementation of
the present Agreement.

IT IS AGREED:

Clause 1: Purpose of the Agreement

     The purpose of this Agreement is to establish the bases
of cooperation between the Government of ______ and PAHO/WHO
for the implementation of the second phase of the Project.

Clause 2: Objectives of Cooperation

     The general objective of this technical cooperation
between   the Parties is the development and strengthening of
the capability to maintain the medical and nonmedical instal-
lations and equipment of the country.

     The specific objectives of technical cooperation provided
for in the present Agreement are:

     1.   To promote and support the implementation of a
National Policy for Engineering and Maintenance, the
organization of its services, and the strengthening
and development of maintenance systems with emphasis
on Local Health Systems, including up to the level
of health centers and health posts, according to
their needs and capabilities, taking into consider-
ation the programs that are carried out and the
international cooperation they receive.

     2.   To promote the establishment in health institutions
of programs for continuous technical and practical
training, directed toward the training of users,
operators, technicians, engineers and administra-
tors, in the area of maintenance.

     3.   To support and promote the creation of technical
documentation centers, systems, mechanisms and
procedures for the exchange of information and
experiences among the countries of the Sub-region.

     4.   To develop, disseminate, support and implement
programs of preventive maintenance, preparation of
manuals, organization and information systems,
technical and  training material incorporating
appropriate technology and technical standards.

Article 3:    Plan of Work

     The activities to be carried out by the Parties under the
present Agreement are set out in the Plan of Work for the
Second Phase of the Sub-regional Maintenance Project, which
is attached as an integral part of the present Agreement as
Annex B.  Said Plan of Work also contains the budget for the
Project and the timetables for disbursements and activities.

     The Plan of Work may be updated by mutual agreement
between the Parties, to set out the modifications that become
necessary for the proper performance of the Project.


Article 4:    Commitments of the Government

     The Government, through the Ministry of Health, is com-
mitted:

1.   To provide the institutional, logistical and administra-
     tive support necessary for the proper implementation of
     the Project.

2.   To provide the communications and transportation instal-
     lations, equipment and services necessary for the proper
     execution of the Project.

3.   To include within its budget resources necessary to pay
     to PAHO/WHO 13% of the total cost of the Project, to
     cover those administrative expenditures incurred by
     PAHO/WHO in the implementation of the Project.

4.   To carry out all other activities necessary for the
     proper execution of the Project, as specified in the Plan
     of Work, Annex B hereto.

Article 5:    Commitments of PAHO/WHO

     In accordance with its policies, regulations, and  proce-
dures, and subject to the availability of funds for the
Project, PAHO/WHO is committed:

1.   To provide the technical cooperation services required
     for the proper implementation of the Project, in accor-
     dance with the Plan of Work, Annex B hereto.

2.   To coordinate the handling and purchase of equipment,
     spare parts, materials and tools required for the per-
     formance of the Project, as set out in Plan of Work,
     Annex B hereto, in accordance with its usual applicable
     standards and procedures.

3.   To provide the services of expert consultants, to be
     charged against the funds of the Project, in accordance
     with the requirements set out in the Plan of Work, Annex
     B hereto.

4.   To administer the resources contributed for the perform-
     ance of the Project, in accordance with the timetables
     for activities and disbursements set out in the Plan of
     Work, Annex B hereto. 


Article 6:    Performance

     PAHO/WHO shall be responsible for the general coordina-
tion of the Project at the sub-regional level. 

     The National Commission for Coordination, under the
direction of the Director General of Health in his position
as Nation-  al Coordinator, or similar person, shall be
responsible at the local level.  The National Commission for
Coordination will con- sist of the chiefs of the engineering
and maintenance agencies of the participating institutions,
the staff members charged with the training of personnel in
this field, and any another representative designated by the
country.  Said National Commission for Coordination will be
in charge of the coordination, performance, supervision and
evaluation of the Project at the national level.

Article 7:    Evaluation

     The evaluation of the Project will be done in accordance
with the provisions of the Plan of Work, Annex B hereto. 

Article 8:    Reports

     The Parties jointly will prepare semiannual progress
reports of the Project and a final report of accomplishments
within  sixty days following the termination of the present
Agreement.

     PAHO/WHO for its part will present semiannual financial
reports, and a final report within sixty days following the
termination of the present Agreement.

     The National Commission for Coordination shall be charged
with providing the Government of Holland with information the
latter may request, as well as the progress and financial
reports that are required in the performance of the Project.

Article 9:    Audit

     All audit work shall be performed by the person or per-
sons designated by PAHO/WHO for this purpose, applying at all
times PAHO/WHO's applicable standards and procedures. 

Article 10:   Force Majeure

     Neither Party to this Agreement shall be liable if it is
unable to perform its obligations partially or totally due to
reasons of force majeure  such as war, natural disasters,
civil disturbances, and any other cause beyond its control.


Article 11:   Settlement of Disputes

      Any dispute arising between the Parties that is not
settled by negotiation shall be submitted to arbitration. 
Each Party shall appoint one arbitrator, and the two arbitra-
tors so appointed shall appoint a third.  The procedure of
the arbitration and the choice of law shall be decided by the
arbitrators.  The arbitral award shall be final and unappeal-
able.


Article 12:   Privileges and Immunities

     Nothing in or related to this Agreement shall be deemed
to constitute any waiver, express or implied, of the immuni-
ties, privileges, or exemptions enjoyed by PAHO/WHO as an
international organization under international law, interna-
tional conventions or agreements, or the domestic legislation
and laws of its Member Countries.


Article 13:   Entry into Force, Duration, Modification and
Termination

      This Agreement shall enter into force upon signature by
the Parties, and shall remain in force for a period of _____
years.

     This Agreement may be extended or modified by mutual 
written agreement of the Parties. In addition, this Agreement
may be terminated by either Party upon (90) days written
notice, stating the reasons for such termination.

     The obligations assumed by the Parties under the present
Agreement shall survive the expiration, cancellation or
termination thereof to the extent necessary to permit the
liquidation of accounts between the Parties, attention to
matters concerning  international personnel, the fulfillment
of any obligations that have been contracted, and the with-
drawal of the personnel, funds and property of PAHO/WHO. 


IN WITNESS WHEREOF, the duly authorized representatives of
the Parties affix their signatures to the present Agreement
in two originals of equal content and validity, in the places
and dates   set out below. 



BY THE GOVERNMENT OF ___________________




________________________________ Place:_____________________-
___
Dr.
Minister of Health               Date:_____________________-
___






BY THE PAN AMERICAN HEALTH ORGANIZATION/
 WORLD HEALTH ORGANIZATION 



________________________________ 
Place:_____________________-
___
Dr. Carlyle Guerra de Macedo
Director                         Date:_____________________-
___

 





[TRANSLATOR'S NOTE -  See Article 11 re settlement of dis-
putes by arbitration.  The Spanish text obviously considers
three (3) parties to this Agreement; however, there are only
two (2).  The Translation to English correctly states the
number of parties and of arbitrators - it is recommended that
the Spanish text be corrected.]

   [TRANSLATION OF DOCUMENT   EOO97.FIN]
E0103.FIN







REPUBLIC OF NICARAGUA












1991 Annual Evaluation
Project on Strengthening Capacity
for Controlling Vector-borne
Diseases in Local Health Systems in
Border Areas in
the Countries of Central America












 Ministry of Health of Nicaragua
Pan American Health Organization
World Health Organization














Managua.  February 1992
CONTENTS


   I.     INTRODUCTION                                          1

  II.     PROGRESS AND RESULTS                                  2

Progress Achieved                                     2

Activities and Results Obtained by Project
Component                                             4

Other Projects and Activities                        15

 III.     EVALUATION                                           15
I.  INTRODUCTION

     In 1991 the guidelines in the plan of work, "Lines of Action
of the Campaign Against Malaria in 1991," which are analyzed
below, were adopted as the basic strategy for executing the
projects sponsored by the Nordic countries.  These guidelines
were presented to the participants in the Meeting on Sub-Regional
Technical Consultation on Malaria in Central America, held in
July 1991 at Managua.                                            
     It is important to note that in planning the activities of
the projects, the criteria adopted at the Ministry of Health\PAHO
meeting to evaluate international cooperation in Nicaragua, which
was held in June 1991, were used.  This meeting's principal
objective was to propose an execution of the projects more
logical and consonant with the priority policies of the Ministry
of Health, that is to say, based on the real needs of the Local
Systems of Comprehensive Care in Health (SILAIS) and their most
direct and effective participation.

     Also in 1991, Nicaragua succeeded in holding several
intercountry border-area meetings and another entitled "Sub-
Regional Technical Consultation on Malaria" with the
participation of all the Central American countries and Mexico,
whose immediate results were the preparation of a "Three-year
Project for 1992-94" and the Border-area Operational Plan for
1992.

     During the execution of the projects in 1991 two
occupational factors occurred which seriously affected the
execution of what had been programmed:  the general strike of
health workers (two months) and the Occupation Conversion Plan
(PCO), which affected a high percentage of personnel.

     In addition, the first financial allocation for 1991
transmitted by FINNIDA was received in March, which made
execution of the First Four-Month Plan difficult.

     It was in the above context that the execution of the
program was initiated almost in June, but planning was carried
out in order to promote development of Local Systems of
Comprehensive Care in Health (SILAIS) through the execution of
activities defined for that level.


II.  PROGRESS AND RESULTS

     Progress achieved
     
     The principal objectives of the project dealing with
strengthening decision-making capacity at the local level in
order to prevent and control vector-borne diseases in the
Honduras-Costa Rica-Nicaragua border regions (1991 Plan, drawn up
at San Pedro Sula in November 1990) were fulfilled:

     -    To promote increased closeness and strengthen the ties
of friendship among the people of Costa Rica, Nicaragua
and Honduras.

     -    To promote cooperation and mutual assistance among the
health sectors of the countries, as well as to be an
example and basis for cooperation among other sectors.

     -    To seek joint solutions to common health problems in
the border area through appropriate strategies.

     -    To maintain and improve health levels in border
communities.

     -    To strengthen the strategy of primary care, with Health
for All by the Year 2000 as the target.

     -    To promote the community's participation in the
identification and solution of its problems.

     -    To diminish the incidence and prevalence of vector-
borne diseases with emphasis on malaria, dengue, dengue
hemorrhagic fever/shock, leishmaniasis, and Chagas'
disease.

     The areas of cooperation among the border countries which
participate in the project were fulfilled by intensifying the
exchange of technical and operational information and mutual
support for works undertaken in the border areas.

     An increase in border-area epidemiological surveillance was
achieved through the signing of cooperation agreements at the
level of local systems (meetings at Estelí, Nicaragua; Liberia,
Costa Rica; Granada, Nicaragua, and local border-area operational
meetings).

     A joint review of the lines of action for controlling the
vector-borne diseases was carried out which emphasized patient
care, protection of the environment, and protection of workers'
health.  It was established in addition that hereafter the attack
on the vector will be based on analysis of risk factors to
diminish the indiscriminate use of insecticides.

     Joint plans for intercountry training were concluded,
especially in the SILAIS bordering on Costa Rica.

     The exchange of technical and epidemiological information
was carried out with both countries, particularly Honduras.

     All the activities were focused on development of the
SILAIS, a common strategy in the three countries.

     The operational decentralization of the projects toward the
SILAIS 
was initiated through direct relations with the regional health
directors, who assumed management of the activities planned in
the projects.

     Lines of propaganda and popular education in malaria were
defined as the acceptance by the population of medication and in
dengue as community participation in the destruction of breeding
sites.

     In Regions I and IV, meetings with voluntary collaborators
(345 participants) were carried out.

     Diminishing the incidence of malaria and dengue was achieved
in some border SILAIS, and epidemics of hemorrhagic dengue did
not occur.  Research on the incidence of Chagas' disease and
leishmaniasis continued to be carried out, and the structuring of
the national programs to control both diseases, which has the
technical and organizational support of Honduras, is under way.
     
In Summary:

     Concrete activities were defined in 1991 in accordance with
the National Plan for Controlling Vector-borne Diseases and the
projects were carried out according to lines of well-defined
action, in contrast to the execution in previous years when
technical material supply occupied a preponderant place and had
little relation to the targets to be fulfilled.  As a result, the
financial allocations were expanded to other areas of action
(1991 lines):

     1.   Training in measures against malaria and other vector-
borne diseases for SILAIS personnel.

     2.   Consolidation of social participation in the SILAIS.

     3.   Strengthening of regional entomology.

     4.   Development of operations research in the SILAIS.

     5.   Protection of the environment, utilizing insecticides
according to epidemiological criteria (risk factors).

     6.   Stimulus of intersectoral coordination.                

     7.   Increase in supervision and improvement of its quality.
     

     Activities and results obtained by project component

1.   Strengthening of the SILAIS.

     Activities aimed at strengthening the execution capacity of
the SILAIS were prioritized as the central strategy of the
Ministry of Health of Nicaragua.

     This is reflected in the direct award of funds to the
regional bureaus for expenditures on field operations (were
covered all the regions in this item) utilized in per diem,
repairs of vehicles, fuel, and purchase of technical equipment to
provide the SILAIS (20 microscopes, 600,0000 lancets, and 600,000
slides for taking blood samples).
     
     Automobile equipment (7 double-traction pick-up trucks),
water transport (5 pangas), 45 motorcycles, and 30 bicycles, all
obtained with funds allocated in the previous year, were
distributed.

     One hundred forty-seven Hudson sprinkler pumps, motorized
backpacks, and Swinfog devices which were purchased with 1990
funds were distributed.

     Funds were allocated to the border regions to control the
Aedes aegypti vector in vehicles which cross our borders.

     The Regional (100%) and Local (50%) Technical Councils were
carried out.  Activities to structure the Border-area Technical
Councils were initiated.

     Four local border-area meetings with Costa Rica by San
Carlos, Río San Juan, have been held.  The central subject was
epidemiological analysis and joint field measures between both
countries.

     A meeting was also held at Estelí in September by the health
personnel of Regions I and II and the personnel of the
neighboring SILAIS in Honduras, with 30 participants.

     A meeting to plan joint training activities for 1992 was
held at Granada (Region IV) with personnel from the border
regions of Costa Rica and participation by the central level of
Nicaragua.  A project to strengthen the educational processes in
the border-area SILAIS (38 participants) was prepared.  A joint
health diagnosis (Rivas SILAIS-Upala Canton-La Cruz Canton) was
also made and a system of epidemiological surveillance was
designed.

     In October there was participation in the subregional
meeting on dengue at San Pedro Sula (Honduras) and a three-year
operational plan for controlling dengue was prepared which is
pending approval by the Nordic countries.

     Other international events:

     -    A Technical Sub-Regional Consultation on Malaria in
Central America and Mexico, with the attendance of 40
participants, was held at Managua in July.

     -    Another meeting was held in August whose product was
the Three-year Plan for 1992-1994 for Controlling
Malaria and Other Vector-borne Diseases in Central
America and Mexico.  The first half of 1991 was
evaluated and the Operational Plan for 1992 was
structured with respect to the Honduras-Nicaragua-
Costa Rica border-area cooperation projects.

     Among the activities to develop the information and
surveillance system, six national meetings were held on
epidemiological evaluation of tropical diseases (50% of the
program), with the attendance of the regional management teams
(20 participants on the average).

     In addition, two courses were offered in the Central
Ministry of Health on "Basic Principles of Computation for
Personnel in the Regions" for a total of 80 persons from Regions
I, II, III, IV, and VI.

     The tropical disease personnel in the SILAIS were provided
personal protection equipment.

     With respect the active and passive search for cases of
malaria, the general health services contributed 40 percent of
the blood samples drawn and the voluntary collaborators
contributed 60 percent.

     Blood sampling was 64% accomplished, with 362,696 slides out
of a programmed total of 567,350 examined (Table 3).

     A total of 27,569 cases of malaria were detected (8,213
cases less that in 1990), and the Chinandega SILAIS, which
borders on Honduras, was found to be the most affected.  Even
though its Annual Parasite Incidence diminished with respect to
1990 from 44.8 to 33.8 cases per thousand population, it
contributed 43.3% of the country's malaria cases and 77.9% of the
cases in Region II in 1991 (Table 1).

     There was an increase with respect to 1990 in Plasmodium
falciparum cases of from 1,568 to 1,656 in 1991, and the most
affected SILAIS was Chontales (23.8% of the total) (Table 2).

     It is important to note that in the border-area SILAIS in
1991 there was a reduction in malaria cases, except for the Río
San Juan SILAIS bordering on Costa Rica, which because of
migration and new settlements resulting from the peace process in
the country experienced a marked deterioration in its
epidemiological situation (Table 2).

2.   Malaria and dengue situation by region

     REGION I (bordering on Honduras):

     Malaria increased by 106% over 1990.  Sampling increased
1.65 times.

     There were 964 detected positive cases, of which only three
were due to P. falciparum.   Cases increased in the three SILAIS,
although the most significant increase was in the Nueva Segovia
SILAIS, with an increase of 755.  The most problematic municipios
are Jalapa and Quilalí, which represent 70% of the cases in the
region and 92% in the Department of Nueva Segovia, located in the
zone bordering on the Republic of Honduras.  The parasitic index
increased from 1 to 2 per thousand population, and in Nueva
Segovia it rose from 2.11 to 4.37 per thousand.

     Control measures

     Household spraying was carried out in 5,029 dwellings (87%
of the total) in the municipios of Jalapa and Quilalí, but no
greater impact resulted because the situation worsened.

     Chemotherapy

     The principal measure was directed toward treatment of
positive cases, 92% by mouth, and there was also treatment of
cohabiters and control of foci in the localities of greatest
incidence.

     Training

     Training workshops were held for workers in the programs,
and five workshops were given for SILAIS workers and voluntary
collaborators in the municipios with the greatest malaria
problems, especially Jalapa and Quilalí.

     
     Dengue program

     Epidemiological situation:

     Only five presumptive cases of dengue were reported, three
in Estelí and two in the Madriz SILAIS.

     Entomological Situation:

     Control levels in infestation by the A. aegypti vector are
maintained in the region.  The SILAIS with greatest infestation
was Madriz, with 0.5% of the dwellings positive for the vector.

     Measures to control dengue were directed toward the vector:

     -    Inspection of dwellings.

     -    Treatment of foci, with abatization and peridomiciliary
and household spatial sprayings.

     Entomological surveillance measures using larval traps
located in places of highest risk gave us good results in
detecting foci, including the border posts of Las Manos and El
Espino.  As a surveillance measure, control was also maintained
by disinsecting vehicles in the border posts of Las Manos and El
Espino.

Positive cases of malaria in the municipios
with greatest problems, by SILAIS



SILAIS

MunicipioPositive Cases19901991Nueva SegoviaJalapa183553Nueva
SegoviaQuilalí68144Nueva SegoviaEl
Jícaro3223EstelíEstelí6879EstelíLimay2952EstelíCondega1833MadrizT
elpaneca920

Principal problems

     -    The strike and the conversion plan, which reduced
personnel by 30%.

     -    Lack of supervision due to lack of transportation and
flexibility in per diems.

     -    Lack of inputs to fulfill the antilarval targets.

     -    Lack of materials for diagnosing malariaÐlancets, glass
slides.

     -    Lack of follow-up to vector reactions to the
insecticides used in the region for lack of a
biologist.

     REGION II (León, Chinandega, bordering on Honduras):

     Epidemiological situation of malaria

     Region II, located in the northwest part of the country
(Nicaragua), has an area of 9,896 km2 and a population of 688,868
inhabitants.

     It is an eminently agricultural region, with cotton,
sugarcane, and banana growing.

     Region II has the most serious malaria problem in the
country, having 52% of the cases nationally.  According to
statistical analysis and epidemiological studies, it has been
verified that of the 23 municipios that form region, only four
(El Viejo, Chichigalpa, Chinandega, and León) are responsible for
reporting up to 70% of the cases of malaria at the regional
level.

     Of these four municipios, El Viejo is that which has the
greatest malaria problem, while the municipio of León, which was
among those with the greatest incidence of malaria, has seen its
cases decrease by up to 50%.  It is important to note that this
municipio carries out its greatest effort in physical and
chemical control of anopheline breeding sites.  At the regional
level there was a reduction in the malaria cases of 5,913 in
1991.

     It is important to note that in blood sampling there was a
reduction of 37,981 samples compared to 1990.

Comparative table of the
evolution of malaria in Region II,
1990-1991

     
Year        ME         MP        ILP         IPA        
IAES 

1990     134,840    21,186      15.7         30.7       
22.5
1991      96,859    15,273      15.7         22.2       
14.8

     
     Conclusions:

     Despite the strike problem at beginning of the year, which
lasted up to two months, and the reduction in the field staff who
joined the Occupation Conversion Plan, the effort to carry out the
work of physical control of anopheline breeding sites, radical oral
treatment for most of the cases diagnosed, and the suspension of
household sprayings, after their application was evaluated,
continued, and we can conclude that the effort has been
advantageous.

     REGION IV (bordering on Costa Rica):

     In Region IV during 1990 and 1991, malaria cases were reduced
by 1,113, with five hundred cases in 1990.  Of a total of 51,616
samples examined, three of the cases which were classified as
imported from other regions of the country, were caused by P.
falciparum.  In 1991 there were 613 cases fewer than in 1990 in a
total of 48,668 samples examined, which means a reduction of 45.84%
in the number of cases and 5.71% fewer with regard to the samples
examined.  Of the cases that appeared in 1991, 11 were caused by P.
falciparum and classified as imported from other regions of the
country.

     1990 finished with a regional API of 2.08 and 1991 with 1.09
per thousand inhabitants.

     The Rivas SILAIS (bordering on Costa Rica) contributed 55.66%
of the malaria in the region, with an API of 2.90 in 1991 and an API
of 5.55 in 1990. 

     The region's problem municipio is Tola, which has 26.93% of the
regional cases and 48.38% of those in the SILAIS, with an API of
9.53.

     The municipios bordering on Costa Rica such as San Juan del Sur
and Cárdenas had a total of 23 and 37 cases of malaria in 1991,
respectively, with an API of 1.45 in San Juan del Sur and 11.21 in
Cárdenas.

     The reduction in malaria cases in the last two years has been
due mainly to the execution of epidemiological analyses in the
problem municipios and the selection, prioritization, and
application of different measures against the vector and the
parasite.  This has also been possible thanks to the fact that in
the same period we have had the effective support and execution of
the NIC-COR border-area agreement, sponsored by the Nordic
countries, which has translated into vehicles, motorcycles,
bicycles, equipment, materials, etc.  This has enabled us to
guarantee coverage to the municipios classified as at greatest risk
and to deal more rapidly with the situations which have arisen with
respect to the transmission of malaria.

     REGION VI (bordering on Honduras):

     From 1990 to 1991 cases were reduced by 3.75%, from 2,554 to
2,458, with an API in 1990 of 3.28 and in 1991 of 4.43.  From 1990
to 1991, sampling diminished by 11,276 (21.58%), with the variant
in population greater in 1990 of 776,297, and for operations in 1991
the population was 554,560.

     
Municipios with IPAs > than 5 in Region VI, 1991


MunicipioPopulationCasesP. falciparumIPAMuy
Muy9,0426256.85Matiwás31,3824272813.92Río
Blanco36,1692901218.01Waslala23,35932012813.69Bocana de
Paiwás4,08744-
10.73Jinotega66,48739755.97Pantasma17,02113617.99Wiwilí26,5951501
5.64El Cua Bocay31,38219096.05(9) Total245,5242,0262988.25

     In the nine municipios mentioned, positivity represents 82.42%
and P. falciparum cases 85.63% for the whole region.

     For the region in 1991, the SILAIS situation was the following:

SILAISPopulationCases%P.
falciparum%APIMatagalpa376,9061,55863.3833295.404.13Jinotega177,6
5490036.62164.605.06Total554,5602,458100.00348100.004.43
     
     The municipios with the greatest incidence of P. falciparum
were Matagalpa, with 16 for 4,59%, Matiguas with 28 for 8.04%, Río
Blanco with 121 for 34,77%, La Dalia with 11 for 3,16%, Waslala with
128 for 36,78%, Bocana de Paiwás with 13 for 3,73%, all in SILAIS
01 Matagalpa.

     

Dengue in 1991


SILAISCases
reportedClassical confirmed%
confirmedMatagalpa1053129.52Jinotega 33618.18Total1383726.81

     Reported by municipios, Sébaco with 4 for 2,89%, Ciudad Darío
with 101 for 73,19%, Jinotega with 33 for 23.91.

     In 1990 the region reported a total 10 cases and none was
confirmed by laboratory analysis.

     Action against the vector

     In 1990, 79,480 dwellings were inspected and 12 were found
infested, for an infestation rate of 0.01%; in 1991, 38,623 were
inspected, with 728 infested for an infestation rate of 1.88.

     Problems:

     It was not possible to regulate technical material supply to
be able to carry out better epidemiological surveillance, and there
was also a great deal of irregularity in the category of per diems
and other inputs, which were also critical in 1991.

3.   Control of cohabiting patients and presumptive cases

     As was pointed out above, attention to suspicious (febrile),
confirmed, and cohabiting cases has been prioritized in this
component.
   
     Radical treatment was given to a total of 16,329 confirmed
cases, 59.2% of the diagnosed total (27,569 cases), and a total
coverage of 77.3%, including treatment of cohabiters, was achieved
(Table 4).

4.   Vector control

     This component prioritized:

     Provision to the tropical disease field staff in the SILAIS of
protection equipment for personnel:  masks, gloves, and goggles,
other work materials for controlling vectors such as lamps and
brushes, and material for physical control of breeding sites, always
within the area of environmental protection.

     With regard to household spraying, 68,926 dwellings were
selected, of which 35,509 were sprayed (51.5%).  This activity
declined by 75% compared to the same period in the previous year
since it was programmed on the basis of epidemiological analysis of
risk factors (Table 8).

     It is important to note that in accordance with the "Lines of
Action to Control Vector-borne Diseases," the purchase of material
and equipment for fumigation was drastically reduced.

     In 1992, entomology activities will be carried out at the
regional levels as part of the strengthening of epidemiological
surveillance.

5.   Social participation

     With respect to the activities to promote social participation,
the "Manual for Popular Education on Dengue and Malaria" was
prepared and published (8,000 copies).

     In addition, educational folders on dengue were published
(20,000).  The primer for individual education of the population
(2,500 copies) to be used by health brigade workers and dengue
inspectors in their daily visits to the dwellings in the SILAIS will
be implemented in 1992. 

6.   Research

     The following investigations are being executed:

     1.   The National Sero-Epidemiological Survey of dengue.

     2.   Evaluation of the impact of the integration of the
malaria program into the health services of the municipio
of Tipitapa (Region III, Managua).

     3.   Impact of migration on malaria, Region II.

     4.   Research of the resistance of P. falciparum to
chloroquine.

     The programmed intercountry investigations which have not been
carried out were:

     1.   Seroepidemiology of malaria.
     2.   Chagas' disease.

7.   Training

     It is important to note that all the training activities were
defined at the local level and had the teaching support of technical
personnel from the central level.

     Twenty courses were programmed to prepare the personnel of the
SILAIS which ranged from epidemiological aspects to retraining in
vector control (150 persons participated).  In addition, training
was provided in the basic principles of computation to 80 persons
from the regional management teams.

     Two meetings were held with voluntary collaborators, one in
Region I (300 participants) and the other in Region IV (45
participants); the latter also included continuing education on
malaria for 80 persons.

     Eight courses for a total of 300 participants were held in
Region II.  The main subjects were epidemiology and control of
malaria and epidemiology and control of vectors.  Personnel working
in the SILAIS attended both.

     The regional tropical disease chiefs conducted these programs
in this stage.

     Courses for microscopists on malaria and leishmaniasis in
border areas were held in September 1991.

     A meeting was held for hospital personnel on hemorrhagic dengue
at the Fernando Vélez Páiz Hospital which was attended by 120
persons from Regions II, III, and IV.

     One person took part in a course on epidemiological
stratification in April which was held at San Cristóbal de las
Casas, Mexico.

     One person attended two courses at the University of South
Carolina (USA), one on computation applied to control of vector-
borne diseases in August and September and the other on research
methodology in October.

     One person took part in a course on pesticides in Mexico in
December.


5 1991 Budget Execution
      Border-area Projects Sponsored by the Nordic Countries


Budget item         Programmed    Obligated    %        Paid     %

AM/NIC/MAL030/PG/9091$155,169.59$155,021.07   99 $148,332.40     96
AM/NIC/MAL031/PG/909175,249.71    74,034.11   98   67,048.30     90
AM/NIC/MAL040/PG/9091349,322.30  345,575.87   99  285,698.39     83
AM/NIC/MAL041/PG/909175,180.93    72,502.89   96   70,908.26     98


  Other projects and activities

  Activities to control vector-borne diseases in Nicaragua were
externally supported exclusively by the projects financed by the
Nordic countries.


III.    EVALUATION

  Despite the partial execution of the projects in the first four
months of 1991 because of the labor problems already described, it
has been possible to begin real deconcentration in the planning,
programming, and execution of activities, which enabled carrying out
the activities programmed in the second half of 1991.  The
consolidation of this process should result in better execution in
1992.

  In accordance with national health priorities, qualitative
advances were made in the projects which were oriented toward
supporting the process of developing the SILAIS, and it was possible
to achieve the start of real decentralization.  At the same time,
lines of action were revised and the immediate result was the
execution of activities tending to protect patients by decreasing
the predominance of attacks on the vector, as in the first phase of
these projects (1988-1990).

  The logistics and technical support of the Pan American Health
Organization (PAHO), with which an attempt was made to potentiate
the resources of the Ministry of Health itself and make flexible the
use of available funds, were intensified.  No epidemic outbreaks of
hemorrhagic dengue occurred in 1991, and in some border SILAIS the
indicators of the presence of malaria declined.

  In addition, it was possible to pay greater attention to
community participation activities by decreasing the use of
pesticides in accordance with PAHO/WHO guidelines.

  We consider having achieved joint plans of epidemiologic
surveillance and border-area training one of the advanced in 1991,
as well as the holding in Nicaragua of technical events with the
other countries of Central America and Mexico.


Evaluation comparing what was planned and carried out with Nordic
funds

- Strengthening of the SILAIS

  Provision of material and equipment for epidemiology and malaria
  control activities:  20 microscopies; 600,000 lancets; 600,000
  slides; 7 small double-traction trucks; 5 pangas (for water
  transport); 45 motorcycles and 30 bicycles; 147 motorized
  backpack aspersion pumps; Swingfog devices.  Fulfillment:  100%
  (programmed in 1990 with funds from that year).

  Provision of material and equipment to control A. aegypti in
  border areas.  Fulfillment:  50%.

  Training and meetings of regional technical councils. 
  Fulfillment:  100%.

  Training of local technical councils at the SILAIS level. 
  Fulfillment:  50%.

  Border-area meetings and decision making.  Fulfillment:  100%.
  
  Organization of the diagnostic and epidemiological surveillance
  committee at the Nicaragua-Costa Rica SILAIS and border regions. 
  Fulfillment:  100%.

  Holding of the Subregional Technical Consultation of the Malaria
  Programs of Central America and Mexico, Managua, July 1991. 
  Preparation of the Subregional Project to Control Malaria in
  Central America and Mexico and the Triennial Plan to Control
  Malaria for 1992-1994, Managua, August 1991.  Nicaragua-Costa
  Rica meeting to strengthen educational processes, with 38
  participants.  Fulfillment:  100%.

- Control of patients, cohabiters, and presumptive cases

  Operational activities to locate cases were supported. 
  Fulfillment:  63%.  Cause:  reassignment of personnel.

  Treatment of patients, family members, and cohabiters. 
  Fulfillment:  77%.  Cause:  operational problems and reassignment
  of personnel.

- Vector control

  Supply of personal protection equipment, masks, gloves, etc. 
  Fulfillment:  100%.

  Material and equipment for cleaning up breeding sites and
  destruction of receptacles which are a source of A. aedes
  mosquitoes.  Fulfillment:  100%.

- Social participation

  Distribution of 8,000 popular education manuals on malaria and
  dengue.  Fulfillment:  100%.

  Distribution of 20,000 folders on dengue.  Fulfillment:  100%.

- Research

  Operational investigations are now being conducted on:

  -     Seroepidemiological survey of dengue.

  -     Impact of the integration of the malaria program into local
        health services.

  -     P. falciparum resistance to chloroquine.

  -     Remaining to be carried out:  the seroepidemiological study
        of malaria in border areas.

  Overall fulfillment:  60%.  Cause:  Delay foreseen by revision of
  protocols.

- Training

  Practical training at the operational level on the epidemiology
  and control of vectors; regions and SILAIS; 150 participants.

  Two basic computation courses, 80 participants.

  Meetings with voluntary collaborators for approximately 300
  participants in Region I and 45 participants in Region IV.

  A seminar on continuing education in malaria for 80 participants.

  Basic courses on the epidemiology and control of vectors in
  Region II for 150 participants.

  A course for microscopists in the border areas.

  National seminar on the diagnosis and clinical and hospital
  treatment of hemorrhagic dengue at the Vélez Páiz Hospital, with
  participation from Regions I, III, and IV, for approximately 120
  participants.

  Training of two higher-level technicians in epidemiological
  stratification at the international course at San Cristóbal de
  las Casas, Mexico.

  Training of two intermediate and higher level technicians in,
  respectively, (a) a course on computation applied to vector
  control programs, and (b) a course on research methodology.

  Training of one higher-level technician in managing and using
  pesticides in Mexico.

  Overall fulfillment:  100%.










APPENDIXES
1991 Trinational Evaluation
of HON-NIC-COR Border-area Projects


Agreements of the Honduran and Nicaraguan delegations:

Engineer Rubén Gómez, representing the Honduran delegation, and
Dr. Juan J. Amador, representing the Nicaraguan delegation.

a)In relation to intercountry cooperation in the area of
  leishmaniasis and Chagas' disease, it is agreed:

  To carry out a visit to Honduras in the second four-month period
of 1992, specifically to Sanitary Regions 3 and 4 and the Central
Level in Honduras.  The Central Level and SILAIS delegates from
Nicaragua will take part.  Five persons in all.  Proposed date:  9-
13 June 1992.

  This visit will pursue the objective of determining in situ the
progress and experiences of Honduras with these diseases and
comparing the administrative and technical standards of both
countries.

b)Border-area meetings:

  It is proposed to hold meetings with two technical groups:

  First technical group:          Regions I, II, and VI in
Nicaragua; Regions VII, IV, and
I in Honduras.

  Second technical group:    RAAN in Nicaragua and Mosquitia in
Honduras.

  It is proposed to hold the first meeting on 14 and 15 May at
Choluteca, Honduras.

  Three persons from each region plus one from the Central Level in
both countries will take part.

c)Visit of a virologist from Nicaragua to Honduras:

  Second four-month period of 1992 during July or August, to be
confirmed.  The objective of the visit is to gather experiences for
initiation of the monoserum technique in dengue diagnosis.
Table 1
Evolution of Malaria by Region
Comparing January-December 1990-1991
Nicaragua

Region  Examined  Positive  P. vivax  P. falciparum  ILP  IPA  IAES

Total

Source:  Directorate of Tropical Diseases

- 0 -

Table 2
Evolution of Malaria by SILAIS
Comparing January-December 1990-1991
Nicaragua

Department  Examined  Positive  P. vivax  P. falciparum  ILP  IPA 
IAES

Total

Source:  Directorate of Tropical Diseases

- 0 -

Table 3
Blood Sampling Goals and Accomplishments
January-December 1990-1991
Nicaragua

Region  Programmed  Executed  Percentage

Total

Source:  National Directorate of Tropical Diseases

- 0 -

Table 4
Report on Radical Treatments by Region
January-December 1991
Nicaragua

Region  Malaria cases in 1991  Oral  Remainder  Total  Cohabiters 
Total  Oral  Remainder  Total

Total

Source:  Directorate of Tropical Diseases

E0104.FIN







REPUBLIC OF NICARAGUA














1991 Annual Evaluation
Project to Develop
the Comprehensive Health System in
the RAAN











Ministry of Health of Nicaragua
Pan American Health Organization
World Health Organization













Managua.  February 1992
CONTENTS


   I.     INTRODUCTION                                          1

  II.     PROGRESS AND RESULTS                                  3

 III.     EVALUATION                                            8
I.  INTRODUCTION

     During 1991 the project continued to form an essential part
of the health strategy which the region is promoting through the
implementation of Local Systems of Comprehensive Care in Health.

     During the year, the activities related to the drinking
water supply for the population of Rosita were the most important
component which had to be carried out, both because of the
nonexistence of the service in the community and because of the
need for optimizing the use of resources by contracting and
purchasing all the necessary inputs.

     During the first months of the year, efforts were directed
toward preparation of the documents necessary for carrying out
the bidding process, importing materials, and beginning
construction of the works.

     Eight companies participated in bidding on the importation
of materials.  The Costa Rican Construction Plastics Company,
S.A., was selected.  Six companies participated in the bidding on
the construction of the works, and the Construction Engineering
Company of the Ministry of Construction and Transportation of
Nicaragua was selected.

     The contract for the construction of the works was signed at
the highest level to guarantee fulfillment of construction
quality and execution time.  This contract was signed by Dr.
Ernesto Salmerón, Minister of Health, Jaime Icabalceta, Minister
of Construction and Transportation, and Dr. Carlos Linger, the
PAHO/WHO representative in Nicaragua.

     The follow-up and technical evaluation of the project
(supervision of engineering) is carried out by the PAHO/WHO
Sanitary Engineer and an engineer from the Nicaraguan Institute
of Water Supply and Sewerage Systems.  Both the contractor and
the technical supervisors maintain close contact with the
municipio drinking water commission of Rosita to report on the
progress of the works and to coordinate other project activities.

     In addition, the project is responding to the requirements
created by the imminent presence of cholera in the Region by
preferentially gearing its activities toward educating both
health personnel and the population, as well as toward
environmental sanitation.

     The project also contributed to strengthening the
institutional capacity of the Ministry of Health and other
regional institutions linked to its activities (Ministry of
Education, mayors' offices, National Institute of Water Supply
and Sewerage Systems, Regional Centers for training health
personnel, and others).

     The activities originally planned were adapted to the new
organizational model adopted by the Ministry of Health, through
the Local Systems of Comprehensive Care in Health, and to the
demands created by the construction and setting in operation of
the new hospital at Puerto Cabezas.

     Resources for the training and formation of the health
personnel to be assigned to the maintenance and operation of the
center have been allocated for this purpose, as well as to
support agreements established with the National Autonomous
University of Nicaragua for in-service training of the medical
personnel of the Region.

     It is important to note the support given by the Project for
carrying out training and continuing education activities, as
well as those related to physical maintenance of the units and
the motor pool.  With respect to the last activity, construction
of the regional maintenance workshop has still not been concluded
because of noncompliance by the company.


II.  PROGRESS AND RESULTS
     
     In 1991, four activities were programmed:

     -    Strengthening of the training and formation program for
health, health education, and research personnel.

     -    Development of the maintenance system and
rehabilitation of the infrastructure of the health
services.

     -    Improvement of the drinking water supply system.

     -    Supporting coordination and execution of the project.

1.   Strengthening of the training and formation program for
     health, health education, and research personnel.

      In this activity, resources were allocated for carrying out
the following tasks:

     -    Workshops and seminars
     -    In-service training in the communities
     -    Acquisition of materials and teaching equipment
     -    Acquisition of office equipment

     The activities were carried out as programmed, and
noteworthy were those related to the prevention and treatment of
cholera as well as the training of the management team carried
out by the Center for Health Research and Studies (ICDS).

     Project funds were allocated to support the collaboration
agreement signed between the Ministry of Health and the School of
Medicine of the National Autonomous University of Nicaragua
(UNAN).

     As a result of this collaboration, scholarships are awarded
to students from the RAAN to attend the School of Medicine of
León.  In addition, residents in surgery at the Oscar Danilo
Rosales Hospital School are in Puerto Cabezas providing care to
patients and training to the physicians at the Regional Hospital.

     The programmed activities of supervision and training, as
well as the planned vaccination days, were carried out.

     The activities carried out can be summarized in the
following
way:

Three training workshops were held for 80 staff members
of the regional headquarters and the health units.

Training for health personnel and the community on the
prevention and control of cholera.

Twenty supervision and training visits to 12
communities.

Support for conducting three Regional Vaccination Days.

Support for the formation of two medical students at
the National Autonomous University of Nicaragua.

Support for in-service training and patient care at the
Regional Hospital of Puerto Cabezas.

With the support of this component, improvements were
effected in the knowledge of the region's personnel in
malaria, tuberculosis, acute diarrheal diseases,
cholera, and community hygiene, and workshops were held
on methodologies of popular education to promote the
participation of the population in health activities.

Similarly, conditions in the school of nursing in the
region were improved with resources of this component
through the provision of equipment and supplies for its
education programs.
     
2.   Development of the maintenance and rehabilitation system of
     the health services infrastructure.

     In this activity, resources were allocated for carrying out
the following tasks:
        
     -    Acquisition of materials for the health units
     -    Repair and maintenance of vehicles
     -    Contracting of maintenance services
     -    Preparation of the Regional Hospital project
     -    Construction of the Regional Maintenance workshop 

     The activities were completed satisfactorily, with the
exception of the construction of the maintenance workshop, which
is currently 60% finished and approximately 5 months behind
schedule.

     Because of the financial crisis which exists in the Ministry
of Health, the funds of this activity have been essential for the
maintenance of the vehicle fleet, the physical infrastructure,
and the equipment of the units in the Region.
     
The activities carried out can be summarized in the following
way:

Progress of 60% in constructing the Regional
Maintenance Workshop.

Maintenance and repair of eight vehicles.

Purchase of spare parts for the region's vehicle fleet.

Maintenance and remodeling of the health center at
Siuna.

Purchase of materials to repair the health centers at
Puerto Cabezas, Rosita, Bonanza, and Waspán.

Design of the Regional Hospital at Puerto Cabezas.
     
3.   Improvement of the drinking water supply system.

     In this activity, resources were allocated to carry out the
following tasks:
     
     -    Acquisition and transportation of materials
     -    Design and construction of the water supply system at
Rosita

     After all studies and the purchase and transportation of
materials were completed, works construction was initiated on 3
November 1991 with a commitment by the company to finish the work
before 10 May 1992.  The breakdown, size, and progress are shown
in the following table:

     
WorkProgrammedCarried outPreliminary5.925.92Power
line27.1414.00Dam7.537.53Distribution network29.0324.50Storage
tank30.380                                              Total    
100.0051.95

     As can be observed, the overall completion of the water
supply system is approximately 52%, which means that it will be
finished by the planned date.

     The factors which have promoted good progress in the project
are, among others, multisectoral participation at the municipio
level, the responsibility of the contractor, and the strategy of
follow-up and permanent evaluation that PAHO/WHO has exercised in
this project.
     
4.   Supporting the coordination and execution of the project.

     In this activity, resources were allocated for carrying out
the following tasks:

     -    Contracting of national experts for technical advisory
services
     -    Support for the administrative team
     -    Operational expenditures from the Region and
coordination meetings

     An administrator was contracted who lives in the RAAN.  In
addition to reporting to the project's financial management, he
strengthened the administrative capacity of the Region.

     Project funds contributed to contracting national experts
for the preparation and design of the proposal of
decentralization of the health services of the RAAN in the
framework of the SILAIS strategy.

     With respect to financial management, 100% of the funds
initially intended to the project were executed.  A high
percentage of them were intended for carrying out the drinking
water project at Rosita.

     
III. EVALUATION
     
     The Project has contributed to strengthening the mechanisms
of coordination between and among sectors as well as with other
agencies and international cooperation agencies so that the
resources assigned to the region are optimized.

     The activities planned for 1991 were carried out according
to established programming, and 80% of overall fulfillment was
achieved.  The principal limitation in completing the targets was
the construction and equipping of the maintenance workshop, which
was to have been delivered in November.

     Negotiations are now being carried out so that the company
will fulfill its commitment and delivery will be effected before
the Regional Hospital enters into operation.

     Training activities have been systematized and strengthened
by the participation of the Center for Health Research and
Studies and by the School of Medicine of the National Autonomous
University of Nicaragua.

     The component of greatest importance in this project was
Rosita's drinking water supply since, despite the difficulties in
acquiring and transporting materials, the work's progress
indicates that it will be completed by the planned date (May
1992).

     During the last two months of the year the project's
activities in Puerto Cabezas were affected as a consequence of
political changes which paralyzed the normal activities of the
Regional Government.

     Still, it is important to note that teaching, supervision,
and control activities and those related to drinking water supply
for the population of Rosita did not suffer any interruption.
E0105.FIN







REPUBLIC OF NICARAGUA













1991 Annual Evaluation
Ministry of Health/PAHO/FINNIDA
Rehabilitation Project











Ministry of Health of Nicaragua
Pan American Health Organization
World Health Organization











Managua.  February 1992
CONTENTS


   I.     INTRODUCTION                                          1

  II.     OBJECTIVES                                            2

 III.     INDICATORS OF FULFILLMENT                             3

  IV.     STRATEGIES                                            5

   V.     ACTIVITIES CARRIED OUT                                5

  VI.     EVALUATION                                           15
I.  INTRODUCTION

     The present document is a consolidation of the report
presented to the FINNIDA evaluation in September and the
activities carried out in the last quarter.

     The activities programmed were in general carried out, but
the year was characterized by changes in the strategy and models
of care that the Ministry of Health has implemented through the
SILAIS (Local Systems of Comprehensive Health Service), because
of which some activities were postponed to the new year and
others were carried out which were not planned for this year.

     The report has been organized in accordance with the project
document.


II.  OBJECTIVES

A.   Component on institutional strengthening

     -    To strengthen the structure of the General Bureau of
Medical Care by attaching greater importance to the
Department of Rehabilitation in its operation at the
national and regional levels.

     -    To prioritize rehabilitation of the disabled in the
Ministry of Health.

     -    To incorporate the rehabilitation unit as a program in
the bureau of medical care of each region.

     -    To promote the provision of services based on the
strategy of community-based rehabilitation in all the
regions of the country.

     -    To strengthen the Aldo Chavarría Hospital by
standardizing its administrative structure.

     -    To increase intersectoral collaboration at the
different levels with the institutions involved in
rehabilitation of the disabled in order to ensure
coordination and continuity in the process of
rehabilitation.

     -    To establish an organizational structure which
guarantees and supports an appropriate system of
referrals from the central to the regional and
community levels.

     
B.   Component on renovation, construction, and equipping of
     rehabilitation units and orthosis and prosthesis workshops:

     -    To remodel the Aldo Chavarría Hospital.

     -    To equip rehabilitation units in the interior of the
country.

     -    To analyze the location of the orthosis and prosthesis
workshops and of the remodeling of physiotherapy units.


C.   Component on operation and maintenance of rehabilitation
     units:

     -    To survey the rehabilitation infrastructure in order to
program on the basis of needs.

D.   Component on development of human resources:

     -    To train health professionals, technicians, and workers
in basic rehabilitation subjects for the three levels
of care.

     -    To train the personnel of the Aldo Chavarría Hospital
who will undertake education in subjects of pedagogy
and its technical area.

     -    Formation of medical physiatrists, occupational
therapists, and audiologists.

     
E.   Component on community mobilization:

     -    To implement the strategy of community-based
rehabilitation by putting it into operation through the
regional teams.

     -    To support rehabilitation work systematically at the
community level through community organizations,
community workers, churches, and other popular
associations.

     
F.   Component on developing orthosis and prosthesis production:

     -    To analyze the operation of the orthosis-prosthesis
industry in order to strengthen its operation.

     
III. INDICATORS OF FULFILLMENT

     These indicators are established by taking into account
those determined by the project and the reality of the country's
needs for the process of monitoring the implementation and
execution of the project.

     -    That the Ministry assigns the Department functions and
activities to carry out rehabilitation programs and
projects at all levels.

     -    That the Ministry of Health officially includes the
subject of rehabilitation in all its general health
plans, programs, and projects.

     -    That the Ministry of Health holds meetings with other
sectors regularly to seek coordination with them.

     -    That the rehabilitation program falls within the
structure of the regional bureaus of medical care and
has specialized personnel assigned to that program who
have specific activities.

     -    That community-based rehabilitation activities are
fulfilled at the first level of health care like other
health activities.

     -    That the Aldo Chavarría Hospital has an administrative
organization.

     -    To carry out the remodeling proposed in the Aldo
Chavarría Hospital.

     -    That physiotherapy units have the planned resources.

     -    That the location of the orthosis and prosthesis
workshops and the physiotherapy units to be expanded or
remodeled be defined.

     -    To compile data on infrastructure and equipment needs
as to rehabilitation in the entire country.

     -    To have professionals, technicians, and health workers
with basic knowledge of rehabilitation in all the
regions of the country, especially at the first and
second levels of care.

     -    That make sure that personnel who give basic training
courses on rehabilitation have taken the course in
basic pedagogical techniques for education which was
given.

     -    That the management of the Ministry of Health decides
on and communicates to the project how the training of
the medical and technical resources necessary in
Nicaragua (medical physiatrists, occupational
therapists, and audiologists) will be carried out by
implementing the training of human resources necessary
in the first half of the year.

     -    That areas intended for a pilot plan of community-
based rehabilitation be designated by region and
activities to implement community-based rehabilitation
be started, with monthly evaluations of the program.

     -    To have carried out a study of the overall financial
and administrative operation of the orthosis-prosthesis
industry, seeking to optimize its performance as an
enterprise.


IV.  STRATEGIES

     The working team decided that in this phase of execution the
strategies framed by the project would be followed since no
differences with the program were observed.

     
V.   ACTIVITIES CARRIED OUT

     All the activities detailed below were carried out by the
Ministry of Health through the project team, but always in total
coordination.

     The Ministry of Health-PAHO/WHO-FINNIDA rehabilitation
project has been transformed into the rehabilitation program of
the Ministry of Health.

Institutional strengthening:

      The execution of the project has been a decisive factor in
strengthening the Department of Rehabilitation since its human
resources have received training in different subjects which
pertain to the organization, development, and administration of
the department.  In addition, its infrastructure and its
administrative and teaching equipment have been improved.

     The following documents were analyzed:

     * General Hospital Regulation.
     * Levels of hospital complexity

     -    To implement the project in the different regions, the
working team considered it necessary to hold meetings
in them with the objectives of sensitizing the
governing boards of the regions of the Ministry of
Health, delegates from other ministries,
nongovernmental entities, mayors' offices, and the
general community, and of disseminating the strategy of
community-based rehabilitation and the national
rehabilitation system, in order to organize regional
rehabilitation commissions and stress the importance of
regional action in the development of the project.

Sensitization workshops were carried out in:

Region II:

8 May 1991.  The regional management team, composed of
the regional director and the heads of the regional
bureaus of medical care, education, epidemiology,
planning, and finance.

2 July 1991.  21 participants.  Regional bureau team
and delegates from the Ministry of Education,
Autonomous University of Nicaragua, León Nucleus,
community movement, ORD, Los Pipitos, Chinandega and
León SILAIS.

Region IV:

25 June 1991.  The regional management team, composed
of the director of the region and the heads of the
regional bureaus of medical care, education,
epidemiology, planning, and finance.

12 July 1991.  31 participants.  Regional management
and  regional rehabilitation teams and delegates from
the Ministry of Education; community movement;
Revolutionary Organization of the Disabled; Jinotepe,
Granada, Masaya, and Rivas SILAIS; Regional Commission
to Aid Combatants (CRAC); Nicaraguan Institute of
Municipio Promotion (INIFOM); Ministry of Labor, and
municipio educators.

Region V:

27 August 1991.  The regional management team, composed
of the director of the region and the heads of the
regional bureaus of medical care, education,
epidemiology, planning, and finance.

5 September 1991.  46 participants.  The regional
management team and delegates from Special Education,
the community movement, ORD, INSSBI, the vice-mayor of
Boaco, and the Boaco and Juigalpa SILAIS.

South Atlantic Autonomous Region (RAAS):

13 June 1991.  At its Bluefields headquarters.  The
regional management team, composed of the director of
the region and the heads of the regional bureaus of
medical care, education, epidemiology, planning, and
finance.

     -    Regional rehabilitation commissions were organized in:

Region II (León)

Region V (Juigalpa)

Region IV (Granada).

     -    The regional basic rehabilitation team was defined
through a document and its functions were outlined, and
it was implemented through organization of the first
regional team.

     -    Contributions were made to the organization of regional
rehabilitation teams in Region:

I.   Estelí:

Members:   Dr. ROSA EVA ORELLANA
MARTA MEJIA
ELENA CASTILLO
SILVIA ELENA BAEZ
FELICIA ARCIA
ALFREDO VELAZQUEZ

IV.  GRANADA:

Members:   Dr. ROBERTO CABALLERO
LOURDES CRUZ
LILIAN SANCHEZ VADO

V.   JUIGALPA:

Members:   Dr. SANCHEZ
MARTA LOPEZ BLANDON
MARLENE CHAMORRO
LILIAN CALERO BAEZ
NANCY CAJINA

RAAS.BLUEFIELDS:

Members:   Dr. ESTEBAN MACHADO
LIDIA SOLANO
MILAGROS MONTANO
LIDIA AGUILERA
SANDRA CARDOZA
     
     -    The technical and administrative organization of the
Aldo Chavarría Hospital was considered essential, for
which a working team was organized which is preparing
standards of operation and organization for the
institution.

Dr. Hugo Villar was contracted as a specialized
consultant on hospital administration to collaborate in
the reorganization of the Aldo Chavarría Hospital.

An organizational chart of the operations of the Aldo
Chavarría Hospital was prepared.

A provisional draft of the administrative structure of
the Aldo Chavarría Hospital was prepared.
     
     -    A physiotherapy registration system was prepared and
implemented in the Aldo Chavarría Hospital as a pilot
test starting on 1 August of the current year.

     -    The methodology of the survey on prevalence of
disabilities proposed by PAHO was analyzed and it was
decided to implement it, and coordination was begun
with the National Institute of Statistics and Censuses
(INEC) to program its implementation.

     -    A form was designed to survey rehabilitation
institutions.

     -    Levels of care and management in rehabilitation were
designed.
     
     -    Activities were integrated at the first level of care
with the mental health program in Regions I and II.

     -    Activities were coordinated with other projects:

PRODERE:  Training of brigade workers for community-
based rehabilitation in Quilalí and San Juan del Río
Coco.

World Rehabilitation Fund:  Coordination in community-
based rehabilitation activities since the two programs
had the same areas.  The utilization of human resources
who were collaborating in the two programs.  Finally
and at the conclusion of this institution's program,
there was collaboration in the transfer of the
installations to the Ministry of Health in order to
include them in the programming of the FINNIDA project.

ILO (International Labor Organization):  Coordination
in community-based rehabilitation activities since they
have the same areas of work and similar objectives in
regard to regional commissions, sites, and community-
based rehabilitation but with a greater emphasis on
labor.

Los Pipitos Parents' Association:  Coordination to
carry out community-based rehabilitation activities.

Italian Cooperation Agency:  Coordination to carry out
community-based rehabilitation tasks and use the
polyvalent workshop in the health center at Granada.

     
Renovation, construction, and equipping of rehabilitation units
and orthosis and prosthesis workshops:

      -   The physiotherapy units at Juigalpa, Matagalpa, and
Estelí were visited and it was decided that their
possible remodeling and construction would be left for
the new year if the survey which is being made of
rehabilitation units does not show a need for
requesting authorization to change investment sites. 
At this time it is considered most important for the
execution of the project to begin with the center of
greatest complexity.

     -    One hundred thousand dollars was obligated for repairs
of the in-patient section of the Aldo Chavarría
Hospital.

     -    Repair was begun of the hydrotherapy section with
heating of water by solar panels, in-patient
physiotherapy sector, and dining room.

     -    Construction was begun of a storeroom to replace the
current ones, which are in very bad condition, with
resulting deterioration of stored products.

     -    Local companies were contracted to renovate the
rehabilitation units.

     -    Equipment worth $31,608 was bought for various
physiotherapy units in the interior of the country.

     -    The physiotherapy resources which had been acquired
were distributed in the four regions which are the
project's target. 
     -    Four vehicles intended for the regions were bought.

     -    Three vehicles were acquired for the project and the
Aldo Chavarría Hospital.

     -    Furniture and equipment was acquired to upgrade the
rehabilitation section of the Leonel Rugama Health
Center at Estelí in Region I.

     -    Remodeling and repairs were carried out of some parts
of the Aldo Chavarría Hospital to implement the
teaching activity in the physical medicine and
rehabilitation residency.

     -    Repairs were carried out of electrical junction boxes,
refrigerators in the kitchen, and other resources at
the Aldo Chavarría Hospital which required urgent
attention.


Manpower development:

      -   The Ministry of Health decided that the formation of
medical physiatrists would be carried out in the
country.

     -    A general curriculum was designed for the residency to
train medical physiatrists in Nicaragua and was
submitted to the Vice-Minister of Human Resources for
his approval.

     -    A selection was carried out for fellowships to train
medical physiatrists abroad.  They subsequently
remained candidates for the national residency after
decision by the Ministry of Health and the working team
of the project.

     -    The formation abroad of two occupational therapists and
an audiologist was decided.
     
     -    The selection for the fellowships in occupational
therapy and audiology was carried out.
     
     -    Dr. Martha Aristizabal, a Colombian medical
physiatrist, was contracted to direct the residency in
physical medicine and rehabilitation in Nicaragua.

     -    The residency in physical medicine and rehabilitation
in Nicaragua was initiated with four national
physicians.

     -    The project collaborates in training medical residents
in reconstructive surgery.  Dr. Michael Castner is
rotating among the hospitals where systematic post-
doctoral instruction in this specialty is given and
where there are reconstructive surgeons and updating
and continuing in-service education is needed,
especially in surgery for pressure ulcers, hand
surgery, burns, birth defects, and leprosy, which are
the most frequent surgical problems in disabled
persons.  He has performed his duties at the Vélez
Paiz, Huembes, and Manolo Moral Hospitals at Managua,
Rosales Hospital at León, Molina Hospital at Matagalpa,
and Gray's Memorial Hospital at Puerto Cabeza.

     -    Miss Silvia Mendoza Lacayo was sent abroad to train in
occupational therapy at the School of Occupational
Therapy of the Argentine Republic.

     -    A total of seven persons from the Bureau of Programs of
the Department of Rehabilitation was sent to train in
administrative computation programs.

     -    The director of programs and the director of the Aldo
Chavarría Hospital were sent to observe the operation
and organization of rehabilitation centers in Costa
Rica.

     -    The head of the Department of Rehabilitation in the
Ministry of Health was sent to a Latin American
community-based rehabilitation meeting in Mexico and
made a visit to observe the organization and operation
of the Center for Rehabilitation and Special Education
(CREE) at Toluca and Mérida.

     -    A note was sent to the POLISAL (Polytechnic Health
Clinic) to evaluate the possibility of creating
curricula in occupational therapy and audiology at the
national level.
     
After consulting with the National Autonomous
University of Nicaragua, of which it is a dependency,
POLISAL was approached to collaborate in the project,
which contributed two professionalsÐa Colombian
occupational therapist who is coordinating between the
World Rehabilitation Fund and the Ministry of Health,
and an Argentinian audiologist, who was contracted in
NicaraguaÐto design the curricula of the specialties
just noted which, together with physiotherapy, will
have a common trunk in the first year and will then
continue according to each specialty.  Appendix XVII.

     -    Furniture, teaching equipment, documentation, and a
computer were bought for the teaching unit at the Aldo
Chavarría Hospital, which carries on post-doctoral
formation of physicians specializing in physical
medicine and rehabilitation.

     -    Continuous training activities were carried out with
the regional rehabilitation teams.

     -    Managua, second training phase.  Rehabilitation teams
from Estelí, Boaco, and Granada, with 16 participants. 
Duration three days.

     -    A physiotherapist was sent to La Rioja, Argentina, to
take an internship to be trained in community-based
rehabilitation, specifically in the organization and
role of the coordinator.

     
Component on operation and maintenance of rehabilitation units

     -    A survey was made of the equipment and resources in 23
physiotherapy units in the country.

     
Community participation

      -   Promotion through workshops of the strategy of
community-based rehabilitation in all the regions.
     
     -    Fifteen thousand dollars worth of material on
community-based rehabilitation was printed.

     -    Selection of four communities for a pilot community-
based rehabilitation program in Region I.

     -    Workshop to create awareness in the communities of
Santa Cruz, El Regadío, Quilalí, and San Juan del Río
Coco (pilot programs).

     -    Workshop to train health agents to act as local
supervisors in the previously cited communities.

Community            Workshop dates       Participants

Santa Cruz           16 to 21 April       39 agents
Regadío              6 to 10 May                23
agents
Quilalí              10 to 14 June        30 agents
San Juan del Río Coco      8 to 11 August       19
agents

     -    Workshops on verifying the identification of disabled
and disabilities in the communities of El Regadío and
Santa Cruz.

El Regadío           20/21 July
Santa Cruz           22/23 July

     -    Workshops to disseminate the strategy of community-
based rehabilitation in Regions I (Estelí), II (León),
IV (Granada), V (Juigalpa), and RAAS (Bluefields). 
These workshops were carried out with the senior team
of the region, regional representatives from other
ministries, representatives from the mayors' offices,
leaders of the community, and nongovernmental entities
on the need for developing the strategy of community-
based rehabilitation.

     -    The following are defined as pilot localities in other
regions:

Region IV            El Paso Malacatoya
Region V             Boaco
RAAS                 Kukra Hill

     -    San Juan del Río Coco:  Workshop on community-based
rehabilitation (second phase).  32 participants. 
Duration 3 days.

     -    Kukra Hill:  Workshop of community-based
rehabilitation.
39 participants.  Duration 4 days.

     -    San Miguel:  Workshop of community-based
rehabilitation. 41 participants.  Duration 4 days.

     -    El Paso Malacatoya:  Workshop on community-based
rehabilitation.  23 participants.  Duration 4 days.

     -    San Miguel:  Workshop on community-based
rehabilitation.  41 participants.  Duration 3 days. 
Second phase.

     -    El Paso Malacatoya:  Workshop on community-based
rehabilitation.  23 participants.  Duration 3 days. 
Second phase.
     
     -    Quilalí:  Workshop on community-based rehabilitation. 
30 participants.  Second phase.

     -    Meetings with authorities of nongovernmental entities
to explain the project and how to work in coordination
(Cepri, Los Pipitos, ORD, Solidarity, etc.).

     -    Design of a sports program for the disabled.

     -    Survey of areas for sports practice for the disabled.

     -    Design of a training workshop for sports leaders.

     -    Implementation of sports and recreation activities on
the sports beach of the Aldo Chavarría Hospital and
orthosis-prosthesis industry.

     -    Holding of a seminar workshop to organize a
multisectoral entity to plan and regulate sports and
recreation for disabled persons.

     
Manufacture of orthoses and prostheses

      -   It was decided to support and strengthen the national
orthosis-prosthesis industry.
     
     -    After bidding by invitation to several accounting
firms, a financial and administrative analysis of the
orthosis-prosthesis industry was contracted to evaluate
the possibility of optimizing costs.

     -    The study was finalized and its results are being
evaluated.

     -    The orthosis-prosthesis industry proposes the
collaboration of the project to implement a traveling
workshop installed on a truck.

     -    The orthosis-prosthesis industry has already received
the truck through the International Red Cross and the
workshop should be installed on it.


VI.  EVALUATION

     This project is the substantive focal point of the
rehabilitation program of the Ministry of Health.  In its own
view, however, it does not have a substitutive character.  It
involves a structural element which is being firmly included in
the Ministry of Health, so that when this is done the national
program will have been consolidated, will last, and will be
developed as a definitive component of the institution.

     Rehabilitation is one of the current health priorities in
the country, as expressed in the 1991-96 Master Plan and
previously in the 1988-90 Health Plan.

     The conception of the basic project for developing the
rehabilitation area involves substantial resources in the
strategic guidelines of the health sector.

     The project still has not succeeded in getting all the
activities of community-based rehabilitation that it would have
liked carried out at the first level of health care.  This delay
was due to the need to organize the higher levels of care so that
they have sufficient capacity to act as referral from the first
level.

     Comprehensive rehabilitation has as its principal objective
diminishing the impact of disabilities and handicaps.  An
important component in this objective is the technical
cooperation contribution of PAHO/WHO directed so that the
Ministry of Health takes the lead in and organizes the
comprehensive management of rehabilitation.

     However, the activities that the health sector implements
directly do not suffice; an intersectoral effort is necessary to
give the disabled the opportunity to be trained, work, and
developed like any other citizens.

     The 1991-96 Master Health Plan has outlined the priorities
for the National Health System and establishes in its programming
the need for creating a national system with step-like levels of
care and growing complexity for the treatment of the disabled.

     In addition, it defines the need for integrating all the
governmental and nongovernmental institutions in a single
rehabilitation plan in order to organize and expand the services
provided to the disabled population.  This proposal points out
the need for effective participation in the programming of the
disabled and their families.

     The prospective analysis of the area falls within the
framework of a new structure the Ministry of Health is beginning
to implement:  Local Systems of Health Comprehensive Care
(SILAIS).

     The project's activities are directed toward supporting the
establishment of national rehabilitation policies.  These and
their implementation through the national system are correlated
at the SILAIS level through the formation of local rehabilitation
commissions.   

     Resources were mobilized so that the idea was spread that
rehabilitation is an activity tied to prevention and treatment of
injuries and disabilities.  Promoting the interprogram effort is
mainly oriented to this effort.

     In addition, the idea is being spread within the
rehabilitation area that treatment of disabilities should be
directed toward prevention of handicaps.

     
RESULTS

Component on institutional strengthening

      -   The Department of Rehabilitation forms part of the
working group of the Ministry of Health-PAHO-FINNIDA
project.

     -    The Department represents the Ministry in the National
Commission on Rehabilitation.

     -    The Department of Rehabilitation is the representative
of the Ministry of Health with any cooperating bodies.

     -    The Department is the planning agency and evaluator of
programs of rehabilitation of the Ministry of Health.

     -    It has sufficient personnel for its operation and
through the project is well equipped administratively
and for providing collaboration in teaching activities.

     -    The leadership personnel of the Ministry, who are
leading the development of the national program and in
the execution of the project, have strengthened their
technical-administrative knowledge through training
received abroad.

     -    In the 1991-1996 Master Health Plan which specifies the
policies the Ministry of Health will follow in that
period, the Program of Care for the Disabled appears in
third place among the eight priority health programs on
page 123, Item D, Programming.

     -    The Minister made clear that rehabilitation of the
disabled is one of the priorities in health at the
meeting of 4/8/90 with cooperating entities.

     -    The Ministry of Health is part of the National
Commission on Rehabilitation composed of all the
sectors of the state and nongovernmental agencies which
carry out rehabilitation activities.

     -    The Ministry of Health presented an exhibit to the
National Assembly's health committee on the
rehabilitation program and the need for a legal
framework to deal with the problems of disabled
persons.
     
     -    The Ministry of Health forms part of the regional
commissions of Estelí (Region I), Juigalpa (Region V),
León (Region II,) and Granada (Region IV).
     
     -    The Ministry of Health promotes the formation of
regional and local rehabilitation commissions in other
parts of the country.

     -    All the regions sent physicians and technicians to take
basic training courses in rehabilitation, after which
they will form the regional teams.

     -    The management of the hospital, which for three months
was under the responsibility of a resigning director,
has finally been regularized with the appointment of a
director.

     -    The Ministry of Health was represented at the regional
meeting to analyze care for disabled infants held in
Costa Rica in July 1991.

     
Component on repair, construction, and equipping of
rehabilitation units and orthosis and prosthesis repair workshops

      -   The design of the remodeling of the Aldo Chavarría
Hospital was finalized, a folder of conditions to call
for bidding to begin construction was prepared, and a
contract was awarded.  The contract was sent to
Washington for its approval.

     -    A list of physical therapy resources was drawn up to
rectify some shortcomings in physiotherapy units, and
later a request for budgetary obligation and finally
the purchase of the physiotherapy and rehabilitation
resources valued at $31,608 were put through.

     -    Facilities at the Aldo Chavarría Hospital were
remodeled to implement its teaching activities.

     -    Facilities at the Estelí health center and in the
department of physiotherapy at the Juigalpa hospital
were equipped to upgrade the operation of
rehabilitation equipment.

     
Component on operation and maintenance of rehabilitation units

      -   Through the survey of physiotherapy units it was
determined that the 23 physiotherapy units are
operating with human resources and equipment which can
be considered adequate.
     

Component on manpower development

     -    The training of 14 physicians and 31 technicians and
professionals gives all the regions human resources
trained in rehabilitation for the first and second
levels of care, but they continue to be limited and
this is now more evident with the development of the
SILAIS.

     -    The personnel of the Aldo Chavarría Hospital felt more
secure in giving instruction after having taken the
pedagogical training course.  However, the evaluation
of the course revealed disparities in the pedagogical
preparation of the educators, which makes it necessary
to strengthen these courses.

     -    The Ministry of Health decided to initiate a residency
in physical medicine and rehabilitation to meet the
need to extend care coverage to the disabled
population, as established in the priorities of the
Master Plan and in view of the increase in demand for
care of the disabled population in relation to the
universe estimated in the original design of the
project.  An attempt is being made to achieve greater
efficiency, efficacy, and effectiveness in the manpower
development component by making the profile of
formation more compatible with the levels of care
established by the Ministry of Health through the
SILAIS and facilitating the integration of the program
into the National Health System.

     -    After creating the residency in Nicaragua and sending
the rest of the technicians abroad for formation, the
Ministry of Health this year requested the National
Autonomous University of Nicaragua to create curricula
in of occupational therapy and audiology.

The residency for the formation of physicians
specializing in physical medicine and rehabilitation
began in June of the current year.  Four applicants
were selected for the course in this year.

The POLISAL has already designed the curricula of the
two specialties, occupational therapy and audiology,
and is prepared to begin to give them during the new
year.

     
Component on community mobilization

     -    In the communities of El Regadío and Santa Cruz in
Region I which were chosen as pilot areas for
conducting the experiment with community-based
rehabilitation, the programs are already implemented
and in full operation,  They have also been added in
Quilalí and San Juan del Río Coco in the region and are
in the detection phase.  This provides a community-
based rehabilitation coverage of around 30,000
inhabitants, according to Appendix 5 of the project.

     -    Local commissions have been formed in which communities
coordinate and control the implementation of community-
based rehabilitation.

     -    In Region III (Managua) a community-based
rehabilitation project is being carried out which is
coordinated with the Los Pipitos Agency, INSSBI, and
the Ministry of Education in Districts I and II.

     -    A sports program is under way for disabled persons with
participation by all the organizations of disabled
persons and with a workshop being held at the Aldo
Chavarría Hospital.

     
Component on orthosis and prosthesis construction

     -    A contract was put to competition and awarded to the
accounting firm Ramírez S.A. for auditing the orthosis-
prosthesis industry with the aforementioned objectives;
it carried out the evaluation and delivered its study. 
The study indicated a need to adapt some functions of
the industry with regard to the services it currently
provides.  It is proposed to make the appropriate
changes during the process of reorganizing the Ministry
of Health on the basis of the SILAIS.
E0106.FIN





REPUBLIC OF NICARAGUA












1991 Annual Evaluation
project to Strengthen
the Technical, Material, Human, and
Institutional Resources
of the Hospital Equipment
Maintenance Sector
(MINSA - FINNIDA - PAHO/WHO)










Ministry of Health of Nicaragua
Pan American Health Organization
World Health Organization










Managua.  February 1992

CONTENTS


   I.     INTRODUCTION                                          1

  II.     OBJECTIVES                                            3

 III.     INDICATORS OF FULFILLMENT                             4

  IV.     STRATEGIES                                            6

   V.     ORGANIZATIONAL FRAMEWORK                              8

  VI.     ACTIVITIES CARRIED OUT                                8

 VII.     INPUTS                                               12

VIII.     EVALUATION                                           12
EXECUTIVE SUMMARY

     
     A strike by health workers at the start of the year, which
lasted almost 45 days, and a decline in the number and quality of
the maintenance staff because of the government's Occupation
Conversion Plan were important factors in the execution of the
project's activities, mainly in regard to repairs, preventive
maintenance, and training.

     If the low technical and organizational level of the
maintenance departments of the hospitals earlier limited the
execution of operations, those difficulties became greater after
those two events.

     Execution of the investments has been as planned, however,
and almost all the installations and the technical and material
resources for the workshops of the hospitals are in place;
repairs on equipment and, in some cases, preventive maintenance
are being carried out by national companies.

     The equipment repaired is biomedical for the most part since
the replacement parts in the storerooms of the Ministry of Health
were mainly for this type of equipment (of 111 repaired devices,
102 are biomedical).  The diagnosis of 77 devices in the
electromechanical area and 471 electromedical devices, which will
be repaired next year, was entrusted to TECNOMEDIC, however.

     The year's training program was redefined with the objective
of elevating, at the national level, the technical capability of
the maintenance staff which still works for the Ministry of
Health by orienting the program to holding courses on basic
techniques (electricity, electronics, motors, etc.).

     TECNOMEDIC experienced a serious crisis throughout the year,
especially in the financial area and in the general management of
operations.  The labor situation which arose because of this has
made it difficult to organize the workshops and to initiate
systems for planning and controlling operations.

     In summary, the situation in the sector continues to be
critical, mainly with respect to human, financial, and
organizational resources.  The project has focused its activities
on resolving the deficiency in these three areas by trying
whenever possible to find final solutions by raising the level of
technical knowledge of the personnel, seeking a real increase in
the national budget for maintenance in the Ministry of Health,
and adequately implementing the organization in hospital
workshops without neglecting the critical hospital equipment
situation.

     It is expected that the Ministry of Health will take some
measures with regard to these problems in 1992, although to what
extent is unknown.  Other development projects in the maintenance
sector will initiate operations in different regions of the
country, which means that national coordination will be a key
factor in not duplicating activities and in confronting the
problem effectively and efficiently.
I.  INTRODUCTION

     During 1991 the FINNIDA project was that which had the
greatest activity and continuity in the maintenance area in the
Ministry of Health.  It geared its activities toward the
technical and administrative strengthening of the Department of
Engineering and Maintenance, as well as toward training its
personnel and mainly toward repair and maintenance of hospital
equipment.

     The second phase of the Dutch Project Plan officially ended
in May 1991, and final approval of its third phase is still
expected.  The third phase was prepared by the Ministry of
Health, the Government of the Netherlands, and the Pan American
Health Organization (PAHO).

     The subregional engineering and maintenance project in the
Central American area, also administered by PAHO, is being
carried out in coordination with the FINNIDA project.

     The principal activities of this project are geared toward
the training of technical personnel and operators, which is the
area in which it supplements the FINNIDA project.  In addition,
the project is responsible for conducting research projects and
maintaining equipment in the primary care health units in Regions
IV and VI of the country, which are not part of the FINNIDA
project.

     At the hospital level (Oscar D. Rosales, Manolo Morales,
Berta Calderón, Fernando Vélez Paiz, and Lenin Fonseca), the
project is the focus of maintenance activities.  There are other
projects, mainly dealing with equipment and manpower development,
which are implemented by nongovernmental agencies or independent
donors which supplement the efforts of the FINNIDA project.

     A project to improve the telephone system is being carried
out in the Oscar D. Rosales Hospital at León  with support of a
German NGO which consists of the installation of a new telephone
plant and reconstruction of the internal cabling.  In addition,
improvements in the electrical system through provision of a new
power transformer and the improvement of the internal
distribution network are being undertaken with support of the
Senate of Hamburg, Germany, within the sisterhood arrangement
between the two cities.

     Another hospital which carried out equipment improvement
projects is the Fernando Vélez Paiz Hospital through the
provision of refrigeration units for cold rooms with the support
of a church in the United States.

     In general, the project's five hospitals have received major
assistance for improving basic installations (water sanitation
equipment, sanitary devices, repair of buildings) within the
program of the Social and Emergency Investment Fund (FISE) which
the Government of Nicaragua promotes with support from IDB, the
World Bank, USAID, and other cooperation agencies.

     Two major events in the nation's life affected the project's
execution during the year:  the strike of health workers and the
Occupation Conversion Plan, which led to the voluntary
resignation of maintenance technicians, mainly in the hospitals
covered by the project.

     The first meant a complete suspension of activities for
almost 45 days in January and February which saw restoration of
the normal pace of work from one hospital to another vary.

     For its part, the Occupation Conversion Plan affected the
category of maintenance technicians by causing a sizable
reduction in this trained manpower in the hospitals which led to
a reduction in the decision-making and operational capacity of
the maintenance departments of the hospitals.  The most critical
aspect of this situation has been the freezing of work posts,
which means that this situation will not be easily reversed, at
least for the rest of the year.


II.  OBJECTIVES

     The following immediate objectives were proposed in 1991
within the general objectives established in the project
document:

1.   To improve the availability of hospital equipment and the
     holding of maintenance workshops in the project's hospitals,
     two immediate objectives were established:

     -    To renovate and equip maintenance workshops in the
hospitals.

     -    To repair or replace hospital equipment which is out of
operation in the project's hospitals.

2.   Concerning the development of systems of preventive and
     corrective maintenance, the following was proposed as an
     objective:

     -    Developing operational plans in each of the maintenance
departments in the project's hospitals.

3.   In regard to the training and development of human
     resources, two immediate objectives were defined:

     -    To carry out a program of training directed toward the
maintenance staff of the equipment maintenance
workshops in the project's hospitals.

     -    To develop the professional personnel who work in the
area of hospital equipment maintenance.

4.   With reference to the manufacture of replacement parts,
     medical instruments, and small medical devices in the
     TECNOMEDIC workshops, achieving two immediate objectives was
     proposed:

     -    To increase the utilization rate of the TECNOMEDIC
workshops.

     -    To improve the system of calculating costs in the
production workshops of TECNOMEDIC.


III. INDICATORS OF FULFILLMENT

     A)   The designs, technical specifications, and bidding
documents are available for the construction works in
the maintenance workshops of the five hospitals.  The
financial offers for carrying out the works in four of
the workshops are available.

     B)   Operational plans have been formulated in each hospital
in light of the priorities in the budget of the project
and after prioritized diagnoses of the equipment to be
repaired and maintained by the project were made.

     C)   Lists of the spare parts and materials necessary for
making repairs have been prepared, either by personnel
of the Ministry of Health itself or by contracted
companies.

     D)   Contracting of repair and other services has been
carried out with regard to the existence of spare parts
in the warehouses of the Ministry of Health.

     E)   Management of contracts is being performed regularly
and a single procedure for contract supervision,
monitoring, and administration has been established
through which the Department of Engineering and
Maintenance supervises the technical execution of the
works, PAHO monitors it, and both administer it.

     F)   The situation of equipment in good working order has
improved, rising from approximately 65% (the estimate
at the beginning of 1990) to 69% in September 1991.

     G)   Copies of the basic operating and maintenance manual
which was prepared by the Ministry of Health in 1989
have been distributed.  Every hospital has its own
program of preventive maintenance.  Documentation is
available on the supply systems for spare parts and
material and for control of inventories which will be
used in computers in the coming year.

     H)   The information system for the project's activities has
the direct support of the chiefs of maintenance and the
coordinators at the hospital level.  A monthly report
is prepared on hospital maintenance activities and
another on the activities of each coordinator.  The
reports are utilized in the follow-up of the activities
and in monthly planning.

     I)   Definition of training needs is done at the general
level in order to optimize resources.  Training needs
are evaluated with each chief of maintenance every six
months and are incorporated in the national plan.

     J)   The lists of needs in tools and raw material for the
manufacture of equipment and small medical devices have
been prepared according to the manufacturing program of
TECNOMEDIC.


IV.  STRATEGIES

     To achieve the objectives proposed, the strategies below
have been followed:

     A)   It was planned to finish the construction or
improvement of the workshops in the project's hospitals
all at the same time and to initiate operations
simultaneously.  However, the high current costs of
construction made it necessary to make revisions in the
specifications and to seek alternatives to reduce
costs.

     B)   In regard to repair of the equipment that was not
working originally, a process of decision-making has
been followed with regard to:

        -    Priority equipment according to the management of
each hospital, in regard to the services offered and
the most frequent pathologies cared for

        -    The importance of every piece of equipment in each
hospital unit, with respect both to the quantity of
equipment functioning by service and to the existing
quantity of every type of equipment

        -    The technical capability of the maintenance staff in
each hospital to make diagnoses, prepare spare parts
and material lists, and make repairs

        -    The full availability of parts needed for making the
repairs in the storerooms of the Ministry of Health.

  Because of the technical limitations of the personnel,
  information from the national technical inventory of equipment
  was used to estimate their situation and decide which repairs
  could be made by hospital personnel and which by third parties. 
  It was later established which devices of those to be repaired
  had parts in the country to proceed with their immediate
  repair.  The rest of equipment (for which parts did not exist)
  would be evaluated subsequently and the necessary parts
  purchased.

C)Supervision of activities at the hospital level has been
  carried out with the direct participation of the chief of
  maintenance of each unit, the engineers contracted by the
  Department of Engineering and Maintenance, and the project
  coordinator in the respective hospital.  Responsibility has
  usually fallen on the chiefs of maintenance for the work the
  personnel under their command carry out, with the support of
  the coordinator; when third parties perform work in the
  hospital, supervision is performed jointly by the three groups.

D)With respect to in-service training, courses were designed
  which are directed toward supporting the activities carried out
  by the project (operation and maintenance of boilers,
  laboratory equipment maintenance, autoclaves, anesthesia
  equipment, kitchen equipment, laundry equipment) and other
  activities such as organization of the workshops and support
  for the project to rehabilitate the disabled.  In the second
  half of the year, however, the need arose for training the
  maintenance staff of the country's hospitals at the national
  level, mainly in basic knowledge of electricity and
  electronics, with the objective of diminishing the impact of
  the consequences of the Occupation Conversion Plan.  Plans have
  not been prepared to train personnel due to the high staff
  turnover which still persists.

E)Support for the institutional development of the Department of
  Engineering and Maintenance has been manifested through the
  contracting of two engineers (one mechanical and the other
  electronic) whose principal activity is to support the
  technical supervision of repair works and technical assistance
  to the departments of maintenance at the national level. 
  Efforts are also being made to improve its offices so that it
  functions not only as a regulatory unit but also as a unit
  coordinating projects in the maintenance sector.  To accomplish
  this, office equipment has been expanded, and documents and
  written reference materials have been provided.

F)National specialists have been contracted to establish the
  different systems of preventive maintenance.  Implementation of
  these systems is being carried out gradually, beginning in the
  project's hospitals and later in those of the rest of the
  country.

G)Needs for small equipment were defined jointly by the
  hospitals, beginning with hospital furniture; therefrom arose
  designs, specifications, lists of materials, and instrument
  needs.

H)In general, technical assistance is being received from
  national professionals with broad experience in each area, but
  there is also support from the entire Pan American Health
  Organization, which has been resorted to as needs require.


V.ORGANIZATIONAL FRAMEWORK

  There is close coordination between both institutions.  The
annual and four-month programs as well as budgets are prepared
jointly, on the basis of a methodology utilized by PAHO/WHO.

  Purchase of spare parts is done in a centralized way because of
the hospitals' small capacity for it.  The Department of
Engineering and Maintenance makes the requests to PAHO/WHO, which
is responsible for all acquisition and delivery transactions.

  With the support of the project's coordinating engineers, the
chiefs of maintenance make local purchases for urgent small
repairs at their hospitals.

  Urgent repairs are being carried out with funds from the
project, mainly through private companies.

  The contracting of services is requested by the Ministry of
Health, both by the hospital directors and by the coordinator of
the project.  The contracts are signed between the contractors
and PAHO/WHO, and responsibility for their supervision is shared
between the coordinators of the Ministry of Health and PAHO.

  Planning, control, and follow-up of the project at the hospital
level is done by the chiefs of maintenance of the hospitals and
the coordinators at the hospital level, with the technical
assistance of the national coordinator's office.
  

VI. ACTIVITIES CARRIED OUT

  The activities indicated below are those carried out during
1991 for each of the objectives formulated in the project
document.

1.Strengthening of the institutional capacity of the hospital
  equipment maintenance sector at the national level.

  This objective was established to carry out a study of the
human, physical, and financial resources situation and prepare a
report on the matter, which was done in 1990.

2.To improve the availability of functioning hospital equipment
  and to hold hospital equipment maintenance workshops in the
  hospitals of the project.

  The plans, technical specifications, and contract documents
were prepared.  The final plans were approved by the chiefs of
maintenance and the directors of the respective hospitals.

  Agreements were made as to the areas and sites to be utilized
and the ways in which the work would be done, particularly in
regard to the temporary location of maintenance departments
during remodeling of the workshops.

  Three offers were requested for the execution of each of the
workshops from companies in the private sector.  The criteria for
evaluating the offers have been mainly the unit cost of the works
and the quality of the suppliers.  The construction of three
workshops was awarded. The costs estimated in the project
document far exceed the present ones.  To cover the deficit, PAHO
Headquarters has allotted part of the project support cost.  The
works will be concluded in 1992.

  Supervision of the works has been conducted through the
architect designer in order to guarantee the integrity of the
works in time, cost, and quality.

  The maintenance program is being carried out according to the
procedures established by the Department of Engineering and
Maintenance.  The extent to which the standards for using the
forms are fulfilled varies from one hospital to another and
depends on their degree of development.  The "Request for
Service," "Work Order," and "Planner of Preventive Maintenance"
formats are being utilized.  The process of evaluation and
follow-up of the work orders is not consolidated.  With the
participation and impetus of the project's coordinators in the
five hospitals, it is hoped that important improvements will come
about in a short while.

  The basic materials to carry out preventive equipment
maintenance were provided quarterly, and the purchase of spare
parts has been requested so that the maintenance staff of the
hospitals can carry out what repairs it can, mainly of
aspirators, operating lamps, rotary irons, spectrophotometers,
etc.

  The status of 548 pieces of equipment in the five hospitals
(emergency plants, clothes washing machines, clothes driers,
autoclaves, general aspirators, anesthesia equipment, overhead
lamps, electrocauteries, electroscalpels, portable
defibrillators, cardiac monitors, defibrillators with monitor,
respirators) has been diagnosed as part of a program of repair
and equipment maintenance in the five hospitals which encompasses
a total of 564 devices.
  
3.Development of hospital equipment preventive and corrective
  maintenance systems 

  Programs of prioritized preventive equipment maintenance have
been prepared in the five hospitals of the project according to
the procedures of the Department of Engineering and Maintenance. 
Execution of the program is the responsibility of the chiefs of
maintenance.  Execution has been supported through the supply of
basic materials (lubricants, oils, chemicals, etc.) and the
training of operating and maintenance personnel.  Hospital
coordinators are giving full attention to this component and
promoting the fulfillment of the program.

  The systems for the organization and execution of preventive
and corrective maintenance have been drawn up at the central
level (Department of Engineering and Maintenance), with the
support and participation of other projects.  Work is being done
on the computerized version of the System for Controlling the
Spare Parts and Materials Inventory and System for Supplying
Spare Parts and Materials.  None of the planned systems has been
implemented due to the difficulties caused by the labor and
economic situation in the country.
  
4.Training and development of human resources

  There is a five-year plan (1991-1995) for training users,
operators, and maintenance staff which serves as a guide to the
human resources development plan. 

  The documents that define the functions of maintenance
positions are in preparation; their implementation will be
carried out to coincide with the beginning of operations in the
workshops of the maintenance departments after approval by the
authorities of the Ministry of Health so as to be in accordance
with the wage policy, administrative procedures, and the next
reorganization of the Ministry of Health.

  High staff turnover persists in the maintenance sector for
financial reasons, as a result of which individual development
plans are not being made.  Training is being directed toward
support of prioritized equipment maintenance activities or of the
project's own activities (organization and administration of the
Department of Engineering and Maintenance) and basic training for
the personnel who still remain in their positions in the
hospitals.

  Seven courses had been planned during the year but only three
were carried out.  The rest were suspended to be replaced by ten
others directed toward providing basic general information about
electricity, electronics, motors, electrical systems, and boilers
with which it is hoped to increase the resolution capacity of the
hospitals and thus to reduce the deficit of qualified technicians
who joined the Occupation Conversion Plan.

  The Ministry of Health has only one engineer in the maintenance
sector and he is the Chief of the Department of Engineering and
Maintenance.  Recruiting professionals to train abroad and then
work in the Ministry of Health is very hard due to the difficulty
the health sector faces in paying adequate wages, which means
that professionals have not been sent abroad to be trained. 
There have been talks with the National University of Engineering
to determine the feasibility of launching a post-degree program
in hospital engineering, and the results have been promising.

  In-service training and equipment operation updating is being
given in the hospitals according to the particular needs of each,
and is supported from the central level in both materials and
technical assistance requirements. 

  A supplementary training plan for 1992 is being drawn up which
envisages, in addition to some additional training needs, what
will be a system of accreditation and also a review of the
objectives and content of the courses.

  With support from the Dutch Plan, an engineer with teaching
experience in training has been contracted to work in TECNOMEDIC
in managing and implementing the training programs in the
maintenance area.  The results are highly positive.

5.Manufacture of replacement parts, medical instruments, and
  small medical devices in the workshops of TECNOMEDIC.

  A program has been prepared to produce small equipment, and to
date there are designs, lists of materials, and needs in tools
for carrying out the program, as well as prototypes for testing
the equipment to be built.  TECNOMEDIC faced major financial
difficulties in 1991, however,  which made it impossible for it
to increase staff in the support workshops and carry out the
production program.


VII.INPUTS

  The Ministry of Health has contributed to the project:  the
director of the project, secretarial support, hospital support
(directors, administrators, chiefs of maintenance, and technical
personnel), financial support to undertake some smaller repairs
of equipment or installations, logistical support for local
purchases, legal support, supply of information, and other.

  The Pan American Health Organization has contributed technical
assistance for the general coordination of the project, general
administration of the project, general logistical support,
execution of local and international purchases, contracting of
services and technical assistance at the request of the Ministry
of Health, and part of the overhead costs, which has put at the
direct disposal of the Ministry of Health.

  For its part, FINNIDA has contributed through disbursement of
the programmed funds, a review mission in mid-September to
monitor the project, and the supervision of the Representative in
Nicaragua, who has been in continuous contact with PAHO and the
Ministry of Health.

  
VIII.   EVALUATION

  Because of the political, social, and economic factors which
the country experienced during the first six months, execution of
the project was a bit difficult.  However, the execution of a
considerable number of tasks directed toward preparing conditions
for those activities which are more complex, especially those
related to repair or replacement of equipment and the training of
personnel, is noteworthy.

  The execution of these programmed activities permitted:

  Obtaining complete designs for the maintenance workshops as
  well as offers of works execution, though it was found that the
  total costs exceeded the amount established by the project,
  which caused general revisions to be made in regard to areas of
  construction, materials, and construction methods in order to
  reduce costs.  Part of these have been covered by PAHO/WHO
  utilizing part of the project support costs, by direct order of
  the Director of the Organization.

  Purchase and distribution of tools for the maintenance
  workshops in the hospitals.  For this purpose, standard
  procedures for delivery to users were followed, with the
  participation of the administrators of the hospitals, the
  Department of Engineering and Maintenance, the Ministry of
  Health, PAHO/WHO, and the coordinator of each hospital.

  Provision of spare parts for the repair and maintenance of
  vacuum pumps, spectrophotometers, rotary clothing irons,
  operating lamps, and electronic parts for use in various pieces
  of equipment.  Part of the repair activities were carried out
  by technicians of the hospitals and others through TECNOMEDIC
  and expressly contracted private companies.  Moreover,
  microscopes and spectrophotometers were purchased to replace
  several devices discarded in the clinical laboratories of the
  hospitals.

  Acquiring general use manuals in the areas of electricity,
  operations research, electronics, computation, and mechanical
  engineering for carrying out the operational plans in the
  project's hospitals.  The purchase of operating manuals,
  service, and replacement parts for a large amount of apparatus
  is under way.

  In regard to the establishment of the program of preventive
maintenance, a system was installed directed toward prioritized
equipment using the methodology of the Department of Engineering
and Maintenance.  Basic materials (oils, lubricants, solvents,
and other materials of general use) were purchased, and the
result was that all the hospitals in the project initiated and
conducted their activities according to their 1991 programming.

  Concerning the training program aimed at personnel in the
maintenance workshops of the hospitals, activities were initiated
as programmed; however, because of the negative effects of the
Occupation Conversion Plan it was decided as an urgent measure to
redefine the initial program by orienting it to training the
personnel who still remain in the hospitals.

  Formation of personal professional in the area of hospital
equipment maintenance has not been possible because of the lack
of new positions for professional personnel in this sector, which
has caused training abroad not to be undertaken.

  The financial, legal, and management difficulties TECNOMEDIC
experienced during the year impeded the achievement of any
significant results in "increasing the rate of utilization of the
production workshops of TECNOMEDIC" and in "improving the cost
calculation system in the workshops of TECNOMEDIC."




       REGIONAL PROGRAM ON WOMEN, HEALTH, AND DEVELOPMENT

























Report Prepared by Jorge Díaz-Polanco.
    Professor and Investigator in the Area of Science and Technology at the Center
        for Development Studies (CENDES), Central University of Venezuela













 PAN AMERICAN HEALTH ORGANIZATION / WORLD HEALTH ORGANIZATION 





Washington, March 1992




CONTENTS


I-INTRODUCTION1

II-CONCEPTIONS ABOUT WOMEN, HEALTH, AND DEVELOPMENT3
1. Theoretical and Epistemological Aspects3

III-METHODOLOGICAL CONSIDERATIONS7
1. Subregions7
1.1. Andean Subregion7
1.2. Brazil7
1.3. English- and French-speaking Caribbean7
1.4. Spanish-speaking Caribbean7
1.5. Central America7
1.6. Southern Cone7
1.7. Mexico7
1.8. North America . . . . . . . . . . . . . . . . . .8
2. Priority Areas8
2.1. Health Profiles8
2.2. Processes of Health Technology Development8
2.3. Health Manpower9
2.4. Organization of Health Systems and Services9
2.5. Health Economics and Financing9
2.6. Organization of Environmental Sanitation Systems
and Services  . . . . . . . . . . . . . . . . . .9
2.7. Processes of Growth, Development, and Human
Reproduction. . . . . . . . . . . . . . . . . . .9
2.8. Health/Disease in the Adult Population9
2.9. Health and Work10
2.10. Health of the Elderly10
2.11. Women, Health, and Development10
2.12. Biotechnology10

III- RESEARCH ON WOMEN AT PAHO12
1. General Situation of Research at PAHO12
2. Proposals under WHD and Proposals with a Component 
on Women . . . . . . . . . . . . . . . . . . . . . . 15
3. The Role of Women in Research on Women21

III-CONCLUSIONS AND RECOMMENDATIONS26
1. Conclusions26
1.1. The Evaluation of Research26
1.2. Subject Matter Studied under WHD26
1.3. Characteristics of the Research Proposals27
1.4. Institutional Setting for Research27
1.5. Participation by Women28
2. Recommendations28

BIBLIOGRAPHY
    

     I-INTRODUCTION
     
     In August 1988 the PAHO Research Coordination Unit (DRC)
incorporated the area of Women, Health, and Development as one of
its priorities, specifying the research objectives in various
related documents.  This signified the formalization of research
activities in the area.
     With a view to ensuring the continuity of these activities,
documents have been prepared on theoretical and methodological
considerations. 
     Despite the fact that the subject of women, health, and
development is a current and vital issue, and notwithstanding the
research results to date, there is a certain ambiguity regarding
the specific issues to be studied in this area.
     Within the Organization the subject is approached from a
predominantly biomedical perspective, and, with very few exceptions,
a component on women appears in the plans of action and research
proposals that are presented to the various Regional programs for
consideration.  Nevertheless, a different perspective has developed
on the subject which tends to look at the social, cultural,
economic, and political determinants associated with the notion of
gender.  Consequently, the Regional Program on Women, Health, and
Development has become an eminently social Program that seeks to
have an impact on the overall situation of women through a specific
focus on health.  
     This characteristic makes it quite difficult to delimit the
subject matter to be treated in relation to WHD, a problem that does
not occur with the same intensity in other Programs of the
Organization, since they are guided by more precisely defined
criteria.  Thus, one of the most desirable contributions that
research in the area of WHD can make is to help establish a more
precise definition and delimitation of the subject matter, taking
into account the overall objectives of the Regional Program.
     The purpose of this report is to review, on the basis of
various criteria, the research proposals that have been submitted
for consideration by the Pan American Health Organization on the
subject of women, particularly in relation to Women, Health, and
Development, with a view to determining the broad general
characteristics of these proposals and forming an idea of how
research on the subject has been promoted and encouraged by the
Secretariat.  The report will begin by clarifying certain
methodological considerations so as to allow for a better
understanding of the rest of the document.  The second section will
summarize the principal theoretical and conceptual problems that
derive from the nature of the subject matter.  The third part will
discuss the general characteristics of research on women at PAHO. 
The fourth part will examine the evolution and characteristics of
proposals in the area of WHD and proposals with a component on
women.  Finally, a series of conclusions will be presented, followed
by recommendations on how to address the problems detected. 
    II-CONCEPTIONS ABOUT WOMEN, HEALTH, AND DEVELOPMENT

     As has happened in many other areas of scientific endeavor,
particularly in the social sciences, the way in which subjects
relating to women are approached has undergone an evolution, which
can be examined from two broad perspectives:  one theoretical and
epistemological, the other operational.  The first has to do with
the process by which the subject of women has been accepted as a
legitimate area of scientific study and with the incorporation of
women as legitimate participants in the field of science, while the
second concerns the impact of these changes on the different forms
that technical cooperation may take.  The two are inextricably
linked, and the first is an essential condition for the second.

     1. Theoretical and Epistemological Aspects

     The most radical epistemological currents propose a feminist
epistemology based on a move away from the positivism that dominates
the natural sciences--in other words an epistemological break with
positivist thought.  Within this current there are two main
variants:  the first, which holds that a "feminist science" would
introduce into the scientific domain "the sentiments inherent in
the female character and, in so doing, would reorient science itself
toward more humanitarian objectives" (Farganis, 1990; Jaggar, 1990;
Wilshire, 1990; Morantz-Sánchez, 1985); and the second, according
to which the struggle to affirm the role of women as the subject
and object of science is based a refusal to conform to a male ideal,
with the problem of gender differences being assimilated, sometimes
unconsciously, into a Marxist concept of class differences (Bleier,
1986; Bermann, 1990).
     A third position holds, from the viewpoint of positivist
science itself, that comparative case studies of men and women
reveal no differences in terms of superior abilities or achievements
by men in the area of scientific endeavor (Over, 1990; Jones, J.
and Wheatley, J., 1990; Kass-Simon, 1990; Kelly, 1979; PAHO/WHO (a),
1991).  
     The conception of women as protagonists in science is important
because, as will be seen further on, women are playing an ever
greater role in the creation and dissemination of knowledge in
today's world.

     The second perspective--which concerns forms of technical
cooperation--calls for a review of how the subject of women has been
approached in the field of health.  In this regard three distinct
phases can be identified.  The first places the subject of women
in the biomedical sphere, focusing on women's "maternal-
reproductive" problems.  It is typical in this phase for women to
be viewed from the epidemiological point of view, as a risk group. 
A second phase, rooted in the differentiation of sex and gender,
incorporates psycho-social considerations into the analysis of
women's issues, which in the field of health signifies specifically
the introduction of psychological concerns, particularly in relation
to female sexuality.  For example, the rediscovery of women by
psychiatry has come about as a result of recognition of the enormous
power of conception and childbirth.  In other words, the subject
of women is no longer addressed from a strictly biological point
of view but rather from a perspective that affirms the political
and creative potential that lies in the specific sexuality of women. 
This perspective can be found primarily in psychoanalytic currents.

     The third phase incorporates a social dimension into the
approach to women's issues.  This occurs through a process in which
the role of women's health in development is acknowledged--whence
the designation Women, Health, and Development.  This phase seeks
to identify the social, cultural, political, and economic
determinants of gender differences in historically determined
contexts.  It is for this reason that it is so difficult to delimit
the subject matter to be studied in WHD.  As long as women's health
is seen as a biomedical problem, albeit with psycho-social
"dimensions," it is considered sufficient to obtain data on health
issues, broken down by sex.  This development, as will be seen
further on, is important and plays a fundamental role in the
delivery of technical cooperation.  But the specific consideration
of women's issues from a gender perspective begins with an initial
discussion on the epistemological problem, continues with the need
for greater theoretical and methodological precision, and
culminates--but does not conclude--in the complexity of establishing
a conceptual definition and the difficulty of applying it.
     Important steps have been taken in this direction.  In the
health field the issue to be addressed is defined as the health gap
between the sexes in terms of opportunities and access to resources
that will ensure their well-being and human development.  This gap,
which is based on biological differences, is the historical result
of discriminatory attitudes and practices by individuals, society,
and institutions, and it hinders the enjoyment and equitable
exercise of civil rights by men and women.  The notions of male and
female thus reveal their extrabiological dimension, and the sphere
of action of the Regional Program thus encompasses activities aimed
at improving the health conditions of women and seeking the
progressive elimination of gender-related factors that have given
rise to discriminatory practices in terms of access to and use of
health care resources, thereby hindering the development of women's
real and potential capabilities.  The closing of these gaps will
result in more harmonious human development.  
     From the standpoint of research, this perspective requires a
new theoretical and methodological approach.  Gender differences
should not be assimilated into the class struggle, and neither
should they be seen as quantitative non-differences between the real
capabilities of men and women.  The historical-cultural and
political-economic dimensions represent a challenge that must be
faced at each moment in the implementation of proposals on Women,
Health, and Development.
    III-METHODOLOGICAL CONSIDERATIONS 

     The information presented in regard to research at PAHO was
prepared from the list of research proposals submitted to the
Organization for consideration and possible financing between 1985
and February 1992.  The information was provided by DRC and has been
classified by subregion and priority area.  The information
collected covers all the proposals presented during the period in
question, independent of their approval/rejection status, which is
specified when necessary.  It encompasses not only proposals that
are directly related to WHD but also proposals containing a
component on women that were submitted for consideration by experts
in other Regional programs, with or without the participation of
the Regional Program on Women, Health, and Development.  This group
of proposals is estimated to represent 10% of all the research
undertaken by PAHO. 
     1. Subregions
     The Subregions have been defined as follows: 
1.1. Andean Subregion: Bolivia, Colombia,
Ecuador, Peru, and Venezuela.

1.2. Brazil: Brazil is a subregion unto itself
since it includes a large proportion of both
the geographical area and the population of
South America.

1.3. English- and French-speaking Caribbean:
Antigua and Barbuda, Netherlands Antilles,
Barbados, Belize, Dominica, Guyana, Jamaica,
Haiti, Trinidad and Tobago, and Suriname.

1.4. Spanish-speaking Caribbean: Cuba and the
Dominican Republic.

1.5. Central America: Costa Rica, El Salvador,
Guatemala, Honduras, Nicaragua, and Panama.

1.6. Southern Cone: Argentina, Chile, Paraguay,
and Uruguay.

1.7. Mexico: A subregion unto itself for the
same reasons as Brazil, and to differentiate
it from the other countries of North America.

1.8. North America: Canada and the United
States of America.

     The research proposals are grouped according to this
geographical classification because it is the same one used in
Health Conditions in the Americas and because it makes it possible
to go beyond the national level in analyzing the data. 

     2. Priority Areas

     In 1988 the PAHO Research Coordination Unit (DRC) established
several priority areas in which research grants were to be awarded. 
This classification, which is presented below in summary form, is
used in this document to group the research proposals by subject
area.  
     2.1. Health Profiles:  Includes studies that, using easily
measured indicators based on the spatial distribution of poverty,
focus on the heterogeneity of morbidity and mortality profiles and
the health needs found in different local population areas, with
special emphasis on urban areas.
     2.2. Processes of Health Technology Development: Includes four
specific areas:
     - Supply of technology:  Transfer, production, and
     adaptation of technologies and products.
     - Demand for and use of technology:  Selection,
     dissemination, assimilation, coverage, and access to
     technology, as well as operation, conservation, and
     maintenance of equipment.
     - Technological development policies:  Includes the study
     of the legal-political, institutional, and financial
     instruments that have to do with the demand for and use
     of technologies.
     2.3. Health Manpower:  Focuses on personnel training issues
with a view to strengthening and integrating health services at the
local level.  Includes the following areas:
     - Labor market:  Supply and demand, structural conditions
     of the labor market in health.
     - Sociology of professions:  Political and ideological
     dimensions of health practices.
     - Work force and production:  Analysis of the
     effectiveness and productivity of work in the area of
     health.
     - Personnel training:  Methodologies for studying the
     integration of instruction and service and for continuing
     education.
     2.4. Organization of Health Systems and Services: Includes
research to support the development of local health systems in the
framework of decentralization.
     2.5. Health Economics and Financing:  Includes research that
examines the relationship between economics and health, especially
as regards the impact of the crisis, with a view to identifying
alternatives that will ensure equity, efficiency, and effectiveness. 
     2.6. Organization of Sanitation Systems and Services:  Includes
the following priority lines of research: 
     - Institutional factors that affect the quality and
     provision of environmental sanitation services.
     - Identification of critical technological deficiencies.
     2.7. Processes of Growth, Development, and Human Reproduction:
Research to determine the risk and protection factors associated
with these processes and to study the health services that exist
to address problems in this area. 
     2.8. Health/Disease in the Adult Population: In a frame of
reference that encompasses the social, cultural, economic, and
political conditions that affect adult health, research under this
heading focuses on the following: 
     - Evaluation of programs or models for health promotion
     among adults. 
     - Support for the planning and adaptation of services and
     technologies to meet the health needs of adults. 
     2.9. Health and Work:  Priority consideration is given to
proposals that address this issue from the following perspectives:
     - Analysis of the capacity of health services to develop
     workers' health programs.
     - Epidemiological surveillance in the area of workers'
     health.
     - Health problems of specific groups of workers.
     2.10. Health of the Elderly:  Includes consideration of the
biological, social, cultural, and economic aspects of the aging
process with a view to encouraging the formulation of policies and
plans.
     2.11. Women, Health, and Development: From a historical
perspective and taking into account cultural, social, economic, and
political factors, priority is given to proposals that have to do
with legislation and policies aimed at preventing discrimination
against and abuse of women; the influence that is exerted by women's
organizations in the design and implementation of policies that have
the potential to improve living conditions for women in society;
the identification of indicators that make it possible to determine
the contribution of women from different social backgrounds to
socioeconomic development; the incorporation of women in the work
force and the repercussions thereof on health; and the
identification and characterization of forms of violence against
women.
     2.12. Biotechnology:  This is a priority within the area of
Priority Technological Development.  Support is given to proposals
for the development and evaluation of methods to diagnose important
diseases using reagents that are available or that are to be
developed through the proposed research.

     The area of WHD is emphasized above in order to clearly show
that there are specific types of proposals that are considered under
this specific heading.  It is important to distinguish between
proposals that are submitted under the priority area of WHD and
proposals that contain what has been called a component on women
but are submitted under one of the other areas mentioned above. 
     In the data presented, when reference is made to proposals
under WHD, the proposals indicated were classified by DRC--by virtue
of the issues they addressed and their theoretical and
methodological approach--for evaluation by the Coordination of the
Regional Program on Women, Health, and Development on the basis of
the priorities discussed above, and, of course, the quality of the
research design and the feasibility of execution.  Proposals with
a component on women, on the other hand, are proposals that deal
explicitly with some facet of women's issues but are submitted for
appraisal by some other Regional program.  It is important to
clarify that these definitions are used exclusively for the purpose
of classifying proposals since, as was discussed in the previous
section, delimiting the subject matter to be studied can be quite
a complex task.
    III.  RESEARCH ON WOMEN AT PAHO

     1.  General Situation of Research at PAHO

     It was considered important to include in this report general
information on the research proposals submitted to PAHO for
consideration in order to be able to make some comparison with
respect to those submitted specifically on the subject of women.
     Table 1 shows all the research proposals received during the
period under consideration, classified by subregion as defined
above.
TABLE 1

    PERCENTAGE DISTRIBUTION BY SUBREGIONAL ORIGIN OF PROPOSALS
RECEIVED FROM 1985 TO 1992(*)


    SUBREGION             N      %     

    Andean                 91   13.9    
    Brazil                134   20.5    
    F-E Caribbean          16    2.4    
 Sp. Caribbean          58    8.9 
    Central America        41    6.3    
    Southern Cone         191   29.2    
    Mexico                104   15.9    
     North America          19    2.9     

    TOTAL                 654  100.0   

(*) Information as of 02/12/92
Source: PAHO/DRC. Washington, February 1992


     More than 60% of all proposals originate in the Southern Cone,
Brazil, and Mexico.  However, it is interesting to note statistics
on acceptance and rejection of these proposals by the Committees
responsible for evaluating them.
     Table 2 reflects the statistics on approval or rejection of
proposals by subregion, with the percentages for each one.
TABLE 2

    PERCENTAGE DISTRIBUTION OF THE PROPOSALS RECEIVED FROM 1985
TO 1992 BY STATUS AND SUBREGION (*)

APPROVED    REJECTED        OTHER 


    SUBREGION               N   %       N    %       N     %


    Andean                 27  29.7    54   59.3    10   11.0
    Brazil                 37  27.6    87   64.9    10    7.5
    F-E Caribbean          10  62.5     6   37.5     0    0.0
    Sp. Caribbean          18  32.7    34   61.8     3    5.5
    Central America        16  39.0    21   51.2     4    9.8
    Southern Cone          48  24.6   128   65.6    19    9.7
    Mexico                 27  26.2    69   67.0     7    6.8
    North America           5  26.3    13   68.4     1    5.3


    TOTAL                 188  28.7   412   63.0    54    8.3


(*) Information as of 02/12/92
Source: DRC\PAHO\WHO, Washington, D.C., February 1992

     As can be seen from the preceding table, the ratio of total
proposals approved to total proposals received is much higher for
the English- and French-speaking Caribbean (62.5%) than for the rest
of the subregions; it is followed by Central America (39.0%), the
Andean Subregion (29.7%), and Brazil (27.6%).

     It is also interesting to note the proportion of proposals that
are approved in each of the priority areas established by PAHO. 
Table 3 shows the percentage distribution of proposals approved in
relation to the total received in each of the priority areas.
 TABLE 3

RATIO OF PROPOSALS APPROVED TO PROPOSALS SUBMITTED
    IN EACH PRIORITY AREA, 1985-1992 (*)

  % OF PROPOSALS
    PRIORITY AREAS                 APPROVED 
 
    Health Profiles                 34.9
    Processes of Tech. Dev.         30.8
    Political Processes and Health  25.0
    Health Manpower                 37.3
    Org. of Health Services/Systems 13.9
    Health Economics and Financing  37.5
    Org. of Sanitation Serv./Sys.   51.7
    Growth, Dev., and Human Repro.  25.7
    Health/Disease in Adults        25.0
    Health and Work                 26.5
    Health of the Elderly           25.0
    Scientific Activity in Health  100.0
    Women, Health, and Development  12.5
    Biotechnology                   43.3

    % IN ALL AREAS                  28.7

     (*) Information as of 12/02/92
Source: DRC\PAHO. Washington, February 1992 
     It should be noted that the lowest percentages are in the areas
of Women, Health, and Development and Organization of Health
Services and Systems.  In other areas the proportion of proposals
approved ranges from 25% to 50%.  The proportion of 100% in the area
of Scientific Activity in Health reflects the fact that only five
proposals were submitted and these were part of a PAHO multicenter
research project which, because it is relevant to the subject matter
being discussed in this report, will be described below. 
     With regard to the percentages of proposals approved by
priority area and by subregion, this information is presented in
Chart I, with percentages for the period 1985-1992.
CHART I

PERCENTAGE OF PROPOSALS APPROVED BY PRIORITY AREA AND SUBREGION,
1985-1992(*)PRIORITY AREAS
Andean
BrazilE-F Carib-bean 
Sp.
Carib-bean
Central America
Southern Cone

MexicoNorth America 
% BY  
AREASHealth Profiles    37.5 50.0 100.0 40.0 -33.7 14.3 0.0 34.9 Processes of Technological Dev. 100.0 50.0 100.0 0.0 -38.5 42.9 -30.8 Political Processes and
Health 20.0 25.0 --0.0 40.0 0.0 -25.0 Health Manpower55.6 25.0 -100.0 66.7 27.3 30.0 -37.3 Org. of Health Services and Systems21.4 8.7 -16.7 20.0 10.0 15.8
16.7 13.9 Health Economics and Financing 0.0 40.0 100.0 --33.3 33.7 -37.5 Org. of Sanitation Services and Systems50.0 60.0 66.7 50.0 75.0 20.0 33.7 100.0
51.7 Growth, Devt., and Human Repro.  38.5 25.0 66.7 30.0 20.0 18.2 19.0 33.7 25.7 Health/Disease in Adults20.0 42.9 33.7 21.4 28.6 16.7 23.1 25.0 25.0
Health and Work15.4 16.7 100.0 40.0 100.0 17.9 50.0 -26.5 Health of the Elderly0.0 0.0 -66.7 100.0 37.5 0.0 0.0 25.0 Scientific Activity in Health100.0
100.0-100.0 -100.0 100.0 -100.0 Women, Health, and Development0.0 0.0 ---28.6 0.0 -12.5 Biotechnology28.6 60.0 -33.7 0.0 55.6 40.0 -43.3 % BY
SUBREGION29.7 27.6 62.5 32.7 39.0 25.1 26.0 26.3 28.7
     (*) Information as of 02/12/92
     Source: DRC\PAHO\WHO. Washington, D.C. February 1992

     One of the partial conclusions that can be drawn on the
basis of the data presented thus far is that the percentage
of proposals approved is quite low for all subject areas and
subregions.

2.  Proposals under WHD and Proposals with a Component on
Women

     Taking into account the conceptual clarifications made
above, the following figures and tables reflect the situation
of research on women at PAHO.  Figure 1 shows the proportion
of proposals under WHD, as well as proposals with a component
on women, in relation to the total number of proposals
received.
GRAPH 1


PROPOSALS UNDER WHD AND PROPOSALS WITH A COMPONENT ON WOMEN 
IN RELATION TO ALL OTHER AREAS 


























     Source: DRC\PAHO\WHO. Washington, 1992.



     Only 2.2% of all proposals fall under WHD, while 9.8% of all
proposals have a component on women.
     Table 4 shows proposals with a component on women and
proposals under WHD, by approval/rejection status and priority
area.




TABLE 4

      PROPOSALS WITH A COMPONENT ON WOMEN AND PROPOSALS UNDER WHD
BY STATUS AND PRIORITY AREA, 1985-1992 (*)

STATUS


Received   Approved    Rejected    Other 


PRIORITY AREAS                    N   %      N   %      N   %      N   %


    Health Profiles               2   2.7    0   0.0    2 100.0    0   0.0
    Health Manpower               3   4.1    0   0.0    2  66.7    1  33.3
    Org. of Health Systems/Serv.  1   1.4    1 100.0    0   0.0    0   0.0
    Growth, Dev., and Human Repr.28  38.4    8  28.6   17  60.7    2   7.1
    Health/Disease in Adults     11  15.1    2  18.2    8  72.7    0   0.0
    Health and Work              11  15.1    2  18.2    7  63.6    2  18.2
    Health of the Elderly         1   1.4    1 100.0    0   0.0    0   0.0
    Women, Health, and Develop.  16  21.9    2  12.5   12  75.0    2  12.5


    TOTAL BY STATUS              73 100.0   16  21.9   48  65.8    7   9.6

 
    (*) Information as of 12/02/92.
    Source: PAHO\DRC. Washington, February 1992.


     Note that this table includes 16 proposals under the heading
of Women, Health, and Development, which are understood to be
included among the proposals with a component on women.
     It should be noted that the percentage approval of proposals
relating to women is lower (21.9%) than for all proposals in all
areas (28.7%).  If the 16 proposals under WHD were excluded, the
percentage approval would rise to 24%, which is closer to the
percentage for all proposals. 
     The following table presents these same figures for
proposals specifically classified under the priority area of
Women, Health, and Development.
TABLE 5

    PROPOSALS UNDER WHD BY STATUS AND SUBREGION, 1985-1992(*)

STATUS 


Received    Approved    Rejected    Other


    SUBREGION         N   %       N   %       N   %       N  
%



    Andean            4  25.0     0   0.0     4  33.3     0  
0.0
    Brazil            2  12.5     0   0.0     2  16.7     0  
0.0
    Southern Cone     7  43.8     2 100.0     4  33.3     1  50.0
    Mexico            3  18.8     0   0.0     2  16.7     1  50.0



    TOTAL            16 100.0     2 100.0    12 100.0     2 100.0


    (*) Information as of 02/12/92
    Source: DRC. PAHO/WHO, Washington, D.C., 1992


     Proposals were prepared specifically in relation to WHD in
only four of the subregions, and the only Subregion that
succeeded in having any proposals approved was the Southern Cone.
     It is important to note that only 12.5% of all proposals
under WHD are approved against the similarly low figure of 21.9%
(or 24.0% if the proposals under WHD are excluded) for proposals
that include a component on women (Table 4).  The contrast is
even more striking when the WHD percentage is compared to the
percentage approval for all proposals (Tables 1 and 2).  
     As for distribution of the proposals over the time period
studied, only one proposal was received from 1991 to February
1992, while fifteen were received during the 1985-1990 period. 
This distribution over time is shown in Figure 2, in relation
to the rest of the proposals with a component on women.
FIGURE 2


Source: DRC\PAHO\WHO. Washington, D.C., February 1992
(*) Information as of 02/12/92


     It should be borne in mind that for all the data presented
herein, the information on 1992 corresponds only to January and
February.  It is expected that there will be an increase in the
number of proposals with a component on women that are received
if the trend noted prior to 1990 continues.
     It is particularly interesting to consider the specific
subject areas covered by the proposals with a component on women
and those under WHD.  Table 6 shows the distribution of proposals
by specific subject area during the period considered.
TABLE 6
    PROPOSALS UNDER WHD AND PROPOSALS WITH A COMPONENT ON
WOMEN, 
    BY SUBJECT AREA, 1985-1992 (*)


  SPECIFIC AREAS              N       %

    Occupational Health       17     23.3
    Reproductive Health       35     47.9
    Adult Health               8     11.0
    Violence                   5      6.8
    Health Services Devt.      7      9.6
    Manpower Development       1      1.4

    TOTAL                     73    100.0

    (*) Information as of 02/12/92
    Source: DRC\PAHO\WHO, February 1992


     The data included here show that more than 70% of proposals
on women are concentrated in the areas of occupational health
and reproductive health, which is consistent with what was seen
in relation to the priority areas.  Table 7 shows the
distribution of proposals by status.
TABLE 7
   PERCENTAGE DISTRIBUTION OF PROPOSALS UNDER WHD AND
PROPOSALS WITH A COMPONENT ON WOMEN BY SPECIFIC AREA AND
STATUS, 1985-1992(*)



    SPECIFIC AREA       Approved  Rejected   Other


    Occupational Health     23.5     76.5      0.0
    Reproductive Health     23.5     61.8     14.7
    Adult Health            12.5     87.5      0.0
    Violence                40.0     60.0      0.0
    Health Services Devt.   14.3      6.6     14.3
    Manpower Development     0.0     50.0     50.0


    (*)Information as of 02/12/92
    Source: DRC\PAHO\WHO. Washington, February 1992

     The highest percentage of proposals was approved for the
study of violence (i.e., violence against women), reflecting the
priority assigned to this subject under the WHD Program.  It
should be taken into account that this is quite a new subject
area for research and only five proposals have been presented. 
Of these, two have been approved.
     It could be concluded that the percentage approval of
proposals under WHD is quite low--only 12.5% of all the proposals
received.  In fact, it is the lowest figure of all the priority
areas, consistent with the proportion of such proposals in
relation to the total received (Figure 1).  
     As regards the content of the proposals, it is noteworthy
that a significant proportion continue to be formulated in the
areas of reproductive health and occupational health, which
points up the conception of women as a "risk group" without
regard to the social dimension of women's health problems.  The
same observation could be made for the proposals formulated in
the area of adult health.     The fact that proposals are being
formulated on violence is important, particularly since a gender
approach must almost always be adopted if this problem is to be
truly understood.  Proposals in the areas of health services and
human resources also offer the opportunity for introducing gender
perspectives in the explanation of women's health problems. 

     3.  The Role of Women in Research on Women

     One of the ways in which a profile can be constructed of the
research proposals received by any institution that finances and
promotes research is on the basis of the characteristics of the
principal investigators and their institutional affiliation. 
Although the information presented here is not averred to be
sufficient or exhaustive in this respect, an analysis will be
made of the principal investigators by sex and by type of
institution with which they are affiliated.
     Table 8 presents this information in relation to the
proposals with a component on women that were received by PAHO.
TABLE 8

      PROPOSALS WITH A COMPONENT ON WOMEN RECEIVED AND APPROVED, BY 
      INSTITUTIONAL AFFILIATION AND SEX OF PRINCIPAL INVESTIGATOR, 
1985-1992 (*)

SEX OF PRINCIPAL INVESTIGATOR

MALE             FEMALE       


TOTAL PER    % PER
    SPONSOR                Rcvd.  App.1 %      Rcvd.   App.1 %   AFFILIATION  AFFILIATION


    Government         5     2  40.0    12     2  16.7     17   23.3
    Universities      13     5  38.5    13     3  23.1     26   35.6
    Research Inst.    12     4  33.3    13     3  23.1     25   34.2
    Health Service     2     2 100.0     2     2 100.0      4    5.5
    Other              1     -   0.0     -     -   -        1    1.4


    TOTAL             33    13  39.4    40    10  25.0     73  100.0


    (*) Information as of 12/02/92
    1 Approved proposals include those classified as "other."
    Source: DRC\PAHO, Washington, D.C., February 1992

     Almost 70% of the institutional affiliations are
universities and research institutes, with health service
affiliation representing quite a low percentage (5.5%).
     As for sex of the principal investigators, though women
submit more proposals than men, the proposal approval rate is
higher for men than for women (39.4% for men, 25.0% for women),
which leads to the following noteworthy considerations.
     In a recent study concluded at the end of 1991 it was found
that in the countries that account for more than 90% of
scientific production in the Region the majority of investigators
in the area of health area are women.  In countries where this
is not the case, women represent almost half of the total.  In
other words, female participation in research, especially when
considered over time, is growing.  What is not clear from the
aforementioned study is the position of women in terms of control
over the proposals.  A review of some of the data available
suggests two important points (among others):  first, it is only
relatively recently that women that have come to account for the
majority of investigators; and second, in the countries that have
the largest number of women engaged in health research, in
previously male-dominated fields such as biomedical research more
than 50% of the investigators are now women.
     This information is interesting from the following
standpoint:  it can be assumed that the same phenomenon is
occurring in the area of research on women and health, where most
proposals are submitted by female principal investigators;
however, the profile of the subject areas covered by those
proposals does not reflect the impact of the "feminization" of
research.  This can be seen in Table 3, which indicates that
almost 70% of the proposals received were concentrated in areas
that do not necessarily incorporate a gender perspective.
     One possibility would be to introduce the subject of women
from a different perspective, one that is more typical of what
is now understood as WHD.  If a whole set of variables that
intervene in this process were controlled--for example, financing
and institutional affiliation of the investigators and proposals-
-there would be a certain basis for affirming that the
"feminization" of research could have an impact on the selection
of subject matter and thus on the orientation of research.
     Findings from the study cited above reveal that the
feminization of health research is taking place through a process
of substitution, i.e., new generations of health professionals,
and thus potential investigators, include an increasing number
of women.  These women will eventually replace the men who are
currently engaged in research, who are aging and will therefore
soon be leaving the profession.
     In this connection, Tables 9 and 10 below show the
distribution of research proposals by sex of the principal
investigator. 

TABLE 9
    DISTRIBUTION OF THE PROPOSALS RECEIVED BY SEX OF THE
PRINCIPAL INVESTIGATOR AND BY SUBREGION, 1985-1992 (*)

MALES      FEMALES          
TOTAL FOR
    SUBREGION           N     %     N     %   SUBREG.


    Andean               57  62.0    35  38.0       92
    Brazil               67  59.3    46  40.7      113
    E-F Caribbean         9  52.9     8  47.1       17
    Sp. Caribbean        29  60.4    19  39.6       48
    Central America      22  55.0    18  45.0       40
    Southern Cone       137  67.8    65  32.2      202
    Mexico               67  54.5    56  45.5      123
    North America        15  78.9     4  21.1       19


    TOTAL BY SEX       403  61.6   251  38.4      654


    (*) Information as of 02/12/92
    Source: DRC\PAHO\WHO, Washington, D.C., 1992

     Although as regards the proposals submitted to the PAHO
grants program there continue to be more male than female
principal investigators, in some subregions the percentages of
females approaches that of males.  It should also be taken into
account that these proposals are representative of only a small
portion of all the research being conducted in the countries.


Table 10 presents the foregoing information classified by
priority area.

TABLE 10
DISTRIBUTION OF THE PROPOSALS RECEIVED BY SEX OF THE
PRINCIPAL INVESTIGATOR AND BY PRIORITY AREA, 1985-1992 (*)

MALES      FEMALES 

 TOTAL PER
    PRIORITY AREAS                N     %     N     %   AREA


    Health Profiles                47  82.5    10  23.8   57
    Proc. of Technological Dev.    20  76.9     6  23.1   26
    Proc. Politics and Health      13  56.5    10  43.5   23
    Health Manpower                54  71.1    22  28.9   76
    Org. of Health Systems/Servs.  70  68.6    32  31.4  102
    Health Econ. and Financing     10  62.5     6  37.5   16
    Org. Sanitation Systems/Servs. 27  75.0     9  25.0   36
    Growth, Dev., Human Repro.     56  48.7    59  51.3  115
    Health/Disease in Adults       53  62.4    32  37.6   85
    Health and Work                53  70.7    22  29.3   75
    Health of the Elderly           9  56.3     7  43.8   16
    Scientific Activity in Health   1  20.0     4  80.0    5
    Women, Health, and Development  6  37.5    10  62.5   16
    Biotechnology                  21  58.3    15  41.7   36

    TOTAL BY SEX                      440 
64.3   244  35.7  684


    (*) Information as of 02/12/92
    Source: DRC\PAHO\WHO, Washington, D.C., 1992

     Here it can be observed that in certain areas the majority
of principal investigators are women--specifically in the areas
of Growth, Development, and Reproduction, and Women, Health, and
Development.  With respect to Scientific Activity in Health, as
was indicated above, this area includes only five proposals,
which are interrelated.  There is also a significant female
presence in the area of Political Processes and Health.  
     What should be emphasized here is that the field of health
research has come to have a high level of female participation,
and this trend does not appear likely to be reversed in coming
years.  It would seem that the feminization of scientific work
in the area of health should be seen as a condition that needs
to be taken into account when planning the delivery of technical
cooperation for the production of knowledge from the perspective
of Women, Health, and Development.  This idea will be expanded
below.III-CONCLUSIONS AND RECOMMENDATIONS

     1. Conclusions

     1.1. The Evaluation of research: The figures presented in
this report on the percentages of proposals approved and rejected
appear to point in two directions.  The first has to do with the
quality and relevance of the proposals submitted to the
Secretariat, which could help to explain why less than one-
third of all the  proposals received are ultimately approved. 
More in-depth consideration could be given to this matter by
examining the reasons for rejection or approval as reflected in
the proceedings of meetings of the evaluating committee. 
     The second has to do with how--once the above-mentioned
criteria are known--the proposals submitted are appraised, what
scientific requirements are imposed, and what criteria are used
in judging them.  However, this is a task that corresponds to
other entities; it is mentioned here only because it affects the
area with which this report is concerned.  As was seen above,
although the proposals formulated specifically under WHD account
for a very small percentage of the total, if the situations
mentioned above were closely examined it would be clear that they
also affect these proposals. 
     1.2. Subject matter studied under WHD: In classifying the
proposals by priority area it has been considered that the
proposals that fall under the heading of WHD are those that have
been submitted to the Regional Program on WHD for evaluation. 
However, as was stated at the outset, owing to the eminently
political and social nature of the perspective adopted by the
Regional Program, its sphere of action has not been precisely
defined, nor is it expected that it can be, given this
orientation.  However, each proposal, in its formulation and
execution, contains elements that contribute theoretically,
methodologically, and empirically to progress toward such a
definition.  This characteristic of the social disciplines should
be taken into account in the formulation of research proposals
in this area.
     1.3. Characteristics of the research proposals:  The way in
which women's issues are approached in the proposals submitted
continues to reflect a mainly biomedical focus.  Proposals under
the area of WHD represent less than 3% of all proposals received,
while three of the areas traditionally linked to biomedical
approaches account for almost 70% of all proposals submitted for
consideration.  Within these areas, the area of Growth,
Development, and Reproduction accounts for almost 40% of the
total.  These figures serve to illustrate the biomedical bent
of the most of the proposals.  A gender perspective needs to be
cultivated first in the areas that are considered most propitious
for this purpose.  In this regard, the analysis of the breakdown
of the specific areas in which proposals on women were formulated
provides an idea of what these strategic priority areas should
be.
     With respect to the number of proposals approved, although
there was a significant increase from 1989 to 1990, and while
it is expected that this trend will continue through the end of
the year, the percentage of proposals approved continues to be
low.  
     1.4. Institutional Setting for Research: The work of
producing knowledge about women continues to be an eminently
academic task that is undertaken by research institutes and
universities.  This in itself does not constitute a problem;
however, it is considered that one important indicator of the
impact of research promotion in the field of women's health
should be the formulation of an increasing number of proposals
within the governmental offices of the sector and the health
services.  It would appear that only limited progress has been
made toward this objective.  There may be a sort of institutional
sequence over time, in the sense that the substantive discussions
about theoretical and methodological questions relating to the
subject must first take place in an academic setting and then
be generalized to other spheres of scientific endeavor in the
field of health.  In any case, this sequence might be important
in terms of what was stated under point 1.1. above, and, of
course, with regard to the stimulation of possible interest in
the subject at other types of institutions, especially those
related directly or indirectly to the health sector.
     1.5. Participation by Women: The relatively low levels of
participation by women in the formulation of proposals at PAHO
is illustrated by the data on principal investigators by
subregion (Table 9).  The significance of this situation was
discussed above, as were the implications thereof and the
contrasts with regard to the processes of producing knowledge
about health in the Region in general.  This suggests a series
of hypotheses that might be of interest to investigators and also
points up the need to delimit the problem by identifying all the
variables that are influencing how women produce knowledge about
their own reality.

     2. Recommendations

     2.1. In view of the low percentage of proposals that are
submitted and approved under WHD, it is recommended that a
special effort be made to promote research in this area, that
a closer look be taken at the reasons for rejection or approval
of proposals, and that there be an examination of the
orientations on the basis of which proposals are prepared, taking
into account the relative newness of this area as a topic for
research, as well as the lack of conceptual and methodological
precision.
     2.2. There is a need for greater reflection and discussion
about the theoretical and methodological implications of research
on the subject of Women, Health, and Development.  It is
necessary to begin by creating opportunities for such discussion,
including the organization of at least one meeting during the
current year to bring together experts in the area for the
purpose of formulating conclusions and recommendations on the
gender approach to issues relating to Woman, Health, and
Development.  It is specifically proposed that a meeting--
tentatively titled "Theoretical and Methodological Orientations
for Research on WHD"-- be held, possibly next June, in Caracas,
Venezuela.
     2.3. Research centers that study women should be identified
and a data base, compiled, including information on these
centers' characteristics, production, orientations, and areas
of expertise, with a view to developing strategies for
supranational, multicenter, and interinstitutional cooperation
at the subregional and Regional levels in order to enrich the
theoretical-methodological discussion and to promote
collaboration for the formulation of more significant and higher
quality proposals.  The Regional Program has at its disposal the
initial elements needed to develop such a data base and design
the strategies required.  It is proposed that this task be one
of the cooperation targets for the 1992-1993 biennium.
     2.4. There appears to be a need to partially redefine the
priorities established in the area of WHD, taking into account
the specific areas in which proposals having to do with women
are formulated.  Work from a gender perspective in an area such
as occupational health, for example--especially in view of the
fact that 1992 is the Year of Workers' Health--would make it
possible to change the perspective from which proposals are
formulated.  This subject can also be linked to Manpower
Development and Health Services Development, bearing in mind the
objectives of the Regional Program on WHD.  It would be desirable
to include this topic on the agenda of the meeting proposed for
June.
     2.5. The examination of research in the area of WHD appears
to be increasingly important in the determination of
participation by women in the process of producing knowledge. 
Although it appears that the administration of health research
will tend to be in women's hands in coming decades, this trend
does not suffice to guarantee that a gender perspective will be
adopted in research on women.  A very special effort will be
needed to generate awareness in this regard and to thus have an
impact on the thematic and disciplinary profile of scientific
production in the area of WHD.  We propose that a special effort
be made to encourage proposals that, while meeting requirements
for high scientific quality, will address these issues.BIBLIOGRAPHY 

Baer, D. and D. Bositis.  Biology, gender and politics:  an
assessment and critique. Women and Politics 3: 29-52, 1983. 

Barganis, S.  Feminism and the reconstruction of social scien-
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ge. Rutgers University Press, 1990.

Barroso, C, and Y. Ingianna. Mujer, Salud y Desarrollo. 
Washington, D.C., PAHO\WHO, July 1989.

Benjamin, M. Science and Sensibility: Gender and Scientific En-
quiry. Cambridge, 1991. 

Berman, R. From Aristotle's dualism to materialist dialectics:
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1992.

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Initiative "1992:  Year of Workers' Health"















COOPERATION OF THE PAN AMERICAN HEALTH ORGANIZATION
IN WORKERS' HEALTH


Contents

Introduction
Cooperation Provided by the PAHO/WHO Representations
General Characteristics and Mechanisms of Cooperation
Interprogram Cooperation
Cooperation Provided by the Workers' Health Program 
Events to be Held in Connection with the Initiative
Publications








Working Document

Programs of the PAHO/WHO Representations (in preparation)
Interprogram Cooperation (undergoing revision)                                                                            March 1992

     COOPERATION OF THE PAN AMERICAN HEALTH ORGANIZATION
IN WORKERS' HEALTH



PAHO AND COOPERATION IN WORKERS' HEALTH

In the PAHO/WHO Representations (general support
and actions by the Focal Point for Environmental and
Occupational Health)

Through general activities (sharing of 
information and knowledge, training,
fellowships, research, intercountry initiatives,
intercountry cooperation)

Through the activities of various programs

Through the Program on Workers' Health
(coordinated by Environmental Health)


1.         INTRODUCTION
Cooperation in the area of workers' health will be examined in terms of general
PAHO cooperation and the specific capacity of the Program on Workers' Health.

-          The Pan American Sanitary Bureau was established on 2 December 1902 with the
proposed objective of achieving improved sanitary conditions in the countries of
the Americas.

-          The cooperation provided by PAHO in the area of workers' health falls within the
context of Health for All (HFA 2000) and the primary health care strategy,
designed to benefit the entire population, including the working age population (14
years of age and over), which in Latin America and the Caribbean comes to more
than 55%.  The efforts to be expended by the programs in the areas of health
systems infrastructure and health development are enormous, since 43% of the
population does not have access to health services and less than 10% of the workers
have general coverage that includes health promotion, maintenance, and the
prevention of negative effects on health as well as the usual curative and
rehabilitative care and financial benefits in the event of work-related disability.

2.         COOPERATION PROVIDED BY THE PAHO/WHO REPRESENTATIONS

Workers' health stands to benefit from the cooperation provided the countries
through their PAHO/WHO Representations located in all the countries of Latin America
and in many of the Caribbean countries, which have a Focal Point for Workers' Health
that is usually also the Focal Point for Environmental Health, as well as from the support
provided by certain basic actions of the Organization.

-          The cooperation provided by the PAHO/WHO Representations in workers' health
is also supported by the collaboration provided by the Program at Headquarters and
by the mechanisms referred to in the section below.


3.         GENERAL MECHANISMS OF COOPERATION

-          Dissemination of knowledge (via PAHO/WHO publications, bibliographic
resources and libraries, and advisory services upon specific request).

-          Fellowship programs, which can support the training of experts in workers' health
when the countries consider this to be a priority.

-          Awards under the Organization's Research Grants Program, when high-
caliber proposals are presented that meet the requirements and correspond to areas
identified as having priority for workers' health.

-          In the context provided by the subregional initiatives (Andean, Central American,
Southern Cone, and Caribbean).

-          In the context provided by the intercountry cooperation initiatives.

-          Through the program responsible for resource mobilization, which can assist the
countries in identifying cooperation agencies and in establishing bilateral
cooperation plans.

-          Through the various programs under the area of Health Systems Infrastructure and
under Health Programs Development.






4.         INTERPROGRAM COOPERATION

Activities to be carried out in 1992 as defined by the PAHO Interprogram Group
on Workers' Health:

All the PAHO programs will arrange to undertake activities that are specifically
oriented toward workers' health.  Considerations related to workers' health will be
included in all publications, meetings, courses, and other activities.  Efforts will be made
to ensure that the agendas of congresses and other events include topics relating to
workers' health.

As a mechanism for promoting activities in the countries and as an indication of
the support being given to all the programs, Headquarters staff, in their missions to the
countries, should address matters in the area of workers' health.

The Annual Report of the Director will stress workers' health (contact Dr. Teruel -
 Magdalena Collins).

DAP        Analysis and Strategic Planning Coordination

-          Evaluation of compliance with Resolution XIII of the XXIII Pan American
Sanitary Conference on Strategic Orientations and Program Priorities in the area
of workers' health.

DEC        External Relations Coordination

-          Collaboration on, and revision of, plans and projects to be distributed for purposes
of resource mobilization.

-          Identification of agencies with interest in workers' health, and support for a
meeting specifically aimed at mobilizing resources for workers' health.

-          Preparation of a document on the economic and social importance of workers'
health and on the priority it represents for PAHO, as evidenced by the approval of
Resolution XIII.  Transmittal of the document to IDB and other agencies to
promote consideration of this component in cooperation projects (jointly with
WH).

-          Identification of PAHO projects currently under way in which it is would be
appropriate to include a component on workers' health (jointly with WH).


DPI        Information and Public Affairs 

-          Development of a logo for the Year of Workers' Health.

-          Development of a workers' health component for inclusion in the video unit on
environmental health to be exhibited at Expo 92.

-          Reference to 1992 as the Year of Workers' Health in photographic displays on the
health situation in the Americas and in the section on PAHO in the pamplet for the
Inter-American Exhibit.

-          Reference to the Year of Workers' Health and the subject of workers' health as part
of World Health Day and World No-Tobacco Day (and in any another material
being distributed to the public).

-          Promotion of the Year of Workers' Health in connection with celebration of the
90th Anniversary of PAHO.

-          Identification of strategies and sources of assistance for promotion of the Initiative.

-          Collaboration in optimizing the use of the mass media.

DRC        Research Coordination

-          Promotion of multicenter projects on health and labor, to be totally or partially
financed by the Research Grants Program.

PED        Emergency Preparedness and Disaster Relief

-          Interprogram development of actions to prevent and mitigate disasters in the
workplace, especially in industries that deal with chemical substances and
radioactive materials.

-          Training of health workers in selected hospitals on how to prepare for a disaster. 
Dissemination of the series on safety in hospitals.

PWD        Women, Health, and Development

-          Inclusion of the subject "Woman, Work, and Occupational Health" on the agenda
of the XII Meeting of the Special Subcommittee on Women, Health, and
Development.

-          Preparation of a technical document for analysis and consideration at this meeting
(costs to be shared).


HBI        Scientific and Technical Health Information

-          Publication of an issue of the Boletín de la OPS devoted to workers' health.

-          Compilation of articles for publication in issues of the Boletín and the PAHO
Bulletin to be published in 1992.

-          Inclusion of the logo and other news related to workers' health in issues of the
Boletín.

-          Examination of the feasibility of producing publications on workers' health based
on materials developed by the Program.

HSD        Health Services Development

-          Preparation of a document on workers' health in local health systems, dealing with
the integration of activities in this area into the health services and into the local
health system process (costs to be shared).

-          Joint working and interprogram meetings to decide on content and strategies for
incorporating the workers' health component into the planning and implementation
of local health systems and the health services.

-          Support for research on the development of workers' health in local health systems.

-          FEPPEN in Argentina, Ecuador, and Uruguay is carrying out studies on health and
labor that are currently in various stages of execution (Mrs. Land to give a progress
report).

HSM        Health Manpower Development

-          Incorporation of a component on workers' health into the training program in
international health.

-          Workshop on human resources in occupational health.

-          Preparation of basic documents on health information, occupational health training,
and prevention in the workplace at various levels of instruction.

-          Meeting to be organized with the collaboration of the Ministries of Education.

-          Publication of a document on health information and occupational health training
at various levels of instruction.

-          Meeting of the Schools of Public Health devoted exclusively to training in workers'
health.

-          Meeting of the Schools of Medicine of Mexico to identify teaching curricula and
methodologies to be used for the development of workers' health (jointly with WH
and PWR Mexico).

-          Preparation of a publication on workers' health and the health services (Textbook
Program).

-          Publication of an issue of Educacíon para la Salud devoted to workers' health.

HSP        Health Policies Development

-          Preparation of a document on policy guidelines for workers' health.

-          Incorporation of the subject of workers' health in activities to be carried out with
lawmakers at the national and regional level (Health Commission of the Latin
American Parliament; Committee on the Environment of the Andean Parliament).

-          Intercountry seminar organized jointly with ILO to analyze the problem of regional
integration (MERCOSUR, NAFTA, etc.) and its implications for workers' health.

-          Preparation of basic documents on:

The concepts of work/workers' health; structural changes and transformations in
the labor market and health.

-          Promotion of relations between social security and health institutions and agencies
that provide compensation for accidents and insalubrious working conditions.

-          Promotion of the relationship between the subject of workers' health and the
departments of occupational safety and health in the Ministries of Labor.

-          Promotion of the analysis of various alternatives for strengthening the development
of workers' health jointly with representatives of workers, employers, and various
sectors.

HST        Health Situation and Trend Assessment

-          Study on health and living conditions with employment as an important variable. 
Emphasis will be on workers' health and employment status--formal, informal, or
independent--and on the work of minors (study expected to be expanded in the
future to several countries).

-          Evaluation of health trends: increased attention workers' health by strengthening
the capacity of countries to analyze and understand their own health conditions. 
These efforts will be reflected in the contribution to the publication Health
Conditions in the Americas.

-          Promotion of studies on the risk of HIV transmission in the workplace.

HPA        Health of Adults

-          Revision of the reference document on adult health with emphasis on workers'
health.

-          In the area of mental health, promotion of programs that provide for the
strengthening of social support and the management of critical situations in the
working environment.

-          Development of self-help programs for workers who are dependent on drugs or
alcohol.

-          Preparation of a document on employment and mental health; organization of an
event on this subject (jointly with HPE and PWR Mexico).

-          Preparation of a manual on eye health and preventive ophthalmology for workers.

-          Dissemination of information to promote behavior changes in workers regarding
the risks associated with chronic noncommunicable diseases: smoking, alcoholism,
sedentary lifestyle, hypertension.

-          Promotion of studies on alcohol abuse and consumption of psychoactive substances
in various occupations.

-          Survey of morbidity and mortality related to the consumption of psychoactive
substances in various occupations.

-          Promotion of a review of studies in treatment centers, emergency rooms, and
hospitals on the causes of absenteeism, low levels of performance, and work-
related accidents.

-          Promotion of a review of the literature on various means for preventing, treating,
and studying addictions in the working environment.

-          Promotion of a study on the cost of health problems resulting from the
consumption of psychoactive substances, including alcohol.

HPV        Veterinary Public Health

-          International meeting on occupational zoonoses.

-          Preparation of manuals on the situational diagnosis of occupational exposure to
zoonoses for the development of prevention programs.

-          Promotion and support of training programs on the epidemiology of occupational
zoonoses:  characterization of risk factors for zoonoses, rapid diagnosis of the most
important zoonoses.

-          Promotion of studies on screening for the priority zoonoses in specific population
groups:  agricultural and livestock workers, workers in meat-packing plants and
abattoirs, laboratory workers, miners, hunters, and explorers.

HPE        Environmental Health

-          Course in preparation on water treatment plants, to include the subject of
occupational hygiene and safety (Raymond Reid).

-          Collection of material for an audiovisual presentation on safety in the handling of
substances for the disinfection of water.

-          Preparation of guidelines on hygiene and safety for workers who handle
wastewater.

-          Review of the manual for the course on hygiene and safety for workers who handle
hazardous wastes.

-          Collection of material and preparation of guidelines on occupational health
programs for workers who handle trash and sewage.

-          Inclusion of the workers' health component in the project on CHOLERA.

HPM        Maternal and Child Health

-          Collaboration with the Latin American Center for Perinatology and Human
Development, with particular emphasis on working women during pregnancy,
delivery, the puerperium, and lactation, as well as on the search for ways to
significantly reduce exposure in the workplace to certain chemical agents and other
undesirable working conditions.

-          Family planning and actions to prevent maternal and perinatal STD/AIDS, with
campaigns specifically aimed at working women.

-          Promotion of research on demography, health, and lifestyles in the in-bond
assembly industries, which employ many women along the US-Mexico border.

HPN        Food and Nutrition

-          In collaboration with the specialized centers in Central America and the Caribbean,
emphasis will be placed on actions relating to the diet of workers with a view to
preventing the health effects of chronic diseases caused by nutrient deficiencies or
malnutrition of excess.

HPT        Communicable Diseases

-          Development of programs and projects for the prevention and effective control of
the major endemic diseases and epidemics that affect workers through integrated
intersectoral actions.

For further information, see memorandum HPD/28/1 (014-92).

Presented at the Meeting of the Interprogram Group with the Director on 3 March 1992.



5.         COOPERATION PROVIDED BY THE WORKERS' HEALTH PROGRAM

-          Coordinated by HPE (Environmental Health)
-          Priority program area for the quadrennium 1991-1994
-          Mandated by Resolution XIV on Workers' Health of the XXIII Pan American
Sanitary Conference
-          Mandated by the Initiative "1992: Year of Workers' Health"
-          Network of Collaborating Centers
-          Collaboration with 11 Master's degree programs in workers' health in Latin
America and various graduate-level courses in the United States and Canada
-          Focal Points in the countries

Principal Concerns

-          Stimulation of political commitment
-          National policies
-          Intersectoral articulation and coordination
-          Increased knowledge
-          Human resources
-          Participation of the community, workers, and management
-          Mechanisms for the extension of coverage (industry versus other activities and
informal work).


Forms of Cooperation

-          Information
-          Training
-          Education
-          Research methodology 
-          Identification and mobilization of internal and external resources
-          Preparation and revision of National Plans


6.         EVENTS TO BE HELD IN CONNECTION WITH THE INITIATIVE "1992: 
YEAR OF WORKERS' HEALTH"

During the initiative "1992: Year of Workers' Health" a series of events will be
promoted:

At the National Level

At least one scientific/technical event on the subject of workers' health should be
organized in each country.  In the programming of other national events organized by
scientific societies or institutions concerned with health or labor, an attempt should be
made to ensure that there are topics related to workers' health.

On 1 May, as well as on other occasions, advantage should be taken of the
opportunity to promote activities related to workers' health and to publicize the problem
in all sectors--including universities, trade unions, and community-based
nongovernmental organizations--and also to emphasize the importance of participation
by all in the search for solutions.

The PWRs will promote technical meetings and frequent working meetings with
national groups of experts in connection with the preparation and implementation of
national plans.

At the Subregional Level

The Andean and Central American initiatives are planning to promote events
relating to the Initiative "1992: Year of Workers' Health."

Since the workshop held in Barbados on 13-16 January 1992, the countries of the
English-speaking Caribbean have been engaged in the preparation of national plans, and
it may be possible during the course of the Initiative to hold a meeting with the
responsible personnel from these countries.

At the Regional Level

The following events will take place:

-          Two meetings of the Organizing Commission for the Initiative "1992: Year of
Workers' Health" (February and last week of October 1992);

-          Various meetings of the PAHO Interprogram Group to identify activities in the area
of workers' health promoted by each program and to offer the support of the
Secretariat of the Organizing Commission;

-          Cycle of consciousness-raising and resource mobilization; meetings with
cooperation agencies in order to mobilize resources under the auspices of the
Organizing Commission for the Initiative and its Chairman (possibly organized
jointly with DEC, CCOSH, NIOSH, and WHO/OCH); 

-          Meetings with UNDP, UNICEF, and other agencies;

-          Cycle of meetings with lawmakers (jointly with HSP);

-          Participation in the meetings of the PARLATINO (Cuba and Brazil);

-          Meetings with educational institutions (jointly with HSM);

-          Consideration of the feasibility of promoting an event geared to trade unions jointly
with ILO;

-          Principal event of the Initiative "Health and Work" (mobilization of counterparts,
including ILO, Collaborating Centers, etc.);

-          Incorporation of workers' health within the PAHO public relations mechanisms
(including, among others, EXPO Seville and celebration of the 90th Anniversary
of PAHO).

Presented at the Meeting of the Interprogram Group with the Director on 3 March 1992.


7.         PUBLICATIONS DURING THE COMMEMORATION OF THE
INITIATIVE "1992: YEAR OF WORKERS' HEALTH"

Notes for follow-up:

-          Various documents on the extension of coverage - technically complete. 




-          New directions in workers' health (three scenarios) - technically complete. 

-          Academic standards and resources for the development of a new Master's degree
program in workers' health (UAB); version in three languages; in press.

-          Epidemiological surveillance in workers' health - technically complete. 

-          Adult health and its relationship to work - prepared by HPA; under review by Drs.
Hernán Sandoval and Danuta Rajs.

-          Ergo-ophthalmology - HPA has arranged to contract a consultant.

-          Mental health - possibly to be prepared for the meeting to be held in November
1992 in Mexico.

-          Workers' health and local health systems - in preparation with the advisory services
of Dr. René Mendes.

-          Training in workers' health at various levels of instruction - in preparation, with
the advisory services of Dr. Oscar Betancourt.

-          Working women during pregnancy, the puerperium, and lactation - consultant in
the process of being identified.

-          Publications on workers' health coordinated by the following editorial committee:

Volume 1 - Dr. Alvaro Durao and Clara Barrera
Volume 2 - Dr. René Mendes
Volume 3 - Dr. Hernán Sandoval
Volume 4 - Dr. Oscar Feo, Dr. Maritza Tennassee, Dr. Samuel Henao
Volume 5 - Ergonomy - Dr. Alvaro Durao.





PAN AMERICAN HEALTH ORGANIZATION
ENVIRONMENTAL HEALTH/OCCUPATIONAL HEALTH PROGRAMS








INITIATIVE "1992:  Year of Workers' Health"












        GUIDELINES FOR THE PREPARATION AND ADJUSTMENT OF A NATIONAL
PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH

Terms of Reference

Summary Version














Washington, D.C., December 1991





































RILKE, recalling a conversation
with the sculptor RODIN about the question:
   - How must one go about living?
remembers that RODIN answered:
   - By working!
RILKE understood this very well:  he feels that
   - To work is to live without dying.





      GUIDELINES FOR THE PREPARATION AND ADJUSTMENT OF A NATIONAL PLAN
FOR THE DEVELOPMENT OF WORKERS' HEALTH


1.    INTRODUCTION

      The National Plan for the Development of Workers' Health is a basic
organizational and operational instrument that sets forth the policies,
objectives, directives, mechanisms, and actions which over time are
expected to produce the conjunction and coordination of forces that are
required at the national, regional, and local level in order to achieve the
common goal of extending health coverage to all workers.


2.    JUSTIFICATION

    The preparation and implementation of a National Plan for the
Development of Workers' Health is justified on several counts:

      -   Every worker, as a person, is entitled to health as a human
right.  The highest possible degree of well-being for workers is
a goal of society; its attainment will contribute to a
satisfactory level of health for the population as a whole and
will also help countries to achieve their targets for economic
and social development.

      -   In the countries of the Americas, with few exceptions, the
programs or services that are responsible for workers' health
have only limited coverage.

      -   Despite the existence of national legislation and international
and subregional mandates and agreements on the subject,
compliance is minimal.

      -   The problem of workers' health implies has an economic and social
dimension that affects the budgets of countries, institutions,
and employers, and even the peace and harmony of nations.

      -   If maximum use is to be made of the scarce resources available
for meeting national, regional, and local goals, there must be
intersectoral coordination and cooperation in the planning and
development of workers' health.

      Since the social and economic development of a country depends on
the capacity of its human resources, the implementation of a National
Health Plan for Workers' Health is fundamental to achieving, inter alia,
the following outcomes:

      -   Reduced human suffering;
      -   Longer average working life;
      -   Increased individual working capacity;
      -   Fewer cases of individual disability and lost days of work;
      -   Reduced cost of curative care for sick or injured workers,
particularly those who are affected early in life because of
unhealthful and unsafe working conditions;
     -   Increased productivity;
      -   Better living conditions.

      All these outcomes contribute to a country's progress and to the
general well-being of the population by keeping it economically productive
and helping to break the vicious cycle of poverty.


3.    CONCEPTUAL FRAMEWORK OF THE PLAN

      The National Plan for the Development of Workers' Health, in
addition to conforming to international mandates and existing national
legislation, should take into account the prevailing political framework
and its underlying conceptual doctrine, particularly in terms of the
following:

      -   The conceptualization of health and work;
      -   The nature of the relationship between health and work;
      -   Specification and categorization of the factors that influence
workers' health;
      -   The different spaces in the life of a worker;
      -   The concept of workers' health and its implications;
      -   The concepts of occupational disease, work-related disease,
occupational accidents, and accidents in transit;
      -   The concept and responsibilities of workers' health services and
comprehensive health care.


4.    INFORMING AND GUIDING PRINCIPLES OF THE PLAN

      The drafting and development of a National Health Plan for Workers'
Health should take several principles into account, including:

      -   Comprehensive health care for workers;
      -   An eminently preventive approach;
      -   The epidemiological criterion and the risk approach;
      -   Teamwork and multisectoral and multidisciplinary contributions;
      -   Shared responsibility on the part of the state, employers, and
workers;
      -   Active and informed participation by the community, employers,
and workers;
      -   The workplace seen as a hub for preventive actions.


5.    PRIOR CONDITIONS FOR PREPARATION OF THE PLAN

      In the preparation of the National Plan for Workers' Health,
provision must be made for the promotion of actions that will result in:

      a)  Mobilization of support from the community, the various
governmental sectors, employers, and workers, as well as the
development of public awareness.

     b)  Manifestation of a political commitment and the decision to
coordinate efforts among the institutions involved, especially in
the areas of health, work, social security, planning, and
education.

This decision should be expressly aimed at achieving a common
objective such as improving the level of health of the
economically active population and thus contributing to increased
production and to economic and social development; at attaining
health for all workers as its single goal; at facilitating active
participation by the foregoing institutions and others, such as
Ministries of Energy, Mining, and Industry, in a broad
information campaign via the mass media; and at securing more
active and aware participation on the part of employers, workers,
and labor organizations, as well as other collaborating
individuals and institutions.

The Ministry of Health would be able to reinforce this political
decision by drafting a simple and brief declaration, signed by
the Ministers of Health and Labor, the Director of the Social
Security Institute, and other involved sectors.

      c)  Creation of an intersectoral group to draft the Plan

This initiative could come from the government, based on mutual
agreement between the principal sectors responsible for workers'
health, or it could come from one or two of these sectors, or
even from a university institution.  An alternative approach
would be needed in countries that have a National Council or
Committee on Workers' Health.

It is important that the planning team be intersectoral and
interdisciplinary in its composition and that it include both the
decision-making sectors and those directly affected by the
decisions taken.

      d)  The establishment of a National Council or Committee on Workers'
Health at the highest national level, to include representation
from the health, labor, social security, welfare, industry,
agriculture, mining, and energy sectors, as well as
representatives of employers and workers.

Establishment of a structure for the National Council or
Committee at both the technical and the political levels.

      The technical advisory services can provide the justification for
      setting up commissions or working groups to assume responsibility
      for specific circumscribed areas.


6.   POLICY LINES IN WORKERS' HEALTH

      A National Plan for Workers' Health includes the formulation of
policy and the setting of priorities, for the development of programs and
the integration thereof into the national health system, and for
surveillance and evaluation of the strategies, programs, services, and
institutions involved in its execution.

      Specific policies on workers' health depend on the orientations of
the government, but in general they should guarantee:

      -   The principles of equity and social justice in protecting and
maintaining the health of all workers;
      -   The extension of workers' health coverage through the provision
of services characterized by quality and efficiency;
      -   The development of workers' health programs and services through
activities in the areas of health promotion and health
protection, treatment, and rehabilitation and retraining, if
possible with emphasis on prevention;
      -   The intensification of actions aimed at the reduction of risk
factors and the improvement of working conditions;
      -   The development of mechanisms for coordination, concerted action,
and functional integration;
      -   Broad-based and active participation and cooperation by all
sectors;
      -   Adaptation of machinery, equipment, and work routines,
operations, and processes to the physical and mental capacities
of workers;
      -   Adequate design and maintenance of the material components of the
workplace;
      -   The protection of workers and their representatives;
      -   The exchange of experience and knowledge;
      -   Interdependence between workers' health and all segments of
society;
      -   The worker as an indivisible unit;
      -   The workplace as a base from which to promote the health of the
entire population.


7.    CHARACTERISTICS OF THE PLAN

      The National Plan for Workers' Health should be global,
comprehensive, coordinated, participatory, organic, and multidisciplinary,
and there should be provision for it to be developed by stages and
progressive actions, with short-, medium-, and long-term targets.


8.    STAGES IN THE STRUCTURING OF THE PLAN

8.1.  Analysis of Participation

      Prior to a study of the national health situation of the workers,
and before the particulars of the Plan are decided on, other sectors,institutions, organizations, trade associations, and groups should be
identified to participate in its development.

8.2   Diagnosis of the Current Situation and Trends

      This is an important stage in the planning process in that it
enables targets to be set.  It involves studying the background and trends
of the economically active population (EAP) and the health risks that have
come about as a result of economic development and working conditions.

      The information should include:

      -   Data on distribution of the EAP by activity, age, and sex, and
projected growth of this population;
      -   Number of workers exposed to specific risk factors;
      -   Types of production processes and substances used;
      -   Epidemiological background on mortality, morbidity, disability,
and absenteeism caused by occupational accidents (mortality,
frequency, and index of severity), occupational diseases, and
work-related diseases; general pathology; trends;
      -   Workers covered by social security programs and by workers'
health programs or services;
      -   Value of benefits awarded for occupational accidents;
      -   Institutional structure of workers' health in the country: 
responsibilities, human resources, and available technological,
technical, and financial resources;
      -   Existing coordination mechanisms with regard to medication and
occupational hygiene and safety;
      -   Degree of worker and employer participation;
      -   Existing legal framework;
      -   Research, information, and dissemination in the area of workers'
health;
      -   Historical evolution of workers' health in the country;
      -   Economic development policies and their impact on workers'
health.


      The following may be used to identify problems and needs:

      a)  Structured interviews to collect data on the prevalence and
severity of the problems and on the factors that are impeding
their solution;

      b)  Inferences about the types of accidents to be expected and the
damages to health that could ensue;

      c)  Surveys to obtain information on:  the population, the
epidemiological profile, available resources, forms of prevention
and treatment, existence and operation of structures, and
predictions regarding the incidence and prevalence of accidents
and other pathologies.

8.3. Perceptions about the Health Problems of Workers

      The National Plan should take into account the views and
expectations of lawmakers, technicians, politicians, workers, employers,
and various other sectors and institutions with regard to the health
situation of workers.

8.4.  Prioritization of the Health Problems of Workers

      The number of workers involved and potentially affected, the
potential loss of productivity, the severity of the risk, and the
feasibility of implementing control measures are all important criteria
that help to set priorities among the problems identified.

8.5.  Purposes and Objectives of the Plan

      The purposes of the Plan are based on the impact of workers' health
and the improvement of working conditions with respect to:

      -   The population's quality of life;
      -   Social welfare;
      -   Increased productivity;
      -   National economic development.

      The common multidisciplinary, multisectoral, and participatory goal
for all the institutions and sectors involved is to:

      -   Promote the health of workers:  maintain their health and working
capacity, prevent work-related risk factors, and provide
preventive as well as curative medical care, rehabilitation, and
financial compensation for disability.

      In the formulation of objectives, special attention should be given
to their relevance, specificity, measurement, consistency, and adaptability
to changes in the situation.

      The objectives may be grouped according to whether they are
legislative, political, technical, or administrative.

      The specific objectives of the Plan should take into account program
projections for:

      -   The development of specific policies;
      -   The individual and collective protection of workers and the
community against occupational risk factors and the transfer of
technology;
      -   The improvement of working conditions and the elimination,
reduction, and control of work-related risk factors;
      -   The advance identification of potential work-related risk factors
with a view to providing for their elimination in the planning
phase;
      -   The extension of qualitative and quantitative coverage of
workers' health services and programs;
     -   The establishment and maintenance of relations at the
organizational level for coordination and cooperation with all
sectors;
      -   Community participation and participation by employers and
workers;
      -   Research, generation of knowledge, and increased gathering of
information;
      -   The development of human resources;
      -   The generation of technical and financial resources;
      -   Legislation, standardization, and regulation;
      -   Surveillance and evaluation of the processes and outcomes
expected from the Plan.

8.6.  Targets

      All the institutions share in common the commitment to attain,
within a specific period of time through participatory intersectoral
activity, the following targets:

      -   Extension of health coverage for workers to a degree to be
determined;
      -   Improvement of the state of health of workers:  quantified
reduction of occupational accidents, reduction of cases of
disability, and reduction of occupational diseases and frequent
and severe work-related diseases;
      -   Reduction of risks:  elimination or control of the most serious
risk factors to which the majority of workers are exposed;
      -   Effective implementation of an information and epidemiological
surveillance system that provides up-to-date knowledge about the
situation;
      -   Preparation and implementation of programs and plans for
activities by existing institutions and services;
      -   Increased research on high-risk unprotected workers and on
technology for monitoring and control;
      -   Increased formation and training of human resources;
      -   Compliance with legal provisions to a degree to be determined.

8.7.  Strategic Orientations

      Once the priority objectives and the targets of the Plan have been
set, the appropriate strategies for achieving them will be identified. 
These strategies should encourage innovation and action by various sectors
in addition to health.

      Although the strategies may differ between countries and from one
institution to another, in general they are related to: 

      -   Promotion of workers' health;
      -   Development of specific policies; legislation, regulation and
standards; and institutional, regional, and local programs for
workers' health;
      -   Generation of knowledge;
     -   Use of mass media;
      -   Development of human resources;
      -   Surveillance and monitoring of the body of law;
      -   Concentration of actions on high-risk workers;
      -   Development of coordination and cooperation;
      -   Development and strengthening of workers' health programs and
services;
      -   Utilization of existing information and epidemiological
surveillance systems;
      -   Mobilization of resources and creation of the mechanisms for the
promotion of investment in workers' health;
      -   Participation of employers and workers.

8.8.  Components Plan, or Areas of Effort, and Lines of Action

      Resolution XIV on Workers' Health of the XXIII Pan American Sanitary
Conference (1990) approved the lines of program action to be implemented by
the member countries.  On the basis of these orientations, with due respect
for the particular conditions in each country, a National Plan for Workers'
Health would serve to develop and organize activities along the lines of
the following program components:

      Component 1: Policies on Workers' Health

      Component 2: Legislation, Regulation, and Standardization

      Component 3: Promotion of Workers' Health

      Component 4: Strengthening and Development of Workers, Health
Services and Programs

      Component 5: Development of Human Resources

      Component 6: Generation of Knowledge

      Component 7: Information and Epidemiological Surveillance

      Component 8: Surveillance and Monitoring

      For each component, specific objectives and characteristic lines of
action are to be identified.

8.9.  Activities and Timetable

      The foregoing lines of action will govern the planning of the most
important activities, especially interventions recommended in order to
resolve the most common aspects of the problem.  The following must be
specified:

      -   What should be done:  nature of the activity, coverage, quality;
     -   Who should carry out the measure:  sector and entity, needs
involved, and type of personnel required;
      -   When the activity is to be carried out:  establishment of a
timetable and schedule for their fulfillment in the short,
medium, and long term;
      -   Where the activity is to be carried out:  level or levels of
action;
      -   What is needed in order to accomplish it:  indication of the
resources needed in order to carry it out.

      It is important to identify the critical activities and the
particular configuration of prior coordinated steps that they require.

8.10  Intersectoral and Institutional Commitment to Development of the
      Plan; Levels of Organization and Action

      The sectors and institutions that will participate in the Plan
should be identified, with specific delimitation of the responsibilities
and functions of each.  Consideration should also be given to:

      -   Definition of the regulatory body;
      -   Formation of an intersectoral support committee to give impetus
to the formulation of policies and the definition of strategies;
      -   Establishment of a scientific/technical secretariat, which in
some cases could correspond to a specialized occupational health
center that would be responsible for defining policies and
monitoring their practical application.

8.11  Budget

      On the basis of the foregoing elements, at this stage it is possible
to prepare the budget for the National Plan, take stock of the human and
material resources available versus those that are needed, and determine
how they will be mobilized and used.

      The source of funding should be identified, and ways should be
proposed for obtaining and allocating them and for supporting the programs.


9. INSTITUTIONALIZATION OF THE NATIONAL PLAN

    Once the National Plan for the Development of Workers' Health has been
drafted, the next step is to prepare a summary document setting forth a
Plan of Action that spells out procedures for implementating the National
Plan within a specific period of time and outlines the steps for putting it
into operation.  This document should contain the mechanisms for bridging
the transition between the current status of workers' health and the levels
proposed in the Plan.

    This document should cover:

      -   The need for national policies on workers' health, the objectives
to be achieved, and the corresponding targets;

     -   The political, social, economic, administrative, and
technological processes that are involved in developing the
National Plan;
      -   The legal structure that needs to be in place in order to
organize and administer the Plan, mechanisms for coordination and
management, coverage, and the responsibilities of each sector;
      -   The list of principal actions that have been agreed upon by all
the sectors, together with a schedule for their accomplishment on
a short-, medium-, or long-term basis.  The short-term actions
should focus on problems that are readily solvable, the
deployment of existing resources, the application of technologies
known to be effective, and the creation of mechanisms for
implementing changes in the future.
      -   The allocation of resources, with broad reference to the human,
technical, and financial resources needed in order to carry out
the Plan, taking into account the resources available, those
expected to be obtained, and the gradual increase thereof as the
Plan becomes increasingly operational.  It should be emphasized
that these resources are not regarded as expenditures but rather
as an investment that will yield economic and social benefits in
the future.
      -   Social involvement, with arrangements for the document to be
presented both to the government and to a mediation body, for
study, revision, and approval by the principal sectors involved,
by employers, and by workers.


10.   RECORD-KEEPING, REPORTING, AND INFORMATION SYSTEMS

      Records should be kept of the actions taken under the Plan and other
useful information for ensuring continuity and monitoring the system. 
Reporting should be in the form of feedback that will make it possible to
monitor present or past activities under the Plan.  Its usefulness will
depend to a great extent on the quality of the information generated.  A
management information system requires a unified, integrated, and complete
subsystem for the collection, analysis, and storing of information in order
to coordinate data for the overall system corresponding to the Plan.


11.   EVALUATION

      It is necessary to evaluate implementation of the Plan at every step
in order to test the validity of the objectives and to determine the
effectiveness and impact of the solutions proposed.

      This evaluation will make it possible to reformulate the objectives
and to seek new solutions for attaining them, either within the program
already under way or as background for the formulation of a new project.

      The need for ongoing evaluation calls for the formulation of
measurable objectives and the quantification of effectiveness in order to
carry out the activities programmed.

     Planning is a reiterative process, and it is only through
information on the results obtained from previous attempts that it is
possible to introduce improvements and to propose new solutions to problems
as they arise.

      Evaluation should mainly take into account the indicators of
relevance, progress, efficiency, effectiveness, and impact; it should also
consider such elements as:

      -      The content of workers' health services;
      -      The coverage of workers' health services;
      -      Manpower and technical resources available;
      -      The active participation of workers and employers in the
planning, programming, organization, and evaluation of health
services for workers;
      -      The coordination of workers' health services with the various
sectors, with other health programs, and with programs for
economic development;
      -      The improvement of working conditions;
      -      The health conditions of workers.






     MATRIX FOR THE PREPARATION OF A NATIONAL PLAN FOR WORKERS' HEALTH






/     POLITICAL DECISION, LEGISLATIVE ACTION, AND SOCIAL INVOLVEMENT

/     INTERSECTORAL AND MULTIDISCIPLINARY COOPERATION BY THE PUBLIC AND
      PRIVATE SECTORS

/     ANALYSIS OF SECTORAL PARTICIPATION BY EMPLOYERS AND WORKERS

/     ANALYSIS AND PRIORITIZATION OF THE PROBLEM OF WORKERS' HEALTH

/     IDENTIFICATION OF THE CAUSES AND EFFECTS OF PROBLEMS

/     FORMULATION AND ANALYSIS OF THE OBJECTIVES OF THE PLAN -  FUTURE
      SITUATION TO BE ATTAINED - POSITIVE OUTCOMES DESIRED AND ACHIEVABLE

/     ANALYSIS OF ALTERNATIVE SOLUTIONS - STRATEGIES FOR THE PLAN

/     ESTABLISHMENT OF THE PURPOSES OF THE PLAN

/     TIMETABLE FOR LINES OF ACTION COMPATIBLE WITH SUSTAINED DEVELOPMENT

/     MECHANISMS FOR SEQUENTIAL EVALUATION OF EXECUTION










COMPONENTS/OBJECTIVES
ACTIVITIESEVALUATION INDICATORSSOURCES OF INFORMATION FOR WORKERSPARTICIPATING SECTORS AND INSTITUTIONSIMPORTANT
ASSUMPTIONS COMPONENT:
SPECIFIC OBJECTIVES


RESULTS PRODUCED


ACTIVITIES TO BE CARRIED OUT


SHORT TERM


MEDIUM TERM


LONG TERM



E0117.FIN




PUBLISHED VERSION                                       12/III/92


DOMINICAN REPUBLIC



     The electoral process of 1990, which resulted in partisan
pluralism in the legislative branch and at the municipal level,
made the adoption of decisions by consensus, such as approval of
the national budget, difficult. The health sector faced serious
difficulties during 1991 because of the reduction in the
allocation of public spending for the Ministry of Public Health
and Social Welfare and in part because of prolonged strikes by
workers in the health services.  Contributions to private social
welfare institutions were nine times higher, however, which
reflects the privatization of the social sector.  Preventive
programs and hospital services deteriorated, which resulted in
some political instability as well as changes in authorities in
the sector.
     The participation of the country's authorities in several
international meetings convened in order to mobilize resources
for the social sector became a major incentive for defining and
preparing projects.  The need for analyzing deeply and widely the
transformation of the health services has become increasingly
evident.  As a result of the dissemination of a document on the
national health situation, in which various proposals were
included for dealing with the problems, extension of health
services coverage (including decentralization, financing, and a
review of the role that nongovernmental agencies and social
security play); the response capacity of the hospital services
(supply of inputs and availability of drugs, maintenance of
physical infrastructure, and continuing education of personnel);
and improvement of preventive programs, in view of the high rates
of morbidity and mortality caused by preventable causes, the
increase in epidemic outbreaks, and the lack of focusing
activities and resources, were identified as national priorities.

     PAHO/WHO continued providing support for the national
working groups organized to deal with the complex panorama of the
health sector and sought to strengthen the country's capacity for
the preparation of proposals, intersectoral agreements, and
multidisciplinary participation.  Cooperation with the Ministry
of Public Health focused on coordinating the formulation of
national plans for drinking water and sanitation, maternal and
child health and the reproductive health of women, and prevention
of disasters.

     With regard to the infrastructure of the health services,
the Organization cooperated in implementing the provincial health
systems in selected areas, maintenance of hospital equipment,
availability of drugs, radiological protection, managerial
capacity, project management, formulation of policies,
preparation and reform of legal instruments, and definition of
lines of work with nongovernmental agencies.  It also
collaborated in a study of hospital production, performance, and
costs; in restructuring psychiatric care; in community-based
rehabilitation in pilot areas; in a review of the health
information system, especially of registration of vital events;
in feasibility studies of the fluoridation of water and salt,
maintenance of dental equipment and dental biological materials,
and in cooperation activities among countries.  With regard to
nursing (with funds from the W. K. Kellogg Foundation), it
collaborated in the integration of education and service to
improve the quality of care at the community and hospital levels. 
In regard to epidemiology, application of the epidemiological
method in analyzing health conditions and the quality of life and
in evaluating the impact of the strategies in crisis situations
was promoted, and a second national scientific meeting on
epidemiology was sponsored.

     The Organization formulated and collaborated in the initial
execution phase of a local health systems plan for the Province
of Salcedo which was then incorporated in a health,
environmental, and anti-poverty campaign project financed with
funds from the Government of Italy.  Activities in other
provinces were initiated using the same methodology, and there
was a possibility of mobilizing external and internal funds for
their implementation.  A similar project for Health Region V
(five provinces) will be put into execution soon, also with funds
from the Government of Italy.

     In light of the threat of cholera because of its appearance
in the Region, significant advances were achieved in integrating
maternal and child health plans with those dealing with water and
sanitation, food protection, and epidemiological surveillance. 
In the field of communicable diseases, there was cooperation in
strengthening the capacity of analysis to focus activities and
evaluate interventions in malaria and vector control,
tuberculosis, AIDS and other sexually transmitted diseases, and
rabies and zoonosis.

     Given the success obtained with the activities programmed
using resources of technical cooperation among countries, a
working group on tropical diseases met to formulate lines of
cooperative research and areas of joint operational intervention
among countries, with good potential for external financing.  The
Dominican Republic achieved its goal of eradicating poliomyelitis
and carried out a detailed review of its national immunization
program in order to overcome certain obstacles in current
strategies to be able to maintain the achievements already made
and advance in the control of other diseases, such as tetanus and
measles.

     In veterinary public health, the development plan of the
Central Veterinary Laboratory made it possible to strengthen
relations between the Ministries of Health and Agriculture.  The
national authorities, with the cooperation of PAHO/WHO, prepared
a plan of activities to improve human and animal health which was
implemented and succeeded in carrying out training activities,
utilization of new technologies, agreement on managerial reform,
and financing.  The country continued providing human and animal
rabies vaccine to the countries which requested it.

     In human resources, significant advances were made in
analyzing the work force, continuing education, teaching and
service integration, and strengthening public health education. 
Cooperation agreements were signed between PAHO/WHO, the Ministry
of Public Health and Social Welfare, and several universities to
provide a legal framework for the numerous activities already
under way.

     Concerning information management, the National Network of
Health Information was created through an agreement signed by 14
institutions in the health sector.  In addition, the programs of
public information and social communication in health were
strengthened; extension of the Expanded Program of Textbooks and
Instructional Materials (PALTEX) was continued, with the creation
of new book sales points, and a study was concluded on the
utilization of texts by educators.  Technical cooperation was
also provided to specialized information units in hospitals,
health services, nongovernmental agencies, scientific societies,
unions, and universities.  Preparation of modular teaching
material on research methodology, which included the formulation
of 12 proposals on health services research, was finalized.
E0118.FIN



PUBLISHED VERSION                                       12/III/92

NICARAGUA



     During the year the pacification and democratization of the
country continued and deepened.  As a part of this process, an
economic and social agreement was concluded which served as a
basis for establishing measures of stabilization.  At the same
time, the Government continued making concerted efforts with the
principal political forces in the country to depolarize society
and allow the stabilization measures to achieve the targets
proposed.  Simultaneously, the process of modernizing the State,
which includes administrative decentralization in order to
increase the efficiency of its institutions, was initiated.

     The disorderly reentry of more than 500,000 repatriates,
refugees, and displaced persons who had emigrated as a result of
the recently ended war caused serious conflicts.  Although this
phenomenon was initially dealt with through the creation of
"development poles" (geographical regions in which productive
companies have been established to attract population), a sizable
segment of this population settled spontaneously in other rural
areas and mainly in the largest urban centers, which saturated
the capacity of the services' basic infrastructure to respond.

     The Government oriented its activities toward carrying out a
Plan of Economic Stabilization directed toward eliminating
hyperinflation, stabilizing the currency, and promoting
investment.  To implement the Plan it was necessary to seek
external financing, both for the entry of new foreign exchange
and for the payment of pending interest on the debt.  As a result
of the Plan, inflation has remained at minimum levels since April
and the economy began to show signs of reactivation.

     The country's morbidity profile was characterized by a high
incidence of infectious diseases, among which are the acute
diarrheal diseases, acute respiratory infections, and infections
of the urinary tract.  In addition, there are high rates of
vector-borne diseases, mainly malaria, dengue, and leishmaniasis. 
Despite the fact that diseases preventable by vaccination have
remained at control levels, they continued to produce epidemic
outbreaks, in particular measles and whooping cough.  Cholera
began to manifest its epidemic potential when the first cases
were identified in November at the opposite ends of the country.

     The country has an overall death rate of 10.08 per 1,000
inhabitants, with high mortality in infants and those over 50
years of age.  Although the principal causes of mortality are the
acute infectious diseases, there is a trend toward an increase in
chronic degenerative conditions, especially the cardiovascular
and neoplastic diseases.  Infant mortality has shown a continuous
decline, but its current levels (71.8 per 1,000 live births)
still place the country in the group with the highest rates in
Central America.

     The national health policies, which were ratified at the I
National Health Conference, were guided by the Master Health Plan
for 1991-1996 toward the strategic foci of decentralization,
primary care, attention to priority problems, and social
participation.  Within these foci the principal activities were
implementation of the Local Systems of Comprehensive Care in
Health (SILAIS), attention to priority problems in the
populations at greatest risk and in the regions and municipios of
greater vulnerability, the search for alternative financing for
services at the local level, strengthening of installed physical
capacity, development of the health work force, establishing a
policy on supply of medical inputs, and strengthening community
participation.

     Because of the effects of the economic crisis, the
accumulated deficit, and the structural adjustments which the
Government is carrying out, the budgetary allocation to the
health sector has undergone considerable reductions, producing a
generalized shortage of the basic inputs necessary to meet the
population's growing demands.  To this is added a reduction in
the Ministry's work force since its staff members were able to
join the Occupation Conversion Plan, which makes it possible to
rotate employees within the offices of the Government.  All this
began to be manifested in a reduction of the indexes of
production of the health services, both at the first level and in
hospitals, and in the activities of some preventive and curative
care programs such as malaria and dengue control, child growth
and development, and prenatal, puerperal, and fertility control. 
International cooperation has been increased by the creation of
new institutions of technical and financial assistance.  It has
not been possible to offset the sector's budgetary deficit,
however.

     The technical cooperation of PAHO/WHO focused on providing
support for the reorganization of the health services through
implementation of the SILAIS.  This general orientation, which
follows the policies of the Ministry of Health, has as its
principal objective diminishing the effects of the economic
crisis on the capacity of the health services to meet the demands
of the population.

     For this purpose, PAHO/WHO cooperated in developing the
Ministry's operating capacity and institutional strengthening to
try to achieve greater efficiency and effectiveness at all care
levels, especially the local level.  In addition, it carried out
activities oriented to the mobilization of resources,
preservation of the environment, promotion of social
participation, the supply of essential drugs and inputs,
maintenance of equipment and health units, and training of human
resources.

     In order to deal with the principal health problems,
PAHO/WHO collaborated with the Ministry in carrying out programs
and projects to prevent and control communicable diseases,
rehabilitate the disabled, care for mothers and children, and
deal with food and nutrition.

     The imminent presence of cholera required the Organization
to make all its resources available to strengthen the response
capacity of the country, particularly in establishing prevention
and control measures, diagnosis and treatment of cases, and
searching for financing to deal with the problem.

     The Organization continued collaborating with the country in
developing the Health Initiative of Central America and in
preparing projects directed toward obtaining financial resources
from the Inter-American Development Bank, World Bank, and other
cooperation agencies.  In addition, it cooperated in
strengthening interinstitutional coordination by establishing
lines of joint action with agencies in the United Nations system
and other bilateral and multilateral cooperation agencies.

     The joint Ministry of Health-PAHO/WHO evaluation was very
important, for it made it possible to identify the correspondence
between the policies and strategies established in the country
and the lines of cooperation defined in the strategic
orientations and programming priorities for PAHO/WHO in the 1991-
1994 quadrennium.
E0119.FIN




PUBLISHED VERSION                                       12/III/92
GUATEMALA


     The Government maintained the policy of deepening the
process of democratization, of orienting its efforts toward
achieving peace, of strengthening agreement with entrepreneurs
and workers, and of promoting coordination of the social
participation of guilds, associations, and unions.  The economic
and social policies are based on achieving economic stability,
productive efficiency, and international competitiveness.  Since
1990 the economy has shown signs of recovery:  the rate of growth
in the GDP has reached a little more than 3% annually, although
this situation has not extended to the interior of Guatemalan
society.  Illiteracy among those over 15 years of age is more
than 60%, infant mortality is more than 50 per 1,000 live births,
overall mortality is higher than 10 per 1,000 inhabitants, the
population without excreta service is a little more than 43%, and
the proportion without water services is higher than 36%.  The
increase in poverty, delinquency, alcoholism, drug addiction,
accidents, violence and the problem of the populations of
refugees, migrants, the indigenous population, working women, and
marginal urban dwellers, among others, are phenomena that show
the severity of the situation and express the social urgency of
the activities of the State.  The appearance of cholera and the
increase in cases of shigellosis, dengue, malaria, and of child
undernutrition, among other problems, show the deterioration in
environmental sanitation and the scarcity or slight coverage of
drinking water services, latrine building and refuse control, and
the deficient availability of food.

     Despite these serious difficulties, there are significant
signs of progress and strategic measures which can lead to
stimulating the activities of the social sector as a whole, such
as the recent establishment of the National Health Council and
the proposal on social development which the country presented to
the summit meeting of the Central American Presidents held in
Honduras in December.

     During 1991, one of the principal lines of PAHO/WHO
cooperation was its support for the development and execution of
a plan to prevent and control cholera.  When the first case
appeared in Guatemala in July, cooperation intensified and
standards and technical procedures to cope with the epidemic, a
guideline for the care and control of cases, and an operational
plan in which activities of epidemiological surveillance,
environmental sanitation and food hygiene, management and control
of cases, health education, and social participation were defined
were prepared.

     Dealing with the cholera epidemic received priority within
the National Health System.  Activities focused on surveillance
and control of cholera and other diarrheal diseases, training in
epidemiology, and strengthening the information system.  The
strategy was maintained of promoting national interest in
utilizing epidemiology as an instrument for planning and
orientation in decision-making to favor the adoption of changes
in the National Health System.

     A sectoral study, financed by IDB and PAHO/WHO, was
completed which has been of great usefulness in supporting the
activities carried out within the National Health Plan for 1991-
1995.

     The need was identified for establishing an information
system which facilitates decentralization and local programming
to allocate human resources, drugs, and critical supplies.  In
this regard, PAHO/WHO cooperated actively with the Guatemalan
Institute of Social Security (IGSS) in developing the Information
System for Cholera Management and Control, which makes it
possible to relate epidemiological information with needs in
critical supplies.  In addition, it collaborated in holding a
seminar-workshop on local strategic administration which
representatives from the Ministry of Public Health and Social
Welfare and the General Bureau of Health Services attended.

     The IGSS backed a PAHO/WHO proposal to extend the
Institute's services to some 800,000 migrant agricultural workers
who work along the Southwest coast.  In addition, the Ministry of
Public Health is interested in a project to strengthen cholera
control activities in this population group.  The private sector,
represented by the associations of sugar, cotton, and coffee
producers along the Southwest coast, and other organizations,
such as UNICEF, Physicians without Borders, and other
nongovernmental agencies were actively involved.

     The physical and operating situation of the health
establishments is a national priority.  PAHO/WHO cooperated in
this field with short-term consultantships, courses and seminars,
fellowships, repair of equipment and installations in the health
establishments, and in acquiring equipment and supplies.

     Concerning the program on women, health, and development,
PAHO/WHO cooperated in promoting the use of the gender
perspective in analyzing and dealing with health problems in
general.  Research was carried out in the health services on
intrafamily violence toward women to determine the demand this
problem poses for such services.  Support also was given for
preparing the project on the health and development of indigenous
women, which the country considers a priority.

     In the Development Program for Displaced Persons, Refugees,
and Repatriates in Central America, the health component focused
on the comprehensive activities of caring for high-risk groups in
the geographical areas in which these populations are located. 
There was community participation in identifying the measures
necessary for promoting health from and for the community. 
Priority cooperation activities were aimed at comprehensive
maternal and child health, basic sanitation, and dealing with
preventable diseases, with emphasis on the organization of local
health systems and environmental protection and sanitation.

     Concerning human resources, the principal foci of
cooperation were oriented toward strengthening the planning of
personnel development in the health sector and strengthening the
leadership and management capacity of human resources units, in
particular of the Ministry of Public Health.  The cholera
epidemic has been considered a strategic axis for training
personnel in service and for generating processes of continuing
education.

     In regard to drinking water supply and environmental
sanitation, the national priorities underwent certain
modifications due to the presence of cholera.  PAHO/WHO
cooperation was oriented in particular toward the sector's
institutions which operate programs of public water supply and
toward preparation of a drinking water and sanitation plan to
cope with the cholera epidemic as part of the National Plan which
the various institutions in the sector are carrying out.  The
Organization also advised the urban and rural conglomerates of
the area affected by the epidemic, especially with respect to the
disinfection of water for human consumption and the adoption of
preventive measures in other sanitation sectors by coordinating
the institutions in the sector.  In addition, PAHO/WHO
collaborated in implementing the regional projects on the
environment and health in the Central American Isthmus and on the
production and marketing of chemical substances and other inputs
commonly used in drinking water and sanitation systems.
     In veterinary public health and food protection, there was
cooperation with the plan to prevention and control cholera, and
support was provided to national institutions in detecting cases
and training ambulant food sellers in urban areas, as well as in
preparing educational materials on food hygiene for mass
dissemination.  There was also collaboration in the elimination
of rabies, control of brucellosis and bovine tuberculosis,
control of the taeniasis/cysticercosis, and strengthening the
epidemiological surveillance system of the Ministry of
Agriculture and Livestock Raising.

     Diseases preventable by vaccination continue to be a
priority for the national authorities because the country has a
policy commitment to eradicate poliomyelitis, eliminate neonatal
tetanus by 1995, and eradicate measles in Central America by
1997.  Through the EPI, PAHO/WHO collaborated in preventing
measles, diphtheria, whooping cough, and tuberculosis in the
infant population and tetanus in women of reproductive age.  It
also participated in eradicating the indigenous transmission of
wild poliovirus, in strengthening the System of Epidemiological
Surveillance of Flaccid Paralyses of acute onset in children less
than 15 years of age, implementing a system of epidemiological
surveillance of neonatal tetanus to achieve its control by 1995,
and strengthening decentralization and local programming in the
execution of these activities.  Through the EPI it was possible
to establish effective interagency coordination at the technical
and operational level and transfer technology and information. 
Because of the cholera epidemic it was necessary to reprogram
some activities during the second half of the year such as
dissemination of information to the population about how to
prevent the diarrheal diseases in general and cholera in
particular through so-called "sanitary sweepings."  Consequently,
it was possible to mitigate the impact this situation would have
generated on vaccination coverage.  It improved the exchange of
information among the border areas with Belize, El Salvador,
Honduras, and Mexico through intercountry meetings.

     The Organization also collaborated in activities to promote
adult health, mental health, care of the disabled and elderly
persons, prevent smoking, control cancer, provide essential
drugs, nutrition, care for women, children, and adolescents, and
control and prevent communicable diseases.  Among activities to
control dengue was the approval of a project between Guatemala,
Honduras, and El Salvador with the Government of Finland, which
will grant $US130,000 to each country.

     To prevent and control AIDS the national authorities, with
the collaboration of PAHO/WHO, strengthened the managerial and
administrative functions of the national program, improved
coordination among governmental nongovernmental and agencies and
private companies with this program, trained personnel, screened
blood samples, and disseminated information to the population. 
The new health authorities have provided significant policy
support him to this field, in which it is expected that
significant advances will occur in the near future.

     The situation of the cholera epidemic made it possible to
advance in establishing standards and capacity for providing care
at all levels of the network of services.  In addition, it
promoted formulation of the National Maternal and Child Health
Plan with the close cooperation of UNFPA, UNICEF, and INCAP. 
Ministerial approval of the Plan to Reduce Maternal Morbidity and
Mortality was obtained, and the formulation of this objective
within the National Health Plan was initiated.

     
E0120.FIN




PUBLISHED VERSION                                       12/III/92

COSTA RICA



     The social policy of the Government, which reaffirms the
historical objectives of Costa Rican society, is oriented toward
achieving the well-being of the population with equality of
opportunity, and ensures every individual social goods such as
economic, health, and educational security.  For this purpose,
the Government gave priority to activities which tend to reduce
geographical inequalities and those of social groups with regard
to access to health services.  The Health Sector Program's
objectives are (a) to preserve the health of the entire
population in a healthy environment suitable for comprehensive
and rationally productive development, at the same time that the
idea of self-reliance for their health and that of the community
is promoted in individuals and the communities, and (b) to
modernize and develop the sector and its institutions by applying
the concept of systems, principles of integration,
decentralization, sectorialization, regionalization, and
democratization so that they play their role with efficiency,
effectiveness, and equity.  In addition, local health systems
will be utilized to implement the strategy of primary care.

     PAHO/WHO technical cooperation was oriented toward
supporting strategies which ensure health the greatest importance
within the policies of national development and reform of the
State.  Toward that end the II National Forum on Health and
Development, which lasted four months and in which 150 high-
level technicians participated, was carried out.  These
discussions culminated in a Sectoral Forum, sponsored with the
collaboration of PAHO/WHO, which had major representation by
national policy and international technical and financial
cooperation agencies.  The political lines and strategies to
follow in reforming the health sector were analyzed at it.  As a
result of these activities, the Organization established a
dialogue and continuing cooperation with the Legislative Assembly
and the Ministries of National Planning, State Reform, and the
Presidency, and laid the foundations for bases of understanding
so that the World Bank's support of the health sector can be
conducted in close coordination with PAHO/WHO.  Progress was made
in analyzing sectoral organization, coverage, and operations,
especially in regard to the financing, costs, efficiency, and
quality of new models of service administration.

     Although the health services extend throughout the country,
it is recognized that the substantive programs are not directed
in their entirety toward the neediest population and that the
Ministry of Health and the Costa Rican Social Security Fund have
not integrated their resources, which means that a dichotomy
persists between preventive and curative activities.  PAHO/WHO
collaborated actively with these institutions to achieve the
formulation of programs integrated on the basis of health
problems and risk factors, as well as reorientation of activities
targeted toward populations at the greatest disadvantage.  For
this purpose an analysis was made of the situation at the local
level and of the technical and administrative systems necessary
to achieve good operations in the local health systems.

     The threat of cholera has resulted in the diarrheal disease
control program orienting its activities toward environmental
health, safety in the production and handling of food, and
promotion of personal and social responsibility in regard to
hygiene.  In addition, it has served to recognize the weakness of
epidemiological surveillance and the need for training personnel
to make decisions on the basis of an analysis of the situation;
to mobilize mass information through the social communications
media, and to favor an alignment of and greater comprehension by
such media with respect to health promotion and protection. 
PAHO/WHO collaborated with the national authorities in all
activities related to the prevention of cholera and especially in
regard to basic sanitation, excreta disposal and solid wastes,
drinking water services, and food hygiene.

     In order to increase the efficiency of the sector, the
Government, with the support of the Organization, made an
analysis of the efficiency of hospitals in relation to the
quality of their services.  The true impetus to this line of
cooperation will occur when sectoral reform is initiated in depth
and greater social participation and responsibility in promoting
health are obtained.  After the technicopolitical commissions
established in this respect define the structure and function of
the health sector, the national authorities, in cooperation with
PAHO/WHO, will make an analysis of local health systems, their
common programming, and the programming and evaluation of the new
models of service administration at the local level.

     Concerning manpower development, PAHO/WHO focused its
technical cooperation on strengthening the local and regional
structures to enable local programming of training needs,
management of such programs, and application of education at a
distance.  It also prepared a data base which brings together
information on processes and methods utilized in manpower
development in the sector which is already being utilized.  In
addition, cooperation has been resumed with the Center for
Planning, Research, and Strategic Development of Human Resources
for the Sector and with the National Information Network, in
accordance with the wishes of the country's authorities.

     Cooperation among countries was cemented through bilateral
agreements:  with Argentina, in nuclear medicine and
municipalization; with Colombia, in legislation and
municipalization of services, and with Chile, in financing,
privatization, and control of new models.  Interinstitutional
agreements were achieved with the United States of America,
especially with the Costa Rican Social Security Fund; the Health
Initiative of Central America and collaboration in border areas
with Nicaragua and Panama, which involves not only dealing with
specific problems but also achieving the functional integration
of border health services continued to be in effect with the
Central American countries.

     In the field of nutrition, PAHO/WHO gave priority to food
control, to the study on the increase in second-degree
undernutrition, to the revitalization of the preventive nutrition
approach in chronic diseases, and to improving articulation among
sectors for nutritional surveillance.

     PAHO/WHO provided technical cooperation in developing
policies, legislation, and programs that support the
incorporation of women into health and development.  During the
year the Commission on Women, Health, and Development was
institutionalized in the Ministry of Health and greater
coordination developed with the Departments of Education to
integrate the subject of women in health programs, specifically
in mental health, transmission of sexual diseases, pharmacy,
AIDS, and disaster preparedness.  Coordination was maintained at
the interinstitutional level with the Office of the First Lady,
as well as with the Legislative Assembly, where a line of work
was profiled to give advisory services and training in this field
to deputies.  PAHO/WHO cooperated in preparing and developing
specific investigations from a gender perspective.

     PAHO/WHO also stimulated the analysis of morbidity due to
communicable diseases to better determine their behavior and
impact on social costs and the services, since although Costa
Rica has advanced notably in reducing mortality due to acute
diseases, it is still attempting to diminish the incidence of
such diseases.  The country, together with PAHO/WHO, continued
making an effort to bring about administrative and programming
integration in health care for mothers, children, and
adolescents; in addition, it centered efforts in the area of
perinatology as a national priority.

     Progress was achieved in the prevention of and campaign
against AIDS.  There is a high degree of alert in the country in
this respect, but it is necessary to stress the need for more
surveillance activities to prevent and control the disease. 
Advantage has been taken of the potential of this program to
achieve integrated activities with other projects, such as
manpower development, maternal and child health, essential drugs,
and health services.
E0121.FIN



PUBLISHED VERSION                                       12/III/92

HONDURAS



   In 1991 a stage of questions with respect to the long-term
socioeconomic prospects and the immediate situation was initiated
in the country as a consequence of the consolidation of the
economic measures taken by the Government and the prospects for
peace, Central American integration, stabilization of democracy,
and popular expectations of economic improvement.

   The economic measures--which consist basically of freeing
market prices, reducing expenditures and the budget deficit, and
privatization of services--have been implemented gradually since
1990, the first year of the new Government.  In addition,
recognizing the vulnerability of groups with limited resources or
who are unprotected, the Government has organized a "social
compensation" program based on a social investment fund and on
family award programs dependent on the Presidency of the Republic
to support various projects with such priorities and with
measures of individual redistribution for the unprotected who
request health services.

   There is a negative trend in the economic indicators--such as
the gross domestic product, exports and imports, balance of
payments, external debt, and inflation--but the authorities
consider that the measures of macroeconomic policy will modify
that trend and will make it positive in the medium or long term.

   In 1991 the health sector seemed on the verge of improving,
possibly because of its protagonism as the sector of social
compensation and the government's responses to the principal
epidemic problems such as cholera, AIDS, and dengue.  The health
services provided examples of positive response in other areas,
even before 1991, such as the increase in the coverage by the
Expanded Program on Immunization and the elimination of urban
rabies.

   The Organization collaborated with the Government in
controlling and preventing epidemic outbreaks of cholera and
hemorrhagic dengue, which did not get an explosive start in the
country.  Cooperation in favor of environmental health was
concentrated largely on preparations to combat cholera.  There
was collaboration in addition in the preparation of a national
water and sanitation plan for 1991-2000, in the formulation of
the report that Honduras will present to the United Nations
Conference on Environment and Development which will be held in
1992 at Rio de Janeiro, as well as in the management of solid
wastes, workers' health, and food safety.  Concerning policies
and health services, it was possible to consolidate consistent
social participation at the local level and achieve significant
interprogram coordination, as in the case of cholera control. 
There was notable progress in improving the quality,
availability, and timeliness of vital statistics for use by the
health services, as well as in regard to innovations and
administrative reform of the health sector.  With regard to the
communicable and vector-borne diseases, in particular hemorrhagic
dengue and cholera, the Organization collaborated with the
Government in implementing educational measures and in carrying
out prevention and control activities, at the same time that the
population was facilitated, seemingly with success, in becoming
the principal protagonist of the activities.

   In the subregional plan, the Organization continued promoting
analysis of major problems by the Ministers of Health of Central
America.  For example, in addition to generating a request to
eliminate measles in the present decade, PAHO/WHO collaborated in
preparing a document on the repercussions of the economic crisis
of the 1980s on health in Central America which was presented by
the Ministers to the summit meeting of the Presidents of Central
America at Tegucigalpa in December.  The Organization actively
cooperated with the Ministry of Public Health and Social Welfare
and played a preponderant role in coordination with the Agency
for International Development (USA), Inter-American Development
Bank, World Bank, International Rotary Club, United Nations
Children's Fund, United Nations Food and Agriculture
Organization, Office of the United Nations High Commissioner for
Refugees, United Nations Development Program, and World Food
Program.
E0122.FIN



CHAPTER IV.D                                            12/III/92
PUBLISHED VERSION


Women, health, and development
     In the document "Strategic Orientations and Programming
Priorities for the Pan American Health Organization in the 1991-
1994 Quadrennium, it is noted that the integration of women in
health and development is a strategic orientation of the
Organization, given the need for encouraging change in the
unequal relations between the sexes as an integral part of
development of humans and the health of the population as a
whole."  To achieve that target it is necessary that all the
regional programs of the Organization adopt the gender approach
as an essential component in their activities, and above all that
it not be thought that responsibility for this achievement falls
only on the Regional Program on Women, Health, and Development,
because it involves an effort by entire Organization.

     The information concerning the activities of the regional
programs of the Secretariat brings to light the difficulties it
faces in achieving this objective.  On the one hand, this concept
is resisted or faces difficulties in being accepted in some of
the areas of action of the programs of the Secretariat; on the
other, it is considered that presenting information by sex
concerning a specific problem is the maximum attainable.  Despite
the fact that the development of a strategic orientation as the
approved by the XXIII Pan American Sanitary Conference with
regard to women is difficult to achieve, and without ceasing to
assess the achievements made, it should be understood that it is
necessary to renew efforts to advance much further, in the sense
of including in the analysis the specific problems and
sociopolitical and cultural determinations which adopting the
gender perspective represents, and dealing with the adjustments
and changes that carrying it out implies.

     The Regional Program on Women, Health, and Development of
the Organization programmed its activities for 1991 according to
the guidelines of the plan of work approved in the X Meeting of
the Subcommittee of the Executive Committee on this subject and
taking into account the objectives of technical cooperation and
the Strategic Orientations and Programming Priorities on Women,
Health, and Development for the 1991-1994 quadrennium, as
detailed in the document entitled "Criteria to Orient Technical
Cooperation on Women, Health, and Development."

     The Program's strategy of technical cooperation defined
three areas of action for 1991:  regional, subregional and
national.  In the regional area the Program placed priority and
concentrated its efforts on formulating regional projects and
managing extrabudgetary resources of support; on mobilizing
political and institutional resources and those of the civilian
society in the countries of Latin America and the Caribbean to
promote women's health, and on strengthening the coordination
relationships with other regional programs of the Secretariat in
order to promote the complementarity of cooperation activities
under a gender perspective.

     In the subregional plan, the Program supported the Health
Initiative of Central America through the continuity of the
activities under way with regard to the subject of women, health,
and development and the preparation of Phase II of this
initiative; the Initiative of Cooperation for Health in the
Caribbean in regard to the Plan of Action approved by the
Ministers of Health of the Subregion and the Caribbean Community,
and the identification of the foci of work to promote in the
Initiative of Andean Cooperation in Health on the subject of
women, health, and development.

     Concerning the national area, the Program concentrated its
activities on the initiatives of the countries of the Central
American subregion and gave priority to direct technical
cooperation with those national initiatives that requested
technical cooperation resources for their programs (Argentina,
Colombia, Cuba, the Dominican Republic, Mexico, Peru, and
Venezuela).
     During the year the general strategy of technical
cooperation was directed toward the conceptual development and
dissemination of the gender approach through a concentration of
efforts to disseminate that approach and stimulating every
country to determine in greater depth the situation of women's
health from this perspective.  In addition, the political,
institutional, academic, and social actors were identified who
are interested in the subject of women, health, and development,
and a study was completed which made it possible to update
information about the situation of the focal points of this
program in the Americas.
EBS13107.WPF
Epidemiology Activities

Group on Health Surveillance and Planning in Costa Rica
In the framework of the integration agreement recently subscribed
to by the Ministry of Health and the Costa Rican Social Security
Fund, a working group has been formed made up of a planner and an
epidemiologist from each of these institutions to develop a
project to promote analysis of the health situation at the local,
regional, and national levels and ensure the development of
decentralized surveillance and health systems. 
The agreement stipulates that both institutions should provide
comprehensive health care for the population.  For this purpose
it is considered essential to determine what the health problems
and needs are and what differences exist with regard to these
problems and needs among the various population groups.  At the
same time, the foundations should be laid for the organization of
common systems, such as health surveillance and joint local
programming, that will make it possible to control, monitor, and
evaluate health actions in all local health systems, both in the
regions and at the national level.

Special Graduate Epidemiology Program in the Health Services
In order to facilitate development of the above-mentioned project
on surveillance and planning, a personnel training program has
been launched in order to strengthen epidemiology in the nine
health regions.  In each region an officer, who will be the focal
point, has been placed in charge of epidemiology, but training is
provided to the entire team in the region.
The course will not require physical attendance and will be based
on the problems prevalent in the regions during development of
the project.  The course will begin next May and will be
coordinated by the Public Health Department of the School of
Medicine of the University of Costa Rica with the support of the
programs for Health Situation and Trend Assessment and Health
Training for Central America and Panama (PASCAP) of the Pan
American Health Organization.

Third Brazilian Congress on Collective Health and First Southern
Cone Meeting on Collective Health 
The Third Brazilian Congress on Collective Health/First Southern
Cone Meeting on Collective Health will take place 16-20 May 1992
at the Federal University of Rio Grande do Sul, Porto Alegre,
State of Rio Grande do Sul, Brazil.
The event is being organized by the Brazilian Association of
Graduate Studies in Public Health (ABRASCO), the Municipal Health
Secretariat of Porto Alegre, and the Extension Course Program of
the Federal University of Rio Grande do Sul.  The meeting will be
sponsored by the Secretariats of Science and Technology, Health,
and the Environment of Rio Grande do Sul; the Pan American Health
Organization; the Ministry of Health; the National Council for
Scientific and Technological Development; the Studies and
Projects Investment Corporation; the FIOCRUZ National Public
Health School; the Federal University of Santa Maria, the Federal
University of Pelotas; the University of Ijuí; the Regional
Council of Psychology of Rio Grande do Sul; and the Latin
American Association of Social Medicine.  The main subject of
discussion will be health as the right to life.
Further information may be obtained from:  Secretaria dos III
Congresso Brasileiro de Saúde Coletiva e I Encontro de Saúde
Coletiva do Cone Sul, Av. Oswaldo Aranha, 1423, Sala 102, 90210
Porto Alegre, RS, Brazil.

Second Brazilian Congress of Epidemiology
The Second Brazilian Congress of Epidemiology will be held 13-17
July 1992 in the School of Medicine of the Federal University of
Minas Gerais and in the Minascentro, Belo Horizonte, State of
Minas Gerais.  The meeting is being promoted by the Brazilian
Association of Graduate Studies in Public Health (ABRASCO), the
Department of Preventive and Social Medicine and the Core Studies
Program in Public Health and Nutrition of the Federal University
of Minas Gerais, and the Ministries of Health, Science,
Technology, and Environment of the Government of the State of
Minas Gerais.  Support is being provided by the Pan American
Health Organization, the Ministry of Health, the National Council
for Scientific and Technological Development, the Studies and
Projects Finance Corporation, the Ministry of Sports, Tourism,
and Recreation of Minas Gerais, the FIOCRUZ National Public
Health School, and the Municipal Health Secretariat of Belo
Horizonte.
The success of the first Congress, held in Campinas in 1990, was
reaffirmed by approximately 1,500 participants.  The number and
quality of the papers presented were testimony, on the one hand,
to the growth of epidemiology in Brazil and, on the other, to the
great demand that exists for knowledge and experiences in this
area.
The core subject of the second Congress will be the quality of
life and the historical commitment of epidemiology.  The event
will take place in two stages:  the pre-congress stage, during
the first two days, will consist of workshops and courses; and
the congress per se during the following days will consist of
conferences, seminars, round tables, coordinated communications,
and the presentation of posters based on the core subject.
Further information may be obtained from:  Secretaria do II
Congresso Brasileiro de Epidemiologia, Av. Alfredo Balena 190,
10o andar, 30130 Belo Horizonte, Minas Gerais, Brazil.

System of Health Surveillance and Living Conditions in Cuba
As a result of the workshop on the health situation, carried out
in the context of the research plan devised by the National
Academy of Sciences in mid 1991, a multidisciplinary and
multi-institutional working group was formed to formulate a
project for the development of a National System for Surveillance
of the Health Situation and Living Conditions.
This group is made up of epidemiologists, statisticians,
geographers, economists, sociologists, and physicians, all staff
members of the Schools of Public Health, Economy, and Geography,
of the Superior Institute of Medical Sciences of Havana; and of
the Office of the Deputy Minister of Epidemiology and Health
Services, with the support of the Office of the Deputy Minister
of Economy, all from the Ministry of Public Health.  There has
also been participation by a staff member from the Institute for
the Study of Internal Demand.
In accordance with the design of the project, reports will be
made every three months on the performance of indicators of
health damages, the health services, and the living conditions of
a national sample of families classified according to varying
living conditions.  The offices of family medicine physician are
used as a sampling unit to implement this strategy.
In addition to this basic and permanent module of indicators, the
design of the project makes it possible to introduce occasional
modules for the evaluation of specific problems.
The first stage of the project envisions a field test scheduled
for 1 April 1992.  The first preliminary results will probably be
available sometime in May.
It is expected that this field test will make it possible not
only to work out the operational details, but also, if necessary,
to adjust the selection of indicators and of the families
included in the sample.  It will also make it possible to
evaluate the usefulness of the system for decision-making at the
national level with regard to health actions and well-being. In a
later stage, the design could be adjusted for use at the
provincial and local levels.


Mortality and Living Conditions in Venezuela
Investigators from the Department of Preventive Medicine of the
Central University of Venezuela are carrying out an exploratory
study on mortality profiles in various population groups,
classified according to living conditions.
The study uses the mortality information registered by the
Ministry of Health and the results of a study on the extent and
distribution of poverty carried out by the Ministry of the Family
and seeks to validate the accessibility of information sources
and the methodological proposal (see Surveillance of Living
Conditions and the Health Situation, Epidemiological Bulletin,
Vol. 12, No. 3, 1991).  It is expected that the preliminary
results will be available during the first four months of 1992
and will serve as a basis for the design of a research proposal
on mortality profiles and living conditions in the 1980s.

Second National Workshop on Epidemiology in the Health Services
and the Family Physician in Cuba
In June 1988 the First National Workshop on Epidemiology in the
Health Services was held, which brought together distinguished
professionals from the health services and from the fields of
education and health research.  During the event the foundations
were laid for strengthening epidemiology in the years to come in
the context of profound transformation of the Cuban health system
with the introduction of a new model for primary care based on
the family physician.
Guidelines were designed in the workshop to enhance epidemiology
as a specialty and as a general work method for the National
Health System, both in the health services and in education and
research.
The Second Workshop will be held 22-23 March 1992 at the
headquarters of the National Institute of Hygiene and
Epidemiology in Havana in order to examine both compliance with
the agreements adopted and the degree of development attained. 
In addition, the work guidelines for the coming years will be
designed, taking into account present-day health profiles and
current circumstances, with a view to strengthening the role of
epidemiology in improving the health situation and the living
conditions of the population.

EBS13104.wpf
MEETING ON THE TEACHING OF EPIDEMIOLOGY IN 
MEDICINE AND NURSING CURRICULA IN ARGENTINA
The meeting on the Teaching of Epidemiology in Medicine and
Nursing Curricula in Argentina was held in the city of Mendoza
4-5 November 1991. The event was organized jointly by the
Association of Schools of Medical Sciences of the Argentine
Republic (AFACIMERA) and the Association of University Schools of
Nursing of the Argentine Republic (AEUERA), under the auspices of
the Secretariat of Health of the Ministry of Health and Social
Action, PRONATASS, and the Pan American Health Organization.
The aim of the meeting was to make a critical analysis of the
situation of training in epidemiology in both curricula and to
identify the principal theoretical-methodological, pedagogical,
and organizational problems of training in this field in the
current Argentine context with a view to adopting measures to
overcome the deficiencies detected.
As a general frame of reference the need was pointed out for
promoting an epidemiological approach capable of contributing
theoretical and practical elements (educational and care) in
order to reconsider the satisfaction of health needs from the
perspective of the population and not exclusively from that of
the medical services.
The importance was pointed out of the meeting held in Buenos
Aires in 1983 on "Uses of and Prospects for Epidemiology" in
reorienting the role of epidemiology in the health services and
health programs.  The need was also pointed out for continuing to
strengthen the following areas:  identification of groups at risk
and priority areas in the health programs; diagnosis and
assessment of the present health situation and future needs; new
approaches for the planning, execution, and evaluation of the
services and programs; promotion of mechanisms to facilitate the
coordination of activities and scattered resources and to
organize intervention packages that will result in greater impact
on the priority groups through more efficient use of resources;
promotion of health services research; and epidemiological
training for clinicians and administrators in close collaboration
with the training institutions.
Both groups--Medicine and Nursing--directed their efforts toward
defining the targets to be attained in the educational process in
developing the epidemiological approach.     
The Schools of Medicine defined critical contents and proposals
for thematic units and areas of practice whose general objectives
serve to "provide the students with an instrument to be utilized
for constructing an alternative model that transcends clinical
practice and is focused on a paradigm conceptually based on the
health of the population and not solely on medical care."
Among the contents proposed, emphasis was placed on knowledge and
critical analysis of present-day health-disease trends and
paradigms, the interrelationship with other disciplines, new uses
of the discipline directed toward a comprehensive analysis of the
health situation of the population, the identification of risk
factors, the comprehensive management of services and health
programs, and the importance for the training process to be
carried out within a whole network of services integrated into
the community at all levels and sectors.  A particularly salient
point was the essential role of research in creating
epidemiological criteria and in approaching and solving problems. 
Research has thus been identified as an end (one of the uses of
epidemiology) and as a means for forming epidemiological
criteria. 
The Schools of Nursing identified concrete proposals in the
educational process, arguing that it is there that students
identify and opt for a specific practice.  Accordingly, a
proposal was made to promote care programs based on
multidisciplinary integration of teaching and service, assisted
by community participation.
TECHNICAL MEETING OF HSD STAFF MEMBERS

Washington, D.C.
23-27 March 1992


I.         BACKGROUND

The HSD Program has felt it necessary to call a technical meeting to bring together
all its personnel at Headquarters and in the countries for the general purpose of
exchanging information on cooperation activities and contemplating future lines of action
in relation to the Strategic Orientations and Program Priorities for the quadrennium.

Collective analysis constitutes a valuable approach in this matter, given the
importance of cooperation in the specific area of health services, not just because it is one
of the central strategies of the Organization but also because it involves the efforts of
various PAHO programs. 
It is well known that HSD staff members in many cases have taken on the
responsibility of acting as focal points for cooperation with other programs and projects.

This gathering should be seen as an important opportunity to facilitate the
necessary interprogram integration and cooperation.

The topics on the agenda will focus on the immediate responsibilities that will be
encountered in the development of cooperation as the sector is being reorganized, the role
of the central level, decentralization and local health system development, community
participation and the instruments for its development, and evaluation of the coverage and
impact of this strategy.

Thus, the general objectives of the meeting will be:

1.         To conduct a strategic evaluation of the management of the HSD Program
in the Region and in each country.

2.         To review the responsibilities of HSD personnel in each country and their
interprogram functions.

3.         To discuss strategic administration of local health systems as an important
form of cooperation and to facilitate interprogram coordination.

4.         To propose future lines of action, especially in regard to evaluation, the
analysis of coverage and impact, and community participation.
II.        SPECIFIC OBJECTIVES OF THE MEETING

1.         To exchange information on activities in the countries and at the Regional
level in relation to health services development and the integration of
programs. 

2.         To analyze the Organization's strategy in relation of the SOPPs and the HSD
program.  Strategic administration.  Local health system evaluation.

3.         To propose ways of strengthening teamwork in these areas and to develop
a plan of work.



III.       PROCEDURE


-          Maximum participation by all personnel will be encouraged.

-          The participants will meet in plenary sessions and working groups.

-          The outcome of the meeting is expected to be a report and a joint plan of
work.



IV.        WORKING GROUPS


During the meeting and on an ongoing basis, seven working groups will examine
three topics (strategic administration, local health system evaluation, and the
integration of programs).  Each group will prepare a report to be presented at the
end of the meeting. 





TOPIC I

Strategic Administration in Local Health Systems:
How to develop the process of strategic administration in each country.


Coordinator:  Mario Boyer


GROUP I - Andean Area, Southern Cone (South America)

Participants:

Mario Boyer, Moderator*
Humberto Alarid
Ramón Granados
Patricio Hevia
Rodrigo Salas
Edgardo Torres



GROUP II - Central America, Cuba, Dominican Republic, Mexico

Participants:                    

Miguel Segovia, Moderator*
Leonel Barrios
José M. Marín
Joaquín Molina
José A. Pages
Mariana Pimentel









GROUP III - Caribbean

Participants:                    

Sandra Land, Moderator*
Eduardo Carrillo
Ana Rita González
Peter Mertens
Richard Van West
Patricio Yépez




TOPIC II

Local Health System Evaluation:  Case studies


GROUPS IV - Local Health System Evaluation

Coordinator:  Roberto Capote

Participants:                    

Roberto Capote, Moderator*
Rigoberto Centeno
Dolores Ortíz
Ana Lucía Ruggiero
Diego Victoria





GROUP V - Local Health System Evaluation

Participants:                    

Humberto Novaes, Moderator*
J. Guerrero
Gastón Oxman
Esequiel Paz
José Dekovic


TOPIC III

Development and Integration of Programs in Local Health System Development: 
Information will be included from the countries and from the Regional programs.


GROUP VI -  INFORMATION FROM THE COUNTRIES

Coordinator:  Enrique Fefer

Participants:

Antonio Hernández, Moderator
Luis Arcila
Julio Caldera
Enrique Fefer
Samara NitØo
Roberto Rodríguez
Carlos Valerín








GROUP VII - INFORMATION FROM THE PROGRAMS

Participants:

Rosario D'Alessio, Moderator
Cari Borrás
Gloria Briceño
Francisco Castro
Philippe Lamy
Julio Suárez
Francisco Vallejos




General Coordination of the Meeting

José María Paganini, General Coordinator
Tatiana Lagos
Miguel Segovia


Secretariat

Olga Yuri
Jenny Newhall
Fernando Garra


AGENDA FOR THE PRESENTATION OF
REGIONAL ACTIVITIES

Tuesday, 24 March
(2:00 - 6:00 p.m.)



Radiology                                              Cari Borrás

Rehabilitation                                         Alicia Amate

Drugs                                                  Enrique Fefer - Rosario D'Alessio

Maintenance                                            Antonio Hernández

Nursing                                                Sandra Land

Information System                                     Gastón Oxman

Urban Areas                                            Roberto Capote

Financing                                              Mario Boyer

Administration                                         Miguel Segovia

Hospitals                                              Humberto Novaes

Laboratory - Dentistry,
Community Participation                                           

Research                                               José M. Paganini - Ana Lucía Ruggiero

HSD Administration                                                José M. Paganini - Tatiana Lagos



PRELIMINARY AGENDA
FOR PROGRAM PRESENTATIONS 

Wednesday, 25 March


 9:00 -  9:30 a.m.                          José R. Teruel/Francisco López Antuñano

 9:30 - 10:00 a.m.                          Claude De Ville - Disaster Preparedness

10:00 - 10:30 a.m.                          Mariela Vargas - Health Program Analysis 

10:30 - 11:00 a.m.                          Coffee break

11:00 - 11:30 a.m.                          Rebecca De los Ríos - Program on Women, Health, and
Development 

11:30 - 12:00 m.                            Pablo Isaza - PAHO/IDB Technical Cooperation Coordinator

12:00 -  2:00 p.m.                          Lunch break

 2:00 -  2:30 p.m.                          Alvaro DurØo, HPE - Workers' Health

 2:30 -  3:00 p.m.                          Eric Nicholls, HPA - Program for Health Promotion

 3:00 -  3:30 p.m.                          Fernando Zacarías, HST - AIDS

 3:30 -  4:00 p.m.                          Coffee break

 4:00 -  4:30 p.m.                          Oscar Fallas, HSP - Policy Development and Social Security

 4:30 -  5:00 p.m.                          Fernando Beltrán, HPT - Communicable Diseases

 5:00 -  5:30 p.m.                          Miguel Gueri, HPN - Nutrition


AGENDA
TECHNICAL MEETING OF HSD PERSONNEL
Ellicott City, Maryland
23-27 March 1992

TIMEMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY 7:30 -  8:30BreakfastBreakfastBreakfastBreakfastBreakfast 9:00 -  9:30Presentation of objectives
of the meetingTopic III 

Exchange of information on "The Sphere of Responsibility of HSD Personnel"Topic III

Presentations by the various PAHO programsGroups discussions on Topics I, II, and III

Final plenary session

Report on Topics I, II, and III





General discussion


Evaluation


Closing session 9:30 - 10:30





10:30 - 11:00


11:30HSD policies and strategies in the framework of the Organization's policy and strategy 

Free time to take care of personal business

Travel to the meeting site12:30 -  2:00LunchLunchLunchLunchLunch 2:00 -  6:00Topic I

Analysis of proposal on local strategic administration


Topic II

Local health system evaluation
Topic III

Analysis of strategies and objectives of various technical components of the HSD ProgramPresentations by the various PAHO programs  (continued)Groups
discussions on the various topics (continued)
Return 7:00 -  8:00DinnerDinnerDinnerDinnerTopics I, II and III - Working Groups
It is expected that these groups will be formed on Monday after dinner and will continue to meet at their discretion during the rest of the week.Preparation of
consolidated report on the various topics:
group rapporteurs







The meeting at Quebec called "International Health:  A Field
of Professional Study and Practice" made clear the pertinence of
a meeting whose subject was an analysis of the status of thinking
in the field of international health.

As the sessions revealed, that pertinence was emphasized
from three viewpoints.  The first was represented by those
participants who held that the meeting could create a landmark by
helping advance from the old to the new international health,
from the colonial or neocolonial idea which has reigned until now
to an independent-cooperative model.  The second viewpoint was
represented by those who thought that beyond a break, the meeting
established the status of the question in the field and to what
point it had advanced, and who were concerned about the impact it
might have on formulating new approaches to the subject. 
Finally, some participants stressed the relationship between
public health and international health, and noted that the
meeting disclosed certain limitations on explanations provided
exclusively by the health sector.

With the idea of recovering some of the central points in
the discussion, some of the items of collective reflection are
dealt with quite schematically in this section (Part I), while
aspects that are considered central to defining a field of study
and practice are taken up later (Part II).  Finally, a few
proposals for developing the field of international health as to
the production of information and training of human resources are
enumerated (Part III).


I.          Recapitulation:  Toward the construction of an alternative
to the classic international health approach

On the basis of the discussions which took place during the
meeting, it is possible to identify the existence of at least
three approaches to the question of international health
according to the boundaries of their subjects of study.  Indeed,
this is the aspect dealt with most extensively during the
discussions.

International health approached from the viewpoint of
delimiting its subject matter obviously does not exhaust all the
aspects which various authors have taken into consideration in
defining the field.  The approaches which are implicit in an
equal number of meanings of the idea of international health,
using different variables, have been the subject of a survey
which is set out in one of the studies published here.  Such
approaches involve other ways of defining priorities, theoretical
frameworks, and areas of application.1

The first of the three approaches identified during the
meeting, which might be called the "classical approach,"
construes its subject of study and intervention as health in the
underdeveloped countries and, in some instances, adds minorities
and marginal groups in the central countries to this
delimitation.  This approach basically occurs in most of the
international health programs offered by schools of public health
in the United States.

The second approach tries to go beyond the classical
approach by highlighting the need to construct a "new
international health" whose subject would not be defined by
delimitation based on the level of development achieved by
countries but by recognition that there are national and
international arenas.  International health would be the
correlate of public health on the plane of the ... "phenomena,
links, actions, and interactions in the health-disease process
which occur between the subjects and the spheres of international
society."2

Finally, the third approach joins the international
dimensions of health with health as an international matter.  It
is differentiated from the first in that it does not limit its
subject to the underdeveloped countries; on the contrary, it
characterizes a view of that kind as ethnocentric.  And it is
differentiated from the second by not giving priority to the
national-international relationship in its delimitation but
rather to the structure, processes, and relationships of world
power which in turn and to a different extent and in different
ways affect the configuration of the health-disease process and
the care systems within each national unit.

1.          The classical approach

The discussions during the meeting of concern to us revealed
the structural features of the model underlying the classical
approach to international health.  There was basic agreement as
to the characteristics of those features.

The features in question refer to both the definition of the
subject of study and the practices stemming from it.

In trying to present the characteristics of the classic
model schematically, as discussed during the meeting, the
ideological nature of the definition of the subject of study
which, based on an ethnocentric concept, defines the subject of
international health in relation to the "others" is seen.  This
definition of the "other" involves an attempt to understand what
is different by focusing on an implicit "we."  The "other" may be
peripheral countries or minorities in the central countries. 
Public health is limited to explaining and intervening in the
health question of the central countries, sometimes by excluding
minorities.  On the basis of this concept, the subject of public
health is thus defined on the basis of this implicit "we," while
that of international health is constructed in relation to the
cultural or economic "other."

This definition is not based on a relational analysis, i.e.,
on an approach that explains the emergence of a state of
development (for example, technologic underdevelopment) through
observation of those general processes which produce states of
technologic overdevelopment on the one hand, associated with
situations of technologic underdevelopment on the other.

Indeed, in this approach each category (underdeveloped
countries or minorities) appears as a total system, to explain
which it is only necessary to refer to the internal functions and
relationships of the system.

In this way, the asymmetry of power which occurs on a global
scale is hidden, and thus the fact that this may to a large
extent explain the conditions under which the countries on the
periphery are evolving.

In the same way, the fact that the asymmetrical
relationships of the different social groups within a national
unit is often omitted, which may explain the structures and
processes on which the subordinate social groups in the central
countries are articulated.

As discussed during the meeting, one of the consequences of
this definition is that the subject of study is made uniform. 
The peripheral countries appear to be subjects of uniform
actions.  The classic approach has in many cases operated on the
assumption that such countries are homogeneous among and within
themselves.

The foregoing has been expressed in the activities carried
out on the basis of this viewpoint in homogeneous and
decontextualized responses imposed on heterogeneous realities,
both from the cultural and economic viewpoints, of the peripheral
countries.

At the same time, the care concept was noted among others
which is implicit in the classic approach and which determines
the set of activities that are undertaken on the basis of this
viewpoint and that reduces a counterpart to an uncritical
internalizer of models and technologies whose priority and
pertinence was decided extranationally and from a unilateral
perspective.  Likewise, the importance of the prevalence of this
care concept in the treatment provided to social groups defined
as minorities became clear.

This care concept has impeded the execution of activities
aimed at strengthening the scientific and technologic capacity of
technologically underdeveloped countries.


2.          Some categories that could shape an alternative view of
international health

Points of agreement in relation to the critique of the
classic approach were not the only matters presented during the
meeting.  Certain categories could also be identified which were
pointed out by participants supporting different approaches which
could shape an alternative view in the subject of international
health.

In other words, there was a consensus on two points:  first,
on the recognition of the limitations of the so-called classic
approaches, and second, the need to construct new approaches in a
process already initiated by various groups in the Region.

The characteristics proposed for working out this new
approach include the aspects of delimiting the subject of study
from adequate theoretical and methodologic frameworks as well as
those aspects dealing with the mechanisms on the basis of which
the principles of international health can be implemented.

The need was pointed out for constructing independent
approaches which do not uncritically reproduce the dominant
concept of international health in the developed countries.  This
construction should include the contributions of investigators in
such countries who share the need to achieve a cooperative
approach.

The importance of not establishing a false dichotomy between
the northern and southern positions was stressed, but rather of
making an effort to develop, in view of the scant reflection in
this field in Latin America, an alternative of Latin American
thought as well as self-reflection for the set of actors involved
in matters of international health in the developed world.

With respect to delimiting the subject of study, it was
understood that international health should not be limited to the
field of the underdeveloped countries.  It was noted that there
are common themes in the regional health question which warrant
common reflection, basically at the level of the powerful spurs
which influence the health systems in most of the countries above
and beyond the north-south relationship and which are
crystallized in problems of financing the system; of asymmetry in
the relationships between the different professional categories
working in the sector; of the limitations of the proposals which
are predicated on volunteers, from whom it is expected that they
will make up for the inadequacies of the system; the introduction
of indiscriminate technologies; attempts to solve through
biomedical criteria the social problems arising from
socioeconomic determinants, environmental risks, and the
atomization of the health system.

As was emphasized in the meeting, the field of international
health requires an interdisciplinary approach.  This involves the
concurrence of both those disciplines which focus the analysis on
the international arena and the contribution of public health and
the social sciences.

At the same time, the intersectoral nature of the problems
of international health was noted for dealing with which both the
sectors directly linked to health care and those related to their
conditioners and determinants should take part.

Considered central in constructing an alternative approach
was the historical, national, and regional contextualization of
the activities established in order to preclude standardizing
normative actions by the countries, with a lack of information
about national processes.  Such contextualization would be based
on recognition of the cultural and economic heterogeneity among
and in each of the countries.

The essential objective of international cooperation in
health adjusted to this new approach would be to strengthen the
self-capacity of the countries intervening in the process of
cooperation in a conception according to which international
health activities would be used as an instrument of diplomacy and
solidarity and not as a mechanism of domination.

In turn, stress was put on the need to strengthen technical
cooperation among countries, which means a process of interaction
which is not unidirectional in nature and which is conducted not
only in the way in which it has been classically, i.e., from the
technologically developed countries toward the underdeveloped
ones.  In fact, the need was also considered of stimulating
cooperation between developing countries, between developed
countries, and from the former toward the latter, highlighting
the subjects of financing, organization, and development of
medical care services, human resources development, social
participation in health, and the environment.


3.          Two approaches to drawing up alternative models in
international health

Basically, two proposals were put forward during the meeting
to deal with the field of international health in order to
overcome the limitations of the classical approaches.  The first
is known as "new international health,"2 in contrast to that
called "traditional international health."  The second refers to
two dimensions of analysis:  on the one hand are the questions
which, from the international sphere, unduly influence the
health-disease process and the health care systems obtaining at
the national level (international dimensions of health); on the
other, there is the question of health as an international
matter.

These two proposals3,4 are developed by their authors in this
book and reflect the presentations made during the meeting.

The first approach starts from the idea that traditional
international health focuses on the health problems which affect
the developing countries, while the new international health
extends to health problems which affect all countries.

Traditional international health could be characterized by
an approach based on a view of developing countries which assumes
them to be homogeneous, while the new international health takes
into account the diversity between and within the developing
countries.  Traditional international health protect through
unilateral measures from the center to the periphery, while the
new international health would stimulate bilateral and
multilateral measures.  Traditional international health would be
based on the concept of aid in providing health services, while
the new international health would define the relationship
according to the concept and practice of cooperation in a gamut
which would include health teaching, research, and services.  The
approach of traditional international health would be based on
the concept of dependence, while that of new international health
would be carried out through the concept of interdependence.  In
turn, there is probably a difference of emphasis between
traditional and new international health:  while the former deals
with the communicable diseases, the latter would operate on the
basis of the epidemiologic transition.  Finally, while
traditional international health be based on primitive health
services, new international health would operate on and for the
transition of the health services.2

In the latter approach, international health is defined as a
field of public health and its interdisciplinary nature is
stressed.  Between the one and the other the difference would be
in the spheres of action:  while public health would constitute a
field of research and of action in health activities defined by
its population level and framed within the political and
administrative boundaries of the countries, international health
would take into account questions that transcend a country's
borders by using the tools of public health and information
contributed by other disciplines.

The second approach rests on two substantive factors: 
consideration of international health as a division of the vast
field of international relations which are thought of as a system
of power relationships and, in the second place, international
health as a field of health, thought of on the basis of its
internationalization as part of the transnationalization of
economics.5

These two elements are articulated to delimit a field
expressed as follows:  " ... one which corresponds to a
definition in the broad field of international relationships
considered as a political, economic, and military superstructure
which regulates relationships among nations and which we call
health as an international matter.  Health as an international
matter enables us to analyze ... the regulations, uses, and
customs of a health nature in the international framework,
financial resources, goods and services which flow from one place
to another on the planet, its participation in global flows, and
certain health events which are transformed into political
(border closings), economic (quarantines), or military events
(blockades of drugs and medical inputs, etc.)" ...  "Another line
of reflection arises from the national arenas of the Latin
American countries, i.e., from national health systems, by trying
to keep alive those phenomena or processes which are
international in nature.  We have called this second line of work
the international dimensions of health."3

From this approach an attempt would be made to reveal
dimensions which are systematically concealed in most
investigations of the health sector and which are, for example,
related to the marked and growing dependence which national
health systems have toward the transnationalized medico-
industrial complex.

From this perspective it is emphasized that the concept of
interdependence, used to take into account relationships between
countries of different technologic, economic, and military
development hides the asymmetry of such relationships.  "It is
obvious that a technologically advanced nation state needs the
markets and human and material resources of other nations in
order to guarantee its development, and in this sense there is a
certain amount of interdependence, but the quality of the two
`dependencies' is different."4


II.         Elements for defining a field

One of the advances at the meeting was the articulated
formulation of a set of questions about international health. 
Some of these questions are strategic in nature, while others are
theoretical and methodologic, and still others deal with
practices.  All of them refer to points which appeared to be
central in the discussions and implicitly or explicitly express
that need several times to construct explanatory models which
from international health lead to the search in which various
groups in the Region are engaged which, from different
disciplines, deal with the health-disease process and care
systems.

From this set of questions arise those which deal
specifically with international health as a subject of
consideration and whose point of departure is, What is meant by
the concept of international health? and continues with the
following:  When international health is spoken of, is one
referring to an explanatory model, a discipline, an intellectual
field, a problem area within public health, or a subject for
consideration?

And, in any case, What is the strategic usefulness of
arguing about legitimacy in a field appropriated by a concept
termed ethnocentric by most of the meeting's participants?

And then:  if up to now international health has had to do
with health in the developing countries defined according to the
views of certain interests in the central countries, what meaning
does the subject of international health have when seen from the
perspective of the peripheral countries?  And in such a case, Is
it pertinent to work out a view of international health which has
an explanatory capacity about the problems we have to confront in
the Region and therefore important in the North and South?

What are the body of knowledge, specific skills, and the
field of application of international health?

These and other questions should be dealt with in order to
define the nature of the question.  Some of them are also found
in the studies presented here.


1.          Why international health?

Without other intent than to initiate a problematization
and, in any case, a contextualization of the foregoing questions,
it is understood that it is important to observe that, in the
concern of the teams which are trying to develop international
health as a subject of reflection two observations converge, the
first sociohistorical in nature and the second of a theoretical
character.

In the first, reference is made to the intensification of
economic and political processes at the global level during the
past decade, with repercussions in the health field, which have
resulted in the adoption in the Region of economic adjustment
measures which lessen the ability of health systems to care for
the health of the population at the same time that poverty
increases and health conditions worsen.

As noted in one of the studies presented in this
publication, at the beginning of the 1990s the Latin American
economies had experienced a serious economic regression which
accentuated their basic characteristics of rates of inflation,
external indebtedness, and inequalities in distribution of income
which are among the highest in the world.6

Latin America's economic regression, as another of the
studies published notes, imposed to a large extent by concealment
of the geopolitical nature of external debt, occur in a world
which has undergone changes during the past decade characterized
by the development of the multipolarity of the centers of world
power, a period of instability in the industrialized countries
characterized by chronic inflationary processes, reduction in
their rates of growth and disequilibriums in the balance of
payments, inclusion of the peripheral countries in the new world
order under conditions of asymmetry characterized in the economic
sphere by the internationalization of their national markets and
by the external indebtedness and a strengthening of the
relationships of economic and political interdependence
stimulated by the expansion of financial markets, the interests
of transnational companies, and the opening of economic borders
caused by decontrol of exchange rates.5

The industrialized countries take part in this process of
economic internationalization by forming internal alliances among
economic interests, cooperation agencies, and the state.  For
that purpose, they also redefine the role of the state and adapt
their national policies on the basis of the new stage and, in
turn, formulate through it the rules which stimulate trade
exchanges and different bilateral and multilateral forms of
cooperation.

Meanwhile, the periphery attends this process with national
states weakened by those who impose integration rules on them
which are often contrary to national interests because of the
external indebtedness and relationships of subordination with the
centers of power.

In Latin America there is discussion about the need for
regional integration as a way to deal with such a situation of
subordination. It is recognized that the health sector can
contribute thereto by drawing up joint policies designed and
implemented through different mechanisms of technical and
financial cooperation among countries.

To support the processes of drawing up such joint policies,
whether they are governmental in nature or not, as well as to
take account of the socioeconomic and health conditions in which
they will be formulated, a level of explanation is required which
can be seated in the field of international health, as will be
defined below.

The foregoing does not mean that that level of explanation
required cannot be found through another kind of approach, but
that the concept of international health necessarily refers to
the consideration that the sociohistorical and health conditions
mentioned above with an implicit unity of analysis which is the
global social system.

Up to this point the sociohistorical reasons which draw us
to international health, a characterization of which are set out
in the first part of this book.

The second observation to which we refer is theoretical in
nature and is based on the notion that explanatory models which
try to take into account economic, political, health-system
processes which Latin America is experiencing are passing through
a crisis or stagnation which began about fifteen years ago and
corresponds to that of the model of Latin American development
promoted since the 1950s.

Both public health and the social sciences and social
sciences applied to health are in a process of constructing new
approaches which include a reconstruction of its epistemologic,
theoretical, and thematic basis which go beyond those which today
seem mechanistic explanations with slight power of explanation
and prediction.

Equally, in the social sciences and in public health,
present ability to intervene and the lack of effectiveness of
activities undertaken of normative and ahistorical principals is
questioned.

The concerns of the teams which are trying to develop the
field of international health thus occur in a movement which
attempts to undertake the construction of new analytic frameworks
by recovering the knowledge produced in a group of areas and
disciplines of which it forms part.  Such analytic frameworks
will in turn support the configuration of alternatives of
intervention in accordance with the explanations obtained.


2.          Elements for defining a concept of international health

Approaches can be found in the bibliography on international
health which present it as a discipline, others which describe it
as an approach or an explanatory model, and still others which
define it as a field.  Some of these approaches are illustrated
in the studies presented in this book, while others have served
as a basis for preparing some of the articles which were
discussed at the meeting.

In the bibliography published on international health which
defines it as a field are authors who limit that field to a set
of activities of international technical and financial
cooperation in health and those who define it as a field of
professional knowledge and practice.

In the perspective proposed here, international health is
not a discipline in the sense of consisting of a particular body
of knowledge and methodology, nor is public health a discipline. 
International health is shaped on the basis of the knowledge
produced by different disciplines which converges in an area of
specific problematization.

According to the direction which we have opted to examine,
the concept of international health refers to two levels, which
it is pertinent to limit:  the first refers to international
health as an approach and the second to a field of study and
practice.  In this view, the two levels are not exclusive; on the
contrary, it is understood that they participate in delimiting a
field from a particular approach.

The approach in international health attempts to make
reference to a dimension of analysis of the health-disease
process and the care systems which involves explicit
consideration or not of a set of determinations which occur on a
global scale and which not only refer to economic and political
processes but also to health ones.  In this approach, the
category of totality is both a theoretical and methodologic
requirement in the construction of the subjects of study.

Going beyond some reductionist approaches to public health
involves not only switching from a sectoral to a multisectoral
viewpoint, or from an institutional one to a relational approach
with an axis set in the social groups, but also transition to
consideration of the world social system as a unit of
reproduction in power relationships, which in varying degree
influence the configuration of the morbidity and mortality
profile as well as the structure, execution, and response
capacity of health systems.

Explaining the health-disease process and care systems in
most cases involves bearing in mind the global operation of the
capitalist system and the international division of work between
the central capitalist countries and the periphery and asymmetry
in the power relationships which spring from that structure.

In the second place, an attempt is made through the concept
of international health to limit a field of professional study
and practice by adopting an alternative to the traditional
definition, according to which international health is the study
of health in the underdeveloped countries.

In this alternative view, the term international health is
used to designate a field of research and intervention which
designates the international dimensions of the health-disease
process and care systems.  This refers to a level of analysis
which includes focusing on external economic, political, and
health determinants as well as reciprocal determination of the
health of populations.

To take account of the problems identified in this field,
the articulation of knowledge produced in different disciplines
is required.

The processes of intervention in international health
include, among other dimensions, international technical and
financial cooperation in health and analysis of the assumptions
and mechanisms on the basis of which such cooperation is defined.

An approach to these characteristics may reveal other levels
of explanations than those customarily offered by public health
by promoting the production of information about international
arenas and the external processes which influence national health
systems.


3.          International health and commitment

One of the emphases of the meeting was on the idea that
talking of international health also involves recognizing a
dimension of political activity which defines the service from
which the strategic project will be the information produced and
the practices derived from it.  This was again noted basically
because international health is defined as a field of
intervention as well as a field of professional study and
practice.

If the activities of one country can be used as both an tool
of diplomacy and cooperation and of domination, then an
independent approach in international health has a role to play
in supporting the strengthening of solidarity among peoples.

This commitment also involves the production of information
about strategic problem areas which support both the development
of health awareness at the level of social groups as well as the
unlinking of processes oriented to redefining the relationships
of subordination of the peripheral countries to the central ones.

At the level of the training of human resources, in addition
to the academic aspects related to the training of investigators
in various disciplines oriented to scientific production, it is
important to consider the spheres of international action in
which a sizable part of the practices in the subject which
concerns us are carried out and the commitment of the subjects
toward the processes of cooperation.

As the study which refers to PAHO's international health
program noted, "... the articulation of a subject in a practice
of cooperation per se does not guarantee the transformation of
the individual nor the execution of a commitment.  An uncritical
articulation which only gives an individual knowledge of how to
be a successful manager, without real commitment to the
countries, would be really frustrating.  We believe that the
dynamic of carrying out the process, collective reflection, and
the effort of the individual aware of his responsibility as a
social subject are basic elements in ensuring adequate
interaction of the participants in the different arenas of work
of the institution and is an element enhancing his future
employment."

The program has been quite clear in that its objective is
not to train individuals to enter the competitive market, or what
Taussig calls the grants rat race.  On the contrary, we are
convinced that the individual should not only formulate a
project, determine the financing institutions and their policies,
but and above all should determine the impact or the implications
of assistance, the role they play, the timeliness of their
awarding, and the responsibility for following up their
utilization.  We would not like our former residents to enter
this labor market of experts who parade around the countries
without any commitment and with complete unsettling of the
country and the groups they are supposed to help and for which
they are remunerated.  We therefore repeat that the most
important thing in this articulation in the work of international
health is that technical excellence that includes mutual
commitment.  Recognizing that work in international health is not
only determining the technical and financial resources which
exist in the field, is not only being an uncritical participant
in that history."7


III.        Some proposals

It should be pointed out that the contributions made during
the meeting focused basically on the aspects noted above, without
for reasons of time being able to deal in depth with proposals
for carrying out lines of work at the different levels.

The proposals which are set out here were in part drawn from
those made by the participants during the discussions and can be
organized in two categories:  the first are those which have to
do with the production of knowledge; the second are those which
deal with aspect of training human resources in the field.


1.          Production of knowledge

It is understood that it is necessary to conduct the
production of knowledge at three main levels:  (a) in each of the
problem areas which appear to be the most noteworthy in the field
of international health; (b) in the aspects of conception,
transmission of knowledge, and practice in international health,
and (c) of the processes and mechanisms of international
technical and financial cooperation in health.

(a)        The problem areas initially identified were:  (1) the
health-disease process:  the international determinants of
environmental health (including the environment and occupational
health); (2) the health-disease process:  profiles or morbidity
and mortality, opening of borders, and communicable diseases; (3)
processes of health care:  the medical-industrial complex, the
medical model, and dissemination of service models on an
international scale; (4) processes of health care:  comparative
national health systems; (5) processes of health care: 
comparative informal health care systems; (6) the health-disease
process and international policies on controlling birth rates,
communicable diseases, and developing national health services.

(b)        A second aspect to take into account is production of
information based on the field of international health taken as a
subject of reflection, i.e., those aspects having to do with the
study of the conception, transmission of knowledge, and practice
in international health.  The objectives would be to (1)
reconstruct the emergence and development of the concept of
international health and analyze the historical processes which
affected it; (2) continue research on the teaching of
international health in schools of public health in the United
States by determining the times of structuring of the units and
their determinants, as well as the amounts and origins of the
financing obtained; (3) making a survey of the academic
institutions in Latin America which work in fields which, because
of their content, are interested in the field of international
health, not limiting this to the programs of schools of public
health, and (4) studying the state of thought in international
health, which means the updating of information in each of the
identified problem areas.

(c)        Finally, it was thought that information must be
produced about the processes and mechanisms of international
technical and financial cooperation in health.  The main aspects
are (1) international cooperation in health:  international
economic and political determinants in the processes of
cooperation; (2) international cooperation in health:  the actors
and arenas in the processes of international cooperation; nations
and agencies, banks and cooperation agencies; strategies; and (3)
international cooperation in health:  international policies
regarding health and how they are implemented.


2.          Training human resources in the field of international
health

The characteristics of the training of human resources in
the field of international health are determined both by the
approaches employed by training institutions and the spheres of
recruitment of qualified staff.

To analyze the interests of the training institutions, the
objectives which are pursued in the field of international health
in each institution, and the national needs according to which
they operate to definitively design the nature of training in
this field as well as the arenas of professional practice, a
process of regional discussion must be undertaken which deals
with matters such as (1) the scope of training in international
health:  area of specialization or supplementary training
programs for public health workers, social scientists, or
specialists in international affairs; (2) scope of training in
international health:  public health-international health
articulation, analyzed at both the theoretical and methodologic
levels, of the delimitation of their subjects of study and
intervention, as well as matters dealing with prevailing or
anticipated professionalization in each area; (3) scope of
training in international health:  training institutions and
limitations or not on training in schools of public health; (4)
scope of training in international health:  definition of
curricula linked to the production of information in the field,
and (5) scope of training in international health:  programs of
training for international cooperation in health.


IV.         Final thoughts

We have so far presented an outline of the contributions
made during the discussions at the Quebec meeting and certain
proposals worked out on the basis of analysis of the reports and
discussions.

The significance the meeting may will depend on the ability
of those who took part in it to move forward and deepen the
orientations which were profiled and, in turn, promote the
production of information, training of human resources, and
action in the field of international health in relevant spheres
in accordance with a concept which goes beyond the limitations of
the classical models and appropriately establishes the actors
linked to the commitment to health and solidarity among peoples.
E0134.FIN



PUBLISHED VERSION                                       26/III/92

PANAMA
     The general purpose of the health policy of the Government
of Panama is to achieve for all inhabitants in the country a
level of well-being and health which enables them to live better
and lead lives useful to their families and the entire national
community.

       The institutions in the health sector--the Ministry of
Health, which is the regulatory unit, the Social Security Fund,
and the National Institute of Water Supply and Sewerage Systems-
-each has its own identity, carry out their programs in
coordination, and form a decentralized, pluralist, and
articulated National Health System in which responsible
participation by the community is promoted.

     During the year the health authorities continued
strengthening local health systems to provide greater flexibility
at the local level in using their resources and to motivate them
to program, carry out, and evaluate their own health activities. 
Responsibility for the administration of policies and health
standards continues at the central level.

     The efforts and national resources of the health sector were
oriented toward the prevention, surveillance, and control of the
problems or conditions that affect the great majority of the
population.  The maternal and child, workers' health,
environmental sanitation, old age, chronic and social disease,
communicable disease, and vector control health programs were
strengthened; a national policy on human resources in the sector
was formulated in which coordination is established with
institutions training health resources; and policies on drugs and
information science systems for health management were prepared. 
To develop the physical health infrastructure, the application of
technical and economic criteria in the planning of installations
and equipment was promoted, and a national system of medical
equipment and physical infrastructure maintenance was
established.

     PAHO/WHO's technical cooperation with the country responded
to the cooperation priorities proposed by the national
authorities and was framed within the strategic orientations and
programming priorities defined by the Governing Bodies.  The
principal axis of cooperation was support for local health system
development in a search for an adequate strategy for coordinating
the Organization's various programs in the country.  The policy
of decentralization continued to be applied, and the training of
personnel for local levels in various aspects of management was
given support, mainly in administrative systems, maintenance,
statistics, planning, local programming, use of computers, and
administration of health services.  There was collaboration with
the National Commission on Drugs in regard to the selection,
purchase, quality control, storage, distribution, and use of
drugs, information for patients, remodeling and equipment,
personnel training, and the establishment of pharmacies within
local health systems.

     Special situations made it necessary to introduce
significant changes in the programs of the Ministry of Health and
also in PAHO/WHO's technical cooperation.  An important region of
the country, in addition to experiencing an earthquake in April,
suffered heavy floods in May which caused destruction in the
infrastructure of the health services, including water and
sewerage networks.  In addition, in September the epidemic of
cholera made its appearance, strongly attacking one of the most
disadvantaged regions in the country.  PAHO/WHO supported the
national program of emergency preparedness and disaster relief
coordination, and because of the epidemic of cholera cooperated
with the Ministry of Health in the control, surveillance, and
treatment of cases.  It also collaborated with technical
personnel in the Ministry and the communities in organization,
logistical support, and health education to control and treat
diarrheal diseases.

     In collaboration with the Program of Training in Health for
Central America and Panama (PASCAP) and the Schools of Medicine
and Public Health of the University of Panama, the Organization
reviewed the curricula of the regional teaching units and gave
financial assistance to 12 fellows so that they could participate
in the master' degree course in public health which the latter
School offers.

     Through INCAP, PAHO/WHO provided technical advisory services
and financial support to several national projects for defining
policies on nutrition, the introduction of food and nutrition
components in the formal teaching curricula, research on iodine
deficiency, and oral health in schoolchildren.  In addition, the
Organization worked jointly with the Ministry of Agriculture in
programs to improve seeds and food production, and with the
Spanish Agency of International Cooperation (Spain) and the
Ministries of Agriculture, Education, and Health in the
production of the fortified foods "PANACREMA" and the "Enriched
Cookie."

     PAHO/WHO collaborated with the Interinstitutional Committee
on Water, Sanitation, and the Environment in carrying out
projects to mobilize external resources, and with the National
Technical Commission against Cholera on aspects of water quality
control, environmental sanitation, and elimination of hospital
wastes.

     In regard to workers' health, the national authorities were
supported in planning activities to define and implement a
national program in this field.

     In maternal and child health, PAHO/WHO cooperated in
training personnel in the management of programs and in self-
management projects; it tried to bring about the participation of
adolescents in activities to prevent and control sexually
transmitted diseases, family planning, AIDS, the improper use of
drugs, tobacco, alcoholism, and adolescent pregnancy.  The
Organization continued cooperating with the National Department
of Epidemiology in the activities of the Expanded Program on
Immunization (EPI); follow-up and evaluation of vaccination
coverage was established, and specific activities were carried
out to serve population groups that still had not received
immunization services.  PAHO/WHO also collaborated in purchasing
biologicals for the EPI, chain cold surveillance, and personnel
training.

     The national program against AIDS received considerable
support from the Organization, mainly in matters relating to
epidemiological surveillance, prevention of transmission by blood
and blood derivatives, and health education, as well as
logistical support and the supply of materials, equipment, and
other inputs.

     During the year PAHO/WHO cooperated with the National
Service for the Eradication of Malaria in the campaign against
malaria and the vector Aedes aegypti.  In addition, it provided
support for the mental health, hypertension, diabetes, smoking,
food safety, zoonosis control, and foot-and-mouth disease
surveillance programs.

     The National Focal Group of the Program on Women, Health,
and Development received technical advisory services and economic
support from PAHO/WHO to carry out activities aimed at its
strengthening and development.

     During the year nearly 90 foreign experts provided technical
advisory services through the Organization for a total of
approximately 300 days.  In addition, the Organization
contributed technically and financially to holding 359 national
seminars with 14,062 participants and to the participation of 163
nationals in 80 seminars, workshops, and meetings abroad. 
Through the Organization's purchasing program, several national
institutions acquired materials, vehicles, parts, drugs,
vaccines, and other inputs.
E0135.FIN





HSI:

  The last paragraph herein is quite muddled.

Tr.E0135.FIN



CHAPTER V.A                                             26/III/92
PUBLISHED VERSION

CHAPTER V

DEVELOPMENT OF HEALTH PROGRAMS


INTRODUCTION


     During 1991 the application of the strategic orientations
and programming priorities for the Pan American Health
Organization during the 1991-1994 quadrennium were promoted. 
Efforts focused on the lines of action of greatest impact for
articulated execution of technical cooperation programs, and
emphasis was put on intersectoral cooperation and social
participation in national programs to promote health and
environmental health.

     Periodic meetings of the program coordinators and the
Organization's Pan American centers were held in order to analyze
information about the planning, execution, surveillance, and
evaluation of the programs and projects concerning the
performance and development of personnel, budget management, and
generation of scientific and technical documents.

     Progress was made in articulating plans of work, and quite
concrete results were achieved in joint, coordinated, and
institutional action among the centers, the regional programs,
and PAHO/WHO's Country Representatives' offices in the countries.

     Plans of action were shaped for every program and Pan
American center in the Area of Development of Health Programs for
1992-1995.  The experience acquired during the year was
appropriately documented so that this information can be utilized
by the Bureau of the Organization, the Member Governments, and
other interested agencies and institutions.

     Critical analysis continued of the quality and quantity of
technical cooperation activities; progress was made in
identifying and quantifying indicators to measure the factors
which determine efficiency, effectiveness, and equity, and the
structure, process, and impact of technical and financial
cooperation provided to the countries were evaluated.

     The mechanisms for the most efficient execution of joint,
interprogram, and intercenter activities and projects were
reviewed by working groups of experts, committees, and action
nuclei for manpower development in the Secretariat itself;
manpower development in the countries; research proposals and
projects, feasibility studies, direct technical cooperation;
mobilization of scientific, technical, and financial resources;
development of plans, standards and manuals, and generation and
dissemination of scientific and technical information, for which
the data bases in the information systems of the Organization's
Secretariat were utilized fully.
E0136.FIN



CHAPTER V.B                                             25/III/92
PUBLISHED VERSION

FOOD AND NUTRITION


     Food and nutrition activities are embedded in all the
Organization's work and are carried out according to the
Strategic Orientations and Programming Priorities for the 1991-
1994 quadrennium approved by the XXIII Pan American Sanitary
Conference (1990), which pointed the Food and Nutrition Program
out as one of the Organization's priority programs.  In addition,
nutrition policies are identified in numerous declarations by the
World Health Assembly on the prevention and control of
communicable diseases, chronic noncommunicable diseases, and the
care of vulnerable groups.

     The most recent information on nutritional status shows a
small reduction in the prevalence of undernutrition at the
regional level, but it is estimated that approximately seven
million children under 5 years of age suffer from moderate to
severe undernutrition.  The trend toward reduction in
undernutrition has not been observed in some countries or is so
slight that the reduction can be considered null.

     During 1991 the Organization directly supported all the
countries through the Program and its two specialized centers,
the Institute of Nutrition of Central America and Panama (INCAP)
and the Caribbean Food and Nutrition Institute (CFNI).

     Disorders due to iodine deficiency and hypovitaminosis A are
part of the group of diseases whose eradication or elimination
was backed by the Directing Council of PAHO at its XXXV Meeting
(1991).  During the year, PAHO/WHO continued expanding its
support of the countries through the Expanded Program for the
Campaign Against Disorders Due to Iodine Deficiency.  There was
collaboration in evaluating the existing situation and in
reorienting the programs in Argentina, Bolivia, Colombia,
Ecuador, Haiti, Mexico, Paraguay, Peru, Uruguay, and Venezuela
and in the countries of the Central American Isthmus. 
Cooperation with other agencies that work in this field (UNICEF,
Centers for Disease Control (USA), International Advisory Council
on Disorders Due to Iodine Deficiency) as well as with the
Ministry of Cooperation of Belgium was also strengthened.  The
prevalence of these disorders has diminished in almost all the
countries, mainly in Bolivia, Ecuador, and Peru.

     In 1991 the problem of controlling hypovitaminosis A was
taken up again.  INCAP is performing an important role in this
respect, not only in Central America but also in the rest of the
Region.  There was collaboration with the International Institute
of Science and Technology, the International Advisory Group on
Vitamin A, UNICEF, and the Agency for International Development
(USA) in the Vitamin A Field Support Project (VITAL) to determine
what the situation is and what interventions will be necessary in
Central America, Bolivia and Ecuador, and the ground was cleared
for future activities in Brazil, the Dominican Republic, Haiti,
and Peru, where it is thought that this problem occurs.
     Data about the nutritional status of pregnant women show
that iron deficiency anemia continues to be the fundamental
nutritional problem in that group.  The Organization began to
plan a regional technical meeting in order to formulate a plan of
action to control this problem.  In addition, while the nutrition
of the maternal and child group cannot be neglected, preventive
nutrition is being emphasized, taking into account the high
prevalence of obesity and chronic diseases related to diet.  This
aspect received particular attention in the countries of the
English-speaking Caribbean through CFNI.

     Current information shows an increase in the availability of
energy and protein in most of the Region's countries, although it
is necessary to take into account that this does not represent an
increase at the level of the home in vulnerable groups or an
equitable distribution to the entire population.  The
Organization collaborated in strengthening food and nutrition
surveillance systems (FNSS), especially in the English-speaking
countries of the Caribbean and in Argentina (Province of Salta),
Bolivia, Colombia, Costa Rica, Ecuador, Mexico, Peru, and
Venezuela.  It is evident that the information is being utilized
most frequently for planning and programming at the state or
provincial level and at the local level, as well as to identify
priority aspects of intervention.  PAHO/WHO published and
distributed an updated version of its report on the "Food and
Nutrition Situation in Latin America and the Caribbean," and
completed part of its computerized program for a food and
nutrition data bank.  INCAP collaborated in the training courses
carried out with FAO and the Costa Rican Institute of Research
and Teaching in Nutrition and Health on food and nutrition
surveillance in Costa Rica, and CFNI organized a meeting with the
nutrition coordinators of the Caribbean countries on nutritional
surveillance with emphasis on the chronic noncommunicable
diseases related to nutrition and the diet.
     INCAP carried out activities to define the plan of the
institutional information system and strengthen the capacity of
its member countries and the Institute for the access, use, and
dissemination of scientific and technical information.  Together
with the French Institute for Development and Cooperation in
Scientific Research (ORSTOM), INCAP made a comparative analysis
of the evolution of minimum wages and the prices of principal
foods.  In addition, it collaborated with El Salvador and Panama
in updating the basic food "basket."

     INCAP continued providing support for the countries of the
Central American subregion in formulating food and nutrition
policies, especially in Guatemala, Nicaragua, and Panama.  In
addition, it continued implementing strategies of decentralizing
technical cooperation and collaborating in the establishment of
basic technical groups in this field in the countries.

     For its part, CFNI maintained an active program of
disseminating information through pamphlets, radio and television
programs, exhibitions, and lectures at schools and meetings of
professional associations, and distributed information on the
cost of nutrients, economical foods, and feeding to groups at
risk.  It also continued collaborating with its member countries
in developing standards, policies, and plans according to the
priorities of the subregion, especially in the analysis of
information about chronic diseases; it developed and applied
corrective measures to control iron deficiency anemia in Antigua,
Grenada, St. Kitts and Nevis, and St. Vincent and Saint Lucia;
and it collaborated with the governments in implementing the
subregional food and nutrition strategy.  A basic activity, with
regard to both chronic diseases and research, has been the
"lifestyles" project financed by the Government of France within
Cooperation for Health in the Caribbean.

     In the second phase of the Health Initiative of Central
America, the Ministers of Economy selected five proposals
prepared by INCAP for presentation to the European Economic
Community to obtain financing.  As part of its agreement with
IDB, PAHO/WHO provided technical assistance to Haiti in
formulating a project to improve the food and nutrition situation
in the central plateau of that country, and with the World Bank
offered a seminar in Brazil on nutritional policies and
strategies in Latin America.

     The Organization formulated and carried out food and
nutrition projects in primary health care in Antigua, Barbados,
Bolivia, Costa Rica, Guatemala, Jamaica, Nicaragua, and Peru. 
With the World Food Program (WFP), the Organization collaborated
in reviewing new projects and in evaluating some which were under
way.  External food aid programs  helped improve the availability
of food in the countries.  WFP and the Agency for International
Development (USA) provided a total of 2,162,088 metric tons of
food valued at $US450 million (without counting freight and other
logistical and administrative expenditures) in 1990.

     Taking into account the problem that causes the lack of
human resources in the area of food and nutrition, the
Organization developed a plan of action for 1991-1994 to
strengthen the teaching of nutrition and dietetics in health
schools.  The plan was analyzed at the IV Meeting of the
Commission of Studies for Academic Programs in Nutrition and
Dietetics of Latin America (CEPANDAL), which took place in Puerto
Rico before the IX Latin American Congress on Nutrition. 
PAHO/WHO also conducted a study of the human and institutional
resources of the Regional Operational Network of Food and
Nutrition Institutions (RORIAN), of which INCAP is the Executive
Secretariat.  As a result of the study, the Network was
strengthened as a strategy for mobilizing resources, exchanging
information, training personnel, and promoting research.  In
addition, INCAP continued restructuring a graduate course on food
and nutrition, and in collaboration with CFNI offered a course in
Jamaica on rapid methods of evaluating nutrition knowledge,
attitudes, and practices in the home.

     Concerning maternal and child nutrition, a publication was
distributed in English on maternal nutrition and anthropometric
evaluation (Scientific Publication 529), which was being
translated into Spanish at the end of the year.  In addition, a
WHO monograph on infant feeding and its physiological basis was
translated into Spanish and will be published in 1992.  INCAP
collaborated with integrated maternal and child health programs,
especially in El Salvador, Guatemala, and Nicaragua, and was
carrying out studies on indicators of risk of retardation in
intrauterine growth; agriculture and food safety in the home; and
the processing, management, storage, marketing, and quality
control of basic grains in Central America.

     The Organization is conducting a study on the validation of
anthropometric indicators to evaluate the nutritional status of
pregnant women.  Ten countries in the Americas, selected by WHO
and with its financing, are analyzing information on this
subject.

     A report entitled "Current Situation of Breast-feeding and
Application of the International Code on the Marketing of
Maternal Milk Substitutes in Latin America and the Caribbean" (in
English and Spanish) was disseminated during the year, and the
document "Evaluation of a School Feeding Program:  the Argentine
Case" was also published.
     Efforts were intensified to expand the number of WHO
Collaborating Centers in this field as a mechanism to mobilize
resources, and the Center for Studies on Child Nutrition of
Argentina, the Nutritional Research Institute of Peru, the
Institute of Nutrition and Food Hygiene of Cuba, and the Campaign
Against Endemic Goiter and Cretinism Program of the Ministry of
Public Health of Ecuador were designated as such.  At the end of
the year, requests from the Department of Epidemiology and
Nutrition of Harvard University (Boston, Massachusetts) and the
Division of Natural Breast-feeding and Maternal and Child Health
in the Reproductive Health Institute in the Department of
Obstetrics and Gynecology at Georgetown University (Washington,
D.C.) were being processed.
E0137.FIN



CHAPTER IV.E                                            23/III/92
PUBLISHED VERSION


(The last part, without title, of Health Situation and Trend
Assessments)

     In regard to the International Classification of Diseases
(ICD), the Organization continued preparing the Spanish edition
of the three volumes that compose the 10th Edition of the ICD and
revising the Portuguese version of Volume 1, which was prepared
by the WHO Collaborating Center at SØo Paulo.  In addition, it
cooperated with WHO in preparing the original version in English,
in preparing specific parts of the index to Volume 1, and in
developing the modules that will make up Volume 2.  To facilitate
uniform development of the national versions, guidelines were
prepared which were very well received by the international
community interested in the subject.  In addition, the
Organization developed and expanded the concept of the "Family of
Classifications," and worked actively on two of its components: 
the Spanish edition of the adaptation for oncology and, at the
request of the countries of the Region, the methodological
development for a classification of surgical procedures, which
can be updated automatically.

     The Organization continued working to improve the basic data
and national statistical systems, with significant achievements. 
In 1991, programs were launched in various countries which range
from efforts to improve the quality of information to regional
cooperation in overall statistical systems projects using an
integrated, subregional, and intersectoral approach, such as the
work being carried out with the Caribbean Community (CARICOM) or
the support for development of information systems in priority
areas, as in the case of the Program of Development for Displaced
Persons, Refugees, and Repatriates (PRODERE) in Central America.


     The methodology for analyzing and processing multiple causes
of morbidity and mortality continued to be enhanced to better
understand the health situation.  In addition, work was done on
applying unconventional methods of health information to solve
problems of coverage, opportunity, and quality, using the
techniques already initiated for strengthening vital statistics
and epidemiological surveillance but adding new areas.  Among
them the concept and methodology of the community clinical
history, which at the end of year was ready to be tested before
incorporating it as a methodological resource for practical
application, deserves to be cited.  An effort was initiated for
the first time to concentrate within a frame of reference the
theory which sustains these methods with the results provided by
their practical application to incorporate them into the overall
concept of health information.

     Steps were taken to strengthen the network of centers and
national nuclei devoted to the International Classification of
Diseases and health statistics through an electronic network
which will make it possible to facilitate the process of updating
between revisions.

POST DESCRIPTION -  GUATEMALA

Under the supervision of the Administrative Officer, the incumbent is responsible for:

a) Collaborating in the formulation, preparation, and execution of the Annual Program of Technical
   Cooperation (APB) and the Four-Month Programs of Work (PTC) of the Representation;

b) Recording and documenting, by computer and manually, all budget-related transactions, including
   the disbursement, modification, write-off, or transfer of funds, and establishing all the auxiliary records
   required in order to ensure adequate control of the budgetary, financial, and accounting transactions
   of the Representation during the fiscal year;

c) Issuing allotments for regular and extrabudgetary funds approved by Headquarters, as well as
   processing transfers, increases, reductions, and write-offs of those funds;

d) Issuing obligations for regular and extrabudgetary funds of the Representation, as well as recording
   increases, reductions, write-offs, transfers, and liquidations;

e) Ensuring that budgetary obligations are adequately justified and documented for submission to
   Headquarters;

f) Recording the non-local obligations authorized by Headquarters or other Country Representations
   and keeping track of the balances and payment thereof; 

g) Carrying out periodic financial evaluations and analyses, presenting the required budgetary reports,
   and recommending the reprogramming of activities and adjustments, as necessary;

h) Reconciling the report on allotments, obligations, payments, and revisions contained in the "Allotment
   Notification" received from Headquarters with the records of the Representation and initiating
   appropriate corrective action when discrepancies are found;

i) Monitoring the disbursement and control of funds allotted to the Representation and preparing periodic
   reports on expenditures;

j) Analyzing the general expenditures of the Representation (telephone, fax, telex, courier, photocopies,
   etc.) on a monthly basis and assigning the respective allotment and obligation numbers based on the
   expenditures incurred by each project so that the corresponding payments may be processed;

k) Reconciling the Representation's bank accounts in local currency each month on the basis of bank
   statements and Imprest information;

..||Post Description -  Guatemala
Page 2


l) Processing payments made outside the Representation in accordance with information received from
   Headquarters;

m) Participating in the direct training of personnel in the Budget Area of the Representation through special
   sessions and on an individual and ongoing basis;

n) Preparing and providing the budget information authorized by the Representation to agencies in the System
   and government offices that may require it for statistical purposes;

o) Issuing periodic financial reports to all the technical units of the Representation, as well as specific reports,
   as required;

p) Participating in the planning and implementation of new methods to improve administrative procedures;

q) Performing other duties, as assigned; 

r) Maintaining the files of the Budget Area.



PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION (PAHO/WHO)









SUBREGIONAL PROGRAM ON ENVIRONMENT AND HEALTH
IN THE CENTRAL AMERICAN ISTHMUS - MASICA







PROJECT FOR
INSTITUTIONAL STRENGTHENING

EVALUATION, 1991













SAN JOSE, COSTA RICA
MARCH 1992



SUMMARY


The Project for Institutional Strengthening, which is designed to develop the
institutional conditions for implementation of the projects under the Program on
Environment and Health in the Central American Isthmus (MASICA), serves, in effect,
as a guide for the Program.

Through this Project, MASICA has achieved a considerable presence in the
management of Environment and Health in Central America and has established
coordination mechanisms with the principal entities of the subregion that are active in
these areas.  Of these, special mention should be made of the CCAD, CICAD, REDES-
CA, UNICEF, IUCN, UNEP, AIDIS, CATIE, ICAITI, CAPRE, environmental NGOs,
and the international cooperation agencies.  At the country level, activities have been
geared to the strengthening of national capacity for diagnosis, planning, and intervention
in order to preserve, rectify, and improve environmental conditions that have an effect on
health.  The first MASICA project got under way in 1991 with a total budget of
US$272,166.62, and it achieved 99.79% execution.

During the first 10 months of execution (1 March to 31 December 1991), a number
of actions were undertaken in different subject areas pursuant to the program that had
been decided on.

Specific activities were carried out in the seven countries of the Region in the areas
of Manpower Training; collection and analysis of Environmental Legislation; and surveys
on Community Participation in sanitation projects, on Environmental Information
Systems, and on Laboratories for Environmental Analysis.  In addition, Focal Points were
established and coordination was achieved between the various governmental institutions
and NGOs that interact in the area of the environment and health, which joined together
to form a Project Advisory Group.

The outcomes of these activities are designed to facilitate efforts to identify suitable
counterparts and to seek the resources needed by the projects in the areas of Water
Resources and Drinking Water Quality, Management of Hospital Solid Wastes,
Pesticides, Education on the Environment and Health, Assessment of Environmental
Impact on Health, and Industrial and Vehicular Pollution.

In early December 1991, after adjustments were made in the mechanisms of
administrative coordination with the Ministries of Health and the PAHO/WHO Country
Representations, and after the roles of the Focal Points and Support Groups were defined
at the country level, the Headquarters site of the subregional Project was transferred to
San José, Costa Rica.

This project has been financed by the Norwegian Agency for International
Development (NORAD).  It is anticipated that additional resources will be forthcoming
to continue the activities and tasks that have been programmed.

PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION (PAHO/WHO)

SUBREGIONAL PROGRAM ON ENVIRONMENT AND HEALTH
IN THE CENTRAL AMERICAN ISTHMUS -  MASICA

PROJECT FOR INSTITUTIONAL STRENGTHENING

Evaluation -  1991




 I.        INTRODUCTION

The Project for Institutional Strengthening of the MASICA/PAHO Program began
to channel resources from the Norwegian Development Agency (NORAD) into activities
at the level of the countries and the Central American region so that they will have a real
impact and help to build the capacity necessary in order to improve the quality of life of
the 30 million people currently living in the seven countries of the Isthmus, particularly
in the area of health and the environment.  Specifically, there have been advances that
were initially qualitative but which have also been translated into quantitative elements,
such as the following:

1.         The national structures, which coordinate their activities on the basis of a holistic
approach, have been consolidated, and the six remaining MASICA/PAHO projects
are being readied for execution.  The Focal Points have been designated and the
Advisory Groups have been formed with the participation of public institutions,
NGOs, private companies, and technical assistance agencies.  The administrative
scheme promoted by MASICA, in close coordination with the Ministries of Health
and with the support of the local PAHO/WHO Country Representations, has
improved the mechanisms of interinstitutional coordination and has demonstrated
its usefulness in providing technical assistance to the environmental and health
agencies in the countries.

2.         The process geared to achieving effective coordination among all the actors of the
environmental management systems in the respective countries and in the
Subregion has been strengthened.

3.         All the activities foreseen in the subject areas that make up the Project for
Institutional Strengthening have been initiated, with concrete results in the
collection and assessment of Legislation on the Environment in all countries of the
region.  In the area of Management of the Environment, agreements have been
signed; activities undertaken with the CCAD, CICAD, CAPRE, AIDIS, REDES-
CA, and IUCN; and advisory services have been provided for events such as the
XVII Central American Congress on AIDIS and the V Encounter of First Ladies,
the main subject of which was "Women, Environment, and Development."  A
survey was carried out on Community Participation to determine the experience
with such participation in specific projects for environmental improvement.  In the
area of Manpower Training, three courses were given with a total of 62
participants, and three delegates attended courses outside the region.  In the area
of Laboratory Strengthening, a survey was prepared to evaluate laboratory capacity
and analytical capacity with regard to the physical-chemical and bacteriological
aspects of water.  In addition, a practical course was prepared on methods for the
detection of V. cholerae in the environment.

In each country, a survey was carried out on Environmental Information Systems
to assess the situation of these systems.  It contains recommendations to establish
a subregional network and to strengthen the principal national centers.  In the area
of Data Bases, work has been initiated for the design and generation of data to be
supplied to the projects on Water Resources and Solid Waste, in the area of
Environmental Legislation, and for a Directory of NGOs concerned with the
environment in Central America.

In November the I Boletín Informativo del MASICA was published.   Also, two
documents, one an introduction to MASICA and the other a description of the projects,
were published in English and Spanish.


II.        RESULTS ACHIEVED, BY COMPONENT

1.         LEGISLATION ON THE ENVIRONMENT

1.1        Compilation of the most important environmental legislation in Central America was
concluded except in Costa Rica, which is to deliver its report soon.  The local
consultants contracted for this phase were:

Eng. Carlos Guerra                                     Belize
Ms. Anabelle Porras Zúñiga                                        Costa Rica
Mr. Magno Tulio Sandoval                               El Salvador
Ms. Elisa Colom de Morán                               Guatemala
Ms. Clarisa Herrera                                    Honduras
Mr. Wladimir Pérez L.                                             Nicaragua
Eng. Juan Héctor Díaz                                             Panama

1.2        Coordination meetings were held with Ms. Isabel Chacón, international cooperation
officer at the United Nations Latin American Institute for the Prevention of Crime and
the Treatment of Offenders (ILANUD), an institution that is attempting to promote a
project similar to MASICA on environmental legislation, natural resources, and
sustained development in the Central American Isthmus (February 1991).

1.3        Several contacts were made and communications exchanged with Dr. Raúl Brañez of
the UNEP Regional Office in Mexico on advisory services regarding the methodology
for the collection and systematization of current environmental legislation in Latin
America and the Caribbean.

1.4        Conversations were held on the subject with Dr. Ricardo Koolen (Argentina), a
possible consultant for successive phases in this area of the project, as well as with Ms.
Grettel Ortiz (Costa Rica).

1.5        The technical and legal analysis of environmental legislation in Central America has
been concluded.  This effort took two months.  The consultants that have been
contracted are the same as those indicated under 1.1, with the exception of Nicaragua,
where arrangements were made to contract Dr. Juanita Ortega, and Panama, where Mr.
Gabino Díaz Proll was contracted.

1.6        The process of national consultation on the index of environmental legislation and the
assessment of that legislation was initiated in each of the countries.  This process will
be carried out through national workshops, which will include participation of the legal
departments from institutions concerned with environment and health, national
commissions, professional organizations of jurists, and universities.  It is hoped that
the results ensure the national collaboration required in order to publish an Index of
Environmental Legislation and an assessment for each country.

1.7        Coordination meetings have been held with the Central American Commission on
Environment and Development (CCAD), which is engaged in consciousness-raising
among Central American lawmakers.  MASICA joined in the deliberations of some
of the committees on the environment and similar committees of the Central American
parliaments, in meetings of the Interparliamentary Commission of Committees on
Environment and Development in Central America and Panama (CICAD).  The first
such meeting was in Managua, Nicaragua, in August 1990, and the second in Panama,
in March 1991.  Both included a complete presentation on the purposes of MASICA
and its activities vis-a-vis the need to improve legislation on the environment and
health in Central America.

MASICA maintained contact with several Central American lawmakers who are
members of Committees on the Environment and similar bodies in the legislatures of
the countries of the Isthmus to further sensitize them on the subject of environmental
protection and its relationship to health.  Among these lawmakers were the following:

Mr. Manuel A. Bolaños Salas - Costa Rica
Ms. Anabelle Castro Camparini-Guatemala (adviser)
Mr. Arturo Amiel Escobar-Guatemala
Mr. Moisés Daboub Orellana-El Salvador
Mr. Mauricio Flores Urrutia-El Salvador
Mr. Samuel E. Bográn-Honduras
Dr. Alejandro Pérez Arévalo-Nicaragua
Dr. Frank Panton-Belize
Mr. Erik Santamaría-Panama

The fifth meeting of CICAD was scheduled to be held in Belize in February 1992, and
it was planned that MASICA would provide support and sponsorship.

1.8        Information was exchanged and strategies coordinated with Representative Felipe
Franco, Chairman of the Permanent Commission on the Environment of the Latin
American Parliament (PARLATINO).  This contact is one of several that have been
made with Central American lawmakers.

1.9        Views were exchanged with representatives of the Central American Parliament
(PARLACEN), especially with Ms. Dolores Henríquez.


2.         MANAGEMENT OF THE ENVIRONMENT

2.1        MASICA established a very fruitful exchange with the Central American Commission
on Environment and Development (CCAD), and on 23 January 1991 a Cooperation
Agreement was signed by the CCAD and PAHO/WHO for execution of the Project
"Environment and Health in the Central American Isthmus (MASICA)."

A report on progress under MASICA and the plans of work for 1992 was scheduled
to be presented at the VIII Regular Meeting of the CCAD in Belize in February 1992. 
The V Meeting of the Chairmen of the Committees on Environment and Development
of the Central American Parliaments (CICAD) will be held at the same time.  These
two events will occur simultaneously, with some of the activities combined.

The last meeting to review the Central American Agenda on Environment and
Development was scheduled to be held in Panama on 16-18 January 1992, and it was
planned that MASICA would participate to ensure significant incorporation of the
relationship between Environment and Health in the resulting document.  MASICA
will also participate in other technical events organized by the CCAD in 1992.

2.2        Initial steps have been taken with the CCAD to jointly promote the 1st Central
American Conference on Ecology and Health in 1992, and the provisional agenda for
this event was prepared.

2.3        Under the Project for Institutional Strengthening, MASICA provided advice on the
organization of the V Encounter of First Ladies of Central America and Panama, held
in Managua 18-23 November, which addressed the subject "Women, Environment,
and Development."  Technical support was provided for the development of
documents and training workshops, and advisory services were provided on activities
leading up to the Encounter (Preparatory Meetings of the Central American Technical
Committee, etc.).

2.4        Support was provided to the Organizing Committee of the XVII Central American
Congress of the Inter-American Association of Sanitary and Environmental
Engineering (AIDIS), held in Managua, Nicaragua, on 10-13 November 1991. 
MASICA was invited to give a talk on the nature and scope of its work at the
Congress.  Eng. Rodolfo Sáenz Forero of HPE/PAHO participated as well.

2.5        A contract was signed with REDES de C.A. to compile a list of environmental NGOs
that have health-oriented activities in Central America, using a format prepared by
MASICA.  The work was completed and is under review for publication in the form
of a Directory of NGOs that work on environmental and health issues in Central
America.

2.6        Under the Project for Institutional Strengthening there were conversations with Dr.
James A. Merchant, Director of the Center for International Rural and Environmental
Health, Department of Preventive and Internal Medicine, at the University of Iowa. 
These conversations examined the possibility of eventual collaboration in the areas of
training for, and strengthening of, laboratories under the Project for Institutional
Strengthening, as well as several components of the project Occupational and
Environmental Aspects of Pesticide Exposure in the Central American Isthmus.

2.7        MASICA has established contacts with a large number of subregional organizations
and entities that work in related areas, including:  UNDP, UNICEF, AIDIS, CCAD,
RESSCA, ILANUD, ICAITI, AID-ROCAP, FAO, REDES-C.A., ERIS, IUCN, and
others.  The complete names of these institutions appear in the glossary annexed to this
Report.  The Program was also present at all the principal seminars and conferences
on environment and health held in Central America during 1991.

2.8        The First Meeting of Focal Points of MASICA was held in Managua on 2-5 April
1991, with the following participants:

Eng. Carlos Guerra                                     Focal Point for Belize
Eng. Jorge Bravo                                       Focal Point for Costa Rica
Dr. Héctor Emilio Castillo                             Focal Point for El Salvador
Eng. Pedro Saravia                                     Focal Point for Guatemala
Eng. Franklin Bertrand Anduray                         Focal Point for Honduras
Dr. Jerry Valladares                                   Focal Point for Nicaragua
Eng. Ambar Mereno de Pinzón                            Focal Point for Panama
Architect Jorge Cabrera H.                             Executive Secretary CCAD
Mr. Juan José Montiel                                  Chairman of REDES-CA
Eng. Iván Estribí F.                                   MASICA
Mr. Silvia Ayón R.                                     MASICA
Mr. María Ivette Fonseca                               MASICA
Mr. Hermes Gutiérrez A.                                MASICA
Mr. Rogelio Espinoza I.                                MASICA
Dr. Héctor Gutiérrez                        ECO/PAHO

The meeting was opened by the Minister of Health of Nicaragua, Dr. Ernesto
Salmerón, and the PAHO/WHO Representative, Dr. Carlos Linger.

The principal outcomes of the meeting were:

-          Joint preparation of the Second Four-month Work Plan, with definition of the
actions to be coordinated in each of the seven countries.

-          Decision to reactivate the Advisory Groups in each country.

-          Identification of mechanisms for coordination with the PAHO/WHO
Representatives on the selection of local consultants to be contracted.

-          Decision to prepare a directory of environmental and health NGOs in Central
America.

-          Improvement of the survey on the information systems prepared by MASICA,
and a commitment made by each country to fill it out.

-          Discussion of criteria for a subregional system of environmental surveillance
and information, based on the document presented by Dr. Héctor Gutiérrez of
ECO/PAHO.

-          Declaration of support for the objectives, purposes, and activities of MASICA
by all the Focal Points (see annexes to this Report).

2.9        In each country of Central America efforts were initiated with the support of the local
PAHO/WHO Country Representations to organize a meeting between the MASICA
Focal Points and the Advisory Groups to exchange views on administration and
execution of the Program and to identify a national project for environmental
improvement which would have repercussions for health (Pilot Project) and which
would receive support from MASICA.  During 1991 these meetings were held in five
of the seven countries.

l2.10      The administrative scheme of the Program was defined; San José, Costa Rica, was
chosen as the headquarters site; and a meeting is being planned for the local
counterparts of the PAHO/WHO Representations (country engineers and technical
personnel responsible for liaison and monitoring--TES) to define forms of Program
support, establish administrative liaison, define the national institutional counterparts
for each project, specify in greater detail the role of the Focal Points and of the
Advisory Groups, and report to them on the advances and future outlook for MASICA
in Central America.  The Coordinator of the Environmental Health Program
(HPE/PAHO) and the Coordinator of the MASICA Program will set the date and place
of the meeting in early 1992.

2.11       The Project Coordinator made the following trips in the course of performing his
duties:

Washington, D.C.                                       13-23 March 1991
San José, Costa Rica                        8-10 April 1991
Tegucigalpa, Honduras                                  16-19 May 1991
Guatemala City                                         10-12 June 1991
Tegucigalpa, Honduras                                  13-16 June 1991
Panama City                                            24-26 June 1991
San José, Costa Rica                        27-29 June 1991
Washington, D.C.                                       11-14 September 1991
Oslo, Norway                                           17-20 September 1991
Washington, D.C.                                       7-11 November 1991
Oslo, Norway                                           12-16 November 1991
Panama City                                            21-24 November 1991
San José, Costa Rica                        25-27 November 1991
Guatemala City                                         27-30 November 1991
San José, Costa Rica                                   5-8 December (moved)
Washington, D.C.                                       8-11 December 1991

Consultant Eng. Iván Estribí F. traveled on the following missions:

San José, Costa Rica                        10-13 June 1991
Tegucigalpa, Honduras                                  1-3 July 1991
Guatemala City                                         3-5 July 1991
Panama City                                            25-28 August 1991
Belize City                                            2-3 September 1991
Tegucigalpa, Honduras                                  3-4 September 1991
Guatemala City                                         9-10 September 1991
San Salvador, El Salvador                              10-13 September 1991
Panama City                                            21-24 November 1991
San José, Costa Rica                        25-27 November 1991
Tegucigalpa, Honduras                                  2-3 December 1991
Guatemala City                                         4-5 December 1991

2.12       Up to the time of this report, the Project had been visited by the following                                            missions:

-          Mission from the Nordic countries (Reidar Persson, SIDA; Pierre Fruhling,
SIDA; Jan Robberts, SIDA; Soren Wium-Andersen, DANIDA; Kari
Silfverberg, FINNIDA; and Milagros Barahora from the NORAD office in
Managua), 25-26 January 1991.

-          Mission of Dr. Hendrik de Koning of the HPE program of PAHO/WHO, 23-
28 May 1991.

-          Visit of Ms. Leonor Rodríguez, of the PROQUIM program, 2-4 July 1991.

-          Mission of consultants Marcel Saby and Luis Reveco of the EEC, 7-
11 July 1991.

-          Visit by consultant Ole Frank Nielsen, former DANIDA staff member, August
1991.

-          Supervisory mission of Eng. Horst Otterstetter, Coordinator of the HPE
Program (PAHO/WHO), 22-24 August 1991.

-          Visit from Mr. Rommel Calvo and Eng. Rodrigo Barbosa of CAPRE to explain
the PROQUIM project and the possibility of coordinating activities with
MASICA, 29 November 1991.

-          Visit by Mr. Virgilio Cozzi, Regional Director of the IUCN for Central
America, for a briefing on the MASICA and IUCN projects in the countries of
the subregion, November 1991.

-          Visit by Eng. María Flores de Otero, President-elect of the Inter-American
Association of Sanitary and Environmental Engineering, with whom
discussions were held on a possible AIDIS-PAHO/WHO cooperation
agreement for the execution of MASICA.  The draft of such an agreement was
prepared and is being studied by PAHO/WHO.

2.13       The Project has been integrated into the technical group of the PAHO/WHO
Representation of Managua, at the request of the Ministry of Health of Nicaragua, for
the purpose of assisting with measures to combat and control a cholera epidemic in the
event that one should occur.

2.14       The Coordinator of MASICA participated in a meeting of the Collaborative Council
of the Global Forum on Water Supply and Sanitation held in Oslo, Norway, on 18-
29 September 1991, where he presented a paper on drinking water supply in Central
America, which is closely related to the MASICA project on Water Resource
Conservation and Surveillance of Drinking Water Quality in Central America.  The
presentation proposed a debt-for-health swap in which part of the countries' external
debt would be exchanged for basic sanitation facilities, and this was well received by
the Collaborative Council.

2.15       The first issue of the Informative Bulletin of MASICA was published; it includes news
about the Program and topics of concern to the countries of the Subregion (November
1991).

2.16       There was participation in the third meeting of consultation (1991) between the Nordic
countries and PAHO/WHO, in Oslo, Norway, in November 1991, at which MASICA
clarified some of the donors' questions and explained the scope of its environmental
action in Central America.

2.17       Eng. Iván Estribí Fonseca (Panama) was contracted as a consultant on several
occasions (21 March-20 April 1991, 20 May-20 June 1991, 21 June-20 September
1991, and 20 October-20 December 1991).  He has provided support for the project
in connection with the various environmental management activities specified in its
terms of reference.

2.18       MASICA recently published two more documents that complement the seven projects. 
One is an introduction to MADICA and the other is a description of the Projects, the
latter of which appeared in both English and Spanish versions.

3.         COMMUNITY PARTICIPATION

3.1        Work was begun to determine the most appropriate ways of promoting community
participation in projects for environmental improvement with health repercussions in
Central America.  A survey was prepared to classify the various institutions and
organizations that have carried out or are carrying out environmental projects with
social participation in Central America, and this list was sent to the MASICA Focal
Points in the seven countries.  Based on the results obtained, the most representative
and experienced institutions will be selected and questioned about the forms and
methodologies of social participation that have proved to be most successful.  A
second survey is currently in the testing phase with 19 institutions that work in this
area in Nicaragua.  Consultant María Ivette Fonseca was contracted for this purpose
on 15 March-15 May 1991 and 15 July-14 October 1991.  National consultation
workshops on this subject are being prepared for 1992 in the seven Central American
countries.

3.2        MASICA provided assistance to the Emergency Meeting on Health and the
Environment held on the Island of Ometepe on 27-28 August 1991, with the
participation of several environmental NGOs and the community of Ometepe, through
the mayor's offices of Moyogalpa and Altagracia.  This experience may provide
insight leading to a methodology for working with NGOs and community movements
in Central America.
4.        MANPOWER TRAINING

4.1        On 6-10 May 1991 a subregional course was given on basic concepts of toxicology
with the collaboration of the Pan American Center for Human Ecology and Health
(ECO/PAHO).  The course was given in Managua, with the participation of
representatives from 15 Central American countries plus an additional 12 from
Nicaragua.  The instructor was Dr. Pedro Jauge (Mexico).  Advantage was taken of
the presence of these representatives to inform them about the objectives and scope
of MASICA.  MASICA prepared a report on the evaluation of this course, including
some recommendations for possible improvements in the teaching methodology,
which will be published soon.

4.2        On 23-27 September 1991 the second subregional course was given in Managua.  It
was a continuation of the first, on environmental toxicology.  There were 11 Central
American and 10 Nicaraguan participants.  This course was also given by Dr. Pedro
Jauge, and materials were provided by ECO/PAHO.  The results of the course are
being evaluated and will be published.

4.3        In November 1991 the third subregional course on environmental epidemiology was
given in Costa Rica, once again with the collaboration of ECO/PAHO.  The
Environmental Sanitation Division of the Costa Rican Ministry of Health and a local
university also participated in this course (25-29 November 1991).  In all there were
26 participants (14 nationals and 12 from the other countries, at two per country).  The
course was given by Dr. German Corey and Dr. Rob McConell.

4.4        Staff from the Nicaraguan Institute of Water Supply and Sewerage participated in the
following courses with support from the Project:

-          Meeting of the REPIDISCA cooperating centers in Colombia, 28 May-6 June
1991 (one delegates).

-          International Conference on the use of oxidizing gases generated in situ, held
in Mexico, 4-8 November 1991 (two delegates).


5.         LABORATORY STRENGTHENING

5.1        A survey was developed to evaluate the analytical capacity of water laboratories in
Central America, especially the physical, chemical, and bacteriological aspects.

5.2        A brief practical course was given in Guatemala on methods for detecting Vibrio
cholerae in the environment; the methodology, materials, and results are being
analyzed in preparation for giving the course in the other countries.

5.3        In collaboration with the HPE program and ECO/PAHO, a consultant is being sought
to assess the situation of environmental analysis laboratories in Central America with
a view to standardizing methods, systems, and equipment.  This work will lay the
groundwork for setting up criteria and establishing a reference laboratory in the
Subregion.

6.         INFORMATION SYSTEMS

6.1        The work of analysis of the situation of information systems on the Environment and
Health in Central America is currently in its final stages.  Work was completed on
evaluations for the countries not yet covered (Honduras and Guatemala) and will be
incorporated in the final assessment.

This document includes recommendations and criteria for the establishment of a
Subregional Information System, as well as suggestions for strengthening the existing
information centers in Central America.  It will be published in 1992.

6.2        Ms. Silvia Ayón was contracted for the first phase of this work (1 March-30 May
1991, 1 June-31 August 1991, and 1 September-31 December 1991).

6.3        MASICA has compiled abundant information on international information systems,
especially those linked to PAHO/WHO, such as REPIDISCA, LILACS, and ECO-
LINE, with a view to coordinating actions and avoiding duplication of effort.

6.4        From 14-28 April 1991 advisory services were provided by Mr. José Luis Lima of
ECO/PAHO, who collaborated in setting up the data base for MASICA's
Environmental Information System and also gave a course on the CDC MICRO-
ISIS system.

6.5        During the first meeting of the Focal Points (2-5 April 1991) Dr. Héctor Gutiérrez
(Mexico) presented, at the behest of MASICA, a document on environmental
surveillance and information systems, which is a basic document on the subject for
broader discussion.

7.         DATA BASE

7.1        The work of setting up the data base for the Project for Institutional Strengthening was
concluded.

7.2        A worksheet was developed for the information data base generated by the project on
Water Resource Conservation and Surveillance of Drinking Water Quality in Central
America.

7.3        A data entry sheet was designed for the information data base on environmental
legislation in Central America was designed.

7.4        The following personnel were contracted for the above-mentioned tasks:  
Hermes Gutiérrez (1 March 1991-14 May 1991; 15 May-14 September 1991).
Orlando González (1 March 1991-30 May 1991).

7.5        Maintenance and expansion of the data base for the projects on Institutional
Strengthening and Water Resource Conservation and Surveillance of Drinking Water
Quality are programmed for the Third PTC, along with the creation of a data base for
the Project on Management and Control of Solid Wastes and their Effects on Health
and the Environment.

8.         ADMINISTRATIVE ASPECTS

8.1        It was decided that the subregional headquarters of the MASICA Program and the
Project for Institutional Strengthening will be located in San José, Costa Rica, and the
moving process was begun on 5 December 1991.  The offices are currently being
refurbished and local support staff are being hired.

8.2        MASICA's mechanism of administrative relations was fine-tuned both nationally and
subregionally.  The respective roles of the Focal Points, Support Groups, and Country
Engineers or technical personnel responsible for liaison and monitoring (TES) were
further defined.  In addition, contacts were strengthened with a number of
organizations that operate in areas related to the work of MASICA in Central America. 
Two organization charts, showing the Program's national and subregional
relationships, are annexed to this report.

8.3        Mr. Rogelio Espinoza I. was contracted locally to follow up on the work of providing
administrative support for the Project's activities, for the following periods:  1 March-
30 May 1991; 1 June-31 August 1991; and 1 September-31 December 1991.

8.4        The budgetary resources used during the period amounted to US$ 272,166.92. 
Detailed expenditures under the budget are shown in the following table:


BUDGETARY EXECUTION, 1991

ITEM       AMOUNT       % EXECUTION        % BUDGET

040        77,045.89                    98.95                 28.31
390        91,065.63                    99.97                 33.46
490        13,000.00                  100.00                    4.78 
550          5,000.00                 100.00                    1.84
820        86,055.00                  100.00                  31.61
272,166.62                     99.79               100.00

GLOSSARY


AIDIS                            Inter-American Association of Sanitary and Environmental Engineering

CADESCA                          Action Committee for the Sustained Development of Central America

CATIE                            Center for Research and Teaching in Tropical Agriculture

CCAD                             Central American Commission on Environment and Development

CICAD                            Interparliamentary Commission of Committees on Environment and
Development in Central America and Panama

CEPIS                 Pan American Center for Sanitary Engineering and Environmental Sciences

ERIS                             Regional School of Sanitary Engineering, Universidad de San Carlos,
Guatemala

ECO-LINE                         Sources of information and data bases of the Pan American Center for
Human Ecology and Health

FAO                              Food and Agriculture Organization of the United Nations 

ICAITI                           Central American Institute for Industrial Research and Technology

ILANUD                           United Nations Latin American Institute for the Prevention of Crime and
the Treatment of Offenders

LILACS                           Latin American Literature on Health Sciences

MASICA                           Subregional Program on Environment and Health in the Central
American Isthmus

PAHO                             Pan American Health Organization

PARLACEN                         Central American Parliament

PARLATINO                                   Latin American Parliament

UNDP                             United Nations Development Program

UNEP                             United Nations Environment Program

REDES/CA                         Network of Nongovernmental Conservationist Organizations for
Sustained Development in Central America

REPIDISCA                        Pan American Network of Information and Documentation in Sanitary
Engineering and Environmental Sciences

RESSCA                           Special Meeting of the Health Sector of Central America

ROCAP                            Regional Office for Central America and Panama (USAID)

IUCN                             International Union for Conservation of Nature and Natural Resources

UNICEF                           United Nations Children's Fund

USAID                            Agency for International Development (United States of America)
SUBREGIONAL ORGANIZATION CHART MASICA

ENVIRONMENTAL HEALTH PROGRAM (HPE)   
DEC
DAP
DONORS
SUBREGIONAL ORGANIZATIONS

CCAD
AIDIS-REGION II
ICAITI
CSUCA
UNEP
REDES/CA
UNICEF
ERIS
UNDP
ETC.

SUBREGIONAL COORDINATION MASICA
PROJECT FOR INSTITUTIONAL STRENGTHENING

COORD.

WATER
WASTE

COORD.
PESTICIDES
INDUSTRIAL POLLUTION

COORD.
EIAS 
ENVIRONMENTAL EDUCATION

NATIONAL LEVEL ORGANIZATIONAL CHART MASICA

ADVISORY GROUP
MINISTRY OF HEALTH
CONAMA 
MINISTRY OF NATURAL RESOURCES AND ENVIRONMENT
MINISTRY OF EDUCATION
MINISTRY OF PLANNING
UNIVERSITIES
WATER SUPPLY AND SEWERAGE
MUNICIPALITIES
NGOs
RESEARCH CENTERS
ETC.


MINISTRY OF HEALTH

FOCAL POINT
TECHNICAL PERSONNEL FOR LIAISON AND MONITORING 
PAHO/WHO COUNTRY REPRESENTATION

 
9.4 WORKERS' HEALTH

1.   At the Country Level

     The National Plans for the Development of Workers' Health,
prepared with advisory services from PAHO in connection with the
Initiative "1992:  Year of Workers' Health," constitute the body
of national doctrine and policy regarding occupational health and
are being taken into account in the formulation of health, social
security, and development policies.  There is a new culture
surrounding workers' health in the Region of the Americas, which
has led to greater cognizance of the situation and increased
recognition of the impact of this area on social and economic
progress.  It has also led to a new dynamism within the National
Councils (which are primarily oriented toward policy-making) and
the Intersectoral Committees on Workers' Health (which focus mainly
on technical aspects of workers' health).  The efforts of these
bodies have been supported by information dissemination campaigns;
the creation of new training courses in various branches of
occupational health; intersectoral participation by the health,
labor, education, and social security sectors; more effective
collaboration by employers and workers; and resource mobilization. 
The new institutional structures and mechanisms that have come
about through new policies on worker's health have facilitated: 
the identification and evaluation of the principal health problems
that affect not just workers but the entire population living in
areas where companies have created unhealthful, hazardous, or toxic
conditions; recognition of the right of workers to be aware of the
risks to which they are exposed; the achievement of reductions in
the number of accidents and other preventable pathological
situations; and the implementation of standards and regulations for
the control of risk factors.  Special attention is being given to
the most vulnerable and exposed groups, including women, children,
farm workers, and workers in the informal sector.  The creation and
dissemination of scientific and technical material has been
accompanied by the distribution of information to the general
public with a view to raising awareness among employers and workers
and contributing to an increase in preventive spirit, self-
care, and the capacity to collaborate in programs.

2.   At the Regional and Intercountry Level

     In fulfillment of the mandate that designated workers' health
as a priority program area for the quadrennium 1991-1994, PAHO is
cooperating with the countries of the Region to increase their
capacity to develop programs that will provide effective protection
against occupational risk factors, as well as programs to promote
workers' health, both in the formal and the informal sectors of the
economy, through coordination with the various social groups and
institutions.  In the context of primary health care and the
integration of workers' health into local health systems, all
programs of the Organization will carry out activities related to
health and disease in workers.  Through the Program on Workers'
Health, the Organization will coordinate multisectoral activities
and will cooperate in the preparation of criteria and instruments
aimed at preventing and controlling occupational risk factors. 
PAHO is promoting concerted action by various agencies with a view
to strengthening the delivery of cooperation to the countries, and
it will also encourage activities between countries in order to
achieve integration and common objectives.  The Organization will
collaborate in the mobilization of resources to enhance the
technical and functional capacity of institutions, establish more
effective information systems, and strengthen education in the area
of occupational health.
13.10ZOONOSIS

     PAHO will continue to give priority to consolidation of the
final attack phase in the campaign to eliminate canine rabies. 
Activities in this connection will be aimed at strengthening mass
vaccination programs for dogs in cities with populations of under
100,000 and expanding disease-free areas, promoting rabies
surveillance to ensure that countries and areas remain disease-
free, and preventing human mortality in the Region through proper
treatment of persons exposed to rabies.
     Pursuant to a mandate from the Governing Bodies, the
Organization will provide support to enable the countries to
develop programs for the eradication of bovine tuberculosis and
continue existing programs for the control of other zoonosis,
particularly hydatidosis and taeniasis/cysticercosis (Taenia
solium), brucellosis, and leptospirosis.
     Through the Pan American Foot-and-Mouth Disease Center, PAHO
will continue to foster the countries' efforts to eradicate foot-
and-mouth disease in the Americas.  Emphasis will be placed on the
expansion of disease-free areas in the Southern Cone, the Andean
area, and Brazil, and support will be provided to countries that
are free of food-and-mouth disease countries to strengthen their
systems of prevention.
     Technical cooperation by the Program on Veterinary Health
will support applied operations research carried out jointly by
national institutions and the Program's two specialized centers. 
The Program will also endeavor to strengthen instruction in
veterinary public health at schools of veterinary medicine.
11.5 FOOD SAFETY

     PAHO will continue to support the countries in their efforts
to establish integrated national programs of food protection
through the formation of intersectoral and interinstitutional
commissions and the preparation of annual national plans of action
for the coordination of resources from the different institutions
in order to achieve common objectives.

     Technical cooperation activities will be carried out in the
framework of the following five lines of action:  development of
integrated programs of food protection, strengthening of food-
testing services, strengthening of inspection services,
surveillance of food-borne diseases, and consumer protection
through community participation.  Emphasis will be placed on the
surveillance of hygiene among street food vendors, and cooperation
will be provided to the countries, particularly those that are food
exporters, with a view to strengthening their surveillance and
control services in order to ensure food quality and safety in
international and subregional markets.

     The Pan American Institute for Food Protection and Zoonoses
(INPPAZ), which was created in January 1991 through an agreement
between the Government of Argentina and PAHO, will provide
increased support in the area of food protection.
E0142.FIN



CHAPTER V.C                                             27/III/92
PUBLISHED VERSION

ENVIRONMENTAL HEALTH



     The framework of the activities of PAHO/WHO's Environmental
Health Program consisted of resolutions on environmental
protection and workers' health approved by XXIII Pan American
Sanitary Conference.  The activities aimed at fulfilling these
resolutions, together with the results of the International
Drinking Water and of Environmental Sanitation Decade and the
demand caused by the appearance of cholera in the Region gave the
work carried out in this field in 1991 special importance within
the cooperation PAHO/WHO provided to the countries.

     During the year a series of activities were initiated in
order to develop a new approach in environmental health to make
it interprogrammatic and intersectoral; operational and
structural adjustments had already been carried out.

     Support continued to be provided for strengthening
environmental health institutions through projects in Brazil,
Costa Rica, Honduras, and Mexico; new projects were formulated
for Ecuador, Peru, and the countries in the Environment and
Health in the Central American Isthmus project (MASICA).  In
addition, the Program maintained its relations with several
nongovernmental agencies and continued supporting the
institutional development of the Inter-American Sanitary and
Environmental Engineering Association (AIDIS), particularly in
formulating the plan of work of its Division of Education and
Training.

     Manpower training received special attention.  During the
year 450 short courses were offered for a total of 13,557
participants, and support continued to be provided for training
programs at the graduate and postgraduate level.  The
implementation of mechanisms to certify the operating capacity of
technical personnel in the water and sanitation sector gathered
force in three countries, as well as activity promoted by AIDIS
at the regional level in this field.

     With financing from PAHO/WHO, 10 research proposals related
to the environment were kept active in 1991 and six others began
to be analyzed. 

     With respect to the dissemination of information, 43 new
publications were produced and the Pan American Network for
Information and Documentation in Sanitary Engineering and
Environmental Sciences (REPIDISCA) and the information system of
the Pan American Center of Human Ecology and Health (ECOLINE) and
its integration into PAHO/WHO's information systems continued to
be strengthened.

Water supply and sanitation
     The arrival of the cholera pandemic in the Region awakened
great concern with respect to the condition of water supply,
sanitation, and sanitary excreta disposal systems.  This
generated for the Organization, and specifically for the Pan
American Center for Sanitary Engineering and Environmental
Sciences (CEPIS), an enormous demand for direct technical
cooperation and collaboration in identifying and formulating
projects, as well as in mobilizing technical, human, and
financial resources.  Priority attention was given to aspects of
water quality, community participation, and utilization of social
communication.   Technical documents on environmental measures to
control and prevent cholera, as well as educational material,
including practical guidelines and audiovisual material, were
prepared and distributed.  It was also oriented toward the
countries with regard to prevention and control measures and the
preparation of national plans toward that end was promoted; the
plans prepared by several countries were then reviewed.  In
addition, specifications and purchase orders for equipment and
materials for disinfection and surveillance of the
bacteriological quality of water, which were acquired with
external resources granted by various agencies to the most
affected countries, were drawn up.

     Taking into account the shortage of water and the
deterioration in its quality, a problem which has been aggravated
by the economic crisis, the Organization and the Government of
Mexico sponsored an International Seminar on the Efficient Use of
Water in October.  The seminar was inaugurated by the President
of Mexico, who offered the political support necessary for
achieving more efficient use of water, not only in that country
but also at the world level.  CEPIS continued actively supporting
activities intended to control losses and to promote efficient
use of water, and with the Federal Republic of Germany's Agency
for Technical Cooperation (GTZ) initiated a similar project
designed for the countries of Central America and the Dominican
Republic.   Preparation of institutional development projects
with extrabudgetary funds was also reinitiated, and support was
given to Colombia, Peru, and Trinidad and Tobago in carrying out
certain activities related to the efficient use of water.

     PAHO/WHO convened an advisory meeting of representatives of
the countries and bilateral and multilateral agencies to deal
with the need for increasing the coverage of wastewater
collection services and the problem of the treatment and disposal
of such water.  In Bolivia, Costa Rica, and Uruguay, a group of
professionals was trained in the utilization of a mathematical
model developed by CEPIS to determine the microbiological quality
of the effluents in stabilization ponds which may be of great
usefulness in the campaign against cholera.  In Costa Rica,
professionals were contracted to apply this model to all
stabilization ponds in the country, calibrate it, and utilize it
in the operation, maintenance, and design of new installations.

     In Bolivia, Costa Rica, Mexico, Peru, and Uruguay, PAHO/WHO
collaborated in developing technologies for wastewater treatment
which facilitate the application of WHO guidelines on the use of
such water in agriculture and hydroponics.  In Peru, CEPIS
carried out an investigation on the reduction of Vibrio cholerae
in wastewater and through the treatment of stabilization ponds.

Control of risks related to the environment
     Because of greater awareness of the relationship between the
environment and health, and due to the United Nations Conference
on the Environment and Development, which will take place in
1992, new demands have been placed on the Organization.  This led
to a better breakdown of responsibilities at the regional level
for supporting national projects, whose number is increasing. 
Considerable technical, human, and financial resources were
mobilized from other institutions, mainly the World Bank, Inter-
American Development Bank, Environmental Protection Agency and
the Centers for Disease Control (USA), Federal Ministry of
Economic Cooperation (Germany), Swedish International Development
Authority (SIDA), Norwegian Cooperative Development Agency
(NORAD), and the Finnish International Development Agency
(FINNIDA).  The Organization made plans to intensify its
collaboration with the countries' Ministries Health of in
strengthening their capacity to promote and deal with different
aspects of environmental health.

     In addition, it began to prepare the methodologies and
resources necessary for disseminating information to communities
pertinent for identifying and controlling environmental factors
that represent a risk to health.  The Pan American Center of
Human Ecology and Health (ECO) was charged with evaluating the
risk factors and the aspects of toxicology related, among other
things, to mercury, lead, pesticides, and dangerous and polluting
atmospheric wastes, and acted mainly in Brazil, Colombia, Costa
Rica, Cuba, Ecuador, Guatemala, Honduras, Mexico, Venezuela, and
the USA/Mexico border area.

     CEPIS focused basically on the control of factors related to
the biological contamination of water, dangerous wastes, and
chemical contamination of surface and underground water, and
provided direct technical advisory services to Ecuador and
Paraguay and collaborated with two states in Brazil in
strengthening their control programs.

     PAHO/WHO placed a great deal of emphasis on training
personnel in methods and instruments for evaluating the impact of
national development projects on the environment and health.  For
this purpose, ECO participated in 33 national workshops with 933
participants in 19 countries, as well as in 77 local and
international meetings, and continued supporting seven graduate-
level programs in four countries.

     The MASICA Project was implemented through activities
directed toward strengthening institutional capacity to cope with
environmental problems in Central America.  During 1991 the
project focused on the organization of national and subregional
infrastructures and on collecting the information necessary for
formulating national plans of work.

     PAHO/WHO collaborated with IDB's Environmental Protection
Division in training its staff members in the evaluation of
environmental impact through four courses.  This activity, in
addition to facilitating the coordination of IDB-PAHO/WHO
collaboration with the countries in this field, will serve to
incorporate methodologies for evaluating environmental and health
impact in national development projects.

Urban sanitation and residential hygiene
     The growth of urban areas, and especially of human
settlements on the peripheries of large cities, has resulted in
an increase in the magnitude of problems linked to the solid
wastes they generate.  Because of this, PAHO/WHO devoted greater
attention to expanding the coverage of urban sanitation services
and to improving the management and final disposal of municipal
wastes.  The use of nonconventional systems, among others,
was promoted in marginal urban areas 
     PAHO/WHO provided technical assistance to several countries
and sought to multiply its support capacity through the strategy
of horizontal cooperation among countries.  In order to promote
the formation of subregional associations of urban sanitation
services, two meetings were held, one for the Andean countries
and the other for those in the English-speaking Caribbean.  The
creation of the Andean Association of Sanitation Companies
(ASEAS) and the Solid Wastes Association of the Caribbean (SWAC)
was achieved.  In addition, in order to form a regional urban
sanitation cooperation network, the establishment of
communications among sanitation services associations, such as
the Mexican Association for the Control of Solid and Dangerous
Wastes, Civil Association (AMCRESPAC), ASEAS in Colombia, Andean
ASEAS, Brazilian Public Sanitation Association (ABLP), and
Caribbean SWAC, was promoted.

     In the Central American area a proposal was formulated
within the framework of the MASICA project to improve management
of solid wastes in the hospitals in the capitals of the six
countries of the Isthmus.

     Urban sanitation courses were offered in the Bahamas,
Brazil, Colombia, Ecuador, Mexico, Paraguay, and Peru which 638
persons attended.  The five-week Latin American course on public
sanitation, reinitiated in 1991 at Rio de Janeiro after having
been suspended for three years, was completely restructured to
include managerial, administrative, and dangerous waste aspects. 
Among the documents produced by PAHO/WHO in this field during the
year were a guide on the development of the urban sanitation
sector in Latin America which offers guidance for such services
at the national and municipal level; another guide on managing
solid wastes from hospitals, and a document in which United
States legislation on sanitary landfills, which is used as for
reference purposes in many developing countries, is analyzed.

     A workshop was held at Rio de Janeiro on the environmental
health aspects of urban planning and housing which was sponsored
by WHO with PAHO support and had more than 100 participants. 
Preparations were begun to hold a regional seminar on residential
hygiene, with support from the State University of New York, at
Buffalo (USA) in October 1992.
     The strategy in regard to residential hygiene was based
mainly on the mobilization of resources.  At the world level,
PAHO and WHO carried out some activities on residential hygiene
and urban health and planning.  In addition, it initiated
contacts with the WHO Regional Office for Europe for the healthy
cities project.

     PAHO/WHO continued cooperating with the WHO Collaborating
Center at the State University of New York in Buffalo in carrying
out a residential housing project in Honduras.

Workers' health
     Efforts to mobilize national and international resources to
achieve the objectives of "1992:  Year of Workers' Health" were
intense.  In this context, greater participation by the WHO
Collaborating Centers in occupational health was promoted, and
the responses of the Universities of Alabama and Texas, both in
the United States of America, and the National Institute of
Occupational Hygiene and Safety in Spain deserve special mention.

     The preparation of national plans and projects was promoted,
and in several countries the integration of national
intersectoral committees and the formulation and adjustment of
national development plans and workers' health was achieved. 
Such plans are oriented mainly toward the gradual expansion of
workers' health coverage, with special attention to less
protected and vulnerable labor groups by utilizing various
organizational alternatives such as inclusion of occupational
health in local health systems and execution of specific
activities in the most pertinent health programs.

     Efforts to train human resources specializing in workers'
health and research on high-risk groups were intensified.

     As support for local programming of occupational health
activities and the development of multicenter projects dealing
with aspects of common interest, a guide on research methodology
applicable to workers' health was prepared.  A package of
specific projects oriented toward knowledge of the occupational
health situation of less protected labor groups, the development
of techniques for identifying, evaluating, and controlling health
risks and alterations, and the development of epidemiological
surveillance systems was also prepared and analyzed in technical
meetings.

     The mobilization of resources was enhanced by the
presentation of several projects at meetings in Spain, Finland,
and Italy.  An agreement especially directed toward the stimulus
of Italian cooperation in occupational health for the countries
of Latin America was drawn up in the last country.

     Efforts were made to strengthen the technical cooperation
provided by PAHO/WHO Country Representatives' in occupational
health through preparation of technical and audiovisual material
and a meeting of the Country Representatives in Central America,
the Dominican Republic, Haiti, Mexico, Panama, and Paraguay in
which national counterparts also participated.
E0143.FIN



CHAPTER IV.F                                            27/III/92
PUBLISHED VERSION


DEVELOPMENT OF HEALTH POLICIES


     During the year a series of changes occurred whose
implications in the field of health represent challenges and
incentives to the activities of the Development of Health
Policies Program, which is charged with supporting the countries
and the Secretariat in implementing strategies and priorities
relating to health in development, utilization of the potential
of social security, sectoral analysis, and financing of the
health sector.  In the framework of the detente between the world
powers and the emergence of new fronts for international
cooperation, the regional economy entered a period of
stabilization and reactivation thanks to the adjustment policies
which have been adopted in recent years in the Americas because
of the crisis.  Social and sanitary costs continue to be high,
however, mainly for the strata of the population with low
incomes.  Because of these circumstances, questions such as
recognition of the need for involving other actors like private
health care providers and the population in general in the
definition of health policies, in addition to the State and
social security as traditionally has been done in Latin America
and the Caribbean, have become important.  Social compensation
programs have become the preferred instrument of action of the
Governments in light of the crisis and the adjustment of costs,
which requires a major effort by health authorities to adapt to
new modalities of action at the same time that advances achieved
in earlier years are maintained in more favorable circumstances. 
The consolidation of democratic regimes in the Region is creating
opportunities for the enhancement of health legislation, while
the processes of regional and subregional integration impose a
new framework for its harmonization at the intercountry level. 
In addition, economic adjustment and its social consequences make
it necessary to better understand and more effectively monitor
the relationships between economics and health, with the constant
concern of guaranteeing equity and efficiency in current
expenditures and investments in health.

     To strengthen PAHO/WHO's capacity for understanding and
managing the relationships between health and development, the
Program interacted with the legislative institutions of the
countries; the national authorities of planning and economy;
social security institutions; centers for training and research
in the social sciences, economy, planning, and legislation, and
workers' organizations.  It also promoted and supported the
interest of regional programs by the macro-determinants of the
problems and their policies.  At the same time, it established
working links with the most important centers in related
disciplines as well as with other international organizations and
agencies.  It also strengthened the channel of communication with
the units of WHO and its other Regions dealing with these
subjects.  Ten sessions in the series of "Technical Discussions
on Health in Development" were held, and the reports thereon were
distributed to the countries.  It continued the organization of a
documentation center, which already has nearly 5,100 documents,
on matters related to health in development, and several
documents on policies in this regard were distributed to the
countries.

     As follow-up to the subregional meetings of the legislatures
held with the OAS in 1990 and in the framework of the "Democracy
and Health" project, cooperation agreements were signed with the
legislatures of 20 countries (Argentina, Barbados, Bolivia,
Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador,
Guatemala, Haiti, Honduras, Jamaica, Mexico, Paraguay, Peru,
Saint Lucia, Trinidad and Tobago, Uruguay, and Venezuela).  The
agreements' objective is to support legislative efforts related
to health through distribution to the legislatures of technical
and legislative information on health, in addition to
facilitating the participation of lawmakers and their advisers in
cooperation activities promoted by the Organization.  In
addition, PAHO/WHO and the Latin American Parliament, the Andean
Parliament, and the legislatures of the countries composing the
MERCOSUR promoted the definition of legislative agendas in health
at the national, subregional, and regional levels.  In addition,
it supported the Latin American Parliament in holding a meeting
on the environment, health, and development in the context of the
United Nations Conference on the Environment and Development,
which will be held in 1992, and of the Inter-American Legislative
Conference, to be held in 1993.  This agency has a Health, Labor,
and Social Security Committee, which will help facilitate the
work of PAHO/WHO in this field.

     Taking into account the growing importance that redefinition
of the relations between the State and society are acquiring, an
initial evaluation was made of the processes of privatization of
health care in the Region.  The focus was on the cases of
Argentina, Brazil, Chile, Costa Rica, Jamaica, Mexico, Uruguay,
and Venezuela, where there are varied versions of the
public/private combination in health, pertinent information is
available, and there are investigators interested in the matter. 
The report on the study, which it is expected will be published
in 1992, should facilitate major contributions to the policies
the countries decide to adopt in this respect, as well as
cooperation by PAHO/WHO in support thereof.  PAHO/WHO also
collaborated with Argentina, Brazil, Chile, Costa Rica, Cuba,
Mexico, Paraguay, Peru, Uruguay, and Venezuela in activities
related to health in development.  In Costa Rica the support also
included cooperation with the process of reform of the State and
participation in a forum on health and development.

     To promote utilization of the potential of social security
in transforming health systems and expanding coverage, PAHO/WHO
presented policy and analysis documents on subjects related to
health in social security at meetings of the Inter-American
Social Security Center, International Social Security
Association, and Ibero-American Social Security Organization.  A
joint cooperation study was made with the International Labor
Organization (ILO) and WHO Headquarters in Geneva which has
awakened greater interest in the function of social security in
the field of health.  There was cooperation in the processes of
reform and reorganization of health systems in Bolivia,
Guatemala, Panama, Peru, and Venezuela; in Colombia, in holding
two forums to analyze the reformulation of the health system; in
Ecuador, in the preparation of a similar process in coordination
with WHO; in Mexico, in reaching a cooperation agreement with the
Inter-American Center for Social Security Studies, and with the
National Center for Education and Research in Health and Social
Security of Costa Rica and the Colombian Association of Schools
of Medicine in health manpower development in social security.

     At the subregional level, PAHO/WHO and the Stony Brook
Institute of the State University of New York collaborated in
conducting studies on the participation of social security in the
financing of health care in Saint Lucia, Grenada, and Dominica. 
The results of these studies were made known in a publication
prepared in collaboration with the Institute.  In the Andean
Area, the Organization collaborated in four meetings of the
directors of social security agencies at which the bases for the
Andean Agreement on Social Security and the Andean Social
Security card were laid; it cooperated in the inclusion of the
directors of social security agencies in the Meeting of Ministers
of Health of the Andean Area, and it provided support for the V
Meeting, which coincided with the VI Andean Presidential Council
held in December in Colombia at which the terms of the Agreement
mentioned above were reviewed.  In Central America, preparation
of the Subregional Project on Social Security Development, which
will be carried out starting in 1992, and the signing of
agreements which include reciprocal care for members and
interinstitutional administrative support among the countries was
promoted.  At the request of the social security agencies of the
Andean Area and Central America, the Organization acts as
Technical Secretariat of their respective meetings and, in that
capacity, completed two reports on health and social security in
those subregions.

     In regard to intersectoral planning and action, the
Organization designed a health sector analytic approach with
recent contributions in the social sciences and health, and
strategic planning in which future scenarios are projected.  Its
principal objective is to facilitate identification of the
principal problems in the health sector and to define
corresponding policies of action when little time is available
and opportunities for more complex studies are limited.  With the
support of WHO and the Network of Future Health Scenarios, plans
were made to apply this analytic approach in some countries in
1992 to put it to the test and make necessary adjustments before
recommending that it be utilized more widely.

     PAHO/WHO held two seminars on the planning of development
projects in health (at Quito and Montevideo) and concluded
preparation of the Spanish version of the 17 modules utilized in
these seminars, which it is expected will be published in 1992. 
In addition, in cooperation with the OAS it held a subregional
workshop on social and health policies for the Andean Area at
Quito and programmed three others for 1992 in the Southern Cone,
Central America, and the Caribbean.  It also collaborated in the
VIII Inter-American Course on Social Policies with Emphasis on
Health, which was held at the headquarters of the Inter-American
Center for Social Development (OAS) in Buenos Aires.  In
addition, it cooperated with the Dominican Republic, Ecuador,
Nicaragua, and Uruguay in formulating and implementing health
programs and investment proposals.

     In regard to health legislation, the LEYES data bank, which
has been developed in cooperation with the Library of the
Congress of the United States of America and the Library of the
School of Law of the University of the West Indies, already has
more than 4,000 records of health legislation in Latin America
and the Caribbean.  The Organization's cooperation in health
legislation took a new step with the incorporation of the
legislatures among their counterparts through the agreements
mentioned previously.  The legislatures now have access to the
LILACS-CD/ROM network, which provides them technical and
legislative information in support of their legislative work
concerning health.

     PAHO/WHO made an analysis of health legislation in the
countries belonging to the Treaty of Asunción to determine the
gaps that exist in it and made recommendations for its review and
harmonization in order to make the MERCOSUR viable.

     In regard to the economics and financing of health, a study
was completed of the implications of emergency or social
investment funds for the health sector in Bolivia, Costa Rica,
Guatemala, Honduras, Jamaica, Nicaragua, and Peru.  The programs
financed by these funds--which have been transformed into the
principal social policy instrument of many governments in recent
years--emphasize disadvantaged groups and community action,
strategies which usually contribute short-term results but may
affect interventions with an institutional basis and the
universal approach of the sector's conventional programs.  Also,
heeding Resolution XVIII of the XXXV Directing Council, a study
was made of feasibility of converting the external debt into
resources to finance investments in health.  The positive results
of the study led to taking the first steps to establish a project
to promote and support these activities in the Region.  Certain
interested countries and donors have already been identified with
which the possibility of specifying activities or creating
mechanisms for that purpose have already begun to be explored.

     In cooperation with the Institute of Economic Development of
the World Bank (IDE), PAHO/WHO held the IV International Seminar
on Health Economics and Financing in Mexico with the
participation of staff members of the Ministries of Health and
Planning, social security agencies, and universities in Bolivia,
Chile, Mexico, Paraguay, Peru, and Venezuela.  Also with the IDE,
a project of training and research activities at the national
level was being prepared which will be carried out by the
interinstitutional groups that attended the four international
seminars on this subject.  Support was provided to Brazil, Chile,
Costa Rica, Cuba, Ecuador, Guatemala, Mexico, Nicaragua, Peru,
and Uruguay in several matters related to the economics and
financing of health.  Several data bases were also incorporated
into the Organization's Technical Information System which among
other things include socioeconomic indicators, household surveys,
and health expenditure and financing.  Some of these data bases
are produced by international agencies such as the IDB, World
Bank, International Monetary Fund, CEPALC, CELADE, and the ILO,
and are useful for the analysis and development of health
policies.  Work was also done on defining indicators which may
better reflect impact that the changes in the economic situation
have on the health situation.  In that regard, the report on the
National Household Survey of Health and Nutrition, carried out in
Brazil in 1989 with PAHO/WHO support, was reviewed to evaluate
the use of household surveys in surveillance of the implications
of the crisis and adjustment policies for health and the health
services.  These surveys appear to permit short-term follow-
up of health conditions and access to services in a way difficult
to attain with indicators used conventionally in the analysis and
formulation of health policies.
Introduction

    The "Bibliography on the Health Situation
in Latin America and the Caribbean" is
presented with a view to providing PAHO
personnel with  an updated listing of the
pertinent information available through the
PAHO/INFO data base at the PAHO Headquarters
Library.  The Bibliography covers statistical
data as well as information on social
policies, national health plans, legislation,
health services development, the environment,
risk groups, etc. in the countries of the
Region.

    The listings contained in this
publication represent a selection of the
titles that have been received on an
unsolicited basis, together with others that
have been acquired by special request.  In
both cases an attempt has been made to ensure
that the listings are as representative and
current as possible.

    The serial publications contained in this
catalog correspond, for the most part, to
secondary sources (information on
information) published by the various
countries and by international organizations. 
The publication does not include PAHO
publications such as reports from consultants
or articles from periodicals and serial
publications.  Neither does it include
articles from other periodicals or
publications of WHO or foundations.  Such
information may be accessed, however, through
PAHO/INFO, MEDLINE, and other data bases.

    We consider that this unique contribution
by PAHO is extremely valuable as a complement
to primary sources of information on the
situation of health and disease in the
Americas.  Wide-ranging publications such as
Health Conditions in the Americas have been
included in the general section, as have
others that contain statistical data on the
entire Region of the Americas or on the
various subregions (Caribbean, Central
America, Andean, and Southern Cone).

    We need to expand this preliminary
edition and publish a more complete final
edition for the benefit of the entire
Organization.  We therefore encourage PAHO
personnel to collaborate by suggesting titles
of publications and/or submitting to the
Headquarters Library any essential
documentation regarding the health situation
in the countries.


Maria Teresa Astroza, M.S.L.S.
Chief, PAHO Headquarters Library
TABLE OF CONTENTS


    Introduction

    How to Use this Bibliography

    Bibliography by Country


    Countries               Page


    General             1
    

    Argentina               17-22

    Bahamas             23

    Barbados                25

    Belize                  27

    Bolivia             29-31

    Brazil                  33-37

    Caribbean               39-40

    Chile                   41-44
    
    Colombia                45-52

    Costa Rica              53-56

    Cuba                    57-58

    Dominica                59

    Dominican Republic      60-64

    El Salvador             65-66

    Grenada             67

    Guatemala               69

    Guyana              71

    Haiti                   73-74

    Honduras                75-76

    Jamaica             77

    Mexico              79-83

    Nicaragua               85-86

    Panama              87

    Paraguay                89-90

    Peru                    91-96

    Saint Lucia             97

    Suriname                99

    Trinidad and Tobago     101

    Uruguay             103-104

    Venezuela               105-107





INDEXES:

    Authors             109-171

    Descriptors             173-271
       PAN AMERICAN HEALTH ORGANIZATION
     REGIONAL PROGRAM ON WOMEN, HEALTH, 
AND DEVELOPMENT


I Central American Seminar on
Violence against Women:  A Public Health Problem

Managua, Nicaragua, 11-13 March 1992











Closing Session




Remarks by Dr. Rebecca de los Ríos
Coordinator, Regional Program on
Women, Health, and Development














Washington D.C.
March 1992


Dr. Douglas Sosa, Deputy Minister of Health and medical internist, who in his work in intensive care
wards has had intimate contact with violence and death; our distinguished colleague, Carmen Cecilia
de Narváez, Director of the Nicaraguan Institute for Women, who has been entrusted with the important
task of working at the central government level to promote policies and actions aimed at narrowing and
eliminating gender gaps in all senses; Dr. Yolanda Batres, who represents the other men and women who
are endeavoring with tremendous sensitivity and commitment to construct alternative forms of care for
female victims of violence; and Dr. Carlos Linger, Representative of the Pan American Health
Organization in Nicaragua, friend, colleague, and co-worker:

     I am pleased to have been invited to address you during this closing session, because it affords
me the opportunity to bestow well-deserved praise on each and every one of you present today, and on
those who were unable to attend as well, for your dedication and responsibility in working to ensure
renewed respect for the value of life and thus contributing to human development in the broadest sense. 
Your efforts will help to transform this renewed respect, infused by a gender perspective, into the central
axis of public and health policies in the countries of the Central American region.
     
     I would like to thank the Organizing Committee of this Seminar, which included various
institutions and governmental and nongovernmental organizations, for their warm reception and
unwavering support.  I would also like to recognize the contribution of the National Assembly, the Office
of the President, the Nicaraguan Institute for Women, the Ministry of Health, the Ministry of the
Interior, the Nicaraguan Social Welfare Institute, the AMLAE Women's Movement, and the IXCHEN
Women's Center.

     I would like to express my appreciation to all the men and women, both those present here today
and those who are absent, who are engaged in the women's movement in Central America--
whether through academic or research centers, ministries of health or justice, legislatures, or
nongovernmental organizations--and to all professionals and specialists engaged in social and
institutional practice in our Region.

     I would like to acknowledge the support that we have received from the Governments of Sweden,
Norway, and Spain, who have fostered our initiatives, expressing utmost confidence in our efforts in the
scientific, technical, and political realms.

     Finally, I would like to acknowledge the new ways in which technical cooperation to the
countries is being managed, an area in which new ground is being broken by the Program on Women,
Health, and Development in Central America.  These new forms of cooperation are facilitating dialogue
and joint reflection, while promoting research and the dissemination of knowledge not just as a means
for knowing and understanding reality but as a way of promoting collaboration with a view to bringing
about more equitable development that will narrow and eventually eliminate social and gender gaps.

     These gaps are manifested socially through different forms of violence that cast a pall over the
daily lives of men and women of all ages, classes, and ethnic backgrounds. 

     I would like to take this opportunity to review the accomplishments of the first phase in a process
that began just over a year ago and is culminating today with the initiation of a new phase of action
aimed at bringing about change--change in terms of new forms democracy, dialogue, and negotiation
of conflicts between the state and civil society, between the institutions of government and social
organizations, between the ministries of health and women's organizations.

     This process began with an effort to encourage the countries to see violence as a public health
problem, in particular gender-based violence directed specifically against women of all ages, from young
girls to elderly women.  It was necessary to reassess the whole way of thinking about female gender and
then, drawing on the experiences of real women, to endow our analysis with scientific rigor and find new
ways of interacting with other areas of thought and action in the economic, social, and health spheres.

     This initial step formed the basis for research and documentation on the way in which biological
differences between the sexes have been utilized to construct individual, social, and institutional practices
that discriminate against women.  Such practices continue to be justified as something inherent in nature
and are thus sanctioned socially by custom and institutionalized by law.  This seminar has provided an
opportunity for joint review and analysis of the results of the research that has been carried out in all
the countries of the subregion.  The analysis, in turn, has made it possible to gain an idea of the
magnitude of discrimination against women and inequality of opportunities between the sexes, which
are among the factors that account for gender-based violence against women.

     The exercise of conducting research, compiling documentation, and disseminating the results
was not just an academic exercise but a political one as well.  It was political in two senses:  on the one
hand, it was an enriching, affirming exercise that clearly showed us the collective strength and
leadership of women and, on the other, it allowed us to formulate proposals and strategies for action
aimed at promoting, from within the State and civil society, a new culture--a culture based on the
promotion of new ways of living together in the midst of differences, with criteria of equity and support
for new forms of democracy based on the objectives of human development.


     The working group and plenary sessions of this seminar have produced a number of concrete
conclusions and recommendations, and, with due consideration of the specific circumstances in the
various countries, a commitment has been made to implement them in the short and medium terms. 

     We will respond to the call for technical cooperation, collaborating with the Member
Governments of the Organization to facilitate, inter alia:

     ·    The formulation, adoption, and implementation of public and health policies that will
work from the central government level to narrow and eliminate gender gaps,
particularly those that are identified as causal factors behind the individual, social, and
institutional abuse and violence directed at women of all ages.

     ·    The provision of support to strengthen the initiatives that from within the different strata
of civil society--the academic sphere, the scientific community, trade unions and
associations, the church, and nongovernmental organizations, among others-
-are being promoted with a view to confronting and responding to this grave social and
public health problem.  This will require dialogue, consultation, and coordination
between governmental and nongovernmental institutions and, in particular, between
health institutions and the women's movement. 

     ·    The incorporation or maintenance, as a permanent item on the agendas of national
institutions and international health organizations, of policy formulation for the
promotion of a new culture, the adoption of measures for the prevention of violence
against women, and the provision of care to address the physical and psychological
consequences of violence on the health of women of all ages, with respect for their
social, ethnic, and cultural diversity.

     ·    The leadership of health institutions in the mobilization of efforts to dispel the myths and
traditions that reinforce the use of violence as a way of resolving conflict.  This will
involve coordination with the mass media to combat fatalism and sensationalism and,
above all, to recapture the capacity to be shocked by violence, so that violence against
woman will cease to be trivialized and will be recognized as the social and public health
problem that it is.

     ·    The promotion of policies and positive action on the part of the Governments in the
subregion, in coordination with all strata of civil society, with a view to expanding
women's options, access, and use of health care resources as their right and as a means
of raising their standard of living and offsetting the effects of the economic adjustment measures that have been imposed
in the countries of the Region.

     ·    Collaboration in the intensification of international technical and financial cooperation
to support the national, subregional, and Regional initiatives aimed at facilitating
implementation of the above-mentioned recommendations. 

     In conclusion, I would like to issue a call for the affirmation of women and for the creation of
imaginative and resourceful solutions that will enable us to bring new substance to our commitment to
life, as men and women who aspire to a just, equitable, and ever more perfect society. 

     Thank you very much.
MANPOWER DEVELOPMENT IN NURSING
REGIONAL PROGRAM

$40,000 (2 yrs)     Source of financing: DANIDA   Countries:Costa Rica1990-1992, 1992-1994
El Salvador
Guatemala
Honduras
Nicaragua
Panama 



NURSING EDUCATION IN CENTRAL AMERICA

Objectives:To strengthen nursing education in the countries of Central America with a view to identifying
problems and seeking strategic solutions.

Summary:  The project covers four areas:  prospective analysis, continuing education, leadership, and research.

Outcome:  To date, three workshops have been held.

In the first, activities were identified in each of the above-mentioned areas. In addition, a Central American
Technical Group was formed to monitor these activities.
      
The second involved the study and discussion of proposals presented by each country.

In the third, the results of the prospective analysis of nursing education in each country were presented and a
consolidated subregional report was prepared. 

In addition, a research proposal was presented on the impact of nursing activities on the health of the population. 
The general outline for the prospective analysis of nursing services was also developed.


PAHO funds    Countries:Andean Group        Southern Cone       1989-1990, 1991-1992, 1992-1994
Colombia       Argentina
Ecuador        Bolivia
Peru           Chile   
Venezuela      Paraguay
Uruguay


PROSPECTIVE ANALYSIS OF NURSING EDUCATION IN SOUTH AMERICA

Objective:To develop a methodology for ongoing analysis of the training of nursing professionals as instruments for the
institutional development of founding and service institutions, with projections for the future.

Summary:  A series of workshops are being held in each country, utilizing a methodology for the training of multipliers in order
to support the countries in carrying out the prospective analysis in each of their institutions.  This has been fully
accomplished in 80% of the countries and partially accomplished in 20%.

Outcome:  90% of the countries have carried out a situation assessment and on the basis thereof have prepared plans for
institutional development, including a component on nursing, with emphasis on strengthening the integration of
teaching and service, curriculum development, leadership, research, and teacher training. 

QUALIFICATION AND PROFESSIONALIZATION OF AUXILIARY PERSONNEL 

Objective:To retrain empirical personnel as nursing auxiliaries and to implement a project of continuing education for the
development of nursing auxiliaries.  This project is being implemented in Argentina, Brazil, El Salvador, Paraguay,
and Uruguay (retraining of nursing auxiliaries).

Summary:  A series of workshops are being held to provide pedagogical training for "trainers" (in unconventional methods
based on actual practice in the workplace).  Moreover, a process of continuing education is being implemented, with
an initial stage for the retraining of empirical personnel and later stages for training to improve the performance of
auxiliary personnel.

Outcome:  The process has been initiated in all the above-mentioned countries, and in some countries 25% of empirical
personnel have been retrained as auxiliary personnel (Argentina).  Three countries have implemented continuing
education for nursing auxiliaries.CONTINUING EDUCATION FOR NURSING PERSONNEL

Objective:To improve the performance of nursing personnel through the application of participatory methodologies that will
enhance the qualifications of personnel and transform nursing practice.

Summary:  The project is currently being carried out in Argentina, Brazil, Chile, Colombia, El Salvador, Guatemala, Honduras,
Nicaragua, and Peru.  Different strategies are being used depending on the particular situation in each country.

Outcome:  Development of integrated multidisciplinary projects and projects that combine university and in-service training,
with emphasis on the development of local health systems.


20,000 every two years  Countries involved: Brazil    Collaborating Center
Colombia  Collaborating Center
USA       Collaborating Center
Chile
Honduras
Mexico
Panama
Venezuela

STRENGTHENING OF RESEARCH AND SCIENTIFIC AND TECHNICAL INFORMATION IN NURSING

Objective:Strengthening of research on Latin America through the development of policies and lines of research in the
countries and the organization of international meetings on nursing research, with emphasis on primary care models.

Summary:  Nursing research is being promoted through the methodological strengthening of research proposals and
opportunities for the development of joint proposals by investigators from North America and Latin America in
common areas of interest.

Outcome:  Nursing research policies have been developed in Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico,
Nicaragua, Panama, Peru, and Venezuela.  International conferences on nursing research have been held in
Colombia, Mexico, and Panama.

SCIENTIFIC AND TECHNICAL INFORMATION

Objective:To strengthen scientific and technical information about nursing in the countries and to promote the acquisition of
textbooks and instructional materials for nursing students and all nursing personnel. 

Summary:  A Regional meeting has been organized to analyze and formulate recommendations regarding the selection and
utilization of texts and instructional materials in the Textbooks Program.  Bibliographic support is offered to the
institutions that train nursing personnel through the provision of publications from all the Regional programs and
from several groups in Latin America.  The documentation centers in the countries (in the PAHO Representation
and/or Ministry of Health) are being strengthened in the area of nursing.

Outcome:  All the Spanish-speaking countries have facilities to support education and manpower development in the various
areas of nursing.  An effort to encourage local publications has been launched in several of the countries.


SUBREGIONAL PROJECT FOR THE DEVELOPMENT OF
LOCAL HEALTH SYSTEMS 

I    BACKGROUND AND JUSTIFICATION

     The economic crisis in Central America, originated by a rise
     in oil prices, a decline in export prices, and an increase
     in international interest rates, led to a substantial
     increase in the subregion's external debt that has resulted
     in a per capita GNP in 1990 of 17.2% less than that of 1980
     and a drastic loss in the purchasing power of real wages.

     National programs for stabilization and short-term
     adjustment, directed toward curtailing inflation and the
     imbalance of the balance of payments, were implemented
     through the imposition of austere fiscal and monetary
     policies, which diminished public spending and eliminated
     subsidies.  At the same time, the programs initiated for
     structural adjustment, designed to modify the production
     structure in the medium and long terms, appear to suggest
     changes in the role of public sector action.

     At the present time, these programs are having a negative
     impact on the lowest income groups and on the satisfaction
     of their basic needs, since they are also manifested in
     significant reductions in the budgets of the Ministries of
     Health, the Social Security institutions, and other social
     sectors, which in turn translates into an average real
     expenditure on health of approximately US$10 per person per
     year in the subregion.  At the same time, investment in
     water, sanitation, and health infrastructure has also
     declined, resulting, by 1990, in a social deficit whose most
     dramatic manifestation is the current epidemic of cholera.
     
     The social consequences of the crisis have also signified an
     increase in inequality and poverty and an adverse and
     far-reaching impact on the health conditions of the Central
     American population.  Undernutrition has increased, the
     decline in infant mortality in the subregion has been
     brought to a halt, and in two of the countries it has even
     risen.  The maternal death rate has been stabilized,
     although it as much as 40 times higher than that of the
     industrialized countries.  At the present time in the
     subregion there are approximately 12 million people without
     permanent access to health care services, a resurgence of
     malaria and dengue has taken place, there are persistent
     outbreaks of measles, and AIDS and cholera have assumed
     epidemic proportions.




     The great challenge of the crisis since 1990 is to achieve
     not only recovery and sustained growth but also to ensure
     that economic and social benefits are provided to the most
     neglected sectors of the population.  This challenge, which
     the subregion is confronting in responding to the cumulative
     and emerging needs of vast sectors of the population,
     demands serious consideration by all of the most appropriate
     solutions, together with concerted action by the economic
     and social sectors in order to resolve the problems at hand
     and satisfy the substantive requirements of social equity,
     effectiveness, and efficiency.

     The 1990s in the countries of Central America will mean
     laying the bases for a redefinition of the social role and,
     consequently, of the importance of government in the modern
     State in its duty to emphasize the positive value of health
     in the process of development.

     Current conditions and the magnitude of present-day social
     needs require enhancing the capacity of governments to
     function as suppliers and facilitators of health services. 
     A process of sustained development necessarily entails
     improving the living and health conditions of the
     population.  Furthermore, economic and social development of
     these characteristics is based on better distribution of
     both income and of access to essential social services,
     among them the health services.

     Improvement of the health and nutrition of the population
     has a direct impact on well-being and economic growth. 
     Well-being derives from improving the living conditions of
     the population and increasing the number of days of healthy
     life that can be enjoyed by individuals and their families. 
     In addition to improving the social benefits derived from
     investment in education, important economic advantages are
     obtained from growing work productivity, the social gains
     accrued by reducing the number of absences caused by
     illness, and the additional number of days of productive
     life that result from extending the useful life of the
     population.
     
     The aforementioned economic and social crises that
     underscored the insufficiencies and deficiencies of the
     models of development adopted in the past, the structural
     adjustment measures presently being applied that require an
     institutional framework in order for the increase in
     production and productivity to be directed toward the
     benefit of the people, the inadequacy of the institutional
     responses to the growth and evolution of the problems faced
     by the health sector, the cumulative and unsatisfied health
     needs of the unprotected population groups, and the lack of
     equity, effectiveness, and efficiency of the health actions
     taken all point to an imperative and urgent need to reassess
     the actions taken in the field of health, both with regard
     to the contribution that health can make to the social
     progress of the people of the subregion in the decades to
     come and with regard to the profound interdependence between
     health and the process of sustained and equitable human
     development.

     Reassessment of health demands that activities in this field
     be geared toward promoting the search for social stability
     and peace, evaluating and strengthening democracy,
     increasing productivity, and fostering citizen participation
     and shared responsibility in efforts directed toward
     generating a greater degree of social well-being through the
     contribution of health to the satisfaction of basic social
     needs.

     In summary, the characteristics of health and living
     conditions in Central America, the effects of the structural
     adjustment of the economies of the countries, the general
     requirements for the development models that are to be
     adopted, and the emerging challenges in the countries in
     terms of health and their accumulated social needs have
     resulted in a situation that requires proposals for action
     from the standpoint of the social sector that are capable of
     supplementing the overall efforts to achieve sustained and
     equitable development.

     Thus, the XI Summit Meeting of Central American Presidents,
     held in December 1991 in Tegucigalpa, Honduras, concluded,
     in view of the situation and the most promising approaches
     for dealing with its underlying processes, that
     consideration of health, in the context of the development
     of Central America, should most ideally include the
     following fundamental factors: 

     -    Reexamination of health from the perspective of human
development, inasmuch as expenditures on health are a
social investment.

     -    Consideration of the impact on health of vulnerable
groups as the basis for the negotiation and formulation
of development policies and programs, including
programs for structural adjustment.

     -    Appropriate inclusion of health actions in social
programs that are consistent with the strategy for
national health and long-term development of the
country.

     -    Strengthening of the Ministries of Health in order to
improve their ability to perform their regulatory role
in the health sector as the vanguard of the process of
social development, the fundamental agent in the
improvement of human capital, and the manager of
national strategies for achieving substantial reduction
in infant and maternal mortality and increasing life
expectancy.

     -    Adaptation of the policies, strategies, and instruments
of the health sector to ensure that the available
resources are oriented toward increasing access to
health care, essentially in accordance with the
priority needs of the people. 

     -    Adoption of measures to incorporate community
participation and control in the processes related to
the organization, management, and provision of the
health services.  In this context, an effective process
of decentralization and deconcentration is a central
element of the strategy that should be framed in a
general process of decentralization of the State.

     -    Establishment of the conditions for ensuring effective
interinstitutional health actions, especially in
national processes to strengthen the functional
coordination between the Ministries of Health and the
Social Security institutions.

     -    Identification and implementation of mechanisms that
will lead to organization of a regional network of
health services and to the free flow of human resources
and inputs for health between the countries.

     The Strategic Orientations and Program Priorities for the
     Pan American Health Organization during the Quadrennium
     1991-1994, adopted by the XXIII Pan American Sanitary
     Conference, and the Resolutions of the VI Meeting of the
     Health Sector of Central America (RESSCA) stress the
     development of health infrastructure as one of the priority
     areas of the Second Phase of the Plan for Priority Health
     Needs in Central America (PPS/CAP).  In this context, the
     Ministers of Health and the Directors of the Social Security
     institutions have agreed to mobilize resources and carry out
     actions aimed at transforming the health systems, which,
     with greater capacity for control, organization, and
     management, will be able to serve the growing needs of the
     population with greater efficiency, effectiveness, and
     equity and thus overcome the effects of the economic and
     social crisis and contribute to peace, development, and
     democracy in the subregion.

     The general guidelines prescribed by the aforementioned
     organizations entrusted with management of the health sector
     emphasized the integration of regional efforts so as to give
     greater importance to health as a fundamental ingredient in
     the process of human development and assign special priority
     to including previously underserved population groups within
     this development process.  With particular regard to the
     priority area of development known as Health Systems
     Infrastructure, the guidelines referred to the principal
     goal of expanding coverage through the local health systems
     to those who lack services and at the same time ensuring
     integrated and qualitatively appropriate care.  This, in
     turn, is again premised on emphasizing primary health care
     and developing managerial capacity in order to bring about
     decentralization.
     
     In complying with these guidelines and reducing the effects
     of the social and economic crisis, it is of vital importance
     for the countries to orient, mobilize, and utilize in the
     most efficient way all possible resources for comprehensive
     health care as part of the principle of social equity.  This
     requires transformations of the national health systems that
     must be soundly based on comprehensive analysis of the role
     and importance of the government in the modern State and of
     the health sector itself as part of the governmental
     structure.

     In this context, decentralization and local development of
     the health sector through the strengthening of local health
     systems are considered appropriate steps to be taken in the
     process of democratization, supported by greater citizen
     participation and social justice in order to bring about
     efficiency, effectiveness, and equity in public management
     of the health services.

     In order to achieve this it will be necessary to subject
     current national models of health development to intense
     scrutiny and to bring about change in the countries in the
     subregion through the adoption of national processes
     supported by mobilization of external resources.

     The Project presented below suggests the appropriate
     jurisdictional levels and the resources required for
     implementing the previously mentioned political decisions
     and resolutions, principally by setting up processes that
     will serve as core elements in prioritizing and organizing
     programs and in identifying the geographical areas and the
     biologically vulnerable population groups at greatest social
     risk with a view to assigning them priority in applying the
     strategies of primary health care and local health systems
     and making decentralization of the resources and focusing of
     the health programs viable and feasible.  These actions are,
     furthermore, considered to be a fundamental mechanism for
     integrating the activities of the second phase of the
     Central American initiative "Health and Peace for
     Development and Democracy".

II  FRAME OF REFERENCE OF THE PROJECT

     The abovementioned social and economic crises that the
     countries are facing have made it necessary to take urgent
     measures in all public administration sectors in order to
     find ways to attenuate their negative impact.  Such
     circumstances represent for the health sector at the present
     time a most important challenge for its component health
     systems.  It means that if these systems in general have not
     yet been able to provide health care for the entire
     population efficiently, effectively, and equitably, they
     should be reorganized and reoriented in order to bridge the
     current gap and respond to the changing and growing demands
     of the population, which have been increasingly polarized by
     the socioeconomic differences that are accruing between the
     various social groups that make up national and local
     communities.

     Discussion of the role of the government structure within
     the State has also brought forth new ideas on the role of
     the health sector in social and economic policy.  Emphasis
     has been placed on the leadership and regulatory role of the
     State; however, given the magnitude of social demands, the
     need has also been recognized for governments to strengthen
     their participation as suppliers and facilitators of the
     health services.  Sustained development is founded on better
     distribution of both income and access to essential social
     services, such as health services.

     Among the social functions formally accepted and developed
     by the Central American states was the provision of health
     services.  In the framework of the current social model, the
     model of health services delivery with emphasis on a
     curative approach has been geared to the needs of those who
     were in a position to have their demands heard.  

     Nevertheless, even before the beginning of the crisis it had
     become evident that the resources at hand were insufficient
     to ensure the population adequate coverage of basic
     services.  Although some improvements have taken place in
     the indicators of the state of health of the population, the
     need has become evident that a new care model is required
     that would permit a comprehensive approach to health and
     provide greater access for all population groups.  It was
     also necessary to redefine the criteria for allocating
     financial resources to the sector and to redistribute the
     resources so as to produce the greatest impact possible and
     to benefit heretofore underserved population groups.  

     In this effort, the transformation of national health
     systems is a crucial element that entails both redefining
     how the health sector is to be organized and how the various
     institutions involved are to intervene in providing goods
     and services related to health.  Most particularly, however,
     it is necessary to redefine the relationships between the
     health services and social welfare actions, in addition to
     the relationships between the central government, the
     peripheral public organizations, and other civil society
     organizations. 

     In carrying out this mission, the strengthening of local
     health systems is one of the key strategies for improving
     equity, efficiency, effectiveness, and social participation
     in the provision of health services.  The process of
     strengthening and developing local health systems
     constitutes the dynamic force underlying reorganization of
     the sector.  Local health systems should continue to
     reaffirm their role of facilitating the concerted action of
     the public sector, Social Security institutions, the private
     sector, nongovernmental organizations, and civil society
     organizations in fulfilling the common goals of providing
     comprehensive care for the health of the population.  It is
     at the local level and from an interinstitutional approach
     that national health policies should be analyzed, detailed,
     and fully articulated with the concrete realities of local
     populations; and it is at this level that political goals
     should be transformed into specific acts.

     Thus, local health systems are recognized as an operational
     tactic for accelerating the primary health care strategy and
     its components and assigning priority to the least served
     groups and those at greatest risk.

     The operational tactic of local health systems has been
     adopted with a view to orienting and implementing the
     transformation of national health systems in order for them
     to be able to:  

     -    Reassess health in terms of its interdependence and
contribution to the process of sustained and equitable
human development.

     -    Increase the operating and decision-making capacity of
their health services in the paradoxical situation in
which greater demand is concurrent with a scarcity of
resources in the outlook for social welfare and human
development.

     -    Extend health service coverage based on the primary
health care strategy.

     -    Improve the provision of health services in terms of
opportunity, adaptation, and quality with regard to the
priority problems of specific population groups.

     -    Transcend the vertical and partial management systems
of the health programs in order to provide effective
comprehensive health care.

     -    Achieve active social participation for the promotion,
administration, and provision of services.

     -    Develop mechanisms and attitudes for intra- and
intersectoral coordination and for coordination between
the public and private subsectors.

     This tactical-operational dimension assumes that local
     health systems are a new profile of organization and action
     for providing comprehensive health services that derives
     from directed and coordinated operation of all the resources
     available in a determined geographical area or jurisdiction
     in order to provide appropriate and comprehensive attention
     to the priority problems of given populations.  Hence, to
     the extent that the health situation is analyzed at the
     local level and that the resources available for the
     production of services are known and coordinated, it will be
     possible to make a better response to the health needs and
     problems of the jurisdictional populations of local health
     systems.

     Organization into a network of health services characterizes
     the typology of local health systems, inasmuch as they are
     merely a part of the organization of the national health
     system that enjoy relative autonomy and decision-making
     capacity, in addition to having certain competencies that
     have been delegated to an established territorial
     jurisdiction with precisely and clearly defined
     responsibility for a given population.

     Organization into a network of local health systems is the
     appropriate mechanism for increasing decision-making
     capacity through the integration of health actions with
     other actions with a view to satisfying basic needs and
     improving living conditions.  This should be carried out on
     a scale large enough for making a thorough study of the
     current health problems and their underlying causes and for
     building a capacity for the management and production of
     services sufficient to deal with the principal human
     development problems that affect most of the population
     within a given jurisdiction.

     Furthermore, in the subregional context of the development
     of local health systems it is considered that the local
     health systems do not alone entail a new form of
     organization within a network of health resources available
     to a specific population-space; rather they also largely
     involve a new profile of integrated and decentralized
     management in this network of health resources and services,
     which points to the need for reorienting the action and
     interaction of all the social actors involved in order to
     resolve the particular health problems of those who fall
     within the jurisdiction of each local health system.

     In this connection, the greatest efforts so far have been
     devoted to developing the new scheme of organization, which,
     based on the conceptual framework adopted, has resulted in
     the establishment of local health systems, especially with
     regard to delimiting the geopolitical-population area and
     structuring the network of services.  Although efforts have
     also been made with respect to the operation component in
     subject areas as varied as local planning and programming,
     managerial information, and the deconcentration of certain
     administrative systems, an integrated approach has still not
     been devised to deal fully and properly with strategies for
     the development of local health systems in accordance with
     the new profile of action resulting from involving the
     establishments making up the network of services in local
     processes of development and social participation.

     Decentralization policies are in force in the countries of
     the subregion that are of great strategic significance for
     local health system development and that are expected to
     result in greater decision-making and resolution capacity at
     the peripheral levels of the health services system as a
     means of adapting actions to the needs and the requirements
     of the local communities.

     Decentralization is not only a strategy and instrument for 
     bringing about a process of change in government management
     but also has the potential for affecting the desired
     adaptation of local health systems by improving the
     productivity of the services, changing the administrative
     mind-set by introducing new actors into management and
     control, redistributing State resources, and strengthening
     social participation.  

     The experience accumulated in recent years has led to
     revision of the approach, the dimension, and the practices
     of traditional administration and also to the recognition
     that such revision, although necessary, is also insufficient
     vis-Õ-vis the new profile of organization and action that
     is required for the development of local health systems.

     The operation of local health systems so that they fulfill
     their purposes and objectives as a strategy for
     transformation requires the development of:

     -    Capacity for strategic and integrated management of the
institutions that make up the local health systems in
order for them to be able to solve priority problems
and achieve their common objectives; and

     -    Capacity for institutional administration of the
resources in a decentralized and flexible manner in
order to respond to the requirements of the fully
negotiated and agreed-upon operational plan.  

     Both managerial and administrative capacities constitute
     managerial capacity required to increase operating and
     resolution capacity in local health systems--that is,
     managerial, institutional, and interinstitutional capacity
     with a new approach that extends beyond traditional
     administration and is considered to be institutional action
     that makes optimum application of the resources viable for
     the achievement of predetermined development objectives
     through a decision-making process provided with continuous
     feedback for the organization and execution of activities
     assisted by reliable and pertinent information. 

     In the countries of the subregion the managerial and
     strategic approaches have been explicitly and intentionally
     adopted in order to orient and promote transformations in
     the most critical aspects of health management that will
     lead to increasing the decision-making and operational
     capacity of the health services.

     This managerial approach is founded on the bases of the
     nature, functions, and responsibilities of the management of
     public policies, which demand reexamination of the criteria
     for social and economic productivity in providing the
     services and a strategic approach for optimizing the
     resources for solving the problems of social groups in order
     to bring about social welfare as the ultimate purpose of any
     process of development.

     Accordingly, the concept of management, applied to local
     health management with a strategic approach, represents the
     ability to identify the means of relating three general
     elements:  a) health problems and needs, b) knowledge and
     resources, and c) consensus on common problems and
     priorities of specific social groups for the purpose of
     making the best possible use of the resources available for
     achieving health.

     In the local health systems, agreement is essential among
     the various social actors who constitute the local forces
     for developing health and the health services.  This is a
     feature that differentiates it from any another approach or
     traditional effort that has been made to improve health
     conditions within a health jurisdiction.  The term local
     forces is taken to mean the sum total of local and regional
     health teams, organized community groups, and the State and
     nongovernmental agencies in all sectors that act at the
     local level and that perform functions or have
     responsibilities directly or indirectly related to health
     and welfare. 

     Development of local health systems with these
     characteristics is a complex operation.  Their initiation
     and activation demands a managerial leadership potential
     capable of catalyzing and mobilizing technical,
     administrative, financial, and political-social resources
     and initiatives in order to:

     -    Identify, motivate, and convoke the local social forces
that are in a position to intervene in the
health-disease process.

     -    Carry out a rigorous and realistic process of study and
evaluation of the health situation, the production of
the service units, and the health programs and projects
in operation.

     -    Promote the design and implementation of strategies,
necessary instruments, and new systems for a
participatory process of change in almost all areas of
management of the services.

     -    Organize and carry out personnel training in order to
fill whatever gaps the health diagnosis and
planning-execution-evaluation may reveal. 

     -    Maintain appropriate coordination at all times with the
regulatory units at the central levels of the
participating organizations in order to ensure
consistency in direction and continuity, in addition to
support of technical assistance in any programs that
are put into operation.  

     It is important to implement and support large-scale
     national efforts aimed at redesigning national models for
     the development of health in the form of sets of regulatory
     criteria that can progressively serve as very effective
     guides and promoters of change in the management,
     configuration, and operation of health programs and actions
     in an intense and ongoing process of analysis and
     application that systemically synergize and integrate the
     principal components outlined below.


III  COMPONENTS OF THE PROJECT

     COMPONENT 1:   Redefinition of the Strategies for Attacking
Health Problems

     From a new concept of health in development, the business of
     the health sector extends beyond the limited framework of
     traditional concepts of health to consider the factors of
     living conditions and social welfare.  This imposes the need
     for the forms of sectoral action to review and reconsider a
     field of intersectoral intervention by multiple social
     actors in the biological, ecological, cultural, and
     socioeconomic processes that are predominant in a given
     society at a given time and that constitute a different
     approach and a different procedure in rethinking health
     problems and redefining the attack strategies by emphasizing
     consideration of the risk factors and the groups at risk in
     light of the sociopolitical, economic, and environmental
     trends characteristic of the present decade.

     COMPONENT 2:   Review of the Organization and Operation of
Health Care Systems 

     The fact that large sectors of the population still do not
     have access to the health services at a time when the living
     conditions of large social groups are deteriorating
     constitutes a great challenge to the ability of the health
     sector to organize and interact in a network of health
     services that functions as a system--especially in regional
     and local areas--improve the consistency and the
     complementarity of sectoral and intersectoral policies and
     programs in reducing the fragmentation of the organizations
     and the dichotomy between sectoral institutions and civil
     society, and achieve intense and coordinated mobilization
     and productive utilization of the resources available for
     population groups for the purpose of increasing coverage and
     resolving their priority health problems.


     COMPONENT 3:   Review of Sectoral Financing

     Concurrently with the transformations proposed in the
     organization, operation, scope, and strategies of sectoral
     action, the challenge emerges of reviewing the procedures
     for financing and channeling the expenditure on health. 
     Economic and financial criteria should be considered as
     determinants in evaluating the alternatives for
     incorporating the changes pursued by the aforementioned
     components into models for the development of health. 
     Furthermore, any transformations that are achieved should
     gear the decisions made regarding the allocation and
     application of national resources for health to achieving
     more intense and decided mobilization in accordance with the
     priorities of development in a framework of stability,
     productivity, equity, and social progress.

     COMPONENT 4.   Development of Strategic Administration at
the Local Level
 
     Within the context of policies of decentralization for the
     purpose of expanding participatory democracy that are linked
     to the need for establishing strategies to resolve the
     particular health problems of specific social groups
     deriving from particular conditions of life in a given
     historical time and place, the need arises for organizing
     comprehensive health actions and programs at the local level
     that are consistent with the needs and expectations of
     specific population groups by integrating the knowledge and
     resources of the various social actors making up such groups
     in a specific geographical space.  This makes it necessary
     to undertake a process of review and reformulation of the
     forms and instruments of local management through the use of
     a strategic approach that takes into account the objectives
     of development and social welfare adopted by these groups. 

     COMPONENT 5:   Development of Social Participation
     
     Both the concept and practical application of strategic
     administration at the local level are implicitly founded on
     the broadest possible social participation of the population
     groups and the institutions involved in identifying and
     resolving the health problems of the entire population under
     the responsibility of the local health system.  Social
     participation and social control, promoted through health
     education and new forms of local programming and management,
     will make it possible to join together the wills,
     capabilities, and resources of the
     various public and private protagonists who are in a
     position to play a role in promoting and improving the
     health of the population, in addition to promoting a sense
     of responsibility for individual and collective health care
     and for the development of community projects aimed at
     generating a greater degree of social welfare. 

IV   COOPERATION STRATEGIES 

     Transformation of the health systems with a view to
     providing a more effective and equitable response to growing
     and changing health care needs that is consistent with the
     changes expected in national political, social, and economic
     conditions is a process that is peculiar to each country. 
     However, the magnitude of the changes, the pluralistic
     nature of the approaches required, and the understandable
     uncertainty regarding the ultimate findings and their
     effects pose a challenge to the creative capacity of the
     institutions that must deal with such highly complex
     processes. 

     The Subregional Project is consequently oriented toward
     providing support to the countries in developing the
     required national institutional capacity through the
     generation and management of knowledge (methodological and
     instrumental frames of references), together with support
     for local creativity and experimentation and for the
     exchange of experiences and skills between the countries of
     the Subregion.

     Emphasis will be given to the Project's activities at the
     local level, and the opportunity and the means will be
     provided for the local health systems involved to carry out
     their own search for and experimentation with the
     technological responses required by the transformations they
     seek to bring about.  As a result, the Project will be
     effective in making deconcentration of this technical
     cooperation a reality.

     In summary, the Project recognizes the individuality of the
     various national processes for the transformation of country
     health systems and even the peculiarities of local systems;
     nevertheless, it promotes and facilitates cooperative action
     in the joint production and increase of technology and
     institutional capacity for the creative search for options,
     experimentation with the findings, and evaluation of the
     results.

     For this purpose, once the priority components to be covered
     by the Project were validated by the countries, the ways and
     means for obtaining cooperation and support for the
     development of local health systems were identified, based
     on the premise that the Project would be carried out
     predominantly at the local level.

     The modalities of cooperation selected and ranked in order
     of interest and expectations of the countries, which does
     not necessarily imply any specific arrangement of the
     logical sequence of execution, are the following:

     1.   Actions aimed at increasing the operating capacity of
the network of services.

     2.   Development of decentralized management systems.

     3.   Formation, training, and dissemination at the
institutional and community level.

     4.   Development of the capacity to mobilize resources and
provide critical supplies within the local health
systems.

     5.   Support for the formulation of policies and strategies
for the development of local health systems. 

     6.   Review of the legal and regulatory framework. 

     Each country also established Project coverage for the 35
     local health systems considered as priority targets for
     development, with a total beneficiary population of
     3,819,481. (Annex 1).

     The Project will be carried out in close coordination with 
     other subregional projects that are part of the second phase
     of PPS/CAP, primarily through the projects for the
     Development of Managerial Capacity, Essential Drugs,
     Engineering and Maintenance, and the Central American
     Consortium for Health Technology Development.  For this
     purpose, the subregional authorities responsible for these
     projects will attempt to provide and channel their
     technological, regulatory, and instrumental production as
     inputs for application in the local health systems covered
     by the Project.  In addition, they should coordinate their
     annual operational plans with the Projects's Annual Plan of
     Work, especially with regard to training.

     Moreover, the technical contents of the comprehensive care
     promoted by the Project in each local health systems will be
     coordinated with the subregional projects on the Promotion
     of Health and Disease Control, Care for Special Groups, and
     Environment in such a way that the process supported by the
     Project in each local health system will become a mechanism
     for integrating programs and actions for the development of
     health.

     Validation of the five priority components of the Project
     and of their combination with the six modalities of
     cooperation (Annex 2) resulted in specification of the
     objectives, which in turn led to the establishment of the
     Projects' expected outcomes, its lines of action, and its
     operational characteristics. 

     The Project will have a duration of three (3) years, during
     which a total of US$2,500,000 will be invested, financed by
     resources provided by international cooperation
     organizations.  In addition, the governments of the
     participating countries in the subregion will contribute
     operational personnel and the facilities for executing the
     Project as counterpart funds.

V    OBJECTIVES

     A.   General Objective
     
     A contribution to improving the health and welfare of the
     least served population groups through development of the
     institutional capacity of the health sector in the countries
     of the subregion in order to respond to their realities,
     design proposals for transformations in the health care
     models and systems, and experiment, evaluate, and provide
     feedback for the strengthening of local health systems in
     terms of their impact on the welfare of the population in
     accordance with the criteria for efficiency, effectiveness,
     and equity.

     B.   Specific Objectives

1.   Review and redefinition of the strategies for
attacking health problems in order to make changes
concerning priorities and technical standards of
care, mobilize resources, and select appropriate
technologies, in the knowledge that a great many
of the actions required are not sectoral in
nature.  Utilization of health criteria of an
epidemiological, socioeconomic, and environmental
order consonant with the renewed concept of health
in development.

2.   Review and development of forms of organization
and operation of systems of health care and
promotion at the local level that permit the
incorporation and coordinated interaction of the
population, the health authorities, the sectoral
institutions, and other governmental, social, and
productive sectors in a systemic network of
services oriented toward improving individual and
collective health conditions in order to make them
more efficient and productive in terms of
accessibility, opportunity, quality, decision-
making capacity, and cost.

3.   Analysis and redesign of the structure,
mechanisms, alternatives, and implications of
current health financing in order to achieve
articulated mobilization of public and private
resources for providing the services necessary for
addressing essential health problems, in addition
to reorientation of the expenditure on health by
assigning priority allocation of the resources to
actions and programs that promote equity and
greater effectiveness.

4.   Review and development of the styles, processes
and instruments for the management of health
systems at the local level and their articulation
with the intra- and intersectoral intermediate and
central levels for the integration and application
of knowledge and of institutional and community
resources in order to proceed to
socioepidemiological analysis, participatory
definition of priorities, agreement on courses of
action, and shared execution by the various social
actors involved in resolving the particular health
problems that affect specific social groups in a
defined geographical space.

5.   Reorientation and development of social
participation approaches and procedures in the
health-disease process as a means of opening the
way to genuine participation by the sectoral
institutions and the actors in civil society in
defining health problems through deliberation on
action priorities and strategies, consensus on
commitments, and the request for and rendering of
accounts with regard to the responsibilities
assumed for promoting the health of a given social
group. 
     
     Based on the above specific objectives adopted by the
     countries of the subregion, a list was drawn up of the
     outcomes expected, by components of the Project, which in
     turn will determine the lines of action for achieving them
     and the criteria for success in evaluating them. 

VI   OUTCOMES EXPECTED, BY COMPONENTS

     COMPONENT 1:   Redefinition of the Strategies for Attacking
Health Problems          

     1.1  Incorporation of the contents of the programs for
prevention and control of damages and risks, including
the environment, in the management of local health
systems through local programming organized in
accordance with the problems at hand.

     1.2  Incorporation of ecological and socioeconomic concepts
into the design of health development models. 

     1.3  Design and experimentation of mechanisms for
intersectoral action, especially in nonsectoral areas
of local health systems, in order to achieve
health-related objectives. 

     1.4  Evaluation of technological options in light of the
criteria for efficiency, effectiveness, and equity in
attacking the priority health problems of specific
population groups.
     
     1.5  Development of procedures to orient policy-making and
administration in selecting, obtaining, and utilizing
health technology.

     1.6  Methodological development of local participatory
programming, incorporating in an integrated manner the
contents of the priority programs aimed at specific
population groups.

     COMPONENT 2:   Review of the Organization and Operation of
Health Care Systems 
     
     2.1  Design and experimentation of mechanisms linking the
process of health system development and the trends
toward decentralization and privatization of the social
services.

     2.2  Review of the composition, training, and utilization of
health manpower for health development models that are
adopted.

     2.3  Review of the current forms and of the generation of
possible alternatives for organization of the health
sector in connection with the reduction of paperwork
and of the size of the government bureaucracy. 

     2.4  Design and experimentation of agreement mechanisms
between the public sector, Social Security
institutions, the private sector, and the
nongovernmental organizations with regard to local
health systems for the achievement of common goals for
comprehensive health care for the population within
specific territorial boundaries. 

     2.5  Organization of the services as networks and
strengthening of referral and support mechanisms
between them in order to increase the decision-making
capacity of local health systems.

     COMPONENT 3:   Review of Sectoral Financing

     3.1  Generation in the political area and in public opinion
of a favorable response to assigning priority and sound
resources for the development of health based on
necessary transformations of the systems to provide
them with greater credibility as an effective means for
development, social peace, and the redistribution of
income.

     3.2  Development of institutional capacity for economic and
financial planning that includes and evaluates the
relationship between needs and the various sources of
funding, on the one hand, and the evolution of the
national economy, on the other, to assist in orienting
the negotiation of financing.

     3.3  Evaluation of the impact on the least served groups at
greatest risk of the measures taken to reduce public
spending and increase privatization in order to devise
compensatory mechanisms in accordance with the
principle of equity.

     3.4  Analysis and evaluation of the feasibility of
alternative solutions for financing and distributing
sectoral expenditure in reference to reforms in the
State apparatus and the impact of structural adjustment
currently taking place in the countries.

     3.5  Design of mechanisms to make the best possible use of
public sectoral resources and recover the available
idle capacity that will permit the sector to demand the
inclusion of the health component in investments in
other sectors.

     COMPONENT 4:   Development of Strategic Administration  at
the
Loca
l
Leve
l

     4.1  Design and installation of work systems and concrete
instruments for development of the management and
production of services in local health systems with a
strategic approach and a view toward deconcentration.

     4.2  Review and development of the basic information systems
with emphasis on managerial and epidemiological
analysis capacity applied to the management of local
health systems.

     4.3  Reorientation and strengthening of the processes of
training and utilization of human resources in the
context of continuing education in order to increase
the capacity to resolve problems through interprogram
and intersectoral actions that will respond to the
changing health needs and characteristics of specific
population groups. 

     4.4  Development of the capacity for negotiation, consensus,
and management at local management levels in the sector
so as to take account of the pluralism characteristic
of the social protagonists who are involved in the
development of health.

     COMPONENT 5:  Development of Social Participation

     5.1  Formulation and experimentation of strategies and
mechanisms that will increase effective social
participation at all stages in the management of local
health systems.

     5.2  Development of mechanisms that will promote shared
responsibility on the part of the population in dealing
with its health problems autonomously and carrying out
actions to reorganize the sector and develop the health
care model.

     5.3  Development of the institutional capacity for health
education in order to promote and orient genuine social
participation and positive social control as a
prerequisite for democratizing health and social
welfare.

VII  LINES OF ACTION, BY COMPONENTS, FOR THE FIRST YEAR

     Processing of the initial needs and expectations of the
     countries leads to the following preliminary outline of
     lines of action for the first year of the Project:

     COMPONENT 1:   Redefinition of the Strategies for Attacking
Health Problems

     1.1  Development of local programming with a risk approach
(COR, ELS, PAN).

     1.2  Support for operational integration of the priority
programs in accordance with the health conditions in
each local health system (ELS, GUT, HON, NIC).

     1.3  Identification of strategies for effective
incorporation of the health-developing potential of the
governmental and nongovernmental agencies and
intersectoral coordination for social development (ELS,
GUT, HON, NIC).

     1.4  Support for the development of the regional and local
technical capability for the formulation of attack
strategies (GUT, HON, PAN).

     1.5  Coordination with teaching institutions for the
training of auxiliary nursing personnel and technicians
in hygiene and epidemiology using the risk approach
(NIC).

     1.6  In-service training of local teams in local
programming, attack strategies, and the local health
systems approach (ELS, GUT, HON, PAN).

     1.7  Development and validation of educational material for
training and information of institutional and community
personnel with regard to the local health systems
approach and the attack strategies (ELS, HON, NIC).

     1.8  Review and adaptation of the technical standards of 
priority programs (NIC).

     1.9  Provision of teaching material, basic equipment, and
essential drugs to community personnel and midwives
(ELS, GUT, HON),

     1.10 Review and adaptation of the attack strategies to
health problems using the local health systems approach 
(HON).

     1.11 Legal and regulatory review of national and local
health systems (GUT, NIC).

     COMPONENT 2:   Review of the Organization and Operation of
the Health Care Systems 

     2.1  Design and experimentation of alternative care models
(COR, GUT).

     2.2  Review of the role of hospitals in local health systems
(COR, ELS, GUT, NIC).

     2.3  Strengthening of the referral systems between care
levels (ELS, GUT, HON, NIC).

     2.4  Development of local capacity for supervision,
monitoring, and evaluation (COR, ELS, GUT).

     2.5  Strengthening of development of the work force in the
network of services and support for operations research
at the local level (GUT, HON).

     2.6  Support for development of the communication network
and referral of patients between care levels (HON).

     2.7  Formulation of strategies and plans for
decentralization and deconcentration (COR, ELS, GUT).

     2.8  Redefinition of the functional profiles of the
establishments and technical-administrative levels
(COR, ELS).

     2.9  Review and adaptation of the legal and regulatory
frameworks for operation of the units according to the
various functional profiles according to
technical-administrative levels (ELS, GUT, NIC).

     COMPONENT 3:   Review of Sectoral Financing

     3.1  Development of strategies for financing and recovery of
costs at the regional and local levels (ELS, NIC).

     3.2  Development of strategies for the mobilization of
resources (ELS, GUT).

     3.3  Preparation of strategic criteria for allocation of
resources based on risk (COR).

     COMPONENT 4:   Strategic Development of Administration at th
e
Lo
ca
l
Le
ve
l 

     4.1  Comprehensive development of information systems at the
local level that includes risk conditions and levels of
well-being, in addition to strengthening the capacity
for local strategic surveillance (COR, ELS, GUT, HON).

     4.2  Development of a managerial information system at the
local level (COR, ELS, GUT, HON).

     4.3  Development of systems, standards, and procedures of
decentralized administration:  budget, supply, and
general logistical support services (COR, ELS, GUT,
HON, NIC, PAN).

     4.4  Training for management at the regional and local
levels (COR, ELS, GUT, NIC, PAN).

     4.5  Development of strategies to supplement and provide
intersectoral support for the administrative systems
(HON).

     4.6  Development of the legal framework for local health
administration (ELS, GUT, NIC).

     COMPONENT 5:  Development of Social Participation

     5.1  Evaluation and systematization of community
participation experiences and their impact on social
development (GUT, HON, NIC).

     5.2  Development of strategies to involve other social
actors in the local health systems process (COR, ELS,
GUT, HON, NIC, PAN).

     5.3  Development of local negotiating capacity for consensus
and management with regard to local health systems
(COR, ELS, HON, NIC, PAN).

     5.4  Training of health personnel for community work (HON,
PAN).

     It is recognized that the logical relation of causality
     between the lines of action presently indicated for the
     first year and the outcomes expected at the end of the
     Project is not completely coherent; however, it is assumed
     that they should be used as a point of departure in
     preparing the first national work plans to specify the
     initial activities in the lines of action considered to be
     of a priority nature and to indicate the local health
     systems in which this is feasible.

     This option is considered to be fully valid, since, while
     respecting the current expectations of the countries, it
     provides the opportunity for identifying and reformulating
     the actions that must be taken in order to attain the
     expected results through in-service apprenticeship in the
     real environment of the local levels.  Successive
     evaluations and programmings will provide feedback for this
     preliminary assessment, and the new lines of action decided
     upon will be incorporated into the Project document.

     As a result, once the Project is approved, the next step
     will be the preparation of local programs for the
     formulation of national plans, which will be consolidated in
     the Annual Subregional Work Plan, to which will be added
     activities it is considered desirable to carry out at the
     subregional level in accordance with the principles of
     subsidiarity and economy of scale. 
VIIIBUDGET FOR THE FIRST YEAR

     The Project budget for the first year has first been
     organized generically and indicatively by each of the five
     components and then distributed according to cooperation
     mechanisms and resources. 


A.   COMPONENTS                         AMOUNT IN US$       % 

     COMPONENT 1:                       225,000.00          30%
     COMPONENT 2:                       180,000.00          24%
     COMPONENT 3:                        45,000.00          6%
     COMPONENT 4:                       180,000.00          24%
     COMPONENT 5:                       120,000.00          16%



TOTAL        750,000.00          100%


B.     TYPE OF COOPERATION              AMOUNT IN US$       %

     CONTRACTING LOCAL PERSONAL:        420,000.00          56%
     IN-SERVICE TRAINING:               180,000.00          24%
     PROVISION OF CRITICAL SUPPLIES:    100,000.00          13%
     REGIONAL AND SUBREGIONAL SUPPORT:   50,000.00           7%



TOTAL        750,000.00         100%



     The specific breakdown by component, type of cooperation,
     and resource will be carried out on the basis of the
     specific requirements that are agreed upon to implement the
     programs approved by each country for each local health
     system in the four-month programming periods.
IX  ORGANIZATION AND ADMINISTRATION OF THE PROJECT

     A.  Operational Characteristics

In using decentralization as a policy, primary health
care as a core strategy, and the development of local
health systems as the operational tactic to bring about
the transformations discussed above, the Project will
be resolutely oriented toward analysis, design,
experimentation, and evaluation in networks of services
in specific population areas in support of the 35 local
health systems that have been considered as priority
targets for development in the subregion.
     
As a result, the activities will be developed
predominantly at the regional and local level, although
intervention will take place at the central levels when
necessary for development of the local level. 
Accordingly, the resources will be applied principally
in local health systems in accordance with the
realistic requirements of the processes that are
effectively taking place. 

Social participation is a key element in the success of
the Project, and consequently viable and flexible
activities are required that will allow for the
expression and involvement of all community groups and
institutions that are interested in and are capable of
making a contribution to improving the health and
welfare of the population covered by local health
systems.

Attempts will be made to bring about true democratic
participation, and in this connection it will be
necessary to orient the social groups toward active
participation in the formulation and execution of
specific actions that respond to the priority needs of
each local health systems.

Implementation of this nature is expected to bring
about greater social control in executing the Project
that will provide better knowledge of the areas in
which the most effective solutions for each situation
can be achieved.

Consequently, the Project will incorporate as executing
entities all the social actors--sectoral institutions, 
nongovernmental agencies, political-administrative
authorities, and civil society organizations that are
truly engaged in local health system development and
will support the Project in accordance with the social
participation arrangement and strategy that each local
health system adopts.

The Project will not require setting up a specific
subregional or national specific infrastructure, since
it will operate by utilizing the existing subregional
cooperation organizations and by increasing the
installed cooperation capacity in the PAHO/WHO
countries so that it can be decentralized and used to
provide direct support to the local health systems.

     B.   Organization

At the national level, the Project will be directed by
the organization that coordinates the PPS/CAP
subregional projects in each country and by the local
PAHO/WHO Representation. 

At the local level, the Project will be coordinated by
a professional from the population covered by the local
health system who will work with full dedication and in
close collaboration with the local health authorities
and supported by the technical supervision provided by
the local PAHO/WHO Representation. 

The mechanisms for coordination, programming, and
national and local evaluation of the Project will be
defined by each country when the first operational plan
is formulated in accordance with the following
principles:

-    No establishment of parallel structures or
suprastructures.

-    Shared responsibility with the national
authorities and the PAHO/WHO Representations.

-    Deconcentration of technical cooperation.

-    Representation of the social forces at the local
level.

-    Requesting and rendering of accounts.

At the subregional level, the Project will be directed
jointly by a Subregional Coordinating Council to be
composed of national responsible officials and the
PAHO/WHO subregional coordinator who will participate
on an equal footing.  This committee will carry out the
subregional annual evaluation and will approve the
Annual Subregional Work Plan after coordinating the
national operational plans.

     C.   Administration

Subregional action will be largely subsidiary to the
national processes at the local level in terms of
facilitating the exchange of experiences, providing the
opportunity for consideration and synthesis of the
knowledge produced locally, supplying a mechanism for
disseminating findings and products that are jointly
validated by the countries, and providing support for
the PAHO/WHO Representations in programming,
administering, monitoring, and evaluating the Project
through the use of criteria based on economy of scale
and decentralization. 

National operational plans and requirements for
resources will be formulated annually through the
presentation by each PAHO/WHO Representation of an APB
to the subregional officer responsible for the Project,
who, after its approval by the Subregional Coordinating
Council and with the support of an annual evaluation of
the results expected by components and the lines of
action foreseen in the Project document, will
consolidate the Annual Work Plan and the Subregional
Budget for negotiation with the donor. 

The allocation of resources by country will be carried
out every four months based on consolidation of the
programs and commitments generated in each
participating local health system on the basis of
principles of rationality, feasibility, and equity and
in accordance with the programming mechanisms and
instruments utilized by PAHO/WHO.
     
Local management of the Project resources will be
decentralized, and for this purpose the means and
procedures will be established that best support the
local activities of the Project in each local health
system and that permit the review and approval of a
four-month program of work that responds to the
expected outcomes and the lines of action foreseen for
each four-month period.  Before the four-month
allocations are carried out, an evaluation will be made
of the fulfillment of the activities and targets
programmed for the previous four-month period.  The
Local Coordinator of the Project should make reports to
the PAHO/WHO Representation in accordance with the
Organization's technical and administrative procedures.


Evaluation of the process and of the results of the
Project will be consolidated at the subregional level
based on the national evaluations carried out with the
information and participation provided by the local
health systems involved.  The process will be evaluated
every four months based on fulfillment of the actions
and targets programmed by each local health system,
whereas the annual evaluation of the results will be
based on the changes brought about in the organization
and operation of each local health system and their
impact on the coverage with respect to the
comprehensiveness of the care provided and the access
afforded the population in terms of the criteria for
success adopted for this purpose.



E0156.FIN



PUBLISHED VERSION                                         9/IV/92

NETHERLANDS ANTILLES AND ARUBA



     The need to optimize excessive health expenditures to solve
problems of public health and social orientation continued to be
a priority for the Governments of the Netherlands Antilles
(Bonaire, CuraÛao, Saba, St. Eustatius, and St. Martin), an
autonomous part of the Kingdom of the Netherlands, and of Aruba. 
PAHO/WHO collaborated with the authorities in developing and
strengthening local health systems, in executing specific
programs for vulnerable populations, and in increasing primary
care activities through community organization to solve local
problems.  Several workshops on community participation were
held, and this strategy was applied in the programs to prevent
drug abuse and alcoholism in CuraÛao.  As a result of this
experience, PAHO/WHO sponsored a workshop in St. Martin attended
by members of the community in that island as well as from St.
Eustatius and Saba.  These and other activities helped
increasingly bring to light the need for establishing greater
collaboration among the six islands and mutual support in health
matters.  A border meeting between the French and Dutch sides of
St. Martin at which common problems in the most vulnerable
population, which in this island consists of illegal immigrants,
were identified, was also very important.
     Within the strategy of technical cooperation among
countries, there are agreements between the governmental health
units of CuraÛao and Bonaire; between CuraÛao and St. Martin on
community organization, and among Venezuela, the Netherlands
Antilles, and Aruba on a permanent exchange of professionals,
processing of biological material samples at the National
Institute of Hygiene of Venezuela, and training of staff members
from the Netherlands Antilles and Aruba in different public
health fields.  Aruba shares its expertise in occupational health
with the Netherlands Antilles.
     In accordance with the need to emphasize the development of
epidemiology for utilization of the risk approach, the
Organization cooperated in offering a workshop on epidemiological
surveillance in CuraÛao, with participants from St. Martin; two
of the participants also attended a course on epidemiological
surveillance in Chile.  The training of these personnel will
facilitate the establishment of epidemiological surveillance
systems, initially for AIDS, the Expanded Program on Immunization
(EPI), and the cardiovascular, respiratory, and diarrheal
diseases.
     AIDS is a problem of high prevalence in these islands, where
infection with human immunodeficiency virus (HIV) is very high. 
During the year, 221 HIV-infected persons were registered in
CuraÛao, 76 in St. Martin, 5 in Bonaire, 4 in St. Eustatius, and
4 in Saba; among these there were 64 cases of AIDS in CuraÛao, 2
in Bonaire, 7 in St. Martin, 2 in St. Eustatius, and 2 in Saba. 
The Organization collaborated with the national authorities in
looking for mechanisms to prevent and control this disease.
     Concerning EPI, PAHO/WHO contributed to the purchase of a
computer which will facilitate evaluation of vaccination coverage
by the Department of Child Care in CuraÛao and sponsored
participation of the administrators of the program in Bonaire,
CuraÛao, and St. Martin at a meeting held in Jamaica.  Specific
budgets were assigned to these programs beginning in 1992 which
will help attain the goal of eliminating the transmission of
measles in the Netherlands Antilles by 1995.
     As for maternal and child health, PAHO/WHO supported
community education and the establishment of hospitals and health
centers in CuraÛao.  In order to increase the capacity of these
services, personnel responsible for management and the direct
care of the population were trained, with emphasis on
surveillance of child growth and development and adolescent
health.  In addition, personnel responsible for managing the
programs were trained.
     In regard to oral health, the program for schoolchildren
continued in Aruba, and epidemiological diagnosis and the
development of alternative care systems to establish a program
for schoolchildren similar to that in Aruba and another for the
entire population were initiated in CuraÛao.
     The food protection program consisted of two components--
food-borne disease prevention and an information system for
protection against such diseases.  Due to the cholera epidemic,
the Organization trained a microbiologist from CuraÛao at the
National Institute of Hygiene of Venezuela, and participants from
Netherlands Antilles and Aruba attended meetings on the
prevention and the control of this disease at the Caribbean
Epidemiology Center (CAREC).  In addition, a course was given on
risk analysis and critical points of control applied to food
hygiene which was attended by 23 participants from CuraÛao, St.
Martin, and Bonaire.  An epidemiological characterization of the
diarrheal diseases was completed, and plans were made to redesign
a food protection information system similar to that in
Margarita, Venezuela, in CuraÛao in 1992.  These information
systems and the methodology of analyzing risk and critical points
of control, together with epidemiological studies on the
diarrheal diseases, will make it possible to draw up educational
programs to prevent food-borne diseases and courses for food
handlers based on local diagnoses.
     With regard to the program to control health risks related
to the environment, staff members from CuraÛao were trained at
CAREC in order to initiate a pilot study for the biological
control of Aedes aegypti, as a principal activity in an
integrated program.  The control programs in Aruba and Bonaire
were also reviewed; the participation was financed of five
inspectors from the Netherlands Antilles and Aruba in the course
on public health entomology held at Maracay, Venezuela, and
personnel were trained in rodent control.  In coordination with
staff members from the Ministry of the Environment, fire
department, Petróleos de Venezuela, and universities in that
country, a diagnosis was made of the risks to the environment
that construction of an oil terminal on the island of St.
Eustatius might pose.
     In a joint country-PAHO/WHO study, the needs for technical
cooperation by the Organization in the Netherlands Antilles and
Aruba were reviewed in order to make it more efficient and
effective, especially in regard to the program against AIDS.
E0157.FIN



CHAPTER IV.G                                              9/IV/92
PUBLISHED VERSION

ORGANIZATION OF HEALTH
SERVICES BASED ON
PRIMARY CARE

Development of Health Services


     During the year a new reaffirmation of the policy decision
of the Region's countries related to the decentralization and
development of local health systems occurred.  The Organization
supported this policy decision through its cooperation programs
to develop health infrastructure and cope with the priority
aspects of disease control.
     By mandate from the Governing Bodies, it collaborated in
carrying out practical experiments in administration, planning,
and programming in local health systems.  Extensive material was
collected in the countries on strategic administration, its
concepts, and methods applied to local health systems.  It dealt
with subjects such as health and development, health promotion,
health and the environment, the role of science and technology;
leadership, programming, and management, and instruments for
their development.  With this material a document was prepared
which was presented at a regional meeting held at Santiago,
Chile, with the participation of 150 staff members from 18
countries in the Region.  Support for the process of local health
system decentralization and development was ratified at the
meeting, and a regional agreement was worked out to continue
advancing in this line of cooperation with the countries.
     The Organization continued cooperating with the countries in
activities to evaluate experiences in local health systems.  For
this purpose, subregional workshops were held at Santa Cruz,
Bolivia, Tabasco, Mexico, and Montego Bay, Jamaica, at which a
total of 23 countries presented their experiences and shared
proposals for local health system development in their respective
subregions.  In addition, the Organization participated in
national meetings to evaluate local health system development in
Argentina, Brazil, Nicaragua, Panama, Paraguay, and Venezuela.  A
workshop with the Latin American Center of Administration for
Development was held at which the administrative aspects of local
health systems were analyzed.
     The interdisciplinary and interprogrammatic character of the
strategy of health system development through local health system
decentralization and development within the reorganization of the
sector itself motivated an important strategy of cooperation in
which efforts to resolve health specific problems were unified. 
In that respect, experiences were carried out in the fields of
mental health, occupational health, health promotion, and women,
health, and development.
     Information management with regard to the development of
health services continued to have a high priority.  In addition
to compiling and analyzing the experiences in the countries, its
broad dissemination through publications devoted to laboratories
and the network of services, hospital infections, health
financing and costs, as well as two special publications
containing 1,800 bibliographic citations, was facilitated.
     The Organization also finalized studies for publishing an
anthology on health services research, a work which will be of
great use in disseminating scientific material on the theory and
practice of research on this subject.  In coordination with the
WHO research unit and the Research Institute of Canada, PAHO/WHO
prepared teaching modules on developing service research
protocols.  In addition, it cooperated with the countries in
concrete research on nursing, social participation, models of
care, and financing of health services.
     At a regional meeting held at the Institute of Public Health
of Mexico in which five of the Region's countries participated,
the curricula of graduate-level education in public health were
analyzed with regard to the development of health services.  In
regard to social participation in local health systems, the
development of specific indicators and their testing in various
communities in order to produce an instrument which makes it
possible to measure progress in this field advanced.
     With regard to information systems, PAHO/WHO cooperated with
social security agencies in analyzing specific aspects of service
decentralization and information systems.  The recommendations
obtained from the Andean countries will be of great use for other
countries in the Region that are facing similar challenges.
     The Organization also made an effort to strengthen the
practice and administration of nursing services, including the
design of strategies and lines of action in collaboration with
nongovernmental agencies, WHO, and nursing leaders in the Region. 
Among the most important activities should be mentioned the
preparation of a two-year plan of work with the Pan American
Federation of Nursing Professionals which resulted in the
development of research proposals in 10 Latin American countries. 
In addition, several nursing services projects were initiated at
the national and subregional levels.  With the participation of
WHO, a survey was made of nursing personnel resources in the
Region and a workshop was held on information systems in this
field.
     Joint cooperation and conceptual development efforts were
carried out with various governmental agencies.  Work was done
with the Latin American Federation of Hospitals on preparing a
Manual on Hospital Accreditation, which is a basic instrument for
promoting activities to control quality in the services, and two
meetings were held, one on the control of nosocomial infections
(Washington, D.C.) and the other on national referral hospitals
(Havana, Cuba).
     Concerning the development of health services, the
Organization, with the support of UNDP, continued carrying out
the subregional project to develop the managerial capacity of the
health services in Central America.  Approval of the second phase
of the project, in which it is planned to extend proposals for
developing managerial capacity at the local level, was
successfully negotiated.  Despite budgetary restrictions, it
succeeded in mobilizing internal and external resources to
support the countries in increasing sectoral operating capacity;
for example, in Costa Rica it formulated and negotiated with IDB
a project to develop local health systems, and joint efforts were
made to institutionalize managerial capacity in El Salvador and
Honduras with bilateral agencies.  In addition, three subregional
workshops for 225 participants were organized, and there was
cooperation with Costa Rica, El Salvador, Guatemala, Honduras,
Nicaragua, and Panama in organizing courses on the managerial
information system (SIG) and institutional development for 640
participants.  In addition, a manual was published on the SIG and
a second edition on the theory and techniques of organizational
development of that system.
     During the year, special studies were implemented on
comprehensive health development in local health systems in six
countries with the collaboration of the W. K. Kellogg Foundation,
and in four countries with cooperation by the Government of
Italy.
     In regard to engineering and maintenance, the second phase
of the subregional projects to strengthen and develop the
engineering and maintenance services in health establishments in
Central America, in which the Ministries of Health and social
security agencies participate, was initiated.  Fifty percent of
the financial resources were assigned to the countries to be used
primarily for strengthening programs at the local level and
participation in local health systems.  About ten courses per
country were offered with the participation of more than 1,000
professional and technical staff members; an inventory was made
of 70% of the equipment and 80% of the personnel responsible for
the maintenance programs in the hospitals of the countries of the
Isthmus, and in every country the program to repair and maintain
equipment continued.  A course was also given in Central America
on radiological quality and protection, with the participation of
15 staff members from the countries, and publication of a twice-
monthly newsletter by the subregional maintenance project was
initiated.
     At the regional level and together with the International
Federation for Medical and Biological Engineering and the
American College of Clinical Engineering, PAHO/WHO sponsored a
month-long workshop at Washington on biomedical equipment
maintenance and financed internships in different hospitals in
the United States of America.  Twenty-one engineers from the
countries participated in these activities.
     Rehabilitation activities were reoriented in 1991 to be
included as a component in local programming, and thus to
contribute to the equity and comprehensive nature of the process
of planning and execution of general health services.  In
addition, there was active work with the policy levels not only
to increase the quality and effectiveness of rehabilitation
services, but also so that they will be recognized as one of the
basic rights of humankind.
E0158.FIN



CHAPTER IV.I                                              9/IV/92
PUBLISHED VERSION

MANPOWER DEVELOPMENT



     Based on the definition of the strategic orientations and
programming priorities for the 1991-1994 quadrennium, a broad
analysis was made of advances in technical cooperation in the
field of the coordination, administration, and training of human
resources, and goals were established to give priority to develop
such resources to provide an effective response to the needs of
the health services.

Coordination and support
     External relations were strengthened with other agencies,
and complementary fields in the Organization's work such as
awarding fellowships, the Expanded Program of Textbooks and
Instructional Materials, the Program of Training in Health for
Central America and Panama, and the scientific and technical
documentation system of the Organization were coordinated. 
During the year relations were intensified and mechanisms of
coordination with a number of organizations, institutions, and
groups interested in human resources development were
strengthened.  Joint studies were carried out with various
nongovernmental agencies and collaborating centers such as the
University of Illinois, University of New Mexico, Medical School
of Galveston, and University of Texas in the United States on
medical education, and the Universities of Illinois and
Pennsylvania in the United States and of SØo Paulo, Brazil, on
nursing education. 
     Cooperation with social security agencies in the field of
manpower development deserves special mention, particularly the
activities that were carried out with the National Center for
Education and Research in Health and Social Security of Costa
Rica and with the social security agency of Colombia.  After
coordination mechanisms were strengthened, specific resources
were developed in the WHO Collaborating Centers and social
security institutions which were included in the broad effort to
attain the goal of health for all by the year 2000 within the
framework of the financial crisis that affects the Region.  The
Organization also collaborated with academic and university
organizations such as the Pan American Federation of Associations
of Medical Schools, the Association of Schools of Medical
Sciences of the Argentine Republic, the Brazilian Association of
Medical Education, the Latin American and Caribbean Association
of Public Health Education, the Latin American Association of
Social Medicine, the Organization of Faculties, Schools, and
Departments of Dentistry, the Latin American Association of
Faculties and Schools of Nursing, and the Union of Universities
of Latin America.  With the last organization, the first stage of
the "Universities and Health in Latin America and the Caribbean-
-XXI Century" project, which consists of academic discussion of
the problems and strategy of primary health care, in which the
universities had little participation, was completed.  Finally, a
seminar jointly organized by PAHO and WHO on the training and
utilization of intermediate-level personnel, which was held in
the former Soviet Union for 16 participants from Latin America,
deserves to be noted.
     During the year the Program of Training in Health for
Central America and Panama (PASCAP) supported the policies
presented by the Ministries of Health and collaborated in
identifying human resources problems which make the application
of health strategies difficult.  For this purpose it had a
subregional project financed by the Danish International
Development Agency (DANIDA) through which the Government of
Denmark contributed funds for manpower development in the Central
American subregion; this contribution, included in the framework
of the Health Initiative of Central America, facilitated greater
financial flexibility so that PASCAP may meet the needs and
demands for cooperation from the countries.  An initial
evaluation of the project's progress by DANIDA concluded that the
operational, technical, and administrative response of PASCAP had
been very satisfactory.  In addition, the Government of Spain
cooperated in the Central American subregion by offering
subregional courses in Belize (nursing auxiliaries), Costa Rica
(epidemiology), Guatemala (sanitary engineering), Nicaragua
(public health,) and Panama (human resources needs).
     The reorientation of PAHO/WHO's fellowship program, which
continued during the year, involved major changes in both the
type of activities which are carried out and in the
administrative aspects of the program at the central level. 
PAHO/WHO promoted the creation of advisory committees on
fellowships at the national level.  The experience of Cuba, the
subject of a recent evaluation, illustrated how beneficial the
selection of fellows based on technical criteria and needs
emanating from health policies and strategies is.  Table 1 shows
the fellowships awarded in 1991 by country or region of origin of
the fellows and by country or region of study.
     In the area of scientific and technical information, the
development of an electronic communication network (BITNET),
which already includes a large number of countries in the Region,
is noteworthy.  Also warranting mention is the dissemination of
the quarterly journal Medical and Health Education, as well as a
series of publications which disseminate innovations introduced
into the area of human resources and the experiences of the
countries in this field.
     The Expanded Program of Textbooks and Instructional
Materials (PALTEX) continued improving its administrative
conditions and expanding the selection of subjects related to the
health strategies of the ministries.  It continued the
publication of new material (eight books prepared by the Program
and 19 by other publishers).  A significant increase in sales
(191,000 units, which represented $US3.5 million) occurred in
1991.  The beneficial impact that the Program has on the student
population, as well as on personnel working in the health
services, continues to be notable.

Administration of human resources
     A data bank began to be established at the Organization's
Headquarters which includes quantitative and qualitative
information collected from the countries and obtained in
agreement with the Latin American Center of Demography (CELADE);
the information will be available to and updated by the countries
themselves.  This activity had the support of WHO, which brought
together an advisory group on human resources policy and
management which formulated a protocol for the selection of
pertinent information that will be applied in Mexico and
Paraguay.  The project's purpose is to strengthen capacity for
quantitative and qualitative analysis with regard to the
processes of manpower development to facilitate and strengthen
the formulation of policies in this field in the countries.
     The Organization promoted the establishment of manpower
planning with a strategic approach as a part of a plan directed
toward dealing with complex problems in situations of high
fragmentation and when outcomes are very little predictable. 
PAHO/WHO prepared a proposal that was subject to discussion by
different groups.  The proposal is articulated with the
employment of the prospect for analyzing education in the health
professions, a modality which began three years ago and has
proven to be useful in the processes of institutional development
and academic-organizational reformulation in entities training
personnel.  It is hoped that with the introduction in the
countries of Strategic Planning of Health Manpower, the
theoretical and methodological development of planning applied to
the field of human resources and to particular questions such as
the articulation of learning, work, and research in the changing
context that characterizes current society will advance even
more.
     Advanced training activities continued to provide the
countries professionals capable of dealing with human resources
problems and utilizing conceptual and methodological instruments
more consonant with the situation of crisis and constant social
and economic change, as well as making decisions concerning the
planning, education, and administration of personnel based on new
knowledge which is generated from work in concrete situations. 
After an exhaustive review of work carried out in previous years,
the programming of a new Latin American course on health manpower
development which brings together the experience accumulated by
several technical groups in Argentina, Brazil, Ecuador, Mexico,
and Peru was reformulated.  It is planned to give this course for
the first time in 1992 in Brazil for fellows from all countries
in the Region.  In addition, the first stage of a similar process
designed for Central America, which has the technical support of
PASCAP and a financial contribution from DANIDA, was completed.
     Clear advances were made in the conceptual and
methodological development of continuing education as an
alternative in the training of personnel in health institutions. 
The most significant facts in this field in 1991 were greater
precision and objectivity in critical aspects of the process,
such as the identification of learning needs, the articulation of
this with the incidences of work, and a conceptual redefinition
of surveillance and follow-up of the educational process; the
adoption of the line of continuing education by the Ministries of
Health of Cuba, Bolivia, and Nicaragua, by nursing education
institutions in Colombia and Honduras, and, tacitly, by
institutions in 14 countries in the Region; the articulation of
the pedagogical proposal with other technical branches of the
Organization and the countries, basically in the fields of
development of health services, maternal and child care, control
and prevention of communicable diseases, environmental
sanitation, epidemiology, administration, and food and nutrition;
the organization of national research groups in support of the
educational process, and of multicountry groups to exchange
experiences and information; the gradual inclusion of
universities (schools of nursing and of medicine, essentially) in
educational development activities centered on the work and with
strategic approaches, and the preparation of a regional project
to search for extrabudgetary funds which has been presented to
agencies and governments of Europe and Canada.

Training of human resources
     Support for professional schools in the health area,
specifically of medicine and nursing, continued to be of
particular concern to the Organization.  Advisory service
activities relating to curriculum revisions in both professions
are included in most of the countries of the Region; the process
of articulating the biological and social sciences initiated two
years ago, and the follow-up of the results of the prospective
analysis carried out in previous years.
     One of the most important activities carried out in 1991 was
the conference on "the Latin American university and health of
the population" which took place in Havana.  Its purpose was to
make sure that training institutions at the undergraduate level
progress in understanding the principal health problems and their
determining processes.  The conference was preceded by a stage of
preparation which included three previous meetings, and
culminated with the integration of all professional careers
directly related to health care.  Seven hundred thirty university
staff members from 24 countries, who issued a declaration
reaffirming the purpose of bringing about practice which responds
to the health demands of the population, participated in the
conference.  Another activity that deserves mention was an
international meeting on information science in nursing which was
held at the Organization's Headquarters and had 27 participants.
     To promote leadership in health in the Region, the
Organization continued its program for residents in international
health.  In 1991 six cohorts of young professional people in
various health fields in the Region, with a total of 54
residents, were completed.  The program attaches special
importance to expanding knowledge of the health situation and its
socioeconomic and political determinants at the country level,
strengthening capacity to identify alternatives, and thus to
contribute to the transformation of the health systems to attain
the goal of health for all by the year 2000.  An analysis the
destinies of the graduates of Program notes that 54% of them work
in activities of an international nature, either in their own
countries or in international agencies; 22% have assumed
positions of national leadership in the health sector, and 22%
have returned to their specialized fields.  As a corollary to
this initiative, an international conference was held at Quebec,
Canada, to analyze international health as a field of
professional practice and as a theoretical body of knowledge.
     The Organization resumed its analysis and study of the
social sciences as an important part of knowledge in the field of
the human resources and the health professions.  In that vein, a
line of work was undertaken with two principal prongs:  one to
review graduate-level programs in social medicine in Latin
America, which resulted in the preparation of a document that
will serve as a basis for formulating recommendations and
proposals of work, and the other to review preventive medicine
curricula in schools of medicine and nursing in order to include
the social sciences in such curricula in a way articulated with
other specific subjects of the professions in question.  This
culminated in a meeting on the social sciences in nursing which
took place in mid-1991.  All these studies and reviews were the
germ for a series of documents and investigations on the social
sciences which were published in the first number of volume 26 of
Medical and Health Education.
     PAHO/WHO continued attaching fundamental importance to the
process of developing political and scientific awareness of
critical areas and gaps in the field of public health and its
evolution in Latin America in order to promote formulation of
guidelines orienting necessary decisions.  The objectives of this
process included recognition of the principal trends in the
development of public health in the Region, as well as
identification of bases for reorienting their conceptual,
methodological, and operational development.  The activities
carried out included intense production and dissemination of
bibliographic material followed by a meeting to analyze and
discuss the relevant findings.  The continuity of this initiative
was discussed at the meeting, and the desirability of multicenter
projects which deepen study of the determinants of the public
health crisis on the one hand, and the need for expanding the
technical, scientific, and policy discussion, as well as the
participating institutions, on the other, was pointed out.  The
process will continue through the dissemination of information
and the generation of subregional and national initiatives, and
it is hoped that it will culminate in 1994 with a conference at
the hemispheric level.
E0159.FIN



CHAPTER IV.G                                              9/IV/92
PUBLISHED VERSION

Oral health


     PAHO/WHO's technical cooperation in this field emphasized
mass prevention of dental caries through salt fluoridation in
experiments carried out in Colombia, Costa Rica, Jamaica, Mexico,
and Peru.  In addition, it supported other countries in
implementing similar programs, and with the Organization of
Faculties, Schools, and Departments of Dentistry of the Union of
Universities of Latin America (OFEDO/UDUAL) and the W. K. Kellogg
Foundation jointly sponsored an international seminar on the
subject in which experts and technicians from the Region and
guests from France and Switzerland participated.  PAHO/WHO also
promoted joint activities by the teaching, labor, and service
sectors in Latin America in this regard, and a plan of action was
implemented for Latin American dentistry--with the participation
of the Coordination of Dental Services of Latin America (COSAL),
OFEDO/UDUAL, and the Latin American Dental Federation (FOLA)--
which includes aspects of information production, production of
services, manpower development, and development of technology. 
The Organization also organized a working group to draw up
theoretical and methodological as well as technical and
operational guidelines for including an oral health component in
local health systems.  Public health physicians, sociologists,
and dentists from the services, education, and labor in Aruba,
Bolivia, Chile, Colombia, Costa Rica, Cuba, the Dominican
Republic, Ecuador, El Salvador, Mexico, Paraguay, Peru, and
Venezuela participated in the group.
     Special support was given to the continuing education of
dental personnel through subregional courses on oral pathology
and AIDS (Chile), research methodology (Ecuador), caries
prevention (Argentina), care of adults (Panama), and dental
biological materials (Venezuela).  These activities were
supplemented with scientific and technical as well as financial
resources from OFEDO/UDUAL.
     At Andean Area and Southern Cone subregional meetings it was
decided to include a dental component in an appropriate
technology project the Organization is carrying out jointly with
the Latin American Economic System.
     In regard to technical cooperation among countries, the
third stage of the project on technology of biological materials
concerning research, continuing education, quality control,
communication and information, and the technological network was
carried out.  This project, in which the countries of the Andean
Area, Central America, and the Spanish-speaking Caribbean
participate, initiated its linkage with the Southern Cone and
English-speaking Caribbean countries.
     The Organization cooperated in research on the
epidemiological profile being carried out by El Salvador and
Peru, and collaborated in the dental practice study being
conducted in Argentina, Colombia, the Dominican Republic,
Ecuador, Nicaragua, and Venezuela with financing from PAHO's
Advisory Committee on Medical Research and the administration of
OFEDO/UDUAL.
     The WHO Collaborating Center in Oral Health, located in
Ecuador, continued offering training activities, especially in
regard to methodology.  In addition, it formulated research
proposals on the relationship among nutrition, fluorine, and
caries, training of human resources, and development of three
experimental centers.
     Dental associations in Latin America, Europe, and the United
States of America worked with PAHO/WHO in organizing a World
Federation of Dental Education.  The Organization also cooperated
in preparing and holding of the UDUAL's I Integrated Health
Sciences Conference (nursing, medicine, public health, and
dentistry), held in Havana in June.
E0160.FIN



CHAPTER IV.A                                              9/IV/92
PUBLISHED VERSION

CHAPTER IV

HEALTH SYSTEMS INFRASTRUCTURE


INTRODUCTION


     The countries of the Region of the Americas are in a dynamic
process of transformation and economic adjustment which has
affected their health service systems.  The health sector had to
make renewed efforts to counteract the deterioration in living
standards of the population in a situation in which resources
have been reduced and mechanisms of financing are being reviewed. 
Such efforts have been reflected in a continuous reduction in
death rates and in an increase in activities to control and
prevent diseases.
     The sustained action of the sector has helped maintain
conditions of social and political stability which facilitated an
environment that avoided deeper crisis in the great majority of
the countries.  Evaluations of the development of primary care
and local health systems have brought to light the advances
achieved in attaining the goal of health for all by the year
2000.
     Major economic and social difficulties and significant
challenges for the national health systems persist, however.  A
need remains for finding better paths leading to expansion in the
coverage of the services and access to primary care levels, as
well as urgency to identify forms of management and organization
of the sector that will increase efficiency and equity.  It is
also necessary to monitor the training of human resources and the
processes of continuing education.  In addition, it is essential
to improve capacity for analyzing the situation to identify
groups at risk and set priorities for the most adequate
formulation of health policies and programs.
     The epidemic of cholera which heavily attacked the Region in
1991 had, up to end of the year, caused a total of almost 400,000
cases but fewer than 4,000 deaths.  Despite the fact that the
epidemic and its inexorable progress was due to the existence of
deteriorated social conditions, poverty, and an inadequate
drinking water and sanitation infrastructure, it is also true
that the health services--with limited resources and in the midst
of a process of transformation--reacted effectively to the
pressure to provide mass emergency care to control the disease. 
This reaction made it possible to counteract the effects that
otherwise would have been much more ominous for the countries.
     The processes of democratization that are going on in the
Region seek to consolidate human freedoms and standards of
living, in addition to promoting an increase in political
leadership and satisfaction of basic needs to allow dignity of
life.  PAHO/WHO, in addition to promoting analysis of the
interrelationships between the health situation and models of
economic and social development, succeeded in establishing
satisfactory relations between the health sector and policy
decision-making levels and promoted discussion of ethics and its
consideration in the preparation and formulation of economic
development plans.  For this purpose, meetings with groups of
lawmakers from several countries and implementation of a program
that the Organization began in the countries with the
collaboration of the Organization of American States were
essential.
     The programs of the Organization's Area of Health Systems
Infrastructure worked intensely to support the countries in
carrying on their plans and corresponding programs under the
conditions of economic and social austerity through which the
Region is passing.  The principal activities carried out in
compliance with the decisions of the Governing Bodies of the
Organization are summarized below.

GEOGRAPHICAL VARIATION OF INVASIVE CANCER
OF THE UTERINE CERVIX IN COSTA RICA

     In Costa Rica, the incidence of cancer of the uterine
cervix in coastal areas is almost double the incidence in inland
areas.  In order to determine whether the regional variation is
related to detection programs or whether it results from the
differential prevalence of specific risk factors, data were
examined from a study of cases and controls carried out in Costa
Rica from 1986 to 1987.  The study population included 192 women
with invasive cancer of the uterine cervix and 372 controls, and
it took into account the following risk factors:  number of
sexual partners, age at first intercourse, number of live
births, detection of human papilloma virus (HPV) 16/18 by means
of in situ filter hybridization, history of other venereal
diseases, previous vaginal cytology (Papanicolaou smear), and
socioeconomic status.  In the results, the sexual and
reproductive factors predominated in high-incidence areas, but
the Papanicolaou smear and HPV screening had been performed with
equal frequency in both areas.  Although it is possible that
there are qualitative differences in the detection tests (for
example, laboratories, follow-up, etc.), it was concluded that
the regional differences reflect different patterns of behavior
rather than differences in detection.  The fact that screening
had failed to reveal regional differences in HPV prevalence
might be related to ambiguous classification of the
hybridization test.  However, it is possible that cofactors
related to HPV are playing an important part in cervical
carcinogenesis.  The greater frequency of the disease in high-
incidence areas points to the need for more intensified
detection.
     Having given the foregoing medical background, I would now
like to focus on some of the many ethical and legal
considerations that arise in the face of a pandemic of the
magnitude of AIDS.  I will begin by discussing the following two
real-life cases, which exemplify situations that are being
repeated frequently, with slight variations, in most of our
countries.  

     Case 1:

     Rafael López, a 26-year-old homosexual journalist,
     described symptoms that led his physician to consider the
     possibility that he had AIDS.  The physician ordered a blood
     test to detect the presence of HIV.  When the test results
     came back positive, the physician's nurse called Rafael's
     office and left a message saying that the blood test had
     turned out positive.  On the same day, Rafael learned that
     he was infected with HIV and that had been fired.

     Case 2:

     Antonio, 60, suffered from hereditary hemophilia.  In one of
     the many blood transfusions he had received during the
     preceding year, he had contracted HIV.  When Antonio was
     admitted to a hospital for internal hemorrhaging, his wife
     considered that she should explain her husband's condition
     to the attending physician in the emergency room so that
     proper precautions could be taken.  The information spread
     throughout the hospital and the reaction was unexpected. 
     The orderlies and nurses and even the doctors were unable to
     hide their repulsion when caring for Antonio, and, worse
     still, many refused to have any contact with him at all for
     fear of contagion.  The warning, "Be careful not to touch
     him--he has AIDS," was heard on several occasions and surely
     contributed to the lack of care that Antonio received during
     his hospital stay.  After several days, Antonio begged his
     wife to take him home, where at least he could suffer his
     disease with the little dignity he had left.  During the
     days he was in the hospital, the bedclothes were not changed
     and the mattress was always soaked.  Even when a needle
     slipped out and he lost a great deal of blood, his sheets
     were not changed.

     I have no doubt that everyone present here has seen or at
least heard of situations similar to those that I have just
described.  What ethical and legal considerations do these
examples raise?
     
     In the first case, Rafael loses his job because his boss
learns that he is infected with HIV.  The first thing that comes
to mind for us, as lawyers, is that one of the fundamental
principles of professional ethics has been violated--namely,
confidentiality.

     Confidentiality is the basis for the trust that should exist
in a professional-client or doctor-patient relationship.  It is
on this basis that the patient is willing to reveal to his
physician the personal details that are essential for treatment
of his problem.  It is clear that this information is and should
continue to be part of the individual's private life unless, of
course, he consents to make it public.  Confidentiality is the
patient's right; it is the guarantee that protects him from
having the details of his private life revealed to third parties
without his consent.

     In the case of patients with AIDS or those who are
HIV-infected, the right to confidentiality takes on special
significance.  The results of the screening tests for the disease
may be associated with very negative connotations for the
patient.  He or she may be labeled a homosexual or drug addict,
for example.  Even the simple fact of taking the test can lead to
discriminatory reactions.  There have been cases--and
unfortunately their number is growing--in which persons like
Rafael in our example have been subjected to public disgrace and
all manner of humiliating treatment, ranging from rejection by
the medical establishment to isolation in special centers.

     Respect for the right to confidentiality has been identified
as one of the fundamental premises in campaigns to prevent and
control the disease.  The reason is quite obvious:  if AIDS and
HIV testing and test results are not kept strictly confidential,
very few people will be willing to have these tests for fear of
the ominous consequences that would await them if this
information were to become public knowledge.

     However, the problem is more complex still.  We must ask
ourselves, for example, whether confidentiality, as an undeniable
right of the patient, is an absolute principle.  This is a
crucial question, inasmuch as the rights of the individual must
be weighed against the rights of society.  There is no clear-cut
response to this question.  The medical establishment appears to
favor protection of the right to privacy within certain limits,
which have to do with the need to protect other persons who find
themselves at serious risk for contracting the disease.  And this
in turn raises another series of questions:  Who has the right to
know if a person has AIDS or is infected with HIV?  Whose
responsibility is it to inform them?  Who makes the decision?

     Let us begin with the health authorities.  The World Health
Organization has strongly urged its Member States to classify
AIDS as a disease that must be reported to the competent public
health authority.  Many of the countries have done this. 
However, very few countries have provisions for the positive
results of HIV detection tests to be reported for purposes of
epidemiological surveillance.

     Information on the seropositivity of individuals can be made
known in two ways so as to maintain privacy:  (i) "anonymously,"
in which case only the overall number of detected cases--in other
words, a figure or percentage--is known; or (ii)
"confidentially," in which case the name of the infected person
is known, but access to this information is restricted.  The
World Health Organization has not taken a definite position with
regard to which of these two forms is the most desirable,
although in general terms it does recommend that priority be
given to those measures that will allow for the least
interference in the private life of the individual while still
making it possible to accomplish the sanitary objectives pursued.

     In addition to health authorities, who else has the right to
know if a person has AIDS or is infected with HIV?  What are the
rights of sexual partners, persons with whom the infected
individual has shared IV drug paraphernalia, medical personnel,
employers, colleagues, insurers, etc.?

     Up to now, tracking and notification of the contacts of
HIV-infected persons or persons with AIDS has been the most
immediate response to the question of who has the right to know
about a person's seropositivity.  The rationale for this is as
follows:  people who are in imminent danger of contracting the
infection have the right to know if a person has AIDS or is
infected with HIV.  Who falls within this category?  It would
certainly include sexual partners, persons with whom the infected
person has shared IV drug paraphernalia, persons who have been
sexually assaulted, and health professionals who have been in
contact with blood from the infected individual.

     As long as the AIDS patient or HIV-infected individual
cooperates in identifying his or her contacts, this does not pose
any problem.  If, however, the infected person refuses to inform
his or her contacts, either personally or through medical
personnel, an ethical problem arises:  it becomes necessary to
define at what point society's right to protection and prevention
of the disease must override the individual's right to
confidentiality. 

     With a view to discussing this and other issues, in January
1989 the Global Program on AIDS convened an advisory meeting on
the notification of contacts to prevent HIV infection.  This
meeting was attended by 27 participants who represented 20
countries in all the Regions of the world.  A number of
conclusions came out of this meeting, and these are summarized
below.

     First, the term "contact" was defined as a person who, by
virtue of his or her relationship with the HIV-infected person,
is in imminent danger of contagion or infection.  This concept is
important because it serves as a criterion for determining who
has the right to be notified of the health status of another
person.  However, the World Health Organization has not taken a
specific position in this regard.

     Second, it was concluded that any program for the
notification of contacts should be carried out within the
framework of a complete AIDS campaign and prevention program.  A
complete AIDS campaign and prevention program is indeed
important, but we must not overlook the context in which it
occurs.  In our countries in South America, Central America, and
the Caribbean we are talking about a context marked by poverty,
malnutrition, and disenfranchisement--a context in which the
right to privacy is not conceived of in the same terms as in the
first world.

     What privacy, I wonder, can an individual have who shares a
single room with ten or more people, when that room is the only
space available for all cooking, social, sanitary, and other
activities?  Indeed, in such a context it is logical to ask if it
is not more essential than ever to safeguard the right to
privacy.  How can the lawmaker treat the subject of
confidentiality in such a way that it corresponds to the daily
reality of individuals without succumbing to vague, substanceless
generalizations? 

     Unfortunately, I cannot answer that question.  I can only
say that local authorities should bear in mind not just the
epidemiological situation in the environment but also the social
and economic context, the community's level of knowledge and
assimilation of the information, and its willingness to deal with
the subject.

     Let us now examine the second case.  In it, Antonio is
mistreated by health personnel, who not only fail to provide him
with the medical care and attention that he requires but also
condemn him morally, showing no compassion whatsoever at a time
when he is most in need of understanding and support.  What
ethical and legal issues does this case raise?

     The treatment that Antonio receives is directly related to
his condition as an HIV-infected individual.  The case
exemplifies the discrimination to which AIDS patients and HIV-
infected people are subjected.  This situation is extremely
serious in the context of a broader policy on AIDS prevention and
control for the reasons that I will explain below.

     Equality before the law and the right to be protected from
discrimination constitute the foundation for both civil and human
rights.  The prohibition of discrimination is nothing more than
an attempt to ensure that the law offers the same opportunities
and is applied alike for all individuals.  Moreover, the right to
equal treatment is based on the conviction that all human beings
are created equal.  We are all therefore equally entitled to
develop ourselves and live normal lives within our own
possibilities.

     Let us recall the many international instruments that
consecrate the protection of human rights and in one way or
another prohibit discrimination on the basis of race, color, sex,
language, religion, political or other opinions, national or
social origin, economic status, birth, or any other status or
condition.  In these terms, AIDS and HIV infection would
constitute a specific status or condition and thus not be
justification for discriminatory treatment.

     Nevertheless, what happens in many cases with AIDS patients
or HIV-infected individuals?  In view of the fact that the
symptoms of the disease may not become apparent for years, should
the person be deprived of a normal life in the interim?  The
World Health Organization has taken a firm stance in this regard. 
Its position was ratified during the Forty-first World Health
Assembly in 1987, which adopted a resolution on the avoidance of
discrimination against HIV-infected people and people with AIDS. 
This resolution urges the 166 Member States of the World Health
Organization to foster a spirit of understanding and compassion
for HIV-infected people and people with AIDS through information,
education, and social support programs.  

     The experience accumulated in national and local AIDS
programs indicates that as the public gains more knowledge and
information about the disease, irrational fears concerning HIV
and its transmission tend to decrease.  Nevertheless, I must
point out that, unfortunately, even though people are aware that
HIV cannot be transmitted through casual contact, specific,
individual cases of HIV-infected children or adults with AIDS
often give rise to scandals, outrageous commentary in the
sensationalist press, and extreme reactions of rejection based on
deeply rooted biases held by society.

     This insistence on protection of the human rights and
dignity of persons who have AIDS or are infected with HIV is
founded on clear and powerful public health reasons to which I
have already alluded.  If HIV infection, or even the mere
suspicion of such infection, leads to stigmatization and
discrimination in the form of refusal of medical and hospital
care (as in the case of Antonio) or loss of employment, isolation
or quarantine, forcible separation from family, expulsion from
school, loss of housing, or any other similar situation, there is
great danger that the disease will spread unchecked, since
infected persons will choose to keep their condition a secret,
thereby hampering epidemiological prevention and control efforts.

     Thus, it is clear that protection of the human rights and
dignity of HIV-infected people, people with AIDS, and members of
population groups with risk-prone behavior is not a luxury but a
need.  It is essential to understand that it is a fallacy to view
this issue as a dilemma pitting the "rights of the many who are
uninfected" against the "rights of the few who are infected."  We
must realize that protection of the uninfected majority is
inextricably linked and ultimately dependant on protection of the
rights and dignity of infected persons. 

     It is for this reason that the World Health Organization has
urged the international network that exists for the protection of
human rights to endeavor to prevent discrimination against
HIV-infected people, people with AIDS, or members of population
groups who are stigmatized for their behavior.  The World Health
Organization has also underscored the need for human rights
groups, government agencies, and nongovernmental organizations to
take an active role in this effort, especially at the national
and local levels.

     I would like to conclude here with the examples that I have
presented, recognizing that I have by no means dealt with all the
concerns that are raised by these cases.  Indeed, many ethical
and legal issues surrounding AIDS and HIV infection remain to be
addressed.  To cite but a few examples, there are questions
regarding the need to obtain an individual's consent before HIV
screening tests can be conducted; the doubtful effectiveness and
the lack, in most cases, of sanitary justification for isolating
HIV-infected individuals; and the testing of new drugs on human
subjects. 

     There are certainly no easy answers for the ethical and
legal questions raised by AIDS and HIV infection.  It is
difficult to take a definite position on these issues because in
many situations our most sacred values will be in conflict with
one another.  Moreover, the act of adopting one position or
another may have consequences for the most intimate and valued
aspects of the life of both a single individual and society as a
whole. 

     Nevertheless, if anything is clear from this debate it is
that there is need for a revival of ethics in the broadest sense
of the term.  Ethics, as a set of principles for good behavior--
such as those that govern the actions of individuals or
professions, or the philosophy underlying those principles--can
guide us in our search for coherent responses.  Let us not forget
that the principles of justice, based on the idea of not causing
damage in the practice of a profession and of respect for the
autonomy of the individual, serve as instruments for ordering our
system of values.

     Thus, in the practice of our profession, once we know and
understand the basic facts about AIDS and HIV infection, we must
be aware of those situations that raise ethical and/or legal
conflicts, and we must be prepared to offer our fellow citizens a
response based on a desire to win the battle against AIDS rather
than on a desire to punish its victims because of social biases.
E0169.FIN



VERSION EDITADA                                          16/IV/92

ECUADOR


     In accordance with its plans and national development
policies, the Government has directed its attention toward the
need for improving the social conditions of those who live in
rural and marginal urban areas through a process of social
information and community participation which deals with the
manifestations of poverty (especially in the indigenous
population), unemployment and underemployment, maternal and child
morbidity, and undernutrition.  The Ministry of Public Health
established a National Health Plan for the decade 1991-2000, in
agreement with the National Development Plan, through which it
commits itself to implementing a care model oriented to promoting
health with family and community participation; to improving the
system of food and nutrition surveillance; to promoting basic
sanitation and the provision of drinking water; to strengthening
and expanding the health services, and to promoting institutional
development and an integrated national health system.

     The care model which will be implemented in all the
provinces is based on the strategy of primary care, adapted to
the social, cultural, and economic conditions of the country, and
it gives priority to children under 5, pregnant women, and
lactating mothers in the rural and marginal urban population. 
Consonant with the criteria for the new care model, a
regionalized network of health services was designed which has
four basic modules of organization, namely:  1) metropolitan, for
the health areas of Quito and Guayaquil; 2) intermediate urban,
which includes the health areas of cities with a population of
from 70,000 inhabitants; 3) small urban, for cities of from
35,000 to 70,000 inhabitants, and 4) rural, for rural areas which
have populations of 30,000 to 50,000 inhabitants.

     The Comprehensive Family and Community Health Program
gathered great impetus in the period 1990-1991; in this period 
standards, methods, processes, and instruments were formulated
and updated which are the infrastructure of the Program.  There
have already been positive results:  at the end of the year 200
medical units were in operation to serve 260,000 families
totaling approximately one million persons, including 200,000
children and 50,000 mothers who lacked health services.  Within
the process of decentralization and regionalization, operational
units were organized in local health systems which include
improvement of managerial capacity, control of the quality of
services, reconstruction of works under way or suspended, and
updating and improvement of systems for programming needs. 
Impetus was given to the establishment of popular drug stores;
supply of basic drugs to the vulnerable population; construction
and equipping of hospitals and health centers, and provision of
drinking water, elimination of excreta, and control of
environmental pollution.  Concerning nutrition, the Government
has implemented a system of food and nutrition surveillance which
permits it to respond to problems detected, among them the
deficiency of specific nutrients such as iodine, iron, and
vitamin A.  To eliminate duplication of activities by the many
bilateral, unilateral, and nongovernmental international
cooperation agencies, the Ministry of Public Health assumed
responsibility to the National Health Council for coordinating
the activities of such institutions.

     Within the framework of the strategic orientations and
programming priorities for the 1991-1994 quadrennium, the Andean
Cooperation in Health, and the national priorities, PAHO/WHO's
technical cooperation in 1991 was directed toward organizing the
health services, manpower development, feeding and nutrition,
environmental health, the maternal and child health, communicable
diseases, evaluation of the health situation, adult health, and
technical cooperation between countries.  In regard to the
organization of the health services, PAHO/WHO cooperation was
oriented to promoting and supporting the conceptual,
methodological, and instrumental development of the comprehensive
family and community health model.  Special attention was given
to the components related to the care model, organization of
local health systems, social and intersectoral participation,
modernization and decentralization of management and
administration, manpower training, and formulation of the health
component of the Social Front project in which the Ministries of
Public Health, Education, and Labor and Social Welfare
participate.  This project has strategic value for the health
reforms planned for this decade.  The priority given to
cooperation with social security and with the national oral
health program; coordination with the World Bank in drawing up
the Social Front project; activities related to the prevention of
catastrophes and natural disasters, and the beginning of a
project, in which the Netherlands collaborates, to develop and
strengthen the social drug programs also warrant mention.

     In the field of human resources, the activities of PAHO/WHO
were linked closely to the Comprehensive Family and Community
Health Program. Within this framework, a proposal was prepared
for continuing education for all health personnel taking part in
the new care model which includes occupational profiles,
programming of courses and seminars, timetables, and budgets.  A
manual was prepared on human resources administration, whose
objective is to strengthen the activities of the Ministry of
Public Health, in which guidelines are laid out for its
organization and specific directives for the decentralized
management of classification of positions, recruitment,
selection, and evaluation of performance.  The Organization also
participated actively in the creation of a School of Public
Health, which will train human resources suitable for performing
health services and increasing research and in-service education;
it collaborated with the Ministry in strengthening activities
related to manpower planning, for which research was carried out
to determine the actual relationship between the supply of and
demand for health professionals; it reviewed the human resources
information system of the Ministry, and it prepared a proposal to
establish a program of education in health administration.

     In regard to food and nutrition, the Organization
participated in formulating the nutrition component of the Social
Front project; in preparing and implementing the system of food
and nutrition surveillance; in reviewing and restructuring the
program of supplementary feeding for mothers and children; in
analyzing the food and nutrition problem, and in strengthening
support mechanisms, included those of training and research.
In environmental health, cooperation activities were related
basically to the prevention and control of cholera, which means
that the focus was on public water supply and sanitation
services.
     In maternal and child health work was done on preparation of
the National Plan of Action for applying the World Declaration on
the Survival, Protection, and Development of Children resulting
from the World Children's Summit of the United Nations.  Although
because of the cholera epidemic in the country high priority was
given to activities to train personnel in the health services in
preventing and controlling diarrheal diseases, there also was
active cooperation in applying the national maternal and child
plan to reduce mortality in mothers and children under 5, and in
the program on adolescence.  In addition tasks were carried out
related to the processes of pedagogical and managerial training,
and with the Expanded Program on Immunization, especially with
regard to surveillance of the eradication of wild poliovirus
transmission.

     In the field of communicable diseases, PAHO/WHO began to
collaborate with the Government in controlling the epidemic after
the first case of cholera occurred in the country in February. 
At the same time, activities were also carried out aimed at
controlling Aedes aegypti and malaria, tuberculosis, leprosy,
rabies, foot-and-mouth disease, and especially AIDS.  The
presence of cholera caused most of the time and effort to be
devoted to epidemiologic field study, case study, and witnesses,
and to preparing scientific material and practical standards for
local use, as for example the "Guide for preventing and
controlling cholera" prepared by the technical team of the
PAHO/WHO Representative's office.  Work was also done on the
national family health plan, control of nosocomial infections,
and the national program of epidemiological surveillance, and an
information network was established in the Representative's
office which permitted computerized tabulation of statistical
data related not only to cholera but to all notifiable
communicable diseases.

     In regard to adult health, PAHO/WHO cooperated in
formulating a project to restructure the law on mental health and
stimulated geriatric care through preparation of a project to
promote the health of the elderly, review of a draft law, and the
organization of a national commission to improve living
conditions in old age.  It also provided technical cooperation to
the campaigns against smoking and alcoholism, rehabilitation,
cancer registry, and nephrology programs.

     In regard to technical cooperation between countries, the
activities programmed with Colombia, Cuba, Peru, and Venezuela
were carried out; a project continued to be negotiated with
Chile, and a provisional draft was formulated with Honduras. 
Broad support was given to the Amazon Cooperation Agreement, the
Hipólito Unanue Agreement, and Andean Cooperation in Health. 
Finally, PAHO/WHO prepared technological development projects
which were presented to the meeting on Andean Cooperation in
Health held at Quito.
E0170.FIN



PUBLISHED VERSION                                      17/IV/92

COLOMBIA



     The Government has implemented a National Development Plan
whose long-term objective is to raise income and the standard
of living of the neediest groups in the population.  It
attempts to internationalize and modernize the economy through
economic liberalization, market freedom, deregulation, and
dynamization of supply with investments in ways, ports, and
education.  One of the macroeconomic objectives is inflation
control, for which the Government has the active participation
of the private sector and concentrates public spending in
sectors such as education, health, and safety.

     The health policy attempts to achieve efficiency in
benefits through a model of universal insurance and a plan of
hospital management.  The Government is attempting to
decentralize the health services and to organize sectional and
local health funds.  The Ministry of Health implemented a
normative research and development project to analyze current
constitutional, legal, and regulation provisions in order to
structure a National Health Code and fill existing gaps in
legislation.  The basic objective of the sector's policy is to
raise the health level of the population by promoting health
and disease prevention.  The corresponding activities will be
carried out through schemes of prepaid medicine, subsidy for
demand, and equity and social redistribution criteria.  The
strategies proposed are focused on improving effectiveness,
strengthening services at the local level, controlling the
quality of drugs and essential inputs, and decentralization,
and are applied through the following projects:  healthy family
in healthy environment, healthy municipios, and organization of
the new departmental and local health system, inexpensive drugs
of good quality, and institutional development.  The Ministry
carried out important national campaigns in light of critical
situations such as drinking water supply and sewerage, the
crisis in the hospital system, the resurgence of malaria, the
epidemic of cholera, vaccination and "sanitary sweeping" days,
and preventing and controlling cancer, sexually transmitted
diseases, and AIDS.

     The Ministry of Health was restructured during 1991, and
the process of decentralization, in which emphasis was put on
the transfer of resources to municipalities so that they become
responsible for management of health services at the first
level of care, was implemented.  The services will be
strengthened through local health systems with broad community
participation.  A "municipal self-management" model was
implemented and the administration of the health services,
which remained the responsibility of the 1,017 mayors and the
32 governors in the country, was decentralized.

     The Ministry coordinated international cooperation
intended to promote the processes of self-management as a
strategic aspect of the overall development of the sector. 
Priority was given to manpower training and promoting the
development of science and technology, for which the policy of
obtaining support from other governments and international
agencies was continued.  In addition to the agreement with
PAHO/WHO, those with UNICEF, the Treaty of Amazon Technical
Cooperation, and the Hipólito Unanue Agreement for the Andean
area, and bilateral agreements with some European countries, in
whose negotiation the Organization participated in its capacity
as the agent mobilizing the support of other international
organizations and governments (IDB, World Bank, the Governments
of Italy, Spain, and Venezuela, and the European Economic
Community), were noteworthy.  In addition, the institutional
relations of the health sector with other countries, including
some not belonging to the Andean Pact, intensified.

     PAHO/WHO's technical cooperation during the year was aimed
basically at strengthening the process of decentralization of
the health sector at local levels to improve capacity for
organizing, planning, and executing health activities which the
communities expect and in which their participation is
beginning or intensifying.  The Organization cooperated
especially in establishing operational, financial, and
management mechanisms.

     Other technical cooperation activities were oriented to
improving the National Health System in order to increase its
capacity to meet the needs of broad sectors of the population. 
PAHO/WHO collaborated with the country to obtain IDB financing
for the national "hospital management" project to improve the
care hospitals provide, their maintenance, and the development
of their personnel.

     There was also collaboration in an analysis of the
national situation and of the experiences of other countries in
regard to ways to articulate the health sector and social
security.

     Since March 1991 Colombia has been experiencing the
effects of the epidemic of cholera, particularly the population
that resides along the Pacific Coast and on the banks of the
Magdalena and Cauca Rivers, and the disease has continued
spreading toward the Atlantic Coast.  Up to the end of
November, more than 10,000 cases and 145 deaths had been
recorded in the entire country.  The Organization cooperated in
efforts which were carried out to control the epidemic through
"sanitary sweeping" activities in the affected areas.

     Extrabudgetary contributions helped finance activities in
the areas of essential drugs, eradication of wild poliovirus,
and vaccination of children under 1 year with the support of
the Expanded Program on Immunization, as well as in diarrheal
disease control, acute respiratory infections, and the family
planning program in large cities in the country.  Also meriting
notice are the activities which are being carried out in
compliance with the medium-term campaign against AIDS program,
which concentrated its resources on dissemination and education
activities.

     In environmental health the Government, with the support
of PAHO/WHO, continued carrying out efforts to improve sanitary
conditions through the efficient use and quality control of
drinking water, elimination of excreta and solid wastes, and
pollution control; in addition, the occupational health program
was strengthened.

     In regard to veterinary public health, activities focused
on implementing a epidemiological surveillance network for
food-borne diseases, various activities related to the
elimination of taeniasis/cysticercosis, eradication of bovine
tuberculosis, controlling urban and rural rabies, and the
diagnosis and surveillance of equine encephalitides.  In regard
to foot-and-mouth disease, the Organization worked with several
institutions in the country on activities to eradicate the
disease and, through Pan American Foot-and-Mouth Disease
Center, cooperated in training personnel and in research
activities.

     In response to the priorities recognized by the national
policies, PAHO/WHO expanded its technical cooperation
activities through the creation of two new projects on
nutrition and human resources which began to function in the
second half of the year.

E0172.FIN



CHAPTER V.D                                                      
PUBLISHED VERSION                                        21/IV/92

FAMILY PLANNING AND
MATERNAL AND CHILD HEALTH


     The Regional Maternal and Child Health Program was carried
out according to the policies and strategies of the Organization
and the targets of WHO's Eighth General Program of Work, which
are oriented to reducing mortality and morbidity in mothers,
children, and adolescents.  For the medium term, the Program took
into account the orientations and priorities approved for PAHO in
1991-1994, as well as the targets adopted at the Summit Meeting
on Children of the United Nations.
     Technical cooperation was concentrated on activities
directed toward the most vulnerable population groups, for which
more resources were assigned to interventions that can have a
greater impact against injuries and risks, and to those enhancing
an increase in coverage and access to and efficiency of services. 
In addition, the Organization supported the countries in the
decentralization and strengthening of local health systems;
development of methodologies and programs that facilitate
favorable behavior and health promotion; utilization of social
communication techniques; dissemination of technical and
scientific information; research; mobilization and organization
of women's groups as agents vitalizing activities in the field of
health and development; cooperation between countries;
mobilization of resources; incorporation of the components of the
health of women, children, and adolescents in policy and
socioeconomic development agendas; and subregional and national
initiatives.
     Adolescent health was made a new program to better identify
the lines of action to follow, because the specific interventions
of health promotion and disease prevention in that population
group have an important effect not only on the behavior and
lifestyles of the young people and adolescents of today but also
on future generations.  The prevention of AIDS, maternal and
child health, and development of the plan to reduce maternal
mortality were consolidated as lines of work.  Epidemiological
research related to perinatal health was promoted and support was
given for the consolidation of the Regional Perinatal Network
through the Latin American Center of Perinatology and Human
Development (CLAP).
     As a result of the signing of a "memorandum of
collaboration" in May 1991 by PAHO/WHO, UNICEF, UNFPA, AID (USA),
and IDB to support fulfillment of the agreements of the World
Summit on Children in the Americas, a regional Interagency
Coordinating Commission was organized.  Interagency coordinating
committees had already begun to be established in the countries,
and the Organization will collaborate with them in the future.
     The participation of Program staff members in several
international meetings provided an opportunity to make the work
of the Organization in this field known and to disseminate its
pertinent policies.  The mobilization of resources deserves
special mention.  The W. K. Kellogg Foundation approved $US1.5
million for adolescent health and AID (USA) donated $US20 million
for the Expanded Program on Immunization.  The women and family
planning health projects, which have received a contribution of
$US6,333,700 from UNFPA, continued to be carried out in 24
countries in the Region.  In addition, contributions were
received from UNICEF, CIDA, the Government of Sweden, and the
Kingdom of the Netherlands, among others.
     The activities related to growth, development, and human
reproduction were carried out within three areas of action: 
health of women and mothers, health of children, and health of
adolescents and young people.  The Organization gave technical
support to all the countries in incorporating specific activities
to reduce maternal mortality and to review and update maternal
and child health programs and technical standards for controlling
pregnancy, caring for deliveries, newborns, the postpartum, and
family planning.  All the countries have adopted standards for
controlling children's growth and development, and continuing
education on the subject has been implemented in 12 countries. 
The Organization also collaborated in disseminating the Child
Health Card, a graphic for surveilling growth and the basic
benchmarks of children's psychosocial development.
     Twenty countries have official adolescent health policies,
and with support from PAHO/WHO, local, state, provincial,
departmental, or national programs to promote the health of this
group were carried out in all the countries.  In addition, the
development of reference and focal centers strategically located
in countries in all the subregions was facilitated.  A project by
the W. K. Kellogg Foundation and PAHO/WHO was initiated in 11
countries which supports comprehensive national adolescent health
initiatives, and it is hoped that it will have impact on
neighboring countries.
     The XXXV Meeting of PAHO's Directing Council reviewed the
third report on the execution of the Organization's policy of
action in population matters in which changes in demographic
variables, their future prospects, and their repercussions on
health were analyzed.  PAHO/WHO collaborated with 24 countries in
carrying out UNFPA projects, and specifically in family planning
education and services.
     In the area of personnel training, three regional courses on
management in maternal and child health were given in Brazil,
Colombia, and Costa Rica; a regional course on growth and
development in Nicaragua, and two subregional workshops with
participation by INCAP and PASCAP on the same subject were held
in Bolivia and Mexico.  Innovations incorporated in the training
of nurses and the utilization of traditional midwives through a
project to develop nursing in maternal and child health in ten
countries, which had support from the W. K. Kellogg Foundation,
also deserve to be pointed out.  During the year the results of
an investigation of teaching on children's growth and development
carried out with the participation of 105 schools of medicine and
66 schools of nursing and with support from the Latin American
Association of Pediatrics were analyzed.   The Organization
continued cooperating in an evaluation of the efficiency of
maternal and child health services; by the end of 1991, 3,450
services in 23 countries had been evaluated.  In addition, a data
base on maternal and child health was designed and implemented in
seven countries.
     CLAP gave priority to activities aimed at strengthening
perinatal health services, and in 12 countries emphasized
evaluation of the technologies utilized in the services of local
health systems.  In addition, it gave priority to multicenter
collaborative research of the intervention/action type, to
controlled clinical tests, and to application of appropriate
epidemiological methods to every situation.  During the year it
carried out 20 investigations of this type in 13 countries (with
880 days of consultantship).  In addition, the Center conducted
four formal courses, offered internships for staff members in the
health sector, and carried out other teaching activities.  In
all, 1,313 participants from 26 countries benefitted from these
activities, which will result in better care in the treatment of
pregnancy, delivery, and puerperium.  The Perinatal Information
System developed by CLAP encompassed more than 250 institutions
which process a total of 400,000 perinatal histories per year. 
At the same time, design of the Child Information System was
completed and tested in six countries.  Bolivia, Honduras,
Nicaragua, and Peru received extrabudgetary funds from the
Canadian Agency for International Development ($US4.8 million for
four years) for these activities and from the W. K. Kellogg
Foundation ($US220,000) for the dissemination of information.  
     The Expanded Program on Immunization (EPI) progressed in
reducing diseases preventable by vaccination, especially in
eradicating poliomyelitis and eliminating and controlling
neonatal tetanus and measles.  A coverage of 75% with the
vaccines included by the EPI (diphtheria, whooping cough,
tetanus, measles, and tuberculosis) was achieved.  Seven cases of
wild poliovirus (6 in Colombia and 1 in Peru) were reported, and
some 1,400 districts with a high risk of neonatal tetanus
infection were identified.  Measles control in children up to 15
years was implemented in Cuba and the countries of the English-
speaking Caribbean, and similar plans were initiated in
Argentina, Brazil, Mexico, and the countries of Central America. 
The EPI focused on its activities in epidemiological
surveillance, training and supervision of personnel, evaluation
of the cold chain, and expansion of information systems.
     In regard to the prevention and treatment of diarrheal
diseases, priority was given to strengthening national capacity
to organize and develop programs and to the training of
personnel.  The presence of cholera in the Region created new
challenges for the development of the activities in this field. 
The Country Representatives' offices of PAHO/WHO devoted more
resources to controlling and preventing cholera and other
diarrheal diseases, and collaborated in applying technologies
available in the countries, which helped diminish deaths from
cholera.  In addition, joint activities were promoted with the
food and nutrition, veterinary public health, disaster
preparedness, and sanitation programs, among others.  The
participation of the social security institutions in the
countries in diarrheal disease and cholera control, and the
establishment of oral rehydration units in such institutions and
of oral rehydration and sanitation units in the communities
should be noted.  The strengthening of units providing training
on treatment of diarrheal diseases and intense educational
efforts in homes and health establishments helped prevent these
diseases and improve the treatment and care of patients with
diarrhea, including those with cholera.
     With reference to acute respiratory diseases, the
Organization focused its technical cooperation on reducing
mortality due to those diseases, basically pneumonias in children
under 5; reducing the inappropriate use of antibiotics and other
drugs; reducing the severity of such diseases, and preventing or
reducing complications through early diagnosis and timely and
adequate treatment.  All the countries have adopted PAHO/WHO's
technical recommendations in regard to national standards for the
prevention and the treatment of these diseases; 16 countries
implemented operational plans following PAHO/WHO criteria, 18
reviewed and published national standards, 20 utilized the models
for training personnel at the operational level, 20 carried out
activities to control and prevent acute respiratory diseases in
local health systems in at least one area, and seven established
training units in hospital centers.  The Organization also
disseminated protocols for treating these diseases and
collaborated in the training of personnel responsible for their
fulfillment and in managerial training for personnel at the
central and intermediate levels in almost all the countries. 
Eighty-seven courses or workshops were offered for personnel of
the local health services, with 3,063 participants.  The
Commission on Intermanagerial Coordination, made up of UNICEF,
AID (USA), and PAHO/WHO, prepared a document on acute respiratory
disease control, which was published and distributed in the
countries of the Region.  The Organization also published and
disseminated 123,000 copies of technical publications and
scientific documents on the control of these diseases.
     The Organization's Maternal and Child Program produced a
total of 162 publications and offered 385 courses, 365 in the
countries and 20 at the regional and subregional levels which
benefitted 10,636 participants from all the countries of the
Region.
     A high proportion of the regional advisers' available time
was devoted to direct technical cooperation to national
institutions, programs, and projects or to active participation
in national or international scientific and technical meetings
related to the Program.  Three hundred thirteen missions to all
the countries were carried out, with a total of 1,918 days of
field activity in 27 countries, and 243 short-term
consultantships (7,600 days of technical support).
     The Program contributed to the decentralization and
strengthening of local health systems, to incorporation of social
security institutions and governmental and nongovernmental
agencies in the study, coordination, and activities in maternal
and child health, and promoted interinstitutional, interprogram,
and intersectoral activities.




MEXICO

Although the problem of contamination of food by pesticides is
general in the country, it has particular characteristics in each
region.  Thus, the food that comes from the areas devoted to export
agriculture tends to be contaminated with pesticides that have very
low persistence but are highly toxic, but in the food that comes
from the cotton-producing areas of the country, especially in food
of animal origin, such as meat, milk, eggs, and milk products,
concentrations of pesticides are very frequently found (81, 82).

According to existing information, the principal contaminants of
food in Mexico are the organochlorine pesticides and their
biodegradation products; next in importance are the residues of
organophosphorus pesticides.  Their presence is a result of
deficiencies in the agricultural practices; for example, the
harvest is collected before the waiting period has expired, or more
applications than are recommended are made or unauthorized
pesticides are applied.

Some illustrative data follow:

In milk coming from the Lake Region, an area that has been devoted
to cotton-growing for many years, the following compounds were
found in 100% of the samples:  alpha and beta BHC, DDT and its
metabolites DDE and DDD, and, in 80% and 50% of the samples
respectively, the compounds dieldrin and hexachlorobenzene, of
recognized chronic toxicity.  In the case of DDT and its
metabolites, the concentrations exceeded by a considerable amount
the tolerances recommended by the Codex Commission.  For example,
the average concentration of DDE was 2.56 g/g (based on the lipids
extracted).  In contrast, the average concentration of this
contaminant in samples of milk from other parts of the country was
0.05 g/g, calculated on the same basis.  The same pattern was
observed for the other residues.  The number of compounds per
sample was also different; thus, in the samples coming from the
Lake Region there were from eight to nine compounds per sample,
while in milk from another source, the number of compounds per
sample ranged from two to seven (81).

In cheeses coming from the cotton region known as Soconusco, in the
southwestern part of the country, in addition to the pesticides
mentioned above, gamma BHC, heptachlor, and heptachlor epoxide were
identified.  DDE was found in 100% of the samples (83).

In eggs basically the same residues, plus endrin, have been found
(84, 85).

In a study that included eleven species of fresh-water organisms,
from two to five classes of residues were found per sample.  The
compounds that were found most frequently were DDT and DDE.  The
maximum concentration of DDE was 27.30 g/g, based on the lipids
extracted from the sample.  In this and other studies on fresh-
water fish, no samples without residues were found and, in addition
to the residues described above, residues of alpha and gamma
chlordane were detected.  These results indicate the changes in the
quality of the bodies of water in the country and, in general, the
ecological imbalances that may be occurring, but without the
existence of relevant data (86).

Similar results have been obtained in all of the food samples that
have been studied in the country, independently of their area of
origin and of the date of study.

With regard to the residues of organophosphorus and carbamic
pesticides, in addition to the studies carried out by the Ministry
of Agriculture and Water Resources, whose results have not been
published, there have been two others, on both fruits and other
plant parts that are consumed without cooking - including tomatoes,
strawberries, avocados, lettuce, peppers, onions, lemons,
pineapple, and oranges.  In the two studies, residues of
organophosphorus and carbamic pesticides were found in excess of
the tolerances established by the Codex Commission.  In the first
study, there were no samples without residues and from 30% to 80%
of the samples had two or more residues of these products.  In a
large number of samples - for example, 50% of the tomato samples -
 the concentrations of methyl parathion and parathion exceeded the
Codex limits.  In the second study the results were generally
similar.  In addition, residues of leptophos were identified in
five of the plants studied.  It should be emphasized that, in
theory, this pesticide is prohibited in the country (87, 88).
ANNEX 13

GLOSSARY

     ENVIRONMENT - Surroundings, including water, air, and soil and
their interrelationship, as well as the relationships between these
elements and any live organisms.

     COMPETENT AUTHORITY - Agency or agencies of the government
charged with regulating the manufacture, trade, and utilization of
pesticides, and in general, applying legislation on pesticides.

     MARKETING - The general process of promoting a product,
involving publicity, public relations concerning the product, and
information services, as well as its distribution and sale in the
national and international markets.

     MERCHANT - Anyone that is devoted to commerce, including
export, importation, formulation, and internal distribution.

     MEDIAN LETHAL CONCENTRATION (LC50) - This is the concentration
of a substance required to cause the death of 50% of a population
exposed during a specific time and observed over a given period
after the exposure.  It can refer to the concentration of the toxic
substance in the air and exposure by inhalation; it can also refer
to the concentration in water.

     INTEGRATED PEST CONTROL - A system for fighting pests that,
in the context of the associated environment and the population
dynamics of the species of pests involved, utilizes all of the
appropriate techniques and methods in their most compatible form
and maintains the pest populations below the levels at which
unacceptable economic losses or damages are produced.

     DISTRIBUTION - The process of supplying pesticides through
commercial channels in the national or international markets.

     MEDIAN LETHAL DOSE (LD50) - This is the statistical estimate
of the number of mg of the toxic substance per kg of body weight
required to kill 50% of a group of animals under test.

     PACKAGING - The container, together with its protective
covering, utilized in the delivery of the chemical products to the
users through wholesale or retail distribution.

     POISONING - Injuries or disorders caused by a poison,
including intoxication.

     LABEL - Any written, printed, or graphic material that goes
on the pesticide or is printed or engraved on or applied to its
immediate container or is included in the package or exterior
covering of the container.

     MANUFACTURER - A company or other public or private entity or
any individual devoted to the business or to the function
(directly, through an agent, or through an entity controlled or
contracted by them) of manufacturing an active ingredient of a
pesticide, its formulation, or product.

     FORMULATION - The combination of several ingredients used to
make the product useful and effective for the purpose intended,
that is, the form of the pesticide purchased by the users.

     PUBLIC SECTOR GROUPS - These include, among others, scientific
associations; groups of farmers; civic organizations;
environmental, consumer, and sanitary organizations; and unions.

     PESTICIDE INDUSTRY - All the organizations and individuals
devoted to the manufacture, formulation, or marketing of pesticides
and pesticide products.

     ACTIVE INGREDIENT - The biologically active part of a
pesticide formulation.

     PESTICIDE LEGISLATION - Any law or regulation applied to
regulate the manufacture, marketing, labeling, packaging, or
utilization of pesticides with respect to their quality, quantity,
or effect on the environment.

     MODALITY OF USE - The set of all the factors that are involved
in the use of a pesticide, such as the concentration of the active
ingredient in the preparation that is to be applied, the dosage
applied, the period of treatment, the number of treatments, the use
of an adjuvant, and the methods of application and placement that
determine the quantity applied, the periodicity of the treatment,
and the interval prior to the harvest, among other factors.

     COMMON NAME - The name assigned to an active ingredient in a
pesticide by the International Organization of Standardization or
adopted by the national standardization authorities for use as the
generic or unpatented name of that specific active ingredient
alone.

     TRADE NAME - The name used by the manufacturer to label,
register, and promote the pesticide; if that name is protected by
national legislation, it can be utilized exclusively by the
manufacturer to distinguish his product from other pesticides that
contain the same active ingredient.

     DANGER - The probability that a pesticide will cause
unfavorable effects (damage) under the conditions of its use.

     WAITING PERIOD OR SAFETY INTERVAL - The number of days that
must pass between the last application of the pesticide and
harvesting.  In the livestock sector the number of days between the
last application to livestock and their slaughter or the next
milking.

     REENTRY PERIOD - The number of days that must pass between the
application of a pesticide in a field under cultivation and the
reentry of any personnel to the treated area without equipment for
personal protection.

     PESTICIDE - Any substance or mixture of substances used to
prevent, destroy, or control any pest, including the vectors of
diseases affecting humans or animals and the undesirable species
of plants or animals that cause injury or interfere in any other
form in the production, preparation, storage, transportation, or
marketing of food, agricultural products, wood and wood products,
or animal feed; also included are substances that one can
administer to animals to combat insects, arachnids, or other pests
in or on their bodies.  In addition, the definition includes those
substances destined to be utilized as plant growth regulators,
defoliants, desiccants, agents to reduce the density of fruit, and
agents to avoid premature dropping of fruit, and the substances
applied to fields before or after harvest to protect the product
against deterioration during storage and transportation.


     PRODUCT - The pesticide in the form in which it is packaged
and sold; it generally contains an active ingredient plus the
adjuvant and can require dilution before use.

     PROHIBITED - Said of a pesticide whose registered uses have
been totally prohibited by a firm decision of the government
relative to the registration, or whose registration or equivalent
action has been denied for reasons related to health or the
environment.

     PUBLICITY - The promotion of the sale and utilization of a
pesticide by the print and electronic media, presentations,
exhibits, gifts, demonstrations, or speech.
     
     REPACKAGING - The transfer of a pesticide from one commercial
container to another, usually smaller, container for subsequent
sale.

     REGISTRATION - The process by which the competent national
authority approves the sale and utilization of a pesticide, after
evaluation of complete scientific data that demonstrate that the
product is effective for the purpose intended and does not involve
undue risks to human health or the environment.

     RESIDUE - Any specified substance present in food,
agricultural products, or animal feed as a consequence of the use
of a pesticide.  The term includes any derivative of a pesticide,
such as conversion products, metabolites, and reaction products,
and the impurities considered of toxicological importance.  The
term "pesticide residue" includes both the residues of unknown or
unavoidable origin (for example, environmental) and those resulting
from known uses of the chemical substance.

     RISK - The expected frequency of undesirable effects resulting
from exposure to a pesticide.

     PROTECTIVE CLOTHING - All clothing, material, or devices worn
by individuals to provide protection from pesticides when they are
handled or applied.

     EXTENSION SERVICE - The activity of transferring to the
farmers information and advisory services regarding practices that
improve the production, handling, and marketing of agricultural
products.

     SEVERELY RESTRICTED - Said of a pesticide most of whose
registered uses are prohibited by a firm regulatory decision of the
government while some specific registered use or uses continue to
be authorized.

     TOXICITY - The physiological or biological property that
determines the capacity of a chemical substance to cause damage to
or produce injuries in a live organism by nonmechanical means.

     POISON - A substance that can cause structural or functional
disorders that induce injuries or death if they are absorbed in
relatively small quantities by human beings, plants, or animals.



BIBLIOGRAPHIC REFERENCES


1.   Food and Agriculture Organization of the United Nations (FAO). 
     International Code of Conduct on the Distribution and Use of
     Pesticides.  Rome, 1985.

2.   Ministry of Agriculture, Fisheries and Food, Pesticides
     Branch.  Pesticides Safety Precautions Scheme.  London, United
     Kingdom, Ministry of Agriculture, 1979.

3.   Hainault, S., and G. Corey.  Plaguicidas inhibidores de las
     colinesterases [Pesticides that are inhibitors of
     cholinesterases].  Pan American Center for Human Ecology and
     Health (ECO/PAHO).  Metepec, State of Mexico.  Mexico, 1991.

NATIONAL PROGRAM
        FOR THE PREVENTION AND CONTROL
OF AIDS











MONITORING AND CONTROL SYSTEM
MCS (VERSION 2.0)
USER'S MANUAL




















Edgar Serna Q., PAHO/WHO Consultant
Fernando Morales, PAHO/WHO, Guatemala
Washington, D.C., 14 April 1992
MONITORING AND CONTROL SYSTEM (MCS)


PRESENTATION

     With a view to strengthening the process of development and
     the managerial capacity of the National Programs on AIDS in
     the Region, the Pan American Health Organization/World
     Health Organization (PAHO/WHO) has collaborated in the
     preparation of a computer program that will enable the
     countries to begin utilizing the planning instrument known
     as the Four-month Work Plan (PTC) and will, at the same
     time, facilitate programming and financial monitoring of
     the AIDS prevention and control activities that are being
     carried out with funds utilized by the national programs.

     To facilitate introduction of the PTC into the National
     Programs on AIDS, a simple MONITORING AND CONTROL SYSTEM
     (MCS) has been developed.  This document constitutes the
     user's guide for the System.

     The Four-month Work Plan is a recognized planning
     instrument that has been utilized by many national health
     programs, as well as by PAHO cooperation programs, to plan
     short-term activities on the basis of policies designed to
     cover much longer periods.  All the countries have
     established Medium-term Plans for the Prevention and
     Control of AIDS--which generally span three-year periods-
     -and in this context the PTC should prove to be a valuable
     strategic instrument for implementing existing AIDS
     policies. 

     In addition, by monitoring the activities and controlling
     the resources utilized by the National Program during each
     four-month period, the countries will be able to
     systematically reinforce the process of coordination
     between the various components of the Medium-term Plans,
     make better use of external cooperation, and create the
     potential for attracting new sources of financing.

     This system is designed to be practical and easy to use.
     However, its effectiveness should be continually monitored
     so that any improvements needed can be introduced in order
     to better adapt it to the needs of the various National
     Programs.

1.- THE MONITORING AND CONTROL SYSTEM

     The MCS is a computer program designed to enable those
     responsible for the National Program to:

     a.- Prepare four-month programs of the activities and tasks
     that will be carried out with resources from various
     sources, using the PTC format.

     b.- Record numerical and conceptual information on the
     development of each activity and task in an additional box
     included within the PTC document.  This space can be used
     by the authorities responsible for the National Program to
     keep track of the funds used and available and to include
     any pertinent observations regarding the execution of the
     activities.

     c.- Analyze, in a single document, the execution of
     activities vis-Õ-vis initial programming, and facilitate
     the implementation of corrective measures.

     d.- Oversee the development of activities, tasks,
     components, and the Program in general.

     e.- Keep track of budgetary execution through reports
     generated automatically by MCS.

     f.- Prepare a general analytical report on the evolution of
     the Program during a given period.

     g.- Standardize the presentation of periodic reports by the
     countries of the Region.


2.-  PROGRAM SIZE

     The program uses just over one megabyte of memory and is
     contained on one high-density diskette.  It can be
     installed on any IBM-compatible computer with a hard disk.

3.-  INSTALLATION

     Get into the root directory of the hard disk of the
     computer on which MCS is to be installed, insert the
     diskette, enter a:install and then press <Enter>.  A
     directory called MCS will automatically be created and all
     the program files will be copied into it.  Once this is
     done, the program has been installed.
4.- STARTING THE PROGRAM

     At the screen prompt C:>, enter cdmcs and press <Enter>. 
     Type mcs and press <Enter>.

      NOTE:  Refer to the end of this manual for a list of the
     word processing commands used herein.


5.-  BASIC DATA AND THE FOUR-MONTH PERIOD

     The System will display the following information on the
     screen and prompt you to indicate the four-month period in
     which you wish to work.  After entering the corresponding
     four-month period, select the Utilities option and press
     <Enter>.  Then move the cursor to System Parameters and
     press <Enter>.  Next, enter the biennium, year, country
     acronym (e.g., COL, ECU, etc.), country name, and type of
     printer that will be utilized:  L for laser or M (dot
     matrix) for any other type.  You will only need to provide
     this information when you initially install MCS and when
     you begin work on a new year.

     Exit the menu by entering <Esc> and return to the main
     menu.  Any operation you carry out subsequently will apply
     to the four-month period you have just selected.

     



PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
































Indicate Four-month Period:  1 











MCS                  
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  







6.- MAIN MENU

     The MCS main menu will be displayed as shown below.


Four-month Period: 1                                              <Esc> to exit 
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project: 92/XXX-HIV         ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-month
Period
Utilities       



















MCS                  
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  





   


     To select one of the seven options, use the arrow keys < 
     >  and <  > to move the cursor and highlight the option
     you want to use and press <Enter>.  To exit the program,
     press <Esc>.
    The following options may be chosen from the main menu:

     WORK PLAN:  This option allows you to prepare the PTC for
     the four-month period selected in the previous step.  The
     program has the current format (see Format 1).  The block
     on the right side, under the heading of Monitoring, is not
     actually part of the PTC and should therefore be blank at
     the time that procedures are initiated for PTC approval. 

     MONITORING:  With this option you can access the four
     columns on the far right side of Format 1.  This space is
     provided so that you can periodically enter information on
     how execution of the PTC is proceeding.  This information
     should be entered as it becomes available rather than at
     the end of the four-month period.

     ANALYTICAL REPORT:  This is another option available to the
     Head of the National Program on AIDS, or any another
     national authority designated for this purpose, for
     describing the evolution and status of the Program
     following completion of the tasks that were programmed.

     VIEW DOCUMENT:  With this option, any document may be
     viewed, although no changes may be introduced.

     PRINT:  With MCS three types of documents may be printed: 
     the Four-month Work Plan with its corresponding Monitoring
     section; the Budgetary Execution report, which the System
     processes automatically; and the Analytical Report.

     Four-month Period:  With this option you may select the
     four-month period that you wish to access by typing a
     single digit.

     UTILITIES:  This is a set of options that may be used to
     enhance the performance of the System and allow the user to
     make backup copies on diskettes for safekeeping.
     

7.- WORK PLAN

     The first option on the main menu is the Work Plan.  With
     this option it is possible to prepare or modify the PTC by
     defining the Components, Activities, Tasks, and Steps. 
     When this option is selected, MCS will display the
     following submenu.


Four-month Period: 1                                             <Esc> to exit 
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV       ACQUIRED IMMUNODEFICIENCY SYNDROME          







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-month
Period

UtilitieSelect

Components   

Activities   

Tasks        

Steps        







MCS                  
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  






    7.1  Components
     
To begin preparation of the Work Plan, first select
Components from the submenu and press <Enter>.  This
option is used just once to create all the components
of the PTC.  MCS will prompt you to enter the
component number and name, as shown below.

Next, enter the name of the person responsible for the
component.

(Data correct?  <Y>es or <N>o)

Four-month Period: 1                  Components                    <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV       ACQUIRED IMMUNODEFICIENCY SYNDROME          




Component Number: 01

Description:  MANAGEMENT AND ADMINISTRATION

Person in charge:  DR. J. CARRILLO







Data Correct? Y/N  Y

  
Any component that has been entered can be modified or
deleted.  If you choose to delete, MCS will notify you
that if you delete a Component, all the activities,
tasks and steps associated with it will also be
deleted.  You should therefore think carefully before
deleting a component. 

Once you have finished entering all the PTC
components, press <Esc> to return to the submenu.

     7.2  Activities

After the components have been defined, you are ready
to enter the description of each activity.  To
maintain consistency with the criteria and definitions
used in the Medium-term Plan, activities under the PTC
should correspond to what the Medium-term Plan calls
objectives and tasks under the PTC should correspond
to what the Medium-term Plan calls activities.  This
system uses two basic terms for the definition of what
is to be done.  The term "activity" indicates an ideal
situation, which one aspires to create through
completion of one or more tasks.  Select Activities
from the menu and press <Enter>.  MCS will first ask
you to enter the component number.  After verifying
that this number exists, it will automatically display
the corresponding name.  If MCS is unable to find the
number, it will ask you again for the component.  You
should assign a two-digit number to the activity (01
through 99).  If you wish, you can also enter a short
title or name for the activity in order to help you
identify it.  Press <Enter> to continue.

Example:  If one activity is to "Provide the National
Program on AIDS with the Resources Needed to Raise
Managerial Capacity to Acceptable Levels," you could
assign a short title like "Managerial Capacity" in
order to be able to easily distinguish it from other
activities such as "Laboratory Supplies," "Nursing
Workshop," etc.

The screen on which activities are entered is shown
below:


Four-month Period: 1               Activities                    <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV      ACQUIRED IMMUNODEFICIENCY SYNDROME           




Component:     01    MANAGEMENT AND ADMINISTRATION      ...

Activity:      01    MANAGERIAL CAPACITY


A C T I V I T Y

Provide the National Program on AIDS with the Resources Needed        
to Raise Managerial Capacity to Acceptable Levels                     



Activity OK? Y/N  Y                           






Ctrl-W to
save



Your descriptions of the activities--and all other
items--should be clear and sufficiently detailed,
taking into account that the document will be used by
persons who are interested in learning more about your
AIDS program and who will require in-depth knowledge
of the local situation.

Once your have finished the description of the
activity, simultaneously press <Ctrl> and <W> to save.


Any activity that has been entered can be modified or
deleted.  If you choose to delete, MCS will alert you
that if you delete an Activity, all the tasks and
steps associated with it will also be deleted.

When you have finished entering the Activities, press
<Esc> to return to the submenu.

     7.3  Tasks

After defining the activities, you are ready to enter
the information about the tasks.  Select Tasks and
press <Enter>.  MCS will ask you for the component
number and will check to see that it exists.  It so,
it will automatically display the component name.  If
not, it will ask you again for the component.  Enter
the two-digit activity number (01 to 99) and MCS will
verify that it exists.  If so, it will automatically
show the activity title (e.g., Nursing Workshop).  If
not, it will ask you again for the component.  Next,
enter a number to identify the task (01,02,...99), and
then enter the following information about the task:

Source of financing, beginning and ending dates (in
the following format:  day/month/year), and place.


If the information is correct press <Y>.  If not,
press <N> and repeat the entry.

The screen on which this data is entered is shown
below:


Four-month Period: 1                  Tasks                      <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (COUNTRY
NAME)
Project 92/XXX-HIV     ACQUIRED IMMUNODEFICIENCY SYNDROME            




Component:   01                             Activity: 01
MANAGEMENT AND ADMINISTRATION      ...      MANAGERIAL CAPACITY
Task No:    01



Fin. Source:  PAHO

Dates:       01/01/92 - 30/04/92

Place:       CAPITAL CITY







Data Correct? Y/N  Y


MCS will then display a window (box), in which you
should enter a complete description of the task,
providing specific details so as to give an adequate
idea of the nature of the task.  Include the following
types of information:  number and general profile of
persons who will attend an event, content of an event,
impact that the task is expected to produce in various
areas, expected changes, image-objective, results and
reports expected from a trip, expected outcomes,
coverage of the task, type and quantity of elements to
be acquired, etc.  Once the entry is complete,
simultaneously press <Ctrl> and <W> to save it. MCS
will ask you if the information about the task is
correct.  Type <Y> if there are no corrections to be
made.

Tasks should always be associated with their
respective activities.  In order to maintain
consistency, it is a good idea to ask yourself the
following question as you describe each task:  "Will
this task really contribute to the attainment of the
objective proposed in the definition of the activity?"


Four-month Period: 1                   Tasks                    <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV        ACQUIRED IMMUNODEFICIENCY SYNDROME         




Component:   01                            Activity:   01
MANAGEMENT AND ADMINISTRATION      ...      MANAGERIAL CAPACITY
Task No.:    01



Fin. Source: PAHO

Dates:       01/01/92 - 30/04/92

Place:        CAPITAL CITY

T A S K

secretary for the Headquarters of the National Program to support     
the Head of the prog coordinators by      
carrying out administ     Task OK?  Y/N  Y     contract preparation 
and execution, streamfiles, controlling   
supplies, etc.).                                                      
Ctrl-W to
save

An example of the foregoing is shown below (one
activity and four associated tasks):

Activity 01:  To provide the National Program on AIDS
with the resources needed to raise managerial capacity
to acceptable levels. 

Task 01:  Hire a full-time administrator and executive
secretary for the Headquarters of the National
Program. These two individuals will support the Head
of the Program and the component coordinators by
carrying out administrative duties (submitting bids,
overseeing contract preparation and execution,
streamlining processes, maintaining files, controlling
supplies, etc.).

Task 02:  Procure office equipment for Program
Headquarters, including:  2 desks, 2 chairs, 2
auxiliary tables, 1 telephone line, 1 computer (40 Mb,
1 Mb RAM, monitor, printer), 1 filing cabinet,
miscellaneous supplies. 

Task 03:  Attendance by the Head of the National
Program at a meeting on the Monitoring and Control
System in Quito, Ecuador (5 days) to learn how to use
MCS and implement it in the National Program at the
start of the next four-month period.

Task 04:  Hold a 3-day meeting on dissemination and
analysis of current administrative processes within
the National Program, to be attended by the Head of
the Program and the Program Administrator from all the
departments/provinces/regions of the country.  The
objective will be to update the 30 people in
attendance on current processes and to discuss and
adopt viable mechanisms that will facilitate overall
administration of the Program.  
Tasks that have been entered can be modified or
deleted at any time.  However, it is important to bear
in mind that, once approved, a PTC is an official
document and certain steps involving national
officials and the PAHO Representation must be taken
before any change can be introduced.  As a result, it
is not advisable to make changes simply because MCS
allows it.  Because the PTC is in the computer's
files, you will be able to continuously monitor the
tasks programmed and add any necessary data in the
monitoring box, without modifying the content of the
initial Plan.

The number assigned to a task should be maintained if
this task continues into a four-month period in a
different year.  Once a task has been completed, it is
recommended that the same number not be utilized for
any other task.

Once you have finished entering the tasks, press
<Ctrl> and <W> to save and <Esc> to return to the
submenu.

     7.4. Steps

The steps refer to the rising consecutive numbers that
correspond to the different budget element allotments
for each task.  For example:  A task has two allotted
amounts, one for the purchase of a computer and
another to cover a contract for training in how to
operate the computer (the first corresponds to Element
550 and the second to Element 390).  Consequently,
there will be two steps:  01 and 02, without any
criteria for determining which is first and which is
second).


Four-month Period: 1                  Steps                      <Esc> to exit

PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




Component:   01                            Activity:   01
MANAGEMENT AND ADMINISTRATION      ...      MANAGERIAL CAPACITY
Task No.:01

Step:01

Allotment: XXX-HIV-250/FX/9293/390

Allotted:  2800.00

Name:ROA, F. and RUIZ, M.





Data Correct?  Y/N  Y

For the country programs on AIDS, the allotment number
will include the following components:

a.   Country acronym
b.   HIV
c.   Three PAHO code numbers that identify the
series.        d.   FX (fund)
e.   Four numbers that identify the budget period 
f.   Three numbers that identify the budget element

a   b   c  d   e    f   
Ex:  XXX-HIV-250/FX/9293/390


Enter the amount allotted to the task for each budget
element.  All amounts should be expressed in U.S.
dollars.

Under "Name" enter the names of the persons who, for
example, will be covered by a contract, will be taking
a trip, etc. 

Finally, answer the question "Data correct?" by typing
a <Y> if no changes are required in the foregoing
information. 

8.- MONITORING

     The second option on the main menu is Monitoring, which
     allows you to enter information about the execution of the
     PTC, referring to the steps, tasks, and activities.

     When you select this option, MCS will display the following
     submenu:


Four-month Period: 1                                             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-
monthSelect
Utilities Monitoring of Steps    

Monitoring of Tasks    

Monitoring of
Activities












MCS                  
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  









     The commands and the information to be entered in this
     section are similar to those for the Work Plan.  MCS will
     prompt you to enter the data.

     Information about execution of the Plan should be entered
     and saved on the hard disk as soon as it becomes available. 
     Corrections can then be made subsequently, should any be
     required.
    8.1.  Steps


Four-month Period: 1            Monitoring of Steps              <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




Component:  01                             Activity:  01
MANAGEMENT AND ADMINISTRATION      ...       MANAGERIAL CAPACITY
Task No.:     01

T A S K

Hire a full-time administrator and executive secretary for the Head-  
quarters of the National Program.  These two individuals will support 
the Head of the Program and the component coordinators by carrying    
out administrative duties (submitting bids, overseeing contract       





Step:  01                             Obligation:  XXX/92/00124-5    
Description:                   
Allotment:   XXX-HIV-250/FX/9293/390  ROA, F. JAN-APR /92            
Allotted:    $   2800.00                                             
Obligated:   $   1500.00                Obligated: $      1500.00    
Disbursed: $         0.00    
Available:  $   1300.00                 Balance:   $      1500.00    


Data Correct?  Y/N  Y


     Obligation:  Refers to the number that PAHO assigns to each
     obligation of all or part of the amount allotted in the PTC
     after it is approved.  The obligation is an official
     authorization granted by PAHO so that commitments can be
     carried out and payments disbursed out of an amount
     allotted in a PTC.  There may be several obligations
     against an allotted amount during the four-month period,
     but the total obligations cannot exceed that amount.  Each
     time data is entered about an obligation, MCS will
     automatically show the balance remaining to be obligated
     (i.e., the balance available).  The balance available is
     equal to the allotted amount less all the authorized
     obligations against that amount.

     Description:  This is a short reference that makes it
     possible to easily identify the purpose for which resources
     are to be used.  For example:  surname of a person hired,
     name of a company that provides a service, number of an
     invoice, goods procured, etc. 

     Allotted:  Refers to the exact amount that corresponds to
     the obligation number.  It cannot be greater than the
     allotted amount.

     Disbursed:  This is the real amount disbursed and charged
     to the obligation.  It cannot exceed the obligated amount. 
     

     Balance:  The balance is calculated by MCS and is equal to
     the total obligated amount less any disbursements; in other
     words, it indicates the amount that has been authorized to
     be spent but has not yet been paid out.

     The source of these data is the report on obligation
     balances by resource/allotment produced by FFMS at the
     PAHO/WHO Representation.


     8.2.  Tasks


Four-month Period: 1           Monitoring of Tasks           <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV       ACQUIRED IMMUNODEFICIENCY SYNDROME       




Component:   01                            Activity:  01
MANAGEMENT AND ADMINISTRATION      ...      MANAGERIAL CAPACITY
Task No.:    01

T A S
K
Hire a full-time administrator and executive secretary for the Head-  
quarters of the National Program.  These two individuals will support 
the Head of the Program and the component coordinators by carrying out
administrative duties (submitting bids, overseeing contract           
preparation and execution, streamlining processes, maintaining files, 
controlling supplies, etc.)                                           




Status:       CD  NS=Not Started, OG=Ongoing, CD=Completed, CA=Cancelled
MO=Modified
Fin. Source:  PAHO                      Place: CAPITAL CITY

Dates:        01/01/92 - 30/04/92





     Use the following codes to indicate the status of the task
     at a given time during the four-month period:

     NS:  not started,  OG:  ongoing,  CD:  completed, 
     CA:  cancelled,  MO:  modified.

Four-month Period: 1            Monitoring of Tasks              <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




Component:    01                            Activity:  01
MANAGEMENT AND ADMINISTRATION      ...      MANAGERIAL CAPACITY
Task No.:     01

C O M M E N T
S
The two people were hired and their contracts were renewed.  Program  
administration is now more efficient and the Program Head has dele-   
gated to them many of the tasks that previously he carried out.  He   
now devotes more      time to technical   
aspects.              Comments OK?  Y/N  Y                          




Ctrl-W to
save
Fin. Source:  PAHO                      Place: CAPITAL CITY

Dates:       01/01/92 - 30/04/92







     The next option under "monitoring of tasks" allows you to
     enter comments about the execution of the task.  In this
     space you can indicate any difficulties (delays in
     obtaining resources, unforeseen price changes, import
     delays, personnel changes, lack of motivation, suspensions,
     breaches of contract, reformulation of the task or
     activity, etc.) and facilities (unexpected additional
     resources, utilization of some new technique that yielded
     good results, reduction of costs, etc.) that have
     characterized the execution of the task.

     Press <Ctrl> <W> to save and <Y>es or <N>o to indicate if
     the comments are correct.

    8.3.  Activities
     


Four-month Period: 1          Monitoring of Activities           <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




Component:     01    MANAGEMENT AND ADMINISTRATION         ...

Activity:      01    MANAGERIAL CAPACITY




A C T I V I T
Y
To provide the National Program on AIDS with the resources needed     
to raise managerial capacity to acceptable levels.                    





C O M M E N T
S
There has been a real improvement in the managerial level within the  
National Program as a devote more time to 
coordinating with the    Comments OK?   Y/N  Y  carry out the tasks 
contained in the PTC.                     
Ctrl-W to
save


     Entering comments about the overall activity is similar to
     entering comments about each task.  Indicate how the
     situation has changed as a result of the execution of the
     activity.

     9.ANALYTICAL REPORT



Four-month Period: 1                                             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       






ANALYTICAL
REPORT
(Description of the Analytical Report).......                          





Analytical Report OK? Y/N  Y                    









Ctrl-W
to save






     By selecting this option from the main menu you can enter
     a detailed analysis of the factors that have helped or
     hindered the development and successful completion of the
     Work Plan.  This analysis is intended to provide an overall
     idea of the interaction between all the components of the
     National Program at the conclusion of the respective four-
     month period. It should be sufficiently concise to give the
     reader a true picture of the situation and trends in the
     Program.

     When you select this option, MCS will display a window
     (box) with the heading ANALYTICAL REPORT.  Enter the text
     corresponding to the four-month period selected.
     
     As a minimum, the Analytical Report should include:

     a.-An evaluation of the results obtained.

     b.-Validation or reformulation of the results to be sought
     by the Program in future periods.

     c.-Degree to which activities and tasks have been executed,
     tasks not programmed, reformulations.

     d.-Validity of the cooperation priorities proposed for the
     National Program at the beginning of the four-month period.

     e.-Budget utilized vis-Õ-vis tasks carried out.

     f.-Favorable and unfavorable factors.

     g.-Validation or reformulation of the image-objective
     outlined for the National Program.

     Press <Ctrl> <W> to save.  Answer the question "Analytical
     Report OK?" by typing <Y>es or <N>o.


7.- VIEW DOCUMENT

     The View Document option makes it possible to view reports
     on the screen in order to check the quality of the
     information contained therein before printing them.

     When you select this option, MCS displays the following
     submenu:  


Four-month Period: 1                                             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print   
Select
Four-montWork Plan and Monitoring  

UtilitiesBudgetary Execution       

Analytical Report         
















MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  







    7.1  Work Plan and Monitoring

This option will allow you to display the PTC and it
corresponding Monitoring box (Format 1) by component. 
MCS will ask you for the project component that you
wish to view.  If you wish to see all the components,
leave the component number blank and press <Enter>. 
MCS will then ask you for the source of financing.  If
you wish to see all sources, do not specify any source
and press <Enter>.


Four-month Period: 1        Work Plan and Monitoring            <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




FOUR-MONTH WORK PLAN AND
MONITORING
Four-month Period:  1                                                  
YEAR: 1992                                                             


 
W O R K  P  


 
Component: 01  MANAGEMENT AND ADMINISTRATION                           


 

A T              DESCRIPTION ACTIVITY/TASK               ST    A L L 
EP          


 
01  To provide the National Program on AIDS with the                 
resources needed to raise managerial capacity to                 
acceptable levels.                                               





[PgUp] or [] = Up, [PgDn] or [] = Down
[End] or [Ctrl ] or [] = Right, [Home] or [Ctrl ] or [] = Left



Instructions will appear on the screen about how to
move the cursor within the table.  No changes can be
made in the document with this View Document option.

Press <Esc> to exit.
    7.2  Budgetary Execution

This option enables you to see the report on Budgetary
Execution.  If you wish to see all the components,
leave the component number blank and press <Enter>. 
MCS will then ask you for the source of financing.  If
you wish to see all sources, do not specify any source
and press <Enter>.  An example is shown below:



Four-month Period: 1            Budgetary Execution             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




BUDGETARY
EXECUTION

BUDGETARY EXECUTION  

COUNTRY:  (NAME OF COUNTRY)                                     Project 
Four-month Period:  1                                           TITLE:  
YEAR:  1992                                                             


 
Component:  01  MANAGEMENT AND ADMINISTRATION                           


 
A   T  STEP      ALLOTMENT         ALLOTTED    OBLIGATION      DE 


 
01                                                                
01                                                            
01 XXX-HIV-250/FX/9293/390    2,800.00                    
XXX/92/00124-5ROA,  

 



[PgUp] or [] = Up, [PgDn] or [] = Down
[End] or [Ctrl ] or [] = Right,  [Home] or [Ctrl ] or [] = Left

    7.3  Analytical Report

This option allows you to see the Analytical Report
for the four-month period with which you are working. 
An example is shown below.


Four-month Period: 1             Analytical Report              <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




ANALYTICAL
REPORT

......................................................................... 
Page:   1                                              Date: 13/04/92     


COUNTRY:  (NAME OF COUNTRY)                                               
Project   92/XXX-HIV                                
Four-month Period: 1       TITLE:     ACQUIRED IMMUNODEFICIENCY SYNDROME  
YEAR:   1992                                                              


(Description of Analytical Report).......                                







[PgUp] or [] = Up, [PgDn] or [] = Down
[End] or [Ctrl ] or [] = Right,  [Home] or [Ctrl ] or [] = Left

8.- PRINT

     By selecting this option from the main menu you can print
     the Four-month Work Plan (Format 1), the report on
     Budgetary Execution, and the Analytical Report.

     When you select this option, MCS will display the following
     submenu:  


Four-month Period: 1                                             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-
montSelect
UtilitiesWork Plan and Monitoring  

Budgetary Execution       

Analytical Report         













MCS                
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  








     8.1  Work Plan and Monitoring

This option will allow you to print the PTC and its
corresponding monitoring section for the current
period (Format 1), either by component or in its
entirety.  MCS will ask you for the component that you
wish to print.  If you wish to print all components,
leave the component number blank and press <Enter>. 
MCS will then ask you for the source of financing.  If
you wish print the document for all sources, do not
specify any source and press <Enter>.  MCS will ask
you for confirmation to print.

(Requirements:  For laser printers, 8.5" x 14" legal-
size paper.  For other printers, 14" x 11" traditional
large-size continuous paper).
    8.2  Budgetary Execution

This program is designed to automatically generate the
Budgetary Execution table on the basis of the
financial data that has been entered.  An example is
shown in Format 2.

This document makes it possible to assess in greater
detail the financial activity that has taken place
during the period.  This feature is very useful as an
internal control instrument for the National Program
on AIDS.  You can ask for a printout of the budgetary
execution report for a particular component by
indicating the component number or for all components
by leaving the component number blank and then typing
<Enter>.  MCS will ask you for the source of
financing.  If you wish to print this document for all
sources, do not specify any source and press <Enter>. 
MCS will request confirmation to print.


(Requirement:  For laser printers, letter-size paper. 
For other printers, 14" x 11" traditional large-size
continuous paper).


     8.3  Analytical Report

This option allows you to print the Analytical Report
in its entirety.  The system will print the report
corresponding to the four-month period selected, after
asking for confirmation to print (Format 3).

(Requirement:  Letter-size paper for all printers).
9.- FOUR-MONTH PERIOD

     This is the sixth option on the main menu.  By selecting
     this option you can change the four-month period in which
     you wish to work, as shown below.  This step is important,
     since all operations that you carry out subsequently will
     be associated with the four-month period you select.


Four-month Period: 1                                             <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-month
Period

Utilitie


Indicate four-month period: 1 











MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  












10.- UTILITIES

     The last option on the main menu is Utilities.  With this
     option you can perform several important operations that
     will enhance the performance of MCS.  The following submenu
     is displayed when you select this option:
Four-month Period: 1                                            <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print           

Four-
montSelect
UtilitiesReorganize Files          

Backup                    

Information Recovery      

System Parameters         










MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  








     10.1 Reorganize Files

This is an MCS internal function that allows you to
reindex the system's files.  During this process, any
entries that had previously been deleted will be
physically and permanently deleted.  This process can
be utilized periodically.  It is particularly
important to use it in the event that a power failure
has prevented you from exiting the system normally.


Four-month Period: 1              Reorganize Files              <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print     

Four-mont                   Reindexing                         
UtilitiesR                                                      
B                   Tasks File                         

I

System Parameters         










MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  






    10.2 Backup 

This option makes it possible to back up (copy)
information for safekeeping by transferring it from
the hard disk to a diskette (use a different diskette
from the original one that contains the System).  It
is advisable to perform this operation on a daily
basis or after entering any new information into the
System.  MCS will ask you to insert a diskette in
drive A.

Once you have copied all the information for an entire
year onto a backup diskette, it is advisable to begin
the first PTC of the following year by reinstalling
the System.  When MCS is reinstalled all the
information from the previous year--which you have
already copied onto the backup diskette--will be
deleted.  In this way, you can keep the files for each
year on a separate diskette and free up space on the
hard disk.

It is also advisable to keep a printed file with
copies of all the documents that are generated.


Four-month Period: 1                Backup                   <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print     

Four-mont                                                      
UtilitiesR                        Backup                        
B                                                      

I

System Parameters         










MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  






Insert your BACKUP diskette in drive A, press  to continue


    10.3 Information Recovery


Four-month Period: 1        Information Recovery                 <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       







Select

Work Plan       

Monitoring      

Analytical
Report
View Document   

Print     

Four-mont                                                      
UtilitiesR                 Information Recovery                 
B                                                      

I

System Parameters         










MCS                 
Monitoring and Control System 
   
Version 2.0  (c)
PWR-GUT/HST-HIV  






Insert your RECOVERY diskette in drive A, press   to continue


This option makes it possible to recover the
information that was stored in the backup process (see
Section 10.2).


     10.4 System Parameters


Four-month Period: 1                                            <Esc> to exit
PAHO/WHO-NATIONAL PROGRAM ON AIDS (NAME OF
COUNTRY)
Project 92/XXX-HIV          ACQUIRED IMMUNODEFICIENCY SYNDROME       




Biennium:9293

Year:92

Country Acronym:XXX

Country Name:(NAME OF THE COUNTRY)

Printer:L



Data Correct? Y/N Y



     Use this option to enter the following data:  biennium,
     year, country acronym, country name, and type of printer. 
     As was indicated above, this is the first step that should
     be taken after installation.

WORD PROCESSING COMMANDS USED IN MCS
     
[PgUp]         Takes you to the top of the page.
[PgDn]         Takes you to the end of the page.

[Home]         Takes you to the beginning of the line.
[End]          Takes you to the end of the line.

[Shift-Home]   Takes you to the beginning of the paragraph.
[Shift-End]    Takes you to the end of the paragraph.

[Ctrl ]        Takes you to the previous word.
[Ctrl ]        Takes you to the following word.

[Insert]       Allows you to overstrike text.

[Delete]       Eliminates characters one by one.

[Shift ]       Marks a line.       (In order to mark more than
one line, continue to press
[Shift] and [].

. To delete    1)   Press [Delete]. The line(s)
will be eliminated. 

. To move      1)   Press [Ctrl-X] to remove the
highlighted text.
2)   Move the cursor to the
position where you want the
text moved.
3)   Press [Ctrl-V] to retrieve the
text and complete the move.

. To copy      1)   Press [Ctrl-C] to copy the
highlighted text.
2)   Move the cursor to the
position where you want the
text copied.
3)   Press [Ctrl-V] to retrieve the
text and finish the copying
process.

[Ctrl-W]       Saves the text and exits the document.
[Esc]          Cancels entered text and exits the document.

     [Alt-a] = á    [Alt-o] = ó    [Alt-M] = 
     [Alt-e] = é    [Alt-u] = ú            
     [Alt-i] = í    [Alt-n] = ñ 

Note:  It is recommended that you not use [TAB ] or [TAB ]
E0180.FIN



CHAPTER III.D                                            23/IV/92
PUBLISHED VERSION

EXTERNAL COORDINATION FOR HEALTH AND SOCIAL DEVELOPMENT


     During 1991 PAHO/WHO continued strengthening its relations
with other international multilateral, bilateral, and
nongovernmental organizations in order to promote the policies,
strategies, and programs of the Organization framed in the
priorities established for the 1991-1994 quadrennium, for which
it conducted both general and specific activities.  The former
were basically promotional in nature and were aimed at ensuring
that PAHO/WHO supported its presence and prestige as an
international technical cooperation agency in the field of
health.
     The priorities of the Organization were discussed with the
World Bank, specific matters such as the epidemic of cholera were
discussed, collaboration between the two agencies was facilitated
in projects which the Bank finances or is going to finance in the
countries, and a dialogue was initiated on the initiative of a
Regional Plan of Investments in Environment and Health for Latin
America.
     Discussions took place on interinstitutional collaboration,
support for subregional initiatives and specific projects with
the Government of Germany [Ministry of Economic Cooperation, Bank
of Credit and Reconstruction, and German Agency for Technical
Cooperation (GTZ)], European Economic Community, UNDP, UNFPA, and
bilateral agencies such as the Finnish Agency of International
Development (FINIDA), Danish Agency for International Development
(DANIDA), Norwegian Agency for International Development (NORAD),
and the Agency of Cooperation of Belgium.
     Interinstitutional meetings to follow up the agreements and
commitments resulting from the World Children's Summit were
coordinated with UNICEF.
     An international meeting of donors was organized to prepare
the emergency phase of the campaign against cholera; the meeting
took place at Washington, D.C., in December.  The III Madrid
Conference was held with the collaboration of the Government of
Spain to mobilize resources to support the second stage of the
Health Initiative of Central America.  Formulation and execution
of the "Convergence" project, which will culminate in a regional
meeting to be held in 1992 in order to initiate negotiations
among countries on health technology, was initiated with the
SELA, UNDP, and CEPALC.
     The Organization also carried out activities to disseminate
among staff members of the countries and PAHO/WHO the potential
for external financing for health and mechanisms to mobilize it. 
In addition, it strengthened the skill of its technical units and
PAHO/WHO Country Representatives' offices in the countries, as
well as of the Ministries of Health, in negotiating external
assistance and disseminated information on trends in official
assistance for development to increase the flow of financial
resources for priority health projects of the countries and the
Organization.
     The Third Meeting of Consultation of PAHO/WHO with the
Nordic countries was held at Oslo in November.  The Government of
Italy and PAHO/WHO signed a collaboration agreement which
includes support for Cooperation for Health in the Caribbean, the
Health, Environment, and Campaign Against Poverty project, and
care for refugees in Central America.  In addition, the
Government of Spain continued collaborating in carrying out
regional and subregional technical cooperation projects in
Central America and the Andean Subregion.
     Extrabudgetary resources for special initiatives and
specific programs rose to $US145 million for the 1990-1991 budget
period, which equals 36.3% of the biennial budget and 52% of the
total budget.
     During 1991 the part corresponding to the third and last
year of the agreement between IDB and PAHO/WHO for studies of
investment proposals in the fields of health services and
environmental sanitation was carried out, which resulted in IDB
financing of projects amounting to $US750 million.
     In 1990, PAHO/WHO expanded its activities with
nongovernmental agencies to mobilize resources.  Directives for
PAHO/WHO activities in this new field of cooperation in health
were established in December 1990, and since then an information
system which collects data from approximately 300 nongovernmental
agencies has been active.  Based on the information compiled, and
in collaboration with the PAHO/WHO Country Representatives'
offices in the countries and some of the technical programs,
dialogue was promoted between nongovernmental agencies and the
governments in Chile, the Dominican Republic, Mexico, Peru, and
Trinidad and Tobago with positive results.
     The Government of Holland approved a project presented by
PAHO/WHO on collaboration between governments and nongovernmental
agencies which consists of a proposal to establish new precedents
in the field of health care in the Americas and will mobilize
$US1.3 million.  The project, which will enter full execution in
1992 and will benefit Chile, Ecuador, Guatemala, and Haiti, is
already under way in Chile and Ecuador.
     PAHO/WHO reviewed some 150 projects drawn up by
nongovernmental agencies which have been presented or are going
to be presented to various sources of financing.  Finally, it is
noteworthy that nongovernmental agencies financed part of
PAHO/WHO's activities to prevent AIDS in the Region.
E0181.FIN



PUBLISHED VERSION                                        17/IV/92

CUBA



     During the year the difficulties, mainly economic in nature,
which have arisen since the end of 1989 and are determined
essentially by the gradual disappearance of European socialism
and the serious limitations on commercial, scientific, and
technical exchange imposed by the blockade of the island
worsened.
     The evolution of the health status of the country's
population in recent decades, according to mortality and
morbidity indicators, reflects an increase in life expectancy, an
accentuated reduction in deaths at early ages of life, and a
trend toward an increase in chronic noncommunicable diseases and
violent deaths at the same time that communicable diseases,
mainly those preventable by vaccination, are decreasing.  Indeed,
the changes in health status reflect the modifications that have
taken place in the living conditions of the population in the
last 30 years, determined by a clear policy of eliminating the
social inequalities which are customary in developing countries. 
Significant achievements in education, health services, social
security, work, sports, social infrastructure, development of
science and technology, as well as in other social spheres, have
in turn resulted in demographic changes which are associated with
those which have taken place in the health situation.
     As a result of the efforts carried out despite the fact that
Cuba is a developing country, there has been total coverage of
the population with health services of high quality since the
1960s.  A constant increase in access to services and in the
quality of care has been achieved, as has the mass application of
preventive measures such as vaccination and early detection of
diseases, and advanced technologies have been introduced which
are within the reach of the entire population.
     The introduction of the "Family Physician and Nurse Model"
as the basic element in the national health system is one of the
most important facts which have occurred in Cuban public health
in recent years.  During 1991 the model, through which an attempt
is made to guarantee comprehensive care to the population under
the responsibility of each physician and nurse team which, in
addition to giving priority to health promotion and prevention
activities, carries out curative and rehabilitation work,
continued to be extended to the entire country.  Such teams
operate in both the community and in schools, kindergartens,
industries, and other labor centers.  At the end of the year, 70%
of the population of the country was served by the program.
     The priority assigned to health has favored scientific and
technical development in fields related to it, and there have
been important technological achievements such as the production
of various vaccines, drugs, and high-technology medical
equipment.  This is one of the clearest results of the investment
in health which the country has carried out in the last 30 years,
and indeed has made the medical-pharmaceutical industry and
biotechnology sector a productive branch of great importance and
one which, together with the food program and tourism,
constitutes the triad of strategic priorities for development in
coming years.  The conversion of the health sector into a
"productive sphere" also occurs in the marketing of services in
different specialties through "health tourism," the construction
of hospitals, and maintenance of installations and medical
equipment, among other possibilities.
     For Cuba, which has begun the 1990s in what has been called
a "special period in time of peace," the most important challenge
in health consists of finding the route for continuing
development and improving the living conditions and health of the
population by the year 2000.
     For PAHO/WHO's technical cooperation program in the country,
"health in development" was the principal strategic orientation
throughout 1991; this means an on-going search for improvement in
the living conditions and health of the population, which are
still unfavorable.  Within this strategy, PAHO/WHO carried out
important efforts to develop municipal health systems, or local
health systems.  Strengthening capacity for analyzing the health
situation, programming, and strategic administration, including
the components of community participation and intersectorality,
received special attention because all the cooperation programs
which the Organization provides flow together in greater or
lesser degree at that level and in those areas of action.
     The promotion of health, in an intersectoral spirit and with
the positive connotation of the Charter of Ottawa, emerged as a
priority line of cooperation in the conditions of the country. 
To conduct the services in the framework of local health systems
and health promotion, the development of the epidemiological
approach, analysis of the relationships between the economy and
health, and focusing activities on high-risk groups were
identified as priority aspects.  Identification of such groups
will permit intensification of interventions in the most
vulnerable groups, with a consequent gain in efficiency in the
utilization of resources at the same time that the effectiveness
of the activities is increased.
     PAHO/WHO's contribution in information management had a
clearly strategic character, taking into account the high
priority that the authorities of the country give to developing
science and technology.
     Intercountry technical cooperation with Belize, Bolivia, the
Dominican Republic, Ecuador, Guyana, Nicaragua was intense during
1991 in training of human resources, medical equipment
maintenance, diagnostic techniques, and tropical disease control,
among other areas.
     The impetus given to the utilization of social communication
in health and to the integration of women in health and
development also formed part of the priority activities which
were carried out in the framework of technical cooperation.
     In November the process of joint evaluation of the
Organization's technical cooperation with Cuba during 1988-1991
culminated in a meeting in which 80 specialists from the Ministry
of Public Health and PAHO/WHO staff members participated.  Among
the most significant recommendations for future cooperation, the
need to continue working toward developing comprehensive
approaches to health problems appears with special strength.  In
view of its importance for national health development, the
following areas of cooperation were selected:  development of the
epidemiological approach, strengthening of local health systems
and the family doctor strategy, enhancement of health personnel,
development of science and technology, the economy and health,
mobilization of resources, and multicountry technical
cooperation.  At the end of the evaluation meeting, the new
headquarters of the PAHO/WHO Representative in Cuba was
inaugurated. 
     During 1991 several national and international meetings of
great importance were held in the country, among them:  a seminar
on care of patients in the third world with renal insufficiency;
an international course on the epidemiology of cancer; an
international seminar on primary health care, the family
physician, health for all, and local health systems; a conference
on Latin American universities and the health of the population;
a Latin American congress on stomatology and a meeting on
technology and intercountry collaboration sponsored by the Latin
American Dental Federation and PAHO/WHO; an international seminar
on epizootiologic surveillance and simulation of exotic diseases;
the First Latin American Conference on Complex National Referral
Hospitals; a meeting on the management of corpses in disasters;
and the V Congress of the Cuban Society of Nursing.
E0182.FIN



PUBLISHED VERSION                                        16/IV/92

MEXICO


     During 1991 the economy of the country showed notable
advances compared to 1990.  There was greater productive growth,
slowing in the inflation rate, and improvement in the public
accounts.  This climate of optimism promoted private investment
and resulted in considerable external capital revenue, which made
it possible to finance a large negative balance in the current
balance of payments account.  In addition, within the policy of
external liberalization, negotiations toward signing a free trade
agreement with the United States of America and Canada
progressed, a commercial agreement was signed with Chile, and the
"Group of the Three" was economically integrated with Colombia
and Venezuela.  During 1991 the Government countersigned the
programming priorities of the 1989-1994 National Development
Plan, which fulfills the constitutional mandate that imposes
democratic planning of national development on the Government of
the Republic.

     The health activities carried out in 1991 corresponded to
the National Health Program, which details the objectives,
policies, strategies, programs, and health projects for 1990-
1994 and is part of the National Development Plan.  The Program
establishes specific policies on promoting the "culture of
health"; universal access to health services with equity and
quality; disease and accident prevention and control; protection
of the environment and basic sanitation; regulation of population
growth, and stimulation of social welfare.  The central
strategies of the Program include functional coordination of the
National Health System, strengthening of local health systems,
decentralization of the health services, administrative
modernization and simplification, intersectoral coordination, and
community participation.

     Given the growing development of tourism, interest in the
subject of "tourism and health" has increased since November
1990, and specific action projects congruent with the priorities
of the National Health Program were prepared.  Mexico is the seat
of numerous international scientific and world meetings in the
field of health.  The World Mental Health Congress, sponsored by
PAHO/WHO, which had more than 5,000 participants, took place in
1991.
     PAHO/WHO cooperation during the year was based on the
National Health Program and emphasized the strategic orientations
and programming priorities for the Organization during the 1991-
1994 quadrennium.  Thus, the Organization took an active position
on health in development, especially promotion of local
programming, utilization of experience from the national
solidarity program in aspects of critical poverty, identification
of health problems which may result from the free trade treaty
with Canada and the United States, discussion of health and
development with other international organizations and the policy
sector, mobilization of bilateral and multilateral resources, and
promotion of activities related to health and tourism. 
Concerning reorganization of the health sector, PAHO/WHO
collaborated in strengthening 100 sanitary jurisdictions, instead
of the 32 planned, and in interinstitutional coordination between
the Ministry of Health and social security institutions to carry
out priority national programs and strengthen local health
systems.  Because of financing from the World Bank and IDB, it
also participated in activities oriented to a great extent toward
the social sector through the National Solidarity Program and,
within that Program, toward strengthening the health
infrastructure, improving sanitary conditions, and preventive
activities at the local level.
     Concerning improvement of the population's health
conditions, PAHO/WHO cooperated in disease prevention and control
activities directed toward groups at greatest risk:  children,
women of reproductive age, and inhabitants of marginal areas, in
addition to vulnerable groups in the population in general.  In
addition, it supported educational activities to promote and care
for the health of the population, particularly of vulnerable
groups, as well as activities to train and evaluate personnel and
health promotion programs at the national and regional levels. 
Educational material was disseminated on breast-feeding,
diarrheal disease control, and the health of adolescents, and
informative material was provided to the national authorities to
be transmitted by radio, television, and the press to educate the
public on subjects and special events related to health.
     The activities of the program to integrate women, health,
and development were expanded to all the federative entities of
the country.  PAHO/WHO cooperated in preparing the book  Health
of adolescent, adult, and elderly women, which contains
documentary and statistical information on the subject, and
collaborated in organizing a national workshop to prepare
strategies oriented to favor improvement in the health conditions
of working women.
     With regard to information management, PAHO/WHO cooperated
in carrying out research programs at the state level; preparation
of protocols on several health subjects, and holding a meeting on
scientific production in health, the second national congress on
health research, and an international workshop on the methodology
of research on health services.  In addition it collaborated in
preparing and publishing the books Quality assurance in food
microbiology laboratories and Irradiation of food.
     In regard to technical cooperation among countries, the
Trinational Border Health Association of Mexico, Belize, and
Guatemala, which implemented a plan approved at the inaugural
meeting, was consolidated and legalized.   Activities along the
border between Mexico and the United States were coordinated
concerning chronic disease prevention and control, promotion of
maternal and child health, veterinary public health, and health
statistics; technical meetings on cooperation and discussion of
health and tourism were also sponsored.
     With regard to programming priorities for the development of
infrastructure, PAHO/WHO cooperated with the national authorities
in an analysis of information on causes of death by age groups
and sex; in the preparation of a monthly newsletter to
disseminate epidemiological information to the federative
entities, and in negotiations to designate the Mexican Center for
the Classification of Diseases as a WHO Collaborating Center for
the International Classification of Diseases and epidemiological
information.  It effectively articulated the information produced
by the different statistical and epidemiological areas of the
National Health System.  It contributed to strengthening the
coordinated intersectoral activity of the National Health System
with the education, urban development and ecology, and
agriculture and water resources sectors, and sponsored studies
and interinstitutional technical meetings to analyze the
financing of the health sector.  PAHO/WHO also cooperated in
strengthening the sanitary jurisdictions, the state system of
basic information, and the simplified epidemiological
surveillance system; it sponsored an international seminar-
workshop on evaluation of the experiences in local health
systems, and cooperated with the Congress of Folkloric and
Traditional Medicine.  In addition it provided support for the
technological development of the pharmaceutical industry and the
training of personnel belonging to this branch of activities. 
National chiefs in this field participated in international
meetings on medical technology, and biotechnology in Canada,
Uruguay and Venezuela sponsored by PAHO/PAHO.
     Concerning manpower development, the Organization supported
implementation of a program to train intermediate-level
technicians in community health and definition of a nursing
project with Japan for the creation of a center for nurse
training; it formulated a research protocol on patterns of
utilization of human resources, and it collaborated in an
international course on planning given by the School of Public
Health.  The PAHO/WHO Representative's office in the country
reopened its technical information center, which will have a
network of subcenters in the principal institutions of the
country training health manpower.  The institutions of higher
education, research, and specialized health services of Mexico
annually receive a large number of health professionals from
Latin American countries who carry out graduate studies or make
observation visits to operational programs of the National Health
System; during 1991, 53 fellows and 18 participants on
observation visits financed by PAHO/WHO were received.
     In health and environment, the Organization promoted
measures to prevent and control environmental conditions and
factors affecting health in collaboration with the Secretariats
of Urban Development and Ecology and of Agriculture and Water
Resources, and numerous national institutions.  In water and
sanitation, activities were oriented toward strengthening and
extending drinking water supply and excreta and wastewater
disposal services to achieve and maintain their coverage and
quality.  There was collaboration in human health protection
against the adverse effects of environmental pollution, both
biological and chemical, in sanitary provision of urban and rural
solid wastes, and in the safe elimination of toxic wastes and
special solid wastes.  The priorities initially planned were
strengthened through the creation, by presidential decision, of
the national "clean water" and "prevention and control of
cholera" programs.
     In the food and nutrition program, PAHO/WHO cooperated with
national authorities in intersectoral activities aimed at
monitoring the quality and hygiene of tourist establishments; in
a study to find a way to control and establish standards for
street food sales in the Federal District to prevent cholera, and
in carrying out a diagnosis of the food protection situation as
reference for decision-making and support of epidemiological
surveillance of food-borne diseases.
     The Organization also cooperated in carrying out evaluating
chronic disease programs in different states of the country and
in manpower training for information management.  New programs
such as the health of the elderly were implemented, support was
given for strengthening mental health, and the initiation of a
proposal for research and intervention in the chronic diseases in
the state of Zacatecas was promoted.
     Concerning the control and elimination of avoidable
diseases, the Organization collaborated with the National Malaria
Control Program, which succeeded in reducing the number of cases
through intensive simultaneous activities, although a major
Plasmodium falciparum outbreak in the state of Tabasco occurred
in 1991.  The Organization contributed to the training of 45
chiefs of jurisdictions (instead of the 32 planned) in the
control of sexual transmitted diseases, and collaborated in
activities to control leprosy, tuberculosis, and diarrheal
diseases.
     During 1991 no case of poliomyelitis was confirmed, thanks
to intensive vaccination campaigns.  PAHO/WHO cooperated in those
campaigns, sponsored a course for auxiliary vaccinators, and
collaborated in maintenance of the cold chain and in specific
vaccination operations.  To eliminate neonatal tetanus in 97
high-risk municipios, all the women in them of reproductive age
were vaccinated.  For epidemiological surveillance
interinstitutional meetings were supported to exchange
information among the National Council on Vaccination, the Bureau
of Epidemiology, and governmental, nongovernmental, and
international institutions.  PAHO/WHO supported the National
Public Health Laboratory in processing specimens from cases of
acute flaccid paralysis.  At the end of 1991 the Ministry of
Health proposed a strategy to eliminate measles from the country.
     Technical cooperation given to the Ministries of Health and
of Agriculture and Water Resources to control zoonoses was
directed toward strengthening the national program to control
rabies and implement or restructure the control of other zoonotic
diseases such as brucellosis and the taeniasis/cysticercosis
complex.  Measures were sought to integrate control,
characterization danger zones, and facilitate the epidemiological
surveillance and information system through intra- and
interinstitutional cooperation.  For the second year a national
canine rabies vaccination week was carried out with satisfactory
results.  In addition there was cooperation with the Department
of Livestock Raising of the Secretariat of Agriculture and Water
Resources in an animal health feasibility study.
     Concerning maternal and child health, to fulfill the
commitments contracted in 1990 at the Children's Summit meeting
of the United Nations, PAHO/WHO helped design a maternal and
child health survey, train those responsible for care in the
services, promote breast-feeding, the application of perinatal
clinical histories, diarrheal disease and acute respiratory
infection control, and follow-up of the family planning project
financed by UNFPA.  With financing from the Rockefeller
Foundation and PAHO/WHO, a Latin American workshop on maternal
and child health was held.
     With PAHO/WHO collaboration, an intersectoral meeting was
held to program activities relating to "1992:  The Year of
Workers' Health," in which the Secretariat of Labor and
representatives from national organizations of workers and all
the institutions that make up the health sector participated.
     PAHO/WHO cooperated with the Centers for Juvenile
Integration devoted to caring for young drug addicts in
disseminating educational material and searching for sources of
financing for research in this field.
     In 1991 the anti-AIDS program received $US1,102,478 from
extrabudgetary funds mobilized by PAHO/WHO for epidemiological
surveillance of HIV infections and control of the disease.  The
Organization cooperated in establishing AIDS information centers,
training of professional and volunteer personnel, carrying out
public information campaigns and offering local courses in the
interior of the country, and mobilizing resources to strengthen
capacity to conduct AIDS research and evaluate the national
program against this disease.  Since November PAHO/WHO has had a
consultant who is exclusively devoted to the follow-up of this
program.



Provisional Agenda Item 6.2               CE109/22 (Eng.)
10 May 1992
ORIGINAL:  SPANISH-
ENGLISH

STATEMENT BY THE REPRESENTATIVE OF THE PAHO/WHO STAFF
ASSOCIATION

     Attached is the Staff Association presentation to the Executive Committee on staff
matters.  The issues discussed include:

   1.   The Organization and International Commitments

   2.   New Headquarters Building

   3.   Contracts
   
   4.   Staff-Management Relations 

   5.   Field Duty Stations

   6.   Women's Issues 

   7.   Post Reclassification System 

   8.   Selection Procedures

   9.   Job Security

   10.  Meetings of the Federation of International Civil Servants Associations
        (FICSA) and WHO Staff Associations

CE109/22 (Esp.)



STATEMENT BY THE REPRESENTATIVE OF THE PAHO/WHO STAFF
ASSOCIATION

1. The Organization and International Commitments

   The Organization, as the Regional Office of the World Health Organization,
is linked through WHO to the United Nations system.  The United Nations has
established and determined a series of mechanisms, procedures, and committees
that regulate staff matters, as well as staff rights and responsibilities.

   Through the International Civil Service Commission (ICSC), proposals are
made to for changes in the terms and conditions of service within the UN Common
System.  Currently proposals are being implemented that will prove detrimental to
the working conditions of staff members in the Common System.  These include:

   -  Changes in pensionable remuneration for general service staff, with a
      decrease in their pension benefits, which the Staff Association considers
      unwarranted and unacceptable;

   -  Changes in the methodology for conducting the general services salary
      survey. 

   Application of the Flemming Principle to determine changes on the basis of
the best prevailing conditions is indispensable if organizations are to recruit and
retain qualified personnel.

   Although in some countries a conflict is created between the salary scales for
general service and professional staff, salaries for these two categories are
calculated on the basis of different principles (the Flemming Principle for general
service salaries and the Noblemaire Principle for professional salaries). 
Professional salaries have been frozen since 1985, the result being that purchasing
power has been eroded by 30% relative to market levels.
   
   The PAHO/WHO Staff Association and the other staff associations in the
United Nations system oppose the policy of freezing professional salaries.  It does
not behoove the organizations to implement this type of policy in their quest to
reduce their budgets in times of severe economic crisis.
   
   The development of an austerity program based on clear and reasonable
criteria will allow the organizations and staff associations to work together to find
the least painful solution to the crisis.

  The General Assembly of the Washington Local Organization discussed the
construction of a new Headquarters building and adopted a resolution requesting
the Director to include staff representatives, appointed by the Washington Local
Organization, in all the stages of the planning, design, and construction of the new
Headquarters building (See Annex I).



3. Contracts

   The XI Staff Committee, at its Annual Meeting, agreed to once again bring this
matter before the Executive Committee of PAHO.  The problems surrounding local
contracts are the following:

   1. Lack of appropriate accident insurance.

   2. Lack of health insurance coverage.
   
   3. Lack of participation in a retirement fund.
   
   4. System of discriminatory employment conditions.

   5. Effect of the reduction in permanent posts on the pension and retirement
      fund and on health insurance.  PAHO should carefully review the different
      types of contract.  The practice of hiring personnel without offering
      sufficiently attractive benefits runs counter to the principal objective of
      international civil service, which is to attract the best and most qualified
      personnel to carry out the mission of promoting development and
      improving the living conditions of people in the member countries.


4. Staff-Management Relations

   Both the XXXV Meeting of the Executive Committee of PAHO, held in June
1991, and the XI Staff Committee affirmed the need to reestablish dialogue and
communication between the Staff Association and the Administration.  In February
of this year a meeting was held with the Director in fulfillment of the
resolutions/recommendations agreed upon.  In accordance with the foregoing,
participation by the Staff Association and the Administration in resolving
differences over the application of staff rules and procedures should take place in
an atmosphere of mutual respect and professionalism for the benefit of both the
Organization and its staff (the Organization's most valuable resource for carrying
out its mission).

   The Staff Association appreciates the fact that an independent program has
been made available to provide staff members with staff assistance services.  The
Staff Association will participate actively in the development of this program,
which will undoubtedly help individuals to resolve problems of a social nature, as
well as problems of adaptation and integration experienced by a staff member or
his/her dependents in connection with the staff member's joining the Organization.

   There are a number of issues to be addressed in connection with staff-
management relations.  These include:  post reclassification, staff selection, post
descriptions based on personal abilities rather than on the needs of the unit or
program, and staff intimidation.  The Staff Association recognizes the need to
create a mechanism or body capable of mediating and providing guidance for staff
members affected by these issues.


5. Field Duty Stations

   The basic problems continue to be the correct and expeditious implementation
of the results of salary surveys, post adjustments, and the payment of pensions to
retirees in countries where the inflationary indexes fluctuate frequently and where
the purchasing power of the local currency is being continually eroded.  The Staff
Association requests the Office of Personnel to participate jointly with the Office
of UDI in order to facilitate prompt implementation of changes in remuneration
before these changes lose their purchasing power. The reclassification-unification
on the basis of the seven-grade system is also one of the largest sources of
problems and discrepancies in field duty stations.  Staff dissatisfaction and
demoralization over this issue have led to several appeal efforts, including a
suggestion by one of the duty stations for a mass appeal.  It is for this and other
reasons relating to reclassification that the Staff Association has requested the
reinstatement of the Joint Administration/Staff Committee on Classification.

   In April 1991, the Subcommittee on Planning and Programming approved a
document containing a section on "The Deconcentration of Some Regional
Activities and Rescaling of the Centers," which was discussed by the XI Staff
Committee.  The implications of this for staff were examined and a
recommendation was made "that the interest of regional and Center staff be taken
fully into account in the development of this policy" (Annex II).



7. System of Post Reclassification

   The Staff Association is optimistic about the future reestablishment of the Joint
Administration/Staff Committee on Classification.  Bearing in mind the delicate
and complex task to be carried out by this Committee, the Staff Association
requests the Administration to utilize the services of a UN expert on post
reclassification to develop a program of training/orientation for the members of the
Committee.

   The Staff Association expects that the Joint Administration/Staff Committee
will help the Administration enormously in preventing unnecessary conflicts
relating to the reclassification of posts.  It is our desire that this Committee be
reestablished as soon as possible and that the rules and procedures for the
classification and review of posts be updated without delay.


8. Selection Procedures

   The XI Staff Committee discussed the selection process, observing that the
present scheme for filling regular posts within the Organization permits the
appointment of external candidates over qualified internal candidates, which leads
to staff dissatisfaction and demoralization and affects productivity.  The Staff
Association therefore requests the Executive Committee of PAHO to recommend
that the Administration monitor compliance with the rules governing the selection
process.


10.Meetings of FICSA and WHO Staff Associations
   
   Meeting of FICSA
   
The main issues discussed by the FICSA Council were:

   -  General Service Issues 
   
   Crucial issues are at stake for general service staff in 1992, particularly since
the International Civil Service Commission (ICSC) is reviewing the methodology
used to determine the salaries and pensions of the general service categories.  This
led the Federation to create a working group to study the proposals, with particular
attention to the technical and political aspects of the review, so as to safeguard the
conditions of service and the interests of general service staff.
   
   - Conditions of Employment in the Field
   
   The main issues discussed were the security measures implemented by the ad
hoc interagency commission and the problem of lack of job security for personnel
hired on short-term contracts in the field offices.
   
   - Professional Salaries and Remuneration
   
   The members of the committee on professional salaries and remuneration
firmly maintain that the loss in purchasing power of professional salaries must be
recovered, and they strongly oppose any freezing of salaries.
   
   - Staff-Management Relations
   
   Several members of the Federation reported that since the last Council meeting
the problems of previous years have diminished and favorable practices have been
instituted.  Several associations have had the opportunity to approach the Member
Governments, which have shown interest in staff issues. Some of the Executive
Directors have met regularly with staff, and there has been better response and
more information about staff problems.  Staff representatives have even been
invited to participate in the executive meetings of the Administration and have
been asked to help draft changes in personnel policies. 
   
   Meeting of WHO Staff Associations
   
   The meeting of the Regional Associations with the Association at
Headquarters in Geneva was held in February 1992.  The main issues discussed at
that meeting were:
   
   - Budget Reductions
   
   Concern was expressed about the impact of budget cuts on the financial
situation of WHO and its Regional Offices. Mr. Aitken (ADG) reported that the
reduction of the operating budget would result in certain necessary measures that
would affect certain posts within the ILO and several Regional Offices.  It was
reported that one Regional Office had already taken steps to reduce posts.  Among
the Regions immediately affected were the European and African Regions.
   
   The approximate projected deficit at the level of the ILO is $20 million, $9
million of which will be applied this year, with the remaining $11 million to be
applied subsequently either by freezing posts, some at the global level, or reducing
activities during 1992-1993, etc.
   
   The deterioration in dollar exchange rates and the failure by approximately 50
member countries to meet their quota obligations, combined with uncertainty over
payment by the former Soviet bloc, have been the primary causes of the crisis
situation now facing the Organization.  Preventive measures will undoubtedly be
taken, and these should include a contingency plan to be implemented
immediately, rather than forcible measures which would have more serious
repercussions.  The Staff Association requests that it be included in the discussions
on any substantial reduction in the budget before a final decision is made.
   
   Other matters discussed included:  reduction in force, personnel training, post
adjustments, and working conditions for professional and general service
categories.
E0187.FIN



PUBLISHED VERSION                                        24/IV/92

VENEZUELA


     Since 1989 the country has carried out a policy of promoting
non-oil exports, import substitution, saving public sector funds,
and utilization of external financing that has brought about
economic recovery, but this economic growth has increased social
inequality and caused an increase in poverty.  To mitigate this
situation, the Government initiated a policy of direct subsidies
through social programs.
     In the field of health, the Ministry of Health and Social
Welfare has established a System National Health Law and a
Jurisdiction Decentralization and Transfer Law, as well as
policies which promote upgrading of a basic sanitation system,
health education, strengthening of the primary care and hospital
system, malaria control, and labor peace.
     These laws guided PAHO/WHO's technical cooperation during
1991, which established a global strategy with four objectives: 
1) support for decentralization and strengthening of local health
systems by integrating technical cooperation adapted to the local
epidemiological profile; 2) collaboration with the central level
of the Ministry in formulating plans, policies, and standards to
carry out the process of integration; 3) technical cooperation
among countries in executing common plans, and 4) cooperation
with the agriculture sector by establishing a program to
eliminate foot-and-mouth disease and control paralytic rabies and
other zoonoses, with full social participation.
     The process of strengthening of local health systems, known
as "sanitary districts," which is carried out with the
Organization's technical cooperation, became the priority policy
of the Ministry in October to promote adoption of the primary
health care strategy and establish an interprogram approach to
solving problems at the local level.  During 1991 six sanitary
districts were created in different states, and at the end of the
year the country had a total of 15.  The "health in development"
component was also integrated into the process since the
organization of microbusinesses in local health systems is
promoted.  The development of pharmaceutical services in the
sanitary districts has not advanced as had been expected,
however, because of difficulties in operating capacity and
promotion at the central level.
     The dynamics of the projects and programs linked to manpower
development, which have PAHO/WHO's cooperation, resulted in the
organization of an interprogram group to promote
interinstitutional and intersectoral action, whose strategy
consists of making available information on institutions,
experts, and methodological proposals which can be utilized in
solving local problems to the chiefs of districts.  To develop
the epidemiological surveillance component in local health
services, the Organization collaborated with the national
authorities to increase the capacity of the senior personnel in
this field, which will make it possible to improve the use of
epidemiological surveillance and identify and solve problems
affecting the most vulnerable groups.
     In regard to adult health, activities were oriented toward
the local level.  Among this area's achievements was the
establishment of a program of integrated interventions in
promoting health and changing lifestyles to prevent chronic
diseases in the local health system of District 5 in Caracas, and
the preparation of a five-year plan of action to control cancer
of the cervix in the Chivacoa district of Yaracuy State.  A
national mental health plan was prepared and, following its
guidelines, a program in this field and another on gerontology
were included in the Quíbor sanitary district.  The restructuring
of psychiatric care also continued at the national level, and a
rehabilitation program was established in the Colón district
sanitary.  At the request of the Ministry of Health and Social
Welfare, a diagnosis was made of the traffic in and consumption
of psychoactive substances, and elderly persons were trained in
hydroponic cropping so that they can perform productive tasks in
their spare time.
     A new activity was the establishment of a social
communication program, coordinated by a journalist contracted
locally, in which all the consultants of the PAHO/WHO
Representative's office in the country participate.  This
program, mostly oriented toward the marginal urban population,
has national coverage and is disseminated through the social
communications media (press, radio, and television).
     In regard to nutrition, collaboration continued in
strengthening the Food and Nutrition Surveillance System (FNSS),
for which a manual on the computer program that will be utilized
at the district level was prepared.
     In the field of communicable disease prevention and control,
the Organization cooperated in preparing an integrated endemic
disease control project based on epidemiological stratification
which will be presented to the World Bank for financing.  The
schistosomiasis control program was strengthened through
serological diagnosis, and studies were sponsored on controlling
Aedes aegypti with community participation.  These studies
demonstrated that in most cases the leading cause of the high
index of Aedes aegypti infestation in dwellings was the presence
of deposits of water for consumption.
     The formulation of a project was initiated to promote
rehabilitation of leprosy patients and to link the programs to
control this disease with those dealing with tuberculosis.
     The III Pan American Teleconference on AIDS, which was held
in Caracas in March, was one of the most important achievements
in the national campaign against AIDS.  Other significant
activities carried out during the year were the incorporation of
educational programs to prevent and control disease in the
schools, the execution of national mass education campaigns
directed toward high-risk groups, the development of legal
instruments, and the improvement of a system of epidemiological
surveillance.
     With regard to environmental health, the existing
expectation of a cholera epidemic made it possible to improve the
system for surveillance of efficient water chlorination.
     Concerning growth, development, and human reproduction, the
Organization continued promoting the utilization of perinatal
clinical histories to determine the groups at greatest risk to
solve the problems they identified.  The diarrheal disease
control program established community oral rehydration units in
almost all the states of the country and continued training
personnel at the local level in controlling and preventing acute
respiratory infections and diarrheal diseases, breast-feeding,
and adolescent care standards.  There are managerial deficiencies
in the program, however, which did not allow their
decentralization and effective presence in the sanitary
districts.
     The most important achievements concerning immunization were
the absence of cases caused by wild poliovirus (after March
1989); the control and near eradication of neonatal tetanus; a
reduction in morbidity and mortality due to measles and whooping
cough, and the absence of confirmed cases of diphtheria for two
years.  In addition, surveillance of active case-finding of acute
flaccid paralysis and neonatal tetanus was improved, and in some
states the epidemiological investigation of measles was
initiated.
     Concerning veterinary public health, work was done with the
national program to eliminate urban rabies in the endemic areas
of Apure, Mérida, Táchira, and Zulia States, and preparation was
initiated of a program to eradicate bovine tuberculosis, which
together with those on paralytic rabies, brucellosis, and foot-
and-mouth disease will be presented to IDB for financing. 
Support was also provided for an epidemiological study of
leptospirosis in febrile patients, and at the end of the year a
test was made of the epidemiological surveillance system in
slaughterhouses. PAHO/WHO also continued sponsoring specialty and
master's degree courses in preventive veterinary medicine.
     Because of the cholera epidemic, there was collaboration
with the national authorities in making a diagnosis of the
hygienic-sanitary and food protection situation, studies to
analyze risks and critical points in controlling fresh fish and
cheeses were concluded, and a study was sponsored to characterize
morbidity and mortality due to diarrheal diseases, by sanitary
district, in Táchira State which will serve as a model for
guiding epidemiological surveillance of suspected cases of
cholera.  PAHO/WHO also cooperated in investigating outbreaks of
paralyzing shellfish intoxication and ciguatera in the
northeastern part of the country.
     In regard to the activities on women, health, and
development, a diagnosis of the mental health of women in
Venezuela was made, and two priority problems were selected: 
violence and early pregnancy.  A course was also given on
designing and preparing projects in the program on development
and promotion of women, and the strengthening of centers for
comprehensive care of women continued as part of the development
of the sanitary districts.
     With respect to technical cooperation between countries,
Venezuela, with the support of the Organization, expanded the
activities in a project on technology in dental biological
materials between Banta, Caracas, and Buenos Aires; it initiated
cooperation activities with Colombia, Cuba, and Ecuador, and it
began a project to strengthen and develop epidemiology in
marginal and indigenous areas along the Venezuelan-Colombian
border.






Eighteenth Meeting
Washington, D.C., 8-9 April 1992


SPP18/FR (Eng.)
9 April 1992
ORIGINAL:  SPANISH-ENGLISH









F I N A L   R E P O R T










SPP18/FR (Eng.)


FINAL REPORT


The Eighteenth Meeting of the Subcommittee on Planning and Programming
of the Executive Committee was held at the Headquarters of the Pan American
Health Organization in Washington, D.C., on 8 and 9 April 1992.

The following members of the Subcommittee, elected by the Executive
Committee, were present:  Barbados, Brazil, Cuba, and the United States of
America.  Also taking part, at the invitation of the Director of the Bureau, were
representatives from Argentina, Canada, and Mexico.


OPENING OF THE MEETING

Dr. Carlyle Guerra de Macedo, Director, PASB, opened the meeting and
welcomed the representatives.


OFFICERS

The Officers of the Subcommittee were as follows: 

Chairman:                                                     Mr.  Branford M. Taitt                                                          Barbados

Vice Chairman:                                                Mr.  Neil A. Boyer                                                              United States
of America

Rapporteur:                                                   Dr.  Ramón Prado Peraza                                                         Cuba

Secretary ex officio:                                         Dr.  Carlyle Guerra de Macedo                                                   Director, PASB

Technical Secretary:                                          Mr.  Mark Schneider                                                             Acting Chief,
DAP/PASB
AGENDA

     In accordance with Article 10 of the Rules of Procedure, the Subcommittee
adopted the following agenda:

     1.       Opening of the Meeting
     2.       Election of the Chairman, Vice Chairman, and Rapporteur
     3.       Adoption of the Agenda
     4.       Provisional Draft of the Program Budget of the World Health Organization
for the Region of the Americas for the Biennium 1994-1995
     5.       Debt Conversion for Health
     6.       Evaluation in the Pan American Health Organization
     7.       Regional Plan for Investment in Health and the Environment 
     8.       Health of Indigenous Peoples
     9.       Democracy and Health
10. Other Matters


PRESENTATIONS AND CONCLUSIONS

     A summary of the discussions and conclusions on each item follows:

Item 4:                                                      Provisional Draft of the Program Budget of the World
Health Organization for the Region of the Americas for
the Biennium 1994-1995

     Mr. Milam, Chief, Budget Office, presented the item and summarized the
provisional budget proposal that will be submitted in June to the Executive
Committee and in September to the Directing Council, as the Regional Committee
for the Americas of the World Health Organization.  The Directing Council will
then make a final recommendation to the Director-General of WHO.  The global
proposal of WHO will be presented to the WHO Executive Board in January 1993
and to the World Health Assembly in May 1993.

     The tentative proposal for this Region, which amounts to $79,355,000, reflects
an overall increase of 11.0% with respect to 1992-1993.  This is the maximum
increase approved for this Region by the Director-General of WHO.  Because costs
have increased by 16.0% as a result of inflation and UN-mandated increases, it was
necessary to make program cuts amounting to $3,625,100, or 5.0%, including the
elimination of 14 positions.

     Owing to the drastic program decreases made during 1991 in the 1992-1993
program budget--which carry into the 1994-1995 projection--the proposal
presented in the document does not include the combined 5% increase that the
Director-General had called for in the following five priority programs:

     -          Managerial Process for National Health Development
-    Organization of Health Systems based on Primary Health Care
-    Nutrition
-    Promotion of Environmental Health
-    Disease Prevention and Control

A 5% increase in these five programs would have required a reduction of
approximately $5,500,000 in the other programs.

The Director pointed out that the proposal under discussion should be
considered provisional since it will be discussed and considered again by the
Subcommittee, as well as the Executive Committee and the Directing Council,
when they consider the joint PAHO/WHO budget for the period 1994-1995, about
which the secretariat will provide much greater detail.

   He noted that 1994-1995 will be the third consecutive biennium in which the
Organization will operate on the basis not just of zero growth but of negative
growth.  The increase in the budget is lower than the increase in estimated costs. 
Although costs are expected to increase by 16%, the proposed increase in the
budget is 11%, which implies a real reduction, in program terms, of 5% in the
WHO budget for the Region.  The cumulative effect of these reductions as of 1994-
1995 will be almost equal, in real terms, to one-third of the budget approved for
1988-1989.  This is one of the reasons why in this first draft proposal no attempt
was made to implement WHO/Geneva's instructions regarding a 5% real increase
in the five aforementioned programs, especially since these programs currently
represent 60% of budget expenditure for the Region and are therefore already
receiving sufficient priority.  To increase that 60% by 5% would have meant a
reduction of some 13% in other programs that are considered priorities in the
Region of the Americas.

   The Director asked the Subcommittee to give its guidance and opinions
concerning the tentative proposal while bearing in mind that the overall PAHO and
WHO proposal for 1994-1995 will be presented to the Governing Bodies in 1993.

   Discussion

   In the discussion that followed it was pointed out that, when the provisional draft
of the program budget is submitted to the Governing Bodies, it would be desirable
to include information that would make it possible to know and compare how other
Regions are handling and resolving the problem of increased costs, what
percentage is being allocated to them, and what priority they are assigning to the
various programs.  Attention was called to the fact that WHO Headquarters and the
Regional Office for Europe had drawn criticism during the last World Health
Assembly because they had received a percentage increase that was considerably
higher than that allocated to the other regions.

   It was pointed out that cholera, given its political dimension in the Region, should
be reflected in the WHO proposal for the biennium 1994-1995, and concern was
expressed that the program reductions had primarily affected health promotion.

   It was reported that the last Executive Board had created a working group to study
the role and structure of WHO, with particular attention to its program priorities,
since it was considered that these were perhaps too numerous, which lessened their
impact.  It is believed that if action were focused on a smaller number of programs,
these would have a greater economic impact and would therefore ultimately be
more successful.

   It was mentioned that, although the suggestion was perhaps somewhat premature,
it might be desirable for the Bureau, the Governing Bodies, and the Governments
to also begin to think about concentrating PAHO activity on a smaller number of
priority programs.

   It was pointed out that it was perhaps as a result of the aforementioned decision
of the Executive Board that the Director-General had indicated that the Regions
should focus on the five programs mentioned above, a recommendation which this
Region has not followed.  In addition, it was mentioned that it had perhaps been
slightly premature to have indicated these priorities before the results of the WHO
study on priorities were available.

   There was discussion of the desirability of considering a reduction in the number
of years covered by budget projections, inasmuch as the current method does not
appear to be particularly logical or practical.

   Mr. Milam explained that the purpose of including projections for 1994-1995 was
to give the Governments two separate opportunities to consider the portion of the
budget that was being allocated to their countries so that the budget could then be
brought into line with their criteria and program priorities.

   The Director emphasized that this preliminary version of the proposal did not
include a program analysis nor was in-depth consideration given to the five priority
programs indicated by the Director-General because, among other reasons, there
had not been sufficient opportunity to consult individually with the Governments
in order to determine what activities they proposed to carry out in their respective
countries.  This will be done in late 1992 when the joint PAHO/WHO budget is
prepared.

   With respect to the five priorities, the Director pointed out that there are
considerable variations between the different Regions and Governments, both with
regard to conceptualization and implementation.  He noted that in other Regions
the percentage allocated to these five priorities are:  Africa, 36.6%; South-
East Asia, 49.3%; Europe, 13.5%; Eastern Mediterranean, 51.4%; and Western
Pacific, 45.5%.  The figure for Headquarters in Geneva is 23.3%. 

   A comparison of the various Regions and of WHO Headquarters in terms of
increases or reductions in their share of the WHO budget also reveals a rather
uneven situation.  In the European Region, with the exception of one activity in
Turkey, all the resources are concentrated in the Regional Office, whereas in the
Americas emphasis is placed on the activities that are being carried out in the
countries.  Any comparison should therefore take into account the level of
development of the countries as well as the way in which technical cooperation is
delivered to them.  The Director pointed out that the Western Pacific and the
Americas are the Regions that have suffered the largest reductions during recent
bienniums.  In addition, expenditures at WHO Headquarters exceed 35% in terms
of the proposal for the biennium 1992-1993.

   The Subcommittee also supported the Director's decision to continue to charge
the costs of the Country Representatives in the Region to PAHO ordinary funds. 

Item 5:                                                                                                     Debt Conversion for Health

   In presenting this agenda item, Dr. Antonio Campino, PASB, briefly outlined the
reasons that had prompted PAHO to consider debt conversion schemes as a
potential way to provide the member countries with additional health resources. 
He emphasized that in the current context of severe economic and budgetary
constraints, debt conversion might provide a way to leverage health resources, in
addition to offering the Governments of the Region some relief from their debt
burden.

   He explained that, in compliance with the mandate that the Directing Council of
PAHO had given the Director in September 1991 to support the member countries
in their efforts in this regard and in the promotion of this mechanism at the
international level, a team had been established to formulate the project.  In
addition, it had prepared technical and informative material on the subject, made
important contacts, and approached a number of multilateral and bilateral
institutions, including the World Bank, IDB, IMF, US/AID, and CIDA.  Visits had
been made to several member countries in order to explore the feasibility of
undertaking debt-for-health conversions.  On the basis of suitability and degree of
interest expressed, the following seven countries had been selected for a second
phase of activities:  Bolivia, Costa Rica, the Dominican Republic, Ecuador,
Guyana, Honduras, and Peru. 

   Bolivia was cited as an example of a country which actively supports debt
conversion as a means of generating additional resources for priority health
projects and which has officially requested PAHO to enter into contact with its
bilateral creditors.  It was also mentioned that a joint effort is currently being
carried out in Bolivia by PAHO and UNICEF, with support from CIDA/Canada,
with a view to finalizing a debt-for-health swap in the area of maternal and child
health.

   In summarizing the foregoing activities, Dr. Campino indicated that an
interprogram advisory committee has been formed within PAHO to provide
orientation and collaborate in the coordination of project development.  He said
that at the first meeting the following three roles for the Organization had been
discussed:  (1) providing the member countries with technical assistance to develop
appropriate health projects and help them when they decide to establish programs
to facilitate debt-for-health swaps; (2) providing the member countries with
specialized support in drafting legislation on debt conversions; and (3) promoting
debt swaps in the health sector with debtor country authorities. 

   Discussion

   The Subcommittee took note of the experience of Mexico, which over the last
three years has converted approximately $US 3.5 billion of its debt. 
Approximately 5% of this amount went to the environmental sector.  Mexico
recently discontinued these debt conversions. 

   It was considered that the document presented by the secretariat clarified several
of the questions that had been raised at a previous meeting of the Subcommittee. 
However, one of the representatives expressed some doubt with regard to the role
to be played by the Organization, especially in view of the fact that the document
indicates that the total amount of resources presented for conversion is not very
large.

   Moreover, while one part of the document lists possible roles to be played by the
Bureau, another part concludes that it would be necessary to hire financial and
legal specialists.  A question was raised as to how many countries might be
interested, what impact this might have on the work of the PAHO/WHO
Representatives, and whether or not the Representatives had the training required
to participate in this type of activity. It was suggested that perhaps this might be
an area in which Headquarters could provide assistance directly, rather than
attempting to have the required technical capacity at the level of the
Representations.

   The secretariat was asked to edit the document that will be presented to the
Governing Bodies and to revise the country profiles.

   In response to the questions raised by the members of the Subcommittee, the
secretariat indicated that a future version of the document would provide more
specific clarification of the role that the Organization would play with regard to
debt conversion.  The current document had simply attempted to outline what that
role might be and describe some of the implications and consequences thereof. 
Three of the Organization's potential roles are listed on page 8 of the document: 
(1) providing the countries with technical assistance to develop appropriate health
projects, (2) providing specialized support in drafting legislation on debt
conversions, and (3) promoting debt swaps in the health sector with debtor country
authorities.  It was also reported that no ordinary funds from the budget are being
used and that all activities will be carried out by personnel at Headquarters or the
Representations, working with and through the Ministry of Health. 

   Dr. Knouss, Deputy Director, pointed out that the initiative is not a panacea that
is intended to solve all the problems of financing in the health sector but rather an
attempt to identify possible sources of funds, which might be lost to other sectors
unless the health sector takes advantage of them.  Several countries had already
indicated their interest in this source of financing, and the Organization would be
doing them a disservice if it were not prepared to help them in this regard. 
Moreover, several of the donor agencies that hold large debt amounts have
indicated that they would welcome the Organization's efforts to promote this
concept in the health sector, because otherwise these sums will be channeled
toward other sectors.

   At no time has an attempt been made to impose this activity as one of the
Organization's functions; however, it is extremely important that it be able to
respond positively both to the Governments and to the donors.

Item 6:                                                                                                     Evaluation in the Pan American
Health Organization

   In presenting this item, Mr. Dixon, PASB, pointed out that evaluation is one of
the essential components of the PAHO Managerial Strategy.  It is the process by
which an organization:  (1) seeks to determine the extent to which completed work
has achieved the original objectives, and (2) establishes a basis for corrective
action.  Evaluation is a complex task in any field, but it is especially problematic
in social areas such as health because causality is difficult to establish.  The need
for public organizations to be sensitive to public priorities, and the fact that limited
resources need to be administered prudently, are reasons for the establishment of
evaluation procedures.

   Within PAHO, evaluation of the Organization's technical cooperation program
is accomplished through:  (1) the annual internal evaluations of the Regional and
country programs, and (2) the biennial evaluations that are carried out jointly with
national officials at the country level.  Significant advances have been made in the
establishment of evaluation procedures within PAHO, but further efforts are
needed.  In particular, the evaluation process would benefit from a clearer
definition of its purpose and of the results that are sought and the activities that are
to be carried out at the project level, as well as a precise definition of indicators to
facilitate measurement activities.

   Discussion

   All the members agreed that the document was outstanding, both in terms of its
content and the frankness with which the pros and cons of the various issues were
presented.  It was considered that such frankness should always guide the contacts
between the Bureau and the Governments.

   They also concurred with the Bureau's judgment that, given the scarcity of
resources, organizations supported by public funds must show themselves to be
ever more fiscally and programmatically responsible. 

   It was pointed out that the evaluation process, notwithstanding the many
components that comprise it, is rather weak with regard to its capacity to measure
results or impact on health.  In this respect, it was suggested that the secretariat
continue to seek ways of evaluating impact on health since otherwise it would
appear that evaluation is only programmatic.  The possibility was mentioned that
PAHO might directly support the countries in expanding their own capacities for
evaluation.

   It was also mentioned that perhaps too many evaluative mechanisms are being
utilized and it might be desirable to consolidate them, with a view to reducing the
amount of resources that are being invested in this activity.  In this connection, a
question was raised as to whether or not the secretariat had considered the
advisability of creating an evaluation unit within the Bureau in order to partially
centralize the functions that are now being carried out by different units at
Headquarters and in the countries in the evaluation of their own activities.

   It was pointed out that it would be desirable to implement a system to monitor the
results and agreements that come out of the joint evaluations carried out at the
country level, since at present there does not appear to be sufficient follow-
up on the conclusions of these evaluations.

   Dr. Alleyne, Assistant Director, reported that a meeting would soon be held with
officials from the Ministries of three Caribbean countries with a view to
introducing the approach of more specific and precise programming, since this is
considered a sine qua non for good evaluation.  He also pointed out that any
modification in the allocation of resources is always preceded by an evaluation of
the programs in question, which involves confirming whether or not these
programs correspond to mandates from the Governing Bodies.

   The Director mentioned one type of evaluation that had recently been carried out
at the project level with the donors of extrabudgetary resources.  Joint evaluation
and coordination meetings are held with these donors, in which, in addition to
evaluating the projects carried out jointly with a view to achieving more concerted
action, an effort is made to improve the coordination of other cooperation activities
being carried out by the countries on a bilateral basis with these donor entities.  In
so far as the secretariat is concerned, the Director indicated that it is subject to a
number of external evaluations, such as external audits, as well as those conducted
by the Governing Bodies of the Organization.  With regard to the frankness that it
had been mentioned should characterize relations between the Organization, the
Bureau, and the Governments, he pointed out that it must always be borne in mind
that certain information is the exclusive province of the Governments and only
they could decide whether or not it should be made public. 

   With regard to the creation of an evaluation unit it was reported that the Bureau
had concluded, on the basis of several studies, that a central evaluation unit would
tend to grow excessively and would ultimately become an impediment.

Item 7:                                                                                                     Regional Plan for Investment in the
Environment and Health

   The Director presented the document, recalling that the idea of proposing an
ambitious plan for investment in health and the environment came about as a result
of the resurgence of cholera in the Region.  The epidemic had made apparent
something which everyone was aware of but which had been obscured because of
sociopolitical considerations:  the profound deficiencies and inadequacies in living
conditions in the Region, particularly with regard to health and environmental
infrastructure. 

   At the Ibero-American Summit of Heads of State held in Guadalajara, Mexico,
in July 1991, the Bureau proposed the development of a plan for investment in
health and the environment.  The idea was accepted and incorporated into the
declaration of that Summit.  Subsequently, the XXXV Meeting of the Directing
Council adopted Resolution XVII, in which it requests the Director to prepare, in
close collaboration with the Member Countries and other cooperation agencies, a
long-term plan of investment in health and the environment for meeting
infrastructural needs in those areas.

   In fulfillment of that mandate, a working group was created within the Bureau to
prepare an initial proposal document.  This is to be submitted to the Second Ibero-
American Summit of Heads of State, which will be held in Madrid in July 1992. 
If the Summit affirms the idea and approves the plan, this document will be utilized
as a basis for collaboration and coordination with other cooperation organizations,
in particular the multilateral banks, especially for work at the national level.

   In addition to this plan for investment, a proposal will be presented to the heads
of state at the Madrid Summit for the creation of a special pre-investment fund to
support country activities aimed at preparing projects that would put into effect the
provisions of the plan that is being proposed.

   The decision as to whether or not this point will be included on the agenda of the
Madrid meeting will be made at the preparatory meeting to be held in that city on
18 and 19 May 1992.  Based on the indications received from several Ministries
of Foreign Affairs, it seems likely that this matter will become one of the four
items, and probably the central item, on the agenda of the Summit.  The
preliminary version of the document is to be distributed among the various
ministries, and it will be discussed with the Ministers of Health from the Region
at the World Health Assembly in Geneva before it is submitted to the
aforementioned preparatory meeting.

   In the initial proposal it was estimated that the cost of the plan would be $US 200
billion for a period of 12 years.  Now, after more detailed analysis, it is anticipated
that the plan can very well be carried out with a large input of internal resources,
on the order of 70%, together with financing from other external sources, on the
order of 30%.

   All this appears to indicate that the proposal, although it may not be feasible at
this moment, is at least viable, and its feasibility can be ensured if there is
sufficient political will.  The Bureau is committed to making this happen.

   Discussion

   The members of the Subcommittee expressed their unanimous support for the
initiative, which they believe to be essential.  Although they recognized that the
outbreak of cholera had led to the implementation of a number of emergency
measures, these did not resolve the underlying problems, which include lack of
reliable water supply and excreta disposal systems and contamination of water
sources.

   Both the working document and the presentation made by the secretariat were
considered very complete.  The members of the Subcommittee underscored the
necessity of generating sufficient political will and indicated that perhaps the time
is ripe for achieving this commitment.  It was also suggested that those countries
in the Region which would not be participating in the Madrid Summit should be
informed of the outcome of that meeting as well as any other subregional meeting
or forum.
   
   It was noted that the document discusses what needs to be done, as well as what
exists already and what can be recovered or repaired.

   There was discussion of the need to endeavor to influence the officials of the
multilateral banks that may participate in this initiative with a view to ensuring that
investments in activities relating to health and the environment are not be
considered strictly in terms of short-term economic benefit.  The degree to which
health and the environment can be improved will determine to a large extent the
type of society in which future generations will live in the twenty-first century. 

   In response to a concern expressed by one of the members regarding the
competition that might be created with other sectors in terms of demand for both
national and external financing, the secretariat indicated that, in its calculations, it
had taken into account the trends in the countries over the past two decades with
regard to investment financing in these two areas, as well as the decisions by the
World Bank to allocate at least 25% of its resources to social projects.  These were
factors that had been taken into account in order to arrive at the investment
estimates and percentages.

   It was pointed out that the plan is a frame of reference.  It is the first step in a
process that the countries will be responsible for developing.  The plan will not
incorporate projects but rather will indicate areas, approaches, and total financing. 
The plan will be developed using as a frame of reference the national plans for
investment in a set of projects.

   The secretariat, in the conceptualization of its reference model, has attached
particular importance to the matter of cost recovery, the problem of maintenance,
and the burden that is placed on the countries by recurring costs in connection,
inter alia, with the maintenance mentioned.

   The Director pointed out that the plan is, in essence, a strategy for dealing with
the basic problems of infrastructure in the area of health and the environment,
which are directly related to the living conditions of the populations of Latin
America and the Caribbean.  It calls for a different vision of the development
process in Latin America, both in regard to its nature and the specific policies by
which it is implemented.  Development cannot simply be a repetition of past
experiences, which are basically identified with economic growth; rather, an
attempt must be made to utilize economic growth to improve the well-being of the
population through greater equity in the distribution of the benefits generated by
that growth.

   The plan expresses, and at the same time implies, a profound change and a
thorough reorientation of the systems and services that provide individual health
care as well as environmental services.  In addition, the Director indicated that if
the proposal can be made viable and feasible from a political, technical,
operational, and economic standpoint, it will establish a guide for the work of the
Organization in the coming years, consistent with the strategic orientations
approved by the Pan American Sanitary Conference.  Finally, coinciding with the
view expressed by one of the members, he underscored the importance of the work
of political promotion and the contribution that the Governments can make in this
sense.

   The Subcommittee concluded its discussion on the item by recommending to the
Governments of the Region that they promote the inclusion of this item on the
agenda of the Ibero-American Summit of Heads of State to be held in Madrid in
July 1992.

Item 8:                                                                                                     Health of Indigenous Peoples

   Dr. José María Paganini, PASB, in presenting this item, pointed out that the
proposal on the health of indigenous peoples is framed within the strategic
orientations and program priorities for the quadrennium.  He emphasized that
health in development, community participation, health promotion,
decentralization, and the solution to priority problems are all concepts and lines of
action that are applicable to the indigenous peoples of the Americas.

   He reviewed the historical, political, and socioeconomic context of the indigenous
peoples, noting that they occupy the lowest rungs of the socioeconomic ladder in
the Region.  It is estimated that the indigenous population in the Americas totals
42 million.

   Very little is known about the specific health situation of indigenous
communities, and for this reason it is proposed that a Regionwide effort be
mounted to compile and analyze information on this situation as well as on the
health services available to the indigenous population.  It is considered that the
strategies of decentralization and local health system development can support
local efforts to promote participation and organization, taking into account the
special needs of this population.

   He reported that there is a proposal to hold a hemispheric workshop in Canada in
1993, with full participation by indigenous peoples.  The purpose of the workshop
will be to analyze the situation and propose joint lines of action.

   Discussion

   The members of the Subcommittee were unanimous in underscoring the
importance of this issue, and they commended Canada for having raised it at a
previous meeting of the Subcommittee.  The importance that the Organization
attaches to this matter is evidenced by the funds that the Director has allocated for
the workshop to be held.

   It was pointed out that the question of the health of indigenous peoples will be
treated as an initiative rather than as a program or project, since it is seen as a
process that might culminate in a plan of action for a decade that will support
present and future action aimed at improving the health and well-being of the
indigenous peoples of the Americas.

   It was emphasized that this initiative should include the active participation,
guidance, and leadership of the indigenous people themselves.  It was also stressed
that it is essential to obtain as much information as possible on the various
indigenous groups, as well as to listen carefully to what these groups can tell us
about themselves.  It is important to seek out information about how indigenous
communities are caring for their own health, since much remains to be learned in
this respect.

   It was pointed out that it would be wise to proceed slowly at first in order to
ensure full participation by concerned groups in the countries, together with the
Ministries and the PAHO Representatives.

   The meeting to be held in 1993 has been designated a "workshop" expressly to
emphasize the importance of discussion, dialogue, and working as a group to
formulate policy recommendations and strategies aimed at meeting the needs of
indigenous peoples.  It was pointed out that this workshop will provide an
opportunity to discuss the health practices of indigenous groups with the
organizations that deal specifically with health-related matters as well as with other
organizations that have an interest in this issue.

   It was indicated that there is a need to review and expand the concept of the
Caribbean, because the list of countries that plan to participate in the workshop did
not include Guyana and Suriname.  They, like the island nations of the Caribbean,
desire to participate actively in this initiative.

   It was noted that the document presented could benefit from the inclusion of more
data, as well as some examples.  It was pointed out that the problem of statistics
is complicated by problems associated with the self-identification of individuals
with one ethnic group or another. 

   It was also recognized that indigenous groups are living in a precarious social
situation, which makes them extremely vulnerable.  The Organization and the
member countries must address this problem with a view to generating the political
will required to implement concrete solutions so that indigenous peoples can cease
to be the most unprotected and vulnerable groups and become recognized and
respected groups who enjoy the necessary minimum health conditions to enable
them to lead fulfilling lives within the framework of their cultures.

   Mexico was cited as an example of a country that has a national institute devoted
specifically to the study of indigenous issues through an approach that is
comprehensive and multisectoral and takes into consideration all the cultural,
ethnic, and other facets of these issues.

   It was suggested that this matter should not be considered strictly from the
standpoint of health, but rather other factors should be examined, including
education, economics, etc. in the context of development.  In addition, it is
necessary to define the population that is to be targeted by this initiative, i.e.,
whether it is to include those who lack access to health services in general or only
those who lack access for cultural or ethnic reasons.

   The Subcommittee recommended that a report on the outcome of the workshop
to be held in Canada in 1993 should be presented to the Governing Bodies of the
Organization.

Item 9:                    Democracy and Health

In presenting the revised and updated version of the document that was
submitted to the Seventeenth Meeting of the Subcommittee in December 1991, Dr.
Vieira, PASB summarized the factors that had led PAHO to develop this project,
as well as the objectives and conclusions of the four subregional meetings of
lawmakers promoted in cooperation with the Organization of American States,
with which the implementation of this initiative began in 1990.  He reviewed the
evolution of cooperation with the legislatures since then, outlining the activities
that have been carried out at the national, subregional, and Regional levels.

He mentioned several of the positive results of the initiative as elements for
a preliminary evaluation, and he discussed futures prospects in this area.

Discussion

One of the members said that he did not find much difference in terms of
content between the revised document and the one that had been submitted to the
Subcommittee in December 1991.  He asked for clarification regarding the
channels of communication that would be used in contacts with the legislatures, the
priorities, the cost of the program, the allotment of funds for implementing it, and
the development of a methodology for evaluating the program.

Another member voiced the opinion that, although the document was perhaps
not terribly explicit, it did indeed respond to some of the concerns expressed by the
previous speaker.  He considered the initiative extremely important because its
objective was to make legislators aware that health is an area that must be given
the priority that it deserves.  Health is not just one of the basic elements required
for development but one of its objectives.  Advantage should be taken of the
opportunity offered by meetings of different groups of lawmakers in order to raise
their level of awareness about this issue.

The same member commended the Bureau for this initiative and informed the
Subcommittee that a meeting had been held of the Commission on Health, Labor,
and Social Security of the Latin American Parliament, with the participation of 75
lawmakers from 17 countries of the Region.  A wide range of health-related issues
had been discussed, which testified to the interest of legislators in this matter and
to the validity of the initiative.  The Commission appreciated the Organization's
efforts to ensure that the legislative branch, in coordination with the executive
branch, would have a role in the formulation of health policy in the Region.

One of the members, indicating that he supported the initiative, pointed out
that a future edition of the working document on this matter should clarify the
distinction between the parliamentary systems in the English-speaking Caribbean
and the systems in other countries of the Region, since some of the difficulties
indicated might derive from confusion over the functioning of these two types of
legislative systems. 

The secretariat responded to the aforementioned comments, indicating that
the report presented was largely an overview of what had occurred in the past
rather than a plan for future action.  With regard to the question concerning
evaluation, it was indicated that this was to be accomplished through the same
methodology and mechanisms that are applied in other programs of the
Organization, although perhaps in this particular case a more specific mechanism
should be developed.  It was also mentioned that thus far the Ministries of Health
have indicated that they are quite satisfied, and they have even participated in the
activity.  He reiterated that the funds allocated for the promotion of this initiative
are Regional funds and are not taken from funds allocated to the Ministries of
Health.

The Director indicated that pursuant to the Subcommittee's consensus that
this matter should be submitted to the Governing Bodies of the Organization for
formal approval, the secretariat would add to the report under discussion a proposal
of activities, which will specify the objectives and expected outcomes, together
with the mechanisms for action, detailing very clearly the role of the executive
branch, in particular the Ministries of Health.  In addition, a process of monitoring
and evaluation will be established for application in the future.

The Director emphasized that the Bureau considers this activity to be of
extraordinary value both from a political and operational standpoint and even from
a practical standpoint in terms of internal discussions regarding budgeting and the
allocation of resources to the health sector.

The Subcommittee agreed that a revised edition of the report, together with
a proposal of activities, should be presented to the Executive Committee and to the
Directing Council for their approval.

Item 10:  Other Matters

It was decided that the Chairman should present the report on the
Subcommittee's activities to the Executive Committee to be held in June 1992. 
The Vice Chairman or the Rapporteur will submit the report if the Chairman is
unable to do so.

The following two items were suggested for inclusion on the agenda of the
next meeting of the Subcommittee: 

-       Results of the evaluation of PAHO/WHO technical cooperation in Cuba.

-       Evaluation of a Regional program.

With regard to the date for the 19th Meeting of the Subcommittee, it was
suggested that it be held either in late November or early December 1992.





Message from the Director

Latin America and the Caribbean have lived through many years of a severe economic
crisis marked by fiscal austerity, lowered incomes, rising unemployment, and exacerbated
poverty and inequality.  In 1991 the per capita gross national product scarcely reached the
level it had attained in 1977, fourteen years earlier.  This situation has had far-reaching
implications for the health sector.

The Pan American Health Organization/World Health Organization (PAHO/WHO) has
been and will continue to be involved in working with the countries of the Region in the
search for innovative alternatives to improve the health and well-being of their peoples.

The Organization's Managerial Strategy underscores the importance of its role as a
catalyst in the process of resource mobilization and emphasizes the need to ensure more
active coordination with other multilateral and bilateral cooperation organizations in the
area of health.  The Organization must be prepared to assume leadership in the area of
international cooperation in health, helping the countries to identify external sources of
technical and economic cooperation for the health sector.  The Managerial Strategy also
indicates that the Organization should assist the countries in taking the steps required in
order to achieve closer cooperation that is consistent with national needs and priorities,
as well as with Regional objectives.  The importance of resource mobilization is also
stressed in the Strategic Orientations and Program Priorities (SOPPs) for the Pan
American Health Organization during the Quadrennium 1991-1994, approved by the Pan
American Sanitary Conference in September 1990.  The SOPPs urge the countries to
utilize the flow of external financial resources to induce or consolidate the necessary
transformations of their national health systems. 

The Organization must therefore assign top priority to its collaboration with the countries
in the search for additional financial resources for health, both from bilateral sources and
from multilateral agencies.  To this end, it will continue to support the countries in
identifying possible cooperation agencies and in preparing proposals for their
consideration.

This manual, prepared by the PAHO External Relations Coordination Unit, is intended
to strengthen the countries' capacity to mobilize resources for the priority activities of the
health sector.  It includes a description and analysis of the role and characteristics of
international cooperation in the area of health, as well as detailed, up-to-date information
on the cooperation agencies that support activities aimed at improving health in the
Americas.

Part II of the manual will be updated on an ongoing basis, and new profiles of agencies
will be added as the circumstances warrant.

It is my hope that the document will serve as a source of information and an instrument
to aid health sector personnel in their search for additional resources so that "Health for
All" may become a reality.


Carlyle Guerra de Macedo
Director



Introduction


The Global Program on AIDS (GPA) of the World Health
Organization (WHO) regards research as a fundamental element in
the prevention, control, and treatment of this disease.  To the
extent that the GPA is capable of documenting and utilizing
advances in research, it will be better able to develop
effective strategies for intervention and ensure timely
application of new technologies at the national, regional, and
world level.

The difficult conditions under which research is being carried
out in our countries make it essential to ensure that resources
are used rationally and initiatives are taken to prevent
duplication of efforts and unnecessary expenditure of resources. 
Thus it is essential to develop mechanisms that will facilitate
coordination between various research groups and strengthen
their work, enrich the results of their projects, and encourage
access to the benefits of research as they become available.

In order to respond to these needs on a timely basis, the Pan
American Health Organization (PAHO), with the support and
collaboration of WHO and the National AIDS Campaigns, has
conducted an Inventory of Research Resources on AIDS with a view
to learning more about the kind of research being carried out
in the countries of Latin America and the Caribbean.  This
Inventory constitutes a basic instrument for facilitating
knowledge about where and how scientific projects on AIDS and
human immunodeficiency virus (HIV) infection are being carreid
out in the different countries of Latin America and the
Caribbean, with a view to identifying gaps and promoting
projects that will support programs for the prevention, control,
and treatment of AIDS.

The Inventory has yielded information, in the form of the
present catalog, which we hope will be used by investigators,
academic institutions, agencies that coordinate and promote
research policies, national health programs, and persons
concerned with the prevention of AIDS in the Americas.

We also hope that this catalog will help to strengthen ties
between investigators and facilitate contacts and coordination
between them.

Sincerely,



Fernando Zacarías
Principal Regional Advisor on AIDS/STD


Methods


The Inventory focuses on the research project as its primary
subject of concern.  Activities under way or to be carried out
have been identified from the perspective of generation of
scientific knowledge.  The activities should be systematized in
the form of a research protocol or proposal that sets forth the
hypotheses, objectives, methodology, schedule of work, and
budget.  The Inventory includes research projects on AIDS that
have been recognized and approved by the institution and are
either under way or already completed.

The information was collected using a standardized questionnaire
that was adapted by the GPA from a survey conducted in other
regions of the world.  For each research project, information
was gathered on its objective, methodology, results, and
publications.  In addition, the Inventory compiled information
on the investigators, institutions, and project financing. 
Information was also obtained on the characteristics and
resources of the laboratories providing assistance to the
various projects.

The questionnaire was used in all the institutions that are
carrying out research in AIDS, including biomedical,
epidemiological, social, behavioral, and operations research. 
For purposes of the Inventory, epidemiological research is
considered to include studies on distribution of the population,
the risk of transmission and/or natural history of HIV
infection, and the determining factors thereof.  Social and
behavioral research is considered to be concerned with behaviors
that pose risks for HIV, such as sexual behavior or patterns
associated with drug addiction (including preventive behavior
such as the use of contraceptive methods), as well as cultural,
social, and psychological determinants or knowledge.  The area
of operations research is considered to cover the efficiency,
effectiveness, and effectiveness of the interventions, programs,
and services aimed at preventing or controlling HIV infection,
including the economic impact of this disease.  Finally, the
biomedical area is that which is concerned with biological
aspects and the pathogenicity of HIV, as well as aspects related
to diagnosis, therapy, and clinical manifestations of HIV
infection in any of its phases, including AIDS.

In order to obtain information on all the research projects
underway, it was necessary first to identify them.  Accordingly,
a wide net was cast to locate all the institutions and
investigators in all the countries that had presented results
on HIV-related research in scientific journals or meetings.  On
the basis of this information, a preliminary list of projects
and investigators was prepared which served as a basis for the
first step in collecting the information.  In those countries
where a large number of projects were identified, the assistance
of local national personnel was enlisted.  The job of these
collaborators was to ensure that the list of projects was
complete, to contact the investigators working on the projects
and explain to them the purpose and usefulness of the Inventory,
to provide them with the questionnaires and ask them to fill
them out, and to review the questionnaires once they were
completed.  In the countries that had fewer projects, these
functions were performed by consultants who were sent there
specifically for this purpose.

In the field, the investigators who were contacted often were
able to indicate other projects that had not been identified
before.  The collection of data for the Inventory began in March
1991 and ended in September of that year.

A total of 651 research projects were identified, of which 561
met the specified criteria for inclusion in the Inventory. 
Sixty-eight questionnaires were excluded because it was deemed
that the information referred more to programs of activities
that to research as such.  Another 23 projects were considered
to come under other projects already identified and the
corresponding information was merged.

The information contained in this catalog is precisely what was
obtained from the investigators, without any intentional
modification on our part.  In order to avoid any problem of
misinterpretation of the texts, they have been left in their
original form without any editorial intervention.













IMPLEMENTING THE HEALTH PROMOTION STRATEGY

IN THE PAN AMERICAN HEALTH ORGANIZATION:

CONTRIBUTION OF THE PROGRAMS

AND COUNTRY REPRESENTATIONS 

















HEALTH PROMOTION PROGRAM
PAHO/WHO



Washington, D.C.                             April 1992


















  CONTRIBUTIONS RECEIVED IN HPA FROM OTHER UNITS AND COUNTRIES
ON THE IMPLEMENTATION OF HEALTH PROMOTION 

    


TABLE OF CONTENTS


A-  Introduction

B-  Health Promotion in the Countries

. Argentina
. Bahamas
. Costa Rica
. Cuba
. Dominican Republic
. Ecuador
. Suriname
. Venezuela


C-  Regional Technical Programs

. Regional Program on Women, Health, and Development
. Environmental Health
. Health Situation and Trend Assessment
. Maternal and Child Health
. Emergency Preparedness and Disaster Relief
. Health Services Development
. Health Policies Development
. Communicable Diseases
. Veterinary Public Health Program
. Health Manpower Development
. Caribbean Program Coordination
















INTRODUCTION


     The present document, prepared by HPA, provides an
informative summary of contributions received from the PAHO
Country Representations and the Regional technical programs on
implementation of the health promotion strategy.

     These contributions were requested from the Country
Representations in December 1991 with a view to preparing a
working document for implementation of the health promotion
strategy within PAHO, as requested by the Director.

     Cooperation was also sought from the Regional technical
programs.  For this purpose, members of the HPA staff contacted
appropriate personnel in each of the programs.

     The report includes all contributions received as of 31
March 1992.  These contributions cover both conceptual and
operational aspects; in some cases, documents are attached
dealing with local programming or procedural aspects.

     In addition, some of the contributions have been used as
examples in the document "Implementing the Health Promotion
Strategy in the Pan American Health Organization" prepared by
HPA/PAHO with the collaboration of Dr. Milton Terris.

     The contributions and the attached documents are on file in
HPA and can be made available to those who wish to review them in
greater detail.

HEALTH PROMOTION IN THE COUNTRIES

    (Summary of contributions received for preparation of the
document "Implementing the Health Promotion Strategy in the Pan
American Health Organization")


Argentina

     The report received outlines the Ministry of Health policies
on health promotion and protection to be undertaken at the
national level.

     The activities fall into three main categories:

     - ) Control of risk factors and prevention of disease
     - ) Health education of the general population
     - ) Improvement of the quality and safety of food products

     The document cites the need to incorporate intersectoral and
transectoral approaches, as well as community participation, into
the programs and to design "major programs for major problems"
rather than isolated interventions.

     This report has been included as an illustrative example in
the document in question.


Bahamas

     The program for 1992 includes a workshop aimed at defining
strategies and a plan of action in the area of health promotion,
as well as plans for a visit by the Coordinator of HPA to provide
advisory services on the subject.

Costa Rica

     A multidisciplinary working group (Ministry of Health, Costa
Rican Social Security Fund, and PAHO/WHO) has been formed and is
in the process of formulating a National Plan for Comprehensive
Care of Adults" to be submitted to the national authorities.

     The objectives of the plan are to promote healthy lifestyles
and to decrease the prevalence of risk factors associated with
chronic non communicable diseases (CND).

     The plan provides for community participation as a
fundamental element in the planning and execution of activities.

Cuba

     The contribution received includes conceptual and
operational definitions.

     It emphasizes the consensus already reached regarding the
importance of health promotion and the need to find working
elements and solutions that will offer alternatives for advancing
health promotion in the countries.

     The document highlights health promotion as a broad concept
that goes beyond health education, and it underscores the need to
ensure that projects and actions are intersectoral in nature, all
of which is achieved more easily when priority is given to work
carried out at the local level in the context of local health
systems.

     It suggests, moreover, that cooperation projects should be
developed on an interprogram basis from the moment that they are
generated in PAHO.

     Finally, it cites the importance of using epidemiology and
of constructing positive indicators as measurements to facilitate
the diagnosis, design, and evaluation of actions.

     Among the activities currently under way are comprehensive
health intervention projects in the Las Tunas and Cienfuegos
Provinces.


Dominican Republic

     The PWR has provided a brief description of a number of
general topics.

     Efforts in this country have focused on using the promotion
strategy as an approach to dealing with priority local problems,
which are defined jointly with the community.  The community also
participates in identifying and implementing solutions.

     The document emphasizes the preparation and dissemination of
educational messages on health at the local level, utilization of
the mass media at the national level, and the promotion of
research on the perceptions of the population with regard to
health.


Ecuador

     This country's contribution is in the form of a document by
the Ministry of Health on standards for the care of families,
groups, and individuals at the basic and complementary level,
which is part of a project for the strengthening and expansion of
basic health services in Ecuador.

     The document is concerned mainly with medical care services
and includes an initial effort to incorporate aspects of health
promotion and community participation.


Suriname

     The PWR has provided a discussion of concepts and, on this
basis, a list of suggested actions.

     The document underscores the need for more training in the
concept of promotion and the associated technologies, such as
health education, use of the mass media, public speaking
techniques, etc.  This training should begin with staff in the
organization itself and personnel in the national health systems.

     It points out the need to have educational units at the
local level that are well established and have their own
resources, and to undertake actions through the mass media that
will counteract the powerful negative messages that people
receive.


Venezuela

     The PWR notes that work is proceeding on a program for
implementation of the health promotion strategy which involves
the use of social communication with the support of experts in
that area.

     The program seeks to give the population information and
knowledge that will promote awareness about needs and a search
for alternative approaches to the attainment of well-being.

     Work is currently under way in such areas as AIDS, cancer,
alcohol, drugs, accidents, and tobacco.  Also ongoing are
activities aimed at providing social communicators with
motivation and training in the area of health.

     The report is accompanied by a document that outlines the
plan and the actions being carried out.

REGIONAL TECHNICAL PROGRAMS

    (Summary of the reports received as contributions to the
preparation of the document on implementation of the health
promotion strategy in PAHO)


     Regional Program on Women, Health, and Development--PWD

     The Program has provided the rapporteur's final report from
the Latin American Working Group on Women, Health, and Self-Care
(Colombia 1991) and a document on health and self-care, with
focus on women making decisions about their own lives, which
served as a basis for discussion and motivation of the
participants.

     The Working Group discussed the concept of self-care in
light of the theories of development, social participation,
social medicine, and gender.

     It emphasized the broad scope of self-care, which includes,
in addition to physical care, individual and social aspects as
well.

     It was concluded that self-care should permit and foster
self-determination, self-esteem, and autonomy, and that it should
go beyond the realm of the individual and become a social
necessity.

     Given the implications and the progress achieved in this
area, the definitions and suggestions that emanated from this
exercise relate more to the concept of health promotion than to
the traditional meaning of self-care.

     The resulting suggestions focus on:  the need to define the
priorities and content of self-care through a horizontal and
participatory process; the need to disseminate the concept and
practice of self-care via different media; and the need to
delineate the role of state agencies and NGOs in this area.


Environmental Health--HPE

     The unit has provided a document that presents a framework
for care of the environment for use by local health systems in
the Americas.

     It asserts that knowledge of basic information about the
physical and social environment and discussion about
environmental issues at the local level can result in a high
degree of community participation and the involvement of
decision-makers.  This in turn can help to achieve a level of
health and well-being that is in keeping with the particular
circumstances and options of each local situation.

     The program is an adaptation for the Region based on the
"Programa Marco de Atención al Medio para los Equipos de
Atención Primaria de Navarra" [Framework Program on Care of the
Environment for Primary Health Care Teams in Navarra], co-
published by the Institute of Public Health of Navarra and
EURO/WHO in 1989.

     The document deals with various aspects of the environment
in general and their repercussions for health, and it identifies
working tools that can be used at the local level to promote
environmental health through appropriate diagnosis, surveillance,
follow-up, and evaluation of the environmental situation.

     A reading of the document by HPA in the context of health
promotion bears out the need to deepen the process of defining
roles for the different institutions and professionals and to
bring out other environmental aspects related to health promotion
that were not included which might add to the comprehensiveness
of its coverage.


Analysis Situation and Trend Assessment--HST

     This unit's contribution addresses some of the ideas and
actions involved in health promotion, disease prevention, and
curative activities within the framework of the program's
objectives.

     It is believed that social responses to health problems will
shape policies and plans for health and well-being which will be
translated into actions by society, groups, and individuals. 
These actions, in turn, can have an impact on the effects,
mediating processes, and/or conditions in which people live or
the determinants thereof.

     The actions can be developed on a step-wise basis in terms
of current living conditions and the level at which they will
have their greatest effect.

     On the basis of these elements, HST proposes a conceptual
model for the study of social problems and responses within the
context of living conditions.


Maternal and Child Health--HPM

     This contribution focuses on the development of a program in
adolescent health, which has been included as an example in the
basic document.

     The current situation with regard to adolescent health and
its determinants is reviewed, as well as the shortcomings of
existing institutions in dealing with the problem and offering
valid responses.

     The document gives examples of programs being carried out in
selected countries and describes a project for the implementation
of networks to develop work plans, share experiences, exchange
information, develop training programs, and provide leadership
throughout the Region in comprehensive adolescent health.

     The unit has also provided a report and supplementary
materials (manuals, standards, and programs) on the control of
diarrhea.


Emergency Preparedness and Disaster Relief--PED

     The contribution in this area covers basic concepts for
implementation of the promotion strategy in relation to
emergencies and disasters, highlighting the need to raise public
awareness of the risks associated with these situations.

     This consciousness-raising stage is prerequisite to the
implementation of participatory programs for prevention.

     The use of social communication and community participation
strategies will be fundamental to the achievement of these
objectives.


Health Services Development--HSD

     This unit is currently participating in a joint project on
"Healthy Municipios" as a strategy to advance social organization
and involve a maximum number of volunteers and resources in
health promotion.

     To this end, the project takes advantage of the political
and administrative base that is closest to the citizens and their
community structures.

     The "Healthy Municipios" movement in Latin America has been
included as an example in the basic document prepared by HPA.



Health Policies Development--HSP

     This unit is committed to fostering implementation of the
health promotion strategy through:

- Consideration of the subject in the context of activities with
parliaments and labor unions, as well as in exercises of socio-
political analysis.

- Consideration of the subject in courses under the various
projects, in sectoral analysis exercises, and in the advisory
group concerned with policies on care of the elderly.

- Consideration of the subject in PAHO/WHO policy documents
dealing with the financing of health services and the cost-
effectiveness of health promotion policies.

     A document was provided on health promotion policies as a
new challenge for international cooperation which summarizes the
concepts behind the health promotion strategy within the PAHO/WHO
primary health care strategy.

     The document underscores the importance of lifestyles and
social and individual responsibility for health, which are
included among the concepts that underlie the strategy, and it
points out some of the variations between them.

     A three-dimensional approach is presented for analyzing the
concept of lifestyles within the health promotion strategy, and
the document discusses the possible implications that its
implementation will have for international cooperation in the
countries of Latin America and the Caribbean in terms of the
formulation and execution of policies, plans, and programs.

     It suggests that cooperating agencies review their external
and internal activities with a view to applying the strategy in
the way that is most effective and most in keeping with the
sociocultural realities in the countries.


Communicable Diseases--HPT

     A description has been provided of activities under the
program that incorporate the concept of health promotion.

     Problems are addressed using a comprehensive approach that
includes biomedical, economic, social, and ecological aspects,
and emphasis is placed on the strengthening of national capacity
to carry out interventions at each level and in keeping with each
situation.


     Intersectoral activities are under way in the areas of
agriculture, industry, housing, food, public works, etc.

     The program promotes the adoption of healthy behavior
patterns at the individual level.

     The approaches enlisted to attain these objectives include,
among others, health education and use of the mass media.


Veterinary Public Health Program--HPV

     The contribution summarizes the role of veterinary public
health in health promotion.

     Veterinary public health acts as an intersectoral and
community catalyst through the development of activities intended
to improve people's health, well-being, and quality of life.

     The activities fall under five major headings:

     - ) Promotion of animal health for the improvement of human
nutrition and the socioeconomic development of the countries
     - ) Protection of food for human consumption
     - ) Surveillance, prevention, and control of zoonoses and
communicable diseases common to humans and animals
     - ) Promotion of environmental protection
     - ) Development of biomedical models

     The activities in these areas are carried out using the
mechanisms that underlie the health promotion strategy, in
particular:

     - ) Intersectoral and interinstitutional articulation
     - ) Community organization and participation based on the   
community's needs and interests
     - ) Social communication and health education

     Finally, attention is given to the unit's participation in
the initiative "Health and Tourism," which is aimed at promoting
healthful practices in connection with tourism which will yield
increased economic benefits.


Health Manpower Development--HSM

     This unit reported on a series of activities under way or
planned for the future that involve health promotion.

     - Activities in progress:

    . Analysis of the 1989-1990 health services delivery model,
which involves the health promotion strategy, to be published in
the near future.

    . Development of public health theory and practice, 1991-
1994, a multiprogram initiative in which major attention will
focus on health promotion and its related aspects such as social
participation, development, environmental health, etc.

     - Activities planned:

     . Application of the results of critical area analysis for
infrastructure development and the 1987-1990 health services
delivery model in the areas of education and services.

     . Development of a regional course, in collaboration with
other programs, on leadership in health.

     . Stimulation, at the Regional level, of a reorientation in
the teaching of preventive medicine at the undergraduate level in
the health professions.

     - Other options:

     . Incorporation of elements of health promotion into
continuing education for health workers.

     . International courses on health promotion, to be offered
as an interprogram activity.


Caribbean Program Coordination--CPC

     This Program reported on the main activities proposed for
1992 in the area of health promotion:

     - Convocation of an intersectoral regional conference for
the purpose of developing a Caribbean Charter for Health
Promotion.

     - Resource mobilization, with emphasis on technical and
financial support for a joint Caribbean-Canadian project for the
implementation of health promotion programs in four countries of
the Caribbean, with institutional funding.

     Also in 1992, support will be given to health promotion
programs in the Eastern Caribbean and in the British dependent
territories.

     - Use of social communication to provide information on risk
reduction and the relationship between living conditions and
potential for health.

     A further proposal calls for the provision of training at
the local level on the design, implementation, and evaluation of
social communication programs.
E0195.FIN


















PRIVATIZATION OF WATER SUPPLY AND SANITATION
IN LATIN AMERICA AND THE CARIBBEAN:
POSSIBILITIES AND CONSTRAINTS




































April 1992

PRIVATIZATION OF WATER SUPPLY AND SANITATION
IN LATIN AMERICA AND THE CARIBBEAN:
POSSIBILITIES AND CONSTRAINTS


I.   BACKGROUND

1.   At the beginning of the 1980s the United Nations proclaimed
     1981-1990 the "International Drinking Water Supply and
     Sanitation Decade."  Today, from the perspective of the
     early 1990s, that period is now viewed as a "Lost Decade" in
     terms of sanitation--not only because of the obvious failure
     to meet the targets that were set but also because there has
     been major backsliding in the quality and reliability of the
     services provided.  Not only have real investment rates been
     far lower than the amounts needed in order to reverse the
     indexes of population without coverage; there has also been
     a sharp reduction in cash flows intended for the operation
     and maintenance of existing systems, which has resulted in
     the serious deterioration of many installations.  The level
     of risk has actuallly increased in many countries, as
     reflected in the persistence of high infant mortality and
     the reappearance of cholera.

2.   The recurrent crises in the countries of the Region, coupled
     with the problem of external debt and the resulting
     adjustment policies, have been responsible for the greatly
     reduced capacity to maintain investments at the levels
     required.  Inflation, in turn, together with the typical
     efficiency of the agencies responsible for the services, has
     led in most cases to liquidation of the funds allocated for
     operation and maintenance.  This situation, which to a great
     extent applies to all sectors of public activity, reached a
     crisis point, and the steadily mounting public deficit,
     without any margin for external indebtedness, has resulted
     in increased inflation without any positive effect on the
     coverage and quality of the services provided but with
     ominous consequences for economic activity, employment, and
     distribution of income.  As a result, the somber outcome
     that specialists had been predicting throughout the decade
     became a reality to the citizens of the Americas and it
     became clear that the statist model prevailing in the Region
     was no longer able to provide the solutions needed by a
     population now even more impoverished than it was a decade
     ago.

3.   The gradual realization that the pressure of economic
     conditions was exhausting the possibilities of the
     prevailing model gave rise at the policy level to new rules
     of the game, and, as far as this study is concerned, it
     became important that public services began to cease being
     the exclusive domain of the State and were opened up to
     private activity.  The process has not been an easy one;
     there has been strong resistance to change.  The
     possibilities of modifying structures whose operation had
     become largely crystallized over time are not very great
     when the decision-making mechanisms used by political
     authorities have to be designed and implemented by sectors
     for whom any modification alters their own condition of
     existence.  Although policy decisions do in fact prevail in
     many cases, when experts on a particular subject (career
     professionals, union leaders, contractors, suppliers) have
     interests at stake which are not always compatible with the
     change being sought, this can mean that structural change
     does not end up being implemented in the most effective way
     possible.

4.   The activities of the State in the area of sanitation may be
     said to be primarily directed toward the financing and
     operation of physical projects.  Funding has usually been
     awarded on the basis of relatively lax criteria of
     efficiency and without much attention to generation of the
     cash flows required for adequate operation and maintenance
     of the systems being financed.  The logic of a private
     company is virtually antipodal:  minimization of investment,
     strict operational efficiency, and maximum utilization of
     available assets at the lowest possible cost.  Such a
     difference in behavior, which results from empirical
     evidence of the way in which the State has operated rather
     than from the theoretical impossibility of doing things
     differently, may lead to particularly negative consequences
     to the extent that the conditions that govern the operation
     of the services cannot be brought into alignment with policy
     decisions, of the need to expand the systems, and of the
     profitability levels sought by the intervening private
     companies.

5.   There is no question that the various criteria which have
     guided the activities of the State in the area of
     sanitation, compared with those of a private company that
     may be interested in operating the services, must be brought
     into line in an overarching synthesis.  This means
     invalidating investment strategies of the kind that many
     agencies have attempted which involved State financing with
     non-reimbursable funds or, at best, funding on very soft
     terms,  It should be accepted as a basic condition that a
     private company is in business and will at the very least
     require a rate of profitability equal to any alternative
     investment it could make. But it also implies granting a
     monopoly to a private company, allowing it to operate as a
     business in an extremely sensitive area of public health,
     and giving it a captive market from which no one can escape. 
     These elements, which in no way attempt to exhaust the range
     of considerations that need to be taken into account in a
     new institutional model for the sanitation sector, give an
     idea of the kind of synthesis that needs to be achieved. 
     And this is a general scheme that has to be particularized
     according to the conditions and modalities of each case.

6.   The definition of new conditions for the intervention of
     private companies in sanitation does not mean that the
     State's duties are at an end.  Quality control immediately
     arises as a basic responsibility, as well as the insistence
     on coverage of those areas that may be less attractive in
     terms of profitability and prices that can be charged for
     services, given the fact that it is a monopoly activity.  In
     addition, it should be kept in mind that the demand for
     services extends to all parts of the countries, often
     creating situations in which the nature of the business that
     may be of interest to private capital becomes diluted, at
     least at the level of acceptable prices.  In such cases, the
     search for creative solutions that will result in service
     coverage at appropriate levels of efficiency is an ongoing
     task which not only cannot be abandoned but should be the
     subject to special attention to the extent that the goal is
     to eliminate health risks and the deficits in services that
     currently exist in the various countries.


II.  OBJECT OF THE STUDY AND BENEFICIARIES

7.   In the context of the foregoing considerations, an attempt
     is made to evaluate the institutional, technical, and
     financial conditions prevailing in the current sanitation
     systems in various countries of Latin America and the
     Caribbean in order to obtain, on the basis of experience and
     the particular characteristics of the systems being
     analyzed, the following results:

     a)   Characterization of the institutional situation of the
sanitation sector in each country, as well as of the
technical, economic, and financial conditions of the
relevant systems.  Analysis of the participation of
private companies and community organizations in the
construction, operation, and maintenance of systems and
their possibilities for expansion; current and future
policies on the subject.  Critical evaluation and
recommendations for action at the country level, by
international technical and financial assistance
agencies, and by private companies.

     b)   Formulation of viable alternative models of
institutional organization for countries or groups of
countries according to the characteristics identified
which will:  involve private activity in the direct
management of systems; harmonize the various interests
involved; ensure equity, universality, and solidarity
by including sectors and areas at greatest risk; and
strengthen the new role to be performed by the State
(guiding and directing national policy and the
processes of change, promoting decentralized and/or
privatized systems, standardizing, advising, and
regulating activities, etc.)

     c)   Identification of "areas of business" for companies
interested in the management of sanitation systems.

8.   The proposed study does not intend to be either an academic
     analysis or an uncompromising evaluation of the existing
     situation.  It is based on the explicit conviction that in
     order to remedy the serious breakdown in the sanitation
     situation in Latin America it is imperative to radically
     alter the rules of the game by implementing new forms of
     sectoral organization that will bring about changes in the
     role of the State and private enterprise as it currently
     relates to the sector.  Accordingly, what is sought is the
     preparation of a document that will be useful for decision-
     making by various different actors:  governments,
     international assistance agencies (basically WHO/PAHO),
     lending agencies (mainly IBRD and IDB), and private
     companies with an interest in being involved in direct
     management.


III.  PROGRAM OF WORK

9.   It is planned to carry out the study in 19 countries: 
     Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica,
     Cuba, the Dominican Republic, Ecuador, El Salvador,
     Honduras, Guatemala, Mexico, Nicaragua, Panama, Paraguay,
     Peru, Uruguay, and Venezuela.  On-site evaluations would be
     conducted in all cases.  The field work is estimated at 18
     weeks, including travel missions and 54 expert-weeks. 
     Preparatory office work is estimated at 4 weeks for
     methodological preparation and organization of the travel
     missions (8 expert-weeks); 16 weeks of office work (40
     expert-weeks) are provided for processing of the data and
     the country-level evaluations; and another 12 weeks of
     office work (30 expert-weeks) have been allowed for the
     development of alternative models, the identification of
     "areas of business," and the drafting of conclusions and
     recommendations for action.  Evaluations for each country
     would be available beginning the fifth week after the
     relevant field work ends.

10.  The timetable for carrying out the study, starting from the
     date of the agreement, would be as follows:


     a)   Detailed methodology and
organization of travel missions           weeks 1 to 4
     b)   Field work                                weeks 5 to 23
     c)   Individual country evaluations            weeks 8 to 24
     d)   Final products                           weeks 20 to 32

     The field studies are to be carried out in 6 missions, as
     follows:

     Mission 1       Argentina, Chile, Uruguay
     Mission 2       Brazil
     Mission 3       Bolivia, Ecuador, Paraguay, Peru
     Mission 4       Guatemala, Mexico
     Mission 5       Colombia, Cuba, Dominican Republic,
     Venezuela
     Mission 6       Costa Rica, El Salvador, Honduras,
     Nicaragua,                      Panama.


IV.  PERSONNEL, BUDGET, AND DISBURSEMENT  PLAN

11.  The study will be directed by Eng. Luis U. Jáuregui, with
     Mr. Andrés C. Planas and Eng. Oscar R. Vélez functioning as
     alternates.  In all the field evaluations and in the
     different stages of office work, at least one of them will
     direct the study.  Depending on the stage of the study
     involved, Eng. Juan C. Jiménez, Dr. Armando Llop, Ms. Silvia
     Zorrilla, and Dr. de Marco Naon will collaborate as experts.
     

12.  The cost of the study is budgeted at US$357,700.00,
     including honoraria for project management (32 weeks), 132
     expert-weeks, international and domestic transportation, per
     diem, general expenses (communications, secretariat, office
     expenses, and miscellaneous), and unforeseen contingencies
     (5%).  A disbursement plan that would permit execution of
     the study includes an advance of 30%, 20% at week 12 upon
     delivery of the first country-level evaluations, 20% at week
     24 upon delivery of the rest of the country-level
     evaluations, and 30% at week 32 upon delivery of the
     remaining products promised.  A period of 6 months has been
     allowed after delivery of the final results of the study for
     response to specific questions arising from the evaluation
     and/or the rest of the studies promised at no additional
     cost.  During that period, for a maximum of 15 days,
     including travel, the director of the study or on of his co-
     directors would be available to take part in meetings and/or
     seminars to discuss the subject without additional
     honoraria.


APPENDIX:   MINIMUM CONTENT AND GUIDELINES FOR THE STUDY

1.   Evaluation at the Country Level

The analysis will focus on aspects relevant to the
     subject of the study at three different levels:  the level
     of policy formulation, that of sectoral organization, and
     that of the principal and/or representative agencies that
     provide services.  A characterization and an evaluation will
     be developed for each of these levels.

The characterization study consists of an outline of
     the decision-making system at the policy level and the type
     of policies being followed for the Sector, with
     identification of decision-making bodies, priorities, and
     current criteria with regard to private activity as well as
     the degree of development reached in terms of service
     concessions, stock participation, or other forms of
     intervention by private capital, as well as the regulatory
     framework and other legal instruments that govern the
     operations of such companies.

At the level of sectoral organization, the
     characterization will focus on the system that includes the
     planning and financing bodies and service agencies, with
     identification of national, state, and municipal areas and
     the extent of their technical, financial, and administrative
     dependence and autonomy, with special attention to the size
     of existing agencies, their technical and administrative
     capacity, channels of financing, and decision-making bodies.

At the level of specific agencies, the operations of
     the existing agencies will be characterized in terms of size
     in an effort to identify the demand being met and the
     quality of the services being provided, the state of their
     facilities, the levels of investment being maintained, the
     magnitude of investments required, the effectiveness of
     commercial systems, price levels, operational and overall
     results, and in general the effectiveness and efficiency
     with which the prevailing system is meeting the demand for
     services.

At this level an effort will be made to fully describe
     the current work of existing agencies in large metropolitan
     areas and to identify the types of situations that prevail
     in medium-sized urban centers and small localities.

In the evaluation of sectoral operations at the country
     level, the efficiency and effectiveness at the three levels
     covered in the characterization will be assessed in terms of
     the capacity of the overall system to address the deficits
     noted as well as the outlook for change based on possible
     new policies and/or recently applied criteria or criteria
     already being used.

Special attention will be given to those areas in which
     private activity might intervene with greatest involvement
     and to the capacity of sectoral organization to adequately
     regulate such activity.  Consideration will be given to the
     possibility of achieving such private intervention within
     the framework of current legislation and regulations.

Attention will also be given to possible weaknesses
     that might develop in the system, especially in smaller
     localities and/or those that have high operating costs in
     the case of large markets susceptible to management by
     private activities.

In sum, the study will concern itself with evaluating
     the capacity of the current system, and, as appropriate, the
     potential for it to change its form of operation through
     direct involvement of private companies in the expansion and
     exploitation of services.  In addition, an effort will be
     made to assess possible areas of action by private companies
     that have an interest in the matter and the criteria they
     should meet in order to work in the country in question.

Given the working schedule, the proposed
     characterization and evaluation does not attempt to be
     exhaustive or to repeat previous studies.  What is being
     sought is to contribute a practical document that will be
     useful for assessing the sector in question and for initial
     decision-making about activities to be undertaken.

The experience of those who would direct the study,
     conduct the field missions, and evaluate the different
     situations is what makes it possible to ensure the
     usefulness of the product offered.

According to this criterion, each country document
     would constitute a synthesis about 10 pages in length.  The
     background documentation would of course be kept on file and
     would be available to the client.

2.   Alternative Models of Institutional Organization

At this stage of the study, on the basis the
     evaluations carried out for the countries, organizational
     systems at the sectoral level will be designed that are
     applicable to the kinds of situations identified.  The
     models would provide for the intervention of private
     activity in the direct management of services, monitoring
     mechanisms to be used by the State, and possible ways in
     which public authorities might intervene in the delivery of
     services in localities that would not be of interest to
     private companies or the management of which would result in
     excessive cost for the population.

Recent sectoral policies based on operational
     decentralization, community participation, and privatization
     call for the application of models of institutional
     organization that will again integrate all responsible
     sectors by avoiding deconcentration and its attendant risks-
     -including lack of equity and poor quality of services.

According to the characteristics of these models, at
     the present stage the study would include recommendations
     for action at the level of the countries and at the level of
     international technical and financial assistance agencies.

At the national level, recommendations would be
     oriented toward identifying actions which the decision-
     making levels in each country could, if the evaluation
     showed them to be desirable, entrust to direct management by
     private companies, with an indication of the instruments
     that should be generated and the safeguards that should be
     adopted.  They would also tend to identify sectoral
     development possibilities taking into account the scales,
     costs, and capacities of typical systems.

With an orientation toward international assistance
     agencies, the recommendations of the study, in line with
     those carried out at the country level, would focus on areas
     in which activities should be prioritized in order to
     accomplish the changes judged to be desirable.

Given the varied nature of the national political and
     sectoral organizations that would be studied, it is not
     possible to identify a priori the number of alternative
     organizational models that would need to be developed in
     order to find viable solutions in all the cases, but it is
     estimated that this phase of the study can be presented in a
     document of 40 to 50 pages, including recommendations at the
     level of each country (or group of countries with similar
     characteristics) and that of international assistance
     agencies.

3.   Identification of "Areas of Business" for Interested
     Companies

This stage of the study would be aimed at delineating
     and pinpointing systems that might be subject to
     privatization.  A ranking of systems would be included based
     on the degree of feasibility of effective privatization and
     a characterization of the agencies that might be subject to
     such a decision, taking into account levels of risk, levels
     of investment, principal drawbacks that would need to be
     resolved as a prior condition to assuming direct management,
     practical management problems that would need to be
     addressed, and a general outline at the level of similarly
     situated agencies and at the country level of the
     possibilities and drawbacks involved in the management of
     sanitation services.

A set of recommendations for action would also be
     included for different scenarios, as well as an outline of
     the detailed studies that might be needed in order to draw
     up concrete proposals.

According to the criterion that underlies this
     proposal, what is being proposed is the preparation of a
     practical document that will present the basic conditions
     that need to be taken into account in the adoption of
     certain kinds of decisions.  Accordingly, the identification
     and characterization of "Areas of Business," while they do
     not preclude the detailed evaluation that needs to be
     undertaken prior to the preparation of a specific offer,
     provides the elements necessary for showing where efforts
     should be directed, what type of conditions should be dealt
     with in each case, the magnitude of the investments
     involved, and the levels of real and potential revenue. 
     Real experiences from other Regions will be presented in
     summary form.

It is estimated that the results from this phase of the
     study would be presented in a document approximately 30 to
     40 pages in length.
MEETING TO ASSESS THE STATUS OF THE NATIONAL
        PLANS OF ACTION FOR ATTAINMENT OF THE GOALS OF THE
WORLD SUMMIT FOR CHILDREN


21-25 April 1992
Brasília, Brazil


FINAL REPORT

I.   INTRODUCTION

     Through the Declaration and Plan of Action of the World Summit for Children held in
September 1990 in New York, the presidents and heads of state accepted a collective
commitment to adopt national and regional measures to promote maternal and child health;
combat malnutrition and illiteracy; improve sanitation and the provision of drinking water; reduce
the high rates of disease and death among children, adolescents and women; and improve the
social condition of women and families.  The Declaration and Plan of Action establish the goals
that the countries are committed to attaining before the end of the present century.

     The Ministers of Health, meeting during the XXXV Directing Council of the Pan American
Health Organization/World Health Organization (PAHO/WHO), held in Washington, D.C., in
September 1991, adopted Resolution XVI, which urged the Member Governments to: 

     (a)  Review and update their national maternal and child health and family planning
programs in order to reflect the spirit, strategies, and goals recommended in their
respective plans of action; 

     (b)  Promote at the central, regional, and local levels in their countries the decisions
and commitments of the Summit, and call upon the public and private sectors to
join in attaining the national goals on behalf of women and children; and 

     (c)  Help devise a methodology for better estimating the costs of the maternal and
child health and family planning programs in the nineties, which will facilitate the
design of financial strategies and the mobilization of resources.

II. MEETING TO ASSESS THE STATUS OF THE NATIONAL PLANS OF ACTION FOR
     ATTAINMENT OF THE GOALS OF THE WORLD SUMMIT FOR CHILDREN

     In order to follow through with the foregoing mandates and carry on the process of
implementing them, this Meeting was planned, under the auspices of the Government of Brazil,
to bring together representatives from the cooperation agencies and government officials
responsible for making political decisions in the area of women's health, including family
planning, and child and adolescent health.  The purpose of the Meeting was to assess the
progress that has been made toward fulfillment of the commitments of the World Summit for
Children and to plan activities that will accelerate implementation of the National Plans of Action
and strengthen the cooperation with the Governments. 

     This Meeting--the first such gathering to be held since the heads of state met to draft
their historic Declaration in September 1990--brought together representatives from 29 countries
of the Region.  The participants represented the highest executive, legislative, and technical
echelons in the Americas.

     In course of the Meeting, group and plenary sessions were held to assess the progress
that has been made toward attainment of the goals, discuss the difficulties that have been
encountered, suggest corrective strategies, and develop Plans of Work for the period 1992-
1995.

     This report summarizes the issues discussed and the principal agreements and
recommendations made.  A more complete final report will be published and will include the
reports of each of the participating countries, as well as the opinions expressed by the
delegates in attendance.

III. SPEAKERS AND TOPICS FOR THE MEETING

     In the opening session Dr. Rodolfo Rodríguez, PAHO/WHO Representative, and  Dr.
JoØo Yunes, Executive Secretary of the Interagency Committee, addressed the participants. 
The Meeting was opened by Dr. Adib Jatene, Minister of Health of Brazil.

     In the introductory sessions, presentations were made by Dr. Rainer Rosenbaum,
UNFPA, who spoke on "Population, Health and Development"; Dr. JoØo Yunes, PAHO/WHO,
who spoke on the "Current Situation and Future Prospects for Maternal and Child Health in the
Region of the Americas"; and Dr. Gregorio Monasta, UNICEF, whose topic was "Commitments
of the World Summit for Children."

     There were also presentations on "The Situation of the National and Interagency
Committees" and an interagency panel (including representatives from UNICEF, UNFPA,
PAHO, IDB, USAID, UNESCO, and UNDP) on "Strategies for Resource Mobilization to Finance
the National Plans."

     The topics selected for discussion in working group sessions and at plenary sessions
were the following:

Topic I:  "Status of the National Plans"
Topic II: "Identification of Strategies for Improvement of the National Plans"
Topic III:"Preparation of the Plan of Work for the Period 1992-1995"

IV.  CONCLUSIONS AND RECOMMENDATIONS

     The assessment, conclusions, and recommendations of the working groups and the
plenary session on each of the three topics are presented below:

1.   Status of the National Plans

1.1  The Declaration of the World Summit for Children and the respective National Plan have
     been disseminated to an acceptable extent in the Region, taking into account the
     variation in conditions from country to country, which influenced the degree of
     dissemination.  It was considered necessary to step up communication activities in order
     to ensure the involvement of all sectors of society.

     In many cases, as a result of dissemination of the Declaration and National Plan, it has
     been possible to enlist participation by the highest national authorities in the health
     sector, particularly in the area of maternal and child health.  The agencies of the United
     Nations system, as well as other agencies that provide bilateral technical and financial
     cooperation, and nongovernmental organizations have played a significant role in all the
     countries.

1.2  A multisectoral and multidisciplinary approach was used by most countries to prepare
     the National Plan of Action, as well as to develop instruments and program activities
     designed to meet the challenge of attaining the proposed goals.

     Several countries have created Committees to Follow-up on the Goals of the Summit.
     In some cases, these Committees are being headed by the president of the country or
     by a presidential appointee and their membership includes the Ministers of the social
     sectors.  In other countries in which a specific committee has not been created,
     responsibility for follow-up has been assumed by the Ministry of Health in coordination
     with other sectors.

     In many countries Interagency Coordinating Committees have been formed and have
     provided important support.  However, some countries are still in the process of
     establishing a Committee and others have yet to do so. 

     It is necessary to accelerate the process of instituting the Committees to Follow-
     up on the Goals of the Summit and the Interagency Coordinating Committees,
     particularly in the countries in which they do not yet exist.  It was recommended
     especially that an effort be made to involve other sectors of society--including the
     legislatures, the universities, public and private companies, workers, the mass media,
     political parties, and churches--and that active community participation be promoted
     through grass-roots organizations. 

1.3  Some headway has been made with regard to the establishment of agreements to
     support implementation of the Plan of Action.  In some countries, progress in this regard
     has been hampered by the changes in government authorities.  In order to bring about
     further advances it is necessary to secure a commitment from civil society as a whole
     and from the most representative institutions, including the legislatures and the political
     parties, so that the Plans and the proposed goals can be incorporated into State policies. 
     Thus, the continuity of these initiatives will be ensured regardless of any changes in
     authority that may take place as a result of the election of new officials.

1.4  In some countries the activities carried out in connection with implementation of the
     National Plan have been translated into Plans of Operation.  However, in many of them
     this important step has not yet been taken.

     The countries that have not yet done so need to develop Plans of Operation, including
     the corresponding budget, and implement the set of activities planned.

     The principal difficulties that the countries have encountered in carrying out activities
     under their National Plans include the following:

     a)   Financing.  The main problems identified include:  (1) the economic adjustment
policies that have been implemented in the countries and the burden of external
debt payments;  (2) difficulties in estimating the cost of implementing the National
Plans in the medium and long terms; (3) shortfalls in the funds required to cover
the needs that have been identified; (4) failure to include in national budgets the
resources needed to attain the goals of the Summit. 

     b)   Information shortage.  Problems exist mainly in three areas:  (1) difficulty in
making a diagnosis on the basis of which to begin planning, (2) lack of up-to-
date information, and (3) absence of standardization and uniformity in
government and agency data. 

     c)   Limitations in terms of managerial capacity and experience.

     d)   Lack of coordination within the health sector and between the various ministries
and governmental agencies.


2.   Identification of Strategies for Improvement of the National Plans of Action


2.1  With regard to the enlistment of participation by the various sectors and by civil society
     in the countries' efforts to attain the goals set by the Plan of Action, most of the countries
     indicated that insufficient progress has been made. 

     In almost all the countries, support and political commitment have been obtained from
     the highest levels of government.  However, responsibilities have not always been clearly
     defined in terms of coordination and dissemination with other areas of government and
     other social sectors.

     There was consensus on the need to promote participation by society as a whole in
     order to create a collective consciousness that will support the effort and the actions
     aimed at attaining the goals of the Summit.

2.2  As for  the preparation of Plans of Operation for each of the components of the National
     Plan of Action, almost all the countries, after approving the National Plan, have taken
     steps to ensure intersectoral coordination, as well as comprehensiveness and
     complementarity.  The countries that have not yet prepared Plans of Operation are in the
     process of doing so.

     There was consensus on the desirability of making provision in the Plans of Operation
     for work at the municipal level in an effort to ensure regionalization and decentralization
     and to generate participation at the local level.

     The delegates agreed that the Plans of Operation are the basic instrument for launching
     the process of attaining the proposed goals and also for determining resource
     requirements.

2.3  Relative to the establishment of mechanisms for financing activities under the National
     Plan of Action, all the groups recognized the importance of identifying mechanisms that
     will guarantee adequate financing for the plans and programs.

     Most of the groups indicated that there have been demonstrations of budgetary support
     for activities in the area of maternal and child health.  However, only limited progress has
     been made in ensuring more rational use and optimization of the available resources.

     At the plenary session, it was recommended that steps be taken to simplify and
     streamline the slow and cumbersome process of gaining approval for projects and
     obtaining the first disbursement of funds.  Moreover, it was recommended that activities
     be implemented with a view to securing resources from bilateral agencies that provide
     technical and financial cooperation, as well as acquiring information about the areas of
     interest of such agencies and also of the countries and some NGOs that provide this
     type of collaboration.

     Several of the working groups expressed concern about the impact that external debt
     and structural adjustment policies would have on attainment of the goals established by
     the Summit.  In both the working groups and the plenary session, it was recommended
     that an effort be mounted not only to prevent budget cuts but to promote increases in the
     budgets of social welfare programs and the social sectors, particularly health and
     education.

     The participants agreed that it was crucial to identify financing mechanisms in order to
     attain the goals of the Summit.  In this regard, it was underscored that an effort must be
     made to:

     a)   channel government spending toward the health sector, especially areas that
were defined as priorities by the Summit;

     b)   identify other mechanisms of financing such as tax-related reforms, contributions
from the private sector, and funds from regional and local budgets; and

     c)   obtain external resources.

     It was recommended that the international agencies provide technical support to assist
     the countries in their search for financing, including mechanisms to improve efficiency
     and mobilize internal resources.

2.4  In regard to the establishment of mechanisms to follow-up on the National Plan of Action,
     it was considered extremely important to form a Commission to Follow-up and Monitor
     the National Plan in order to safeguard the advances made and indicate corrective
     measures when necessary.

     Very few countries have established a specific commission for this purpose, and it was
     recommended that the formation of such groups be promoted.

     On the topic of indicators, the plenary session recommended that the Governments
     endeavor to improve their information systems and update the existing statistical data
     in close collaboration with the agencies, with a view to establishing reliable, uniform, and
     timely baseline information that will make it possible to evaluate the progress toward
     attainment of the goals of the Summit.


3.   Preparation of the Plan of Work for the Period 1992-1995

     Most of the countries had difficulties in proposing a Plan of Activities for the period 1992-
1995.  The problems were mainly related to the failure to establish Plans of Operation for 1992,
weaknesses in intersectoral coordination, and the need to implement or strengthen certain
activities that are essential for the success of a medium-term plan.

     It was emphasized that it is essential to:  (a) increase the participation and commitment
of society as a whole, (b) prepare and implement Plans of Operation for each component of the
National Plan of Action, (c) establish the National Committees and the Interagency Coordinating
Committees as permanent bodies, (d) institute mechanisms to obtain financing and to follow-
up and monitor the National Plans of Action.

     The working groups proposed that subregional meetings be held for the purpose of
evaluating progress under the National Plans and facilitating the exchange of experiences.
Moreover, the Organizing Committee for the event was asked to seek mechanisms that will
make it possible to follow-up on the agreements and recommendations that came out of this
Meeting, as well as those that will come out of other similar gatherings to be held in the future. 

     The participants reaffirmed their commitment to doing their utmost to see that the goals
of the Summit are realized in their respective countries.


E0197.FIN



PUBLISHED VERSION                                        30/IV/92

BOLIVIA


     In 1991 the Government succeeded in maintaining economic
stability, advancing measures to modernize the infrastructure of
the State, and promoting private capital investment.  Despite the
good results achieved in the country's economy, critical poverty
continues ravaging most of the population and the situation is
aggravated by unemployment, illiteracy, and high maternal and
child death rates.  The Government, recognizing the accumulated
social debt, continued applying a social policy which gives
priority to the health and education sectors and focuses on the
most vulnerable populations in the country.
     In PAHO/WHO cooperation during the year, major support was
provided to carrying out the National Survival, Child
Development, and Maternal Health Plan which the Government
implemented in 1990.  In that respect, activities were oriented
toward developing the infrastructure of the health services,
strengthening local health systems, priority personal health care
and environmental programs, and training health personnel to
carry out the Plan.
     Concerning development of the infrastructure, PAHO/WHO
cooperated in publishing basic documents for the process of
change and the new functions that the Ministry of Social Welfare
and Public Health plans to execute to carry on development of
local health systems, which are known as health districts.  Among
the documents disseminated was a manual on the standards and
procedures of the National Plan which emphasizes comprehensive
health care for women, children, schoolchildren, and adolescents.
     The collaboration given by the Organization to the
authorities charged with the National Bureau of Health Services
and at the managerial levels of the sanitary units and health
districts made it possible to increase technical and
administrative capacity at the national level and develop the
management process.  At the district level, local planning was
initiated with community participation and a guide prepared with
the collaboration of PAHO/WHO was implemented for comprehensive
planning and programming.  With the experience obtained in
implementing the information system of the Polyclinic Hospital as
part of the World Bank's institutional development project,
similar systems were implemented in Cochabamba and Santa Cruz
which have supplemented the health information subsystem.  This
subsystem was put into operation beginning in April in all the
health districts.  As part of the Comprehensive Health Project
financed by the World Bank, the Government, with the
collaboration of PAHO/WHO, continued implementing a national
system of maintenance and conservation for the health services
which now encompasses, in addition to the Department of La Paz,
the Departments of Cochabamba and Santa Cruz.  A subregional
meeting was also held on evaluation of local health systems in
the countries of the Andean Area.  Through the technical
cooperation among countries approach, specialized technicians
from the Government of Cuba contributed to the training of
personnel in the maintenance of intensive care units in the
pediatrics services of Cochabamba, La Paz, and Sucre and to the
rehabilitation of equipment in the general hospitals of those
cities.  In the sanitary units, seminars and workshops were
sponsored on structuring hospital policies with intersectoral
participation, analyses resulting from evaluations and their
review, and hospital procedures.  PAHO/WHO contributed to the
restructuring of social security, especially with respect to the
creation of Departmental Unified Funds and a Unified Basic
Pension Fund; it collaborated in the first meeting of presidents
and directors of social security institutes in the Andean Area,
in April in La Paz; and in preparing a proposal for an Andean
Social Security Agreement. 
     With regard to the country's priority programs, PAHO/WHO
concentrated its efforts on carrying out the National Plan in the
health districts, directed especially toward the provision of
maternal, child health, and family planning services and toward
establishment of 14 health districts within the local health
systems.  In addition, it helped prepare two projects which have
UNFPA financing valued at $US4 million in 1992-1995 to improve
the health situation of women and adolescents in the 27 poorest
rural health districts in the country.
     An agreement was signed between the Bolivian University and
the Ministry of Social Welfare and Public Health to modify the
curriculum on maternal and child health and to unify it at the
national level.  This activity is important since it will make it
possible to train professionals in the three schools of medicine
and the seven nursing courses in knowledge consonant with the
country's health situation.  The process, which will be initiated
in 1992, will have the technical support of PAHO/WHO and
financing from  UNFPA and Johns Hopkins University (USA). 
Community work was strengthened mainly through the inclusion of
traditional and responsible midwives in local health systems. 
The first meeting of traditional midwives was held at a site on
the border between Bolivia and Brazil, an activity that opened up
the possibility of future technical cooperation among countries
in this field.  Bolivia, in its capacity as the coordinating
country in the maternal and child health area within Andean
Cooperation in Health, organized a meeting of the focal points in
that field during which a subregional maternal and child health
plan for 1992-1993 and a manual on the duties of the focal points
in that field and of the coordinating country were prepared.
     In the field of nutrition, PAHO/WHO helped carry out several
activities, among which were strengthening of the Nutritional
Epidemiological Surveillance System at all levels of the health
services system and strengthening the campaign against goiter and
disorders caused by iodine deficiency, control of iron and
Vitamin A deficiencies, nutrition education, and dietary care. 
All these activities were carried out as part of an approach to
local health systems regionalization with multiprogrammatic
management and coordinated with others programs, such as
education, agriculture, transportation, planning, and the Social
Investment Fund, as well as with the National Institute of
Statistics, the World Food Program, and the Corporations of
Development.
     Concerning the development of human resources, changes in
the curricula in the training of medical, nursing, biochemistry,
pharmacy, and nutrition personnel were promoted; in-service
training of auxiliaries and technicians in district training
centers was proposed; a methodological process of continuing
education in managing health services to help the development of
local districts was developed and validated; and a unified
subsystem of managerial information on human resources was
prepared for the Departments of Human Resources and of Personnel
in the Ministry of Social Welfare and Public Health.
     The Organization contributed significantly to the campaign
against cholera in Bolivia:  all its consultants in the country
participated in the national effort against the epidemic and each
of them was assigned to sanitary units where they supported
activities to control the epidemic.  In addition, the development
of mechanisms of information and feedback, epidemiological
surveillance, development of standards, surveillance and control
of food and water, training, and organization of a laboratory
network to identify Vibrio cholerae in human feces, in waters for
human use, in wastewater in food, and research on certain aspects
of transmission was stimulated.  In addition, it collaborated in
training those responsible for cholera surveillance and control
and laboratory professionals at the national and departmental
levels, and contributed to the acquisition and provision of
inputs, mainly for laboratories.  In addition, the Organization
collaborated in research, training, evaluation, and supervision
activities in programs to control other communicable diseases
such as tuberculosis, Chagas' disease, malaria, yellow fever, and
dengue.
     Concerning the Expanded Program on Immunization (EPI),
technical cooperation was basically to progress toward the target
of eradicating poliomyelitis in the Region.  During 1991 the
greatest vaccination coverage ever obtained was achieved, due
mainly to the inclusion of vaccination as a continuous activity
in the health services and to the elimination of lost vaccination
opportunities.  Since 1986 there has been no evidence of wild
poliovirus in the country.  The poliomyelitis surveillance system
exceeded the rate of identifying flaccid paralysis cases required
for the countries of the Americas.  Neonatal tetanus was
controlled in Santa Cruz, a department which up to 1990 was
considered that at highest risk; this was achieved thanks to on-
going vaccination in the health services and to the training of
lay midwives in application of the tetanus toxoid.  Special
emphasis was placed on inventorying the cold chain equipment in
the country, which made it possible to update requirements and
effect adequate distribution of the equipment acquired through
the Interagency Coordinating Committee of the EPI.
     Since food-borne diseases are responsible for 70% of the
total number of cases of diarrheal disease in the country,
PAHO/WHO cooperated in organizing comprehensive food surveillance
and control as well as management and protection programs.
     The Organization cooperated with the Ministries of
Agriculture and of Rural Matters and Agriculture and Livestock
(MACA) in activities to eliminate foot-and-mouth disease, rabies,
and other zoonoses.  In addition, an agreement was signed with
the MACA and the Ministry of Social Welfare and Public Health to
establish a primatology project.
     The national essential drugs program, with PAHO/WHO
cooperation, carried out important activities in the fields of
interinstitutional coordination, formulation of standards and
regulations, review of the national therapeutic form, management
of the drug subsystem, training administrative and technical
personnel of the Ministry of Social Welfare and Public Health and
nongovernmental agencies, and strengthening the Central Supply
Warehouse.  It also had a donation from the Kingdom of the
Netherlands to buy essential drugs.
     In environmental health, PAHO/WHO collaborated with
universities and several institutions in that sector in the
institutional reorganization of the sector, personnel training,
development of a project to control risks to health resulting
from wastewater contamination (from manipulation of heavy
metals), dissemination of information, training of personnel in
occupational health activities, and in strengthening emergency
preparedness and disaster relief coordination.
     In regard to the prevention and control of AIDS, PAHO/WHO
cooperated especially in the educational component and in
personnel training, with the participation not only of medical
personnel but also of dentists, nurses, personnel responsible for
the care of street children, and staff members from institutions
outside the health sector.  One of the most important
achievements was the programming of activities with the active
participation of local-level staff members, including
epidemiologists, laboratory workers, educators, and
administrators of the principal sanitary units, as well as staff
members from other cooperation agencies.
E0198.FIN



CHAPTER V.E                                              30/IV/92

PUBLISHED VERSION

COMMUNICABLE DISEASES


     Within the reference framework of the strategic orientations
and programming priorities for the Pan American Health
Organization during the 1991-1994 quadrennium, the Organization
collaborated with the countries in the decentralization and
integration with the health services of activities to prevent and
control communicable diseases, and in strengthening the services
so that programs to control vector-borne diseases, leprosy,
dengue, and other viral and parasitic diseases could be carried
out efficiently.
     Among activities of note in the reorganization of the health
sector is the program to control and prevent tuberculosis in the
countries of Central and South America.  The program, which for
several years has had decentralized services, was subject to
substantive changes after the establishment of a network of
national tuberculosis diagnosis laboratories.  With financial
support from the Nordic countries (Denmark, Finland, Norway, the
Kingdom of the Netherlands, and Sweden), the Organization helped
decentralize and strengthen malaria control activities within
local health systems, mainly in Central America.  In Colombia, it
continued promoting decentralization of the Division of Direct
Campaigns through preparation of general guidelines and the
formation of a technical-legal group which drew up a project
dealing with the transfer of activities in a period of up to two
years in those municipios considered at low-risk of malaria, of
three in those at medium risk, and of five in those at high risk.
     To focus attention on high-risk groups, the activities were
based conceptually and operationally on the process of
epidemiological stratification.  It was thus possible to give
priority to areas in greatest need of resources and characterize
those which generate the greatest number of cases in a situation
study for projects to invest in the malaria programs in El
Salvador, Guatemala, Honduras, and Nicaragua.  In research on
malaria promoted by the Organization in Brazil and Venezuela, an
attempt was made to identify and rank the principal risk factors
epidemiologically, recognize their relative importance, and
select specific sectoral and intersectoral intervention measures
at the local level to achieve malaria prevention and control.
     Social communication and community participation were
essential elements in PAHO/WHO's technical cooperation with the
countries to prevent and control communicable diseases,
especially as a supplement to integrated entomological
surveillance activities.  Personnel from the Organization
participated in controlling Aedes aegypti in Panama and
collaborated in carrying out two projects, one in Honduras and
another in Venezuela, in which social communication and health
education are combined with integrated entomological surveillance
measures which include biological control.  The implementation of
projects dealing with environmental sanitation to control malaria
and dengue vectors in the countries of Central America, Trinidad
and Tobago, and Venezuela was also promoted.
     Human resources training was an important part of PAHO/WHO's
collaboration with the countries.  In vector control training,
emphasis was put on promoting integrated control, environmental
sanitation, and biological control; emphasis on chemical control
was reduced, and health education and social participation was
promoted.  As for malaria control, workshops on epidemiology and
evaluation of control measures were offered in Panama and on
identifying risk factors in Colombia and Mexico; courses were
given on epidemiology and epidemiological stratification in
Ecuador, Mexico, and Peru; a workshop on vector control was
organized in the Turks and Caicos Islands, and training
activities were carried out for field and laboratory staff in
techniques to evaluate the focal control of malaria in Mexico.
     The Organization, jointly with the Department of
Epidemiology and Biostatistics of the Graduate School of Public
Health of the University of Puerto Rico, offered a course on the
epidemiology of communicable diseases for professionals from
Latin America and the Caribbean.  Its objective was to respond to
the training needs of professional personnel as to the
methodology utilized for the epidemiological stratification of
risk in the communicable diseases.  As in previous years, it
continued supporting the offering of graduate courses in
entomology in Brazil, Colombia, Mexico, and Panama, and on
malaria and environmental sanitation in Venezuela.  In addition,
the training of staff members of the rodent control program in
Dominica was promoted.
     In regard to tuberculosis prevention, there was
collaboration in preparing and offering courses on bacteriology
and organization of laboratory networks in Mexico and Venezuela,
laboratory diagnosis in Bolivia, and epidemiology and control in
Argentina, Chile, and Mexico.  Subregional workshops on
bacteriology were also organized in El Salvador and Peru.  In
addition, PAHO/WHO convened two meetings, one in Mexico and the
other in Venezuela, to define the interventions which national
programs to prevent and control leprosy and tuberculosis should
carry out in coming years.  The need to establish information and
surveillance systems with a capacity for analysis at the local
level was promoted in both meetings.
     According to the mandates from the Governing Bodies,
activities were promoted to eradicate certain communicable
diseases.  Toward that end, a plan of action was carried out to
eliminate leprosy as a public health problem (to less than 1 case
per 10,000 inhabitants) in which nongovernmental agencies are
involved.  In addition, as a preliminary step to conducting
activities to eradicate the non-venereal treponematoses,
activities were initiated to define their distribution in
Colombia and Venezuela.
     With the promotion and support of PAHO/WHO and the
cooperation of the Helen Keller Foundation, River Blindness
Foundation, International Foundation for Eye Care, AID, and the
Donation Program of Mectizan, a meeting was held with
participants from the endemic countries in which a plan of action
was designed which will serve as a basis for eradicating
onchocerciasis.  Activities were initiated to achieve that target
in Ecuador, Guatemala, and Mexico, and epidemiological studies
were promoted in Brazil, Colombia, and Venezuela.  The latter
will provide basic information for evaluating control measures. 
In addition, support was provided to the countries of the
Southern Cone in implementing a subregional program to eliminate
Trypanosoma infestans and eradicate American trypanosomiasis
transmitted by blood transfusion.
     The Organization's personnel participated and collaborated
in surveillance and evaluation of insecticides for malaria
control in Mexico and in entomological studies in malarious areas
in Guatemala, Mexico, and Venezuela; in a test of insecticide-
impregnated curtains in Guatemala and Mexico, and in the
biological control of anophelines and Aedes aegypti in Brazil,
Honduras, and Venezuela.  Follow-up was also carried out of a
comparative test of various strategies to control triatomas, such
as the use of fumigant jugs and paints containing residual
insecticide, and traditional spraying, as well as to determine
the effect of parasiticidal treatment of children infected by
Trypanosoma cruzi.  These investigations, which are being carried
out in Argentina, Brazil, Honduras, and Paraguay, are financed by
the UNDP/Bank World/WHO Special Program for Research and Teaching
in Tropical Diseases.  The Organization also cooperated in
designing an evaluation of phase IV of the vaccine against Junín
virus which is made in Argentina with financial support from AID.
     The activities carried out to control leprosy made it
possible to collect updated statistical data on the disease;
evaluate the various control programs epidemiologically and
operationally (coverage of multiple drug therapy); review the
programs' models of organization, sources of financing, and
degree of integration, and define strategies for formulating
plans of action to eradicate the disease.  In addition, advisory
services were provided in Argentina, Brazil, Colombia, Costa
Rica, the Dominican Republic, Ecuador, Guatemala, Nicaragua,
Panama, Paraguay, and Peru during the year to promote
incorporation of the leprosy control program's activities into
the general health services, improve their decision-making
capacity with regard to diagnosis and treatment, and promote the
practice of multiple drug therapy.
     PAHO/WHO organized the visit of a group of experts to
Venezuela to review the hemorrhagic fever situation in the
country.  The group recommended that studies be carried out to
characterize the viruses biologically and molecularly, develop
methods of diagnosis, define their incidence and geographical
distribution, and identify risk factors.  It also recommended
that ecological studies be undertaken to identify their
reservoirs, population dynamics, and biology to guide control. 
With financial support from the Organization, these studies are
being carried out at Yale University (USA) and the National
Institute of Hygiene of Venezuela.  Also with regard to viral
diseases, PAHO/WHO collaborated in a pilot study on vaccination
against hepatitis B in Peru, and in another on the feasibility of
producing a vaccine against Argentine hemorrhagic fever as well
as other vaccines in Argentina.
     The dengue situation in the Region continued to deteriorate
because of the increase in the density of the mosquito Aedes
aegypti.  In 1991, cases of dengue hemorrhagic fever were
recorded in Brazil, Colombia, Honduras, and Venezuela.  Only
Canada, the Cayman Islands, Chile, Costa Rica, and Uruguay can be
considered free from this vector.  The Organization cooperated in
Aedes aegypti control and surveillance with Brazil, Colombia,
Ecuador, Panama, Uruguay, Venezuela, and the countries of Central
America.  In addition, it prepared jointly with El Salvador,
Guatemala, and Honduras a trinational dengue control plan to
reduce the vector's density to levels which do not permit
transmission; strengthen epidemiological surveillance systems;
increase the response capacity of the general health services,
and achieve the participation of the population in preventing and
combating the disease.  It also promoted and organized an
international meeting to draw up guidelines for the dengue
prevention and control programs in the Americas, as well as a
meeting in Barbados to strengthen the information systems of
national Aedes aegypti control programs in which representatives
from the Ministries of Health of Martinique and Trinidad and
Tobago participated.
     With the collaboration of WHO's Parasitic Diseases Program,
it organized and carried out an informal consultation to define
regional guidelines for parasitic disease prevention and control
programs.  Finally, PAHO/WHO cooperated in rodent surveillance
and control activities in Anguilla, Dominica, Montserrat, and
Saint Lucia.
(Last part of chapter IV.E)
     Many activities to control sexually transmitted diseases
(STDs) were implemented, reflecting the Government's renewed
interest in halting the transmission of these diseases.
     At the scientific and technical level, the VIII Meeting of
the Latin American Union Against Sexually Transmitted Diseases
(ULACETS), held at Santo Domingo, served as a forum for
discussing STD laboratory needs as well as necessary
multidisciplinary support of medical and behavioral interventions
for STD control.  With PAHO/WHO's regional support, ULACETS
developed a protocol to implement the eradication of congenital
syphilis in Brazil and the Southern Cone countries.
     Treatment guidelines and simplified patient management
algorithms for sexually transmitted diseases were prepared and/or
distributed throughout the Region for use by specialists and
health providers at the primary care level.  Reviews of country
STD surveillance reports (Chile, Haiti, Uruguay), analyses of
country data on syphilis and gonorrhea available at the regional
level, and the training of professionals in epidemiological
surveillance at two subregional workshops set the stage for
improving STD surveillance in 1992.
     Finally, acknowledgement of the interaction between HIV
infection and other sexually transmitted diseases resulted in
additional regional efforts to strengthen control programs in the
Member Countries, notably in the Bahamas, the Dominican Republic,
Haiti, Jamaica, Martinique, and the Eastern Caribbean.





MATERNAL AND CHILD HEALTH PROGRAM
 PROGRAM FOR HEALTH PROMOTION/SUBPROGRAM ON THE
MENTAL HEALTH OF CHILDREN















ADVISORY GROUP FOR THE FORMULATION
OF A REGIONAL PLAN OF ACTION
FOR THE MENTAL HEALTH OF CHILDREN 

Montevideo, Uruguay, 4-8 November 1991















PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION
ADVISORY GROUP FOR THE FORMULATION
OF A REGIONAL PLAN OF ACTION
FOR THE MENTAL HEALTH OF CHILDREN 






World Summit for Children


     

     In accordance with both the above commitment and the policies of the Pan American Health
Organization, the Organization, in conjunction with the Government of Uruguay and the Organization
of American States, convened an Advisory Group for the Formulation of a Regional Plan of Action on
the Mental Health of Children, which met in Montevideo at the Latin American Center for Perinatology
and Human Development during the week of 4-8 November 1991.  The following persons acted as
moderators of the Group:  Dr. M. Cherro, Director of the Clinic of Child Psychiatry, and Dr. R. E.
Bernardi, Professor of the Department of Medical Psychology of the School of Medicine of the
Universidad de la República, Montevideo.








     The objective of the meeting was to analyze the conceptual bases underlying the activities related
to promotion of the mental health of children and to the prevention and treatment of the emotional and
mental disorders that typically affect this age group; to analyze the most outstanding health and social
problems; and to propose a preliminary draft for a plan of action at the regional level.






     The meeting was initiated with remarks by Dr. R. Schwarcz, Director of the Latin American
Center for Perinatology and Human Development (CLAP), who welcomed the members of the
Advisory Group, expressed his thanks for the selection of CLAP as headquarters for the meeting, and
reiterated the support given by the Center to the work of the Group.

     Dr. V. Rathauser, Country Representative for Uruguay of the Pan American Health Organization,
officially opened the meeting and transmitted greetings to the Group on behalf of the Director of PAHO,
Dr. Carlyle Guerra de Macedo, who thereby made known his special interest in the subject area and his
willingness to support the Plan of Action formulated by the Group. 

     Dr. Rathauser pointed out that the initiative was the outcome of cooperation between two priority
PAHO programs, Maternal and Child Health and Health Promotion, which had joined efforts to deal
with an aspect of health that until the present time had been touched upon only tangentially by the
programs of PAHO:  the promotion of mental health and the harmonious development of children and
adolescents.  He further underscored the unique impact that a program of this type could have for the
future of the population and expressed his hope that the Group would find creative responses in this
field of major importance.

     Dr. I. Levav, PAHO Regional Mental Health Adviser, reported to the Group on the objectives
of the meeting, pointing out the importance of the deliberations for preparation of the preliminary draft
of the Regional Plan of Action for Mental Health of Children, which would serve as the principal tool
in the search for responses to the priority problems in this field.  The draft would be circulated among
the numerous parties involved in the Region who, in turn, would make suggestions for its enhancement. 
It was planned to convene a Regional Conference that would give final form to the proposed plan. 
Subsequently, national conferences would be convened which, after study of the Regional Plan, would
prepare the respective national plans of action.

     Dr. Levav noted that the Regional Plan should fill certain requirements that would ensure its
implementation and effectiveness, as follows: 

     a)   In consideration of the intersectoral nature of the mental health of children, the Regional
Plan should recommend activities whose execution would be the immediate responsibility
of:

-    the various health subsectors involved (Ministries of Health, social security, health
insurance, and other systems of prepaid health care, etc.) and the corresponding
programs and services (maternal and child health and health of the adolescent,
mental health, prevention and control of addiction,  health education, etc.);
-    the education subsector;
-    the various legislative bodies;
-    other sectors related to social policies;
-    nongovernmental organizations; and
-    international organizations, for example, PAHO/WHO, OAS, UNICEF, UNESCO,
etc.

     b)   A second requirement of the Regional Plan was the recognition that health and well-
being depend on the social, economic and, political conditions of the communities, which
may give rise to adverse situations that affect psychosocial development and result in
diseases and disorders of a biological, psychological, and social nature.  Special
importance should be assigned to examination of the evidence accumulated with regard
to these influences during preparation of the Plan.

     Dr. E. N. Suárez Ojeda, PAHO Regional Adviser in Maternal and Child Health, referred to the
Regional Plan of Action for the Promotion of Development and Growth in the Americas with which
the proposed Regional Plan for the Mental Health of Children would be closely associated.  In this
respect, he called attention to some of the regional health targets for the year 2000:  

     -    life expectancy at birth of more than 70 years;
     -    infant mortality rate lower than 30 deaths per 1,000 live births;
     -    preschool death rate lower than 2.4 per 1,000;
     -    vaccination coverage of 100% of children under one year of age; and
     -    universal access to health services, since adequate delivery care is one of the most easily
obtainable indicators.

     He referred to the World Summit for Children, held in September 1990, in which 150 countries
were represented and more than 70 Presidents and Prime Ministers attended.  In the meeting the
commitment was assumed of investing maximum efforts to strengthen promotion of the family and
ensure care for the psychological needs of children in especially difficult situations.



     The action mechanisms of both the Program for Maternal and Child Health and the Program for
Health Promotion provide the countries with advisory services in special areas such as program
development, orientation and cooperation in the mobilization of human and material resources, and the
promotion of research.  The management and dissemination of information and the use of the
communications media for social purposes are other components of both programs that are important
in the field of the psychosocial development of children and adolescents.

     There are a great number of questions that still have not been answered in the field of
psychosocial development and a great number of areas regarding which on consensus is needed.  It is
also evident that the bio-psycho-social development of children and adolescents takes place in various
environments successively or simultaneously and that its promotion is not the exclusive domain of the
health sector.  Hence, the emphasis should be placed on the intersectoral approach, both for the
achievement of a consensus with regard to theoretical considerations and with regard to cooperation
between the sectors.  To design a plan that weighs the factors mentioned and results in the participation
of such varied fields is the challenge that is being faced at the present time.

The mental health of children is a function of their gene
pool and of the influences of the environment in which
they develop, among which are those received at the
maternal breast and those dependent on the physical and social environment in which they spend their
early years of life.  Among the basic requirements for children to reach an optimum mental state of
health are the progressive unfolding of their cognitive abilities, the establishment of close emotional
ties with the persons in their immediate surroundings, and the development of significant social and
productive relationships through the use of their capacity for play and, subsequently, their performance
at school.












     In addition to those already mentioned, other social sectors influence the life and development
of children, and it is consequently essential that close relationships be established with these sectors and
that strategies and activities be undertaken to promote children's well-being and full development. 
These include those relating to the legislative and legal frameworks, the economy, and the policies
adopted on housing, recreation, and community development, among others.  Linkage with the private
sector, and especially with the nongovernmental and international organizations, is an important factor
in achieving consensus.

     It would surpass the capacity of the health sector to attempt to develop plans and programs for
the promotion of mental health in children in which specific actions are prescribed that rightly fall
within the competency of other sectors.  What is possible and necessary is to communicate with these
sectors, draw attention to the importance of their actions on the lives of children, promote the correction
of unquestionably harmful situations, and encourage measures that will contribute to well-being. 
Specific actions should be coordinated and the preparation of a multisectoral plan of action should even
be considered.

     There exists, nevertheless, a particular instance in which joint action is not only possible but
necessary.  This is the case with regard to the coordination of actions and, ideally, the execution of joint
programs on the part of the health and education sectors.  The Group expressed its agreement on this
point and pointed out numerous opportunities for joint action to identify achievable, common strategies
and ultimately formulate concrete recommendations.






     Whatever Regional Plan of Action on Mental Health of Children is eventually formulated should
be consistent with the policies and targets of PAHO's General Health Plan and with those of the
Regional Plan of Action for the Promotion of Growth and Development.  The regional targets
established by these Plans for the year 2000 envisage the reduction of average child mortality in the
Region to fewer than 30 deaths per 1,000 live births and preschool mortality to fewer than 2.4 per 1,000. 
At the same time, it is expected to increase coverage of the health services to 100% of the child
population.  It should be noted that these targets pertain exclusively to the physical aspects of health
and that the need remains for programs to include psychological and social dimensions as well. 

     Three basic principles of the Plan for Growth and Development are also valid for the mental
health of children, and they should prevail in the Regional Plan of Action:  the risk approach,
community participation, and intersectoral coordination.  In support of these principles and as
fundamental strategies in developing the Plan of Action and the programs deriving from it, emphasis
was placed on matters relating to manpower development and the promotion of research, points on
which specific pronouncements were made.

     In discussing the various items on the agenda, repeated mention was made of the desirability of
incorporating the actions into the framework of primary care.  With this purpose in mind, it was
recommended that this should be carried out as a specific strategy.

     The strengthening of intersectoral relations was another approach underscored repeatedly by the
Group.  The desirability was emphasized of dynamically promoting both intersectoral incorporation of
the formal structures of administration related to the health, well-being, and education of children and
those of a nonofficial nature in the national area and at the level of the communities.

     Legal reforms oriented toward the protection and promotion of mental health of mothers and
children was another of the strategies pointed out during the meeting.  Among the changes discussed,
fundamental importance was given to the reforms required in labor legislation affecting women.

     Another strategy that was considered referred to the promotion of recreation programs
appropriately adapted to the needs of children and their families.






Several approaches through which the activities
making up the Regional Plan of Action could be carried
out were examined, and it was determined that the time-honored categories of promotion of mental
health and primary prevention, repair of damages or secondary prevention, and rehabilitation or tertiary
prevention were appropriate to the purposes of the Regional Program.

     The vastness of the field of action of these approaches confirms the need to establish priorities
both with regard to already selected fields of action and to the population groups for which preference
would be given to the use of available resources.

     From the perspective of the health sector, the setting in which its immediate actions will take
place is the area of the health services, which can play a double role with regard to the mental health
of children in acting as elements of health care per se and, paradoxically, as iatrogenic agents.

     The emotional equilibrium of mothers and children who are seeking health care is often
threatened by situations that arise in the health services.  Certain attitudes and behavior on the part of
the suppliers of the services and the general environment in many centers, where treatment is brusque
or the human rights of the patients are openly violated, sometimes succeed in producing emotional
imbalance. 



     




     The various mental health activities that make up the plans and programs should not be
developed monolithically in the manner of highly centralized vertical programs.  To the contrary, they
should be incorporated horizontally as elements of already existing child health programs, especially
as elements of maternal and child programs, and programs for the health of preschool and
schoolchildren.  At the same time a close relationship to the existing child care programs in other
sectors will be promoted, particularly with regard to education.

     Throughout the meeting several priority subjects considered to be of a priority nature were
discussed in the understanding that they do not exhaust the inventory of problems and conditions that
affect the mental health of children, although by virtue of their importance they deserve to be
considered among the foremost priorities.  They constitute points of departure that can serve as a basis
for the development of proposals for drafting the Plan of Action.

     The tentative nature of the proposals brings to light the general tone it is desired to imprint on
the Plan, whose preparation will not consist merely of the formulation of rigid canons but will rather
form part of a process of consultations, revisions, and reapproximations over the next two years.

     An abbreviated version of the presentations that served as a point of departure for the discussions
is contained in the annexes of the present report.  A summary is provided below of the most outstanding
points of the debate:


     Diagnosis of the Situation

     The information available in Latin America on the programs is insufficient to make an
approximate diagnosis, much less an accurate evaluation, of the situation of the mental health of
children, either with regard to the most important problems or to the services provided to care for them.

     The impression given by the specialized publications and general health reports is that at the
present time no specific programs exist for the mental health of children.  It may be affirmed with
relative certainty that national or provincial programs with defined structures and systematized actions
do not exist, although it is possible to identify actions and isolated programming elements in a very
small number of health services that could be considered to constitute mental health care.

     Thus, in several countries mental health considerations have been introduced into prenatal control
service, delivery care, and the management of high-risk deliveries.  In other countries infant stimulation
has been incorporated into maternal and child health programs.  Isolated mental health actions have also
have been carried out in programs for nutritional surveillance and family planning and in community
activities related to the extension of coverage of the general health services.  Evaluation of the maternal
and child health programs in the Hemisphere generally have to do with physical health care and, with
certain exceptions, do not emphasize the psychosocial aspects of maternal and child health.

     With regard to the most prevalent problems, some epidemiological research on mental health in
the general population in the 1960s included questions on the problems of children, and the results led
to the conclusion that a relatively high prevalence of mental retardation exists, both organic and
functional.  Subsequently, a few studies were carried out on the prevalence of epilepsy in the school
population that indicate surprisingly high rates, in some cases higher than 2% of the population studied. 
Child development studies have generally accentuated physical considerations.  Some studies have been
carried out on family dynamics, emphasizing the small amount of stimulation received by children in
the lower income strata and the consequent impairment of their social and cognitive development. 
More information is available in the education sector, especially with regard to school failure and
desertion, and to a lesser degree to learning and behavior problems.  However, generally speaking, the
health sector does not manage such information nor has it undertaken broad programs of cooperation
with the school system.


     Primary Prevention and Promotion

     Promotion of the mental health of children and primary prevention of psychosocial development
disorders, emotional imbalances, and mental disorders in children was dealt with throughout the
meeting and especially referred to in the working groups.  It was pointed out that the psychosocial
development of children does not end with adolescence, although there is evidence that the first six
years of life are critical to child development and that emphasis should consequently be given during
this period to actions to prevent imbalances and promote optimal development.

     The importance of global policies was underscored, particularly with reference to economic
policies and the consequences for the mental health of the family and children of the restrictions
imposed in most of the countries by the economic readjustment measures that have been carried out,
which have been largely the consequence of the external debt.  Note was taken of the importance of the
legal framework, which influences the daily lives of families and has a decisive effect on the mental
health of mothers and children.  Attention was also drawn to the need for analyzing the sociocultural
aspects involved, especially with regard to the practices followed in rearing children and to certain
attitudes and beliefs particularly prevalent in the Region.

     The existence of numerous prevention measures of proven effectiveness was repeatedly
mentioned, although it was considered desirable to weigh the cost/benefit ratio of each, both in
proposing them and in evaluating them.  

     Among the interventions considered, great importance was assigned to those capable of being
incorporated into programs for family planning, prenatal care, immunization, disaster preparedness,
prevention of malnutrition, and accident prevention.

     Some aspects of general health care that take place outside the health facilities can incorporate
effective prevention and promotion actions at low cost with proven effectiveness, as, for example, house
calls and of school health programs.


Role of the Family

     The family as a determining factor in the mental health of children was an important item on the
agenda; it was also considered repeatedly in discussing other subjects during the meeting.

     The subject of the dissolution of marriages and its social and economic consequences-
-which are mostly negative for mothers and children--was examined in detail, and the promotion of
legal protection measures was suggested.  The Group also formulated other recommendations to prevent
harm, including the identification of couples at risk, the training of health workers to carry out concrete
interventions, the development of educational programs, and, as in other aspects of the Plan, the
adoption of legislative measures.

     The effects of dysfunctional couples and the adverse consequences on children of abandonment
of the home by one of the parents were debated widely.  The provision of psychological counseling and
care services for couples with problems was another one of the recommendations formulated.

     Physical and psychological abuse of mothers and children was analyzed with respect to its effects
on the mental health of the victims and the need for providing specific assistance and for promoting
protection and rehabilitation measures. 

     The role of mothers is customarily underscored as the key element in promoting the psychosocial
development of children, thereby ignoring the role performed by fathers in this process.  It has been
suggested, accordingly, that the programs consider both partners of the couple in educational initiatives
oriented to promotion and prevention as well as in direct care when it is indicated.

     Among the measures for the promotion of mental health and primary prevention based on family
life are the sharing of tasks between the spouses, house-call services, and the granting of paid leave
from work for both parents on the occasion of births and adoptions in the family.

     It should be pointed out that the activities prescribed in this field precede birth and continue
beyond adolescence; consequently, they should be initiated before conception and even before
formation of the couple.


     Role of the School

     The school plays a determining role in the psychosocial development of children.  Unfortunately,
the conditions prevalent in the school system in most of Latin America are not propitious to optimal
development.

     The training of teachers is almost always a cause of controversy, and studies are generally
lacking on what the most appropriate training should be in view of the heterogeneous situations of the
countries.  As a rule, teachers do not receive any training or field experience with regard to the mental
health of children.

     Teachers not only are poorly trained but in practice are forced to develop curricula within a short
period of time, teach a large number of classes, and be subjected to numerous administrative controls. 
The parents, whose opinion as a rule is not required by the school system, cannot make their voices
heard with regard to the educational process, and still less are they able to intervene actively and
contribute along with the educators in processes that are not strictly academic, such as in the promotion
of mental health.

     A high proportion of the children who begin primary education do not finish it, and the number
of school desertions before the third grade is high.  A substantial portion of the population therefore
remains in a state of semi- or total illiteracy.  Under such conditions adequate psychosocial development
is threatened, and a socially and economically disadvantageous situation is created for the future of the
child.  School desertion is associated with patent risks for mental health, as is demonstrated by the high
proportion of school dropouts revealed by surveys carried out on inhalers of solvents, prostitutes,
common delinquents, and the perpetrators of violent acts.

     An appreciable portion of the school population in the Region, which in some cases may reach
as much as 10%, demonstrate learning problems.  However, the educational system does not have
facilities for evaluating these children nor does it provide services for assisting them.  It was
recommended that these deficiencies be remedied, and that in the case of children with learning
problems, that their cultural particularities, their native languages, and their home conditions be taken
into account when they are evaluated in order to ensure that cultural deterioration is not interpreted as
a lack of intelligence. 

     In general, the schools do not possess the equipment and facilities necessary for the promotion
of academic development, such as libraries, data processing, and periodicals. 

     Despite the apparent cultural uniformity of Latin America, the product of Spanish and Portuguese
colonization, the Region is home to a multitude of cultural groups, scattered in a mosaic of communities
that use different languages, are in various stages of development, and have disparate degrees of
technological development.  A particular case is that of the indigenous peoples, many of them
monolingual, for whom the school systems, with certain exceptions, do not provide.  But other
marginalized groups also exist who are not necessarily indigenous and who also live in a state of
abandonment or neglect. 

     The conditions outlined above produce great educational differences, both at the hemispheric
level and within the countries.  Only in exceptional cases have experiments been carried out in which
the modalities of the educational system have been adapted to the characteristics of the various
population groups.  In general it may be said that the Latin American educational system is undergoing
a crisis, determined in part by the economic situation.  There is a predominant trend toward the
decentralization and privatization of teaching that has resulted in progressive abandonment by the State
of its responsibility in the field of education.



     Communications Media

     The influence of the mass communications media on the mental health and psychosocial
development of children is a matter of great concern.  Although these media could be utilized as
instruments to promote and develop mental health, the use that is being made of them at the present
time has, on the whole, produced negative effects.  Of particular interest is the influence of television,
whose effects on the behavior of children and the thought patterns it conveys were strongly underscored
during the meeting. 

     The contents of television programs, in which violence, the consumption of mind-altering
substances, and promiscuous sexual behavior predominate, not to mention the constant encouragement
of consumerism and the introduction of cultural distortions, cannot fail to leave an impression on the
minds of children who are exposed daily, in many cases for hours at a time, to the messages of this
communications medium.  Children can and in fact often do imitate the violence and sexual behavior
shown in television programs and thus generally become familiarized with the lifestyles represented.

     On the other hand, it must not be forgotten that television is a socializing factor which, although
competing with family life and with school activities, can also provide an effective environment for
education and for the promotion of mental health.  In order to achieve this end it is necessary to
undertake the single-minded task of educating and negotiating with the television industry, whose
leaders on many occasions have shown their willingness to cooperate.


     Health Services

     As already pointed out, the mental health services for children in the Region are limited or
nonexistent.  In the few instances in which resources have been allocated for the care of children they
are almost always used to provide direct services to individuals and only in exceptional cases are aimed
at particular population segments. 

     The care pyramid in the field of mental health is inverted:  its broad base corresponds to highly
specialized tertiary care that essentially serves the adult population and consumes most of the resources. 
The intermediate portion of the pyramid corresponds to psychiatric services in general hospitals and
mental health units of limited quantity and coverage in the health centers.  The vertex corresponds to
a few feeble endeavors to provide community services and some very limited attempts to provide care
at the primary level.

     Some specialists are inclined to favor the development of vertical and centralized programs,
which perpetuate the situation described above.  In the opinion of the Group, it would be wiser to
promote the creation of horizontal programs centered on the community and incorporated into the
traditional health programs that serve the communities.

     In this connection, mental health actions can gradually be integrated into the health teams at the
primary and secondary care levels and carried out by nonspecialized health workers.  The function of
the specialist will be to provide continuing education for these workers and to provide advisory services
for the identification and management of problems.  Disorders such as enuresis, hyperactivity, and
convulsive attacks are demonstrative examples of problems that can be solved at the primary and
secondary levels.  Situations will arrive, of course, that surpass the capabilities developed in the health
workers at those levels.  As a result, it will be necessary to establish effective mechanisms for the
referral of patients to specialists and for feedback to the originating entity. 

     Of great importance in this system, which attempts to strengthen the services in the communities,
is the promotion of social support networks.  These are, in fact, the first point of contact between the
population and the health services and education systems.  By promoting them and providing them with
technical support, the services will be able to establish an early warning system to monitor and solve
some of the population's psychosocial problems, in addition to providing care when it is needed. 

     There are numerous examples of maternal and child mental health activities that may be carried
out in the general health care facilities.  For example, prenatal care provides a unique opportunity for
promoting the establishment of early ties between mothers and children; the training of hospital
personnel and workers in health centers can assist in reducing the traumatic effects these institutions
may have on mothers and children; and the family planning clinics can develop activities relating to
family counseling, management of the home economy, analysis of problems, and the improvement of
family communication.

     In general, the relationship of patients and family members with the health care providers can
provide an exceptional opportunity to strengthen the roles of individuals, foster contact with reality, and
promote communication--all of which are elements of great value in the promotion of mental health. 
In order to achieve these relationships, the training of health professionals must be restructured, both
at the academic level and in the services.  Such changes are necessary not only with regard to general
health personnel but also to specialists.


     Research

     Research is a fundamental strategy for the development of services to promote the mental health
of children.  Each country must determine the areas in which special importance will be given to
research and appropriate priorities will be established.  In any case, there was consensus regarding the
desirability of promoting applied research that will be focused on the solution of the most urgent
problems in every country.

     An area of research that is of common interest to all the countries is epidemiological research
on population groups, either of the limited, cross-sectional type or of the longitudinal type.  It was
noted, however, that the latter, in spite of its evident merits, is problematic by virtue of the absence of
a service structure that facilitates data collection and processing over a period of several years and of
the varied and costly resources that would be required to supplant this absence. 


     There was agreement on the need to systematize, register, and disseminate information on
various aspects of the mental health of children.  As the programs are expanded, monitoring of the
population strengthened, and the activities evaluated, exchanges in this area will become more feasible.

     The capacity of the countries to carry out research on the mental health of children is limited by
the lack of human resources, technical capability, and material inputs.  In this regard, the appropriate
international organizations should act as mediators for obtaining material and technical assistance.

     The recommendation was reiterated of carrying out epidemiological research, both operational
and on specific aspects of collective mental health.  The specific subjects for research will vary from
country to country.  A few are mentioned below by way of example:

     -    epidemiological studies of divorce;

     -    landmarks in psychosocial development;

     -    adolescent pregnancy;

     -    birth control practices used by young people;

     -    functionality of low-income urban and rural families;

     -    attenuating risk factors for mental health;

     -    self-care arrangements; and

     -    social support networks and their function in the promotion of the mental health of
children.


     Personnel Training 

     Mention was made of the relative shortage and uneven distribution of personnel specialized in
the mental health of children.  There was also mention of the relative lack of expertise in this field on
the part of unspecialized health personnel and also of pediatricians, family physicians, and internists. 
The lack of training of educators in this field as a whole was also stressed. 

     Manpower development in the field of the mental health of children should include the
participation of the academic environment, in-service education, continuing education, and community
extension programs.  A very important element is the training of primary care personnel by virtue of
the fact that they are the first to establish contact with the community.  It is appropriate to point out that
personnel training cannot follow a uniform pattern in all the countries and that it should be geared to
the particular problems of the population, the availability of resources, and their distribution and
utilization.

     Formal training, conceived in this way, should be supplemented with a system for the
dissemination of information--whether technical or administrative or for the information and education
of the public--and special emphasis should be placed on keeping the decision-making levels duly
informed.








     The text of the present report contains numerous recommendations, some of them implicit, the
majority expressed clearly.  However, at the end of the meeting the working groups formulated the
following additional recommendations: 

     1.   The Plan of Action should take full account of the existence of highly vulnerable
population groups in which risk factors are concentrated.  Such is the case of the victims
of poverty and marginalization, the children of disappeared persons, and refugees, among
others.  As a result, when policies are proposed, specific measures for the protection of
these groups should be indicated. 

2.    A priority that was made evident for the Group and whose specific
      consideration is recommended was aid for the children of refugees and
      disappeared persons, and for abandoned children, who at the present time
      constitute a particularly severe problem for the Region.
     3.   Policies should also be oriented toward the protection of rural and
indigenous populations, who, in addition to suffering the ordeals of poverty
and abandonment, are forced by political, economic, and unlawful interests
to carry out actions that in the final analysis prove to be self-damaging. 

     4.   The Plan of Action should be structured from an epidemiological perspective
that makes it possible to identify priority problems at both the regional and
local levels.  Special emphasis should be placed on participation in this task
by representatives of the various sectors involved, particularly education and
health.

     5.   The mental health problems of children should be dealt with through the use
of comprehensive criteria that consider them in the framework of their
relationship with the environment.  In using this approach, special
importance should be assigned to the prevention of potentially dysfunctional
relations, such as child/family, child/school, and child/community, and the
linkages between peers and with adults should be taken into consideration.

     6.   Steps should be taken to ensure the continuity of child health care from birth
through adolescence.  This continuity should be facilitated in the
administration of mental health services and in the transition within the
school system from preschool education through primary school, secondary
school, and university levels. 

7.    Although the study and correction of the most frequent pathologies and
      adverse situations that affect children should be included in the Plan and in
      the programs deriving from it, no less importance should be given to study
      of the potentials of children who have not been exposed to imbalances and
      who have been able to successfully overcome unfavorable conditions. 
      Adoption of this approach is crucial for the development of promotion and
      prevention programs.
     8.   The Plan should strengthen the regional networks for the exchange of
information on the mental health of children and facilitate the fluid
management and transmission of statistical, clinical, and technological
information.

     9.   Among the lines of program action recommended for consideration are:

-    deficits of development;

-    promotion of the establishment of early ties and study of the factors
that affect them;

-    specific programs for children at high risk (undernourished and
abandoned children, refugees, children of disappeared parents, etc.);

-    the influence of violence on child development and prevention and
care measures, with special emphasis on care for children who are the
victims of aggression.

     10.  The need was emphasized to strengthen research by all available means and
to promote technical cooperation among the countries.  Specific
recommendations were made to: 

-    identify problems of common interest and, if possible, to undertake
research in which several countries participate through the use of a
common protocol;

-    assign priority to epidemiological studies;

-    support action-oriented research or research that will lead to useful
interventions in order to reduce damages;

-    create or adapt appropriate screening instruments for the detection of
risks.

     11.  The recommendation was reiterated of promoting the training of human
resources in the mental health of children in view of the need to: 

-    introduce or strengthen, as required, subject areas concerning the
mental health of children in the curricula of the various health
professions and in other university or technical programs containing
a social component that affects the lives of children;

-    include the subject in programs for continuing education and in-
service education, and for programs for the training of primary health
care personnel.

     12.  A specific recommendation was made to PAHO to convene a meeting of a
group of experts on children who are the victims of aggression. 

     13.  It was recommended to include specifically in the Plan of Action the
bioethical aspects of care and research as they pertain to the mental health
of children. 

14.   PAHO was urged to transmit the present report and the working material for
      the meeting to the World Committee on the Child and to the meeting
      summits that have been programmed.
List of Participants



      Dr. H. Montenegro
      Martín Alonso Pinzón 6702
      Las Condes
      Santiago, Chile

      Dra. E. Radrigán
      Directora, Escuela de Pregrado
      Facultad de Medicina
      Universidad de Chile
      Avenida Independencia 1827
      Santiago, Chile

      Dr. J.S. Piterbarg
      Ministro Brin 570
      Piso 10, Apt. 6
      1158 Buenos Aires
      Argentina

      Dr. L. Eisenberg
      Prof. of Social Medicine 
      Department of Social Medicine
      Harvard Medical School
      25 Shattuck Street
      Boston, MA 02115

      Dra. A.T. León
      Directora
      Instituto del Niño
      Apartado 86
      Heredia
      Costa Rica

      Dra. M. Gomez Palacio
      Universidad de las Américas
      Arquitectura Në 13
      Copilco-Universidad
      México, D.F. 04360
      México
     Dr. M. Cherro
      Director, Clínico de Psiquiatría de Niñez
      José Martí 3152
      Montevideo, Uruguay

      Dr. E. Bernardi
      Profesor del Departamento de Psicología Médica
      Facultad de Medicina
      José Martí 3152
      Montevideo, Uruguay

      Dra. A. Puiggros
      Pedro I.Rivera 4164
      Buenos Aires, 1430
      Argentina

      Dra. A. de Moura Vasconcellos
      Presidente de la Asociación Brasilera
        de Neurología y Psiquiatría Infantil
      Al. Santos 2384 - Apt. 72
      Sao Paulo, 01418
      Brazil


      Secretariat

      Dr. Joao Yunes
      Coordinador del Programa Salud Materno Infantil
      Pan American Health Organization 
      525-23rd Street, N.W.
      Washington, D.C. 20037

      Dr. Ricardo Schwarcz
      Director
      Centro Latinoamericano de Perinatología y Desarrollo Humano
      Organización Panamericana de la Salud 
      Hospital de Clínicas, Piso 16
      Montevideo, Uruguay 

      Dr. Néstor Suarez Ojeda
      Asesor Regional de Salud Materno Infantil
      Pan American Health Organization 
      525-23rd Street, N.W.
      Washington, D.C. 20037Dr. Itzhak Levav
      Asesor Regional en Salud Mental
      Programa de Promoción de la Salud
      Pan American Health Organization 
      525-23rd Street, N.W.
      Washington, D.C. 20037

      Dr. René Gonzalez Uzcátegui
      Consultor 
      Pan American Health Organization 
      525-23rd Street, N.W.
      Washington, D.C. 20037
        








      EXTERNAL EVALUATION OF THE ADMINISTRATION AND 
     ORGANIZATION OF THE PERUVIAN PRIMATOLOGY PROJECT



CONSULTANT:  Dr. Otoniel Velasco F.

REFERENCE:  Contractual Services Agreement No. 92/P-024-ASC



METHODOLOGY


Information on the Project was obtained from Dr. Sato in Lima,
after review of the annual reports for the period from 1985 to
1990.  A field trip was made to Iquitos (from 26 to 28 March)
where extensive interviews with the professional personnel of
the Project were conducted and the animal reproduction
installations in Iquitos and the stations on Padre Island and
Muyuy Island were visited.  The Strategy and Plan of Action of
the Project for the period from 1985 to 1990 were reviewed, as
well as the draft of the report for 1991.


ANALYSIS


1. In the middle of the 1980s the consultant visited the
Project, making it possible to present an opinion on the changes
observed between 1984 and 1992:

a)   With regard to reproduction in captivity, the colonies have
been stabilized; the pathological problems have been reduced
significantly; and the diet utilized has minimized the
importation of supplies from outside the region.

b)   With respect to reproduction in the wild under control of
the above-mentioned stations on the islands, there has been
significant progress in determining the behavior and habits of
the primates and field specimens brought from other areas and
maintained in captivity adapted well to the natural conditions
upon being set free in the forest.

c)   The Project has promoted the seeding of native forest
species that produce fruits and flowers utilized by the primates
in their feeding and ensure ecological equilibrium.

d)   In addition, a very interesting relationship has been
achieved with the small communities on the islands, which the
Project provides with direct and, most particularly, indirect
support, facilitating the provision of agricultural,
educational, and health services by the state organizations of
the country.


2.   As is known, the Project originated in 1975 in an agreement
signed by PAHO and the Government of Peru, represented by the
Ministries of Agriculture, Foreign Affairs, and Health.  The
corresponding letter of agreement has been amended and expanded
four times, the last time in 1992, when its life was extended
to 1995.


3.   It should be noted that the letter of agreement was signed
at a time when the decentralization of the Peruvian state
apparatus had not yet begun.  In the 16 years that have passed
since then, the Peruvian Amazon Research Institute (IIAP) has
been created for the study and protection of the natural
resources of the national Amazon region with relatively
significant financial resources, in particular, those
corresponding to a percentage of the petroleum royalties.  In
addition, in more recent years a vigorous process of
decentralization directed toward the constitution of regional
governments has been initiated.  This process, although it is
questioned by some political forces, is irreversible and
responds to a long-standing yearning in the provinces, which
complain of the excessive centralization in the capital of the
republic.


4.   Although the amendments to the original agreement have
facilitated the participation of the IIAP and the regional
government of Amazonas, this participation is relatively
marginal.  The IIAP has a nominal presence in the governing
bodies and there is potential duplication of functions; with
respect to the regional governments, there are no mechanisms
that permit the participation of the governments of the other
regions in those in which the Project has jurisdiction.


5.   The Project operates as an agreement among the following
parties:  the Ministry of Agriculture, San Marcos University,
the Ministry of Health, the IIAP, and PAHO.  The parties
contribute in various ways; thus:

a)   The Ministry of Agriculture, through the Office of Forestry
and Fauna (DGFF), provides the political and legal framework
inasmuch as the protection of the wild fauna and its enforcement
is within its purview.  According to the letter of agreement the
Project should be administered by the DGFF, but that
organization has formalized an agreement with the Veterinary
Institute for Tropical and Highland Research (IVITA), which is
the administrative entity.

b)   The San Marcos National University contributes facilities
and personnel through IVITA.

c)   The Ministry of Health does not contribute resources but
develops a secondary activity.

d)   The IIAP contributes neither human nor financial resources.

e)   PAHO has a staff consultant at the Project headquarters,
finances temporary consultants, and arranges for the transfer
of primates requested by research laboratories in the United
States of America or third countries.  Until recently PAHO
administered the funds from those transfers but by a recent
agreement these resources are transferred to the Project, which
is charged with their administration.


6.   The financing of the Project comes from several sources:

a)   National sources:

-    IVITA, which finances the wages of twenty-three persons: 
     eight professionals (three veterinarians and five
     biologists) and 15 aides (office and field).
-    Ministry of Agriculture (Loreto Regional Office), which
     finances one professional half time.

b)   External sources:

-    Contributions from PAHO with extrabudgetary regional funds.
-    Income from the transfers of primates.


7.   The Project does not maintain an integrated accounting
system because of the nature of the financing scheme, so that:

a)   It is not possible to establish the total amount of the
budget and analyze the existing relationship among approved
budgets, budgets expended, and the structures of the financing
and of the corresponding expenditure.

b)   According to the information collected, the incomes from
transfer of primates are as follows:

Years               1985 1986 1987 1988 1989 1990 1991
($US thousands)     86.7 l94.2241.6374.8...  214.7249.5

These funds are used to contract auxiliary personnel (32
positions), to augment the wages of the national personnel, and
to cover the operating costs of the Project, including the
feeding of the colonies, fuel and lubricant purchases,
maintenance of the physical infrastructure, and expenditures for
trips into the forest.  When there is money left over, it is
applied to the acquisition of equipment.

c)   On the basis of partial information it has been possible to
establish the following table of expenditures with the funds
from transfers of primates:

 
(In $US thousands)              1990      1991        1992*

- Salaries and wages            66.4      52.4         52.4
- Allowances                    23.5      23.2         32.6
- Animal feed                   31.0      20.8         15.0
- Transport                     23.4      39.7         30.0
- Maintenance and local rep.    2l.2      53.4         l0.0
- Other                         49.2      60.0         l0.0
_______   _______       _______
2l4.7     249.5         l50.0

* Budgeted.


In light of this situation it is foreseen that in l992 serious
difficulties will arise for the functioning of the Project.


8.   In regard to the organization, it is responding to a
solution involving a compromise between the parties and with
slight modifications the same scheme described in the Regulation
of the Organization and Functions in effect has been maintained.


9.   The organization has three levels:  the Advisory Council,
the Directorate, and the advisory, support, and line units.

a)   Advisory Council:  It has its headquarters in the city of
Lima.  Presiding over it is the Director-General of Forest and
Fauna and its members include a representative of IVITA, a
representative of the Ministry of Health, a representative of
the IIAP, a representative of PAHO, and the Director of the XXII
Departmental Agrarian Unit in Loreto in his role as Chairman of
the Directorate.  The Council is the highest level decision-
making body of the Project; it sets the general policy, approves
the budgets and plans, accepts donations, approves the
Regulation of the Organization and Functions of the Project,
arranges legal matters, and secures relationships with other
national or foreign institutions.  In sum, despite its name it
is actually constituted as the Directorate of the Project.

b)   The Directorate has its headquarters in Iquitos.  Presiding
over it is the Director of Natural Resources and the Environment
of the Region of Loreto and it is composed of the Technical
Coordinator of IVITA in Iquitos, the Chairman of the IIAP, the
Departmental Director of Health, and the PAHO Adviser in
Iquitos.  The Directorate is the permanent directing body,
responsible for the operation of the Project and the fulfillment
of the agreements emanating from the Advisory Council.  What is
called the Directorate is actually the Executive Committee of
the Project.

c)   In regard to the advisory units, the Regulation mentions
the Legal Counsel and the Office of Planning and Budget.  But
neither of these was found to be functioning due to a deficiency
of financial resources.

d)   The Office of Administration is the support unit of the
Project; it is charged with the administration of the material,
human, and financial resources.  It is under a Director who
reports to the Directorate.

e)   In regard to the line units, a Bureau of Research and
Management has been established.  It is responsible for carrying
out, coordinating, controlling, and evaluating the activities
in the areas of research and technical assistance and is headed
by a Director who also reports directly to the Directorate. 
This Bureau includes two departments:  Reproduction in Captivity
and Natural Areas.


EVALUATION


1.   The organization described above is understood to be the
result of a transaction among the various integral parts of the
Project which has required the Project to function in practice
with ad hoc solutions in order to ensure that it operated at
least minimally as a unit.  Thus, for several years the
Coordinator of the IVITA in Iquitos was simultaneously the
Director of Administration of the Project, performing in
practice the functions that would correspond to an executive
director.  This solution, although it resolves some concrete
problems, is not basic and introduces an element of instability
in the Project that is expressed in the absence of what we could
call consolidated formulation of policies and plans.


2.   Indeed, when the plans are reviewed it is observed that
these are an aggregate of initiatives by the biologists and the
veterinarians that work in the Project.  Each group attempts to
dominate the Project, creating a hegemony that is translated
into a claim for a greater allocation of resources for
activities that, although they are complementary in the long
term, are competitive in the short term.  The biologists only
pay attention to the field work, that is, to the capture of
primates and to research on their habits in the natural forest,
while the veterinarians devote themselves almost exclusively to
reproduction in captivity and related problems.  Since there is
no executive director, that is, no full-time staff member on the
Project who is responsible for its daily conduct in all its
aspects, there is no discussion of the various initiatives and
no search for consensus; hence, at the meetings of the
Directorate, each group applies pressure so that resources are
assigned to it.


3.   In addition, the presence of the IIAP in the Project is
very important but, according to the information collected, the
Project does not utilize the potential resources of that
organization.  For example, it does not appear reasonable to
have the Chairman of the Directorate of the Project be a staff
member of the Loreto Region which does not have jurisdiction in
the area of the Project.  It would seem to be more desirable to
have the Directorate presided over by the Chairman of the IIAP,
an institution that has jurisdiction in the entire area of the
Project (except the Department of Tumbes) and that, as a center
for research on problems of the Amazon region, is vitally
interested in the business of the Project, which handles matters
related to the protection of primates and wild fauna in general.


4.   In reference to budgetary matters, the Project should
define some expenditures as fixed and others as variable.

a)   Among the fixed expenditures are those for the regular
staff for the operation of the animal reproduction unit and the
field stations.  In total, there are 55 persons working on the
Project full-time and one, half time; of these, eight are
professionals and 47 are aides; this last number appears to be
excessive and there is no rational explanation that justifies
it.  Expenditures for feeding the primates in captivity and a
minimum amount for the maintenance of the installations are also
fixed expenses.  The costs of expeditions to the field which,
according to a consensus of the professionals in the Project,
should include a minimum of one trip a year for each of the
species managed by the Project (six), are also fixed
expenditures.


b)   Among the variable expenditures should be the resources
necessary for expeditions to collecting primates to fill
specific orders.



RECOMMENDATIONS


1.   In regard to the organization:

a)   There should be a review of the role assigned to the
Advisory Council, which, as we have pointed out, actually
performs the functions that correspond to a directorate; it
should be limited to providing advice and support for
negotiations for the Project in Lima.  This presupposes that
what is now known as the Directorate ought to assume most of the
functions of the Advisory Council and delegate to the Executive
Director of the Project most of the functions that currently are
assigned to it.

b)   The Project should have an Executive Director responsible
for the administrative and technical aspects and the pertinent
offices for advisory, support, and line functions should be
under his direction.  The Executive Director should be the only
staff member reporting directly to the Directorate and his
appointment should be made by consensus.  The profile of the
Executive Director should be characterized by abilities in
management and project administration and by academic training
in veterinary sciences and primatology.


2.   The basic agreement signed in l975, which has been being
renewed only formally, should be reviewed in depth.  In the
almost l6 years that have passed, not only has the national
scene been modified, in terms of strong currents of
decentralization as we have pointed out, but also the
international setting has changed, with high priority being
given to the protection of nature, expressed in what is called
the "green wave."  It should be recalled that the Project was
born with the priority of rationalizing the provision of
primates for biomedical experimentation.  Currently, priority
appears to be assigned to the protection of the primate species
as a substantial part of the protection of the natural resources
of the Amazon region and to the utilization of primates bred in
captivity for biomedical experimentation.  These changes in
emphasis can be processed so that the international effort
contributes to their strengthening.  For these reasons the
preparation of a new agreement appears to be appropriate.


3.   Given the precariousness of the national institutions it is
difficult for a project such as this one to be sustained over
a sufficiently prolonged period to achieve self-financing and
be transformed into a center for innovation and technological
development, if it does not have substantive international
support.  In this respect international collaboration is basic
and given that PAHO has carried out pioneer work in this field
it appears desirable that the Project be transformed into an
International Center for Primatology under the auspices of PAHO
which could call on other international entities directly
involved in the defense of nature and other sources of
financing.  The international collaboration can be designed so
that it constitutes 50% of the financing of the center, with the
other 50% financed by national sources.  Among the national
sources it is very important to involve the IIAP for the reasons
previously cited and also IVITA, which already has resources and
experience in this field.


4.   With respect to the budgetary aspects:

a)   It is important to introduce a rationale to the current
expenditures, in particular in regard to auxiliary personnel. 
Apart from continued exploration of the possibilities of
reducing the costs of feeding the primates by increased use of
local supplies, there should be a review of the desirability of
continuing to maintain a significant stock of some species whose
second and third generations have been born in captivity and the
demand for which has been drastically reduced.  The cost of
maintaining these animals constitutes a significant drain on the
finances of the Project and alternatives, such as the donation
of specimens to animal reproduction units or to various
institutions for pets, should be studied.  It is also necessary
to study an alternative destination for some individuals of
endangered species that are kept in the Iquitos reproduction
unit by order of the DGFF.  The costs of maintaining these
individuals fall on the Project and it would not be difficult
to have them transferred to some national zoo.

b)   The fixed costs should be identified precisely so that
their financing is assured.

c)   With regard to the variable expenditures, it appears to us
desirable that the office in Washington, on accepting an order
for primates, request an advance of 50% of the agreed-upon
price, in order to finance the costs of the collecting
expeditions.

d)   The accounting should be unified in such a way that the
Project has timely information on the structure of the financing
and the expenditures.  On the basis of realistic analyses,
medium-term projections could be made to be used in preparing
strategies for financing.


5.   The Project has used as its framework for planning the
Strategy and Plan of Action for l985-l990.  Although it has not
been possible to do a thorough evaluation, broadly speaking it
is perceived that the degree of execution has been relatively
satisfactory.  But we are already in l992 and there is no
framework of planning for the medium term.  It is therefore
desirable that in the very near future a plan of action for the
next four or five years be designed.  In the design of this plan
it would be desirable to take into account the recommendations
of the external evaluation recently carried out.


6.   The consultant has not had opportunity to exchange opinions
with the other members of the External Evaluation Team.  In this
respect I consider it essential that a meeting of all the
members of the Group be held with the advisers from HPV, the
PAHO consultants on the Project, and its directors for the
purpose of discussing the various reports prepared by the
members of the Group and producing an adequately harmonized
single report that can contribute to good decision-making by
HPV.


Lima, 22 April l992

109th Meeting
Washington, D.C.
June 1992

Provisional Agenda Item 4.7                    CE109/14 (Eng.)
25 April 1992
ORIGINAL: 
SPANISH


COMPREHENSIVE HEALTH OF ADOLESCENTS


     Among the relevant agreements that form the basis for the present
  document are the declaration of policies on children and adolescents signed
  by the Heads of State during the World Summit for Children and the
  resolutions of the Governing Bodies of the World Health Organization and the
  Pan American Health Organization relating to the formulation of policies,
  plans, and programs for the comprehensive health of adolescents and young
  people at the global, Regional, and national levels.  The document
  summarizes the demographic, educational, and legal situation of people in this
  age group.  It includes an analysis of the health-disease process and the nature
  of comprehensive care, as well as a discussion of the specific problems of
  adolescents in terms of growth and development, reproductive health, and
  risk-prone behaviors and their consequences.

     On the basis of the political antecedents and taking into account the
  situational framework, a Regional Plan of Action is proposed to the Executive
  Committee of the Pan American Health Organization with a view to
  intensifying technical cooperation to support the creation or reformulation of
  National Comprehensive Health Programs for this important population
  group.  The Executive Committee is requested to analyze the situation of
  adolescent health and the proposed response by PAHO contained in the Plan
  of Action in section III, so that recommendations can be made to the
  Executive Board regarding the action to be taken.
TABLE OF CONTENTS


I. BACKGROUND. . . . . . . . . . . . . . . . . . . . . . 1

II.EXPERIENCES IN THE COUNTRIES OF THE REGION. . . . . . 2

III.PLAN OF ACTION ON THE COMPREHENSIVE HEALTH OF
    ADOLESCENTS. . . . . . . . . . . . . . . . . . . . .12
        
IV.REFERENCES. . . . . . . . . . . . . . . . . . . . . . .



Annex I:CONCEPTUAL FRAMEWORK . . . . . . . . . . . . . . .

Annex II:RESOLUTIONS OF THE GOVERNING BODIES . . . . . . .




HEALTH OF ADOLESCENTS AND YOUNG PEOPLE IN THE AMERICAS



I   POLITICAL FRAMEWORK AND ANTECEDENTS IN THE REGION

1.  World Summit for Children

    The world's Heads of State have committed themselves, in paragraph 20
of the World Declaration on the Survival, Protection, and Development of
Children, to fostering the optimal growth and development of children by
supporting "the efforts of parents...to nurture and care for children, from the
earliest stages of childhood through adolescence," and by working for programs
to "enable children to grow to adulthood within a supportive and nurturing
cultural and social context" and for "special protection of the working child and
for the abolition of illegal child labor."  In addition, they agreed to do their best
"to ensure that children are not drawn into becoming victims of the scourge of
illicit drugs."  The same Declaration draws attention to the fact that 500,000
of the world's young mothers die each year, a tragedy which could be avoided
if greater attention were given to the health, nutrition, and education of women. 
The document also emphasizes the importance of the cultural setting of the
community and the family, as well as the environment, for the growth and
development of children (up through adolescence).

    Among the goals proposed for children and development in the 1990s are
the following:

    a)  Improved protection of children in especially difficult
        circumstances;

    b)  Special attention to the health and nutrition of the female child and
        to pregnant and lactating women; and 

    c)  Access by all couples to information and services to prevent
        pregnancies that are too early, too closely spaced, too late, or too
        many.


2.  World Health Organization

    Over the last 20 years the World Health Organization has repeatedly
acknowledged the signal importance of the health and well-being of adolescents
and young people and has called for the assignment of high priority to programs
directed toward the development and rehabilitation of children and to
prevention of the diseases that affect them.  Numerous resolutions approved by
the World Health Assembly have addressed the subject, with special mention
of the problems related to the sexually transmitteddiseases, reproductive behavior, smoking, and the abuse of alcohol and other
psychoactive substances (see references 1-10).  The last of these resolutions
(WHA42.41) recognizes the comprehensive nature of health and health care for
young people (see Annex II).

    The final report of the Technical Discussions on the Health of Youth, held
in May 1989 in conjunction with the Forty-second World Health Assembly
(11,12) recommended that WHO collaborate with the Member States in
strengthening national institutions to undertake research aimed at improving
knowledge about the situation of youth, that governments have a declared
health policy that clearly spells out plans of action and the manner in which
they are to be implemented, that governments support the involvement of young
people, and that WHO continue and strengthen its collaboration with the
agencies and institutions concerned.

3.  Pan American Health Organization

    The Governing Bodies of the Pan American Health Organization have
addressed the problem on a number of occasions, among them at the meetings
of the Directing Council in 1984, 1988, and 1991 and the XXIII Pan American
Sanitary Conference in 1990.  The XXXV Meeting of the Directing Council
analyzed the status of maternal and child health and family planning programs
(13, 14), reviewed progress to date in execution of the strategies recommended
by the Pan American Sanitary Conference (15), and took note of the
commitment assumed by the Presidents and Heads of State of the Americas in
the Declaration of the World Summit for Children (16).  Resolution XVI of
the XXXV Meeting of the Directing Council (October 1991) requested the
Director (17) to include the subject "Comprehensive Health of Adolescents"
on the agenda of the Directing Council for 1992.

    In recent years PAHO has given greater importance to cooperation
activities relating to the health of adolescents and young people, as seen in the
publications that have contributed to the support of initiatives in this area in the
countries (19-24).


II  EXPERIENCES IN THE COUNTRIES OF THE REGION

    Activities relating to health care for young people have taken on growing
importance in the Region during the last 15 years.  Recently greater emphasis
has been placed on the psychosocial approach, as problems associated with
reproductive health, violence, and the consumption of psychoactive substances
have become increasingly common.

    The efforts that have been undertaken, however, have not made a notable
impact, given their limited coverage, their focus on the solution of specific
problems, and, especially, the lack of specific policies that would ensure the
permanence, coherence, and comprehensiveness of these actions.


1.  Epidemiological Analysis of the Health of Adolescents and Youth:  Facts
    and Trends

1.1 Demographic Aspects

    Of the approximately 196 million adolescents and young people (10-
24 years) in the Region of the Americas, 137 million, or 69%, live in Latin
America and the Caribbean.  By the end of the present century, this figure will
reach 172 million (25) (Tables 1 and 2).

    As a result of the phenomena of demographic transition, the countries of
the Region have seen increases in the population of adolescents and young
people in terms of both the proportion and absolute numbers.  This growth
translates into increased demands on the educational, health, labor, and other
systems.

    The accelerated rate of urbanization in the countries of the Region-
-which meant that, in 1990, 72% of their total population was living in urban
areas--is especially marked in the population of adolescents and young people. 
It is estimated that by the year 2,000 about 80% of this population will be living
in urban areas, compared with a figure of 75% for the total population (26).

    This rapid urbanization in the Region has been seen mainly in the
marginal sectors, where the population lives in precarious socioeconomic
conditions.  The fact that people are crowding into cities in large numbers is
helping to create a psychosocial environment that is plagued by violence and
juvenile delinquency.

1.2 Education

    All the countries of the Region have shown notable improvement in the
educational level of adolescents and young people and a sizable decline in
illiteracy (27-31) (Table 3).

    Despite the overall progress, however, there are still marked disparities in
the Region (29), with illiteracy rates lower than 5% in some countries and
higher than 40% in others.  In those where it is most prevalent, it has been
shown that women have fewer years of schooling and that the rates of illiteracy
are three times higher in rural areas than in the cities.
1.3Legal Aspects

    The term "adolescent" is not sanctioned for use in legal texts, preference
being given to such expressions as "minor," "underage person," and "juvenile."

    "Legal majority"--that is, the age at which a person becomes legally
"competent"--is determined arbitrarily (32).  In most cases it is 21 years, with
a trend for it to be lowered to 18.

    From the health perspective, in many cases such legal provisions
constitute a barrier that limits a young person's options and his or her access to
services.  This is particularly true, inter alia, for medical care and fertility
regulation methods.

1.4 Employment

    The problems of unemployment and underemployment stemming from the
Latin American economic crisis have had an especially acute effect on the
weaker socioeconomic groups and young people, women, and minority ethnic
groups have been particularly hard hit.

    It is estimated that there are some 10 million working children in Latin
America, and many of them are in illegal situations, underpaid, without the
benefits of social security, and engaged in high-risk activities that are hazardous
for their health (26).  Table 4 shows the trends in participation by adolescents
and young people in economic activity over a 15-year period (1970-1985), in
which a reduction can be seen in the group aged 10-14.

    In some countries children and adolescents begin to work before they have
the full biological, psychological, or legal capacity to do so.  In addition, many
of these children and young people are also exposed to fatigue by virtue of the
fact that at the same time they are trying to work and at the same time go to
school and keep up their scholastic performance, which they rarely manage to
do, the result often being that they drop out and end up cutting off their chances
to get better jobs in the future (27, 31, 32).

1.5 Socioeconomic Conditions

    According to the Economic Commission for Latin America and the
Caribbean (ECLAC), the proportion of the population living in poverty in these
countries ranges from 19% to 85%.

    The adverse economic situation has had an enormous impact on
adolescents and young people in Latin America, and it has translated into
reduced qualitative andquantitative availability of food; inadequate health services in terms of quantity,
quality and opportunity; inadequate educational systems; limited access, or
none at all, to recreational and sports activities; insufficient training, or no
training, for the development of working skills; and underemployment and
unemployment (Tables 6 and 7).


2.  The Health-Disease Process and the Nature of Care

    The sources of information for analysis of the health-disease process
among adolescents and young people in the Region are the same as those that
are available for other age groups, with the same strengths and weaknesses. 
Several international agencies publish relevant information on a periodic basis,
but its usefulness depends on the quality and recency of the data generated in
the countries.

    The health needs of adolescents and young people have not yet been fully
evaluated.  This circumstance results both from the nature of the information
available and the shortage of professionals trained to detect their problems.

    The health of adolescents and young people, more than any other age
group, requires a multisectoral and cross-disciplinary approach, both for
diagnosis and for treatment and prevention.  Statistics on literacy and schooling,
school dropout rates, sports and recreation, working conditions, and the health
protection of underage workers, etc., in themselves are indicators of health,
some of them with the advantage that they represent "positive" approximations
to the measurement of health.

3.  General Morbidity and Mortality

    General mortality in the group aged 10-24 years is low (26), as shown in
Figure 1.  This fact probably explains why such a low priority is assigned to
health care for this group.

    The information available on several of the countries in Latin America
indicates that between 1979 and 1988 age-adjusted mortality in adolescents 10-
19 declined from 1.09 to 0.74 per 1,000, as shown in Figure 2 (27).

    Table 8 gives mortality figures circa 1985 for adolescents aged 10-
14 years in selected countries, and it can be seen that the rates ranged between
138 and 18.9 per 100,000 population.  The sex differences confirm that the risk
is greater for males, especially in the group aged 15-24 (Tables 9 and 10).
   The leading causes of death in adolescents in all the countries of the
Region are accidents, poisonings, and violence, followed by malignant tumors
(mostly leukemia and lymphoma).  Mortality from problems associated with
reproductive function is also high among women in this age group.

    Accidents and violence are responsible for large numbers of potential
years of life lost and consequently for a negative economic impact, which is
ample justification for the implementation of prevention programs in this area. 
Moreover, the high death rates among adolescents related to the reproductive
process point to the need to establish adequate programs for pregnancy
monitoring and assistance during delivery and the puerperium while at the same
time taking steps to prevent unwanted pregnancies through sex education,
family planning, and programs for the control of sexually transmitted diseases.

    The information available on morbidity comes from sporadic surveys and
data provided by outpatient clinics, hospital records, and emergency services. 
Its usefulness is relative, since the records suffer from the weaknesses already
indicated, and the information covers only a fraction of the population that
received care.

    There have not been many morbidity surveys in the countries of the
Region.  In one of them (34) it was found that adolescents experience 0.96
episodes of acute disease/person/year, of which 0.26 receive assistance through
the health care system, versus an average of 5 episodes/person/year in the total
population, half of which receive care.

    When the care is given by specially trained personnel, it is possible to see
the specific nature of the health problems of adolescents, both biological and
psychosocial:  normal variations in the process of growth and development,
acne, orthopedic disorders, sensory problems, menstrual disorders, and
conditions related to reproductive health, anxiety, substance abuse, etc. (33-
35).

4.  Specific Problems

4.1 Problems Related to Growth, Development, and Nutrition

    Nutritional problems in adolescents and young people are only partially
understood from the limited research that has been done in this area.

4.2.Problems Associated with Specific Deficiencies

    Iron-deficiency anemia is a significant problem in the countries of the
Region (Table 11).  Disorders due to iodine deficiency, including goiter,
continue to be a problem, especially in the Andean countries (Table 12).

    Although problems relating to oral health include other pathologies, dental
caries are by far the most important in terms of frequency and early occurrence. 
The prevalence of caries approaches 50% in children under 5 and is around
90% at age 15.  Dental caries, in addition to having an impact on physical
health, have repercussions for the mental health of adolescents and young
people because of their negative effect on appearance during a period in life
when body image is very important.


4.3 Reproductive Health
        
    Trends in the Fertility of Adolescents

    Specific fertility in the group aged 15-19 ranged, during the period 1985-
1990, from 61 to 133 per 1,000.  In general, fertility rates in adolescents tend
to be higher in countries where fertility is already high (5.5 or higher) than in
those where it is low (lower than 3).  Between 1950-55 and 1985-90 the rate
declined in most of the countries by between 10% and 52%.  However, the
decline in specific fertility at later ages means that the proportion of pregnancies
and deliveries in minors under 20 years of age is increasing (25).

    Births among Teenagers 

    Although fertility in adolescents has shown a tendency to decline, the
absolute number of births among teenagers is increasing because of the larger
population in that age bracket (25).

    In the countries of the Region as a whole, 14.5% of all births are to
mothers under 20, and in five countries the rate is over 18%.

    Determinants of Fertility in Adolescence

    The earlier occurrence of menarche that is being observed in the Region
is accompanied by certain attitudes and behavior toward the opposite sex, and
these things in combination may lead to the initiation of sexual activity at a
younger age.  There are major contradictions in this area:  on the one hand,
biological characteristics are permitting earlier reproduction, but on the other,
society is delaying the age at which the individual is regarded as an adult with
full rights and responsibilities.

    In Latin America the average age of marriage is 20.5 years.  The legal
minimum age is 12 years in five countries and 14 in nine others.  There is not
always a correlation between legal age and reality.  In any case, among the
factors bearing on marriage, access to intermediate and higher education,
employment, and place of residence are more important than legal age. 
According to a recent survey on demography and health conducted in eight
Latin American countries, approximately half the women had been married or
had initiated a sexual relationship before the age of 20 and one-third before the
age of 17.

    Pregnancy Trends in Teenage Women

    In the Region there is extensive literature documenting the negative
impact of early pregnancy.  In general, a child born to a teenage mother faces
greater risks than a child born to a mother over 20 (38-43), and this translates
into higher rates of low birthweight, greater perinatal morbidity, and later,
increased risk of negligence and abuse.

    In psychosocial terms, teenage pregnancy affects the woman's life plans,
since it tends to interrupt or bring to an end her schooling, reduces her career
expectations, and makes for an uncertain future (44-48).

    Abortion and Maternal Mortality

    The highest maternal mortality among adolescents and young women is
found in a country of the Region where there are 17.8 deaths for every 100,000
women aged 15-24.  The same country also has the highest mortality from
abortion, at 4.8 per 100,000 women aged 15-24.

    In general, 30% of the mortality from abortion in Latin America occurs
in women under the age of 24.

    Contraception

    Contraceptive use among adolescents is lower than among women of all
ages.  Even among teenage women who are married the rates are as low as 9%
in Guatemala, although levels are higher in other countries, such as Brazil
(50%) and Colombia (30%).  The figures are lower in rural areas (49).


4.4.Sexually Transmitted Diseases

    Very little is known about the incidence of sexually transmitted diseases
among adolescents in the Region, although partial studies suggest that the rates
are probably quite high (50, 51).

    AIDS cases among adolescents represent 4% of all reported cases in all
countries except Honduras, where the figure is 8.3%, and the United States,
where it is 9.8%
   According to a report from WHO, at least half the persons who are
infected with the virus are under 25 years of age.  This makes AIDS a problem
of major importance in the young population, especially if it is considered that
the figures on reported cases give an incomplete idea of the magnitude of the
problem since they do not indicate the total number of persons infected.

4.5.Accidents and Other External Causes

    Information from various sources in the Region shows a worrisome
increase in the complex problem of violence and the consequent negative
impact on quality of life, loss of life among adolescents and the young adult
population, and high socioeconomic cost.  Health problems associated with
violence are the principal cause for recourse to assistance in these age groups.

        In addition to accidents, homicides, and suicides, violent deaths
among adolescents and young people also stem from armed internal and
international conflicts, sometimes with a very high toll.

    Death rates from external causes, namely accidents and violent acts, are
high in most of the countries.  In general, mortality from these causes has
declined in recent years in the group aged 10-14, but it remains high and is
tending to increase, albeit with wide variations in the Region, in those aged 15-
24.

    Accidents are among the five leading causes of death in the general
population of the Americas (52), ranking first in the group aged 15-24 (Table
14).  Estimates by the World Health Organization (25) indicate that for every
adolescent who dies in a traffic accident, 10 to 15 survivors in the same age
bracket are left with serious sequelae, and from 30 to 40 present less severe
injuries but still require medical or psychological care or rehabilitation-
-figures that parallel the findings in North America (53).

    Accident proneness, the attribute whereby some persons tend to suffer an
excessive number of accidents in comparison with their peers (54), is observed
very often at this stage of life.  An analysis of motor vehicle accidents shows
that this category accounts for somewhat more than 20% of the deaths from
external causes in this group.

    Homicide, the most explicit expression of violence, is the second leading
cause of death in adolescents and young people in half the countries of the
Region and ranks between third and fifth place in the other half (Table 15). 
Homicide is particularly important as a cause of death in the male population
aged 15-24, and there is one country in which the rate in this group is as high
as 144 per 100,000.

    Suicide is also an important cause of death in the Region, with overall
rates that range between 22.6 and 0.2 deaths per 100,000 population.  In 19
countries of the Region suicide ranks among the first five causes of death in the
group aged 15-44.  Currently it tends to occur in the lower age ranges, and it
already ranks among the five leading causes of death in children aged 5-
14 in five countries of the Region.

4.6 Substance Use

    The use of psychoactive substances in the Region among adolescents and
young people has become extremely widespread.  Although there is less
substance use in the countries of Latin America, this problem is on the increase,
especially in certain groups such as young people from broken homes, school
dropouts, the unemployed, those belonging to the poorer strata and the
marginalized population, and those who present certain pathologies (55).

    It is estimated that from 10% to 30% of all adolescents have used illegal
substances, the frequency of use depending on availability and their capacity to
pay for it (25).

    The frequency of smoking and alcohol consumption is high among young
people and is tending to increase (Figure 6).

    Alcohol

    Consumption of alcoholic beverages in the world has increased in recent
decades (56), particularly among young people.  In Chile (57) it was found that
more than 12% of the students in the capital city of Santiago drank to excess. 
In Mexico (58) a survey revealed that among a population of 12-17 year-
olds interviewed 17.3% consumed alcohol at least once a month, 5.9% did so
one to three times a month, and 4.4% did so at least once a week.  In all, 5.2%
of the population aged 18-29 met the criteria for alcohol dependency.

    Tobacco

    Consumption of tobacco in Latin America and the developing world, in
contrast with the steady decline in most of the developed countries, is on the
increase, especially among young women.

    A National Survey on Addiction carried out in Mexico in 1988 (59)
showed that 42.4% of all smokers were between the ages of 18 and 29; 6.6%
were between 12 and 17; 52.1% had started the habit before age 17; and only
5.5% had begun after age 30.
   Drugs

    The abuse of psychoactive substances by the young population of the
Region has increased considerably, and in some countries it is a major public
health problem, with prevalences as high as 80% in the under-25 age group.

    It has been found that tobacco use, as well as alcohol consumption, are
linked to the use of chemical substances in general by the parents of the young
people studied (61).

    There are clear signs of increasing use of certain substances, especially
marijuana, cocaine, tranquilizers, and stimulants of the central nervous system.

5.  Suggested Responses

    In order to respond to this problem, it is necessary to develop policies,
plans, and programs within a conceptual framework that will make it possible
to understand the close relationship between comprehensive health, the quality
of life that comes from well-being, and emotional and social development. 
There are imposing challenges that must be met.  These include:

    a)  Reducing unequal opportunities for children, adolescents, and young
        people and their families;

    b)  Increasing the levels of health promotion and protection through the
        prevention chain; and

    c)  Strengthening capacity to meet the biological and psychosocial needs
        of this age group.


    The attainment of the following four basic goals may be the key to
meeting these challenges:

    a)  Increasing the capacity for self-care;

    b)  Promoting mutual aid;

    c)  Achieving healthy microenvironments; and

    d)  Promoting healthy lifestyles and behaviors.
    
   The foregoing will require consolidation of the following strategies:

-   Strengthening of social and group participation;

-   Strengthening of the social sectors (health, education, labor, legislation,
    social promotion, recreation, and others);

-   Intersectoral coordination of policies, plans, and programs; and

-   Application of integrative and participatory approaches such as:  a risk-
    based approach that involves the control of risk factors and the promotion
    of protective factors, family- and community-based approaches, an
    ecological approach (microenvironments), and emphasis on actions at the
    local and primary care level.

    For approximately the last three years the Organization has been working
toward the development of a proposed Plan of Action for the quadrennium
1992-1995, which is based in part on a strategic project supported by the W.K.
Kellogg Foundation and will generally follow the Conceptual Framework
presented in Annex I.  Below is a summary of this Plan of Action.


III PLAN OF ACTION FOR THE COMPREHENSIVE HEALTH OF
    ADOLESCENTS

General Purpose:

To contribute to the development of national and Regional initiatives aimed at
ensuring comprehensive health care for adolescents in the countries of the
Region.
A.  OBJECTIVES

    The project described below constitutes an important axis of the
international cooperation with the countries in the comprehensive health area
of comprehensive health of the adolescent.


    General Objectives:

    1)To develop support mechanisms with a view to optimizing the
      participation and performance of the national, subregional, and
      Regional networks of comprehensive health care programs for
      adolescents and to implementing alternative methodologies of
      participation, especially by adolescents, in order to promote and
      strengthen comprehensive health care at the local level.

    2)To develop ways of adapting the health services to provide
      comprehensive health care for adolescents.

    3)To design and implement a plan for human resource development in
      order to facilitate the teaching and delivery of comprehensive health
      care for adolescents.

B.  STRATEGIES

    The proposed project itself is a strategic mechanism for strengthening,
accelerating, and ordering the gradual process of adolescent health development
in the Region.  It, in turn, will be carried out within the following strategic
framework:

1.  From a process standpoint, the project will adhere to the basic principles
of Primary Health Care (PHC) and will seek to:

    a)Give emphasis to basic and primary prevention through the promotion
      of protective measures, the control of risk factors, and the reduction of
      morbidity and mortality.

    b)Apply the following comprehensive approaches:

      - Risk approach

      - Community-based planning and promotion of community and
        intersectoral participation

      - Family approach for prevention and restorative intervention

      - Interdisciplinary and intersectoral teamwork

    c)Encourage the involvement of youth organizations and adolescents and
      young people in the various stages of programming.

    d)Apply a contextual approach to the interpretation of the origin and
      relative importance of determining factors, lifestyles and health-
      related behaviors, and levels of health and development in adolescents,
      taking into account the:

      - Political and economic context (macro)

      - Cultural context and changes therein (intermediate)

      - Local context (micro)
        .Family
        .Schools
        .Workplace
        .Recreation areas
        .Place of residence
        .Other

2.  From the operational standpoint, there will be five main strategies:

    (a) Utilization of local, regional, and national resources through
        scientific societies; technical-scientific institutions; subregional
        agreements; leaders in maternal, child, and adolescent health; local
        programs and projects such as the Kellogg and UNFPA projects for
        the development of activities in the areas of scientific dissemination,
        training, and methodological evaluation and demonstration.  The
        technical, technological, and logistical resources available at the
        Regional (PAHO) and global (WHO) levels will be utilized.

    (b) Activation and strengthening of networks of leaders of community-
        based projects, programs, and institutions within and between
        selected countries.

    (c) Utilization of a subregional focus for the selection of countries and
        for certain activities, taking advantage of the geographical proximity
        of countries and their relative similarity in terms of needs, resources,
        culture, etc.  The objective is to optimize resources and promote a
        possible exchange of cooperation and experiences.  From the
        subregional level activities may be extended to the national and local
        levels through the formation of multipliers (cascade effect).

    (d) Selection of six (6) countries for the formation of a network to
        coordinate the development actions, supported by centers located in
        another network comprising another five (5) countries of the Region. 
        The first network of focal countries will include Argentina, Bolivia,
        Guatemala, Paraguay, the Dominican Republic, and an English-
        speaking Caribbean country to be selected.
      
    The second network will incorporate centers in Brazil, Chile, Colombia,
Costa Rica, and an English-speaking Caribbean country to be selected.

    As is evident, the two networks group together countries located in
various subregions of Latin America and the Caribbean.  This is important
because development activities such as training, dissemination of information,
observation visits, and others may be expanded to include participation by
neighboring countries.


Distribution of Countries Directly Involved 

    In all the countries involved a special effort will be made at the central,
regional, and local levels to initiate activities in the area of comprehensive
health care for adolescents.  There are also resources at the local and regional
level (in the case of the State of SØo Paulo, Brazil), as well as at the national
level (Costa Rica), with valuable experience that may prove useful to other
areas within the same country and to other countries.  It should also be
emphasized that there is expected to be interaction within each network and
between them.  At the least, the following types of activities can be carried out:

     -  Activities in every focal country with support from the reference
        centers.

     -  Activities involving the entire focal network and the network of
        support or reference centers.
    
    (f)Identification in the focal countries of centers for the care of
      adolescents that exercise leadership in the national context.  Examples
      of such central points might be a university that is linked to the health
      services and the community or another recognized national, regional,
      or local entity such as a health commission or committee for adolescent
      health within a pediatrics society.  The plan of action in each focal
      country should benefit an expanding network of centers and programs
      which will gradually become an important resource for national
      initiatives or programs for the comprehensive health of adolescents.

    As is evident from the foregoing discussion, an attempt has been made to
represent the various subregions:  Central America and the Caribbean, the
Andean countries, Brazil, and the Southern Cone.  This approach will make it
easier to concomitantly and successively expand the results, both to other
countries and within the same country, and to carry out development activities
on the subregional and Regional levels as part of the regular international
cooperation activities of the Pan American Health Organization.  At the same
time, it is hoped that the activities carried out in the countries selected will help
to strengthen the local health programs being promoted by PAHO as a basic
strategy for application of the philosophy of primary health care while also
strengthening the community-based adolescent health projects that are being
sponsored by the Kellogg Foundation in Latin America and the Caribbean.
C. PLAN OF ACTIVITIES

    In order to facilitate implementation of the Plan of Action, four basic
components have been included:

1.  Development of ways of adapting the health services to provide
    comprehensive health care for adolescents.

2.  Design and implementation of a plan for human resource development to
    facilitate the teaching and delivery of comprehensive health care for
    adolescents.

3.  Strengthening of the Regional network of institutions that work with
    adolescents.

4.  Development of operating capacity for execution of the project.

    The first three components correspond to the three General Objectives
set forth above.  The last is aimed at strengthening PAHO's structural and
functional capacity to implement the project.  It should be emphasized that the
four components cannot be considered separately since they are complementary
parts of a whole.

    Listed below are the activities to be carried out under the foregoing
components:

Component 1:

    Strengthening of the two networks of countries involved in the project.

Activities:

1.1 Promotion and dissemination of publications, standards, and programs
    related to comprehensive health care for adolescents.

1.2 Strengthening and support for three information centers at the country
    level.

1.3 Organization of three traveling seminars for leaders of local and national
    projects.

Component 2:

    Development of ways of adapting health services to provide
comprehensive health care for adolescents.
Activities:

2.1.Development of instruments for the evaluation of services at the primary,
    secondary, and tertiary levels of care.

2.2.Development of normative guidelines for programming.

2.3.Support for national processes of standardization of comprehensive health
    care for adolescents.

2.4 Development of a model clinical history for adolescents, including the
    instrument, instructions for completing it, computerized management of
    the information, and the analysis thereof.

2.5.Development of an instrument for the identification of dysfunctional
    families.

Component 3:

    Design and implementation of a plan for human resource development to
facilitate the teaching and delivery of comprehensive health care for
adolescents.

Activities:

3.1 Training of trainers for teaching and service personnel (seven three-
    week courses).

3.2 Promotion of intersectoral action in the area of comprehensive health care
    for adolescents in the countries (seven multisectoral seminars).

3.3 Development of participatory techniques for working with adolescents.

3.4 Development of a training module on adolescent health care for workers
    at the primary level.

Component 4:

    The aim of this component is to promote coordination between local
projects in the countries that comprise each network and between the two
networks, as well as coordination of local projects with the regional and central
levels within each country in order to strengthen the impact of initiatives at the
local and intermediate levels, with a view to supporting the national initiatives
for adolescent health.

    In addition to the HPM Program's basic activities of technical cooperation
with the countries of the Region, the Program--through the adolescent health
unit and the maternal and child health unit--will undertake to carry out the
following activities in the area of comprehensive health of adolescents. 

    a)Mobilization of resources from PAHO and other agencies, especially
      UNFPA, UNICEF, WHO, and various NGOs (Carnegie Corporation,
      Pew, IYF).  Mobilization of scientific societies in the countries,
      subregions, and Region as strategic instruments or mechanisms for the
      implementation of new initiatives and for the strengthening of the
      corresponding programming at the country, subregional, and Regional
      level.

    b)Distribution of scientific and educational material to institutions in the
      countries will also be emphasized.

    c)Direct technical assistance to the countries--especially for the
      formulation of plans and programs through PAHO/WHO resources and
      short-term consultants--will continue to be provided to the extent
      possible.  In addition, an effort will continue to be made to mobilize the
      technical resources available in the countries to support other countries.

    d)Support for health services research, including operational,
      epidemiological, and evaluatiional research, will also be continued. 

    e)Gradual incorporation of topics relating to adolescent health into the
      curricula for the international and national courses on maternal and
      child health and management sponsored by the Program.

    It should be underscored that PAHO, through the Program for Health
Promotion, is developing plans and programs aimed at discouraging high-
risk behaviors in the general population, including adolescents and young
people (smoking, psychoactive substance use and alcohol consumption, mental
health problems, and accidents). ANNEX I

    CONCEPTUAL FRAMEWORK

1.  Health, Well-being, Quality of Life, and Development

    The health and well-being of adolescents and young people are essential
ingredients for the development of their countries.  Recognition of the role
played by psychosocial components in the maintenance and restoration of
health, the promotion of well-being, and the prevention of disease are most
important and probably most critical in this age group. 

    Well-being and quality of life are contingent on the safeguarding of
human rights, which include the right to education, housing, nutrition, and good
physical and mental health, as well as the right to employment, to recreation,
and to participation.  Social well-being cannot be achieved if young people are
not guaranteed access to services or given the opportunity for comprehensive
development (1).

    It should be underscored that it is the responsibility of health programs
and services to provide an adequate response to the basic health needs of
adolescents, involving them as partners in their own health care.

    However, it should also be pointed out that, notwithstanding the
magnitude of the problems facing adolescents and the sociopolitical importance
of this group, only a few countries in the Region do not have policies, plans, or
programs for the comprehensive care of adolescents and young people.

    The image that the adult world has of adolescents and young people is
based on stereotypes that emphasize the energy, egotism, and conflictive nature
of youth while underscoring the problems that affect a portion of this age group,
among them delinquency, drug use, and teenage pregnancy.  This image makes
it difficult to create an auspicious climate for the promotion and implementation
of policies, laws, and programs aimed at meeting the needs of adolescents,
including their health needs.

    The modernization of developing countries, in addition to its positive
aspects, produces side effects, notable among them the "crisis of the family,"
(2) which affects adolescents and young people in a particular way.  The
correlation between family dysfunction, on the one hand, and emotional
symptoms and behaviors that impair adolescent health, on the other, has been
widely documented (3.4).
2. Comprehensive Health

2.1 Bio-psycho-social Comprehensiveness

    Despite reiterated affirmations that humans are biopsychosocial beings,
in practice, health programs tend to concentrate their efforts in the biological
sphere.  This bias, which is present in the health care provided to all population
groups, has a definite effect on the health and well-being of adolescents and
young people.

    The processes of growth, development, maturation, differentiation, and
adaptation are nourished by the contributions that the microenvironments of
family, school, and other institutions (churches, peer groups, recreational
centers, sports activities, etc.)  offer children and adolescents.  A central task of
such institutions with regard to the process of socialization is to transmit to new
generations the social standards or values that are sanctioned by the human
group to which they belong.  Adolescence marks the beginning of the
consolidation of spiritual development, which is guided by the system of criteria
and beliefs on the basis of which people perceive, evaluate, and cope with
situations that produce psychological conflicts or that have ethical implications. 
It is also conditioned by the growing capacity to evaluate human nature in its
various dimensions, as well as nature in general and the different manifestations
of beauty (1).  As with other expressions of the process of growth and
development, this aspect follows a sequence of stages, after which the young
adult will be in a position to solve the problems he/she encounters (3).  The
implications of development for the spiritual and mental health and social
equilibrium of the adolescent are evident.  Consequently, they should be taken
into account by programs that provide comprehensive health care, which must
necessarily take place in a continuum that encompasses all the stages of
development.

    Despite the importance of the foregoing considerations, these factors and
attributes are being neglected at the family and social level, and development
is being repressed in children, adolescents, and young people as a result of the
behavior of adults as individuals, families, and society (1).

2.2 Comprehensiveness of the Health Care Delivery System

    The various levels of complexity and coverage of health care delivery
systems should be adequately integrated in order to streamline the system and
facilitate access by young people who seek services.

    Experience with adolescents has shown that their first point of contact
with the system is very often the hospital emergency room.  However, it is
important to understand that the system should extend to and be present in the
various ecological niches in which adolescents are found.

    The success of the system will depend to a large extent on the
characteristics of its personnel, who should be trained to care for adolescents
and young people, both in terms of their physical problems and their
psychosocial needs.  The most effective means of expanding coverage,
detecting needs, and strengthening the success and quality of the service is to
involve the adolescent himself as an agent of health promotion and restoration.


2.3 The Prevention Chain

    The incorporation of a comprehensive approach in the chain of activities
through which health care takes place makes it possible to assign to prevention
the importance that it deserves, articulating it with the various levels of service
delivery.  In this way, while actions aimed at restoring health are not neglected,
at the same time there is an opportunity to carry out actions that will help to
improve the quality of life.

Basic prevention (health promotion) implies the strengthening of protective
factors in order to avoid or control risks, as well as the capacity for and exercise
of self-care and mutual aid (1).

    Through the strengthening of protective factors during adolescence and
early adulthood, health status and well-being in later stages of life can be
improved.  The fact that risk factors are not necessarily associated with
impairment to health during the stage of life in which protective factors are
most effective heightens the importance of health promotion for the prevention
of disease and provides an incentive for young people to make the best use of
it.

    Interventions in this area that specifically target young people may focus
on the entire population, certain groups, or individuals.  They have far-
reaching importance both in terms of their effectiveness in preventing disease
and in positive terms, in the sense that they help to improve the quality of life. 
The achievement of basic prevention requires not only health promotion
interventions but, in particular, the encouragement of a sense of responsibility
and commitment on the part of individuals, families, and groups to the adoption
of healthy lifestyles and behaviors that emphasize self-care and mutual aid.  It
also requires that service delivery systems allow broad participation by
adolescents and young people, both in the design and operation of health
services and in social engineering projects that concern them.    

    Primary prevention, by preventing the appearance or effect of
contributing factors and/or specific causal agents, has a decisive impact on
public health.  Examples of this include vaccination campaigns to prevent
certain diseases, sex education to prevent the problems associated with early
initiation of sexual activity, and legal provisions that make it compulsory to
wear safety belts in order to reduce the injuries caused by traffic accidents or
those that raise the age at which a person may drive a motor vehicle or drink
alcoholic beverages.

    The effective and timely management of assistance systems, especially in
the case of accidents or traumas, as well as the participation of community
support networks in the management of psychosocial problems, are examples
of secondary prevention.  Intersectoral linkage is effective in secondary
prevention.  Thus, work with the schools facilitates early detection of health
problems, especially those that effect a student's performance, such as sensory
defects, cognitive and attention deficit problems, emotional imbalances, and
others.

    Tertiary prevention, which involves intervention to mitigate residual
effects or sequelae and prevent chronicity, is the final recourse when other
forms of prevention have been insufficient or ineffective.  The reintegration into
society of adolescents or young people who have abused alcohol or drugs;
physical rehabilitation for individuals who have been injured in accidents; and
psychological, social, labor, and other types of rehabilitation are additional
examples of tertiary prevention measures that are frequently applied in the
adolescent population.
    
2.4 Integrating Approaches

    The participatory approach implies the involvement of adolescents and
young people in the diagnosis, design, execution, and evaluation of programs. 
Participation by young people is crucial for the determination of their perceived
needs and ideals in terms of health and well-being.  Their involvement,
individually and as a group, makes it possible to expand resources and reach the
most unprotected members of this age group, who are not likely to seek out
health care on their own or respond to the invitation of an adult. The
introduction by community and institutional networks of effective
communication and promotion techniques that expand the scope of programs
can have a great impact on promotion and prevention activities and on progress
toward the achievement of comprehensive health care for adolescents and
young people.

    The anticipatory approach utilizes the possibility of programming health
actions in anticipation of the sequence of events that occurs as part of the
process of growth and development.  In this way it is possible to plan early
intervention--with the participation of adolescents and young people, their
families, the schools and other community agencies--prior to the occurrence of
these events.

    The risk approach in health care for young people and adolescents takes
into account the vulnerability that characterizes this group by virtue of its stage
in life.  It considers the weaknesses or strengths associated with the
biopsychosocial changes that occur at this stage and the influence of elements
in the physical and human environment.  This includes the microenvironments
of the family, school, and peer group, as well as the cultural characteristics and
the political, social, and economic macrostructure.

    Psychosocial research is contributing a growing body of information about
risk-prone behaviors and the moments at which they are initiated, making it
possible not only to formulate the best intervention strategy but also to plan the
best time to implement it, ideally prior to the initiation of such behaviors.

    The intersectoral approach, like the comprehensive approach,
recognizes the multidimensionality of health and its intimate relationship to
individual, group, and social well-being and development.

    It is essential that there be intersectoral linkage at the local or community
level, as well as with governmental or nongovernmental organizations and with
youth groups.  Effective articulation of these entities allows optimal use of
resources.  The education sector, as well as organizations that promote the
constructive use of free time, especially through sports and recreational
activities, and community and solidarity movements are among the most
obvious areas with which the health sector should strengthen its ties in order to
improve the health and well-being of young people and adolescents.

    The environment, both physical and psychosocial, plays a singular role
in the health, development, and well-being of adolescents.  This environment
may sometimes be characterized by a lack of opportunities for education and
job training, lack of employment opportunities, lack of personal safety, and the
presence of unsatisfactory family relations, all of which are factors that
adversely affect the health and well-being of young people.  They may grow up
in a social environment in which they are incited to take risks such as smoking,
drinking, using psychoactive substances, or engaging in promiscuous sexual
activity, or in which they are exposed to violent situations. 

    On the other hand, the environment can provide opportunities for healthy
social, emotional, intellectual, physical, sexual, and moral development.  It can
help to strengthen the adolescent's self-confidence and contribute to
development of the capacity to cope with adverse situations and resist negative
peer pressure. 

3.  Current and Future Impact and Importance

    The consideration of adolescents and young people as a "target group"
establishes a focus on a stage in the life cycle, in contrast to programs that focus
on specific problems.

    From a biological perspective, the period of adolescence and youth is
crucial to health during adulthood, influencing the appearance and course of
diseases and disabilities.  In this stage attitudes, beliefs, and lifestyles are
embraced that will in turn determine health status, well-being, and social
adjustment--in other words, the quality of life--in later periods.  It can thus be
affirmed that growth and development are lifelong processes that are not limited
to specific stages of the life cycle.  However, it is important to emphasize the
consequence of the choices made during adolescence since the selection of
healthy options during this stage will have a positive impact on the quality of
life, both in the present and the future.

    There have been innumerable studies of the chronic noncommunicable
diseases that occur most frequently in adults and the elderly in which it has been
demonstrated that the risk factors for these diseases were already present in the
affected individuals several decades before onset of the disease.  Basic and
primary prevention can have their maximum impact when they are initiated in
the early stages of life, i.e., during infancy, adolescence, and youth. 

    Adolescence and youth constitute the period in life when, based on the
classic indicators of health and disease, people are most healthy.  This age
group has the lowest death rates and the lowest frequency of perceived episodes
of disease.  It is a stage in which there is relatively little demand for curative
services in comparison with other periods of life.  This circumstance should in
theory facilitate the reorientation of health services, making it possible to place
due emphasis on health promotion and the prevention of disease.

BIBLIOGRAPHY

1.  Upland, C.V.  Un Marco de Trabajo Conceptual para Comprender los
    Problemas de Adolescentes y Jóvenes. Working document.  Conference
    on the Health and Development of Adolescents.  Washington, DC., Pan
    American Health Organization, 1992.

2.  Inkeles, A.  Individual Change in Six Developing Countries.  Ethos 3(2):
    323-342, 1975.

3.  Florenzano, R.L., and I Ringeling.  Salud Familiar, Edic. Santiago, Chile,
    Corporación Universitaria, 1986.

4.  Covarrubias, P., C. Reyes, and M. Muñoz.  ¿Crisis en la Familia? 
    Ediciones Universidad Católica de Chile, 1984.

5.  Regional Program on Maternal and Child Health.  Marco de Referencia
    y Conceptual del Programa de Salud Integral del Adolescente.  Working
    document, Washington, D.C., Pan American Health Organization.  ANNEX II:  RESOLUTIONS OF THE GOVERNING BODIES


World Health Organization:

    Resolution WHA 42.41, adopted in 1989, urges the Member States: 

(1) to give appropriate priority to the health needs of adolescents and youth;

(2) to provide the resources and facilities necessary to assess critically the
health situation and needs of adolescents and youth, and to identify major
factors that may influence their current and future health, including policies and
programs in health and other sectors;

(3) to develop socially and culturally acceptable programs and services to
meet the health and development needs of all adolescents and youth, ensuring
the involvement of families, the public at large, health and other relevant
sectors, and young people themselves;

(4) to identify, and provide support to meet, the health and development
requirements of those groups of young people who are particularly vulnerable,
disadvantaged, or have special needs, such as those within minority subcultures,
the disabled, or the marginalized; such action should not be taken in isolation
but, to the extent possible, as an integral part of programs benefiting other
young people;

(5) to train workers from the health and other sectors to appreciate the
developmental basis of the health of youth... and to have the necessary
communication skills for dealing with them;

(6) to collaborate closely with nongovernmental organizations, particularly
youth organizations, in the development, implementation, and evaluation of
programs to meet the needs of youth and to involve them in the national
strategies for health for all;

(7) to draw the attention of those working in the health and other sectors, and
the general public, to the actions required to meet the health needs of youth and
to the important contribution of young people to health for all through different
forums, the media, and events such as national conferences and national youth
days; 

    Resolution WHA 42.41 also requests the Director-General:

(1) to support Member States in developing and implementing national
multisectoral policies and programs promoting the health of youth, in defining
the health needs of young people and strengthening research, training, and
services to meet those needs; 

(2) to develop further and adapt methodologies and innovative approaches in
the promotion of the health of youth, and to develop indicators for the
evaluation of the health of youth and the experiences of the countries, agencies,
and organizations in meeting the health needs of young people.

(3) to take the necessary steps to strengthen WHO's programs at all levels
dealing with adolescents and youth, including networks of collaborating
institutions and centers for adolescent health, training in such areas as
counseling and communication skills, and research.

(4) to mobilize additional financial and human resources in order to strengthen
WHO's capacity to respond, on request, to the health needs of Member States
in this area;

(5) to extend WHO's collaboration within the United Nations system, and
with bilateral and nongovernmental organizations, to meet  the health needs of
young people and to facilitate their participation in the health-for-all movement;
 
(6) to report to future Health Assemblies on the progress made regarding the
health of youth.


Pan American Health Organization:

    Resolution CD30.R8 of the Directing Council, adopted in September-
October 1984, urges the Member Governments to pay particular concern to the
problem of adolescent pregnancy and promote the teaching of family life
education to the young. 

    Resolution CD33.R13 of the Directing Council, adopted in September
1988, urges the Member Governments to initiate intersectoral and sectoral
actions directed toward the community, teachers, and parents, with a view to
helping adolescents develop healthy lifestyles and avoid risk-associated
behaviors that lead to drug addiction, accidents, sexually transmitted diseases,
and unwanted pregnancies.

    Resolution CD35.R16 of the Directing Council, adopted in September
1991, requests the Director to include on the agenda of the next meeting of the
Directing Council the topic of "Comprehensive Health of Adolescents."


ANNEX III:  TABLES AND FIGURES


TABLE 1
      MIDYEAR POPULATION ESTIMATES (THOUSANDS) 
BY SEX AND AGE GROUP, 1990a

AGE GROUPS
COUNTRY  TOTAL     BOTH SEXES      MALES       FEMALES

Source:CELADE.  América Latina:  Proyecciones de Población 1950-
      2025. Boletín Demográfico 23(45), Chile, January 1990.
      Comisión Económica para América Latina y el Caribe.  Anuario
      Estadístico de América Latina y el Caribe, 1990 edition.

a/  The figures correspond to the recommended projection, which implies
adoption of an average fertility hypothesis.







TABLE 2
  MIDYEAR TOTAL POPULATION PROJECTIONS (THOUSANDS)a

Source:CELADE.  América Latina:  Proyecciones de Población 1950-
      2025. Boletín Demográfico 23(45), Chile, January 1990.
      Comisión Económica para América Latina y el Caribe. Anuario
      Estadístico de América Latina y el Caribe, 1990 edition.

a/  The figures correspond to the recommended projection, which implies
adoption of an average fertility hypothesis.



TABLE 3
ILLITERACY
     PERCENTAGE OF THE POPULATION AGED 15 OR MORE

COUNTRY                       CIRCA


Source:Comisión Económica para América Latina y el Caribe.  Anuario
      Estadístico de América Latina y el Caribe, 1990 edition.

a/ UNESCO estimate
b/ Persons without schooling have been considered illiterate
c/ Figure from 1988
d/ Refers to the population aged 10 or more
e/ Persons without schooling have been considered illiterate
f/ Excludes the indigenous population living in the jungle
g/ Refers to the population aged 5 or more






TABLE 4
PARTICIPATION IN ECONOMIC ACTIVITY BY AGE GROUP, 1970-1985

(AGE-SPECIFIC RATEa FOR BOTH SEXES)

Source:Comisión para América Latina y el Caribe. Anuario Estadístico de
      América Latina y el Caribe, 1990 edition.

a/ Percentage of the economically active participation in a given age group over
the total population of the same sex in that same age group. 







TABLE 5
 CENTRAL GOVERNMENT EXPENDITURE (IN $US) ON HEALTH, 
PER PERSON, IN LATIN AMERICA AND THE CARIBBEAN, 1970-1980


COUNTRY/YEAR



Source:Based on data from the Inter-American Development Bank.
      Comisión para América Latina y el Caribe. Anuario Estadístico de
      América Latina y el Caribe, 1990 edition.

a/ Estimates from 1980 onward probably reflect exchange rates.




TABLE 6
     CENTRAL GOVERNMENT EXPENDITURE ON HEALTH 
      AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT,
LATIN AMERICA AND THE CARIBBEAN, 
1970-1988

Source:Based on data from the Inter-American Development Bank.
      Comisión para América Latina y el Caribe. Anuario Estadístico de
      América Latina y el Caribe, 1990 edition.






TABLE 7
 ESTIMATED UNDERREGISTRATION OF DEATHS (PERCENTAGES)
IN LATIN AMERICA, 19975-1980 AND 1980-1985

COUNTRIES


Source:  CELADE, 1989, and United Nations, 1980 and 1985.






TABLE 8
 MORTALITY IN PERSONS AGED 10-14 IN SELECTED COUNTRIES,
CIRCA 1985

COUNTRY           YEAR            NO.           RATE a


Source:  PAHO, Technical Information System

a/ Per 100,000 population in the age group





TABLE 9
       AGE-SPECIFIC AND SEX-SPECIFIC DEATH RATES 
IN THE COUNTRIES OF THE AMERICAS,
RATES PER 1000 POPULATION AGED 15-24,
LATEST DATA AVAILABLE


COUNTRY     YEAR            POPULATION AGED 15-24
BOTH SEXES    MALES    FEMALES


Source:Health Conditions in the Americas, Washington, D.C., (PAHO
      Scientific Publication 524) Pan American Health Organization, 1990. 
      






TABLE 10
        RATIO BETWEEN SEX-SPECIFIC DEATH RATES, 
MALES AND FEMALES AGED 15-24
  IN SELECTED COUNTRIES, MOST RECENT DATA AVAILABLE

COUNTRY (YEAR)

Source:  PAHO, Technical Information System








TABLE 11
PREVALENCE OF LOW HEIGHT-FOR-AGE 
IN SCHOOL-AGE CHILDREN, BY COUNTRY


COUNTRY          YEAR       NO. EXAMINED      LESS THAN 2
S.D. - %


Source:  CFNI, INCAP, and various national sources.



TABLE 12
 PREVALENCE OF ANEMIA (BASED ON LEVEL OF HEMOGLOBIN
IN SCHOOL-AGE CHILDREN), BY COUNTRY
(CUT-OFF POINT:  HB = 12G/DL)

COUNTRY                            YEAR                 %




TABLE 13
PREVALENCE OF ENDEMIC GOITER IN SEVERAL COUNTRIES OF LATIN AMERICA


COUNTRYYEARPOPULATIONREPRESENTATIVITYSAMPLE

SIZECLASSIFICATIONPREVALENCE
(%)BOLIVIA 1981 School-age childrenNational38,500PAHO, adapt.60.8ECUADOR1983School-age childrenMountain regions-PAHO36.5NICARAGUA1981NationalGeneral6,252Pérez & Scamshaw20.0PARAGUAY1986School-age childrenFive localities2,049-59.8PERU1986School-age
childrenMountain regions
Jungle regions35,125
35,125PAHO
PAHO                              34.0
URUGUAY1980School-age childrenDepartments1,254Pérez & Scamshaw2.0VENEZUELA1981School-
age children
and adolescentsNational14,709PAHO, modified21.4
Source: Expanded Program for the Control of Iodine-Deficiency Disorders in Latin America.
      Document HPN/89.2, Washington, D.C., Pan American Health Organization, 1989.



a)    1b = 10g/dl
      Sources:  CFNI, INCAP, and various national sources.






TABLE 14
        RANKING OF VIOLENCE AMONG THE FIVE LEADING CAUSES OF DEATH,
ADOLESCENTS AND YOUNG PEOPLE, 15-24,
        COUNTRIES WITH MORE THAN ONE MILLION INHABITANTS, CIRCA 1986

15-24 YEARS OF AGE
Accidents (E800-E949) and
injuries undeterminedHomicide, legal intervention,Suicides (E950-E959)
whether accidentally orand operations of war (E960-
purposely inflicted      (E978, E990-E999)
(E980-E989)

TotalMalesFemales   TotalMalesFemales   TotalMalesFemales




Source:  Health Conditions in the Americas, PAHO Scientific Publication 524.  Washington, D.C., Pan American Health Organization, 1990.

a)   Includes groups aged 15-44.
b)   Includes all accidents and violent acts.



TABLE 15
MORTALITY FROM ACCIDENTS AND VIOLENCE IN ADOLESCENTS

AGED 10-14 YEARS BY CAUSE, BRAZIL, 1985

        CAUSES (ICD-9)      No.  Rate a

Accidents and violence (E-800-E999)
Motor vehicle accidents (E810-E819)
Other accident
Accidental submersion
Accidents caused by fire and flames (E890-E899)
Accidental falls (E880-E888)
Accidental poisoning (E850-E869)
Inhalation and ingestion of food (E911)
Inhalation and ingestion of other object (E912)
Accidental mechanical suffocation (E913)
Other accidents (Rest of E800-E949)
Suicide (E950-E959)
Homicide (E960-E969)
Other violent causes (E970-E999)


Source:  Ministry of Health.  Mortality Data for Brazil, 1985.  Brasília, 1988.

a) Per 100,000 population in each age group
FIGURE 1
AGE-SPECIFIC MORTALITY 
IN SELECTED COUNTRIES OF LATIN AMERICA
1985-1990


Rate (per 1,000 population)




Age (years)



SOURCE:  TABLES 17 & 18







FIGURE 2
AGE-ADJUSTED MORTALITY,
ADOLESCENTS AGED 10-19,
LATIN AMERICA, 1979-1988

RATE (PER 10,000 POPULATION)







YEARS



SOURCE:  Maddaleno, M.  Adolescents in Latin America:  Are They Healthy?. 
1990.ANNEX IV:
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E0206.FIN



PUBLISHED VERSION                                          5/V/92

ARGENTINA

     The year 1991 was characterized by the consolidation of a
new economic model of accumulation based on a greater role for
the private sector and the withdrawal of the State from the pro-
duction of economic goods and social services.  The efforts of
the Government were directed toward external articulation in the
world capitalist economy and internal stabilization based on a
stern policy of economic adjustment.  This adjustment was
formalized and deepened by reducing public spending, the sale of
the state companies, reform of the State, and a drastic reduction
in the size of the state apparatus by reducing the number of
employees and simplification of the bureaucracy.  The economic
policy has two pillars:  a convertibility plan and a decree
deregulating the economy.  The convertibility plan legally sets
the value of the dollar in australs and prohibits issuance of
currency without the backing of a corresponding increase in the
reserves of the Central Bank.  The immediate apparent success of
the plan in reducing inflation and stabilizing exchange allowed
intensification of the opening of the economy to world markets,
fiscal reform, privatization of public companies, and reform of
the state apparatus.  In the second half of the year, inflation
fell to figures of about 1% monthly.
     Despite the fact that the Government has declared the impor-
tance of the social policy of compensating the negative impact of
the adjustment on the poor and impoverished sectors of society,
it is difficult to establish the features of the policy.  For
example, various assistance measures may be noted in relation to
critical situations without the shaping of a policy of impact. 
In labor policy the most important event was the approval of the
new Law on Employment, which limits stability and cuts corporate
power and the negotiation capacity of unions.  Its objective is
to promote investment and production when profitability
conditions improve by making employment flexible.  These events
are significant if it is considered that in recent years, as a
consequence of the recession and reduction in the number of jobs,
the population that lives below the poverty line or has unmet
basic needs has grown, an important phenomenon in large urban
centers such as Greater Buenos Aires and Rosario, and in rural
sectors which face greater difficulties of adaptation.
     Health sector policy continued to be defined.  The most
significant feature was the frequent renovation of the
Government's management in this sector.  There was a greater
trend toward formulating plans and undertaking more stable
activities, however.  For example, the State's reform plan took
into account the restructuring of the Ministry of Health and
Social Action with the selection of new directives, elimination
of positions, and transfer of services to the provinces.  In
addition, the decree deregulating the economy has deep
implications for the social security system since it favors
privatization of medical care financing and pension plans.
     Important events were presentation of the law on drug
patents in the Congress and the Federal Health Council's document
entitled "Federal Agreement on Health Policies," which states
that one of the basic objectives of State reform should be
deconcentration of the power of the large central bureaucratic
health and social security agencies, and the transfer of re-
sources and delegation of decision making at the agency,
institutional, and local levels.  The transformation of the State
in the health area involves decentralization at different levels
and the generation of new institutional methods of planning and
administration which ensure social participation, consensus, and
control of the management of public services.
     PAHO/WHO's technical cooperation was specifically requested
in the formulation of health policies; execution of studies of
medical care financing; strengthening capacity for analyzing
information on health for decision making; identification of the
principal environmental health problems; support for universities
in formulating and administration of policies on training human
resources in health; improvement of the quality of medical care;
prevention and control of the country's leading diseases, such as
diseases preventable by vaccination, Chagas' disease, and AIDS,
and, finally, for the programming and operational integration of
IDB and IBRD projects to develop health services.
     It is foreseeable that in the near future, PAHO/WHO's
technical cooperation will be oriented toward the technical
strengthening of the new responsibilities of the Ministry of
Health involving the transfer of services to municipal and
provincial jurisdictions.  In addition, as a consequence of the
Government's requirement that the provinces deepen the policies
of adjustment, PAHO/WHO made arrangements to initiate
redefinition of strategies and methods of cooperation with such
jurisdictions.
     An agreement was signed between the Government and the
Organization in November to establish the Pan American Institute
for Food Protection and Zoonoses (INPPAZ).  The agreement was
approved by the XXXV Meeting of the Directing Council (Resolution
XXI), and on 31 December the agreement between the two parties
based on the existence of the Pan American Zoonoses Center
(CEPANZO) came to an end.
E0207.FIN



CHILE                                                      5/V/92
PUBLISHED VERSION

CHILE


     In March 1991 the Government began its second year.  The
full exercise of democracy has already been consolidated in the
country within a framework of normal operation of institutions,
public powers, and political parties; greater participation by
the citizenry, and a clear orientation toward achieving a
national consensus which makes developing the economy and
improving the living conditions of the most deprived sectors of
the society possible.  During the year economic activity was
satisfactory:  the GDP was increased by nearly 5% and there were
a very favorable balance in foreign trade and an increase in
exports and investment, especially in the public sectors, the
mining industry, and energy.  Inflation remained at about the 18%
forecast by the Government; unemployment rose mildly, reaching 7%
at year's end, at the same time there was an increase of 5% in
the real wages of workers.
     Concerning health, the Government reaffirmed its strategic
orientations of trying to facilitate access for the entire
population to health services by applying the criteria which
guide its social policy:  social equity, effectiveness, and
efficiency in the use of resources; social participation; respect
for the dignity of beneficiaries, and social solidarity.  For
this purpose the organization of primary care services was
accelerated by giving them greater decision-making power in order
to provide coverage to all the communes in the country within
four years.  It is also proposed to restore the hospital
infrastructure in the public sector, which is very deteriorated,
through public investment projects which also have external funds
in the form of donations or loans from multinational and
bilateral agencies which will amount to nearly $US45O million
between 1991 and 1995.
     There are clear policies to ensure the availability of human
resources, in number and quality, and to support their adequate
training and updating, at the same time that incentives for the
best performance by personnel are provided through just
remuneration.  Budget funds have been increased for the sector
and strategies have been formulated to recover costs and improve
the allotment of funds to public and private systems of health
care.
     In the framework of service decentralization, it is proposed
to increase the effectiveness and efficiency of the National
Health Service System as a whole through participation by the
private sector.  The normative, regulatory, and management
capacity of the Ministry of Health is being strengthened
according to a strategic plan which includes infrastructure
development projects, personal health care and environmental
programs, strengthening of information and management processes,
and technical and logistical support for local health services.
     PAHO/WHO's technical cooperation focused on the strategic
areas of social communication, information management,
reorganization of the sector, focusing on high-risk groups,
mobilization of resources, promotion of health, health in
development, and technical cooperation among countries.  A large
allocation of resources was awarded to social communication,
especially in regard to the AIDS control program.  The
information management strategy reflects the great priority the
Government gives to training its human resources by means of
fellowships and a significant number of courses, seminars, and
other activities to update the personnel in the programs and
services, as well as to the development of its scientific and
technical information systems.  The reorganization of the sector
is important for the Government, which is engaged in sectoral
adaptation, deepening decentralization, and enhancing its
information, planning, and management systems.  The focus on
high-risk groups chiefly affects activities aimed at the health
of the poor and workers as well as care of newborns.  The
mobilization of resources centers especially on support for
physical investment projects and obtaining external financing for
expanding and rehabilitating installed physical capacity.
     In allocating its funds, PAHO/WHO emphasizes the priority of
AIDS (31% of the funds) and developing infrastructure and
management (18.1% for analyzing the sector and the allocation of
budgeted resources, mainly for the health services project, and
12.9% for development of human resources).  In accordance with
the epidemiological situation of the country, the programming
priority on lifestyles and risk factors occupies third position
in the allocation of PAHO/WHO resources (8.7%), which are used in
projects related to the chronic diseases and adult care.  The
allocation for preventable disease control (6.6%) underwent a
sudden turn in 1991 because funds were redirected from other
programs to cope with the cholera emergency.  Environmental
health would appear somewhat underrepresented in the cooperation
PAHO/WHO provides, although in reality the nation's environmental
pollution priorities are also dealt with by other sectors. 
Strengthening local health systems continued to be a strategic
priority and is present to a great extent in the development of
health services because work was done jointly with the National
Health Services System in managing its decentralization.
     In regard to promotion of health and prevention and control
of noncommunicable diseases, the Organization gave priority to
holding workshops on cervical cancer and control of smoking, and
in the second quarter of the year reprogrammed activities to
control risks related to cholera.  PAHO/WHO cooperated in
addition in strengthening occupational health and the information
system on environmental problems, and in holding workshops on
Chagas' disease and hydatidosis.
     In regard to health services development programs,
activities were centered on the cholera emergency.  Toward that
end, it had the collaboration of short-term consultants and
trained personnel in strategic and logistical planning.  In
addition, 20 workshops and meetings on senior management,
strategic planning, decentralization, and primary care were held,
and national personnel were contracted to carry out specific
projects concerning management, sectoral adaptation, social
communication, and primary care.
     In regard to the dissemination of scientific and technical
information, the Organization contributed personnel and equipment
to strengthening the documentation center of the Ministry and
collaborated in extending the information network to the
hospitals in the National Health Services System.
     To collaborate in training human resources in health, five
international fellowships of a month each and 26 national
fellowships (168 months) for master's level courses in public
health (15), management of health services (5), and maternal and
child health (6) were financed.  In addition, 33 workshops and
meetings on various subjects were held for personnel from the
health services and three national contracts were financed to
develop the personnel management system of the Ministry of Health
and the health services.
     In regard to growth, development, and human reproduction,
PAHO/WHO collaborated in the prevention and the control of acute
respiratory infections.  In addition, it cooperated with the
national authorities in preventing and controlling communicable
diseases and in controlling AIDS, which had an allotment of
extraordinary funds that were used in disseminating educational
material, training personnel, supplies, and strengthening
technical, epidemiological, and management capability for the
campaign against this disease.
     In regard to technical cooperation among countries, Chile
participated in the meetings held among the countries of the
Southern Cone, and PAHO/WHO cooperated with the Government in
drawing up a bilateral agreement with Peru.
E0208.FIN



PUBLISHED VERSION                                          5/V/92

URUGUAY


     The most important political event in 1991 was the signing
of the Charter of Asunción through which the Southern Common
Market (MERCOSUR) composed of Argentina, Brazil, Paraguay, and
Uruguay was created; the treaty was unanimously ratified by the
Congress of Uruguay.  The Government, recognizing the need for
being prepared to compete successfully with the other members of
the MERCOSUR, underscored the need to maximize and control the
quality of products and services, and designated the recently
inaugurated Technology Laboratory as the center to carry out that
task.  It also pointed out the need to adjust other economic
factors such as energy sources, social security systems,
education, and health services to the MERCOSUR situation.  Some
areas of interest to the health sector, as for example the
marketing of drugs and food, were the subject of discussion among
the members of the MERCOSUR.
     The country participated in the Meeting of the Ministers of
Health of the Southern Cone, in which Bolivia and Chile also
participated along with MERCOSUR members, which was held in
Brazil in July.  In November a technical meeting took place in
Montevideo with participants from the MERCOSUR countries and
Bolivia to draw up a project to eradicate the vector of Chagas'
disease in the subregion.
     When new authorities assumed charge of the Ministry of
Public Health in June, certain changes were made in the strategy
of the health program, among them accelerating decentralization,
delegation of the making of numerous decisions at the operational
level, and concentration of activities in four priority areas,
namely, the health of the elderly, accident prevention, malignant
tumors, and cardiovascular diseases.  They also decided to give
priority to automating the information process in the health
sector at both the central and peripheral levels, and to changing
the strategy of the campaign against AIDS to emphasize broad
patterns of behavior instead of concentrating simply on the use
of condoms.  In addition, the Ministry of Public Health assumed
responsibility for training graduates and technicians in nursing
to attempt to overcome the deficit of professionals in that
field.  Finally, the possibility of transferring health care
services to the municipios was considered by the leading
authorities in the sector, but by the end of the year they had
still not made a decision in this regard.
     The country received the collaboration of the Government of
Germany in a primary care program in the Department of Tacuarembó
which includes an expert in public health, and the UNDP drew up a
program for the five-year period 1993-1997 which encompasses
programs related to the health sector, such as the campaign
against AIDS, hydatidosis, and health education.  UNFPA finances
an adolescent health program, which is carried out by PAHO/WHO,
and a rural health program which is the responsibility of the
Institute of Colonization.  PAHO/WHO cooperation activities which
warrant mention are summarized below.
     Although the new health authorities maintained the
orientations of sectoral policy in regard to drinking water
supply and sanitation services, the change led to a delay in
finalizing the programmed activities.  In September a course was
offered on evaluating environmental impacts and studies were
initiated within the Pan American Network for Information and
Documentation in Sanitary Engineering and Environmental Sciences
(REPIDISCA) in collaboration with CEPIS; in November the Ministry
of Public Health launched a program to control the contamination
of waterways, and PAHO/WHO, also with the collaboration of CEPIS,
cooperated with the State Sanitary Works on waterway
eutrophication and in designing wastewater treatment plants.
     The new health authorities modified the previous programming
for the development of health services and decided to update the
diagnoses carried out previously, although they agreed to those
considered still valid.  As a result, a study was made and, in
accordance with its results, PAHO/WHO contributed equipment and
formulated programs to complete the establishment of statistics
and epidemiology units which will provide service to the
Ministry, the Department, and the three General Bureaus.  With
the support of consultants contracted locally, the remodeling of
polyclinics of Montevideo was programmed and a study was made of
the complexity and programming of the regionalized operation of
the Rivera Hospital, especially its nursing component.  In
addition, with the sponsorship of PAHO/WHO two national staff
members participated in the Regional Seminar on Quality Assurance
in Hospitals which was held at Havana; an evaluation of the
information system on production, resources, and costs in
hospital establishments was made; a fellowship was awarded so
that a departmental director could study various aspects of
management in Chile, and workshops and meetings on oral health
were held.
     Concerning the analysis and development of health policies,
PAHO/WHO collaborated with the national authorities in offering a
course on formulating and evaluating projects in which around 30
staff members and national and foreign educators took part; the
course included instruction on the utilization of information
science applied to projects.  In July, two members of the Health
Committee of the Chamber of Representatives attended the Meeting
of Parliamentarians of the Southern Cone held at Brasília
simultaneously with the Meeting of Ministers of Health of the
subregion.  Subsequently equipment and programs as well as
technical information and material on health legislation from
several countries were facilitated for the Congress.
     Concerning prevention and control of noncommunicable
diseases, the new authorities decided on four programs as of
maximum priority:  cardiovascular disease prevention and control,
breast cancer, traffic accidents, and the health of the elderly. 
PAHO/WHO collaborated with the Ministry of Public Health in
formalizing some of these programs; in disseminating their
messages to the population, and in holding a second seminar
workshop on social communication and health, based on the
excellent reception and promising results of the first seminar
workshop carried out in May 1990.
     With regard to veterinary public health a consultant of the
Pan American Institute for Food Protection and Zoonoses (INPPAZ)
gave a seminar on hydatidosis during the South American Congress
of Parasitology held at Montevideo in November in which many
technicians in the national campaign against this disease
participated.  The country signed a subregional agreement on
foot-and-mouth disease eradication, a goal reaffirmed in the
MERCOSUR agreements.  As a result of that agreement, PANAFTOSA
cooperates with the national authorities in the surveillance
activities which are carried out in the country.  In the last
months of the year no cases were detected, which leads to the
assumption that the first phase of foot-and-mouth disease
eradication has begun in Uruguay.
     Concerning technical cooperation between countries, a
meeting was held in Montevideo in November of representatives of
the Southern Cone countries, Cuba, Mexico, and Venezuela to draw
up joint projects related to the exchange of technology; the
meeting was convened by the Latin American Economic System (LAES)
and PAHO/WHO.
     The national campaign against AIDS and sexually transmitted
diseases continued receiving broad cooperation from PAHO/WHO. 
During the year a medium-term plan was formulated; an
Interministerial Commission on AIDS was designated, and
departmental coordinators were appointed; health personnel were
trained in workshops, and 1,250,000 condoms donated by WHO's
Global Program on AIDS were distributed.  During the III Pan
American Teleconference on AIDS, which took place at Caracas in
March, more than 1,000 professionals in the field of health met
in the rooms of the Municipal Government of Montevideo.  PAHO/WHO
coordinated a knowledge, aptitude, and practice survey and
collaborated in a study of seroprevalence of 1,351 persons in
sentinel sites.  World AIDS Day educational activities were
characterized by greater participation of the population in the
interior of the country and by the distribution of more than
300,000 informative pamphlets.  Uruguay inspects almost 100% of
the blood donated for transfusions to prevent HIV infection. 
With PAHO/WHO support, a national workshop was held in April on
diagnosing infection due to HIV in public laboratories and blood
banks.  The national program on AIDS produces and disseminates an
epidemiological bulletin of national scope every month.
     Concerning growth, development, and human reproduction, the
Maternal and Child Health Department, with the support of CLAP,
promoted early care for pregnant women and established standards
for neonatal control; the national maternal and child health
program adopted CLAP's clinical history model.  In addition
activities were carried out to prevent and control acute
respiratory infections and diarrheal diseases.  The beginning of
a system of epidemiological surveillance of diarrheal diseases in
adults, and the task of promotion and dissemination directed
toward the prevention and control of cholera should be noted.  In
this field various forms of mass communication were tried, and
the authorities responsible for preventing cholera participated,
with support from the Organization, in the meeting on the subject
held at Washington, D.C.  The high coverage achieved by the
Expanded Program on Immunization (around 90% and more) is
noteworthy; however, because of an outbreak of measles which
mostly affected children under the age of 1 year and older than
12, the measles immunization timetable was modified.
     Finally, with respect to adolescent health, an investigation
of adolescent reproductive health was made with the support of
UNFPA and PAHO/WHO and workshops and seminars on the subject were
held.  In addition a course on sex education was offered for 50
secondary school educators sponsored by the Ministries of Public
Health and of Education and Culture, and a book on sex education
whose first edition was exhausted during the year was reprinted.
     Jointly with the national authorities, the Organization in
1991 structured PAHO/WHO's cooperation activities in the country
for 1992 according to the national priorities and the mandates
from the Governing Bodies of the Organization.


ANNEX
1

NATIONAL MEETING ON FOOD PROTECTION

PROVISIONAL PROGRAM


1.   BACKGROUND:

     -    It is suggested to include in this chapter:
a)   a brief outline of the epidemiological situation of
food-borne diseases.
b)   a summary of the contents of the laws and
regulations of the countries with regard to the
right to health and to food protection.
     -    If accepted by the national authorities, the following
paragraphs may be included:
Pursuant to the recommendations of the Inter-American
Conference on Food Protection (1985) and in endorsing
these recommendations, the IV Inter-American Meeting, at
the Ministerial Level, on Animal Health (RIMSA, 1985) and
the XXXI Meeting of the Directing Council of PAHO
requested the Pan American Sanitary Bureau to formulate
a Plan of Action for Technical Cooperation in Food
Protection for the period 1986-1990, which was approved
by the XXII Pan American Sanitary Conference in 1986.

At the conclusion of the five-year period 1986-1990, the
Plan was evaluated and submitted for consideration by VII
RIMSA, 1991, which analyzed the achievements attained and
requested PAHO/WHO, through Resolution III, to formulate
a new Plan of Action in Technical Cooperation 1991-1995
for the Regional Program of Food Protection for the
Americas, which was subsequently approved the same year
by the Governing Bodies of the Pan American Health
Organization.

2.   OBJECTIVES OF THE MEETING:
     1.   To present the sectoral health policy in Food Protection
and the development of a national program.
     2.   To strengthen the ties of cooperation between the
official entities, industry, trade, and the community
representatives interested in Food Protection.
     3.   To present the Regional Technical Cooperation Program in
Food Protection, Plan of Action 1991-1995, of the Pan
American Health Organization.
     4.   To report on the establishment of the Pan American
Institute of Food Protection and Zoonosis (INPPAZ) of the
Pan American Health Organization.

3.   METHOD OF WORK:
     The conference method will be utilized. 
4.   PARTICIPANTS:
     It is suggested to invite to representatives from:
     -    The Public Sector:  Health, Agriculture, Industry, Trade,
Economy, National Planning, Tourism, and Transportation.
     -    The Private Sector:  Societies or associations from the
Industry, Trade, Transportation, and Tourism sectors.
     -    The Community:  Professional associations, service clubs,
consumer protection associations, and universities, among
others.
     -    Representatives of the community in the National
Congress:  Members of Ad Hoc Commissions of the Senate
and the House of Representatives.
     -    Representatives of the Judicial Branch.
     -    Representatives of the print, radio, and television
media. 

5.   DATE AND PLACE:
     It is suggested that this meeting be carried out, if possible,
     at the Ministry of Health during office hours. 

6.   INAUGURATION AND AGENDA:
     6.1  Inauguration
-    Remarks by the Minister of Agriculture
-    Remarks by the Minister of Health
     6.2  Conferences
a)   The social and economic factors related to the food
industry. 
Representative of the Association of Industries.
b)   The right to health:  social participation in Food
Protection.
Representative to the Congress of the Republic (We
suggest the Chairman of the Agriculture Commission,
if possible). 
c)   Presentation of the Plan of Action for Technical
Cooperation, PAHO/WHO 1991-1995, for the Regional
Program on Food Protection and the establishment of
the Pan American Institute for Food Protection and
Zoonoses (INPPAZ).
PAHO/WHO Representative. 
d)   The sectoral health policy in food protection.
Minister of Health.
e)   Summary
Moderator of the Meeting
(A Director of the national print media is suggested
as moderator). 
     6.3  Closure
Remarks by the Minister of Health.
Note:
-    If considered desirable by the moderator of the
meeting, he may request intervention by the
participants to support the subjects discussed (this
is not an opening to discussion) before proceeding
with the Summary of the meeting.
-    Each speaker will be allotted 25 minutes.

 

        PROGRAM ON EYE HEALTH, PAHO 1991-1992


1.   Introduction:

The program on eye health initiated its activities in 1991 with a new approach to
     the promotion of eye health through education, information, and social communication.

The program has provided support to the Member Countries for the development
     of programs for eye health and prevention of blindness as part of the strengthening of the
     local health services through primary eye care.

2.   Analysis of the General Policies in Force:

a.   The importance of this program is reflected in resolutions WHA22.29 (1969) and WHA
     25.55 (1972) of the World Health Assembly, which led to the establishment of the WHO
     program for the prevention of blindness.

b.   In the XXXIV Meeting of the Directing Council, 1989, and by recommendation of the
     Executive Committee the same year, it was resolved to urge the Member Governments to
     continue to strengthen their eye health policies and programs, placing emphasis on the
     development of simple technologies for diagnostic prevention, treatment, and
     rehabilitation.  PAHO is committed to collaboration in research, training of personnel, and
     implementation and evaluation of national programs for blindness prevention and the
     promotion of eye health.

Furthermore, taking into account Resolution XVI of the XXIII Pan American
     Conference, the 107th Executive Committee resolved to recommend to the XXXV
     Meeting of the Directing Council the decision to eliminate certain communicable diseases
     such as onchocerciasis.


Activities 1991

     First Four-month Period

The regional adviser on blindness prevention was named, who traveled to the Ninth
     Meeting of the WHO Advisory Group on Blindness Prevention, which was held in Banjul,
     Gambia, in March.

During this first four-month period the regional adviser also had the opportunity
     to participate in the first Inter-American Conference on Onchocerciasis, which discussed
     the multinational plan for elimination of the disease.


     Second Four-month Period

As part of the mobilization of resources through the identification of national and
     international resources, correspondence was established with the NGOs, PWRs, Pan
     American Association of Ophthalmology, and the WHO Collaborating Centers.  Visits
     were made to the Director of the National Eye Institute, to the Executive Director of the
     International Eye Foundation, and to the Director of Helen Keller International.

With regard to the dissemination of information an informational outline was
     prepared on PAHO programs for the promotion of eye health and the prevention of eye
     disease.  This outline was published in the August 1991 edition of the Noticiero
     Oftalmológico Panamericano of the Pan American Association of Ophthalmology.

As part of the development of policies, plans, and standards, a report was made on
     the current state of the AGFUND project that was accompanied by a plan of action for the
     project.  It is hoped to obtain additional funds with this plan of action.

The plan of action of the eye health program for the following four years was also
     developed.

In the program for the elimination of onchocerciasis,  contact was established with
     two groups in Colombia in order to develop the program.  The interaction and
     interprogram cooperation have been outstanding.

With regard to direct technical advisory services, a visit was made to Paraguay, an
     evaluation of the program was made, the human resources were identified for developing
     cataract surgery, and a national committee was established for the prevention of blindness.

     The visit to Haiti had to be canceled by as a result of changes in the Ministry of Health.

A visit was made to the Sanitary Ophthalmology Service of Sao Paulo in Brazil to
     visit the Collaborating Center and to participate in the Seminar on the Prevention of
     Blindness in Joinville in the State of Santa Catarina.

     Third Four-month Period

As part of the mobilization of resources through strengthening of the ties with the
     NGOs, there was participation in the meeting organized by ONCE and Sight Savers in
     Madrid, and collaboration was requested from these organizations for the development of
     eye health programs in the Region of the Americas.

The Inter-Agency Coordinating Group for Eye Care in the Caribbean did not invite
     us to participate in the Caribbean Council for the Blind this year.

Dissemination of information:  During the Congress of the Pan American
     Association of Ophthalmology and the American Academy of Ophthalmology that was
     held in Anaheim, California, the programs on Health Promotion and Eye Health organized
     a working breakfast in which reports were made on eye health programs in the Region to
     a group of 25 ophthalmologists from 15 countries in the Region.  It is hoped to establish
     an information network and to execute regional programs with this group. 

A pamphlet was produced on the Program on Eye Health and Blindness Prevention
     that was distributed during the meeting in Anaheim.
     
With respect to the organization and transformation of the services, a follow-up was
     performed of the National Plan for Blindness Prevention in Peru and there was
     participation as guest of honor in the National Congress for Blindness Prevention.
     
Projects were developed to mobilize resources such as the use of mass
     communications for the promotion of eye health in Peru, Colombia, and Brazil.

An investigative project titled "Prevention of Blindness in Diabetic Retinopathy"
     was presented to the PAHO Internal Research Committee. 
     
With regard to direct technical advisory services, a visit was made to Bolivia in
     order to provide technical cooperation and perform a follow-up of the AGFUND project.


Activities by Country, 1991

A.   Follow-up was performed on the AGFUND project in the following countries:  Belize,
     Bolivia, El Salvador, Guyana, Haiti, Nicaragua, Honduras, and Paraguay.  A report was
     made on the project, additional resources were requested, and the national authorities were
     urged to continue the project.  As a result, all the countries involved expect to continue to
     develop the project, and Belize, El Salvador, Honduras, and Bolivia have showed their
     interest in receiving a visit from the regional adviser in 1992.

B.   Centers or institutions of technical excellence and with interest in the development of
     national eye health programs were identified as part of a regional network of institutions
     sharing this common interest.  The following countries were included:  Bolivia, Ecuador,
     Uruguay, Venezuela, Brazil, Chile, Peru, Mexico, Colombia, Paraguay, Guatemala,
     Argentina, and El Salvador.  The institutions mentioned have the capacity to support the
     secondary and primary care programs in the various countries and to become disseminators
     and promoters of the techniques of primary eye care.  As a result, great interest has been
     awakened in public, mixed, and private organizations in developing eye health programs
     characterized by the profile and the general guidelines outlined in the regional plan of
     action.

C.   A visit was made to Mexico and Guatemala as a participant in the First Inter-American
     Conference on Onchocerciasis, which outlined the regional plan for elimination of the
     disease and from which Mexico, Guatemala, Colombia, Venezuela, Brazil, and Ecuador
     are benefiting at the present time.

A visit was made to Paraguay and the national program was evaluated.  Solutions
     to the problems that were brought up were identified, thereby providing an impetus to the
     program.

In Peru there was participation in the Fourth National Congress on Blindness
     Prevention in support of the actions this country has been carrying out. 

In Brazil a visit was made to the Collaborating Center for Blindness Prevention and
     there was participation in the Eye Health Regional Seminar in the State of Santa Catarina.

D.   The Program on Social Communication and Eye Health is being launched in Peru,
     Colombia, and Brazil.  The benefits of the program will be evaluated once it has been
     implemented.



Activities 1992

3.   First Four-month Period:

     Social communication projects were prepared in order to promote eye health in Colombia
and Brazil.  A similar project was initiated in Peru. 

     There has been participation in the organization of a workshop for ophthalmological
evaluation of onchocerciasis, which will be held in Guatemala in July 1992.

     Advisory services have been provided for the multinational and interagency plan to
eliminate the disease in Colombia, Ecuador, Brazil, and Venezuela.  A visit was made to
Guatemala and Mexico together with the NGOs.

     There was participation in the mounting of a subregional network of national committees
for blindness prevention in Saint Lucia, Dominica, St. Vincent, and Grenada, organized by the
CCB and ORBIS.

     Projects for blindness prevention were presented by five countries (Bolivia, Colombia,
Ecuador, El Salvador, and Paraguay) to ONCE for consideration for financing.

     A meeting of coordinators of the AGFUND project was organized for blindness prevention
with the participation of seven countries (Bolivia, Paraguay, Nicaragua, Honduras, El Salvador,
Belize, and Guyana) in which projects were discussed that have been being developed since 1985. 
Very valuable information was obtained on strategies of great impact as well as on those without
impact.  The conclusions were presented at the regional level in order to be submitted for analysis
and for necessary adjustments for future actions.

     A survey on ophthalmia neonatorum was designed, prepared and sent.  

     Information has been distributed on eye health through the regional information network. 

     A manual on eye health for workers is being published. 

     Johns Hopkins University and the University of Chile are being supported in research on
the effects on the eye of exposure to UV rays due to the depletion of ozone in the extreme south
of Chile.
Y                                                         5/05/92

WORKING DOCUMENT

PRE-PROPOSAL FOR THE DEVELOPMENT OF A
PAHO COMMUNICATIONS SYSTEM

1.   BACKGROUND

     In the course of its history, the Organization has developed
various mechanisms for the formulation and establishment of
operating standards, guidelines for the orientation of personnel
about the management of different processes, and directives and
administrative procedures of various kinds.

     Most of this material has been incorporated into the official
manuals of PAHO and WHO, which currently form the basic guidelines
for the orientation of work and for the specification of
responsibilities at the various operational points of action.

     However, an important void still remains:  all this material
needs to be organized so that it will be readily accessible and
easy for users at various levels in the Organization to consult and
manage.  Also, it has not been systematically reviewed in the
context of the extraordinary advances that are taking place in
management techniques thanks to the availability of computer
systems that offer a vast range of options for information
processing, as well as the use of new tools of communication which
are transforming the institutional environment.

     The project for the organization of a communications system
was born out of interest on the part of the Office of the Director
of the Organization in improving the system of internal and
external communications and making the process for the adoption and
dissemination of measures about the Organization's operations and
administrative procedures more viable and relevant.

     A group of Headquarters staff have been collaborating with the
Office of the Director on the development of a project that will
address this situation comprehensively.  The present document seeks
to block out the steps that are envisioned for achieving this
purpose, including:  the initial formulation of objectives,
definition of an ad hoc infrastructure to be responsible for the
coordination of various aspects of the project, follow-up, and
operationalization of the various instruments approved.

     The group considers that it is fundamental to establish this
frame of reference first, in order to then proceed with the
drafting of a project proposal for presentation to the Director. 
The main focus of the project will be the establishment of key
points for the management of communications at Headquarters, as
well as between these and their peripheral units.  The project also
calls for the preparation and dissemination of guidelines on the
definition of responsibility and on the drafting of communications
between the Organization and other agencies.  In addition, levels
of authority for the approval and transmittal of such
communications will be specified.  Priority will also be given to
the development of an outline on the basis of contributions
obtained from the various units at Headquarters and in the field
regarding the management of program information, including the
utilization of resources and the various technologies available for
the acquisition and dissemination of data.  This step will be
followed by an evaluation and the preparation of proposals for
placing these processes at the disposal of all units.

     The group also considers it important for efforts under the
project to focus on the indication of possible orientations to be
followed in the training of staff.  It is felt that such training
should be particularly directed toward support personnel and that
it should be structured so that it will at the same time contribute
to their comprehensive advancement and provide them with adequate
background so that they can become involved in the management of
processes as members of the production team.  It is especially
important that these training processes be tied in with the
mechanisms for the classification of personnel so that they are
mutually consistent, thus contributing to a step-wise training
program aimed at upgrading the individual in terms of the
Organization's needs.

     The project will be carried out in several phases.  The first
phase will be concerned with organization of the working
infrastructure and its various components.  During the second stage
the plan of work will be defined and adopted, while at the same
time priorities will be established in close consultation with the
Working Groups and the General Committee.  The third stage will be
devoted to the formulation of specific proposals by the Working
Groups, adoption of the proposals by the General Committee, and the
generation of instruments to facilitate implementation.  Finally,
in the consolidation phase mechanisms will be studied and proposed
to the Office of the Director for maintaining project as an ongoing
process.

     It is intended that the dynamics of managing the project will
take into account the production capacity of the working
infrastructure envisaged and that the undertaking will not
represent for the Organization the utilization of any resources
beyond those available at Headquarters.

     The initial schedule calls for the activities of the project
to be carried out over 18 months, bringing it to the last quarter
of 1993.  It is expected that by that time the work should have
settled down to regular agreed-on tasks.

2.   OVERALL OBJECTIVES OF THE PROJECT

     2.1  Evaluation of the provisions that currently govern the
processing of communications in the PAHO Secretariat with
a view to proposing revisions and backing up these
directives by the establishment of key points for the
communications management.  Priority will be given to the
formulation, implementation, and maintenance of the
Executive Communications Handbook.

     2.2  Coordination of activities relating to the development
of executive management functions within the Headquarters
structure in the area of communications management;

     2.3  Development of curricula for comprehensive training from
operational levels up to middle management, in order to
provide support for the development of communications at
Headquarters.  Said curricula should seek, whenever
possible, to coordinate institutional needs with the
requirements of the personnel administration system.
ANNEX

WORKING INFRASTRUCTURE FOR THE PRE-PROPOSAL:
ASSIGNMENT OF RESPONSIBILITIES

General Committee

     A General Committee shall be established to initiate and take
responsibility for the process.  This Committee shall define the
terms of reference and coordination for the project under which the
PAHO Communications System is to be reviewed and reformulated. 
Specifically, it shall:

     (a)  Draw up a general outline of the System and define the
Plan of Work covering the activities to be undertaken by
the various working groups responsible for its
operationalization;

     (b)  Establish priorities and decide on allocation of the
resources available to the Committee for implementation
of the project and for the work of the Secretariat;

     (c)  Suggest to the Director the composition of the working
groups, define the terms of reference thereof, and
coordinate the execution of their activities;

     (d)  Review the partial and general results of the activities
as they are carried out at each stage of the project and
establish guidelines for ongoing adjustment of the
operational plan to changing requirements and to the
availability of resources;

     (e)  Evaluate the proposal, adapt it to requirements of policy
as established by the Office of the Director, and take
appropriate action to facilitate its operation so that
it will meet the objectives that have been set;
     The General Committee shall be composed of representatives of
the following units:  D/DD, AD, AM, HSI, and HPD.  The
Administrative Officer, Office of the Director, shall serve as
Coordinator of the Project, preside over the meetings of the
General Committee, and be responsible for ensuring the viability
of the decision-making process on the part of the Office of the
Director with regard to implementation of the project.  The Chief,
AAA, shall serve as Secretary.

Secretariat of the Project

     The Secretariat of the Project shall be responsible for:

     (a)  Studying and analyzing the programs formulated by the
Working Groups, making them compatible with established
policies and with available resources, and determining
their viability vis-Õ-vis priorities before they are
presented to the General Committee for its decision;

     (b)  Studying and analyzing the requests for resources
formulated by the Working Groups and recommending courses
of action to the General Committee so that these requests
will be in keeping with the priorities that have been
set;

     (c)  Formulating recommendations regarding the form and
periodicity of the reports to be presented by the Working
Groups for implementation of the project;

     (d)  Keeping informed of and analyzing the partial and overall
results of activities under the project and formulating
recommendations on the working procedures to be
implemented;

     (e)  Proposing to the General Committee the membership of the
various Working Groups under the project.

Working Groups

     The Working Groups shall have the following functions:

     (a)  Formulating programs of work within the context of the
general outline of the proposal prepared by the General
Committee;

     (b)  Formulating proposals to the General Committee on the
utilization of authorized resources in keeping with the
priorities that have been set;

     (c)  Distributing tasks to each of the members of the Working
Group, as well as receiving the results and overseeing
the performance of these tasks within the context of the
general program of work;

     (d)  Keeping the Secretariat informed of developments under
the various phases of the program of work and requesting
any support that may be needed;

     (e)  Managing the resources assigned.

Members of the Working Groups shall be appointed by the
Director upon recommendation by the General Committee,
which shall also designate a member to act as coordinator
for each group.  The Working Groups shall receive
administrative and secretarial support from the
Secretariat.

E0213.FIN



CHAPTER III.C                                            29/IV/92
PUBLISHED VERSION

DEVELOPMENT OF THE GENERAL PROGRAM


     During the year a period of management was initiated which
coincides with the start of the mandate issued by the Governing
Bodies for 1991-1994 and which is set out in the Strategic
Orientations and Program Priorities for PAHO for that period.  In
compliance with the relevant resolution of the XXIII Pan American
Sanitary Conference (1990), criteria were prepared to implement
the orientations and set priorities.  These criteria were
consolidated in a document which was approved by PAHO's Executive
Committee at its 107a Meeting in June.
     As part of that effort, regional targets were defined for
each strategic orientation and each programming priority
established which describe situations it is hoped to arrive at by
1994.  In addition, the processes which it will be necessary to
implement to reach them were identified and a proposal of the
activities the Secretariat should undertake was formulated to be
adapted to the requirements underlying the implementation of the
orientations and priorities.
     On the basis these criteria, the draft biennial PAHO program
budget for 1992-1993 was prepared; it was approved by the
Directing Council at its XXXV Meeting in September.  For this
purpose it was necessary to update the dialogue carried out with
each Member Country with regard to its technical cooperation
needs in order to formulate the biennial regional and country
programs composing the draft biennial budget.
     These principles governing the Organization's technical
cooperation policy were also applied in the last quarter of 1991
in formulating the annual operational budget for 1992.
     In close linkage with the foregoing, it should be noted that
during the year the System of Planning, Programming, Follow-
up, and Evaluation for the Region of the Americas (AMPES)
continued to be enhanced.  In that respect, the development of
follow-up and evaluation instruments and full articulation of
automated systems for preparing and executing the biennial,
annual, and four-month plans, programs, and projects was
emphasized.
     As part of the general program's management process, joint
evaluation meetings were held in Belize, Colombia, Cuba, Grenada,
Haiti, Nicaragua, and Saint Kitts and Nevis to analyze the
progress and future orientation of PAHO/WHO's technical
cooperation programs in each country in detail.
     During 1991, continuous coordination was maintained with WHO
Headquarters in Geneva and with other WHO Regional Offices about
matters relating to international and overall activities to carry
out WHO's General Program of Work.
E0214.FIN



PUBLISHED VERSION                                          4/V/92

EL SALVADOR


     The Organization's technical cooperation focused on the
mandates defined by the Government in its National Health Plan
and followed the Strategic Orientation and Program Priorities for
the 1991-1994 quadrennium.  There was collaboration with the
Ministry of Public Health and Social Welfare in carrying all its
programs out and in training personnel and preparing educational
material.  An attempt was made to place health in the complex
process of development which the country is going through, which
is characterized by a search for peace, democracy, modernization
of the State, economic reconversion, and social transformation. 
It was thus sought to integrate the health sector's components
and articulate them with other sectors, to concentrate activities
on the most vulnerable groups, to give priority to promotion and
health protection activities, and to extend the coverage of the
health services to the entire population.
     The Organization collaborated in drawing up national
projects and reports which were presented at the III Conference
of Madrid and the Special Meeting of the Health Sector of Central
America.  In addition, it coordinated its activities with the
Ministries of Education, Planning and Agriculture, the National
Secretariat of the Family, the Salvadoran Social Security
Institute, other international organizations, the Governments of
France and Italy, and the Program of Development for Displaced
Persons, Refugees, and Repatriates in Central America (PRODERE)
in carrying out its health component.
     Programming for 1991 was affected by the epidemic of
cholera, which required reprogramming resources.  PAHO/WHO
collaborated in this process and worked for the unification of
the sector's information system through a single notification
report, and helped prepare a data base and training
epidemiologists from different institutions.
     In regard to the organization of health services, PAHO/WHO
collaborated with the authorities in reorganizing several units
of the Ministry of Public Health and Social Welfare, in local
programming, and in the activities of the health units in every
region to advance the development of local health systems. 
Application of the managerial information system for hospitals
was pushed forward; a study was made of the extension of social
security coverage to rural populations; two health units were
built in the metropolitan area with support from the Kingdom of
the Netherlands, and with community participation, health
programs were organized for the population which it is expected
such units will cover.
     Concerning the program of women, health, and development,
the Organization disseminated information on the situation of
women in health, work, education, legislation, and social
participation to governmental institutions, nongovernmental
agencies, and universities; implemented bills to eliminate
discrimination against the woman; completed a review of the
provisional draft of the Family and Penal Codes; facilitated
interagency and interinstitutional coordination to identify,
formulate, and carry out projects by and for women; supported
programs of nontraditional health care for women, such as clinics
to care for victims of sexual assault and a program for young
mothers; launched a program to prevent intrafamily violence in
rural communities, and promoted research on the problem of women
in general.
     Progress was made developing comprehensive pharmaceutical
services as an important point of liaison between health
institutions and the population.  The professional education of
pharmaceutical chemists was reoriented to make them members of
health teams; continuing education on drugs was emphasized.  In
addition, a review of pharmacotherapy teaching, with a practical
approach toward essential drugs, was promoted in schools of
medicine.
     In regard to emergency preparedness and disasters relief,
within the PRODERE framework and with the Government of Italy and
Ministries of Public Health and Social Welfare and of Education,
the Organization worked to train 150 teachers and staff members
of the Ministry of Foreign Affairs in this field.
     In regard to laboratory services, PAHO/WHO concentrated its
cooperation activities on the cholera epidemic.  It facilitated
training at INCAP for eight professionals in techniques of
diagnosis; it collaborated in diagnosing cases of cholera and in
identifying Vibrio cholerae in the environment, and provided the
Central Laboratory and the Hospital Specialties equipment and
supplies for diagnosing the disease.  In addition, personnel were
trained in techniques of diagnosing rabies, and it gave technical
assistance in establishing a vaccine production laboratory.
     Technical cooperation was provided to the Department Health
Education of the Ministry in preparing a program of publicity and
education for the population on preventing and controlling
cholera, and educational materials prepared by other countries
and PAHO/WHO were provided.
     In regard to the training of personnel, the Intersectoral
and Multidisciplinary Group for the Development of the Health
Manpower was consolidated; it identified priority problems and
coordinated research on the health labor force in the public
sector.  With cooperation from the Kingdom of the Netherlands and
within the framework of the Health Initiative of Central America,
a basic course on health administration was initiated in which 35
physicians from the Ministry and 15 from the Salvadoran Social
Security Institute participated.  In June it concluded the first
course for epidemiologists in the health sector, a teaching
activity which proved to be very valuable given the threat of
cholera.  It continued consolidating the system of continuing
education at the regional and local levels.  Five regional
education units were in operation and 90 apprenticeship 
"facilitators" were receiving training.  These activities receive
support from the Danish Agency for International Development and
the documentation centers in every region, as well as basic
inputs.  PAHO/WHO also sponsored a course for 35 sanitation
inspectors, and collaborated in a prospective analysis of six
curricula at the School of Medical Technology in the School of
Medicine.  The joint program of dentistry of the Ministry of
Health and the School of Dentistry of the University of El
Salvador, in which innovative systems of care were included,
continued; this program is a model which can be duplicated in
other countries.
     Environmental health activities were basically framed within
the Environment and Health in the Central American Isthmus
(MASICA) project.  In 1991 all the activities programmed were
carried out in the country, and there was were an advisory group
for the focal point.  A workshop was held on the environment and
health in the Isthmus and identification of drinking water supply
and sanitation policies.  Owing to the epidemic of cholera,
personnel were trained in controlling water quality and
sanitation.  PAHO/WHO contributed material and equipment and
provided technical cooperation to improve water quality in
municipios and communities.
     In the field of maternal and child health and in
coordination with INCAP and PASCAP, PAHO/WHO collaborated in
strengthening the Regional Continuing Education Units and in
education at a distance, with community participation.  The
Intersectoral Committee on Child Survival and the maternal and
child health program continued receiving support from AID (USA)
and nongovernmental agencies to carry out a project in this
field.  The Organization collaborated with the Ministry in
formulating a national plan to prevent and control cholera and in
specific epidemiological surveillance activities to prevent and
control the epidemic of this disease.
     In regard to food and nutrition, the Government, with
PAHO/WHO collaboration, disseminated the results of a study on
the prevalence of goiter in schoolchildren; it prepared plans of
action to administer iodized oil to populations at greatest risk,
fortify salt with iodine, and continue enriching sugar with
Vitamin A in coordination with the Sugar Producers Association of
El Salvador.  In addition, it prepared a project to fortify the
feeding of children with composed flours during weaning which has
support from the World Bank.  The Ministry of Education continued
to upgrade and develop the health, food, and nutrition components
of the basic school curriculum through the Interministerial
Health and Education Committee and carried out studies of the
availability of raw materials and  technical and financial
feasibility for a nutritional assistance project for
schoolchildren.  The University of El Salvador continued
developing curricula for and training educators and service
personnel in evaluation activities in the field of nutrition.  In
addition, it made a study of the occupational profile of
nutritionists in the country.
     Concerning the Expanded Program on Immunization (EPI),
PAHO/WHO coordinated technical and financial assistance from the
different donor institutions; it provided technical support for
following up and evaluating the execution of the program in its
different aspects, and it promoted activities in areas of
greatest risk.  In addition, it facilitated meetings to plan
joint activities with Guatemala and Honduras; it collaborated
with national technicians in working out an EPI plan of action
for 1992-1996; and it cooperated with the Epidemiology Unit of
the Ministry of Health in strengthening capacity for analysis at
the regional levels through training workshops and review and
dissemination of epidemiological surveillance and vaccination
standards.
     In regard to communicable diseases, PAHO/WHO collaborated in
preventing and controlling tuberculosis, malaria, and dengue and
paid particular attention to the epidemic of cholera.  Manuals on
controlling and preventing cholera were disseminated, and
priority was also placed on training personnel in the management
and diagnosis of cases, international financial support, and
epidemiological surveillance activities.  In addition, PAHO/WHO
contributed equipment and supplies to the treatment and
surveillance of drinking water quality in health establishments
and rural communities, and worked to strengthen the food analysis
laboratory technically.  Arrangements were initiated to
systematize a program to control of street food sales.
     In regard to the surveillance and control of AIDS, the
activities of the National Commission on Preventing and
Controlling Sexually Transmitted Diseases and AIDS were
strengthened through concrete tasks and evaluations of the
program's progress.  With the participation of professors,
students, and heads of household, educational activities were
carried out among groups at risk, in the population in general,
and at selected sites.  At the national level, 37,558 tests were
carried out in donors to determine the presence of HIV, and 51
were found positive; workshops and round tables were held on
preventing perinatal AIDS transmission; screening and Western
Blot tests were done on 100% of the blood donated for
transfusions; and in the health services system, a computerized
notification form was utilized to detect cases and contacts. 
PAHO/WHO prepared and disseminated a videotape to provide support
for AIDS patients.  In addition, a bill on HIV and AIDS in the
country was presented to the National Congress.
     In veterinary public health, a canine vaccination campaign
was carried out to control rabies and a national program to
eradicate bovine tuberculosis was drawn up.  The country is free
from foot-and-mouth disease and maintains a system of continuous
surveillance of cases of vesicular disease in neighboring
countries.
     Within technical cooperation among countries, a consultant
from Guatemala trained personnel in laboratory techniques to
control and prevent cholera and supported preparations for the
subregional meeting on the "Convergence" project.
E0215.FIN



PUBLISHED VERSION                                          7/V/92

BRAZIL


     The national health policies are set out in the 1990-1995
Five-year Health Plan, which defines policy directives with
reference to the universalization of activities, the mission of
the Ministry of Health, the new care model, decentralization,
manpower development, relations with the private sector, social
participation, sectoral financing, health science and technology,
environmental and sanitary conditions, and technical cooperation;
it establishes implementation of the Unified Health System, which
redefines the functions of the federal, state, and municipal
levels and fixes targets, purposes, and activities for 12 general
and 16 specific situations as the central strategy for carrying
out the policy directives.
     In general, the technical cooperation provided to the
country followed the programming for 1991, established strategic
orientations and national priorities, namely, to strengthen the
sector's capacity and efficiency to increase and improve the
quality of the care the health services provide the entire
population and to seek more rational administration and
utilization of available resources to achieve the targets of the
Five-year Health Plan.
     Endogenous and exogenous factors influenced the delivery of
PAHO/WHO cooperation to the country.  Among the later, i.e.,
those beyond the control of PAHO/WHO and the own Government
itself, two significant facts deserve to be pointed out:  in the
field of health, the epidemic of cholera --which invaded the
country through Amazon River tributaries (the Negro and Solimïes
Rivers) and continued spreading to other parts of the country--
made it necessary to reprogram material and human resources to
increase the response capacity and to make a great effort to meet
the Ministry's needs in regard to the administration of
extraordinary financial resources (approximately $US5 million). 
In the socioeconomic plan, the Government faced difficulties in
controlling the national economy.  Growing inflation, the
undervaluation of the dollar, and administrative decisions by the
Ministry of Economy affected ability to mobilize resources
(mainly from national sources) and eroded PAHO/WHO's capability
to serve as an administrator of financial resources.
     With regard to endogenous factors, changes at the second
level in the Ministry of Health and consequent adjustments in the
organization of the PAHO/WHO Representative's office in the
country were made which made it necessary to make an additional
effort to meet originally planned and budgeted cooperation
commitments; within this context, the results obtained may be
considered satisfactory.
     In financial terms, approximately 50% more financial
resources than had been budgeted at the beginning of the fiscal
year was administered with a smaller staff.  This fact was tied
basically to executing a program to prevent the cholera epidemic
which cost $US5 million; to the continuation of the AIDS program,
including a new consultant ($US400,000); to preparations for
participation by the Government of Brazil in the United Nations
Conference on Environment and Development ($US100,000), and to
the start of technical cooperation programs with the National
Council of Municipal Health Secretaries in order to hold the IX
National Health Conference, with the National Council of State
Secretaries to implement the Unified Health System, and with the
National Congress (in all, $US150,000).  An important achievement
was the effective utilization of more than 98% of the resources
assigned within the corresponding period.
     From the technical point of view, all the anticipated
results were achieved and PAHO/WHO technical cooperation
increased notably as to resource mobilization and information
management.
     Local health systems, known as sanitary districts, received
special consideration.  In the cities of Fortaleza, Salvador, and
SØo Paulo the organization and operation of such districts were
enhanced, and their experiences and know-how will be disseminated
to the 4,500 municipios in the country through the National
Council of Municipal Health Secretaries.
E0216.FIN



PUBLISHED VERSION                                        1/V/92

PARAGUAY



     The National Development Plan gives priority to
strengthening the economy to achieve stabilization and
reactivation of the productive apparatus, and is based on the
development of agroindustrial activities, a free market,
promotion of the exports, and the elimination of subsidies.  It
also marks a decision to strengthen the social sectors of
housing, education, and health, as well as to protect
disadvantaged and marginal human groups through agrarian reform
and integrated rural development programs.  In addition, it
guarantees respect for human rights, freedom of press, and free
participation in political processes within the democratic
principles subscribed to by the Government.
     In regard to foreign policy, participation in subregional
and international forums and commercial integration with the
other countries of the Southern Cone, through the Treaty of the
Southern Common Market (MERCOSUR) or bilateral agreements, are
the principal lines of action of Paraguay.
     The Ministry of Public Health and Social Welfare defined
three major priority areas of action:  strengthening of the
Ministry's operating capacity through decentralization and
technical and administrative strengthening of the sanitary
regions, coordination of all the institutions in the sector by
means of a sectoral and consensual health plan, and attention
to the principal health problems that affect the population.
     To strengthen operating capacity, the Ministry stimulated
the reorganization, establishment of standards, and provision
of basic inputs to the sanitary regions and assigned them a
budget twice that of previous years; it enhanced the
application of local programming and redefined a new
information system, and it restructured the central level and
improved the systems for administering personnel, supplies,
transportation, and maintenance.  To strengthen sectoral
coordination, the Ministry supported the National Health
Council through the organization of regional councils, creation
of national commissions for planning activities, coordination
of services, and attention to problems of common interest, and
initiated the implementation of a strategic sectoral plan and
health institution plans.
     In regard to dealing with the principal health problems,
the Ministry concentrated its attention on strengthening the
programs of immunization (EPI), the campaign against AIDS,
control of endemic goiter, the vector-borne diseases, diarrheal
disease control, and environmental sanitation.  The strong
impetus given to maternal and child health, the effort carried
out to strengthen the national manpower development and drug
control programs, and health activities in border areas
resulting from bilateral or regional commitments deserve
special mention.  Social welfare was another area which the
Ministry strengthened through the development of national
standards and the creation of new lines of action for
disadvantaged groups, mainly indigenous population, repatriated
colonists, and the handicapped. The threat of the entry of
cholera into the country required the allocation of
supplementary resources and the mobilization of the national
will for mass dissemination of preventive measures, the
distribution to all services of specific inputs, and the
training of personnel.
     The Ministry also supported implementation of models of
care by levels of complexity; upgrading of the organization of
the regional health centers and the referral hospitals in the
city of Asunción; the reformulation of the national nursing
program and the incorporation of the model of care according to
basic human needs, and the training of management and service
personnel in health administration and evaluation of programs.
     During 1991 the health sector strengthened its ties with
international cooperation organizations, among them UNICEF,
UNDP, AID (USA), IDB, GTZ, W. K. Kellogg Foundation, and
PAHO/WHO.  In the subregional area, major steps were taken to
fulfill bilateral commitments and those contracted at the
Meeting of Ministers of Health of the Southern Cone countries.
     PAHO/WHO's technical cooperation was structured in five
program areas, according to the national priorities and the
strategic orientations of the Organization:  maternal and child
health, environmental health, disease prevention and control,
development of the health infrastructure, and veterinary public
health.  In addition, there was intense activity in
disseminating the policies and principles of the Organization,
and cooperation with other agencies such as the National
Congress, Municipality of Asunción, National Welfare Bureau,
Academy of Medicine of Paraguay, nongovernmental agencies, and
diplomatic representatives was expanded.
     In the maternal and child health area, activities focused
basically on the components of growth, development, and human
reproduction, diarrheal disease control, acute respiratory
infections, immunization, and adolescent health.  The principal
activities carried out deal with the establishment of standards
of maternal and child care, training of personnel and community
agents, formulation of self-instruction modules, implementation
of perinatal clinical histories, collaboration in conducting
the national demography and health survey, organization of
community oral rehydration units, and formulation of the
national acute respiratory infections plan and the national
adolescent health program.  In addition, PAHO/WHO helped
improve the efficiency of the EPI and epidemiological
surveillance of the diseases covered by that program.
     In the environmental health area, PAHO/WHO collaborated
with the Municipality of Asunción in drawing up a plan to
decontaminate the neighborhood La Tablada and in reorganizing
the Department of Urban Sanitation; it continued supporting the
National Environmental Health Service in building a sanitary
infrastructure in rural communities, and contributed to
formulating and implementing the emergency plan against
cholera.
     To support disease control, PAHO/WHO created a position
for an country epidemiologist, who was contracted toward the
end of the year.  The principal activities in this field
consisted of training personnel for the bacteriological control
of food and to manage programs to prevent diabetes and
accidents, strengthen epidemiological surveillance of cholera,
and design and implement the emergency plan for its control.
     Concerning development of health services infrastructure,
the principal task was local programming, which extended to 13
of the 15 sanitary regions, development and application of a
new information system about services provided by the Ministry
of Public Health and Social Welfare, definition of the national
policy of local health system development, application of new
model of care by levels, formulation of a health sector plan,
development of a new model of nursing care in accordance with
basic human needs, and reorganization of certain hospital
centers in the capital.
     It continued training personnel at the graduate level
through the course for specialists in public health which is it
carried out under the auspices of PAHO/WHO for four years.  In
addition, an international consultant was contracted to support
the national human resources program, and a national policy was
formulated which is being implemented.  Nursing curricula were
also reviewed and updated, and a graduate-level program was
launched in the School of Medicine.
     In regard to veterinary public health area, PAHO/WHO
supported the program to control urban rabies, improvements in
the operation of the agreements of cooperation in border areas,
and formulation of the program of sanitary food control with
the Municipality of Asunción and the Ministries of Health and
of Agriculture and Livestock Raising.  In addition, it
collaborated in strengthening the program of epidemiological
surveillance of foot-and-mouth disease and in the activities of
teaching veterinary medicine in the country.
     The Organization continued strengthening the mechanisms of
operational articulation with the national institutions with
which it cooperates as well as the internal administrative
processes of the PAHO/WHO Representative's office in the
country to improve the delivery and efficiency of cooperation,
bearing in mind national demands and the Organization's
priorities.














      ELIMINATING INDIGENOUS

     TRANSMISSION OF MEASLES

IN CENTRAL AMERICA




PLAN OF ACTION--FEBRUARY 1992























EXPANDED PROGRAM ON IMMUNIZATION
MATERNAL AND CHILD HEALTH PROGRAM
ELIMINATING INDIGENOUS TRANSMISSION OF MEASLES IN CENTRAL AMERICA

PLAN OF ACTION--OCTOBER 1991



1.INTRODUCTION- 1 -

2.STRATEGIES AND TECHNICAL COMPONENTS:- 4 -
2.1Mobilization of national resources- 7 -
2.2Immunization activities:- 7 -
2.2.1Vaccination tactics- 8 -
2.2.2Logistical support:- 9 -
2.2.3Training- 10 -
2.3Epidemiological surveillance and control of
        outbreaks . . . . . . . . . . . . . . . . . . . . .- 10 -
2.3.1Identification and notification of cases- 10 -
2.3.2Investigation and control of outbreaks:- 11 -
2.4Laboratory support- 12 -
2.4.1Support of surveillance activities- 12 -
2.4.2Laboratory evaluations- 12 -
2.4.3Establishment of a regional laboratory
network. . . . . . . . . . . . . . . . . .- 13 -
2.5Information dissemination- 13 -
2.5.1Publications- 13 -
2.5.2Information exchange meetings- 14 -
2.6Identifying research needs- 14 -
2.6.1Analysis by the advisory group- 14 -
2.7Certification protocol- 15 -
2.8Evaluation- 15 -

3.ORGANIZATION AND ADMINISTRATION- 17 -
3.1National level- 17 -
3.2International participation- 17 -
3.3Pan American Health Organization- 18 -

4.FINANCING AND FINANCIAL COMPONENTS- 20 -
4.1Level of financing- 20 -

APPENDIX I -Subregionalization project for the campaign to
    eliminate measles and establishment of subregional 
    advisorships. . . . . . . . . . . . . . . . . . . . . .- 21 -

APPENDIX II -Cost components- 22 -

APPENDIX III -Terms of reference of the Technical Advisory
    Group (TAG) of the EPI of the Pan American Health
    Organization. . . . . . . . . . . . . . . . . . . . . .- 24 -

ESTIMATED COST BY COUNTRY- 25 -
COSTA RICA- 26 -
EL SALVADOR- 28 -
GUATEMALA- 30 -
HONDURAS- 32 -
NICARAGUA- 34 -
PANAMA- 36 -

    1.  INTRODUCTION

    The Expanded Program on Immunization (EPI) is based on
resolution WHO 27.57, adopted by the World Health Assembly in May
1974.  The general policies of the program, including the EPI
target of providing immunization services to all children in the
world by 1990 at the latest (resolution WHO 30.53, 1977), were
backed by resolution CD 25.27 of the Directing Council (Pan
American Health Organization) on the Expanded Program on
Immunization in September 1977.

    The following are the long-term objectives of the Expanded
Program on Immunization:

    -   To reduce morbidity and mortality from
        diphtheria, whooping cough, tetanus, measles,
        tuberculosis, and poliomyelitis by providing
        immunization services against those diseases to
        all children in the world by 1990 at the latest
        (other selected diseases can be included when
        and as considered necessary).

    -   To promote self-reliance in the countries in
        regard to provision of immunization services in
        the general context of the public health
        services.

    -   To promote self-reliance in the Region in regard
        to the production of vaccines and their quality
        control.

    Since the Expanded Program on Immunization was implemented in
the Region of the Americas (1977), vaccination coverage has
increased considerably.  In 1978, less than 10% of children under
1 year of age lived in countries in which coverage with the
vaccines in the Expanded Program on Immunization was at least
50%.  By 1984, almost 50% of the children in that age group lived
in countries in which coverage was at least 50% for DPT vaccine,
more than 50% for measles and BCG vaccines, and more than 80% for
polio vaccine.  In 1988, 64% of children under 1 year lived in
countries in which coverage was at least 80% for DPT vaccine;
67%, in countries in which coverage with polio vaccine exceeded
80%, and 83% of the children lived in countries in which coverage
with measles vaccine exceeded 70%.

    In 1990, the overall coverage among children under 1 year in
Central America with the vaccines in the Expanded Program on
Immunization was 74% with three or more doses of DPT; 80% with
three or more doses of polio vaccine; 78% with measles vaccine,
and 70% with BCG vaccine.

    Since the Expanded Program on Immunization (EPI) was
implemented in Central America in 1977, the number of cases of
diseases subject to immunization has been reduced continually. 
The last case of poliomyelitis was an imported one from Mexico
(1990), and more than one year has passed without new cases being
detected.  In 1990 there were cases of whooping cough, tetanus,
and diphtheria in the entire subregion.  Even if underrecording
were taken into account and the cases multiplied by ten, they
would be low.  As a result, we may conclude that the Expanded
Program on Immunization diseases are under control in the
subregion.

    In 1985, a resolution was adopted at the XXXI Meeting of the
Directing Council of the Pan American Health Organization to
eradicate indigenous transmission of wild poliovirus in the
Americas, in view of the reduction in the transmission of
poliovirus, which was attributed to increases in coverage with
polio vaccine.  With the exception of cases imported from Mexico
to Guatemala in 1990, more than 3 years have already passed since
an autochthonous outbreak was discovered in Central America.

    In this region only measles continues to be an important
challenge for the Expanded Program on Immunization.  That disease
continues to be endemic in most of the seven countries.  In the
1980s, several outbreaks were reported by all the countries in
the Region.

    In the 1960s the rate of measles incidence remained above 100
cases per 100,000 population (Figure 1).  Starting in 1969, with
the introduction of the measles vaccine in some countries of the
subregion, the incidence began to decline, and in 1974 it was
lower than 40 per 100,000 inhabitants.  In 1978, with the
implementation of the EPI, the vaccination coverage achieved in
the groups who were the targets of the immunization schemesÐ
usually children under one year of ageÐbegan to be measured, and
starting in 1970 a clear reduction in the incidence was observed. 
Beginning in 1985, with efforts to accelerate the program,
chiefly through national vaccination days, this decline
accentuated until it reached a rate of less than 10 cases per
100,000 inhabitants in 1988, the lowest ever.  Beginning in that
year, due to the sizable accumulation of susceptibles because
optimal coverages had not been achieved and due to difficulties
in reaching a few population pockets, epidemic outbreaks occurred
in all the countries of the subregion:  1989, El Salvador,
Guatemala, and Honduras; 1990, Nicaragua and Panama; 1991, Costa
Rica.  Figure 2 presents the distribution of municipios according
to the range of measles vaccine coverage; it shows that in 1990,
despite an overall coverage of 78% in children younger than 1
year of age in the entire subregion, only 44% of the 1,189
municipios had reached a coverage higher than 80%.  That is not
an adequate situation for controlling and eliminating this
disease.

    Attack rates by age groups invariably show an incidence which
is higher in the group under 1 year and are quite similar in all
the countries.  Figure 3 shows this distribution for the cases
which occurred in Honduras during 1989.








































































































    
With
refere
nce to
mortal
ity,
the
same
situation of higher rates in children under one year of age is
observed in the countries for which data are available.  Figure 4
shows the measles mortality situation in Nicaragua.

    The vaccine against measles was introduced into Central
America in the 1970s.  By 1980 all the countries had included the
vaccine in the Expanded Program on Immunization.  Starting in
1982, coverage with the vaccine increased annually and by 1990 it
had reached 78% of children under 1 year.

    The impact of these increases in vaccine coverage against
measles may be observed in Figure 1, which shows the cases
reported by the countries between 1974 and 1990.  In 1990, all
the countries reported cases of measles.

    At the XXXV Meeting of the Directing Council of the Pan
American Health Organization, held in Washington, D.C., in
September 1991, the ministers in charge of public health in
Central America unanimously declared their determination to
eliminate the indigenous transmission of measles in the subregion
by 1997 at the latest.

    As with activities aimed at eradicating polio, those to
eradicate the preventable diseases through immunization should be
considered in the context of the Expanded Program on
Immunization, which aims at controlling the six diseases of
greatest importance.

    The proposed plan of action is directed toward three
principal objectives:

    a)  To promote the overall development of the
        Expanded Program on Immunization in the
        subregion in order to accelerate the attainment
        of its objectives.
    
    b)  To eliminate the indigenous transmission of
        measles in Central America by 1997 at the
        latest.

    c)  To establish a system of surveillance at the
        subregional and national levels so that all
        suspected cases are investigated immediately and
        effective control measures are applied rapidly
        to stop transmission when importation from
        countries with measles occurs.

    The Plan of Action for attaining the goal in question is
detailed in the following sections of the present study.2.STRATEGIES AND TECHNICAL COMPONENTS:

    The fundamental prerequisite for achieving the stated
objectives will be that which achieves a certain level of
national identification in the policy sphere, denoted by:

    ·   The act of approval by the ministers responsible
        for public health in November 1991.

    ·   It is supported by the Presidents, as expressed
        in their December meeting.

    ·   It is important that a high level of
        international agreement on the objectives be
        achieved, as denoted by the contribution of
        additional resources which are identified.

    ·   The approval of legislative measures whenever
        they are needed for achieving the targets of
        eliminating measles.

    To attain the goal of eliminating the indigenous transmission
of measles in Central America by 1997, it will be necessary to
intensify application of all components of the strategies of the
Expanded Program on Immunization that are being put into practice
and to enhance many of its approaches.  Other essential elements
are coordination of the work of the international agencies at the
subregional and national levels and making available sufficient
financial resources from national and international sources to
cover all the activities related to achieving the target.

    The principal strategies which should be adopted in the
framework of this effort are the following:

    1.  Mobilization of national resources.

    2.  Achievement and maintenance of vaccination
        coverage of more than 95% of the target
        population.

    3.  Activities to capture groups of persons of
        greater age so that 95% of the population at
        large in the countries in question is immunized
        against measles.

    4.  Adequate active surveillance activities to
        promptly detect all cases of measles and
        rubella, accompanied by thorough investigation
        of cases and application of control measures.

    5.  Laboratory diagnosis services put at the
        disposal of all the countries to make it
        possible to conduct laboratory studies of cases
        of eruptive disease accompanied by fever which
        occur in the subregion.

    6.  Dissemination of information within the
        countries and in the entire subregion.

    7.  Detection of operations research needs and
        identifying financing for its execution.

    8.  Preparation of a certification protocol for
        declaring the countries of the subregion free
        from indigenous transmission.

    9.  Evaluation of all the program's on-going
        activities.

    With respect to each of the key strategies, and in order to
guarantee their satisfactory fulfillment, a series of technical
components is recommended.

2.1 Mobilization of national resources

    Taking into account the fact that the resources which the
Ministries of Public Health of many of the countries in question
have are limited, it will be essential to concentrate efforts on
mobilizing all resources in the countries to supplement those
available.

    Toward that end it will be essential to carry out
intersectoral coordination to estimate potential existing
resources and mobilize additional necessary resources.  Agencies
in the education, agricultural, social security, and other
sectors will be essential factors for this purpose.

    Finally, communities and community groups will be called on
to collaborate and contribute their resources and skills to bring
about the expressed objective.  It will also involve achieving
the backing of private voluntary organizations, religious
organizations, and entities that have mass communications media
so that they collaborate in conducting promotion and supplies and
personnel distribution activities and participate in vaccination
activities.  A collaboration strategy will be prepared to link
the measures of the countries in the subregion, as well as the
mutual technical cooperation of the countries, in order to plan,
execute, and evaluate programs, especially in the spheres of
research and control of outbreaks, as well as laboratory support.

2.2 Immunization activities:

    Table 1 shows the annual number of cases reported by each of
the countries in the period 1982-1988.

TABLE 1:  Cases of measles notified by each country, Central America, 1982-
1990

1982198319841985198619871988198919901991BLZ611471242247411707COR167391114,5344,00435833763,566ELS3,6642,4074,7751,413278405787
16,5361,124539GUT3,9922,7623,0722,2721,6504001822,4138,802138HON2,4461,1685,0286,4766039776196,3538,36077NIC2261121539562,55079231
438119,1502,365PAN4,0145953584,2954,1991,8853783011,8912,188TOTAL14,5157,09413,40115,42013,9388,6872,71226,02839,4738,880

2.2.1        Vaccination tactics

    The first essential requirement of the strategy will be to
achieve and maintain a child immunization coverage of at least
95% with a powerful vaccine against measles.  Since the MMR
vaccine is used, the basic target age group will be that of
children from 12 to 15 months of age.

    As many cases occur in children of school age, the countries
will be urged to develop and implement laws that make vaccination
with DPT polio, BCG, and measles vaccines compulsory for school
entry.

    In addition to the routine vaccination of children, special
activities will be carried out to interrupt transmission of the
measles virus by achieving vaccination of 95% of the susceptible
population.

    Before the introduction of the vaccine, epidemics of measles
occurred in cycles of from three to five years in certain areas
(or countries).  As a result, between three and five years should
pass, on the average, for enough susceptibles to accumulate in an
area so that generalized transmission of the virus is possible. 
It should be noted that most such new susceptibles belonged to
the cohort born after the previous epidemic.  After the vaccine
was introduced and greater coverage of the population of children
was achieved, a modification in the age distribution of cases was
observed which reflected a variation in the susceptible
population, which came to include persons who (1) had not
suffered the disease, (2) had not been vaccinated, and (3) had
been but the vaccine had failed.  After the introduction of the
vaccine, a pronounced reduction in measles activity was observed
in many areas in the countries, and transmission of the virus was
practically eliminated in certain periods and the three- to five-
year cycles previously observed did not recur.

    In the United States, where since the beginning of the 1980s
more than 95% of the children admitted to school have been
vaccinated against measles, periodic transmission of the measles
virus has occurred in communities after seven years, on the
average, in which documented transmission of measles in the area
has not occurred.  These outbreaks tend to occur among university
students.  In other countries of the Americas (Chile, Costa Rica,
El Salvador), explosive outbreaks have occurred after a period of
from five to seven years during which there has been almost no
measles activity.  Such outbreaks bring to light the long period
required to accumulate enough susceptibles to make generalized
transmission possible when coverage is high.

    Information on the age distribution of measles cases in the
subregion is limited.  Epidemics occurred in the countries of the
subregion in cycles of four to five years before the introduction
of the vaccine.  In studies conducted in the pre-vaccine era it
was noted that by 5 years of age 95% of the population in the
developing countries had antibodies against measles, which
indicated previous infection.  This was also reflected in the age
distribution of cases, for 95% of the reported cases were in
children under 5 years of age.  In some of the subregion's
countries, epidemics have occurred in children of school age in
recent years.  In other countries they occur in young adults.

    The vaccine against measles was introduced into the
activities of the Expanded Program on Immunization in most of the
countries of the subregion between 1970 and 1978.  Given that
fact, it may be assumed that had all persons born five years
before the introduction of the vaccine (1974) been vaccinated at
the same time, the number of susceptibles would have been reduced
to less than 5% of the total population.  This level of immunity
should interrupt transmission of the measles virus.

    As a result, a "measles elimination month" will be carried
out in 1993 at the subregional level to interrupt transmission in
all the countries of the subregion simultaneously.  All those
countries will carry out a second round of vaccination at the
same time during a month in 1993 and vaccination activities of
("scope") during the same in 1993 to guarantee interruption of
transmission in the entire subregion simultaneously.  Choosing a
month in 1993 as "measles elimination month" will allow almost a
year to identify the necessary additional financing and draw up a
strategy of communication, training materials, and the logistical
systems necessary for attaining the goal of eliminating 95% of
the susceptibles in the subregion.

    All persons less than 15 years of age will be vaccinated
during the second round.  Recognizing the fact that during the
first years of the Expanded Program on Immunization's activities
there may be deficiencies in the cold chain and also recognizing
that errors in diagnosis may occur, all the individuals in that
age group will be vaccinated, whatever their vaccination history
and record of measles infection in previous years.

    The vaccine against measles will be the basic means of
achieving elimination of indigenous measles transmission in
Central America.  The need for reinforcement doses to increase
seroconversion rates and cope with the possibility of dissipation
in immunity will be evaluated continuously.

    The success of this strategy will depend on intensive
planning of supply and demand logistics being carried out.  The
use of mass media communications and professional advertising
companies will be promoted to ensure vaccination of older
persons.  Mobilization of all resources--intra- and
extrasectoral--and participation by nongovernmental sectors in
such campaigns will be essential factors in achieving success. 
It is foreseen that this will involve a single campaign in which
there will be an immediate concentration of efforts on routine
vaccination of the infant population.

    All the countries should maintain a coverage of 95% of the
population of children aged 12 to 15 months by strengthening
routine immunization services and maintaining high levels of
surveillance.

2.2.2   Logistical support:

    All the countries should be assured that the vaccines used in
the framework of the program meet WHO requirements.  The
distribution of vaccines will be a key component of immunization
activities.  To have effective distribution systems it will be
essential to be certain that vaccines are at the delivery points
during the planned days.  To guarantee that immunization
activities are not interrupted, vaccine supplies will be
maintained at the regional level for use in emergencies. 
Manufacturers will be requested to continually maintain 500,000
doses ready for use in emergencies.  The Pan American Health
Organization will supervise such emergency reserves and make then
available in case of need.  The countries should request vaccines
as they need them, as a routine activity.

    Once national plans of work have been prepared, deficiencies
in the cold chain will be detected and needs which should be met
will be reflected in the plans.  In the framework of
collaboration by donor countries, the acquisition and maintenance
of cold-chain equipment should be included.  To cope with
problems detected in maintaining cold-chain equipment the
countries will be called on to design cold-chain systems based on
equipment requiring limited maintenance.

2.2.3   Training

    Special emphasis will be placed on training personnel in the
additional components of the program's operations on which
success decisively depends.  By way of collaboration, the Pan
American Health Organization will prepare a manual on the
technical bases for eliminating measles which will be distributed
in all the countries of the subregion.  The manual will serve as
a prototype so that the countries can prepare specific manuals
adapted to the situation prevailing in them.  The Pan American
Health Organization will give technical assistance to the
countries in adapting, producing, and distributing the manual and
also in planning and offering training courses, if necessary.

2.3 Epidemiological surveillance and control of outbreaks

    Since the number of cases reported annually in the subregion
is relatively low, it is urged that all suspected cases be
investigated immediately.  This is one of the most important
components of the elimination program.  Investigation of the
cases should be carried out according to the definitions in the
Practical Guideline for Eliminating Measles, to which reference
is made in Section 3.

    The following provisional definitions are proposed for
operational purposes:

    -   Suspected case of measles:  Any illness in which eruption
        and fever are present.

    -   Probable case of measles:

a)  Generalized maculopapular
eruption of 2 to 3 days'
duration.

b)  Fever (101Ê F.).

c)  One of the following signs: 
cough, coryza, or
conjunctivitis.

    -   Confirmed case of measles:  adapted to the case
        definition and linked epidemiologically to another
        confirmed or probable case, or confirmed serologically.

    Confirmed cases will also be classified as autochthonous or
imported.  Imported cases will also be identified in relation to
the post-importation generation to which they belong.

2.3.1   Identification and notification of cases

    Surveillance will be both active and passive.  All potential
sources of notification of suspected measles cases from the
countries will be contacted and they will be included in
surveillance activities.  The mechanism of surveillance should
include weekly calls to all outpatient services.  Among the types
of services which should be called are the following:  all acute
care hospitals (public and private; general and specialized) and
outpatient units of the services.  Once suspected cases have been
identified, exhaustive investigation of possible cases and
additional routes of transmission will be carried out in the
community.  Each country will send to the Pan American Health
Organization weekly reports by telex of probable and confirmed
measles cases.

    Containment activities should be carried out which are
adequate to prevent the spread of measles if one or more probable
cases occur.  This will require the immunization of contacts in
the population.  In addition, a geographical area surrounding the
case or cases should be defined, and containment vaccination
activities will be carried out in the target age group
identified.  Persons with documented proof of immunization or a
history of measles in the past will not be excluded.  The area of
containment activities will be determined by an epidemiologist or
experienced health worker to prevent the disease from spreading
to other communities.  It should be borne in mind that some
children in the containment area may be incubating the disease in
the course of the containment vaccination.  Among the containment
measures should be a message making clear that children immunized
during the incubation period will not continue to be protected
against measles so that health workers do not lose credibility.

    In case of outbreaks, the Pan American Health
Organization/Washington will immediately notify all the countries
in the subregion by telex so that advisories can be issued to
travelers.

    The Pan American Health Organization will do what is
necessary to make available the services of international
technical personnel to collaborate in epidemiological
surveillance efforts in the subregion.  The services of such
personnel will be put at the disposal of all the countries in
order to prepare or improve surveillance activities and analyze
records of cases of other diseases included in differential
diagnoses of measles, such as dengue, rubella, and roseola.

    In many of the countries, measles continues to be considered
a normal event of infancy, and when a mother suspects that may be
the disease, the child is kept at home and assistance is not
sought.  To promote reporting of cases of the disease, a basic
target will be the education of the population with respect to
the importance of the health sector being informed of the
existence of measles as soon as possible.  The mass
communications media will be used for these purposes.  Families,
neighbors, and teachers will be urged to report suspected cases
to the health sector as soon as possible.

    An operational investigation will also be carried out to
determine a way to make the private sector participate in public
surveillance activities.  This is important in the subregion
since the private sector is an major source of health care in
many of the countries in question.

    In the countries in which there has been no documented
transmission for at least six years, monetary rewards may be
offered to persons who find cases of measles.  In such countries,
laboratory surveillance of cases of febrile eruptive disease will
be a vital activity.  The Pan American Health Organization will
have personnel to help confirm the validity of the reports.  It
also will have personnel to help evaluate establishments in which
the presence of measles cases is probable, follow up cases of
febrile eruptive disease to confirm that samples are obtained in
adequate form for laboratory testing, and to implement the
mechanism of rewards for cases found.

2.3.2   Investigation and control of outbreaks:

    All suspected cases should be investigated immediately. 
Detailed forms for investigating cases will be designed and
utilized.  For operational purposes, an outbreak is defined as
the presence of a probable or confirmed case of measles.  After a
probable or confirmed case has been identified, a Ministry of
Public Health should make an official announcement to alert all
health personnel and the population in general to the situation
so that the population realizes the need for immunization and to
report all suspected cases without delay.  The Pan American
Health Organization should also be notified immediately.

    The Pan American Health Organization will offer assistance in
investigating cases and controlling outbreaks by contributing
investigative teams who will be mobilized within 24 to 48 hours
from a report of a case so that they can participate in
investigating the outbreak, additional (secondary) case-finding,
and the application of control measures.  An exhaustive
investigation will be carried out to determine the source of the
cases.

    Adequate supplies of measles vaccine should be put at the
disposal of the countries so that control measures can be
immediately taken.  The objective of the latter will be to
vaccinate all persons thought to be at risk against measles. 
Since the measles virus is transmitted rapidly and widely,
immunization is recommended not only in the immediately
surrounding area but also in a broader one.  In some of the
smaller island countries it may be necessary to carry out
vaccination programs throughout the entire country.

    In the framework of activities to investigate and control
outbreaks, the presence of the measles virus in the community
should be identified rapidly.  Once a probable case has been
identified, blood samples should be obtained immediately and must
to be sent to the nearest laboratory for serological studies.  In
addition, the probable epidemiological classification of the case
(autochthonous or imported) will be determined within 24 to 48
hours based on the report.  It is planned that surveillance
activities related to the elimination of measles will be included
in the continuous activities to eradicate polio in all the
countries of the subregion.

    Reports of all outbreaks and imported cases will be published
and disseminated.  When intraregional importation occurs, the
country of origin will be notified and will have the services of
an investigative team.

2.4 Laboratory support

2.4.1   Support of surveillance activities

    A most important component of surveillance activities will be
laboratory confirmation of probable measles cases.  Samples will
be obtained from all probable cases to conduct serological
studies.  Subregional serological confirmation laboratories
should be identified and could be INCAP, in Guatemala, and the
laboratories in Costa Rica, Honduras, and/or Panama.  Close
participation by the laboratories is imperative in the process of
epidemiological evaluation.  If cases clinically and
epidemiologically compatible with measles are identified but
serological studies yield negative or inconclusive results, the
original samples will be sent to reference laboratories for
additional studies.

2.4.2   Laboratory evaluations

    All the countries will have access to laboratory services to
carry out measles serology studies, and the Pan American Health
Organization will help to obtain the necessary laboratory
support.  An internationally recognized team of virologists,
under the auspices of the Pan American Health Organization, will
work with the two laboratories identified in the subregion to
standardize their serological tasks.  Studies will be carried out
to determine the most adequate serological tests for confirming
acute infections.  Ideally, the ELISA and IgM tests will be the
most cost-effective since they can confirm measles infection from
a single sample of serum obtained two weeks after the appearance
of measles.  This process will be completed by December 1991 at
the latest, before the "measles elimination month" in the
subregion.

    The possibility of creating an ELISA testing system in order
to conduct serological studies of measles in national
laboratories will be investigated.  This is based on the
observation that all the national laboratories in the subregion
have been trained in and are conducting ELISA tests with regard
to HIV.  It is planned that a Regional laboratory (INCAP) will be
certified as a reference laboratory.  It will be the source of
technical resources to help the countries establish their own
laboratory services and aid in carrying out epidemiological
surveillance activities and other special studies whose need has
been detected in order to attain the goal of eliminating measles
in the subregion by 1997 at the latest.

2.4.3   Establishment of a regional laboratory network

    According to the Pan American Health Organization's general
policy of establishing networks of national institutions for
purposes of mutual cooperation technical in the developing
countries, a subregional laboratory network will be created.  The
establishment of the laboratory network will make it necessary to
strengthen the logistical system required to transport samples
and distribute necessary supplies such as reagents.  A continuous
supply of standardized reagents for serological studies will be
guaranteed.  The Centers for Disease Control of the United States
will be requested to help establish the laboratory network and
certify laboratories as reference centers.

    In regard to the countries which lack laboratories, reference
laboratories will be designated to help them.  The reference
laboratories will help provide the countries with internal means
of virology support.  The reference laboratories will confirm the
results of the country laboratories.  The uniformity and high
quality of tests and reliability of the results will be
guaranteed through a regional system of laboratory supervision.

    In the framework of the efforts to establish the laboratory
network, a manual will be prepared covering the tests which
should be carried out with respect to all suspected cases,
procedures for conducting tests, acquisition of adequate samples,
methods of acquiring samples, procedures for shipment, management
of samples, quality control procedures, and collection and
processing of data.  The manual should be ready at the latest by
July 1990 and will be distributed to all the participating
laboratories.

    Needs for training at various levels will be met by offering
a workshop for personnel from the laboratories which participate
in the network.  The first course will be given in August 1990 at
the latest, after the laboratories have been identified.

    In addition to laboratory studies dealing with surveillance,
it is necessary to provide additional laboratory support to test
the potency of vaccines.  The laboratories designated as
reference laboratories will be used as reference centers to test
vaccine potency.

2.5 Dissemination of information

2.5.1   Publications

    At the regional and subregional levels, the Bulletin of the
EPI published by the Pan American Health Organization will
contain a section on measles in each issue.  That section will
contain up-to-date information on the epidemiology of measles in
the Region, the number of cases reported in the period since the
previous issue, by reporting week and by country; studies of
individual outbreaks and investigations, problems related to the
elimination campaign, and subjects of interest with reference to
measles research.  The section on measles activities carried out
in the subregion will be distributed monthly.  It is planned to
increase the circulation of the Bulletin of the Expanded Program
on Immunization so that all health services in the subregion
receive copies.  Information should also be disseminated through
other publications of the Pan American Health Organization.

    In addition to the reports on activities dealing with measles
in the Bulletin of the Expanded Program on Immunization, the
Washington office of the Pan American Health Organization will
prepare weekly reports which will be disseminated to all
countries in the subregion.

    The countries will be urged to include a section on measles
in their national epidemiological newsletters, which should be
distributed to all health service workers in the network.

    The Pan American Health Organization will distribute periodic
analyses of the literature dealing with measles to the entire
subregion.

2.5.2   Meetings to exchange information

    To maintain the pace of activities and facilitate
communication within the Region, meetings will be held of program
administrators in the Expanded Program on Immunization for
Central America with as much frequency as necessary to analyze
progress achieved and problems which have arisen.  Such meetings
will serve as a forum for providing mutual assistance and
disseminating information; technical experts who will help
resolve problems encountered will attend them.  The meetings will
include country expositions, analyses of the problems posed in
the country expositions, and presentation of current data
obtained from the field.   Recommendations for the countries will
emanate from the meetings formulated by the working groups
concerning strategies for solving problems encountered.  The
recommendations from the meetings should be published and
disseminated in the subregion.  It is planned that measles
elimination activities will be included in the context of the
polio activities carried out in the subregion.


2.6 Identification of research needs

2.6.1   Analysis by the advisory group

    Recognizing that questions remain to be resolved in the field
of measles elimination in both the technical and operational
spheres, support for research will be provided.  The research
needs found by the Technical Advisory Group (TAG) of the Expanded
Program on Immunization will be dealt with in the two first years
of the project's execution.  The fact is also recognized that
questions will continue to occur as problems are resolved and
others take their place.  An effort will be made to get all
member countries to take part in the task of meeting the needs of
research.

    The Technical Advisory Group (see Section 3.2) will analyze
activities in progress and attempt to determine areas of
necessary research.  In that context, an effort will be made to
find sources of costfree financing, protocols will be analyzed,
and research results will be reviewed.  The Pan American Health
Organization will facilitate the mechanism to implement research
after the areas in question have been detected.


2.6.2   Possible research subjects:

    Among subjects which require immediate attention are the
following:

    ·   Identification of sectors in the target
        population of the activities which will follow
        the "measles elimination month."

    ·   Strategies and tactics to achieve optimal
        coverage during routine vaccination activities.

    ·   Determination of the causes of desertion from
        vaccination programs and of strategies to reduce
        it (desertion is defined as the situation of
        children who have remained in contact with the
        health sector to receive one or more doses of
        vaccine, but have not completed the recommended
        series).

    ·   Optimal surveillance techniques to detect all
        potential cases.

    ·   Causes for specific physicians in the private
        sector not reporting cases.

    ·   Strategies to get the population to report
        suspected cases to the health sector when
        medical care is not sought.

    ·   Simpler methods of diagnosis (such as ELISA and
        IgM) which allow confirmation from a serum
        rather than coupled sera.

    ·   Better inoculation procedures and injectable
        vaccine equipment.

2.7 Certification protocol

    Certification of the elimination of indigenous transmission
of the measles virus in Central America will be made after the
following conditions have been fulfilled:  (1) three years have
passed without the identification of autochthonous cases of
measles, surveillance being adequate; (2) an intensive search for
cases by an international team does not reveal any case which
began in the three years before its visit, and (3) in case of
importation, that no second generation cases are identified
within a month from the date the disease began in the imported
case.

    An international certification commission will analyze the
criteria for certification on the basis of the conclusions from
the studies carried out as well as the need for including other
criteria to detect the presence of the measles virus. 
Vaccination activities should continue until overall elimination
is achieved.

2.8 Evaluation

    Recognizing the decisive importance of evaluation to control
success and detect and resolve problems, emphasis will be
increasingly placed on the evaluation component in the Expanded
Program on Immunization.  International observers will
participate in all country evaluations, and reports containing
the conclusions will be distributed widely.

    Given the difficulties inherent in routine information
systems, coverage studies will be carried out in some countries. 
Questions will be included in the coverage studies on the causes
of fulfillment and noncompliance.  Research on knowledge,
attitudes, and practices (CAP), which will serve as basis for
modifying the strategies for achieving maximum effectiveness of
the intervention measures, will form part of such studies.

    In addition to evaluating the operations of the country
programs, the laboratory network will be evaluated periodically
to guarantee that it has the high level of support needed.  In
the framework of the laboratory evaluation, the reference
laboratories will conduct new tests with the original samples and
with reference samples sent by the reference laboratories to the
national laboratories for testing.

3. ORGANIZATION AND ADMINISTRATION


3.1 National level

    Each country will prepare an overall plan for the Expanded
Program on Immunization and will sign an agreement with the Pan
American Health Organization and other collaborating entities. 
Under the agreement, National Plans of Work should determine
additional needs for collaboration by the Pan American Health
Organization and other participating entities.  All entities
participating in a specific country should sign the agreement.

    Countries which require long-term technical advisers should
approve their assignment to specific places in the agreement and
commit themselves to give priority to efforts to allocate
resources.

    In addition technical cooperation will be provided for
drawing up draft national plans of work.  Complete inventories
will be prepared of existing resources and identify needs which
should be met with complementary resources to achieve maximum
contribution of resources to the program's activities.

    It is essential that there be seminal financing when the
plans of action are designed and the agreements are signed.  When
national plans of work are prepared, an effort will be made to
bring about participation by other international bodies so that
the necessary level of coordination of donors exists.  Since each
donor institution has its own ends, the presence of their
representatives will ensure that the goals of all are fulfilled
and that as a result the all-too-common duplication of efforts
which occurs when project designs are prepared independently is
avoided.  The role of each of the entities participating in a
national program will be determined in National Plans of Work.

    All resources necessary for attaining the goal of elimination
will be determined in the plans of action and a place assigned in
the order of the objectives' precedence to the acquisition of
such resources.

    The Regional Office of the Expanded Program on Immunization
will supervise elimination activities at all levels; it will
ensure that a significant place is assigned to coordination with
the laboratories, that training needs are determined, and that
courses are organized in an effort to meet those needs.  The
office will serve as a center for identifying all international
cooperation and for coordinating extrasectoral assistance.

3.2 International participation

    To collaborate in guiding the activities of the elimination
program, the Technical Advisory Group (TAG), originally formed
when polio eradication activities were initiated in the Region of
the Americas and made up of experts in the field of immunization,
will assume the function of orienting activities in the
subregion.  The Technical Advisory Group is now composed of a
nucleus of six persons, and when necessary it brings in
additional experts to deal with special problem areas.  The role
of the Technical Advisory Group will consist of advising on the
technical components of the program.  Strategies to achieve the
necessary vaccination coverage will be reviewed.  Recommendations
with reference to vaccination activities and the selection of
vaccines will be reviewed annually.  The Technical Advisory Group
will help to determine research needs and supervise the progress
of studies under way, and to analyze the protocols and results. 
In its regular meetings the Technical Advisory Group will analyze
the progress achieved and the problems encountered in the
framework of the measles elimination program.  Its
recommendations will be published and distributed in the entire
subregion.

    To make coordination of all institutional contributions
possible, an Interinstitutional Coordinating Committee (ICC) in
which all international entities will be represented (for
example, UNICEF, Rotary International, AID, IDB, World Bank,
CIDA, AIDS, EEC, JICA, AOD, etc.) will participate in the
elimination program.  The committee will meet as often as
necessary (quarterly, semiannually, or annually) to analyze the
progress achieved and needs for additional assistance.  It will
ensure interinstitutional participation in the country planning
stage to guarantee coordination of donor contributions to the
countries.  This Committee is at the service of activities to
eradicate polio and, as it has done with regard to the activities
of the Technical Advisory Group mentioned above, will assume the
additional task of coordinating efforts to attain the goal of
eliminating measles in the subregion.  If additional entities
participate in the task, the committee will be expanded to
encompass them.  The first meeting of the ICC, which will deal
with matters relating to the elimination of measles, will be held
in October 1989; the subregional Plan of Action will be reviewed
at it and the types of assistance which each institution can
provide in the framework of the program will be determined.  The
EPI office provides secretariat services to the Technical
Advisory Group and the ICC.

    As an additional step to make coordination of
interinstitutional assistance possible, after the Plan of Action
has been analyzed an agreement will be signed between the
international bodies and the Pan American Health Organization. 
It will define the functions of each of the participating
entities.  Thus, when additional needs are detected the
institutions able to undertake measures in this respect will
already have been identified.

3.3 Pan American Health Organization

    The Regional Office of the Expanded Program on Immunization
will coordinate all activities related to the elimination
program.  All reports and requests for assistance from the field
will be processed through the Regional Office, which in turn will
coordinate the assistance which needs to be obtained from other
Pan American Health Organization units.  This is essential to
make coherent efforts, coordinated in the framework of the
subregional activities, possible.

    Technical cooperation in all the fields of the program will
be available through the Pan American Health Organization and its
member countries.  When necessary, assistance by expert
consultants from outside the Organization will be provided; for
example epidemiologists, virologists, laboratory technicians,
cold-chain specialists, experts on mass communication methods in
health education, and economists.

    It is thought that four epidemiologists/technical advisors
should work at the country level.  (See Appendix I.)  They will
aid and collaborate in evaluating needs for special intervention
measures in the countries in their jurisdiction by participating
in the research teams' classification visits and providing direct
technical cooperation when necessary.  Such advisers will help
Ministries of Public Health in planning and carrying out the
activities of the elimination program.

    Personnel at the interinstitutional level will work in close
connection with counterpart personnel in the MPHs.  One of the
principal objectives of the advisers will be to strengthen the
surveillance activities carried out in the countries.

    In addition to the need for personnel at the
interinstitutional level, additional support personnel are needed
for the regional office of the Expanded Program on Immunization,
at INCAP, and in the participating laboratories.  This includes
support virologists (with broad skills in laboratory work) to
help organize the laboratory network in the subregion (which
includes the provision of training, supervision, supply, and
quality control services) and laboratory technicians.  The
predicted increase in data collection and processing will require
additional support in the statistical area.
4. FINANCING AND FINANCIAL COMPONENTS

4.1 Level of financing

    To achieve the objectives by 1997 at the latest and make
certification possible by the year 2000 at the latest, it is
expected that about US$22,979,364 will be needed from
international donor entities for the period 1992-1997.  The
required additional resources consist mainly of provision of
vaccines and another material and equipment for the "attack
phase" (the activities of the "measles elimination month"). 
Those costs will be minimal compared to the cost of the disease
which would be eliminated.  Additional costs with reference to
certification will be smaller magnitude and will be calculated as
the program's execution advances.  Financing should be available
when national plans of action are designed to make immediate
execution of the activities possible.  The following are
projections of the additional costs of the elimination program's
components:

    Estimated costs *                                         US$

   Vaccines, syringes, needles, injectors               8,496,064
   Meetings                                               433,300
   Laboratory                                           1,175,000
   National mobilization activities                     3,000,000
   Promotion activities                                 2,500,000
   Training                                               500,000
   Cold chain                                             500,000
   Evaluations                                            500,000
   Research                                               800,000
   Technical cooperation                                3,775,000
   Administration of information and documentation        500,000
   Financing of unforeseen contingencies                  800,000

   Total external financing                            22,979,364

* Appendix II presents a more detailed cost structure.

   When the individual country plans are designed, cost figures
will be identified and the wages of additional personnel,
transportation costs (including plane trips), daily per-diem
costs, planned expenditures for investigating detected suspected
cases, vehicles, gasoline, vaccines, cold-chain equipment, and
the costs of establishing laboratories (including the costs of
reagents, transportation, and shipment of samples) will be
included.  All recurring and capital expenditures should be taken
into account in designing the program.  The cost of buying time
in the communications media and of producing educational
materials will also be included in the budget.

   The Pan American Health Organization will coordinate its
efforts with those of all the participating entities in order to
seek the financing needed to guarantee achievement of the target,
and could substitute for the entity coordinating all the
financial assistance to the program.  For this Plan to be
successful, the commitments necessary to meet the program's real
needs should be determined before the meeting of the Executive
Committee of the Pan American Health Organization in June 1992.

   It is important to be certain that the funds committed be
assigned and made available in a short period so that the target
activities can be carried out rapidly.APPENDIX I.  Subregionalization project for the campaign to
eliminate measles and establish subregional consultancies:

   Location of advisers in the countries:

   Honduras
   El Salvador
   Nicaragua
   Panama

   Virologist       INCAP, Guatemala
   Virologist       GORGAS, PanamaAPPENDIX II.  Cost components

Personnel                                              $3,775,000

   International:   4 at US$100,000/year x 5 years = $2,000,000
   Consultants: 220 months = $1,775,000

Vaccines/syringes/pressure injectors                   $8,496,064

   Attack phase:  0 to 14 years of age
   (E) Estimated population to be vaccinated:  12,500,000
children
   (U) Unit cost:  US$0.20 per dose
   (W) Wastage:  10%
   (F) Charges FOB:  25%
   Subtotal:  (E) x (U) x (W) x (F)  $3,437,500

   500 pressure injectors x US$1,600   800,000
   7,279,000 syringes/needles x US$0.10   727,900
   Subtotal                     $4,965,400

   Routine vaccination activities (one-year-olds):

   (E) Estimated population to be vaccinated

       1992     1,000,000
       1993     1,020,000
       1994     1,040,400
       1995     1,061,208
       1996     1,082,432
       1997     1,104,080
       Subtotal 6,308,120

   (U) Unit cost US$0.30 per dose
   (W) Wastage:  20%
   (F) Charges FOB:  25%

   Subtotal:  (E) x (U) x (W) x (F)  $2,838,654
   Supplies (syringes/needles)          692,010
   Subtotal                     $3,530,664

Meetings                                                 $433,300

   MEP (measles elimination personnel)
   6 countries x 6 persons/country = 36 persons
   15 regional officials
   5 expert consultants
   Trips (US$1,000/person)           $   42,000
   Per-diems ($150/day/person x 3 days)     18,900
       Subtotal                     60,900
   1 meeting/year x 7 years                            426,300

   ICC (Interagency Coordinating Committee)
   1 meeting/year x 7 years                              7,000
Laboratories                                           $1,175,000

   2 viral diagnostic laboratories (US$400,000/lab)    800,000
   2 national laboratories (US$100,000/lab)            200,000
   Supplies for viral diagnostic laboratories
       (US$10,000/year x 7 years)                   70,000
   Supplies for national laboratories
       (US$5,000/year x 7 years)                    35,000
   Shipment of samples (US$5/sample x 2,000
       specimens/year x 7 years)                    70,000

Epidemiologic surveillance                             $3,000,000
   (costs of mobilizing national personnel,
    trips, and per-diems)

Promotion costs                                        $2,500,000
   (time on communications media (radio, TV, press))

Training (10 courses/year x 7 years = 70 courses)        $500,000

Cold chain (refrigerators, cold rooms, thermoses)        $500,000

Medium-term evaluations                                  $500,000

Investigations                                           $800,000

Administration, information, and documentation           $500,000

Contingency funds                                        $800,000

   Grand total                                        $22,979,364APPENDIX III -Terms of reference of the Technical Advisory Group
(TAG) of the EPI of the Pan American Health Organization

1. In accordance with the Plan of Action for eradication of the
   indigenous transmission of wild poliovirus in the Americas in
   1990 at the latest, a Technical Advisory Group (TAG) should be
   organized to help the Secretariat of the Pan American Health
   Organization to put the Plan into practice.

2. To carry this out, the Director will appoint a team of
   distinguished consultants to advise the Pan American Health
   Organization on accelerating the Expanded Program on
   Immunization in the Americas and on efforts to eradicate the
   indigenous transmission of wild poliovirus from the Region by
   1990 at the latest.

   The Technical Advisory Group will be made up of five persons
   and will be attended by additional consultants and/or study
   panels for whatever specific purposes may be required.

3. The Technical Advisory Group will have the following duties:

   a)  To advise the Secretary of the Pan American Health
       Organization with respect to the priorities of the
       program's objectives for the next five-year period.

   b)  To advise and guide the Secretariat of the Pan American
       Health Organization with respect to the optimal strategies
       and tactics for achieving the overall targets of the
       Expanded Program on Immunization and for achieving
       eradication of the indigenous transmission of wild
       poliovirus from the Americas by 1990 at the latest.
   
   c)  To control execution of the Regional Plan of Action to
       achieve the aforementioned targets.

   d)  To promote understanding of the program's targets and
       support for achieving them among technical institutions
       and bilateral, multilateral, and private entities.

   e)  To participate in missions at the country level to carry
       out analyses and meetings of programs.

4. The members of the Technical Advisory Group will be appointed
   by the Director for a year, which may be extended to his
   discretion.

5. In addition, at least one member of the Technical Advisory
   Group should be a member of the World Advisory Group (WAG); at
   least one member of the Technical Advisory Group should also
   participate in meetings with other entities and agencies to
   ensure effective coordination and information exchange.

6. The meetings will be convened when necessary, usually twice a
   year, and a report will be prepared and when required,
   circulated, on each meeting.          ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES
IN CENTRAL AMERICA








ESTIMATED COSTS BY COUNTRY

(Provisional)

1992 -  1997





ACTIVITIES

 CountryIntercountryTotal1. COSTA RICA$ 1,795,460$ 630,978$ 2,426,4382. EL
SALVADOR$ 2,957,647$ 1,086,230$ 4,043,8773. GUATEMALA$ 5,139,277$ 1,670,676$
6,809,9534. HONDURAS$ 2,994,165$ 1,079,696$ 4,073,8615. NICARAGUA$ 2,170,935$
958,188$ 3,129,1236. PANAMA$ 1,340,580$ 1,155,532$ 2,496,112    TOTAL$16,398,064$
6,581,300$22,979,364ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN COSTA RICA

PLAN OF ACTION
(Cost components)

    AREAS OF ACTION            LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

1.  Supplies and biologicals

1.1 Attack Phase
    (P)  Target Population 
(0-14 years) 1 300,000
    (C)  Unit cost/dose ACE$0,20
    (D)  Wastage         10%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $357 500             $357 500

1.2 Routine vaccination activities 
    (P)  Target population 
(1 year)      656 045
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $295 220             $295 220

1.3 Supplies
1.3.1Attack Phase
    - Pressure injectors (total:  52 x $1 600)$83 200
    - Syringes/needles (624 000 x $0.10)$62 400
    - Syringes of diluent (130,000 x $0.10)$13 000       $158 600
    
1.3.2Routine
    - Syringes/needles (656 000 x $0.10)$65 600
    - Diluent syringes (65 600 x $0.10)$6 560   $72 160

    Subtotal                                             $883 480

2.  Meetings

2.1 Review and regional updating                $71 050
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1,000/person) and per-diems ($150/day)

2.2 ICC                                           $728

    Subtotal                                              $71 778
Costa Rica

    AREAS OF ACTION                 LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

3.  Laboratory                        $7 280
3.1 - 1 sample shipped to laboratory:  $5,00
    - Total samples:  208/year x 7

3.2 Viral diagnostic laboratory
    - National reference (costs of operation)$100,000
    - Supplies (2 500 x 7 years)     $17 500

    Subtotal                                             $124 780

4.  Supervision/Epidemiological Surveillance$312 000     $312 000
    - Mobilization of personnel (transportation and per-diems)

5,  Social promotion                $260,000             $260,000
    - National and local level
    (radio, TV, press, and supplies)

6.  Training                         $52 000              $52 000
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                       $52 000              $52 000
    - Purchase of equipment and parts
    (refrigerators, cold room, and thermoses)

8.  Evaluation                       $28 000    $24 000   $52 000
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research              $83 200              $83 200
    - Costs national personnel, expert
    consultants, and supplies

10. Operating Expenses

10.1- International advisory services          $400,000

10.2- Administration, information, and          $52 000
      documentation

10.3- Emergency funds                           $83 200

    Subtotal                                             $535 200


    GRAND TOTAL                    $1 795 460  $630 978 $2 426 438ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN EL SALVADOR

PLAN OF ACTION
(Cost components)


AREAS OF ACTION                LEVEL OF EXECUTION              
COUNTRY    REGIONAL     TOTAL
1.  Supplies and biologicals

1.1 Attack Phase
    (P) Target population
(0-14 years) 2 287 500
    (C) Unit cost/dose ACE$0,20
    (D) Wastage          10%
    (F) Charges FOB      25%

(P) x (C) x (D) x (F) =    $629 063             $629 063

1.2 Routine vaccination activities 
    (P)  Target population
(1 year)     1 154 386
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $519 474             $519 474

1,3 Supplies
1.3.1Attack Phase
    - Pressure injectors (total:  91 x $1 600)$145 600
    - Syringes/needles (1 098 000 x $0.10)     $109 800
    - Diluent syringes (230,000 x $0.10)$23 000$278 400
    
1.3.2Routine
    - Syringes/needles (1 150,000 x $0.10)     $115 000
    - Diluent syringes (115 000 x $0.10)$11 500$126 500

    Subtotal                                            $1 553 437

2.  Meetings

2.1 Review and regional updating                $71 050
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1 000/person) and per-diems ($150/day)

2.2 ICC                                         $1 280

    Subtotal                                              $72 330
el Salvador

    AREAS OF ACTION                         LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL


3.  Laboratory                       $12 810              $12 810
3.1 - 1 sample shipped to laboratory:  $5,00
    - Total samples:  366/year x 7


4.  Supervision/Epidemiological Surveillance$549 000     $549 000
    - Mobilization of personnel (transportation and per-diems)

5.  Social promotion                $457 500             $457 500
    - National and local level
    (radio TV, press, and supplies)

6.  Training                         $91 500              $91 500
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                       $91 500              $91 500
    - Purchase of equipment and parts
    (refrigerators, cold room, and thermoses)

8.  Evaluation                       $55 500    $36 000   $91 500
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research             $146 400             $146 400
    - Costs national personnel, expert
    consultants, and supplies

10. Operating Expenses

10.1- International advisory services          $740,000

10.2- Administration, information, and          $91 500
      documentation

10.3- Emergency funds                          $146 400

    Subtotal                                             $977 900


    GRAND TOTAL                    $2 957 647 $1 086 230$4 043 877

ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN GUATEMALA

PLAN OF ACTION
(Cost components)


    AREAS OF ACTION            LEVEL OF EXECUTION
COUNTRY   REGIONAL      TOTAL

1.  Supplies and biologicals

1.1 Attack Phase
    (P)  Target population
(0-14 years) 3 975 000
    (C)  Unit cost/dose ACE$0,20
    (D)  Wastage         10%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =   $1 093 125           $1 093 125

1.2 Activities of routine vaccination
    (P)  Target population
(1 year)     2 005 982
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $902 692             $902 692

1.3 Supplies
1.3.1Attack Phase
    - Injectors to pressure (total:  159 x $1 600)$254 400
    - Syringes/needles (1 908 000 x $0.10)     $190 800
    - Diluent syringes (400,000 x $0.10)$40,000$485 200

1.3.2Routine
    - Syringes/needles (2 000,000 x $0.10)     $200,000
    - Diluent syringes (200,000 x $0.10)$20,000$220,000

    Subtotal                                            $2 701 017

2.  Meetings

2.1 Review and regional updating                $71 050
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1 000/person) and per-diems ($150/day)

2.2 ICC                                         $2 226

    Subtotal                                              $73 276Guatemala
    AREAS OF ACTION                 LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

3.  Laboratory                       $22 260
3.1 - 1 sample shipped to laboratory:  $5,00
    - Total of samples:  636/year x 7
    
3.2 Viral diagnostic laboratory                $435 000
    - Regional Reference (costs of operation)
    - Supplies $5 000/year x 7

    Subtotal                                             $457 260

4.  Supervision/Epidemiological Surveillance$954 000     $954 000
    - Mobilization personal (transportation and per diem)

5.  Social promotion                $795 000             $795 000
    - National and local level
    (radio, TV, press and supplies)

6.  Training                        $159 000             $159 000
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                      $159 000             $159 000
    - Purchase of equipment and parts
    (refrigerators, cold room and thermoses)

8.  Evaluation                       $95 000    $64 000  $159 000
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research             $254 000             $254 000
    - Costs personal expert national
    consultant and supplies

10. Operating Expenses

10.1- International advisory services          $560,000
    - Virologist INCAP                         $125 000

10.2- Administration  information y            $159 000
      documentation

10.3- Emergency funds                          $254 400

    Subtotal                                            $1 098 400


    GRAND TOTAL                    $5 139 277 $1 670 676$6 809 953
ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN HONDURAS

PLAN OF ACTION
(Cost components)


    AREAS OF ACTION            LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

1.  Supplies and biologicals

1.1 Attack Phase
    (P)  Target population
(0-14 years) 2 225 000
    (C)  Unit cost/dose ACE$0,20
    (D)  Wastage         10%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F)      $611 875             $611 875

1.2 Routine vaccination activities 
    (P)  Target population
(1 year)     1 122 845
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $505 280             $505 280

1.3 Supplies
1.3.1Attack Phase
    - Pressure injectors (total:  89 x $1 600)$142 400
    - Syringes/needles (1 068 000 x $0.10)     $106 800
    - Diluent syringes (222 500 x $0.10)$22 250$271 450
    
1.3.2Routine
    - Syringes/needles (1 120,000 x $0.10)     $112 000
    - Diluent syringes (112 000 x $0.10)$11 200$123 200

    Subtotal                                            $1 511 805

2.  Meetings

2.1 Review and regional updating                $71 050
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1 000/person) and per-diems ($150/day)

2.2 ICC                                         $1 246

    Subtotal                                              $72 296Honduras

    AREAS OF ACTION                 LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

3.  Laboratory                       $12 460
3.1 - 1 sample shipped to laboratory:  $5,00
    - Total of samples:  356/year x 7

3.2 Viral diagnostic laboratory
    - National Reference (costs of operation)$100,000
    - Supplies $2 500/year x 7       $17 500

    Subtotal                                             $129 960

4.  Supervision/Epidemiological Surveillance$534 000     $534 000
    - Mobilization personal (transportation and per diem)

5.  Social promotion                $445 000             $445 000
    - National and local level
    (radio, TV, press and supplies)

6.  Training                         $89 000              $89 000
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                       $89 000              $89 000
    - Purchase of equipment and parts
    (refrigerators, cold room and thermoses)

8.  Evaluation                       $53 000    $36 000   $89 000
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research             $142 400             $142 400
    - Costs personal national, expert
    consultant and supplies

10. Operating Expenses

10.1- International advisory services          $740,000

10.2- Administration, information y             $89 000
      documentation

10.3- Emergency funds                          $142 400

    Subtotal                                             $971 400

    GRAND TOTAL                    $2 994 165 $1 079 696$4 073 861ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN NICARAGUA

PLAN OF ACTION
(Cost components)


    AREAS OF ACTION            LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

1.  Supplies and biologicals

1.1 Attack Phase
    (P)  Target population
(0-14 years) 1 675 000
    (C)  Unit cost/dose ACE$0,20
    (D)  Wastage         10%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $460 625             $460 625

1.2 Activities of routine vaccination
    (P)  Target population
(1 year)      845 288
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $380 380             $380 380

1.3 Supplies
1.3.1Attack Phase
    - Injectors to pressure (total:  69 x $1 600)$110 400
    - Syringes/needles (828 000 x $0.10)$82 800
    - Diluent syringes (167 500 x $0.10)$16 750$209 950

1.3.2Routine
    - Syringes/needles (840,000 x $0.10)$84 000
    - Diluent syringes (84 000 x $0.10)$8 400   $92 400

    Subtotal                                            $1 143 355

2.  Meetings

2.1 Review and regional updating
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1 000/person) and per-diems ($150/day)$71 050

2.2 ICC                                $938

    Subtotal                                              $71 988Nicaragua

    AREAS OF ACTION                 LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL


3.  Laboratory                        $9 380               $9 380
    - 1 sample shipped to laboratory:  $5,00
    - Total of samples:  268/year x 7

4.  Supervision/Epidemiological Surveillance$402 000     $402 000
    - Mobilization personal (transportation and per diem)

5.  Social promotion                $335 000             $335 000
    - National and local level
    (radio TV, press and supplies)

6.  Training                         $67 000              $67 000
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                       $67 000              $67 000
    - Purchase of equipment and parts
    (refrigerators, cold room and thermoses)

8.  Evaluation                       $40,000    $27 000   $67 000
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research             $107 200             $107 200
    - Costs personal expert national
    consultant and supplies

10. Operating Expenses

10.1- International advisory services          $685 000

10.2- Administration, information y             $67 000
      documentation

10.3- Emergency funds                          $107 200

    Subtotal                                             $859 200


    GRAND TOTAL                    $2 170 935  $958 188 $3 129 123ELIMINATION OF INDIGENOUS TRANSMISSION OF MEASLES

IN PANAMA

PLAN OF ACTION
(Cost components)


    AREAS OF ACTION            LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL
1.  Supplies and biologicals

1.1 Attack Phase
    (P)  Target population
(0-14 years) 1 037 500
    (C)  Unit cost/dose ACE$0,20
    (D)  Wastage         10%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $285 312             $285 312

1.2 Routine vaccination activities
    (P)  Target population
(1 year)     523 5745
    (C)  Unit cost/dose ACE$0,30
    (D)  Wastage         20%
    (F)  Charges FOB     25%

(P) x (C) x (D) x (F) =    $235 608             $235 608

1.3 Supplies

1.3.1Attack Phase
    - Pressure injectors (total:  40 x $1 600)$64 000
    - Syringes/needles (498 000 x $0.10)$49 800
    - Diluent syringes (105 000 x $0.10)$10 500$124 300

1.3.2Routine
    - Syringes/needles (525 000 x $0.10)$52 500
    - Diluent syringes (52 500 x $0.10)$5 250   $57 750

    Subtotal                        $702 970             $702 970

2.  Meetings

2.1 Review and regional updating                $71 050
    - 1 meeting/year x 7/3 days
    - 6 persons/country and regional staff member
    - Trips ($1,000/person) and per-diems ($150/day)

2.2 ICC                                           $582

    Subtotal                                              $71 632Panama

    AREAS OF ACTION                 LEVEL OF EXECUTION
COUNTRY    REGIONAL     TOTAL

3.  Laboratory                        $5 810
3.1 - 1 sample shipped to laboratory:  $5.00
    - Total samples:  166/year x 7

3.2 Viral diagnostic laboratory                $435 000
    - Regional reference (costs of operation)
    - Supplies $5 000/year x 7

    Subtotal                                             $440 810

4.  Supervision/Epidemiological Surveillance$249 000     $249 000
    - Mobilization of personnel (transportation and per-diems)

5.  Social promotion                $207 500             $207 500
    - National and local level
    (radio, TV, press, and supplies)

6.  Training                         $41 500              $41 500
    Courses and seminars (stationery)
    Continuing education

7.  Cold Chain                       $41 500              $41 500
    - Purchase of equipment and parts
    (refrigerators, cold room, and thermoses)

8.  Evaluation                       $25 500    $16 000   $41 500
    - Permanent monitoring and evaluations
    medium term

9.  Operations Research              $66 800              $66 800
    - Costs of national personnel, expert
    consultants, and supplies

10. Operating Expenses

10.1- International advisory services          $400,000
    - Virologist GORGAS                        $125 000

10.2- Administration, information, and          $41 500
      documentation

10.3- Emergency funds                           $66 400

    Subtotal                                             $632 900

    GRAND TOTAL                    $1 340 580 $1 155 532$2 496 112

[Text Box 1, page 2 of Spanish]

Figure 1

RATE OF MEASLES INCIDENCE AND VACCINATION COVERAGE
IN CHILDREN <1 YEAR, CENTRAL AMERICA AND PANAMA, 1950-1991*

    RATE/100,000 pop.

Rate - Coverage

*Adjusted 1991 annual rate
Source:  PAHO

- 0 -

[Text Boxes 2 and 3, page 3 of Spanish]

Figure 2

       DISTRIBUTION OF MUNICIPIOS BY EXTENT OF MEASLES VACCINE COVERAGE,
CENTRAL AMERICA, 1990-1991

Number of municipios:  1990, 1,189; 1991, 1,111
Adjusted 1991 data
Source:  PAHO

Figure 3

MEASLES INCIDENCE BY AGE GROUPS,
HONDURAS, 1989

    Rate/100,000 pop.

Source:  Ministry of Health

- 0 -

[Text Box 4, page 4 of Spanish]

Figure 4

MORTALITY FROM MEASLES BY AGE GROUPS,
NICARAGUA, 1990

    Rate/100,000 pop.

    <1 year     1-4 years     5-9 years     10 years and older

Source:  Ministry of Health




JOINT FAO/WHO/PAHO TECHNICAL CONSULTATION ON
SAFETY AND MARKETING OF FOOD IN RESPONSE TO 
THE CHOLERA EPIDEMIC IN THE AMERICAS


     The Joint FAO/WHO/PAHO Technical Consultation on Safety and
Marketing of Food in Response to the Cholera Epidemic in the
Americas, convoked by Dr. Carlyle Guerra de Macedo, Director of
the Pan American Sanitary Bureau, took place at the headquarters
of the Pan American Institute for Food Protection and Zoonoses
(INPPAZ/HPV/PAHO), in Buenos Aires, Argentina, from 6 to 8 April
1992.

     The unanimously chosen officers of the meeting were:

- President:        Dr. Joseph Madden
Food and Drug Administration (FDA) of the
United States of America
- Vice President:   Dr. Carlos Rivadeneyra G.
Public Enterprise for Fishing Certification
of Peru (CERPER)
- Rapporteur:       Dr. Juan Cuellar S.
Ministry of Health of Colombia

The list of participants appears in the Annex.

     Dr. Primo Arámbulo III from PAHO/WHO and Mr. Richard J.
Dawson from FAO acted as joint secretaries of the meeting.

     The objectives of the meeting were:

     a)   To discuss food safety in response to the cholera
epidemic, considering the special aspects and
characteristics of the countries with respect to
production, consumption, and marketing of food.
     
     b)   To analyze the nontariff barriers established for food
coming from countries affected by cholera, within the
Region of the Americas and by third countries.

     c)   To formulate technical recommendations that can serve
as a basis for the policies of the countries on the
marketing and consumption of food without risk of
transmission of cholera.

     The agenda of the meeting, approved by those present,
consisted of an introduction that included the presentation of
the Food Protection Programs of PAHO/WHO and FAO for the
prevention and control of cholera in the Americas and the main
subjects:  "Cholera in the Americas;" "Cholera and Food;" "Fresh
Fruit and Vegetables;" "Fish Products;" and "Street Foods."

     The inaugural session was presided over by Dr. Angel Tulio,
National Director of Regulation and Control of the Ministry of
Health and Social Action of the Argentine Republic; Mr. Richard
Dawson, Chief of the Food Quality and Standards Service of the
United Nations Food and Agriculture Organization; and Dr. Primo
Arámbulo III, Coordinator of the Veterinary Public Health
Program (HPV) of the Pan American Health Organization.


1.   INTRODUCTION

1.1. The Food Protection Program of the Pan American Health
     Organization (PAHO/WHO).  Prospects for Technical
     Cooperation in Response to the Cholera Epidemic.

     Food protection is one of the priority projects of the
PAHO/WHO Veterinary Public Health Program, which, by mandate
from its Governing Bodies and in response to a recommendation
from the VII Inter-American Meeting, at the Ministerial Level,
on Animal Health (RIMSA VII) held in April 1991, prepared the
"Regional Program for Technical Cooperation in Food Protection: 
Plan of Action 1991-1995" as a continuation of the plan for the
previous five-year period.

     The Plan of Action, approved by the authorities of the
countries of the Region, includes five basic components:

     -    Organization of Integrated National Programs for Food
Protection;
     -    Strengthening of Laboratory Services;
     -    Strengthening of Inspection Services;
     -    Establishment of Epidemiological Surveillance Systems
for Food-borne Diseases; and
     -    Promotion of Food Protection through Community
Participation.

     The appearance of cholera in the region at the beginning of
1991 required a tactical response by PAHO which consists of two
stages:

     a)   a short-term response, directed toward the control of
the epidemic with basic health measures in food
hygiene and sanitation:

     b)   a second, medium long-term response, oriented toward
promoting and supporting the development and
strengthening of the environmental sanitation and food
protection infrastructure.

     From the programming point of view, because cholera is one
of the food-borne diseases, efforts directed toward its
prevention and control will also affect all the food-borne
diseases, with the consequent benefit that this signifies for
public health.

     The principal actions carried out by the Veterinary Public
Health Program in response to the cholera epidemic have been the
following:

     -    Active participation in the PAHO Task Force on
Cholera;

     -    Development of a short-term Plan of Action within the
framework of the agreement between the Inter-American
Development Bank (IDB) and PAHO for prevention and
control of the cholera epidemic in the America.  That
plan includes resources directed toward the
strengthening of epidemiological surveillance;
development in the national laboratories of the
capacity to detect Vibrio  cholerae in food;
strengthening of inspection methods for food at risk
of contamination by V. cholerae; and actions directed
toward reducing the risk of transmission of cholera by
food marketed in public thoroughfares;

     -    Organization of a symposium on "Some Considerations on
Importation/Exportation of Food during the Cholera
Epidemic" and "Risk of Transmission of Cholera by Food
Prepared in Microenterprises," which had as its
objective the preparation of a report and documents
for the Ministers of Agriculture and Health attending
RIMSA VII;

     -    Preparation and dissemination of technical information
on the risk of transmission of cholera by food and,
with the collaboration of the FDA, preparation of a
guideline on "Food Exported to the United States of
America - Considerations during the Cholera Epidemic,"
which was provided to the national authorities and
enterprises in the food-exporting countries in the
Region.

     -    Research on the "Role of Food Prepared in
Microenterprises (such as "cebiche") in the
Transmission of Cholera and the Survival of V.
cholerae," which took place in Peru and Bolivia;

     -    In collaboration with FAO, FDA, CDC, and USAID two
international courses were offered - in Venezuela and
in Mexico - on microbiological analysis of food for
detection of Vibrio cholerae.  Participating in them
were microbiologists from official institutions
devoted to food protection belonging to countries of
the Andean subregion, Brazil, Central America, Mexico,
and the Spanish-speaking Caribbean.  Two more courses
are programmed, one in Argentina and another in
Trinidad and Tobago, for countries of the Southern
Cone and the English-speaking Caribbean, respectively;

     -    Technical advisory services to the associations of
food producers in Argentina, Brazil, Costa Rica, El
Salvador, Guatemala, Honduras, Nicaragua, and Panama,
with a view to orienting them on the sanitary
requirements of the food-importing countries;

     -    Responding to a request from several countries, the
Joint FAO/WHO/PAHO Technical Consultation on Safety
and Marketing of Food in Response to the Cholera
Epidemic in the Americas was organized for the purpose
of formulating technical recommendations to serve as
the basis for the policies of the countries concerning
marketing and consumption of food without risk of
transmission of cholera;

     -    Jointly with the Government of Peru, a Regional
Seminar/Workshop on Airline Catering and Food
Protection for Travelers was organized to be held in
Lima from the 8 to 10 April 1992;

     -    Addressing the request from the Chancellor's Office in
Peru, two advisers will collaborate with the
authorities of the Ministry of Health of that country
to review the procedures in airline catering in their
international airports.

1.2. The Program of the Food and Agriculture Organization of the
     United Nations (FAO) for the Prevention and Control of
     Cholera in the Americas

     Technical assistance from FAO to Latin America related to
the cholera epidemic is focused on collaboration with the
countries in activities to control contamination of food by V.
cholerae, to remove the barriers to their trade resulting from
the epidemic and to facilitate the access of food products to
the international market.

     The specific activities were directed toward:

     -    Development of legislation for food control and
consumer protection;

     -    Strengthening of the monitoring of food contamination
in the entire chain with special emphasis on the
street foods and institutional food services;

     -    Training of national personnel and execution of
campaigns for mass education on a national scale;

     -    Improvement of inspection and quality control in the
importation and exportation of food, to protect the
national supply and promote opportunities for trade.

     Because of the multidisciplinary nature of the above-
mentioned actions, close coordination was established with other
FAO programs and with various international organizations, such
as PAHO and WHO, as well as with the United States Food and Drug
Administration, with a view to strengthening the optimization
of the use of the resources destined to control the epidemic.

     Due to the rapid spread of cholera, FAO gave high priority
to requests for assistance by the Governments of Peru and the
border countries, especially Ecuador, Colombia, and Bolivia. 
However, given the prevalent sanitary and economic conditions
in Central America and in response to requests from other
governments, that priority was extended to include Costa Rica,
El Salvador, Guatemala, Chile, and countries of the English-
speaking Caribbean.

     A total of 16 food control projects totalling more than
$2.6 million are in preparation or under way.  A summary of the
development of some of them is given below:

Peru:

a)   Certification of food for export.

     The project "Control of the Contamination of Food Products
     with V. cholerae" includes advisory services in the
     organization of certification systems for food both for
     export and for domestic consumption; inspection and
     certification of agricultural and other products, fresh and
     processed; certification of fish and fish products; and the
     sanitary control of shellfish, as well as advisory services
     in food microbiology with emphasis on the identification of
     V. cholerae.  The system of certification implemented in
     Peru is carried out through the Public Enterprise for Fish
     Certification of Peru (CERPER).

b)   Street foods.

     Considering street foods as a possible vehicle for the
     expansion of the cholera epidemic, especially in the urban
     areas of Peru, an additional technical assistance project
     was approved to establish an effective program for quality
     control of street food that protects the health of the
     consumer while at the same time maintaining and promoting
     this important source of food.  The legal provisions
     related to the control of street food were updated and, in
     addition, the food inspectors were trained in their
     application and also in the utilization of specific
     inspection procedures.  With the collaboration of FAO, a
     "Manual for the Training of Inspectors of Street Food" was
     developed.

Central America:

     A project was developed to review the food control systems
in various locations in Guatemala, Costa Rica, El Salvador,
Honduras, Nicaragua, and Panama; it covered domestic products,
street food, imported food, and food for export.  Based on this
review, in 1992 harmonization of the regulations and procedures
used was initiated.  Under the coordination of an international
adviser, national consultants in each country are updating their
country's laws and regulations, utilizing the Basic Food Law
recommended by FAO and WHO as a model.

     A basic course on techniques for inspection of food,
including street food, took place in March 1992 in El Salvador. 
In addition, in Honduras a Subregional Course was offered on
Hygienic Practices for the Preparation, Distribution, and Sale
of Food in the Street, which was attended by those responsible
for the training of the street food vendors in Costa Rica, El
Salvador, Guatemala, Honduras, Nicaragua, and El Salvador.

     Through subregional courses in Venezuela and Mexico, the
methods of microbiological analysis and food research for the
identification of V. cholerae were reviewed.  Such courses
correspond to joint action by FAO, PAHO, FDA, CDC, and USAID.

Ecuador:

     In December 1991 a project was established with the
assistance of FAO to strengthen the control of the quality of
the food that is sold on the streets of the principal cities. 
With the assistance of international consultants an updated code
of hygienic practices in the preparation of street food was
prepared and a subprogram organized for its control.  In
addition, a group of inspectors was trained in basic inspection
techniques.

Bolivia:

     A project was formulated, with initiation expected in March
1992.

Mexico:

     A specific, previously adopted project will be initiated in
May 1992; it will strengthen quality control and will ensure the
safety of street foods.  It will begin in specific urban
semiurban areas and in Mexico City and San Cristóbal Las Casas,
Chiapas.

Chile and Countries of the English-speaking Caribbean:

     In those countries projects with emphasis on control of the
importation and exportation of food are under negotiation.  In
the case of Chile, supervision to ensure the correct use of
wastewater is being considered.


2.  CHOLERA IN THE AMERICAS

2.1. Epidemiology of Cholera in Latin America.

     In Latin America there are an estimated 600 million people
that inhabit territories with varied ecology, including
highlands with mountains over 6000 m above sea level, valleys
between the mountains, and immense subtropical and tropical
plains, in addition to extensive coastal areas on the Atlantic
and Pacific Oceans.  In this geographical area white, black,
indigenous, and mixed populations are settled.

     The area also contains large nuclei of populations that
live under marginal conditions in the large cities - an
estimated 40% of the total population, with the consequences for
health that are generated by the lack of basic sanitation and
the lack of health services coverage.  To this should be added
the growing phenomenon of urban expansion so that the cities
will be housing approximately 75% of the population of the
Americas by the end of this century.

     The differences in health among the countries are large,
but those within a single country are still greater, because of
the various living conditions that determine the existence of
groups at greater or lesser risk and the low coverage of the
health services.  Those differences are not just geographical,
but also technical and economic and they contribute to greater
vulnerability to the prevalent etiologic agents.

     That is the scene presented by the American Hemisphere to
Vibrio cholerae which made its appearance at the end of January
1991 in Peru with cases in the port of Chimbote.  The disease
spread rapidly and in March there were approximately 20,000
cases per week, with a nonhomogeneous distribution which
produced three waves of the epidemic, one corresponding to the
coast, another to the mountains, and the third to the jungle
region of the Amazon.

     Thus during 1991 and through 20 February 1992 in that
country 358,247 cases were notified of which 135,835 had to be
hospitalized and 3,058 died.  The incidence in 1991 was 14 per
thousand population and the fatality rate, 0.9%.  The latter was
due to the lack of knowledge of an exotic disease and to the
deterioration of the health and sanitation infrastructure caused
by the present economic crisis in that country.

     The epidemic, once it had invaded Peru, continued by
spreading through the Latin American countries.  Thus the first
cases appeared in Ecuador in February 1991; that country
reported 46,284 cases for that year and for January and February
of 1992, more than 6,000 cases.

     Next, in Colombia the epidemic started in the beginning of
March in the area along the border with Ecuador at the Pacific
coast, with approximately 12,000 cases registered in 1991 and
around 3,600 cases through February 1992.

     Since then the disease has been invading other territories
and its presence is detected in a different country of the
Region month after month.  In the month of April the first cases
were detected in the United States, which had a total of 25 for
1991 and another two for 1992.

     In Latin America approximately 81% of the cases of the
disease have been recorded in Peru, 12% in Ecuador, and 3% in
Colombia, with the rest distributed among the other countries,
except that Paraguay and Uruguay have no diagnosed cases to
date.

     The conditions under which the populations of the continent
live lead to the prediction that the disease will stop invading
all the countries but remain endemic for an undetermined period,
because, among other reasons, there are serious problems in
basic sanitation in the countries and their solution in the
short or medium term is not foreseen.

2.2. Epidemiology of Cholera in the United States of America.

     From history it appears that cholera epidemics originated
in India and then spread to various countries.  In addition, it
is known that during the 18th century practically all the
countries of the world were at risk of suffering this disease.

     It is also known that the pathogenic action of Vibrio
cholerae serogroup 01 is expressed by the presence of a toxin
considered to be virulent and therefore the cause of disease and
epidemics, so that from the public health point of view the
appearance of vibriones without the two principal
characteristics of virulence (antigen 01 and the production of
toxin) is not significant.

     In addition, it should be remembered that an aquatic
environment is the normal habitat of V. cholerae.  It is capable
of remaining viable during indefinite periods in water and
marine environments; this means that it is ecologically
associated with plants and animals.  The organism produces
chitinase, an enzyme that destroys chitin, which makes the
association with shellfish possible, a common occurrence.

     Cholera infections produce no symptoms in 75% of the cases
and only from 15% to 23% present moderate symptoms.  In epidemic
situations, only 2% of the infections are life-threatening.

     In the United States, after 75 years without cholera, cases
were presented in 1973; they originated along the Texas coast,
caused by the bivalve mollusks that appear in the warm months. 
Recently, cases associated with travelers coming from countries
with epidemics have been observed, but no secondary cases have
been recorded.

     It is evident that the nonexistence of a cholera epidemic
after 1866 is due to basic sanitation activities, especially
related to the drinking water supply and to the organization of
health services within the reach of the entire population.  Even
if that "sanitary revolution" was to a great extent responsible
for the eradication of cholera in the United States, it does not
explain the concomitant disappearance of the disease in Latin
America in the 19th century.

     From 1866 to the beginning of the present century, only
sporadic cases of cholera have been reported in the United
States.  In this century, the first case was in 1973, where a
shrimp fisherman from the coast of Texas became ill with
diarrhea that was verified as cholera.  The primary source of
the infection was never found, but today it is known that it was
related to the strain of V. cholerae known as the strain from
the coast of the Gulf of Mexico.  That strain of toxigenic V.
cholerae 01 has persisted in the coastal waters of Texas and
Louisiana and has been responsible for several cases of cholera
through consumption of fish from that area, especially in the
summer months and at beginning of fall.

     In July and August 1991, toxigenic V. cholerae 01,
subsequently identified as the Latin American strain, was
isolated from oysters from the coast of Louisiana, but none has
been isolated since September.  It is suspected that the
contamination of the oysters on that coast was a consequence of
the discharge of ballast water from ships that had previously
sailed in contaminated waters in Latin America.

2.3. The Experience of the United States of America in Food
     Control in Response to the Cholera Epidemic in the
     Americas.

     The Food and Drug Administration of the United States, as
a government agency with responsibility for the protection of
the population, usually submits the food under its jurisdiction
to sampling and inspection when it is suspected that it poses
a risk to public health; however, food that complies with the
FDA regulations and is not considered a risk is permitted to
enter through simple arrangements.

     On the other hand, if the laboratory results demonstrate
that the food does not meet current standards in the United
States, the shipments are stopped and their entry into the
territory is prevented unless the importer can demonstrate to
the FDA that entry should be permitted; these products can be
reconditioned, reexported, or destroyed, depending on the case
and the judgment of the agency.

     When one or more lots of food from a particular
manufacturer, shipper, or geographical area are detained for the
same reason, the FDA can place the products in automatic
detention, which permits the agency to stop the shipment without
laboratory test, solely on the basis of historical information,
that is, the trend shown in previous analyses.  The importer and
the other interested party must present tests to the FDA that
indicate that the product meets the requirements before a permit
for distribution can be issued; after this and after
verification that five consecutive shipments meet the
requirements, the lots of food can be excused from automatic
detention.

     After the outbreak of cholera in the Americas, the FDA
determined that the greatest potential for contamination with
V.  cholerae serogroup 01, biotype El Tor existed in food of
marine origin, both fresh and frozen, with less danger from
products processed with water, such as fruits and vegetables
washed before packing or stored in ice during shipment to the
United States, or products that may contain residual soil from
the field where they grew.  The district offices of the FDA were
instructed to submit these basic products for sampling and
analysis when the shipments were presented for importation to
the United States.  The agency has expanded its sampling to the
countries according to epidemiological situation, that is, when
there is an unusual increase of cases in their territories.

     These measures that the FDA has instituted have not
signified greater obstacles for the producers and exporters. 
That agency has also extended its sampling to the products
coming from different countries to Latin America, as in the case
of Bangladesh; 100% of its products were monitored during the
period following the hurricane that ravaged its territory last
year.  Moreover, products from Thailand have been monitored
since V. cholerae was isolated from coconut milk incriminated
in two cases of cholera in the United States.

     In the United States, cases of cholera in infected
individuals returning from South America have been registered;
some of them illegally transported marine food products and
others consumed possibly contaminated food on a flight from
South America.  Notwithstanding the foregoing, it is accepted
that the disease does not occur in epidemic form in the United
States.

     The FDA is aware of the damage that can be caused by the
wait for laboratory results, in some cases up to 10 days.  For
this reason technologies that reduce the time of the analyses
are being developed.  The strain of V. cholerae causing the
epidemic in Latin America today can be identified by pulsating
field electrophoresis of DNA digested by enzymes obtained from
the microbes.  Those singular electrophoresis patterns allow
characterization, in the laboratory, of isolated samples
distinguished through their DNA "fingerprints" and
identification of the region of the world from which the samples
came.

     The FDA will utilize specifically the polymerase chain
reaction (PCR) technique to detect the presence or absence of
nucleic acids in food.  This PCR technique is specific for V.
cholerae and it will shorten the period necessary for issuing
a report to 48 to 72 hours after receipt of the sample in the
laboratory.

     The FDA is prepared to receive and analyze information on
food safety from the industry, government authorities, and
commercial enterprises to demonstrate that the controls during
the processing are sufficient to prevent or eliminate
contamination of food by V. cholerae, which can be translated
into a reduction or elimination of the regularly established
sampling for surveillance.

     This information should include the measures normally taken
to guarantee the microbiological quality of the water used in
the process, the chlorination treatment applied, the levels of
hyperchlorination, and the frequency with which they are
monitored; the handling that the products receive in their
shipment to the United States and whether they are subject to
some heat treatment that ensures the destruction of V. cholerae;
and the programs that the industry has established to certify
the quality, especially including those to prevent contamination
by V. cholerae.

     Information relative to official control should also be
included, with an indication of the state agency responsible for
the control, the programs applied to the marine products
industries and to the agricultural sector, the sampling and
analytical methods used, and the laboratories utilized.

     To date, from the more than 700 samples of products coming
from the affected countries, it has not been possible to isolate
V.  cholerae serogroup 01, biotype El Tor.


3.  CHOLERA AND FOOD

3.1.  Food at Risk in the Transmission of Cholera.

     There is a marked trend toward the a priori incrimination
of food as the cause of cases of cholera, without the
epidemiological research necessary to demonstrate it, much less
the laboratory studies to confirm it.  Many of the classical
works on the transmission of cholera by food have not stood up
to the test of scientific rigor and to methodologies that
deserve to be considered sufficiently reliable.

     The assumptions concerning food involved in cases of
cholera should not be taken as fact before careful analysis of
the factors related to the microbial ecology of Vibrio cholerae,
the persistence of the microorganism in certain environments,
and the cultural practices that favor the spread of this agent
in specific regions, all of which should be taken into account
in evaluating the possible incrimination of a specific food in
an outbreak.

     Another factor to consider is the biological structure of
the food, which is very important in the survival or
multiplication of the germ; usually when that is kept intact,
it is very difficult for the V.  cholerae to survive or to
multiply; on the other hand, for example, in damaged vegetables
or fruits the pH is increased, permitting physiological activity
of the Vibrio which can produce contamination.

     Moreover, technology introduces modifications in the raw
materials that are going to influence the response or behavior
of the polluting microorganisms notably.  Treatment with heat
is the most effective way to reduce or eliminate the initial
contamination; despite this, account should be taken of the fact
that the resistance of the microorganism is very variable and
dependent on its environment.  Rice did tests that led him to
conclude that the microorganism could be destroyed after being
heated to 99.5C for 30 seconds; for this reason the recommended
practice is to boil the water for one minute at sea level and
for three minutes at high altitudes (above 3,000 m above sea
level).

     Other authors, namely Makukutu and Guthrie, found that the
microorganism El Tor Inaba is capable of surviving for one hour
in food maintained at 60C and concluded that it is more heat-
resistant than is usually believed.  They inferred that some hot
food could have been responsible for some cases of cholera and
that such food had not been considered suspicious in
epidemiological research because it had been believed that the
heat killed those microorganisms.  The survival of Vibrio in
crabmeat submitted to boiling for eight minutes or cooked with
the steam for 25 minutes has also been reported.

     Modifications of some intrinsic characteristics of food,
such as reduction of the PH by natural or artificial
acidification and  reduction of aqueous activity, affect the
survival or growth of Vibrio unfavorably.  Moreover, it has been
demonstrated that irradiation is effective; Vibrio in marine
products was susceptible to 1 kGy of ionizing radiation which
was applied to destroy it.

     Extrinsic factors also have a notable influence on the
survival of the microorganism - for example, storage temperature
and the relative humidity of the environment.  In this regard
the EEC allows the importation of food that has been transported
under anaerobic conditions or in a controlled atmosphere of
carbon dioxide.

     Finally, there are the implicit parameters, such as effects
derived from the characteristics of the microorganisms
themselves and from the microbial associations that can be
created, among them the rate of growth, symbiosis, and microbial
antagonism.

     There have been numerous attempts to recover Vibrio
cholerae or to determine its survival or rate of multiplication
in food that were not conducted with the necessary scientific
rigor.  This suggests the need for assigning organizations, such
as the ICSMF, WHO, and PAHO, with the responsibility of
designing a standardized study of the factors that influence the
survival and multiplication of V. cholerae in food, developing
a microbiological model on the basis of "predictive
microbiology" with the participation of laboratories of
recognized technical excellence so that the importing countries
base their specifications on the results of studies that are
carried out with those methodologies, and the exporters also
apply them to guarantee the safety of the food from production
through final processing.

     Moreover, there is a need to recommend intensification of
the application of the Hazards Analysis Critical Control Point
(HACCP) System during the processing and preparation of food,
both in research, and in production in industry.

     Actions to educate consumers on health also play an
important role in the promotion of measures to prevent cholera
in the handling and use of food.

     When decisions are made that affect the international food
trade, they should be as conservative as possible and should be
based on studies of sufficient scientific rigor.

3.2. The Cholera Epidemic and the Food Trade at the National,
     Regional, and World Levels.     

     The importance of the food trade in the Latin American
countries is recognized in view of the fact that growth in the
export markets has contributed markedly to strengthening the
economies of the countries and to amortization of their external
debt.

     Food, whether raw or processed, then has great economic
importance in Latin America and represents a significant source
of foreign exchange, necessary for the implementation of
development plans.

     Agricultural products and fish are particularly important
in the Region.  They amounted to 31% of all exports in 1989 with
a total value of $US38,000 million, which correspond to almost
one fourth of the total of all exports by category.

     To this must be added the fact that intraregional free
trade is being consolidated and in this way bilateral agreements
or subregional initiatives among countries are being achieved. 
Examples involve Brazil and Argentina; Mexico and Chile; and
Colombia, Venezuela, and Ecuador.  In addition there are great
possibilities among Mexico, Canada, and the United States; and
Mexico, Colombia, and Venezuela.  There are also possibilities
that new markets will open for nontraditional products in Europe
and Japan.

     The cholera epidemic has had dramatic effects on
international food trade, the result of its appearance in Peru. 
The alarms created generated a series of measures that have had
an impact, as varied as it was severe, on the marketing of the
products.

     Thus, products, such as fish and vegetables, were
incriminated in the transmission of cholera.  Their consumption
was reduced drastically in the affected countries and did not
recover until after a prolonged period despite the measures
taken by the governments to counteract the negative effects -
 the reductions in the sources of nutrients for the population
and in the sources of employment and subsistence.

     The figures for the losses due to the epidemic are not very
precise.  They indicate, for example, that Peru lost
approximately $US5,000 million in the fishing industry in 1991,
while the Association of Exporters of Peru reports a total of
$US13,000 million in direct losses.

     Because of the epidemic, the countries have undertaken
various measures.  They have increased inspection activities in
the handling and preparation of food with the cooperation in
many cases of international agencies, such as FAO, PAHO, WHO,
and others providing bilateral assistance directed toward
improving the practices in harvesting, handling, and processing
the products and obtaining their certification to satisfy, in
many cases, the requirements of the importing countries.

     In the case of products for local consumption, the
governments have taken measures to prohibit the marketing of
certain foods, such as vegetables irrigated with wastewater,
and, in some cases, food sold in the streets.  There were cases,
as in Chile, where the order was given to destroy all the crops
growing in areas of risk.

     In any case, the governments have made great efforts to
increase their inspection capacity and their control procedures. 
At the same time several of them have received technical
assistance and have taken the opportunity to review national
legislation on food and increased activities in training,
laboratory testing, and consumer education.

     On the other hand, the importing countries, such as the
United States and the countries of the European Economic
Community, have imposed serious restrictions on the entry of
products from the affected countries:  the sampling of all fish
products especially, and also the requirement of specific
certifications of the absence of V. cholerae.  These constitute
serious nontariff barriers to the trade from the countries
affected by the epidemic.

     One important aspect of the common market is that in
guaranteeing trade it is necessary to guarantee that the
inspection and control are carried out in the countries.

     In the case of the European Economic Community (EEC), each
country has availed itself of the opportunity to make decisions
consisting of setting nontariff barriers for lack of common
standards.  The cholera caused great alarm and the information
coming from the press aggravated the problem.  All this
generated visits to the countries to check the production and
inspection systems, as a result of which there was a measure of
acceptance in all the member countries.

     Thus there have been no greater problems with the fish and
meat trade; on the contrary, the export volumes are being
maintained and even increased.

     The EEC is preparing standards for inspection and
manufacturing practices that will be required for other products
besides fish and meat.  The EEC is prepared to provide its
cooperation in direct support of the trade involving food
products shipped to its member countries.


4.  FRESH FRUIT AND VEGETABLES

4.1. Utilization of Wastewater for the Irrigation of Fruits and
     Vegetables.

     Properly treated wastewater should be integrated into the
water resource planning, because it allows an additional water
supply in areas of scarcity, and it makes it possible to expand
the development of the agricultural frontier, to increase
productivity, and to restore the fertility of eroded soils.

     Crop restriction is a useful measure in the case of those
products that are consumed raw and have been irrigated with
wastewater.  This should be the first step in reducing the risks
to health from bacterial and parasitic diseases, when treatments
that ensure an adequate water quality are not available.

     The principal criterion for selecting a system for treating
wastewater for recycling in agriculture should be the efficiency
of the removal of the pathogen; the others should be low cost
and ease of operation and maintenance.  The stabilization pond
is considered the most adequate system.

4.2. Microbial Contamination of Fruits and Vegetables Consumed
     in Some Cities of latin america and the Effectiveness of
     External Disinfection.

     It is evident that the soil, water, air, and insects
influence the microflora on vegetables and fruits; their
relative importance varies depending on the structural part of
the plant.  Thus, the leaves have greater exposure to the air,
while the roots have greater contact with the soil.  In
addition, variations in microflora due to climate and cultural
practices are recognized.

     Man's activities also have an effect; for example, the use
of pesticides to eliminate insects limits the spread of
microorganisms; the introduction of human or animal wastes into
the irrigation water or the soil also has an effect on the flora
of the plants.

     Recent analytical studies have revealed contamination by
Escherichia coli in 100% of the samples of vegetables analyzed
in Lima, Peru; in approximately 80% of the vegetables marketed
in La Paz, Bolivia; and 50% of those analyzed in Sao Paulo,
Brazil.

     From the above it is deduced that in several countries of
Latin America, contamination of plants and fruits with V.
cholerae is produced:  a) during production, as a consequence
of the irrigation water and the use of human excreta as
fertilizer and b) during processing and marketing, when the
plants are washed with water from contaminated rivers or when
water of doubtful origin is used in a spray to maintain the
freshness of the products.

     In this way, the measures applied to limit or eliminate
environmental pollution during production, harvesting,
processing, and washing are significant activities in a
strategic program to ensure the quality of those products, which
is of particular importance in avoiding the spread of pathogens.

     Epidemiological studies of cases and controls have
demonstrated the association between vegetable consumption and
the spread of the epidemic.  Thus, in Trujillo, Peru, cabbage
was considered a risk factor associated with the disease, and
in Piura, in light of research, consumption of beverages popular
in the street, such as soybean water and barley water, were
considered to be important factors associated with the disease,
without going into the possible contribution of the ice to the
contamination of the beverages.

     Contrary to the above, in a survey of the exposure of 461
individuals through food, conducted in Callao, Peru, no
significant association between vegetable consumption and the
presence of the disease was found.

     Despite the fact that there is epidemiological evidence of
the transmission of cholera by horticultural products, thus far
it has not been possible to isolate V. cholerae from a total of
300 samples analyzed in various countries of the Americas.
     
4.2.1.  Tests of disinfection

     Various experimental studies have been carried out to
determine the behavior of V. cholerae El Tor Ogawa in fruits and
vegetables; they have shown that food, such as lettuce, parsley,
tomato, and strawberries, that are contaminated with V. 
cholerae do not permit the frank multiplication of the
microorganism either at room temperature or under refrigeration;
in addition, the viability of V. cholerae in contaminated food
was maintained for three days in these food kept at room
temperature and up to five days when they were kept under
refrigeration at 10C.  It was also demonstrated that the
recovery of the bacterium in the laboratory requires culture in
alkaline peptone solution.

     Moreover, the utilization of various bactericidal products
to wash the contaminated food showed a reduction of only two
orders of magnitude of the initial contamination for most of the
products, except DG-6 (quaternary ammonia) which produced a
reduction of four orders of magnitude.

     Other studies showed that disinfection of lettuce with
sodium hypochlorite at a concentration of 100 mg/l reduced the
flora naturally present by 98%.  Observation with an electronic
microscope demonstrated the resistance of microorganisms to
disinfection, because they were lodged in hydrophobic folds of
the leaves, which prevented total disinfection.  It is
recommended that the outside leaves of lettuce be discarded,
since they have higher microorganism counts than those from the
interior.  Prolonged washing with running water or disinfection
with a maximum of 100 mg/l of free residual chlorine is also
recommended, in view of research that indicates how the
mechanical action of the water eliminates at least 90% of the
biological contaminants, while only 6% or 8% is due to the
disinfectant.


5.  FISH PRODUCTS

5.1. The Risk of Acquiring Cholera through Consumption of
     Imported Fish Products.

     The risk of transmission of cholera through consumption of
imported fish products has not been verified in the present
epidemic.  Ecuador is the fourth biggest producer of cultured
shrimps in the world; 250,000 persons work in this industry and
significant areas of the coasts of the country are utilized for
this process.  The responsible authority is the Department of
Fishing Resources through the Bureau of Fishing and the National
Institute of Fishing.  Analyses are conducted to certify the
quality, including studies of organoleptic properties and
microbiological and bromatological conditions and determinations
of heavy metals.

     In Ecuador there is a Committee for the Prevention of
Cholera in the fishing sector whose purpose is:  (1) to
intensify the microbiological control of the plants; (2) to
provide technical assistance in campaigns for prevention of
cholera; (3) to advise on quality control in shrimp plants; (4)
to monitor coastal waters; (5) to provide mass education on
prevention to the handlers; (6) to disseminate an image of
sanitary quality; and (7) to give international legal
assistance.

     Vibrio cholerae has not been detected in territorial or
interior waters and the possibility of contamination of those
waters is limited, which means that the principal activity is
focused on monitoring the handling of the products in the
plants.  In the fishing industry following good manufacturing
practices, together with the utilization of freezing tunnels and
pasteurization of the products at temperatures higher than 60C,
guarantees the safety of the fish products.

5.2. The Quality of Fish Products for Export from Latin America.

     In 1991 Latin America produced 16 million of tons of fish,
gaining a significant presence in the world fish market.  Africa
contributed 3.8 million tons and Asia, 38 million.

     The value of the fish exports from Latin America was $3
billion, but there are problems of quality and of
diversification of products.

     Fishing in the region provides a source of food,
employment, and foreign exchange and there is greater interest
in exports than in domestic consumption.

     The quality of the Latin American products is excellent,
which is due to the good conditions in the exporting plants and
to a positive understanding between importers and exporters.

     For domestic consumption, official inspection services are
practically nonexistent and they are considered to be an
interference in production or an imposition by the police.

     The efforts to increase quality are oriented toward the
final products and the export trade; specific legislation is in
many cases obsolete or not very effective, while the personnel
in the government offices often lack technical qualification,
material resources, and authority and sometimes they do not
demonstrate a spirit of cooperation.

     In domestic consumption there are problems of product
contamination and historically there is no tradition of
inspection.

     The principal problems in quality control can be summarized
as follows:  (1) emphasis on the inspection of products for
export; (2) the interests of the producers prevail over those
of the consumers; (3) lack of technical preparation; (4) efforts
excessively concentrated on the analysis of the final product;
and (5) the diversity of responsible state agencies, lacking
programs, coordination, and a definition of competence.

     The introduction of the concepts of risk analysis and
critical control points - for example, what was developed in
countries such as Canada - has contributed to the improvement
of the quality of the exported products.

     According to the FDA, retention of Latin American products
due to salmonellosis is very limited.  Japan had reported that
V. cholerae has not been detected in products from Latin
America.  In Canada rejection of Latin American products occurs
only occasionally.  In the Peruvian case, of the 2,393 samples
analyzed in recent years none were positive for V. cholerae.

     On the other hand, among the occasional problems detected
one can mention the existence of mercury wastes and the presence
of histamine, Salmonella, and Staphylococcus.

     The conditions of fish products are directly related to the
quality of the aquatic environment of the fish and shellfish. 
It is well known that enterobacteria are present in fresh water
and cultured shrimp normally present Salmonella and V. cholerae,
which are part of the usual flora, and hence the need for
detecting their presence should be reconsidered.

     Handling procedures that involve the use of ice and
temperatures around 0C inhibit the growth of bacteria and the
competition of the autochthonous flora is such that it is not
possible for the V.  cholerae to reproduce to cause disease.

     The situation in the fishing industry in the countries of
the English-speaking Caribbean gives rise to the need to
establish an integrated inspection program that includes
legislative aspects, covering imported products and those for
domestic consumption, and, most particularly, the need to
strengthen the training of the personnel and to incorporate the
HACCP system to facilitate quality control and to combine it
with modern technologies to guarantee quality.

     Programs to educate the consumer should be part of all the
efforts for the improvement of product quality in Latin America,
a region that presents fish products whose quality is very much
above that of most of the other underdeveloped countries
traditionally exporting to international markets.

5.3. Nontariff Barriers for Fish Products for Export.

     Peru, because of the cholera epidemic, suffered a series of
difficulties with its exports to the whole world; it is
estimated that the economic losses amounted to more than $500
million, generated by suspension of purchases, lost shipments
of fish products, need for additional shipments, and serious
repercussions on tourism and on the service industry.  In
addition to this, the alarmist information in the press played
a major part in this phenomenon as did several neighboring
countries that closed their borders, rejected products, and
contributed to the exacerbation of the problem.

     The United States carried out intensive sampling of
Peruvian fish products and announced an alert that was only
recently rescinded.

     The problem is considered to have been basically political
since there was no technical basis and in some developed
countries consumption of fish products declined radically.

     The position of WHO was very clear; it declared that
sanitary barriers did not exist and that the decrease in the
sale of Latin American products was generated by historical
positions, signifying serious economic losses in the region.

     The Government of the United States maintains that it had
carried out analyses on only 5% of the products which did not
include canned products; fishing was considered to be a craft,
leading to detention of products which were released only after
results of analyses were available.

     The normal presence of V.  cholerae in water was discussed. 
It signifies a risk to public health only if the microbiological
conditions are such that there is a minimum quantity of germs
that are pathogenic or toxigenic.

     There was consideration of the need to give the clearest
possible technical response so that the community and the
governments do not adopt unnecessary measures detrimental to
international trade.  There was a coincident need to strengthen
the systems of food inspection and of certification of exports,
for which there should be a good system of quality control that
makes it possible to protect the human population and to
guarantee the food for export.


6.  STREET FOODS

6.1. Food Handling in the Street and the Risk of Transmission of
     Cholera.

     The different types of food that are sold in the public
thoroughfares range from the typical food in each country to
preparations exhibiting foreign influences and the contributions
of ethnic migrations; they can be classified as of high or low
epidemiological risk in accordance with their composition, how
they are prepared, and how they are kept.

     In the first group are the ceviches made from fish and
shellfish for which the critical points are the quality of the
raw material utilized for their preparation and maintenance
without refrigeration.
     
     Also included are vegetable salads that usually accompany
main dishes; here the critical points are the cultivation of the
vegetables, which involves in some cases utilization of
contaminated wastewater, and washing with untreated water that
may be contaminated.

     In addition, there are fresh fruits that are peeled and cut
up which can be contaminated by being washed with contaminated
water, handled with soiled hands, and sprinkled with the wrong
kind of water.

     There are also various kinds of beverages that are prepared
with untreated water, poorly washed fruit, and ice from bad
quality water, and submitted to extensive handling. 

     The category of food of low epidemiological risk includes
food that has been submitted to heat treatment to eliminate or
decrease contamination, but it can be recontaminated and suffer
deterioration through inadequate handling and storage.  The
principal examples of these foods include:  stewed and fried
meat, chicken, and fish; small and large tortillas, tacos, and
other such basic foods; sandwiches with various contents, such
as hamburgers and hot dogs; and meat pies, which can be
contaminated by vendors that are carriers, through handling,
through the use of unsuitable water to wash the utensils, or
when they are accompanied by salads or mayonnaise.

     With reference to the transmission of cholera by food, this
can occur because the food has been contaminated at its origin
or at the hands of convalescent or asymptomatic carriers.

     To prevent contamination and the dissemination of cholera
street vendors are being oriented toward the use of plastic bags
for the packing fruit and other products, the protection of the
products in screened showcases, the use of paper wrapping, the
application of chlorine in different proportions to disinfect
the water, the use of cutting boards made of synthetic material
in preparing the products, the design of carts with containers
to store water, washing and disinfecting vegetables, and
improvements in the cooking processes.

6.2. Activities of the United Nations Food and Agriculture
     Organization in the Sanitary Improvement of Street Vending
     of Food.

     In most of the countries, the vending of food in the
streets is not recognized legally.  However, it has been
demonstrated as a sociocultural reality in the developing
countries that constitutes a source of employment for a high
percentage of population that includes a significant proportion
of the women and, in addition, makes it possible to offer low
cost food to workers and students.  It is also accepted as a way
of supplying food that will continue to grow in the future in
parallel with the population that lives in urban areas, which
will make up more than 70% of the total population by the end
of the 20th century.

     Studies have shown that the low-income population can in
this way satisfy its need for inexpensive nutritional food,
while at the same time the workers offering the food for sale
in the street can earn many times more than the minimum wage in
the countries.

     In regard to the risks of transmission of diseases it has
been demonstrated that food sold in the streets can be a vehicle
for different microorganisms, such as E. coli, Salmonella, or
Staphylococcus aureus.  In the case of V. cholerae, some
preliminary studies have shown that food contamination due to
added contamination is almost always possible.

     In addressing the problem of street food vendors and in
light of the cholera outbreak in Latin America, cooperation has
been oriented toward personal hygiene and food handling
practices, the use of water, the disposal of wastewater and
refuse, improvement of the technologies for food preparation,
and control and licensing of street vendors.

     There is special cooperation with the countries to prepare
regulations for street food vending on the basis of the Code of
Hygienic Practices for the Preparation and Sale of Food in the
Streets which was considered recently by the Codex Alimentarius
Committee on Food Hygiene and which will be studied by the Codex
Alimentarius Commission.

     The problem of the street sale of food has been analyzed at
several meetings, such as the FAO/PAHO Regional Seminar on
Street Sale of Food, held in Lima in 1985, the Seminars
organized by FAO and held in Guatemala in 1990 and in Brazil in
1991, the Regional Workshop on Street Sale of Food held in
Indonesia in 1986, and in the FAO Global Consultation of Experts
on Street Vendors held in Yogjakarta, Indonesia, in 1988.

     In addition, street food vending has been the object of
attention by the international agencies since it has become a
very widespread practice in the developing countries and is even
seen now in capitals, such as Washington, D. C., in the United
States.  It is a phenomenon that undoubtedly has an impact on
agricultural production and the nutrition of the population.

     PAHO/WHO, in the framework of the Regional Program for
Technical Cooperation in Food Protection, has continued to
cooperate in the countries for the organization and training of
street vendors in aspects of hygiene, health, and sanitary food
handling at the same time that it has cooperated in the
launching of informative programs on food protection that
involve the community, with special reference to sellers and
consumers.

     The World Health Organization has prepared a guideline for
the formulation of cholera control programs that includes what
was mentioned above with respect to street food vending.

     In order to evaluate the situation of street food vending
and the advances achieved in recent years, a FAO/WHO Joint
Seminar similar to the one held in 1985 has been programmed for
1993.

6.3. Street Foods and Transmission of Cholera in Central
     America.

     In the countries of Central America the street sale of food
constitutes a significant phenomenon, due to the rate of
unemployment, which fluctuates between 25% and 48%, and for
other reasons.  It has become a significant source of employment
and, in addition, constitutes a way of offering food at low cost
and nutritional alternatives.

     In every country there are typical foods that are sold in
the street and follow cultural traditions that can also be
classified as of high or low epidemiological risk.

     In the same way as in other subregions, contamination
occurs mainly in the preparation and sale phases.  Studies
carried out in LUCAM have demonstrated fecal contamination of
food sold in the street and the presence of V. cholerae has also
been demonstrated in preparations based on seafood but without
the scientific rigor to show whether the contamination was from
this food or from what accompanied it.

     On the basis of technical cooperation from FAO and PAHO,
the countries have adopted measures that benefit the street sale
of food and protect the consumer; this translates into official
recognition of food vending in the streets.  The training of the
inspectors and vendors and the promulgation of regulations to
regulate the activity has resulted in an improvement in the
models establishing nuclei of food vending in the public
streets, thus improving notably the presentation and
preservation of the food.

6.4. Street Foods and Transmission of Cholera in South America.

     The principal foci of the cholera epidemic in this part of
the Hemisphere are located where there is a clear association
between the greatest frequency of cases and the conditions of
marginality, which keep the population deficient in basic
sanitation services, facilitating the spread of the epidemics.

     The locations of these foci have also coincided with
localities with tropical climates that present conditions
favorable to the ecology of V. cholerae.  An additional factor
is the association between the consumption of food at risk of
contamination and V. cholerae.

     One clearly identified problem is related to the hygienic
conditions in the street vending of food, which leave a great
deal to be desired.  The sites almost never have potable running
water for cooking and cleaning the kitchen utensils and the
crockery, for personal hygiene, and for the preparation of
beverages and ice, and thus water constitutes a very important
source of food contamination in street vending.

     Some studies carried out in South America have demonstrated
that 98% of the sellers did not have systems to supply water of
good quality or in sufficient quantity, which forces the vendor
to seek the needed water at sources of doubtful quality.

     Another factor to consider is related to the quality of the
raw materials used in preparing the food and, in particular, the
lack of methods of preservation that would allow it to be kept
over long periods.

     The handlers are recognized as a source of food
contamination.  It is known that the profile of the handler in
these countries is characterized by a low level of schooling,
which is naturally associated with ignorance of hygienic habits
that ensure the safety of the food that is prepared and
dispensed.  Studies carried out in several localities in South
America have demonstrated that more than half of the handlers
have barely completed their basic education and 30% are
illiterate.

     Despite the limited information, there are figures
available that indicate the numbers of street vendors in some
capitals; thus in La Paz, Bolivia there are 36,000; in Bogotá,
Colombia, 9,000; in Quito, Ecuador, 4,300; in Panama, 1,900; and
in Lima, Peru, 19,000.

     Other studies indicate the existence of carriers of
pathogenic microorganisms, which implies the need to direct
actions toward modifying the attitudes of the handlers toward
their responsibility for hygienic food handling.

     As in Central America, foods have been found that would
offer greater potential for transmission, namely those whose
preparation is based on water and ice, such as:  bottled water,
pills, beverages, and fruit juices.  Other food can also be
contaminated with water:  seafood, for example, and even some
submitted to heat treatment, which can suffer cross
contamination after preparation if not handled correctly.

     As explained in previous paragraphs, there have been
studies to isolate Vibrio cholerae from various types of food
that may have lacked scientific rigor and the ability to validly
verify the involvement of some food in the transmission of an
outbreak of cholera.

     Current living conditions in the South American region do
not present a picture that allows thinking about the
disappearance of the determinants that facilitate the phenomenon
of the street food vending or of those that favor the spread of
cholera.  The action of the governments and of the international
agencies should, as a result, be oriented toward reorganization,
improvements in sanitation, and regulation of that activity,
which should be supplemented with intense continuing activities
to train vendors and consumers and adoption of appropriate
technologies for the preparation and sale of the food in the
streets.

     In addition to the efforts of the international agencies,
such as FAO, PAHO and WHO, in allocating resources to support
this type of initiative through technical cooperation programs,
cooperation among the countries is required to create a more
favorable scenario that reduces the risk of transmission of
cholera and other diseases that can be transmitted through
consumption of contaminated food.

7.  CONCLUSIONS AND RECOMMENDATIONS

7.1.  Conclusions

     The Technical Consultation recognizes that, in general, the
countries of the Region do not have integrated national food
control programs that can guarantee its safety and quality.  The
Consultation also recognized that the governments are taking the
action necessary to establish and strengthen effective national
food control systems and it applauded these efforts.

     The Technical Consultation noted that the international
community had the mistaken perception that the fragile control
systems existing for food for domestic consumption would be used
for the export products and hence questioned the safety of the
exported food.

     The Technical Consultation has reviewed all the available
analytical information related to the controls carried out in
exported and/or imported food and did not find any evidence
relating the transmission of cholera to commercial exportation
of food.

     The Technical Consultation noted with regret the great
economic damage, estimated at $US500 million, suffered by the
countries of Latin America as a result of restrictive actions
taken by the importing countries without any scientific or
technical basis which have severely restricted the international
food trade.

7.2. Recommendations

     With a view to protecting the health of the consumers and
in order to guarantee the continuity of the food trade, the
Technical Consultation made the following recommendations:

7.2.1. It is recommended that the governments, with a sense of
urgency, establish or strengthen integrated national food
protection systems, including control of institutional foods,
food marketed in the public thoroughfares, and imported and
exported food.  Such programs should include, in addition to the
control infrastructure, components of training and education at
all levels, including processors, lawmakers, transporters, and
consumers of food.  An important component of those programs is
epidemiological surveillance of food-borne diseases, a vital
activity in the monitoring of the integrated systems for
effectiveness.  The harmonization of the national system with
the regional and local systems is stressed.

7.2.2. There is recognition of the urgent need to have highly
effective food control services with trained staffs and also of
the need for the food industry to be completely informed about
problems related to food contamination.  Hence, it is
recommended that high priority be given to the establishment of
effective training programs related to the inspection and
processing of food, including use of the HACCP system.

7.2.3. It was noted that due to the dissemination of information
without scientific basis related to food and cholera, the food
trade was greatly damaged.  In an effort to combat that "bad
press" it is recommended that action be taken to disseminate
widely at the national and international levels information
about the positive activities that the countries of Latin
America have developed to ensure that the food is of high
sanitary quality.

7.2.4. It is recommended that the countries intensify measures
aimed at avoiding irrigation of horticultural products with
wastewater or the fertilization of the soil with untreated human
fertilizer.  When this is not possible, the producers should be
instructed concerning crop substitution or other alternatives
for irrigation.  It should be taken into account that
disinfectant substances alone are a complement to the prior
washing of the food.

7.2.5. There was recognition of the inherent safety, with
respect to cholera, of foods such as acid foods (with a pH of
4.5 or lower); irradiated foods (minimum dose of 1 kGy); and
foods that have been submitted to lethal thermal processing,
such as cooking, pasteurization, sterilization, and/or canning
and that have not been recontaminated during the preparation
process.  In addition, it was recognized that the scientific
community has still not reached a consensus with regard to the
survival of V. cholerae at specific values of water activity
(Aw) or to its survival in fresh fruits and vegetables submitted
to different temperatures for varying lengths of time during
transport.  It is recommended that financial resources be
identified to carry out a study to answer those questions, if
possible.  The results of the study should then be submitted for
consideration by the Codex Alimentarius Commission, through the
Committee on Food Hygiene.  In addition, note was taken of the
great variety of procedures for determining the acceptability
of food by the importing countries with respect to cholera, and
it is recommended that the Codex Alimentarius Commission be
requested, through the Committee on Food Hygiene, to review the
situation so that an appropriate consistent guideline can be
developed.

7.2.6. The importance of the street food vendors in the
development of the economy of the country and in the feeding and
nutrition of the population is recognized.  However, there is
a risk of cholera transmission; therefore it is recommended that
the governments officially recognize the street food vendors so
that there is adequate control of that food.  In addition,
special attention should be paid to the training of itinerant
vendors, the inspectors responsible for the control, and the
consumers.  In addition, the governments should promote the
adoption of regulations to control this activity on the basis
of those prepared by the Codex Alimentarius.

7.2.7. Recognition is given to the valuable technical
cooperation that is being provided to the countries of the
Region through international agencies, including FAO, PAHO, and
WHO, in an effort to increase the protection of the consumer and
ensure the continuity of the food trade.  It is recommended that
coordinated technical cooperation be continued and that the
involved agencies consider the provision of additional
cooperation to the governments of the Region.

LIST OF PARTICIPANTS


Susana Binotti
SENASA
Jefa Departamento Microbiología APAC
Fleming 1653
Martínez
Provincia de Buenos Aires, Argentina
Tel.: 792-0066
Fax: 792-0066

Juan Cuellar Solano
Ministerio de Salud
Jefe, División de Alimentos
Of. 309, Calle 55 No. 10-32, 
Bogotá, Colombia
Tel.: 2550205
Fax: 2358577

Aleira Lucía Chavance
Instituto Nacional de Alimentos
Coordinador Técnico
Avda. Madero 279
(1106) Buenos Aires, Argentina
Tel.: 343-6061/65 and 331-3263

Mirtha Eiman Grossi
Ministerio de Salud y Acción Social
Jefa Departamento de Vigilancia Epidemiológica
Defensa 120, Piso 4, Ofic. 4012
Capital Federal, Argentina
Tel.: 342-9863

Sindulfo Melquíades García Santacruz
Ministerio de Salud Pública y Bienestar Social
Jefe de Departamento Higiene de Alimentos
Brasil y Petirossi
Asunción, Paraguay
Tel.: 210938

Silvia Elena González Ayala
Ministerio Salud y Acción Social
 de la Provincia de Buenos Aires
Presidente Comisión Ejecutiva Cólera
60 y 120 1900
La Plata, Argentina
Tel.: (021) 51-1140 and 3-2652
Fax: (021) 25-5004 and 25-2346

Cataldo Ricardo Grispino
Director
Instituto Nacional de Alimentos
Avda. Eduardo Madero 279 (1106)
Capital Federal, Argentina
Tel.: 331-3263
Fax: (0541)-331-3310 

Bradford A. Kay
Consulting Microbiologist
Centers for Disease Control
Enteric Diseases Branch MS C03
Atlanta, Georgia, U. S. A. 30333
Office: Department of International Health, 
The Johns Hopkins University
School of Public Health, 615 N. Wolfe St.
Baltimore, MD 21205, U. S. A.
Tel.: (410) 550-5292
Fax: (410) 550-6733

Claudia Beatriz López
Instituto Nacional Microbiología "Carlos Malbrán"
Profesional División Bacteriología Sanitaria
Vélez Sarfield 563
Capital Federal, Argentina
Tel.: 21-4115-19, ext. 220

Joseph M. Madden
U.S. Food and Drug Administration
Director, Division of Microbiology
Center for Food Safety and Applied Nutrition
200 C St., S. W.
Washington, D. C. 20204, U. S. A.
Tel.: (202) 245-1217
Fax: (202) 472-1270

María Celia Moirano
Instituto Nacional de Alimentos
Coordinador Técnico
Avda. Madero 279
(1106) Buenos Aires, Argentina
Tel.: 343-6061/65 and 331-3263

María Esther Morales F. de Ramos
Instituto Nacional de Pesca
Jefe de la Seccióm Control de Calidad
Casilla 09-04-151-31
Guayaquil, Ecuador
Tel.: 401776/405637/401773/407680
Fax: 402304/405859

Miguel A. Negrón
U.S. Food and Drug Administration
Regional Milk and Food Specialist
60 8th Street, N. E.
Atlanta, GA. 30309, U. S. A.
Tel.: (404) 347-3576
Fax: (404) 347-4349

José Palomino Huamán
Consultor en Higiene de Alimentos
Ucayali 145, Urb. Sta. Luisa, La Perla 
Callao, Perú
Tel.:  651984

Carlos Rivadeneyra Gutierrez
CERPER
Subgerente Microbiología Alimentos
Av. Santa Rosa No. 601, La Perla
Callao, Perú
Tel.: 654065
Fax: 658443

Jaime Sancho
Subdirector General
Comisión Nacional del Agua 
Insurgentes Sur 2140
México, D. F., México
Tel.: 5509621, 5509622
Fax: 5509623

Torres Leedham
SENASA - DICOM
Coordinador General Análisis de
Productos Alimenticios y Conexos (APAC - DICOM)
Fleming 1653
Martínez
Provincia de Buenos Aires, Argentina
Tel.: 784-1333
Fax: 792-0066

Helio Urzúa
Ministerio de Salud
10 Avenida 14-00 Zona 1
Guatemala
Tel.: 35-25-23-500108-84048
Fax: 500108

Roberto Vargas Sagárnaga
Ministerio de Salud
Director Nacional de Epidemiología
Calle Cap. Ravelo No. 2199
La Paz, Bolivia
Tel.: 375466, 376006, 376674
Fax: 02-376006

OBSERVERS


Waldemar F. Almeida
International Life Sciences Institute (ILSI)
Director Ejecutivo
Alameda dos Araés 1189
04066, Sao Paulo, Brasil
Tel.: (55-11) 542-1538
Fax: (55-11) 61-3276

J.C. López Musi
International Life Sciences Institute (ILSI)
Coordinador
Paraná 1097, Piso 8 "A", 
Buenos Aires, Argentina
Tel.:  313-0265

J. Pérez-Lanzac
European Economic Community (EEC)
Dirección General, Agricultura
Administrador Principal
200 Rue de la Loi
Brussels, Belgium
Tel.: (32.2) 2355092
Fax: (32.2) 2355092

Silvia Malabarba
Banco Interamericano de Desarrollo (BID)
Especialista en Saneamiento y Medio Ambiente
Esmeralda 130, Piso 20
Capital Federal, Argentina
Tel.: 334-1756/59
Fax: 334-6633
SECRETARIA

Claudio R. Almeida
Regional Advisor in Food Protection
Veterinary Public Health Program
Pan American Health Organization (PAHO)
World Health Organization (WHO)
525 23rd St., N. W.
Washington, D. C. 20037, U. S. A.
Tel.: (202) 861-3190
Fax: (202) 223-5971

Eduardo Alvarez
Jefe Cooperación Técnica y Desarrollo de Programas
Instituto Panamericano de Protección 
 de Alimentos y Zoonosis (INPPAZ)
Programa de Salud Pública Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Casilla 3092, Correo Central
(1000) Buenos Aires, Argentina
Tel.: 792-4047, 792-0087
Fax: 112328

Primo Arámbulo III, Joint Secretary
Coordinator
Veterinary Public Health Program
Pan American Health Organization (PAHO)
World Health Organization (WHO)
525 23rd Street, N. W.
Washington, D.C. 20037, USA
Tel.: (202) 861-3190
Fax: (202) 223-5971

Albino Belotto
Asesor en Salud Pública Veterinaria
Programa de Salud Púlica Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Av. 20 de Octubre 2038
La Paz, Bolivia
Tel.: 364-757
Fax: 391-296

Roberto Bobenrieth Astete
Asesor en Protección de Alimentos
Programa de Salud Pública Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Sector de Embajadas Norte, Lote 19 
78000 Brasilia, DF, Brasil
Tel.: (55-61) 321-1200
Fax: (55-61) 225-1551

Richard James Dawson, Joint Secretary
Chief, Food Quality Standards Service
Chief, Joint FAO/WHO Food Standards Programme
Secretary, Codex Alimentarius Commission
FAO
Via delle Terme di Caracalla,
00100 Rome, Italy
Tel.: 57974013
Fax: 57973152

Jaime Estupiñan
Regional Adviser in Veterinary Public Health
Veterinary Public Health Program
Pan American Health Organization (PAHO)
World Health Organization (WHO)
525 23rd St., N. W.
Washington, D. C. 20037, U. S. A.
Tel.: (202) 861-3192
Fax: (202) 223-5971

Carlos Alberto Lima dos Santos
Principal Specialist
Inspection and Quality Control Training Program
Division of Fishing Industries
Department of Fishing, FAO
Via delle Terme di Caracalla, 00144
Rome, Italy
Tel.: 57974476
Fax: 06/5404297

Raúl Londoño
Director
Instituto Panamericano de Protección 
 de Alimentos y Zoonosis (INPPAZ)
Programa de Salud Pública Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Casilla 3092, Correo Central
(1000) Buenos Aires, Argentina
Tel.: 792-4047, 792-0087
Fax: 112328

Silvia Michanie
Microbiólogo de Alimentos
Instituto Panamericano de Protección 
 de Alimentos y Zoonosis (INPPAZ)
Programa de Salud Pública Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Casilla 3092, Correo Central
(1000) Buenos Aires, Argentina
Tel.: 792-4047, 791-0087
Fax: 112328

Norberto Moran
Epidemiologo de Alimentos
Instituto Panamericano de Protección 
 de Alimentos y Zoonosis (INPPAZ)
Programa de Salud Pública Veterinaria
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Casilla 3092, Correo Central
(1000) Buenos Aires, Argentina
Tel.: 792-4047, 792-0087
Fax: 112328

Carlos Pérez Hidalgo
Asesor en Alimentación y Nutrición
Organización Panamericana de la Salud (OPS)
Organización Mundial de la Salud (OMS)
Marcelo T. Alvear 684, 4 Piso 
Capital Federal, Argentina
Tel.: 782-9585

Fernando Quevedo
Food Safety Unit (Scientist) and
Member WHO Global Task Force on Cholera Control
World Health Organization (WHO)
20 Av. Appia 1211, Geneva 27
Switzerland
Tel.: (4122) 791-3556
Fax: (4122) 791-0746
  OBSERVATIONS ON THE DOCUMENT "EPIDEMIOLOGICAL STUDIES"


a)                                                                                                                  Definition of a case

There are certain
combinations of
signs that are
highly unlikely to
be indicative of
pneumonia of
bacterial etiology-
-for example,
"cough with
wheezing."  It
would be desirable
to omit mention
of "wheezing" and
"stridor," since
wheezing is
associated more
with bronchiolitis
and stridor with
the clinical picture
of croup.

Elsewhere we have
pointed out that
wheezing can
almost serve to rule
out a diagnosis of
pneumonia.  Thus,
according to the
latest criteria of
the PAHO/WHO
Program on ARI,
increased
respiration rate or
chest indrawing
in the absence of
wheezing is
compatible with
pneumonia.  In
countries or
regions where
broncho-
obstructive
syndromes or
bronchial
hyperreactivity are
frequent, these
criteria are
extremely useful
for a better clinical
approximation to
the diagnosis of
pneumonias.

We suggest that
the clinical "entry"
criterion for the
identification of
cases for the
collection of a
sample be carefully
reviewed by a
clinical specialist
in pediatric
pneumology or
pediatric
infections.

At the appropriate
time we can
provide you with
a set of all the
technical
publications and
PAHO/WHO
manuals on the
outpatient
management of
ARI cases for use
by the consultant.

b)                                                                                                                  Collection of
material

We would like to
make several
observations on
the collection of
material for
diagnostic studies:

-          Throat
swab:  it is
not clear
why this is
to be done,
since it will
not indicate
an etiology
of
pneumonia. 
We think
that a
nasophar
yngeal swab
would be
more
appropriate.

-          Urinalysis
for the
presence of
antigen:  this
method of
diagnosing
the etiology
of
pneumonia
continues
to be
controve
rsial, since
the
sensitivity
of the
method is
open to
serious
question,
and it would
probably not
be advisable
to draw any
conclusions
regarding
the etiology
of
pneumonia
on the basis
of the results
obtained.

-          Punch
biopsy:  this
method is
not
proposed
but has
proved to
be valuable
if skillfully 
performed. 
Candidates
for this
procedure
would be
children
with
pneumonia
in which
there is
consolid
ation near
the chest
wall.

-          Post mortem
culture:  the
results tend
to be
unreliable. 
Contami
nation is
very
frequent
and, in
addition,
many
patients
have
received
antimicr
obial
treatment
prior to
death,
which
makes it
difficult to
relate the
findings to
the true
causal agent
of the
pneumonia.

-          Urine
culture:  it
is not clear
why this is
to be done,
since it will
not reveal
the cause
of
pneumonia
in the child.

-          Quality
control for
serotype: 
it is
suggested
that a more
detailed
description
be provided,
as well as
an
explanation
of all
laboratory
and clinical
procedures. 

These are some of
the areas that we suggest be examined in greater depth by the clinical and laboratory
specialists to be consulted on the final preparation of the protocol.

c)                                                                                                                  Sample

As we stated
before with regard
to the size and
characteristics of
the sample, we
suggest that you
take into account
the fact that
mortality from
pneumonia in
children under 5
is concentrated
especially in those
under 1 year of
age, and within this
group it is
concentrated in
infants under 3
months.

With regard to
morbidity, in order
to establish
parameters
consistent with
epidemiological
behavior, I suggest
that you investigate
the data registered
at the sites where
the study will be
carried out, that
a retrospective
analysis be
conducted
covering the
previous two years
(or at least one
year) in order to
determine the local
profile of the
pattern of the
demand due to
pneumonia in these
age groups (under
3 months, 3-
11 months, and 1-
4 years).  On the
basis of this
information, it is
suggested that the
proportions of
cases to be
admitted for study
be established in
relation to the total
size of the sample.



HPM/YB
13/V/92

PREFACE

The Declaration on Technical Cooperation among the Countries of the Americas
in the Conservation and Utilization of Nonhuman Primates, known as the Declaration of
Iquitos, was the outcome of a gathering of some fifty scientists from Europe and the
Americas at the Workshop on Controlled Breeding of Primates in thier Own Habitat,
which was held in Iquitos, Peru, in November 1986.

This Declaration was the subject of a report presented to the Ministers of
Agriculture of the Region at the V Inter-American Meeting, at the Ministerial Level, on
Animal Health (RIMSA) in April 1987, pursuant to which the Ministers adopted
Resolution VIII establishing the Regional Primatology Committee for the Americas.

The sentiment that has guided the preparation of the present publication has been
the desire to provide a historical account of the I Regular Meeting of the Regional
Primatology Committee for the Americas (CORP I), held in Seattle, Washington, in
October 1990.

The publication also reviews the scientific issues addressed at the meeting that
were debated or called for clarification and on which agreement was reached, giving rise
to a series of recommendations that were approved by consensus.

The Regional policy regarding the preservation of nonhuman primates and their
sustained use for the benefit of public health was alluded to repeatedly throughout the
Meeting.  The spirit of this policy also pervades the documentation that accompanies the
proceedings.  This policy becomes increasingly important in the changing world in which
we live, inasmuch as it ensures the safeguarding of national patrimony.

The editors wish to express their sincere gratitude to the CORP I assistants whose
contribution, active participation, and willingness to share their experiences were crucial
for the achievement of the objectives of the Meeting and for the production of this
publication.
MESSAGE FOR WORLD NO-TOBACCO DAY 1992

     World No-Tobacco Day, 31 May, has gained growing recognition
and has come to be observed in all the Regions of the world as
addiction to tobacco has become a global concern.  Since 1992 is
the Year of Workers' Health, the motto that has been adopted for
World No-Tobacco Day this year is "Smoke-free Workplaces: Safer and
Healthier."

     The working population is extremely vulnerable to the
occupational risks and dangers of smoking in the workplace. 
Although the risks of smoking to health--which are translated into
three million preventable deaths every year throughout the world-
- are well known, regrettably the occupational risks of tobacco use
continue to be unrecognized or, worse still, ignored by those
responsible for developing programs of prevention and health
promotion for workers. 

     Among the factors that justify more energetic action on the
part of public health authorities to combat smoking in the
workplace are:

     1.   The potential risk of fires and explosions, which are
responsible for numerous occupational accidents;

     2.   Irritation and allergies caused by exposure to tobacco
smoke, which produces acute and chronic changes in the
respiratory tract and the eyes;

     3.   The economic losses associated with tobacco use, which
include the cost of health care, absenteeism, care and
upkeep of furniture and equipment, and insurance
premiums;

     4.   In addition to the smoke that is inhaled by smokers, the
burning of tobacco generates secondary smoke, which
contains as many toxic substances as the inhaled smoke
but is even more dangerous because it can easily
penetrate deep inside the lungs.  Smoking in the
workplace is a major source of problems for the millions
of nonsmokers who may be involuntarily exposed for many
hours a day over a period of many years to the
aggravations, dangers, and health risks irresponsibly
imposed on them by smokers.  No matter how much
ventilation is increased in closed spaces, the colleagues
of smokers, in particular young people, are exposed to
a greater risk of lung cancer, heart disease, respiratory
disease, and conditions affecting other organs;

     5.   In addition, tobacco smoke considerably increases the
health risks associated with exposure to other hazardous
substances, materials, or conditions that may already be
present in many working environments.

     The issue that outweighs all others, however, has to do with
the right of workers to breathe smoke-free air.  The common good
should prevail over the rights of those who continue to smoke in
the workplace.  Smoking control policies are needed at all levels 
that will lead to a better physical and social environment and to
improved health.  The voluntary restrictions that were adopted
initially are now giving way to a set of more stringent policies,
laws, and regulations at the national and local level aimed at
restricting the use of tobacco in workplace.  Such provisions are
receiving growing support and have been endorsed by the Pan
American Health Organization and the World Health Organization.

     Physicians and other health workers need to make a greater
commitment to health promotion efforts in order to bring about
changes in behaviors and in lifestyles that are detrimental to the
health of everyone.  They must play a more active role in society
in order to increase public awareness of the dangers of smoking and
obtain support for control measures and policies.  Workers' health
programs have a responsibility to organize smoking cessation and
social support programs for addicts and to promote policies for the
establishment of smoke-free areas in the workplace.

     On the occasion of World No-Tobacco Day, we appeal again to
the Governments, to nongovernmental organizations, and to the civic
conscience of all people in the Region to take a step toward better
care of their own health and toward the achievement of Smoke-free
Workplaces:  Safer and Healthier.
Dr. José Luis Zeballos
Adviser PAHO/WHO
Emergencies and Disasters    
Washington, D.C.





        GAS EXPLOSION IN GUADALAJARA, MEXICO, 22-IV-92

REPORT



Introduction:

The city of Guadalajara, capital of the State of Jalisco, is
located in the western central region of the Mexican Republic. 
As the second most important city of the republic, it is
characterized by intense commercial and industrial activity.

In recent years Guadalajara has experienced accelerated
industrial development and population growth; from the economic
point of view the state of Jalisco is very rich in agriculture,
industry, and trade.

The population of Guadalajara is estimated at 1.8 million but
when neighboring areas are included the population easily
reaches 4 million inhabitants.  The geographical location of the
state of Jalisco (the seismically active Pacific Coast) makes
it vulnerable to natural disasters such as earthquakes, volcanic
eruptions, and hurricanes; and the extensive industrial
development makes it potentially vulnerable to technological
disasters.

The characteristics of industrial development in Guadalajara are
similar to many Latin American countries undergoing accelerated
industrial development; there is a broad range of chemicals
produced as intermediate or final products, whose production,
storage, transport, use, and toxic waste disposal cannot be
easily controlled in the absence of strong regulation and
enforcement measures. In this regard, the potential risks for
technological disasters and environmental contamination are
evident.


The explosion of gas:

On 22 April at approximately 10 in the morning, a series of
strong explosions shook the central part of the city in the
Reforma area and Gante Street. As a consequence of this and
other secondary explosions that occurred in the course of the
day, approximately 250 persons died and 1,470 persons were
treated for trauma wounds.  Also destroyed or seriously affected
were 1,124 homes, 450 businesses, and 600 vehicles along the
damaged area, leaving approximately 5,200 persons without
housing.

The magnitude of the damages classifies this explosion as a 
technological disaster, second in importance in terms of its
effects on the population only to the explosion of propane gas 
which occurred in St. Juanito, in the state of Mexico in 1984,
in which approximately 500 persons died or were victims of
trauma and severe burns.

The cause of the explosion was initially attributed to the
effusion in the city sewerage system of a solvent (hexane gas),
from a vegetable oil factory.  Hexane gas is classified as a
highly explosive gas that, when more dense than air, accumulates
on the surface, travels rapidly through the drainage system and,
upon contact with the air, rapidly increases its pressurization.
(??can ignite rapidly). Inhalation induces irritation of the
respiratory tract and absorption through the skin can induce
toxic effects.

Various information sources concur in pointing out that the
population of the affected area complained for days before the
explosion of the smell of hydrocarbon that filled the air, and
whose presence was even detected in household drains.

Subsequently, the hexane gas as the causative agent of the
disaster was placed in doubt, when gasoline leaks were detected
in a principal pipeline that came from the Salamanca refinery
owned by the State-run oil company, PEMEX.  Hydrocarbon wastes
were emptied into the sewerage system in quantities considered
significant.  In addition, the washing of the PEMEX fuel tanks
in "nogalera" area, and the construction of a deep drainage
siphon could have contributed to the effusion of hydrocarbons
and trapped gases.

The Attorney General of the Republic, acting on express
instructions of the President of the Republic, was directed to
carry out an exhaustive investigation on an emergency basis to
establish the causes of this disaster.  In accordance with the
report presented on 26 April, the Attorney General's Office
pointed out that the principal causative agent of the explosion
was the effusion of gasoline from a leak approximately a
centimeter in diameter in the PEMEX pipeline that was corroded
from metal-to-metal contact with a water pipe not adequately
isolated from the pipeline, and to the existence of hexane gas
that had been detected in the hours prior to the tragedy, which
would have contributed to the explosion.  This same report
establishes civil and penal responsibilities for local
authorities and executives of institutions, indicating
negligence in the failure to apply preventive measures despite
awareness of the high risk involved.

The actions of those who monitor gas leaks and their explosive
potential were intensified in different parts of the city by the
experts of specialized institutions, and preventive measures are
being taken to evacuate some areas that are considered high
risk.

Response of the health sector:

     a) Medical emergency response

     The city of Guadalajara, as the second most important city
     in the country, has a high concentration of health infra-
     structure and human resources, thus the emergency response
     was timely and efficient.  There was a rational
     coordination in the care and distribution of patients to
     different hospitals, with coordination between ambulances
     and hospitals from a command operations center; among the
     active participants included the Ministry of Health with
     its emergency care unit for accidents and disasters.

     The success of timely care administered in the critical
     moments is reflected in the low case-fatality rate among
     the hospitalized, in spite of the seriousness of the
     lesions.  At the writing of this report, there still was
     not a consolidated diagnosis of the patients treated;
     however, available reports make it possible to evaluate the
     majority treated for exposed fractures, trauma of thorax
     and abdomen, craneoencephalic trauma and multiple trauma
     cases. There were no cases treated for burns or gas
     inhalation.   The causes of mortality have been attributed
     to severe trauma and suffocation.

     Notwithstanding the success of the timely response, various
     sources indicate that the management of the pre-hospital
     phase requires improvement.  Indeed, groups of volunteers,
     in their eagerness to aid the wounded, could have
     inadvertently caused, additional lesions to the multiple
     trauma cases ,especially to those that would have suffered
     lesions of spinal column.

     The training of emergency relief groups in techniques for
     managing and transferring trauma patients, as well as the
     training of search and rescue teams for rescuing trapped
     victims, deserve particular attention in order to improve
     the quality of emergency care and transfer of victims.

     Because of the nature of this disaster, it was not possible
     to do triage at the site of the disaster.

     b) Search and Rescue

     Approximately 30 search and rescue teams, both local and
     from the Federal District, participated in the operations.
     Aid was not required from the international community and
     PAHO quickly communicated with the interested parties to
     stop the unsolicited international assistance.

     Unlike the assistance operations in the case of an
     earthquake, when there is expectation of discovering live
     victims in confined spaces with some reserve of air, the
     nature of this disaster (explosion with collapse of the
     drainage system. gave little hope of finding survivors.

     On the other hand, questions were raised by the fact that
     the early use of heavy machinery may have denied rescue
     teams a better chance to seek survivors.  Up to 26 April,
     four days after the tragedy, unofficial communications
     mentioned the recovery of 16 victims by direct intervention
     of the rescue groups, two of whom were rescued alive.

     This again raises the question of the effectiveness of
     techniques available for search and rescue operations.  It
     is urgent to gather information on the efficiency of these
     means such as the use of trained search dogs, or the
     alternative of using more sophisticated equipment as sonar
     equipment, fiberscopes, infrared rays, etc.  This points to
     the need for greater research in the field of rescuing
     trapped victims.  There remains as well the need to address
     the research hypothesis of examining the degree to which
     the effectiveness of the search dogs would have been
     affected by the odor of gas that could still be perceived
     in some areas.

     c) Temporary shelters

     At first there were 30 temporary shelters installed that
     gave lodging to 5,000 victims; subsequently these shelters
     were reduced to four.  Epidemiological surveillance was
     increased and essential services were provided, for both
     physical and psychological treatment.  The army provided
     food to the refugees in the shelters.  There was special
     attention given to potable water consumption needs (large
     containers), and to hygiene in food management.

     As it has been observed in previous disasters, the display
     of solidarity of the Mexican population is praiseworthy,
     particularly with respect to the provision of food and
     shelter.  In the shelters, one could note the abundance of
     essential food and clothing donated by the community.

     Despite the tragedy, there was no interruption in the 
     National Vaccination Day Campaign.  This was carried out
     two days after the disaster, in accordance with the initial
     schedule. Emphasis was also placed on vaccinating rescue
     groups against tetanus.

     d)   Sanitation, monitoring  of environmental quality

     The health authorities gave special care to the
     surveillance of water quality, and in the determination of
     potential risks for health and the environment resulting
     from the drainage waters and received the support of the
     public health laboratory and of other external
     laboratories.  However, there are aspects that need to be
     strengthened, such as providing basic equipment for the
     daily monitoring of leaks and detection of chemical agents
     that are potentially toxic.

     Particular significance should be given to evaluating the
     integrity of the distribution system of potable water to
     residences.  The strength of the explosions could have
     damaged some of the pipes for drinking water as well as the
     pipes for sewerage in residential areas, creating the risk
     of contamination by waste water siphonage. In this regard,
     monitoring water quality and surveillance of enteric
     diseases constitute a priority, even more so if one takes
     into account the risk of cholera.
    e)   Self-sufficiency in drugs and medical supplies

     Notwithstanding the magnitude of the disaster, the state
     was self-sufficient in meeting its needs for medical
     supplies without assistance from the central government or
     international assistance. However, the assistance sent
     voluntarily by countries or friendly institutions was
     received as a courtesy.  The affected area was less than 5%
     of the geographical area of the city, however the
     longitudinal extension of the disaster area was
     approximately 10Km.  

     f)   Support from PAHO

     As soon as there was knowledge of the disaster, Dr. Juan
     Manuel Sotelo, Representative of PAHO in Mexico, requested
     the support of the Program of Emergency Preparedness and
     Coordination of Disaster Relief of PAHO in order to obtain
     an expert from Headquarters to support the health
     authorities of the state of Jalisco in evaluating the
     impact on the health sector.  The author and Dr. Diego
     González Machin, toxicologist of the Pan American Center of
     Human Ecology and Health, travelled to Guadalajara and
     worked jointly with the authorities and technicians of the
     Ministry of Health in the following:

     1) To estimate the potential risks through direct
     observation of the affected area and of other sectors of
     the city;

     2) To determine if the need for international assistance
     existed or not;

     3) To identify actions of support by PAHO for the phase of
     immediate follow-up after the period of emergency;

     4) To formulate recommendations for operational actions for
     which the health sector is directly responsible.

Conclusions and recommendations:

·    From the available information, the city of Guadalajara is
     vulnerable to natural disasters and apparently highly
     vulnerable to technological disasters, particularly to
     those caused by chemical agents.

·    This disaster reflects its vulnerability and indicates the
     need for preparing a detailed vulnerability analysis and to
     update the existing studies.

·    In the study of risks and vulnerability, special attention
     should be given to the vulnerability of hospitals and
     schools, and prevention measures and mitigation efforts
     should be applied.

·    The plans of the health sector for response to disasters
     should form part of the programs for continuing education
     in the hospitals and they should included in the teaching
     of health disciplines and engineering.

·    One should strengthen infra-structure of the disaster
     response unit in order to optimize its operational
     efficiency, sectoral coordination, and inter-sectoral
     liaison.

·    With regard to international assistance, priority should be
     given (as priority) to the reconstruction phase.

·    It is recommended that cooperation with PAHO be explored in
     the following areas:

     1)   Provision of equipment and basic instruments for
monitoring (chemical and bacteriological) water
quality, and of the presence of chemical agents and
potential toxic substance, monitoring waste water, and
monitoring gas leaks that pose a risk for health.

     2)   Strengthening the public health laboratory for the
operation of a toxicology unit.  The physical
structure exists as well as some infra-structure
equipment.

     3)   Development of a training program in the management of
waste water, toxic chemical agents, and management of
disasters.

     4)   Establishment of a toxicology network. 

     5)   Prevention and mitigation, management of disasters and
support for the unit of attention to the disaster care
unit of the Ministry of Health, provision of
informative material and publications, training in
technological disasters.

     6)   Support for the development of case studies. 

Annexes

·    List of interviewed persons
·    Statistics (tables and graphs)
·    List of request for equipment for monitoring of dangerous
     wastes and of environmental contamination environment,
     presented by the Ministry of Health and Welfare of the
     State.

&\ALICIA\XPLOSIO &N.MEX
Doc.:  J.L. Zeballos
12 May 1992>                                                  



       EXPLOSION OF GAS IN GUADALAJARA, MEXICO                

22 April 1992





I N F Or R M And








Pan American Health Organization (PAHO/WHO)
*
Program of Emergency Preparedness 
and Disaster Relief Coordination 










CONTENTS




     1.   Report


     2.   List of interviewed persons


     3.   Annexes (tables and graphs)


     4.   List of equipment requested by the Ministry of Health and Welfare 
of the State of Jalisco for consideration of international cooperation
and of PAHO.


1. ADVISER IN HEALTH PROMOTION AND PREVENTION AND CONTROL OF CHRONIC
   NONCOMMUNICABLE DISEASES

2. Post No. .5926

3. Under the technical and administrative supervision of the PAHO/WHO Representative and the technical
   supervision of the HPA and DHS program coordinators, the incumbent provides services to the country as
   an adviser in various aspects of the prevention and control of chronic noncommunicable diseases. 

   Specifically, he/she is responsible for:

a) Collaborating in the formulation of policies, in the programming and implementation of short-, medium-
   , and long-term plans, and in the definition of priority areas for programs on chronic noncommunicable
   diseases and health promotion;

b) Cooperating with national institutions in the application of the methods and principles of epidemiology in
   accordance with the objectives pursued by the programs under his/her responsibility;

c) Assisting the country in the development of studies aimed at determining the magnitude and distribution of
   chronic noncommunicable diseases, to serve as a basis for the enhancement of control and prevention
   programs and for upgrading and familiarization of the services with the objectives pursued by these
   programs;

d) Compiling and consolidating the baseline information needed in order to establish a profile of the national
   situation in this area, monitor its development, and identify possibilities for technical cooperation with regard
   to services, training, and research;

e) Advising on the development of national and intercountry projects with a view to demonstrating the
   feasibility of epidemiological studies and the effectiveness of therapeutic and preventive measures;
   facilitating the organization of national control programs;

f) Assisting the country in the development of health promotion activities, with emphasis on the utilization of
   mass media in community programs that seek to prevent risks in the area of noncommunicable diseases;

g) Collecting, analyzing, and disseminating information on any developments and advances that are made in
   the area;

h) Identifying and mobilizing existing resources in the country and promoting the effective utilization thereof;

i) Preparing the annual program of work and budget as well as the four-month work plans in his/her area of
   responsibility;

j) Cooperating with other technical units within the Representation and with other program areas of the
   Organization in order to maximize the effectiveness of program activities and optimize the use of resources;

k) Carrying out other related tasks, as assigned. 

4. The incumbent must possess analytical skills, independence of judgment, and strength of conviction in order
   to provide technical cooperation and guidance for the adaptation of a health services system faced with a
   new epidemiological situation.  The post requires a high degree of familiarity with epidemiology and the
   planning/organization of health services.





5. The PAHO/WHO Representative will discuss with the Adviser in Health Promotion the major courses of
   action to be taken, as well as the general objectives pursued and the results expected.  The supervisor will
   review and approve the annual program of work and budget and the corresponding PTCs.

6. Graduation from a recognized school of medicine.  Graduate studies at the master's degree level in public
   health with emphasis on epidemiology, prevention of chronic noncommunicable diseases, and/or the
   planning and organization of health services for adults.

   Excellent knowledge of Spanish and a working knowledge of English. 

7. At the national level, five years of epidemiological and clinical experience in the area of chronic diseases
   and/or in the organization and administration of promotion, prevention, and control programs.

   At the international level, five years of experience in technical cooperation programs and research activities
   in the area of chronic noncommunicable diseases.

Executive Committee of the Directing Council
109th Meeting
Washington, D.C., 
June 1992

Provisional Agenda Item 4.10                                                                       CE109/24 (Eng.)
May 1992
ORIGINAL: SPANISH                          

WORKERS' HEALTH
        This document is being presented to the Executive Committee to report on fulfillment of the mandates
of the XXIII Pan American Sanitary Conference and to outline the Plan of Action for the initiative "1992: 
Year of Workers' Health."

        This priority program area for the quadrennium 1991-1994 was considered in Resolution XIV of the
above-mentioned Pan American Sanitary Conference, which underscored the need to promote the
strengthening and articulation of activities and of a new culture of workers' health, with emphasis on health
promotion, prevention, and protection.  The Organizing Commission for the Initiative approved a Plan of
Action aimed at achieving political commitment and participation by the various sectors of society and
adopted the Declaration on Workers' Health in Washington, D.C. on 26 February 1992.  The Executive
Committee is asked to manifest its support for this Declaration and the Plan of Action and to make
recommendations on how the desired impact can best be achieved. 

        The targets of the Initiative are for all the countries to approve National Plans for the Development
of Workers' Health and for at least ten countries to implement them.  These Plans will includes lines of
action for the extension of coverage under the coordination of government, employers, and workers and
with collaboration by the media mass and educational institutions.  The will calls for special attention to
be given to the most underserved groups of workers.  Alternatives such as primary health care, local health
services, and new modalities of social security will be emphasized.  The basic components should
contribute to the adoption of an ergonomic approach to workers' health that simultaneously take into
account the working environment, technology and machinery used in the workplace, the organization of
work, and prevention in the workplace.  New benefits for workers will thus be geared toward the current
socioeconomic and occupational realities and the new risks, as well as the technical and medical
possibilities available for prevention, with a view to contributing to the elimination of occupational risk
factors that directly harm the workers exposed to them and are detrimental to the entire population. 

        A set of guidelines has been drafted to facilitate preparation of the National Plans for the Development
of Workers' Health.  These included a frame of reference, specific targets to be reached, identification of
the most serious deficiencies, and suggestions for ways of eliminating them through epidemiological
surveillance, research, information, and education.

        The delivery of cooperation by the Organization in this health priority area includes the intensification
of advisory services to the countries, not just by the Program on Workers' Health but through the WHO
Collaborating Centers in workers' health.  The Organization is focusing its action on activities defined by
an interprogram group that identifies the activities that each program can carry out in its area of
specialization and expertise as well as the activities that require interprogram action in the area of workers'
health.  This interprogram collaboration and solidarity within the Bureau and in the countries will make it
possible to achieve better levels of health and well-being for the working population, prolong the average
length of economically active life, decrease absenteeism, reduce human suffering and disability, and, thus,
increase production and financial and social development.  The Meetings of the Governing Bodies in 1992
have great historical significance in that they mark the official inauguration of the Year of Workers' Health.
CE109/24 (Eng)



Introduction

        This document is being presented to the Executive Committee of this Organization
as the Year of Workers' Health is being observed in the Region of the Americas.  It
reports on the activities and cooperation that the Bureau and the countries have
undertaken in fulfillment of the mandates on workers' health of the XXIII Pan American
Sanitary Conference.  The Secretariat requests that the Executive Committee study the
Plan of Action (Annex II) for the initiative known as "1992:  Year of Workers' Health"
and the Declaration on Workers' Health (Annex IV) and that it manifest its support and
make recommendations on how the desired impact can best be achieved.

        Workers' health was named by the XXIII Pan American Sanitary Conference as one
of the eight priority program areas for the quadrennium 1991-1994.  During the same
Conference, the Ministers of Health adopted Resolution XIV on Workers' Health (Annex
I), which designates 1992 as the "Year of Workers' Health" in the Region of the
Americas.

        The goal of the initiative "1992:  Year of Workers' Health" is to achieve greater
attention to the health of workers without diminishing efforts that are already under way
to develop projects and activities at the national, subregional, or Regional level and, in the
countries, to promote the strengthening and articulation of workers' health through a
comprehensive program and a broader political spectrum.  By giving high visibility to the
area of workers' health in 1992, it should be possible to achieve a commitment from
leaders, promote the exchange of information between employers and workers regarding
the problems and causes of work-related accidents and diseases, and foster the
development of a preventive consciousness.  This, in turn, should result in increased
resources for occupational health programs and the plans of action that have been or are
being developed.  It should also contribute to widespread recognition of the social and
economic importance of these programs and plans.  Finally, it should help to bring about
the needed changes of attitude so that, even after the campaigns carried out during this
initiative have come to an end, the activities and structures established will continue, and
there be increased attention to the health of workers and a new culture of workers' health,
with special emphasis on health promotion and protection, enhanced ability to work, and
the prevention of occupational risk factors. 
Organizing Commission for the Initiative "1992:  Year of Workers' Health"

        In order to plan activities for the development of this Initiative, an Organizing
Commission was formed that included a number of prestigious political and scientific
figures, among them two former presidents of countries in the Region.  The Commission
was given responsibility for promoting broad dissemination in order to ensure political
commitment and encourage active participation by the various sectors of society.  These
objectives are enshrined in the Declaration on Workers' Health, signed by the members
of the Commission in Washington, D.C., on 26 February 1992.  It is hoped that the
Governing Bodies will endorse the content of this Declaration, lending their support so
that it can then be disseminated to all the concerned agencies and institutions and
facilitating the mobilization of resources and the delivery of cooperation.

Plan of Action for the Initiative

        The development of the Initiative will be guided by the Plan of Action, which was
revised and approved by the Organizing Commission.  It is hoped that these program
guidelines will be espoused by the Governing Bodies and adopted by the member
countries.  The Plan is aimed at the attainment of two targets:

All the countries of the Region will formulate or revise and approve a National
Plan for the Development of Workers' Health.

At least ten countries in the Region will set up mechanisms for intersectoral
articulation, coordination, and cooperation and will establish National Committees
on Occupational Health to implement their National Plans for the Development
of Workers' Health.

        In order to prepare a National Plan and achieve its objectives it is indispensable to
obtain the participation of government, employers, and workers.


National Plans for the Development of Workers' Health

        One of the purposes of the National Plans is to ensure coordination between all the
agencies and institutions, both governmental and nongovernmental, that are in a position
to contribute effectively to the promotion and protection of workers' health, stressing the
prevention of the occupational risk factors, with the collaboration of employers and
workers.

        In the governmental sector there are various institutions with basic responsibility for
the preparation, implementation, and periodic evaluation of the National Plan.  These
entities have traditionally worked in isolation and have had a largely pathological
orientation.  They include:

        -  The ministry of health, which is responsible for providing curative care and
rehabilitation for sick workers.

        -  The ministry of labor, which is primarily concerned with legislation on prevention
and standards to regulate the working environment and the techniques used in the
workplace.  There are difficulties surrounding the applicability of such provisions
and limitations with regard to the implementation and enforcement thereof.

        -  Social security institutions or insurance schemes, which serve their affiliated
members in case of illness and compensate them in the event that they become
disabled and cannot work.

        -  Institutes that specialize in occupational health, which sometimes fall under the
aegis of the ministry of labor and sometimes under that of the ministry of health.

        -  The ministries of agriculture, industry, and trade, which play an important role in
the development, dissemination, and enforcement of standards.

        -  The ministry of education, which has the task of bringing about changes in attitude
and disseminating information to help identify the risk factors that threaten
workers' health and find the most effective means of eliminating or controlling
them.  This type of action is a great deal less expensive and more effective than
curative or compensatory actions. 

        In the nongovernmental sector, in addition to the agencies involved, the labor unions,
and the trade associations, it is important to point out that participation by employers and
workers in this area is essential and fundamental.  Without their active and aware
collaboration it will not be possible to carry on economic progress and preserve the social
stability that can result from programs aimed at improving the health and working
capacity of the economically active population.

        Participation by the media mass and educational institutions is indispensable in order
to ensure that human resources in all the professions and trades receive training that
emphasizes a new attitude oriented toward prevention and the promotion and maintenance
of health.

        The National Plans for the improvement of workers' health will incorporate lines of
action for the extension of health care coverage to most exposed, most vulnerable, and
least served workers, including children, women, indigenous peoples, and the
handicapped, as well as those in the informal sector, bearing in mind that only a small
percentage--less than 10%--of the working population currently benefits from
comprehensive attention in accordance with ILO instruments.  These lines of action will
need to be innovative and envisage alternatives such as primary health care and local
health services, in addition to considering new modalities of social security, so that the
action taken will be preventive, rather than strictly curative.  The plans will encompass
various basic components, including:  specific policies, legislation, regulation and
standardization, promotion, utilization of mass communication, information, generation
of knowledge and epidemiological surveillance, active participation, manpower
development, institutional strengthening, development of services and programs,
surveillance, and control.  The will also call for the adoption of an ergonomic approach
to personal health care so that simultaneous consideration is given to the working
environment and the techniques used in the workplace, to tools and machinery, to the
organization of work, and especially to health education and prevention in the workplace.

        The foregoing discussion points up the need to review the types of benefits that have
traditionally been offered to workers, with a view to ensuring that they are line with
current socioeconomic and labor realities, new risks, and available technical and medical
possibilities for prevention.

        The preparation of a National Plan should make it possible to achieve within
institutional structures the constitution of an information network that will promote the
elimination of unhealthful, dangerous, explosive, toxic, and uncomfortable working
conditions, with priority given to the reduction of occupational risk factors that not only
are directly harmful to the health of exposed workers but also produce environmental
changes that are detrimental to the entire population.  In addition, an effort needs to be
made to adapt the requirements and conditions of work to the capacity and ability of
working women and men.

        A set of guidelines (Annex III) has been drafted to aid in the preparation and revision
of the National Plans for the Development of Workers' Health.  These guidelines stress
the importance of multidisciplinary cooperation between the various institutions and
health programs, with support and collaboration from the community, unions and trade
associations, and especially employers and workers.

        The National Plans for the Development of Workers' Health will have, inter alia, the
following frames of reference and specific targets:

        Improvement of the health of workers:
Reduction of the number of fatal accidents
Reduction of the cases of disability and disease
Reduction of work-related diseases 
Promotion of factors that contribute positively to health
Promotion of health education and healthy lifestyles
Implementation of measures to increase the average length of economically active
life

        Adaptation of working conditions to the characteristics of workers:
Reduction of risks (prioritizing the most serious risk factors)
Creation of better safety and hygiene conditions in the workplace
Guarantee of basic sanitary conditions in all workplaces
Control of workers' exposure to dangerous substances

        Formulation of a National Plan of Action:
Generalized participation and interinstitutional cooperation
Programs, services, protection, prevention
Coverage for the least served groups 
Utilization of innovative strategies
Collaboration in the areas of hygiene, safety, and occupational health, and in other
disciplines concerned with the issue, making optimal use of existing structures

        The development of a National Plan presupposes identifying the most serious
deficiencies and finding ways of eliminating them.  The most pressing needs generally
are: 

        Personnel to achieve the objectives in the area of practice, research, and training
        (training at all levels:  training in occupational health for health workers; training of
        specialists in safety, hygiene, occupational medicine, and others disciplines relating
        to occupational health; and training of workers and employers).

        Epidemiological surveillance in workers' health in order to identify the most
        vulnerable groups and those who are exposed to important work-related risk factors
        and pathologies. 

        Research on work-related injuries and diseases, risk factors, measurement techniques,
        tools and equipment, most vulnerable and least covered groups, and preventive
        techniques.

        Information and education to raise awareness and encourage self-care and to enhance
        the effectiveness of interventions.

        Improvement of the human resource development for all professions and trades, with
        a view to providing workers with the training required so that they will become
        involved in prevention activities in the workplace and in the promotion of workers'
        health.

Delivery of Cooperation in Workers' Health by the Organization

        In order to support the enlistment of participation by the national working groups, the
interinstitutional committees, and the multidisciplinary technical commissions responsible
for the formulation and implementation of policies and plans, the Organization is
intensifying the provision of advisory services to the countries, utilizing for this purpose
all the operating capacity at its disposal or within its reach.

        To give priority to workers' health, in addition to enlisting the participation of the
WHO Collaborating Centers in the area of workers' health, the Organization is
concentrating its efforts on the activities defined by the PAHO Interprogram Group on
Workers' Health, which is identifying the activities that each Program can carry out with
regard to workers' health in its area of specialization and expertise, as well as the
activities that require interprogram collaboration.  The same type of articulated
collaboration is being proposed in the Country Representations.

        For the delivery of cooperation the following scheme is utilized:





PAHO AND COOPERATION IN WORKERS' HEALTH

        In the Country Representations (generalized support and actions by the focal points
        for environmental and occupational health)

        General activities (dissemination of information and knowledge, training,
        fellowships, research, intercountry initiatives, intercountry cooperation)

        Activities by the various programs in the area of workers' health, coordination by the
        Interprogram Group at Headquarters

        Activities by the Program on Workers' Health (under the coordination of the
        Program on Environmental Health)


        A basic document has been prepared for evaluating progress in the implementation
of Resolution XIV.  This document is intended to help the countries to find the best
procedures to quantify the advances made and adjust their orientations and activities
accordingly.

        The interprogram solidarity that is being demonstrated within the Bureau and in the
countries will undoubtedly make it possible to achieve better levels of health and well-
being in the working population, extend the average length of economically active life,
decrease absenteeism, reduce human suffering and disability, and, thus, increase
production and financial and social development.  The Meetings of the Governing Bodies
this year are of historic significance in that they mark the official inauguration of "1992: 
Year of Workers' Health."   








        INFORMATIONEDUCATION AT ALL LEVELS
DISSEMINATION:  MASS MEDIA
AUDIOVISUAL MATERIALS
TECHNICAL-SCIENTIFIC
COST/BENEFIT
UNIONS
EMPLOYERS
LAWMAKERS

        TRAINING




FOURTEEN GRADUATE-LEVEL OR MASTER'S DEGREE COURSES IN
OCCUPATIONAL HEALTH



RESEARCH
METHODOLOGY 
OTO-TOXICOLOGY
HEALTH AND WORK
INCIDENCE OF INFECTION IN VARIOUS  GROUPS OF WORKERS


 

       PUBLICATIONS 


EDITING COMMITTEE























      PROTOCOL FOR THE DESCRIPTION OF NURSING PRACTICES 

AND THE ADMINISTRATION OF NURSING SERVICES

IN LOCAL HEALTH SYSTEMS



INSTRUMENT









INSTRUCTIONS


- Parts I, II and III of the instrument are prepared on the
basis of country documents, reports, and studies that provide
the most recent information.

Items 3.6, 3.7, 3.15, 3.16 are prepared from interviews with
nurses in various positions at different institutions.

- Sections A and B of Part IV are prepared from local health
system reports and documents and an interview with the local
health system director.

The following items in Sections C and D are obtained from
interviews with nurses and observation of their work:

Section C, Items 4.10, 4.11.
Section D, Items 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.19,
4.20, 4.21, 4.22, 4.23, 4.24, 4.25, 4.26, 4.27, 4.28.

As a basis for conducting the interviews and observations of
the work, a sample is selected from nurses assigned to in-
hospital and in outpatient units.

Forms #1, #2, and #3 may be used to record the information
from each of the nurses interviewed and observed.

- Part V of the instrument is prepared with information
obtained through analysis of reports and documents and
interviews of nurses in the local health systems (in-hospital
and outpatient units).

- Part VI of the instrument is prepared with data obtained
through the analysis of documents.

The estimate of the average cost of the activity is
calculated by dividing the monthly wage or salary by the
total number of hours worked during the month, which gives
the average time allocated to the activity (additional costs
charged to the activity are not included because the wage is
the greatest cost differential).

Additional benefits may be identified on the basis of
interviews with the nurses and the factor of client (or
patient) satisfaction can be determined through interviews
with patients or users of the health services.






IDENTIFICATION OF THE CASE-STUDY COUNTRY


1. Name of the country:


2. Name and address of the nurse in the country responsible
for directing the preparation of the case study.

Name:

Address:

Telephone:                           Fax:


3. Cities or regions of the country selected for the study.

a)

b)

c)

d)


4. Name of the nurses responsible for the study in each city
or region selected.

a)

b)

c)

d)







PART I. GENERAL INFORMATION ON THE COUNTRY


- Name of the country




SECTION A. Demographic and Health Aspects



1.1. Total Population:                 Urban:              %
Rural:              %


1.2. Age distribution of the population (according to the age
brackets used in this country):

Under 1 year


Children aged 1 to 5


Children aged 6 to 15


Population aged 16 to 55


Women of reproductive age


Over age 55



1.3. Birth rate:


1.4. Life expectancy at birth:

Women

Men



1.5. Ten (10) leading causes     Ten (10) leading causes
     of general morbidity:       of general mortality:

      1.                              1.
      2.                              2.
      3.                              3.
      4.                              4.
      5.                              5.
      6.                              6.
      7.                              7.
      8.                              8.
      9.                              9.
     10.                             10.



1.6. Death rate:

Child

Maternal
      
General




SECTION B.  Socioeconomic Aspects



1.7. Primary economic bases of the country:






1.8. Unemployment rate:



1.9. % of illiteracy:



1.10. Per capita income:



1.11. Responsibility for health services coverage of the
population:

Ministry of Health      %    Actual coverage        %

Social Security         %    Actual coverage        %

Private                 %    Actual coverage        %


1.12. Percentage of the national budget allocated for health:

1988        %

1989        %

1990        %

1991        %

1992        %





SECTION C.  Health and Nursing Human Resources in the         
   Country



1.13. Number of health workers in the country, 1988-1992.




Type of Resource/Year  Totals                             

1988  1989  1990  1991  1992



Professional nurses                                 

Nursing technicians                                 

Nursing auxiliaries                                 

Physicians                                          

Dentists                                            

Nutritionists                                       

Therapists (all types)                              

Others                                              









1.14. Current ratios:

Nurse/nursing auxiliary:

Nurse/physician:

Nurse/10,000 population:

Nurse/100 beds:

1.15. Is there some criterion among the country's nurses for
determining whether these ratios are adequate or not?

Yes                         No


1.16. What criteria are used to evaluate these ratios?







1.17. According to the criteria used, how should the existing
ratios be modified?

Nurse/nursing auxiliary:

Nurse/physician:

Nurse/10,000 population:

Nurse/100 beds:


1.18. What other indicators would be more adequate for
determining the country's need for nurses?









1.19. How have the country's nursing needs over the next
years been calculated?

- For hospital services:


- For community health services:

  Primary health care:

  Local health systems:








PART II.  GENERAL INFORMATION ON NURSING IN THE COUNTRY



SECTION A.  Nursing Education System



2.1. The nursing education system comues under:

____ Ministry of Education

____ Ministry of Health

____ Other (specify)



2.2. Current policies on nursing education:








2.3. Categories of nursing personnel that are trained in the
country:

- Professional nurses:  (specify types, diplomas awarded, and
years of training)







- Nursing technicians:  (specify types, diplomas awarded, and
years of training)





- Nursing auxiliaries:  (specify types, diplomas awarded, and
years of training)




- Other types of nursing personnel:  (specify)



2.4. Undergraduate and graduate-level programs for the
training of nurses in the country:




Types of programs Duration of studiesNo. of programs   in
country Average total graduates/year












2.5. Trends in nursing education in the country:

1. In the orientation of the undergraduate curriculum:

2. In the orientation of teaching at the graduate level:

3. In the orientation of training for auxiliary nursing
personnel:

4. In the development of research topics in the area of
nursing:

5. In the training of the nurses in administration:

6. In continuing education for nursing personnel:

7. In the coordination of education, assistance, research:

8. Other important trends in nursing education in the
country:







SECTION B. ADMINISTRATION OF NURSING SERVICES



2.6. Who is responsible for the direction of nursing
services:

     - At the national level:


     - At the regional level:


     - In third-level HOSPITALS:


     - In second- and first-level HOSPITALS:


     - In LOCAL HEALTH SYSTEMS:



2.7. The country's policies regarding organization and
administration of the nursing component (or service):

     - In hospital institutions:


     - In community health institutions:



     - In Social Security institutions:







2.8. The country's policies or standards regarding the
placement of nursing professionals in local health systems:






2.9. How do nurses prepare themselves, or how are they
trained, to assume administrative nursing functions in local
health systems?





2.10. How are nursing functions defined in the country's law
on nursing?





2.11. Trends in the administration and organization of
nursing services:

     - In third-level hospitals:


     - In second- and first-level hospitals:


     - In the community services:


     - In the local health systems








PART III.  INFORMATION ON THE NATIONAL HEALTH SYSTEM -
PRIMARY HEALTH CARE AND LOCAL HEALTH SYSTEMS



SECTION A. Health Policies



What are the country's principal health policies?








SECTION B.  Policies on Primary Health Care



3.1. How is primary health care defined in the country?






3.2. Outline the country's principal policies country
regarding the primary health care (PHC) strategy:





3.3. Which elements of the PHC strategy have received the
most emphasis in national policies?




3.4. How is the PHC strategy implemented?

     - At the local level:



     - At the regional level:




3.5. How have nurses participated in the definition of
primary health care policies?

a) Through nurses at the central (national, regional,
departmental, provincial, state) level?

Yes                No              

How?




b) Through interdisciplinary committees/groups?

Yes                No 

How?



c) Through special nursing committees?

Yes                No

How?




d) Through professional nursing associations?

Yes                No              

How?





e) Through other mechanisms?

Which ones?





3.6. Is there understanding and acceptance of the PHC concept
in the community?

Yes                No              

How is understanding and acceptance (or lack of understanding
and acceptance) of the PHC concept in the community?




3.7. Is there understanding and acceptance of the PHC concept
among nurses?

Yes                No


How is understanding and acceptance (or lack of understanding
and acceptance) of the PHC concept among nurses?








SECTION C.  Policies and Organization of Local Health Systems
in the Country




3.8. Is there a national policy for reorienting the national
health system in terms of the operation of local health
systems?

Yes                No






3.9. How is the political decision to implement the local
health system concept expressed?






3.10. What legal support do local health systems have in the
country?






3.11. How are local health systems defined in the country?






3.12. What official orientation (principles or standards) are
given for the organization of local health systems in the
country?





3.13. Prepare a table that shows the current status of local
health systems in the country and the number of nurses
associated with these systems.





Department State, or Province



Total Popula-tion

Total no. of local health systems
Are local health systems in operation?              No   Yes
No. of local health systems in op- eration




Nurses assignedNo. of local health systems directed by nurses














3.14. How have nurses participated in the definition a national
policy for the establishment of local health systems?

a) Through nurses at the central (national, regional,
departmental, provincial, state) level:

Yes                No

How?




b) Through interdisciplinary committees/groups:

Yes                No

How?




c) Through special nurses' committees:

Yes                No

How?





d) Through the professional nursing associations:

Yes                No

How?





e) Through other mechanisms:

Yes                No

Which?






3.15. Is there understanding and acceptance of the local health
system concept in the community?

Yes                No

How is understanding and acceptance (or lack of understanding and
acceptance) of the local health system concept translated into
reality in the community?






3,16. Is there understanding and acceptance of the local health
system concept among nurses?

Yes                No

How is understanding and acceptance (or lack of understanding and
acceptance) of the local health system concept translated into
reality among nurses?





PART IV.  THE PLACEMENT AND FUNCTIONS OF NURSES IN LOCAL HEALTH
SYSTEMS



SECTION A.  Organization of the local health system selected for
the case study



4.1. Identification of the local health system:  Name:


4.2. Location:  geographical area (city or area within a city)


4.3. Population covered:

Total inhabitants:

Number of families:

Age distribution of the population covered (according to the age
brackets used in the country or institution):



4.4. Geographical area:  Rural          % Population
Urban          % Population


4.5. Socioeconomic characteristics of the population served:






4.6. Principal basis of the economy in the area covered by the
local health system:





4.7. Organizational structure (charater) of the local health
system:

No. of hospitals by type:




Outpatient services (community):



Other institutions with which the local health system is
coordinated:



4.8. How is the mission of the local health system defined?



4.9. How is the mission of nursing in the local health system
defined?




SECTION B.  Human Resources of the Local Health System under Study



4.9. Number of health workers and average hours/week of service in
the local health system:



Health workers         Number of Number or average work   
persons   hours/week             


Nurses                                                  
Nursing auxiliaries                                     
Physicians                                              
Dentists                                                
Nutritionists                                           
Therapists                                              
Others (Note)                                           





SECTION C.  Placement and Functions of Nurses in Hospital Units


4.10. Placement and functions of nurses in the hospital unit (see
Form #1, Annex 1):


    
Unit or No.ofNo. ofFunctions performed by the nurse        
service beds
nurses         
Direct  Adminis-Edu-  Re-    Other   

care    tration cationsearch            


Pa-                     
tients             



Com-               
munity             
groups             




Stu-               
dents              







4.11. Functions performed by the nurse in cooperation with
the hospital health team:



















SECTION D.  Placement and Functions of Nurses in Outpatient
Units (Health Center, Health Station, Basic Unit of Care,
etc., listed according to the terminiology used in the
country or institution)


4.12. Placement and functions of nurses in outpatient units 
(see Form #2, Annex 2):


    
Type of out-  No. of   Functions performed by the nurse    
patient unit 
nurses         
Direct  Adminis-Edu-  Re-    Other   
  
care    tration cationsearch            


Health                              Pa-                     
center                              tients             

Health                              Stu-               
station                             dents              

Polyclinic                                             

Basic                                                  
care unit                           Others             

Others (list)                                          





4.13. Functions performed by the nurse in cooperation with
the health team in the outpatient units (in the community):








4.14. Health care activities performed by the nurse for
community groups (see Form #3, Annex 3)



Functions performed by the nurse           
       Groups       

Direct  Adminis-Edu-   Re-     Other     
   
care    tration cation search            
   


-Nursing infants                                              
   

-Preschool children                                         

-Schoolchildren                                             

-Adolescents                                                

-Elderly                                                    

-Families                                                   

-Workers                                                    
 (formal sector)                                            

-Workers                                                    
 (informal sector)                                          

-Others                                                     
 (specify)                                                  




4.15. Activities performed by the nurse to assist in the
Social Mobilization of the community:



Activities performed Activities per-    Activities dele-

on a regular basis   formed sporadicallygated to others 
(weekly/monthly)     (every so often)   which the nurse 
supervises      

















4,16. Activities performed by the nurse in the different
positions in the local health system with a view to
organizing the community and ensuring its active
participation:




Posi-   Activities per- Activities per- Activities dele-         
      tion    formed on a reg-formed sporadic-gated to auxil- 
(select ular basis      ally (every so  iaries and su-  
from 3  (weekly/monthly)often)          pervised by     
levels)                                 nurses          


1.                                                      



2.                                                      



3.                                                      






Position 1 corresponds to the level closest to the community
and position 3 corresponds to the level closest to
management.



4.17. Policies governing the practice of nursing in local
health systems:

a) Who sets policy regarding nursing practice in the local
health system?




b) Who determines the placement of nurses in the local health
system?




c) Who defines the functions of the nurse in the different
positions of the local health system?



4.18. Based on an analysis of nursing practice in the local
health system, identify:

a) The strengths, or those aspects and potentials that are
positive and satisfactory and which favor the progress of
nursing practice in the local health systems:






b) The weaknesses, or those unsatisfactory aspects of nursing
practice that should be improved in order for nursing to
assume an effective role in the local health system:





c) The national, regional, and institutional opportunities
that favor the development and current progress of nursing
practice in the local health systems:





d) The barriers, or national, regional, and institutional
threats to the progress of nursing practice in the local
health systems:







4.19. Does the nurse participate in strategic planning in the
local health system?

Yes                No

What strategic planning functions does the nurse perform?









4.20. Is the nurse responsible for management of the nursing
service in the local health systems?

Yes                No

What managerial functions does the nurse perform?





4.21. Does the nurse assume managerial functions with respect
to the budget in the local health systems?

Yes                No

What managerial functions with respect to the budget does the
nurse perform?





4,22. Does the nurse assume functions with regard to the
planning, development, and utilization of nursing personnel
in the local health systems?

Yes                No

What functions does the nurse perform with regard to:

a) Personnel planning:



b) Personnel development:



c) Better utilization of personnel:




4,23. What criteria or standards have the nurses developed
for estimating the needs for nursing personnel in the local
health systems?






SECTION E.  Functions of the Nurse Director in a Local Health
System



4.24. Can the nurses in this country assume administrative
and managerial responsibilities in a local health system?

Yes                No


4.25. List the functions of the director of nursing in a
local health system:










4.26. What aspects of academic training have enabled the
nurse to fulfill the duties of director in a local health
system?










4.27. What qualities or personality traits help the nurse to
perform in the position of director in a local health system?








4.28. What difficulties does the nurse encounter in the
performance of managerial positions in a local health system?




PART V. THE QUALITY OF NURSING PRACTICE AND NURSING
ADMINISTRATION IN THE LOCAL HEALTH SYSTEMS


- The elements of nursing practice and nursing service
administration and their relationship to the criteria of
relevance, accessibility, equity, effectiveness, and
efficiency of nursing actions are described at this point.

- Quality will be described in terms of satisfying the
external client (users of health or nursing services) and the
internal client (nursing personnel).




SECTION A.  Monitoring of the Quality of Nursing Practice and
Nursing Administration in the Local Health Systems



5.1. What systems exist in the country for monitoring the
quality of nursing practice and nursing services
administration in the local health systems?







5.2. What methodology is used for the evaluation of quality
in the local health systems?  (Case study?)







5.3. Are there quality standards for nursing practice in the
local health systems?

Yes                No

If yes:

a) Summarize the quality standards for nursing practice in
hospitals:



b) Summarize the quality standards for nursing practice in
outpatient units:



c) Summarize the quality standards for nursing services
administration in the local health system (hospital and
outpatient services):





5.3. How are the quality standards (or criteria) for nursing
practice and nursing services administration established in
the local health systems?

- Who establishes the standards (or criteria)?


- Who controls their application?


- What process has been used to prepare and approve the
quality standards for nursing practice?





5.4. Give your opinion on the following statement:

The functions and activities of nursing practice in the local
health systems are relevant because they respond to the basic
health needs and risks of the population served by the local
health systems (indicate your opinion by marking an X):

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree

a) Does the nurse make comprehensive assessments of the
health conditions and risks of persons in different stages of
development and growth?

Yes             No

b) Does the nurse assess the state of health and risks of the
families served by the local health system?

Yes             No

c) Does the nurse assess the health conditions and risks of
the community?

Yes             No


d) Does the nurse assess the health conditions of groups in
the community?

Yes             No


5.5. Give your opinion on the following statement:

The nurse plans the delivery of nursing care according to the
basic needs of individuals, the family, and the community
(indicate your opinion by marking an X):

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree

a) What are the basic needs and the priority problems that
you have identified in the community served by the local
health system with regard to the planning of nursing care?




b) How does the community participate with the nurse in the
planning of the nursing services offered by the local health
system?





5.6. Give your opinion on the following statement:

The nurse organizes and directs activities with a view to
distributing and ensuring access to health services by the
population served by the local health system (indicate your
opinion by marking an X)

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree



a) How does the nurse become aware of the demands for health
services on the part of the population served by the local
health system?





b) How does the nurse work with the community in increasing
local health services coverage?




c) How has the nurse contributed to the extension of health
services coverage?





d) How has the nurse helped to organize the system of health
care (medical, dental, or health care) appointments so that
it can accommodate the maximum number of persons on a timely
basis?




e) What activities has the nurse undertaken in the local
health system to provide services to high-risk groups?





f) What activities has the nurse undertaken in the local
health system to deliver health care to groups not otherwise
covered by the social services?





g) What functions does the nurse perform to promote personal,
family, and community self-care?







h) What does the nurse do to ensure that the community served
by the local health system has access to its health services?

- How does the nurse help to ensure cultural access? 
(values, beliefs, customs)


- How does the nurse help to ensure economic access?  (cost)



- How does the nurse help to ensure geographical access? 
(location)




5.7. Give your opinion on the following statement:

The nurse organizes nursing and health services equitably,
avoiding all types of discrimination in health care (indicate
your opinion by marking an X):

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree

a) Does the nurse help to prevent sex discrimination?

Yes             No

How?




b) Does the nurse help to prevent age discrimination?

Yes             No

How?



c) Does the nurse help to prevent socioeconomic
discrimination?

Yes             No

How?




d) Does the nurse help to prevent other types of
discrimination?

Yes             No

How?




5.8. How does the nurse apply "positive discrimination" in
health care?







5.9. Give your opinion on the following statement:

The nurse demonstrates effectiveness in the practice and
administration of nursing services.  The nurse makes the best
possible use of the limited resources assigned to the nursing
service and the local health system to help reduce some of
the priority health problems and improve deficiencies in the
health situation (indicate your opinion by marking an X)

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree

a) Does the nurse mobilize the community to solve
environmental sanitation problems?

Yes             No

How?




b) Does the nurse motivate mothers and parents to increase
vaccination coverage of children?

Yes             No

How?




c) Does the nurse promote breast-feeding?

Yes             No

How?





d) Does the nurse promote timely monitoring of pregnant
women?

Yes             No

How?





e) Does the nurse help to prevent complications in
hospitalized patients and in those attended by outpatient
health services?

Yes             No

How?




f) Does the nurse take measures to prevent hospital
infections or infections incurred during treatment in the
outpatient health services?

Yes             No

How?




g) Does the nurse take measures to help prevent accidents in
the hospital or to the patients and family members who use
the outpatient health services?

Yes             No

How?




Does the nurse help to resolve difficulties so as to ensure
family support during the hospitalization of one of its
members?

Yes             No

How?




i) Note other problems that the nurse helps to resolve with
the limited resources available:






5.10. Give your opinion on the following statement:

The nurse demonstrates efficiency in the practice and
administration of nursing services.  The nurse obtains
satisfactory results by applying health care techniques and
processes to the population served by the local health system
(indicate your opinion by marking an X):

--- Totally agree
--- Agree
--- Partially disagree
--- Totally disagree

a) Has the nurse used health education to bring about healthy
changes in the behavior or lifestyles of the individuals or
community served by the local health system?

Yes             No




b) Mark with an X the areas in which changes have taken place
in individuals or the community:

--- Personal hygiene
--- Housing sanitation
--- Environmental sanitation
--- Dietary habits
--- Utilization of the health services
--- Individual responsibility in health care
--- Community participation in health care
--- Smoking
--- Alcohol consumption
--- Self-medication
--- Drug addiction
--- Child abuse
--- Self-esteem on the part of women
--- Attitudes toward personal improvement
--- Abuse of women
--- Abuse of the elderly
--- Other (list other changes that have taken place)


5.11. Give your opinion on the following statement:

The motivation and assistance provided by the nurse in the
area of social mobilization has contributed social benefits
for the community served by the local health system (indicate
your opinion by marking an X):

--- In terms of the environment
--- In recreational activities
--- In terms of public services
--- In schools, the health center
--- Other (indicate)

a) Progress made toward increased community participation:





b) Progress made in the use of intersectoral coordination
processes and techniques:





c) Results obtained by the nurse through the use of
coordination processes or models in education, research,
assistance:














SECTION B. Effectiveness and Quality in Nursing Practice


5.12.  Give your opinion on the following statement:

The effectiveness of nursing practice and nursing services
administration in the local health systems is evaluated in
terms of the effects or the impact of interventions on the
health of people, families, and population groups.

--- Totally agree
--- Agreement
--- Partially disagree
--- Totally disagree


5.13. What impact has nursing practice had on the local
health in terms of:

- Reduction of ADD.
- Reduction of ARI.
- Increase in monitoring of pregnant women.
- Increase in monitoring of children under the age of 1.
- Increase in comprehensive health management of
schoolchildren.
- Increase in comprehensive health management of workers in
the informal sector.
- Increase in comprehensive health management of workers in
the formal sector.
- Increase in monitoring of the elderly.
- Increase in breast-feeding.
- Changes in health education being offered to individuals,
families, groups.
- Reduction in general morbidity.
- Increase in community participation.
- Progress in self-care.
- Progress in self-management.
- Progress in the coordination of intersectoral activities.
- Cohesion of the health team.
- Other.




5.14. Note any other impact that nursing practice and nursing
services administration has had on the local health system.







5.15. The impact of the quality of nursing practice and
nursing administration on local health systems can be
assessed by means of the following indicators:

a) Satisfaction of the nursing services users (external
clients)

b) Satisfaction of the nursing services users (external
clients) with the attention received in "moments of truth"--
in other words, decisive or critical times when a lasting
impression is gained, such as hospital admission,
emergencies, first visit to the outpatient service, surgery,
childbirth, critical illness, death.

c) Satisfaction of the nursing personnel (internal clients)
with their work in the local health systems.


5.14. The health services users (external clients) express
satisfaction with the nursing services received because of:

- The regular availability of health services.

Yes             No

- Knowledge about the health services offered.

Yes             No

- The timeliness of the services

Yes             No

- The humane and courteous nature of the nursing services.

Yes             No

- Schedules suited to the users' needs.

Yes             No

- Geographical accessibility of the service.

Yes             No

- Cost of the service within the users' reach.

Yes             No

- The scientific and technical quality of the services.

Yes             No

- The ethical quality of the services.

Yes             No

- Other factors (please specify):





5.15. The users of the services express satisfaction with the
quality of the nursing service in "moments of truth" because
of:

- Humane and courteous nursing care.

Yes             No

- Timely and prompt attention.

Yes             No

- Adequate orientation of the patient and the family upon
admission to the hospital or health-care agency.

Yes             No

- Support and understanding offered to the patient and family
at critical times (emergencies, grave conditions, surgery,
death, etc.).

Yes             No

- Adequacy of the information given to the patient and
family.

Yes             No

- Family participation allowed by the nursing care.

Yes             No

- Affective ties  with the patient and family (mother, wife,
children, father) during hospitalization.

Yes             No

- Assistance and orientation provided at the time of
discharge from the service.

Yes             No



- Orientation on home self-care.

Yes             No

- Continuity in the provision of nursing services.

Yes             No

- Punctuality in the provision of services.

Yes             No

- Humane and prompt attention during emergencies.

Yes             No

- Other (please specify):




5.16. The nursing personnel (internal clients) express
satisfaction with their work, the facilities provided for
nursing practice, and the administration of nursing services. 
The following indicators will aid in this assessment:


- Support received from the administration.

Yes             No

- Incentives received from the administration.

Yes             No

- Adequate working conditions, equipment, materials,
resources.

Yes             No

- Respectful and humane treatment.

Yes             No

- Compensation (fair salary and social benefits)

Yes             No

- Cultural, social, and economic incentives.

Yes             No


- Opportunities for continuing education.

Yes             No

- Occupational safety in the workplace.

Yes             No

- Spirit of cooperation in the working team.

Yes             No

- Flexible work schedules that meet personal and community
needs.

Yes             No

- Opportunities for advanced education.

Yes             No

- Democratic and participatory style of management.

Yes             No

- Clear commitment to the mission of the health and nursing
services.

Yes             No

- Rrecognition of the value of the nurse's work.

Yes             No

- Resources and support for nursing research.

Yes             No

- Other:








PART VI.  COST/BENEFIT OF NURSING ACTIONS (FUNCTIONS) IN
LOCAL HEALTH SYSTEMS


- It is proposed to do a comparative cost-benefit analysis of
health actions (falling within the scope of nursing practice)
that are carried out by the nurse, the physician, and the
nursing auxiliary.

- It is proposed to analyze the average cost of a health care
activity practiced by the nurse and to identify the
additional benefits when the nurse uses the comprehensive
care approach, as well as user satisfaction.


HEALTH CARE ACTIVITY




Average cost  Additional benefits    Client satisfaction

of the activ- obtained when the nursewith the activity  

ity           performs the health    performed by the   

activity               nurse              



Performed by                                            
 
the nurse                                               
 
$                                                       
 

 

 

 
Performed by                                            
 
the physician                                           
 
$                                                       
 

 

 

 

 
Performed by                                            
 

 

 

 

 





- Example:

Average cost for a nurse to monitor a pregnant woman. 
Identification of additional benefits (teaching, orientation,
solution of related problems), that improve the cost/benefit
ratio and user satisfaction.

Other activities were similarly analyzed, for example:

- Average cost of a house call.

- Average cost for a nurse to monitor a child under the age
of 1.

- Average cost for a nurse to monitor a schoolchild.

- Average cost for a nurse to monitor an adult worker.

- Average cost for a nurse to monitor an elderly person.

The average cost, plus the additional benefits, plus the
expression of client satisfaction will be analyzed vis-Õ-
vis the cost of the same activity carried out by a physician
and by a nursing auxiliary.

This analysis will be a first approximation of a cost/benefit
and quality analysis of the comprehensive health activities
provided by the nurse in the local health system.


- The exercise should also include other cost/benefit
indicators of nursing care activities in the local health
system being studied in each country--for example, risk
management, etc.

- The respondents are asked to make a list of health services
and health care activities that the local health system
provides to individuals, families, and community groups.  A
panel of experts should determine the percentage of
responsibility that corresponds to the nurse in the
performance of each of the services or health activities.

Example:






 Health activities           Nurse's Responsibility       
 provided by the
local               
 health system        100 %75-99 %50-74 %25-49 %Under 
24 %  



















ANNEX 1



Form #1

PLACEMENT AND FUNCTIONS OF THE NURSE
IN THE HOSPITAL UNIT


Name (or code) of nurse:

Hospital:                       Local health system:

Unit:                           No. of beds:

No. of nurses:                  No. of auxiliaries:


Functions Performed by the Nurse

1. Direct care:





2. Administration:




3. Education:

a) Health education of patients (individuals, families):





b) Health education of groups:



c) Teaching of students:








4. Research:










5. Other duties:






ANNEX 2



Form #2

PLACEMENT AND FUNCTIONS OF THE NURSE
IN OUTPATIENT UNITS



Name (or code) of nurse:

Outpatient unit:

Local health system:

Total population served:

No. of nurses:                   No. of auxiliaries:


Functions Performed by the Nurse


1. Direct care:





2. Administration:





3. Education:

a) Health education of patients (individuals, families):



b) Health education of groups in the community:



c) Teaching of students:





4. Research:








5. Other duties:






ANNEX3



Form #3

ACTIVITIES PERFORMED BY THE NURSE
IN TERMS OF CARE FOR COMMUNITY GROUPS



Name (or code) of nurse:

Outpatient unit:

Local health system:

No. of nurses:                   No. of auxiliaries:



ACTIVITIES PERFORMED BY THE NURSE
IN THE HEALTH CARE OF GROUPS

(One record for each group)


- GROUP

a) Direct care:



b) Administration:



c) Health education:



d) Research:



e) Other activities:


ESTIMATE OF COSTS



Months/Personnel/Resources         Activity     
       Cost/month                                        Total for
project


Consultant/3 months            Preparation - test -
revise protocol      
US $ 3,150

Director/Principal            Prepare national 
investigator-15 months         case study             
US $1,000                                          US $ 15,000       
3 months x country
5 countries - Case Study
Assistant / Research           Collaborate in the
15 months                      collection of infor-
3 months x country             mation - Analysis - 
5 countries - Case Study       Preparation of                 
US $ 600                      a report             US $ 9,000

Office staff/15 months         Secretary - Computer 
(3 months x country)           Data Entry               
US $ 300                                           US $ 4,500

Additional cost per           Logistic support                
country - paperwork -
travel - postage
US $1,500/country                                  US $7,500

Consultant - 3 months         Preparation of general
report (analysis of the
5 country case studies)    
US $1.500                                          US $ 4,500

TOTAL                US $ 43,650                       

10 contingencies %    US $ 4,365                       

GRAND TOTAL          US $ 48,015                       










CHRONOGRAM



    Phases/Activities         Months - Year 1992                                         



Jan.Feb.Mar.Apr.May.Jun.Jul.Aug.Sep.Oct.Nov.Dec.


1. Preparation of protocol                                        
  


2. Test and revision of proto-                                               

   col (Bogotá SILOS)                                                  

   Bogotá)                                                                                     

     
3. Selection/contact case-                                                   

   study countries - I phase                                                 

   (4-5 countries), 6-8                                                      

   SILOS per country                                                  
 


4. Contact Researchers-                                                      

   Director - Assistants                                              
 


5. Data collection/analysis                                                  

   case-study countries                                    
    


6. Preparation of reports                                                    

   from case-study countries                                          
 


7. Preparation of general                                                    

   report                                                         
 



















    PROTOCOL FOR THE PREPARATION OF COUNTRY CASE STUDIES

ON NURSING PRACTICE IN

LOCAL HEALTH SYSTEMS IN LATIN AMERICA



(Corrected version following the test)



















30 April 1992











TABLE OF CONTENTS



PURPOSE. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . .  2
THE INSTRUMENT . . . . . . . . . . . . . . . . . . . . . . . . .  4
METHODOLOGICAL APPROACH. . . . . . . . . . . . . . . . . . . . .  6
GUIDELINES FOR USING THE PROTOCOL. . . . . . . . . . . . . . . .  8
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . 10
THE ROLE OF THE NURSE IN PRIMARY HEALTH CARE . . . . . . . . . . 25
THE LOCAL HEALTH SYSTEM CONCEPT. . . . . . . . . . . . . . . . . 32
METHODOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . 45
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . 64
REFERENCES ON THE METHODOLOGY. . . . . . . . . . . . . . . . . . 69
INSTRUMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
ANNEX 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 15
ANNEX 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 17
ANNEX 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 19
ESTIMATE OF COSTS. . . . . . . . . . . . . . . . . . . . . . . 1 21
CHRONOGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 1 22












PURPOSE



The purpose of the country case study series is:

1. To describe the practices of nursing and nursing services administration in local
health systems both in hospitals and in the community.

2. To clarify the relationships between, on the one hand, local health system
nursing practice and nursing services administration and, on the other, quality of
health care, coverage of the population, access to basic health services, and
cost/benefit returns on health activities.



OBJECTIVES


1. To identify the basic information available in the country on demographic
aspects, the health situation, and the socioeconomic aspects that constitute the
overall context of nursing practice.

2. To present general information about nursing in the country, the education
system, nursing services administration, and the trends in these two areas.

3. To describe health policies on primary health care and local health systems and
the functions of the nurse and nursing services in relation to these policies.

4. To describe and compare the functions of the nurse and the orientation of the
nursing service in local health systems with different degrees of development and
organization.

5. To describe and draw relationships between nursing practice and nursing
services administration in local health systems and identify some indicators of
quality.

6. To identify cost/benefit indicators of health activities carried out by the nurse in
the local health systems.



THE INSTRUMENT


The instrument to be used for collecting the information has the following parts and
sections:

Identification of the Case-Study Country

PART I. General information on the Country
Section A. Demographic and Health Aspects
Section B. Socioeconomic Aspects
Section C. Health and Nursing Human Resources in the Country

PART II. General Information on Nursing in the Country
Section A. Nursing Education System
Section B. Administration of Nursing Services

PART III. Information on the National Health System, Primary 
Health Care, and Local Health Systems
Section A. Health Policies
Section B. Policies on Primary Health Care
Section C. Policies and Organization of Local Health Systems in 
the Country

PART IV. The Placement and Functions of Nurses in Local 
Health Systems
Section A. Organization of the Local Health System Selected for 
the Study
Section B. Human Resources of the Local Health System under Study
Section C. Placement and Functions of Nurses in Hospital Units
Section D. Placement and Functions of Nurses in Outpatient Units

PART V. The Quality of Nursing Practice and Nursing 
Administration in the Local Health Systems
Section A. Monitoring of the Quality of Nursing Practice and 
Nursing Services Administration in the Local Health 
Systems
Section B. Effectiveness and Quality in Nursing Practice

PART VI. Cost/Benefit of Nursing Actions (Functions) in Local 
Health Systems



METHODOLOGICAL APPROACH


The country case study will describe nursing practice and nursing services
administration within the sociopolitical context of the country.

The instrument included in this protocol provides a set of guidelines for collecting
and presenting the information, but each country is free to introduce any
modifications, changes, or additions that may be needed in order to describe the
nursing practice situation in its local health systems.

In view of the fact that local health systems evolve and progress at different rates
and have characteristics that are particular to each specific region of the country, it
is proposed to present the nursing situation in a comparative format based on the
degree of development of the particular local health systems or for local health
systems that are attempting to introduce organization models with innovative
options for health and nursing care.

Accordingly, in each country three or more local health systems at different degrees
of development will be selected as case studies.

The protocol presents a conceptual frame of reference for local health systems and
nursing which is designed to orient the analysis in each country case study. The
methodology for preparation of the country case studies incorporates the concepts
and techniques that are used in this type of study. This methodology has adapted
some of the orientations used for case studies on social participation (PAHO
Document HSD/SILOS-7).



GUIDELINES FOR USING THE PROTOCOL


The protocol will serve as a guide for the nursing professionals in each country who
are responsible for conducting and the case study and putting together the resulting
data. The introduction, the considerations on primary health care nursing in Latin
America, the assessment of the role of the PHC nurse in the search for quality, and
the basic concepts offered on local health systems will help the group to think about
and come to agreement on the fundamental concepts for carrying out the task.

The bibliography, containing the most recommended sources available, will make it
possible to obtain further information on whatever aspects that may arise.

Before the participants begin their work, it is recommended that they read and
review the entire protocol in order to clarify the conceptual and methodological
frame of reference.

The information compiled through use of the instrument should be noted in a clear,
precise, and brief. In order to obtain the data requested under each of the headings
in the instrument, the most authoritative sources should be sought in the country or
region: institutions, persons, documents, reports.

Appointments for interviews should always be made ahead of time and should be
scheduled wherever it is most desirable and convenient for the person being
interviewed.

For those items that call for a table to be used to record the information, a separate
legal-size sheet should be used so as to provide more space for the data. Three
model formats have been provided, which can be used or adapted as appropriate.

The analysis of the situation in the case study country should include an
introduction prepared on the basis of the studies and experiences of the local health
systems which illustrate the sociopolitical situation of the country, the role of the
nurse, the practice and administration of nursing services, and the indicators of
quality. In addition, a general bibliography should be drawn up which includes the
country's documents on local health systems. It is expected that a summary of the
existing country documents, reports, articles, or studies on the subject will be
appended.







INTRODUCTION


The goal that has been set by the governments to achieve Health for All by the Year
2000 with equity, effectiveness, efficiency, and participation poses a ongoing
challenge that is difficult but also stimulating and promising.

This target has already created awareness in Latin America and constitutes an
ineluctable responsibility of the governments, the people, the communities, health
care workers, and other social sectors.

     The social, political, and scientific changes and the existing economic crisis
have had serious repercussions on the lives of the people, on the health situation,
on well-being, on the allocation of resources for health care, and on other vital
social services. These facts are translated into complex and dissimilar situations in
each country as they strive toward the goal of HFA/2000, and hence they call for
the establishment of priorities for effective and orderly action.

In September 1990, Resolution XIII of the XXIII Pan American Sanitary Conference
approved the document "Strategic Orientations and Program Priorities for PAHO
during the Quadrennium 1991-1994," which identifies three main priorities areas,
are follows:

1. Development of the health services infrastructure, with emphasis on primary
health care;

2. Provision of responses to priority health problems present in vulnerable
population groups;

3. Management of knowledge required to make headway in the first two areas.

These priority areas establish a series of guidelines and orientations within the
context of Resolution XV, on the development and strengthening of local health
systems in the transformation of national health systems, approved by the XXXIII
meeting of the Directing Council of PAHO (1988), which defines the orientations
and program priorities of PAHO for the quadrennium 1987-1990. One of the
premises of this resolution is that "it is at the local level that policies and strategies
for social development and health care can be implemented on the basis of social
participation, intersectoral action, coordination of financial resources, and
integration of programs."

In this Resolution the Member Governments are urged to "place special emphasis
on the provision of resources and decentralization to strengthen the operating
capacity of local health systems, and on specific programs for dealing with priority
health problems."

In view of the target of HFA/2000, the strategies and priorities defined for the
Region in the strategic orientations and programs for the past (1987-1990) and the
current quadrennium (1991-1994), it is fundamental to analyze the pattern of human
resources that will be required in order to make this world goal operational and to
follow the program orientations for the Region within the overall sociopolitical
context of interdisciplinary relations and cooperation with the community being
served.

Nursing, one of the fundamental elements of the health workforce, should be looked
at objectively and critically with a view to identifying the strengths and weaknesses
in the performance of nurses within the overall social, interdisciplinary, and
cooperative context so as to ensure their participation in the attainment of equity,
effectiveness, efficiency, and social mobilization in the effort to achieve HFA/2000.


Considerations on the Nurse's Role in Primary Health Care

These considerations take as a point of departure the accepted premise that
nursing works with the health team, whose make-up varies according to the
problems that need to be solved. In PHC, the nurse may work in various capacities
on the team, whether as a leader or in a collaborative role.

Another premise is that nursing works within an interdisciplinary dynamic and on a
participatory basis with the community to which the services are being provided.

The synchronic and diachronic aspects of the interdisciplinary approach require, in
the case of nursing, that the elements inherent in the discipline be studied and
reinforced with a view to supporting and clarifying their relevance, and their
relationship to the health sciences and the social sciences in order to be able to
grow and participate in the analysis and solution of community health problems that
vary in accordance with the historical evolution of the society. It is also necessary to
review the diachronic aspect of nursing in order to make it effective in its
interdisciplinary, cross-disciplinary, and interprofessional mission both today and
tomorrow, in keeping with social change and scientific progress. (1)

Through seven (7) international workshops given by the International Council of
Nurses (ICN) between 1983 and 1986 in different parts of the world, which were
aimed at mobilizing the nursing leadership for PHC, the potential of nurses for PHC
was analyzed and it was concluded that if nurses receive political support and the
necessary means and resources they can constitute a major force in accomplishing
real social mobilization toward attainment of the goal of HFA/2000. (2)

Several problems were identified which tend to limit the effective and sustained
participation and the commitment of nurses to PHC (ICN, 1990).

The main problems have to do with the hospital-oriented approach of nursing
education prior to the 1980s and the institutional restrictions to shifting over, as
rapidly as desired, from a hospital-oriented approach to a social and community-
oriented one. These include:

The pressure that is still imposed by the health services on nurses capable of caring
for the critically and acutely ill.

The attitude, perhaps paternalistic, that is created during professional training
whereby the people and the community are perceived and related to not as peers in
the development of health care but rather as passive subjects in need of treatment.

Although it is true that the nursing education programs offer the fundamental basis
for professional practice, many nurses do not have access to continuing education
or opportunities for updating themselves and advanding in their formation that will
facilitate a change in attitude and the adoption of new occupational profiles.

The limited participation of nurses in the definition of health policies; in decision-
making on regional, local, institutional, health care policies; and in health care
systems and practices was also identified. This fact limits the nurse's motivation to
work actively towrad effecting the needed changes (INC, 1990). (3)

One of the objectives of the regional conference on the development of nursing in
local health systems (Feppen/PAHO 1990), was to analyze the participation and
development of nursing human resources in the health services delivery process." 
Seventeen (17) countries of Latin America gave presentations on their health
situation and the development of local health systems within the political,
socioeconomic, epidemiological, and demographic context. The participation of
nursing was defined as the contribution of the individual, the institution, and the
professional organization to application of the PHC strategy and the process of
health services decentralization. (4)

Most of the countries showed evidence of either lack or total absence of
participation by nursing professionals in the definition of health policies and in
higher-level decision-making. The participation of nurses is more concrete in
interdisciplinary work at the level of program execution.

This conference called attention to the need to reorient the preparation of nurses by
providing a more flexible curriculum and including within it a more intensive social
component.

The recommendations called for analysis and interpretation of the legal and
conceptual bases of local health systems and for the development of legal bases
that will give legitimacy to the training of both professional and non-professional
resources, guarantee exercise of the profession at the different levels of care,
permit the participation of nurses in the process of health services decentralization,
and make it possible to provide comprehensive and timely care that is free of risk to
the user. (4)

Among the accomplishments that have been seen are:  an increase in the
information being provided to nurses about PHC and local health systems,
changing attitudes toward the community, and increased interdisciplinary and
intersectoral efforts. In addition, it was noted that there is a trend toward modifying
the nursing curricula to include the PHC approach.

Only two countries reported on work under way to redefine the professional profile
of the nurse to reflect the orientation toward PHC and local health systems.

During this same conference, Paganini (1990) in a presentation on the challenges
facing the health services in the 1990s, cited the challenges that have to be
addressed in the decentralization of health services development. In addition to the
basic concerns of equity, quality, and efficiency and there are operational ones that
have to do with:

- The comprehensive nature of health activities
- Individual, family, and community care
- Teamwork with a focus on personalized individual attention
- The establishment of a services network
- The development of services at the local level and their relationship to other levels
of the system
- The technological challenge
- Flexibility in the organization of resources
- The shared use of financial resources
- The challenge of participation and of leadership
- The challenge of individual and community ethics (p. 28), to which should be
added the challenge of offering humane health that respects the rights of the
individual. (4)

These challenges are the subject of analysis and reflection on the part of the health
teams and the various disciplines, since entail responsibilities and individual
commitments both for the individual professional and for the health team.

From the findings that emerged from this conference and from the reports of the
countries it may be deduced that national and international nursing organizations
have played an important role in updating, motivating, and mobilizing nurses with
respect to the changes required by the PHC and local health system strategies.

A meeting of nursing leaders in Caracas (1985), held for the purpose of studying
the situation of nursing in Latin America, identified the chief problem areas in
nursing and proposed workable alternatives for the immediate future in the context
of the social changes taking place and the health problems predominating in the
Region. Five years later, the Regional conference on the development of nursing in
local health systems still cited the same problems:  a shortage of nurses, and a
qualitative discrepancy between the profiles of the nursing personnel and the
requirements of the health services. The characteristics of the nursing personnel
are standing in the way of the changes needed in order to effect the social
transformations and the greater expectations of the community that are needed. In
this regard, emphasis should be placed on the lack of preparation of nurses to take
assume their new roles, especially those roles relating to primary health care and
community work. The meeting also pointed out the fact that hospitals are the largest
employers of nurses and called attention to the very weak policies dealing with the
placement of nursing professionals at the local levels. Although changes have taken
place, this phenomenon persists. (5)

Another factor is that the health services expect completely trained graduate
nursing professionals with great expertise and ability both in general and in
specialized areas. The lack of legislation on nursing was noted, with variations
depending on the nature and requirements of professional nursing practice.

The proposals for alternative actions envisage: the establishment of policies for the
training and utilization of nurses; the strengthening of coordination, education,
assistance, and research; fundamental changes in the nursing curriculum, with new
theoretical and conceptual approaches that will orient it toward a more social and
less biological focus; the strengthening of statistical and documentary information
systems; and improved access to bibliographic material in this area. (5)

The results of the two Conferences mentioned point up the need for an in-depth
look at nursing and for effective actions, on an urgent basis, in each of the
countries, pursuant to the general guidelines for the Region and the current
situation and future outlook in terms of the social, economic, and political context;
scientific and technological development; and the values and ethical and legal
aspects entailed in health care.

The first meeting of the regional project on maternal and child nursing (1991) looked
at the health problems of women, children, and adolescents; health indicators; the
major health risks and impairments; and strategies for the training of nursing
professionals according to the health care requirements of these groups and the
needs of each particular country.

The critical areas which were identified and which require special attention in the
region were: 1) the training of teaching nurses in maternal and child care; 2) the
integration of teaching and assistance, and 3) the retrieval and dissemination of
bibliographic material in this area.

The regional project is oriented toward: 1) innovating and creating new models for
the teaching of maternal and child nursing; 2) improving the training of nurses who
work in this area; 3) optimizing the utilization of existing technologies, as well as
resources available in the community, for the teaching of maternal and child
nursing. (6)

When the role of nursing in PHC is analyzed in the overall context of the health
system or specifically in a program or project, as in the case of maternal and child
nursing, it is found that the needs for action strategies are very similar.

The future role of the well-trained nurse in making PHC operational was recognized
explicitly by the World Assembly of WHO. In 1989, Resolution WHA42.27, on the
strengthening of nursing and midwifery in support of strategies for Health for All, the
Member Governments were urged to support the appointment of nurses to national
positions of leadership and administration and to facilitate their participation in the
processes of planning and implementation of health activities; to facilitate research;
to support studies aimed at seeking the improvement of working conditions for
nurses; and to evaluate the nursing component in the health systems. (7)

In view of the limited information available on the role and status of nurses in
national positions, their functions and characteristics, and their participation in
health care planning and policy development, a project was undertaken on the
nurse in health services administration (1990-1991). Among the specific objectives
of this study were:

1) To expand knowledge about the work of nurses in health services administration
in local and district services, in hospitals, and at the national level.

2) To identify the strengths and weaknesses of nurses in administrative positions
and the problems and challenges they have to deal with.

3) To increase knowledge about the content and design of education programs for
nurses which will help to improve population-based health services administration
and develop nursing personnel. (8)

The frame of reference for this study came from a conference held in 1988 with the
participation of nurses, physicians, and health and other administrators. The main
problems faced by nurses in administrative positions were identified. The result of
this conference is summarized in one of the chapters of the book.


International Administration of Nursing Services. (9)

Among its main recommendations, this study called for: development of systems for
interaction between administrative nurses and other professionals; preparation of
job descriptions; improvement of training for nurses involved in administration;
promotion of advanced interdisciplinary education at the doctoral level;
establishment of national research institutions; creation of research positions for
nurses; and promotion of the formation of national and international groups to carry
out research on nursing administration. (10)

Finally, it was felt that nurses need to have strong capacity as leaders and
administrators in order to orient primary health care services and to act realistically
in the context of the new health care paradigm proposed by the Director-General of
WHO, who points out that a new realism is taking hold throughout the world, that
resources are not unlimited, and that consequently those who do the planning and
decision-making in health must identify priorities, focus on efficiency and cost-
effectiveness, and offer better health services through through improved resource
management while at the same time not compromising quality (Henry Beverly et al.,
1991). (11)

Nurses today cannot ignore this appeal of the Director-General of WHO if they wish
to make a more effective contribution to the goal of HFA/2000.

A review of the documents reveals clear contradictions between the declarations
that recognize the great potential of nurses for accomplishing PHC in the health
systems and the opportunities for participation that in reality are open to them in
many of the countries.

Greater consistency should be sought between discourse and action in order to
support and utilize the potential of nurses and promote their real participation in
planning and decision-making on health care policy and in nursing at the national
level and in local health systems.

This brings to mind the words of Dr. H. Mahler (1986) at the inaugural session of an
international meeting on nursing leadership held in Tokyo, Japan, at which he
pointed out that, among the health professions, the profession of nursing has
always shown strong dedication and commitment to social goals, as well as
willingness and readiness for change. The role of nursing in effecting the changes
that are needed in the health systems in terms of PHC, is very clear. Nurses work
everywhere, offer care at all levels, represent the most numerous group of health
workers in a number of countries, and are in direct contact with the people they
serve; and they often serve as the principal link between individuals, the family, and
the health system. Working with the people, nurses are permanent witnesses to the
harm caused to the population by inadequate health services, and as a result they
are in a position to advocate on behalf of those they care for, to give them support,
and to maintain credibility. Nurses, he concluded, can become an important social
force in the community. (12)




THE ROLE OF THE NURSE IN PRIMARY HEALTH CARE


The contribution of nursing to PHC within the sociopolitical and economic context of
the individual countries is unquestioned. However, the impact of their interventions
on the state of health and on the quality provided to individuals, families, and the
community has neither been studied nor demonstrated.

Statistics for the countries and the Region of the Americas indicate that there has
been progress in meeting the targets for the vaccination of children, reducing
mortality in children and mothers, meeting the targets for health care coverage of
pregnant women, reducing morbidity and mortality from ADD and ARI, utilizing
ORS, and increasing the practice of breast-feeding. All these actions rely to a great
extent on nursing, and it is necessary to assess the impact of nursing care in the
advances achieved, as well as the effects of its limitations on attainment of the
desired goals.

An evaluation of progress in the effectiveness of nurses in the provision of primary
health care for mothers and children in three countries of Africa--Nigeria, Zaire, and
Swaziland--showed satisfactory results in terms of the impact of nursing
interventions on the care of mothers and children and in terms of social mobilization
of the community after they had received a short continuing education course in
PHC.

The "praxis" concept--meaning knowledge about the principles and elements of
primary health care and their practical application for the improvement of health
care, in this case for mothers and children--was applied in this project in work with
families and communities.

The results were considered to be successful.  They call attention to the need for a
review of the way in which use is made of the potential and capacity of nurses in the
interdisciplinary health care team. (13)

Also worthy of note is the great potential, undiscovered or not utilized, that exists in
the national and international nursing organizations and the significant role they can
play in making PHC operational in the local health systems.

The evaluation of this project demonstrated:

1. That nurses have a good foundation in their basic training and that, with a short
period of continuing education, they can develop their great potential.

After they had participated in one-week workshops, the nurses had gained a much
greater understanding of the dynamics of community work and the policies and
elements involved in PHC.


2. Nurses are capable of preparing effective tools and developing the ability to
collect, organize, and analyze information related to primary health care.

3. Nurses have the capacity and the attitude to become valuable leaders who are
appreciated by the community when they learn to work on an equal basis with
community leaders and with individuals and groups.

4. When the community sees nurses working with them locally, it understands their
role, clarifies its image of them, and gains the benefit of their support and care.

5. The problems most often solved by nurses were:

a. Environmental:  personal hygiene and hygiene related to housing, food, water,
exposure to excreta, refuse, etc.

b. Physiological problems:  fever, diarrhea, infections, anemia, pain.

c. Psychological problems:  these were the most complex to resolve:  depression,
anxiety, stress, worry.

d. Behavior and beliefs with regard to health:  self-medication, female circumcision,
visits to shamans.

e. Social problems:  alcoholism, religious conflicts, unwed mothers, mental
problems, delinquency. 

With regard to community mobilization, the nurses identified eight (8) priorities and
problems that community leaders worked on with the support of the nurses:  1)
reconditioning of a road, 2) electricity, 3) water, 4) building of a health center, 5)
building of a schoolhouse, 6) ignorance, 7) difficulty in obtaining medical care, in the
site of reference, 8) difficulties in obtaining patient care in the hospital (Morrow
Helga, Holzemer, William, INC, 1990). (13)

Another study aimed at evaluating the impact of nursing interventions in PHC was
carried out in the European Region of WHO.

The Regional Office for Europe (1987), pursuant to the goals of PHC, has been
holding working meetings since 1982 with a view to developing criteria, setting
standards, and defining processes to ensure the quality of nursing services at the
national and local level. Detailed needs for the quality program were identified at the
local level, where this task will begin.

The WHO Regional Office for Europe (1989) held a second meeting to review the
changes that had taken place in nursing practice as a result of the improved quality
of services, to analyze the effects of the training program on the development of
standards for quality, and to examine the possible approaches that will make it
possible to implement these quality standards in local health systems and at the
regional and national level. (14)

Each of the countries in Europe has designed its own methodology and strategies
in accordance with its sociocultural, political and economic characteristics so that
the program on nursing care quality will reflect national and local needs. Systems
have been developed for the classification of patients and for the establishment of
standards for community nursing care for families, schoolchildren, and specific
groups who are experiencing a particular health problem.

As mentioned earlier, different approaches have been taken. For example, in
Sweden the National Association of Nurses (1988) has undertaken a project that
focuses on productivity, efficiency, and quality in nursing care. The purpose of this
research was to document the role of nursing in achieving the goal of efficient
health care. It began by making nurses aware of their responsibility with respect to
this goal as part of the quality health care process.

The participants in this working group identified the critical points that need to be
analyzed in order to establish a program on quality, including: socioeconomic and
cultural aspects; legal and professional requirements for health care; the power and
autonomy of professional nursing practice; techniques and methodologies leading
to quality; and coordination of political, interdisciplinary, financial, and research
activities. (15)

The evaluation of personal and institutional performance should be oriented toward
promoting the quality of the health services that are being provided, and for this
purpose it is necessary to establish standards or criteria with respect to quality.

Quality standards can be used to evaluate aspects relating to the structure,
process, and results of nursing and health care.

Quality standards and criteria can be used to establish different levels of
satisfaction, with an acceptable minimum level.

Novaes (1992) considers that in order to develop a program of quality assurance in
the health services, a specific set of variables must be present. These are:  (16, 17)

1) Technical, ethical, and human quality on the part of professional and other
human resources; 2) efficient use of resources; 3) minimization of risks for injury
associated with the services offered; 4) satisfaction of the patient, the family, the
community in terms of their needs, expectations, and access (economic,
geographical, cultural) to services; 5) local health systems in which in-hospital and
outpatient services are coordinated and integrated and allow for intersectoral
coordination.


As a first step, the mission of a local health system should be determined, as well
as the health concept and the individual and institutional commitment to work
consistently within the conceptual frame of reference.



THE LOCAL HEALTH SYSTEM CONCEPT


In 1988, ten years after the Declaration of Alma Ata, it was found that the principles
and concepts behind the target of Health for All are valid beyond a doubt. Advances
have been made in the health systems of the different countries, but there are still
serious problems affecting the health of large sectors of population, especially those
who live in situations of great poverty and virtually inhuman living conditions.

In view of the urgent need to keep working toward the goal of HFA, in 1988 the
International Council of Nurses reaffirmed its commitment to the continued
mobilization of the nurses of the world and to train leaders capable of promoting
social participation in the attainment of this goal primary health care.

In Riga (March 1988) the principles of Health for All were reaffirmed, and it was
proposed to strengthen this commitment. Ten principles will guide the progress of
the countries in the next years:  (18)

1. Maintaining HFA as a permanent goal for all nations until the year 2000 and
beyond.

2. Renewing and strengthening the strategies of HFA.

3. Intensifying social and political action in behalf of HFA.

4. Promoting and mobilizing leaders for Health for All.

5. Training people to participate in decision-making and the adoption of health-
related measures.

6. Utilizing intersectoral collaboration as the engine of HFA.

7. Strengthening local health systems (health districts) based on PHC.

8. Planning, training, and supporting health personnel for the task of HFA.

9. Overseeing the rational use of science and appropriate technology.

10. Solving the remaining problems that must be overcome in order to realize the
goal of HFA/2000.

These guidelines will govern the search for solutions in each of the countries, which
may adopt different priorities, approaches, and strategies. The problems that stand
in the way of humankind's health and well-being in the world and in each of our
countries are not so simple, and they must be addressed from a global and at the
same time a specific perspective which takes into consideration the historical,
sociocultural, political, and economic variables that characterize the communities in
each case.

In the most of the countries in the Region of the Americas there are still broad
sectors of the population without access to basic health services, and with the
economic crisis, social and political problems, and the growing external debt, the
situation is becoming increasingly difficult. For this reason, it is of the utmost
importance to find ways of administering the available resources with greater
efficiency and ways of orienting the health services so that maximum use can be
made of existing human potential and scarce resources. In this regard it is felt that
the strengthening of local health systems will be an appropriate avenue for applying
the principles of PHC.

Local health systems may be the best means of achieving true social participation,
including participation by communities, intersectoral action, truly effective
decentralization, and maximum utilization of planning and management in the
service of HFA, adapted to the conditions and specific needs of each population
group.

Local health systems call for reeducation of professionals and health workers as
well as of the community. This reeducation, which involves changes in attitudes and
beliefs, will facilitate the search for a new paradigm that takes into account the
sociocultural and economic context of each country and each population group.
This will make it possible to understand how the concept or definition of local health
systems can vary from country to country and region to region. Regardless of the
way in which it is conceptualized, it obeys certain ethical and social principles and is
based on social justice, democratic participation, equity, non-discrimination, and
honesty, correctness, and efficiency in the administration of resources allocated for
health care.

Local health systems should be able to transcend the vertical schema of
management processes in the which decision-making takes place in the upper core
of the organization and the operational structures at the periphery have the limited
function of fulfilling standards and carrying out programs that emanate from the top.
(19)

Local health systems call for a new order of power, new decision-making
processes, a commitment on the part of the government to decentralize both
politically and fiscally, allocation of resources in accordance with local priorities
along with local autonomy to manage them, and decisions made with the
participation of the community.

Local health systems are basic administrative units that have their own direction
and their own authority to administer health actions and their own capacity to relate
to other sectors and to the national health system or service. (19)

Local health systems are the focal point for the planning and management of health
services to meet the preventive and curative health needs of the community, both
individually and collectively, based on general guidelines and logistic and
administrative support from the central level.

The population and geographical size of the local health systems will vary, but they
should not be too small, nor should they be too large to allow for efficient direction
and participation by the community. (20)

The following requirements have been identified for fulfillment of the process of
decentralization and deconcentration that is crucial in the constitution of the local
health systems:

- A firm political decision to carry out the process;

- Transfer of the necessary political power from the central to the local level not only
in legal and administrative terms but also with transfer of the necessary resources;

- Development of local political power backed by real and effective participation of
the community and its various organizations;

- Development of managerial capacity in health services delivery (p. 19).

Other fundamental aspects relating to local health system development and
decentralization and deconcentration are:

- Reorganization of the central level so that there will be effective direction of the
health sector and the local health systems;

- Social participation;

- An intersectoral approach;

- Adaptation of the financial mechanisms;

- Development of innovative health care models;

- Integration of prevention and control programs;

- Strengthening of administrative capacity;

- Adequate training of human resources;

- Research (PAHO/WHO-CD Document 33/14.15, 1988).

The elements, conditions, and postulates that underlie the organization of local
health systems call for a change in attitude on the part of health personnel, political
leaders, the community, and administrators, as well as a review of values and a
decision to break away from routine or traditional styles of behavior.

This awareness cannot be imposed.  It requires personal and group analysis,
reflection on the social realities that concern us, and a rethinking of professional,
social, and ethical responsibility in order to make a decisive move toward change.

A series of subregional workshops were organized under PAHO auspices (1989) for
the purpose of analyzing the experiences of several of the countries in the
development and strengthening of health services.  They considered the following
aspects: social participation, the managerial process, manpower development,
financing, programming in the local health systems, and forms of cooperation.

The conclusions with regard to the development of human resources for local health
systems point to the need to reorient the manpower development process so that it
will focus on the functions of personnel within the local health systems. This
recommendation is applicable both to continuing education and to the curricula for
the training of professionals and technical and auxiliary personnel.  It calls for the
use of new pedagogies that support an interdisciplinary approach and problem-
solving in work with the community, individuals, families, and community groups,
and it is expected that the training will have a greater social component with a shift
toward new forms of graduate-level education. The integration of teaching-
assistance and research is essential in training programs for health professionals
who will be working in local health systems (HSD/local health systems/1). (20)

The health professions--nursing, medicine, dentistry, and related fields--should
reassess their understanding and degree of alignment with the philosophy,
concepts, principles, and components of the goal of HFA, the PHC strategy, the
paradigm of health care delivery in local health systems, and their transforming
function within the health system which stems from the community and its active
and conscious participation in the identification of its needs, the establishment of
priorities, and the formulation of plans. They should undertake, in collaboration with
the interdisciplinary health team, an analysis of current scenarios in nursing
education, the performance of nursing in actual practice, and the functions and
interventions for which it is responsible in the local health systems--all of which are
dictated by the community, in terms of its autonomous area, and by its leadership,
in terms of social mobilization. This self-evaluation will serve as a point of departure
for guiding the transformation of nursing practice on the basis of criteria of quality
and effectiveness that will have an impact on the health services being provided to
the population.

Within the managerial process, evaluation should be an ongoing activity aimed at
achieving maximum quality in the health and nursing services and geared to
improving their performance and the quality of their actions in order to enhance the
relevance, efficiency, efficacy, and effectiveness of health activities.

Wilson (1991) points out that different types of knowledge are needed in each
country in order to deal effectively with inequalities in health. He says this in light of
a discussion on the usefulness of the research and studies that have been
conducted to deal with the problem of equity in health.

It is believed that research can yield knowledge about inequalities in health care
and can implement care models and appropriate strategies geared to the particular
social and cultural situation with a view to responding more effectively to health care
needs.

Is proposed that essential national research in health be carried out with the
participation of the three types of "architects" involved: those responsible for the
formulation of health problems, the suppliers of health services, and members or
representatives of the community. (20)

These three groups of "architects" would be taken into account in the development
of case studies as a means of gaining knowledge about nursing care in local health
systems. 

The following list defines the fundamental concepts involved in the analysis of
nursing in local health systems:

Relevance has to do with the reasons for the adoption of health policies in
accordance with national social and economic policies and with the established
guidelines and broad goals of the health programs so that they respond to the basic
needs of the population and the priorities set by the community.

Efficiency refers to the relationship between the results obtained through a program
or health intervention and the means applied for its implementation, be they human,
financial, technical, or of some other type. A distinction should be made between
technical and cost efficiency.

Efficacy characterizes the effect desired of a program or service, institution, or
auxiliary activity designed to reduce the importance of a health problem or to
improve a deficient state of health. Efficacy determines the extent to which the
objectives or targets proposed for a program or activity have been achieved.

Efficacy is also measured by the degree of satisfaction or dissatisfaction expressed
by the users of a service.

Indicators are the variables that help to determine the direct or indirect changes that
have taken place in the health services.  They should be valid, objective, sensitive,
and specific.

Criteria are the standards (technical or social) by which the different actions are
measured.

Effectiveness, or evaluation of the effect or impact, is the most complex phase in
the process of health care but is also the most fundamental. It should answer the
question: Has there been an improvement, as a result of action X, in a health,
socioeconomic, or general situation or in the quality of life?

The coverage of the population with basic health care has been expressed as the
ratio of health services offered to the number of inhabitants or persons to be served
or who need the service. Ratios tend to be deceiving because they show only the
availability of the services and not the extent to which they have been well utilized.

The usefulness or utilization of health services is determined by the extent to which
they are accessible in every sense--geographic, economic, sociocultural, functional,
assuming that the health services are provided on a regular, timely, and organized
basis and are offered to the entire community without any form of negative
discrimination. (21,22)

The criteria of accessibility and of active community participation are basic to the
concept of primary health care (PHC), which is regarded as the practical means of
putting indispensable health care within the reach of all individuals, families, and
groups of the community in a form that is acceptable and in proportion to their
resources and with full and active participation by the community. Primary health
care is much more than the mere provision of basic health services because it
needs to be linked to services at the second and third levels of complexity. It
encompasses social developmental factors, and its application permeates the entire
health system. PHC is governed by the social objectives of equity, improved quality
of life, and the extension of optimum health service benefits to the greatest number
of individuals. (23)

The elements of primary health care are implemented operationally in local health
systems, understood in the following terms:

Local health systems, conceived as a set of interrelated health resources and
organized according to geographic and demographic criteria in both urban and rural
areas, are based on the needs of the population and defined in terms of risks; they
assume responsibility for the care of individuals, families, social groups, and the
environment and have the capacity to coordinate the resources available in the
sector and outside the sector so as to facilitate social participation and contribute to
the development of the national health system, to which they lend vitality and give
new direction. (24)

Local health systems require an understanding and acceptance of the process of
decentralization, which is complex and conflictive, since it entails not only normative
and structural changes in the organizations but also changes in personal behavior,
especially changes in the power structure, which involves a major change in the
political behavior of persons and groups and a firm commitment to act within the
framework of this new concept. (24)

According to this understanding of local health systems, the essential requirements
for their operation, as outlined by Charny and Paganini, are:

- Equity and quality;

- Democratization of the health services and social participation;

- Development and transformation;

- Efficiency and appropriate technology;

- Humanization, whether non-discrimination or positive discrimination.

The performance of nurses and nursing services administration in local health
systems will be analyzed within this conceptual frame of reference. Its effectiveness
is directly related to the contribution that is made to implementing the basic
concepts and elements of primary health care and the local health systems.




METHODOLOGY


Today one frequently hears reference to the urgent need for more thorough study
leading to innovative models for the integrated and effective delivery of health care
by local health systems. In order to meet this need, health services research must
accompany the entire process of local health system organization and development
from the initial stages all the way up to periodic evaluation. (1)

The studies or research being carried out in the local health systems envisage
several interrelated objectives.

Research on local health systems should be conducted basically with the
participation of those who provide the services, the community or users of the
services, and those responsible for the formulation of health policy and the general
normative guidelines for the health system.

It will be very useful to recall again, in connection with this review of the
methodological approach, the proposal of Dr. Richard Wilson (1991), who considers
that these are the three "architects" that should participate in essential national
health research. (2) These three architects are also important in studies of the local
health systems which today fall under the heading of essential research because of
the importance they have for the transformation and strengthening of national
health systems and because the results will be oriented to the strengthening of
decision-making that envisages changes at the local, regional, and national levels.

In this specific case, the study will be focused on the objective of describing the
participation of nurses in local health systems with a view to enhancing the
effectiveness of their role in administration and in the practice of direct care for
individuals, families, and community groups and to demonstrating the impact of
their actions on quality, health services coverage of the population, and the
cost/benefit ratio of the nurses' interventions.

In this last part proposed for the case studies, it is hoped to identify standards,
criteria, and processes for evaluating the effect of nursing interventions on health
actions.

Among the general guidelines proposed for a PAHO plan of action aimed at
strengthening the local health systems, the following three activities have been
proposed:

1. The collection, evaluation, and dissemination of national experiences relating to
local health system development.


2. Conceptual analysis and methodological development.

3. Support of local health system development processes at the country level.

In order to understand and orient efforts toward the strengthening of local health
systems, there must be, in addition to the inventory of experiences and the critical
analysis and results thereof, comparative studies of these experiences covering the
structural aspects, processes, and results of the local health systems, as well as
such aspects as productivity, coverage, efficiency, effectiveness, cost, participation,
and user satisfaction. (3)

The working group of a workshop on local health systems in the countries of the
Andean Area (1988) suggested the need for case studies of different local health
systems in the area in order to be able to compare training requirements and
educational methodologies and to encourage the exchange of experiences and
information on the operation of the local health systems. (4)

In the case studies designed to describe the situation of nursing in the local health
systems, it is proposed to carry out country studies that will permit comparisons
between local health systems based on innovative models and those that follow the
general orientation of the country or region in order to have comparative data for
analysis of the nursing situation in local health systems with different degrees of
development and in those with different models of organization.

Broad methodological guidelines for these case studies are presented below.


Case Studies:  Methodological Orientations

Concept and Modalities

Case studies are descriptive studies of a social unit over time; the unit may  be a
social group, an institution, or a community. Although these studies are exploratory
in nature, they also need to be sufficiently complete.  Thus, depending on their
specific objectives, they may take quite a long time to be carried out. Their chief
objective is to explore in depth a case that is prototypical of a situation frequently
encountered. A case study makes it possible to evaluate how a human group
identifies, perceives, values, and accounts for their reality and resolves their
conflicts. Case studies contain valuable and detailed information. They are highly
illustrative of the life of the community, since, even though they are the result of an
exploratory study of a small sample, they take into account many important
determining variables.

The preparation of case studies requires personnel who are familiar with the area
and have up-to-date theoretical knowledge about the subject so that they are able
not only to describe the facts of a particular situation but also to analyze them in a
way that will be useful for present and future decision-making.

In order for them to be transferrable and effectively usable in specific
circumstances, case studies require strategies that will guarantee the participation
of both experts or those responsible for their preparation and the community-
-in this particular case, the users of health services in the local health systems,
those who provide the services, and those who formulate health policies for the
local health systems.

Sellitz (1965) offers an analysis of examples of "interior stimulation" as a type of
research that differs from the "typical" case study. It is said that scientists working in
a relatively unspecific area in which there has not been much experience to serve
as a guide have found that the intensive study of selected samples is a particularly
fruitful means of probing for stimulation and deriving interesting hypotheses for
further research.

Unlike a "typical" case study, this is an intensive study of selected cases of the
phenomenon of interest. Attention may be directed toward individuals, situations,
groups, or communities. The method of study may consist of an examination of
reports and existing documents, an unstructured interview, direct observation, and
other procedures.

In this project, selected cases of local health systems will be studied with a view to
identifying and describing the role of the nurse, nursing services administration, and
the relationship of the foregoing to the quality of care, access to basic health
services, and the cost of services.

What are the characteristics of this method of exploratory case studies that make it
an appropriate procedure for identifying the necessary and fundamental aspects?

1. The attitude of the investigator, which is one of attentive receptivity--of seeking
before verifying. Instead of being oriented toward the verification of existing
hypotheses, the researcher is guided by the new aspects as they emerge of the
object under study--namely the role of the nurse in the local health systems. There
is a constant process of restructuring and redirection as new information is
obtained, and there are frequent changes in the type of data being collected.

2. Another aspect is the intensity of the study of the individual, group, community,
culture, incident, or situation selected for investigation. Sufficient information must
be obtained to characterize and explain, on the one hand, the individual aspects of
the "case under study" and, on the other, the characteristics it has in common with
other cases. In the study of a group, a situation (in this case the nurses in selected
local health systems), the individuals may be regarded as informants rather than as
subjects of intensive analysis.

3. A third characteristic of this type of case study is the confidence in the
investigator's power of integration--in his or her ability to tie together various
different parts or pieces of information into a unified interpretation. This
characteristic has led some critics to look at the analysis of examples based on
deep probing as a sort of projective technique in which conclusions primarily reflect
the predisposition of the researcher and not a description of the object under study.
According to Sellitz, although this criticism is valid in many case studies, the
characteristic in question is not necessarily undesirable when the purpose is to
evoke (to describe) rather than to verify a hypothesis. Even if the case material
serves merely to stimulate the explicit statement of a hypothesis that had not yet
been definitively formulated, it may have performed a useful function.

Social scientists have found that the study of a few examples (cases) can give rise
to new perspectives and new ideas. As in any case study, one cannot give simple
formulas or rules for the selection of subjects; experience indicates that for certain
problems some types are more appropriate than others. The following types of
sources, taken from the author's non-exhaustive list, are considered to be most
appropriate for the current study.

1. Persons who have recently arrived.  The curiosity, surprise, or confusion of
persons who have recently arrived--for example, a nurse recently appointed to a
position in the local health systems--can direct attention to aspects of a situation
which older members of the community or group are accustomed to and do not
notice.

2. Persons in "transition" from one stage of development to another--for example,
recently graduated nurses who are returning for graduate-level studies, or who are
near retirement.  Such studies have been fruitful.

3. Persons who "fit in" or "don't fit in" to a given setting.  Such individuals can
provide valuable leads. The assessments of those who feel comfortable in a
situation will be different from those who are frustrated.

4. Individuals who occupy different positions in the social structure.  Together, they
may provide a more complete view of the situation. The social differences between
persons who occupy different positions or perform different functions (different from
nursing, in this case) are important sources of information.

This list of cases to be probed is incomplete.  It will depend on the situation under
study which of these is more valuable. (5)

The case studies include retrospective research on previous events as well as the
observation of behavior, as it is taking place, which is relevant to the subject of
concern. Such studies should include examples that demonstrate the principal
phenomena being examined--in this case, the functions of nursing or examples of
nursing services administration in the local health systems.


Research Techniques. (Adaptation of case studies (Annex 1), Documents
PAHO/WHO) HSD-SILOS-7, 1990)

The techniques that can be enlisted to collect and interpret the information
constitute a part of the body of broad and differentiated knowledge that the social
sciences have developed through the years. It is in not intended to present a
complete list in the present document, nor is it intended to analyze them in depth,
since there is an extensive literature on the subject. (6)

The selection of techniques will depend on the time of the research as well as on
the specific or general objective it is hoped to attain. Usually several techniques are
employed simultaneously. This makes it possible to approach reality from several
angles, to triangulate the information obtained, to enriches perceptions, and to
enhance the possibility of formulating new problems and trying out a broad range of
solutions as the process evolves.

The methods that can be employed in the preparation of the case studies are the
following:  collection and analysis of documentary material, observation, individual
and group interviews, and meetings with focus groups.


Analysis of Written Documents

There are several sources of information about the situation under study. 

The category of written documents may include files, historical sources, yearbooks,
reports, studies, newspapers, and personal and official files.

Use may also be made of statistical or numerical data such as vital statistics,
censuses, etc., collected systematically by international agencies, national
governments (at the local, provincial, state, or central level), hospitals, and other
institutions.

Audiovisual materials include photographs, films, and records captured on magnetic
tape, disk, or videotape.

The gathering of documentation is a basic activity at beginning of the research,
since it contributes to preparations for the analysis (or diagnosis) of the situation
and may later be supplemented with information obtained by other means.

Ministries, national and local governments, universities, and documentation centers
are examples of sources of information. Computerized networks and specialized
data bases in information centers facilitate the task of locating and reviewing
bibliographies and documents.


Observation

Direct observation is a technique for the collection of data and information on the
sociocultural reality of a community or a specific group which is designed to yield
relevant qualitative information on the subject being investigated. It is the intensive
observation of the physical and sociocultural environment of a population.
Depending on the way the procedure has been set up and the guidelines have been
prepared and used, observation may be a more or less structured activity.

Participatory observation is an integrative technique taken from a qualitative
methodology developed for the field of ethnography. It is a mixture of techniques
designed to interpret the real world of the people and their perceived needs, values,
attitudes, frustrations, beliefs, and aspirations, and it involves social interaction
between the investigator and the subjects in their own setting.  During the course of
the observation the data are collected in a systematic, nonintrusive manner. A good
ear and a good eye are essential attributes of a good observer.

The information obtained through participatory observation, which may include
recordings and photographs, is of high quality and value, since living in a
community enables the researcher to somehow transcend his or her way of seeing
the society and the culture. Having an understanding of another reality, however,
can have disadvantages, since the researcher also has class, cultural, or
professional biases that can influence the responses of the population, his or her
interpretation of the reality, or his or her attitude toward the people of the locality.

The investigator develops his or her own system for recording the answers to basic
questions on the subject of interest (How?, Where?, When?, Who?, What?, How
Much?, In how much time?, Why?).

Generally speaking, the records of the observations should be organized along the
following lines:

a) Note the hour, date, and place of the observation and discussion, and provide
certain identifying characteristics of the informants and the situation observed.
Dates, distances, and place names may be noted in that order, followed by a record
of the observations and facts. If numerical information is to be obtained at several
sites, a previously prepared form will save time and will serve to present a first
outline of the results.

b) Notes in a diary should follow a uniform format so that all the topics on the
checklist are covered, with an open section at the end. This will make the work
easier and ensure that nothing is overlooked.

c) It is helpful to prepare a system of abbreviations for frequently used words. Literal
quotes are placed between quotation marks ("..."). Comments and questions of the
observer that may require further research should be specially flagged--for
example, separated by brackets or parentheses.

d) Take pictures of important things unless this may cause offense. Write on back of
each photograph the date, place, and circumstances. A series of pictures taken
over time is useful. If copies of the photographs are promised to the informant,
make certain that the promise is kept.

e) It is helpful to carry a pocket calculator.

f) Tape-record conversations whenever possible, although this may not always be
desirable.  Just as when notes are taken during a conversation, it can hinder the
free expression of views. However, one can use a tape recorder to keep a diary
when there is not enough time to write.


Interviews

The purpose of th equalitative interview is to find out what the informant is thinking
and to discover things that cannot be observed on a day-to-day basis. (7)

The key to the qualitative interview is to create a framework within which the
informants can express their point of view freely and honestly in their own words
(and not those of the investigator), unlike the closed interview, questionnaire, or
test. In a qualitative interview, the interviewer should remain open with regard to the
questions or matters to be discussed and in no case should suggest or provide
phrases or answers that might be used by the informants in the formulation of their
own responses.

The main purpose of an interview is to obtain evaluative information of high quality.
It is important to note that the "quality" of the information obtained through this type
of interview depends much more on the interviewer than on the informant.

There are three types of qualitative interview:  the informal (conversational)
interview, the guided interview, and the open standardized interview. Actually, the
differences between them are largely of degree: they have to do with the level of
structuring and standardization of the questions to be formulated during the
interview.

The informal (conversational) interview has a very open and spontaneous format
and follows the natural course of a conversation between two persons. It is used
mainly in the course of the participatory observation, which means that there is not
a very marked or formal differentiation between the roles of interviewer and
interviewee, and usually no notes are taken during the interview.

The guided interview is a relatively flexible session but is structured by "guidelines"
which specify the topics to be covered prior to the interview. The interviewer is
restricted to pre-established topics but does not have to bring them up in any
particular order, which means that he or she can decide, depending on the context,
the language to be used in framing the questions as well as the sequence of the
topics contained in the guidelines are to be addressed.

The guidelines may contain relatively detailed "prefabricated" questions, or they
simply list topics within which the interviewer is free to probe, question, ask, or
interrogate the informant until a particular point is elucidated or clarified. The
guidelines ensure that there is equal coverage of the topics or subjects among all
the informants, which means that the responses can be readily analyzed and
compared.

This type of interview makes for more of a differentiation between the roles of
interviewer and interviewee and becomes relatively formal, although it can be
adapted to the context, which makes it possible to record the interview and to take
brief notes of the observations and responses.

The open standardized interview has a structured format with a series of open,
carefully formulated questions that are ordered in a specific sequence. The
interviewer uses the exact same words each time (standardized) in order to reduce
variability and minimize bias in the responses of the informants.


Interviews or Sessions with Focus groups

Interviews or sessions with focus groups are a form of qualitative research for
obtaining information on the perceptions, beliefs, and language of a community or
social group on a specific subject. (8) The technique of conducting interviews with
focus groups is based on those used in group dynamics or group therapy sessions,
which have been adapted to market research and other types of research about a
community.

The sessions with focus groups are also called exploratory group sessions and
consist of a meeting or interview with a group of no more than eight to ten persons
who are considered to be "typical" representatives of the population that is being
investigated. The session is led by a trained moderator, utilizing a discussion guide.
Another person, who is not the moderator, assumes the role of rapporteur or
secretary of the group and takes brief notes on the discussion. At the same time it is
recommended that the session be recorded in order to capture responses or eye-
witness statements that might help in the analysis of the content.

A session may last one to two hours or more, depending on the agenda to be
covered and on the skill of the moderator.

When possible, the meeting should be called personally by the investigator or by
the evaluation team with some time in advance. The subject will determine the
make-up of each group.

The meeting should be held outside the health service in an environment
considered as "neutral" (e.g., a school, the town  or a neighborhood meeting room)
in order to ensure that the participants have full freedom of expression. It is best to
sit in a circle, with about the same distance between everyone, and to keep away
"curiosity-seekers" or others who might inhibit or interrupt the session.

As in the case of the qualitative interview, the format of the questions should be
open and neutral. The moderator should assume an encouraging role, giving
everyone an opportunity to express their point of view, and the tone of voice should
be friendly but neutral, avoiding gestures of approval or disapproval of the
participants' comments.

After a brief introduction of each participant, the moderator is introduced.  The
moderator, in turn, explains the purpose of the meeting and introduces the
rapporteur or secretary, who may be either another member of the evaluation team
or a participant who has been informed of his or her role ahead of time. Preferably,
each person should be addressed by name during the session. The moderator
introduces each subject, for which he or she may use the corresponding parts of the
form. Slanted or ambiguous questions should be avoided, as well as those that may
tend to elicit an unqualified "Yes" or "No" response. It is especially desired to evoke
the participants" experiences, perceptions, value judgments, or feelings regarding
the local health service and the role of the nurse.

The rapporteur or secretary should record the site, date, schedule, and duration of
the session, as well as the names of all the participants and other characteristics
that might assist in an analysis of the context of the session. Sometimes it is
important to note between quotation marks any comments or words, together with
the exact language used, which might help in the evaluation of the service or which
illustrate the people's relationship to the local health service. The rapporteur or
secretary should be responsible for operation of the tape recorder and, insofar as is
possible, avoid taking part in the discussion.


REFERENCES


1. Gómez D, Fernando (1976). "Estructura de la Interdisciplinariedad."  In:  La
Universidad Posible.  Bogotá, Universidad Externado de  Colombia.

2. International Council of Nurses (1988). Nursing  and Primary Health Care: a
Unified Force, Geneva, ICN. 

3. Consejo Internacional de Enfermeras (1986). Promover el Liderazgo de la
Enfermera para la  Atención Primaria de Salud, Manual para las  Asociaciones de
Enfermeras y otras Asociaciones  profesionales, Ginebra, INC. 

4. OPS/Feppen, Paganini, José María (1990). Los desafíos de los Servicios de
Salud, en la década de los 90,  Conferecia sobre Desarrollo de Enfermería en los
Sistemas Locales de Salud en América Latina. Caracas, OPS, Serie Desarrollo de
Servicios de Salud No. 81 (Final report and country summaries).

5. Federación Panamericana de Asociaciones de Facultades y Escuelas de
Medicina (1986). La Enfermería en Latinoamerica. Estrategias para su Desarrollo.
Memorias de la reunión de Líderes de Enfermería,  Caracas, Fondo Editorial
Fepafem.

6. OPS/OMS, Fundación W.K. Kellogg, Proyecto Regional de Enfermería
Maternoinfantil (1991). Informe de la Primera Reunión, (Guatemala, 11-15 February
1991).

7. WHO (1989). Resolution on Strengthening Nursing and Midwifery in Support of
Strategies for Health for All. Document WHA42.27, May 1989.

8. Henry Beverly, Lorensen, Margarethe, Hirschfeld Miriam,  (1991). Management
of Health Services by Nurses (draft). Project conducted under the aegis of WHO,
with support provided by U.S. Educational Foundation in Norway, University of
Oslo, Institute of Nursing Science. 

9. Henry Beverly, Heyden Richard, Richardson Barbara (1989).  International
Administration of Nursing Services. Philadelphia, Charles Press. 

10. Henry Beverly, Lorensen, Margarethe, Hirschfeld Miriam, op. cit. 

11. Speech by Dr. Hiroshi Nakajima, Director General of the World Health
Organization, at the World Health Assembly, 1991. (Documento A44/Div/4) cited by
Beverly Henry in Management of Health Services by Nurses. 

12. Mahler, Halfdan (1986). "Why Leadership for Health for All," Keynote address
delivered for the Encounter on Leadership in Nursing for Health for All, published by
the International Nursing Foundation of Japan, in The Effectiveness of Nursing
Practice for Health for All, proceedings of the 12th Senior Nurses International Work
Shop, Tokyo/Hiroshima, Japan. 

13. Morrow, Helga and Holzemer William (1990). Increasing Nurses' Effectiveness
in the Health Care of Mothers and Children through Nationwide Continuing
Education Programmes. Geneva, ICN. 

14. WHO, Regional Office for Europe (1987, 1989). The consultant: Role in Quality
Assurance in Nursing Practice. Meetings, Reports, Informal Publications
EUR/ICP/HSR 324 and EUR/ICP/HSR 336. 

15. WHO, Regional Office for Europe (1985). Nursing Standards: Toward Better
Care, Copenhagen. 

16. OPS/OMS  Moraes Novaes (1992). "Garantía de la Calidad en Hospitales de
América Latina y el Caribe." HSD/SILOS-13, Appendix I. pp. 87-88

17. OPS/OMS (1992). La Garantía de la Calidad, Acreditación 
de Hospitales para América Latina y el Caribe, Desarrollo y Fortalecimiento de los
Sistemas Locales de Salud. HSD/SILOS-13. pp. 14,15). 

18. WHO (1988). Alma Ata Reaffirmed at Riga, WHO from Alma Ata to the Year
2000. Geneva. 

19. OPS/OMS (1989). Desarrollo y fortalecimiento de los Sistemas Locales de
Salud en la Transformación de los Sistemas Nacionales de Salud, Washington,
D.C. 

20. OPS (1989). Desarrollo y Fortalecimiento de los Sistemas  Locales de Salud,
Tallleres Subregionales,  Washington, D.C. p. 52. 

21. Wilson, Richard (1991). Comentarista Grupo de Investigaciones en Salud para
el Desarrollo, Boletín de Investigaciones sobre Servicios de Salud, No. 8, 
August/November, p. 2. 

22. WHO (1981). Health Programme Evaluation. Guiding Principles. Geneva.
Health for All series, no. 6. 

23. WHO (1978). Primary Health Care. Report of the International Conference on
Primary Health Care, (Alma Ata, 6-12 September 1978). Geneva/New York, p. 8. 

24. Boletín Oficina Sanitaria Panamericana de la Salud, special number "Sistemas
Locales de Salud." vol. 109, nos 5-6, November-December 1990. 

Paganini José, Chorny  Adolfo H. "Los Sistemas Locales de Salud Desafío para la
Década de los 90."  p. 430. 

Nirenberg Olga, Perrone, Nestor, "Organización y gestión participativas en los
Sistemas Locales de  Salud." p. 475.




REFERENCES ON THE METHODOLOGY


1. OPS/OMS (1989). Desarrollo y Fortalecimientos de los  Sistemas Locales de
Salud,  Document CD/33, 14,15 August 1988, Washington, D.C., p. 26. 

2. Wilson Richard (1991).

3. OPS/OMS, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud, op.
cit. p. 27. 

4. OPS/OMS (1988). Desarrollo y fortalecimiento de los Sistemas Locales de
Salud, Talleres Subregionales. Washington, D.C., 1989, p. 11. 

5. Selltiz, C. et al. (1965). Métodos de Investigación en las Ciencias Locales.
Madrid, Ed. Rialp. pp. 78-84. 

6. OPS/OMS (1990). Desarrollo y Fortalecimiento de los Sistemas Locales de
Salud en la Transformación de los Sistemas Nacionales de Salud, la Participación
Social en Estudios de Casos. Washington, D.C. Anexo 1, Estudio de Caso. pp. 13-
18. 

MALARIA

  The history told here is in part the story of the arduous task of
transforming and developing health services.  The Organization's
objective has been to eliminate malaria and its consequences from the
Region of the Americas.  In order to achieve this aim, campaigns have
been mounted to eliminate all mosquitoes of the genus Anopheles that
are infected with either Plasmodium vivax or Plasmodium falciparum,
agents that cause the infection in humans, and to check the spread of
the disease by preventing these mosquitoes from feeding on the blood
of plasmodia-infected individuals.  The probability of being infected,
becoming ill, or dying of malaria depends on the risk factors that
increase people's chances of being bitten by the insect vector.
  Elimination of the risk factors calls for interventions that will be
effective under special circumstances, such as those that arise when
new areas are opened up for mining and farming or when migration or
contraband occur. 
  The distribution of malaria in the Americas has changed dramatically
over the last 100 years, during which time it has been eliminated or
has disappeared from most temperate and neotropical areas.  Since the
colonial era, malaria has been an important disease in the area
stretching from the southern United States to Argentina.  The first
official documents on the disease date back to the early twentieth
century.  Before that time, malaria was considered more a process of
acclimation than a disease and it was often confused with other febrile
illnesses.  Malaria fevers were long one of the major causes of
disability and death.  Up until the twentieth century, quinine was the
only control measure available.  
  It was the work of Gorgas in Panama in the early part of the century
that demonstrated the feasibility of controlling anopheline mosquitoes
and awakened interest in malaria as an economic and health problem. 
The control of mosquito breeding sites with larvicides was a widely
used measure until the 1940s.  Drainage operations and the application
of oil larvicides helped to reduce the number of cases in many cities
and seaports in the Hemisphere.  The success of these morbidity-
reducing measures eventually led to the establishment of well-financed
surveillance and control projects, and malaria declined considerably
during the 1930s.  The 1940s saw the organization of community
education programs, the application of measures to control larvae and
adult mosquito populations, and the establishment of central and
regional diagnostic laboratories. 
  Agricultural development, better care of livestock, and the
improvement of housing, environmental conditions, and water levels in
irrigation projects have been decisive factors in controlling mosquito
vectors in some of the developing areas.  During the 1940s, surveys and
efficient malaria campaigns coincided with the integration of
municipal, state, and federal resources, as well as the involvement of
all sectors of society, departments of state, armed forces, and various
foundations.
  One of the first achievements of the malaria campaigns in the Region
of the Americas was the eradication of Anopheles gambiae from Brazil
in 1942.  Once again, the coordination of efforts--in this case, those
of the Pan American Health Organization, the Rockefeller Foundation and
the Government of Brazil--had yielded fruit.  Five years later, at the
XII Pan American Sanitary Conference, attention was focused on the
insecticide dichloro-diphenyl-trichloro-ethane (DDT), which was to
become a basic tool in the effort to break the cycle of transmission
and attain the goal of eradication.
  In the years that followed the appearance of DDT, the Organization
strove to promote widespread use of this insecticide.  It recommended
that national control programs concentrate on increasing the use of DDT
and, in particular, on documenting its effectiveness.
  The notable reduction in the number of cases in many countries of
the world as a result of DDT use led the XIV Pan American Sanitary
Conference (1954) to recommend to the Member Governments that they
convert their national control programs into eradication campaigns
within the shortest possible time.  It was deemed of utmost urgency to
interrupt transmission before the anopheline mosquito developed a
resistance to DDT.  For this reason, the Director of the Bureau was
authorized to raise funds from public and private organizations, both
national and international, to cover the cost of the activities that
needed to be carried out.
  In 1955, the World Health Assembly adopted a resolution calling for
the eradication of malaria from the face of the planet, underscoring
that international collaboration was a sine qua non for success in this
endeavor.  With the goal of eradication in mind, the Directing Council
of the Pan American Sanitary Bureau in 1957 strongly recommended that
malaria be declared a notifiable disease. 
  In 1961, the Expert Committee on Malaria of the World Health
Organization (WHO) set criteria for the establishment of malaria
eradication programs, stressing the need to develop effective rural
health services in order to sustain the maintenance phase once it was
reached.
  Introduction of the concept of health infrastructure by the WHO
Expert Committee on Malaria added a new dimension to malaria control
programs.  The necessity of gradually integrating malaria control
activities into the basic functions of local-level health services was
recognized.  These activities needed to be simple and clearly defined
so that they would be effective in the hands of auxiliary personnel in
the malaria services.  It was also important for health centers to gain
experience with malaria control activities as quickly as possible.
  The scarcity of resources and the economic crisis that was
devastating many of the countries in the Region also threatened the
integrity of the malaria campaigns.  The economic crisis was affecting,
and continues to affect, all sectors of the economy, and the health
sector was not an exception.  Mindful of the situation, the
Representatives to the Directing Council of the Organization, meeting
in 1962, underscored the urgent need for the Member Governments to take
steps to obtain financial assistance in order to surmount the hurdles
standing in the way of efforts to halt transmission of the disease. 
A combination of factors were favoring an increase in the incidence of
malaria.  These included the existence of environmental conditions that
were fostering proliferation of the anopheline mosquito, greater
exposure of the non-immune human population to infection, and an
economic crisis that heightened the chances of becoming ill or dying
of malaria among certain social groups.  Growing involvement of the
Organization in research on the disease--through meetings with experts,
funding for studies, etc.--pointed up the importance of existing
technical problems.  Much remained to be done in terms of research: 
improvement of diagnostic methods and studies on aspects of
transmission related to the genetic characteristics of the vector and
the host, the epidemiological significance of mosquito resistance to
insecticides and plasmodia resistance to drugs, effectiveness and
tolerance to new malaria drugs, the impact of migratory movements and
other social factors on incidence of the disease, and its association
with agricultural and mining activities. 
  During the 1960s numerous studies were conducted to determine the
nature of the biomedical problems that were hindering the malaria
eradication campaigns.  The studies demonstrated that eradication would
not be possible in areas where the only control measure in use was
household spraying with residual insecticides.  On the basis of these
findings, the XVII Pan American Sanitary Conference, held in 1966,
decided that coordination between local health services and eradication
programs should be stepped up.
  The Organization faced a difficult challenge.  The efforts of control
programs needed to be financed and coordinated with those of the
general health services.  In addition, research on the biology of
plasmodia and the malaria vector had raised many questions that had to
be answered.  Accordingly, the XVII Meeting of the Directing Council
(1967) recommended that the Member Governments reorient their malaria
strategies.  The difficulties associated with the numerous factors
governing the disease's behavior, together with the complex economic
crisis, made it necessary to intensify and channel control and
eradication efforts specifically toward problem areas.
  The hallmarks of the Organization's policies on malaria eradication
during the 1970s were the ongoing search for material and financial
resources and the intensification of technical and general support for
national control programs.  Closer cooperation with these programs
highlighted the importance of incorporating them into national
development plans.  
  Taking into account the serious financial difficulties that were
hampering efforts in most of the countries, the XX Pan American
Sanitary Conference (1971) recommended that the Governments reexamine
their eradication programs and continue the production of DDT.  It also
reiterated the urgent need to strengthen basic health services in areas
where malaria was especially prevalent. 
  Shortages of funds and social health services, mosquito resistance
to insecticides, plasmodia resistance to drugs, and lack of
coordination between national control programs and health services were
the principal factors that led to a deterioration in malaria
indicators--annual parasite incidence, rate of household-spraying,
annual blood examination rate--in some areas of the Region.  These
problems were aired at the June 1976 meeting of the Executive Committee
in Washington, D.C., which recommended that the Organization promote
the application of new measures--including technical, economic, and
administrative feasibility studies of the malaria programs--and that
it ask the international financing agencies such as the Inter-American
Development Bank and the World Bank to give favorable consideration to
requests from the Governments for financing to strengthen their malaria
control programs. 
  The 77th Meeting of the Executive Committee in 1977 asked the
Director to include the necessary funds in the Organization's budget
to for training in application of the new strategy for malaria control. 
This strategy called for top priority to be given to primary health
care in order to ensure coverage of the rural population, which would
mean overhauling the basic structure of malaria control services and
programs.
  A year later, the XX Pan American Sanitary Conference decided to
reaffirm eradication as the ultimate goal of the control programs in
the Region and declared 1980 the "Year of Frontal Struggle with Malaria
in the Americas," the aim of which was to intensify operations to
eradicate the disease.  The III Meeting of Directors of National
Malaria Eradication Services in the Americas, held in Oaxtepec, Mexico,
in 1979, laid the foundation for development of a hemisphere-wide plan
of action to combat malaria.  Throughout the years, the Organization
insisted again and again at meetings with the representatives of the
member countries on the need to make malaria control a top priority,
and it continually pressed for the strengthening of education and
training for personnel in malaria programs.  It was clear that the
attainment of these ends hinged on expanding the areas covered by the
programs and strengthening research on methods to control transmission
of the disease.
  At the IV Meeting of Directors of National Malaria Eradication
Services in the Americas (Brasília, Brazil, 1983) it was recommended
that the Governments redefine the objectives of their programs in terms
of malaria stratification, based on available epidemiological data. 
The objectives of any malaria program were considered to fall under one
of three headings:  final (eradication of the disease), intermediate
(reduction of endemicity, mortality, and morbidity in the areas where
eradication is not feasible), immediate (reduction of transmission
levels in epidemic areas and prevention of transmission in disease-
free areas, as well as contribution to socioeconomic development in
affected areas).
  The year 1985 saw a critical review of the advances that had been
made.  The major challenges at that time revolved around how to
administer the correct specific treatment to all plasmodia-infected
persons and how to evaluate the effectiveness of treatment in the
population.  The success of antimalarial chemotherapy was contingent
on discovery of a solution to the problem of P. falciparum resistance
to chloroquine and other alternative drugs.  Success also depended on
the regulations and policies governing the importation, production,
distribution, marketing, and administration of antimalarial drugs.
  It was obvious to everyone that malaria was a very complex problem
that could be both a cause and a consequence of certain socioeconomic
problems that were affecting the population.  Numerous factors had
caused the malaria situation in the Region to grow markedly worse. 
Between 1985 and 1990, 21 of the 37 countries in the Region reported
one million cases of malaria per year.  Of these, two-thirds were
microscopically confirmed P. vivax infections  and the remaining third
were P. falciparum infections.
  In the face of this situation, the Organization was obliged to
rethink and modify the prevention and control strategies that it had
been advocating up to then.  The outcome was a shift by the control
programs to the strategy of malaria stratification.  This strategy had
first been proposed in 1979.  By 1985, stratification had been
recognized as a useful approach for establishing an objective
epidemiological diagnosis and as a basis for prevention and planning
activities.  In the Region of the Americas, stratification has been a
dynamic and ongoing process of research, diagnosis, analysis, and
interpretation of information which has provided a way of classifying
geographical and ecological areas and population groups on the basis
of their chances of becoming ill or dying of malaria.  The most
prominent feature of this approach is use of epidemiological studies,
in individuals and specific social groups, to spot the risk factors
responsible for the incidence of malaria at the local level.  Knowledge
of the profile of these risk factors is extremely helpful for the
selection of interventions to prevent and control the disease. 
Basically, malaria stratification involves:  studying the annual
parasite incidence and its trends in order to identify priority areas,
identifying and measuring the risk factors in these areas, constructing
risk strata based on the ranking of the risk factors identified,
selecting interventions to reduce or eliminate the most important risk
factors, adapting the health services to carry out the interventions
selected, and identifying indicators of structure, process, and impact
in order to measure the reduced risk of becoming ill or dying of
malaria and evaluate the interventions that have been applied.
ALIM3
NUTRITION

     Poor nutrition and its relationship to health have been the
object of studies and legal provisions, in the modern sense, since
the late eighteenth century.  It was at that time, for example,
that Count von Rumford, a champion of popular cuisine, introduced
changes in the German diet which have endured up to the present
day.  The study of childhood nutrition began in earnest towards the
end of the nineteenth century, and in the early part of the current
century public health writings were already describing what today
we recognize in children as multiple deficiency syndrome.  Studies
at that time also explored the role of nutrient and vitamin
consumption in resistance to certain diseases.  By the time the Pan
American Sanitary Bureau was established in 1902, there was a
steady flow of new information about nutrition, and knowledge in
this area was growing at a rapid pace.

The First Steps

     Although in the early days of its existence the Bureau was
concerned mainly with the control of epidemics and the imposition
of quarantine measures, by 1924 it was studying and endorsing draft
legislation relating primarily to the regulation of food products
and the prevention of fraudulent statements of content.  At the
same time, the increasingly evident correlation between nutrition
and human health and productivity led the Bureau to take an
interest in the research that was being conducted in this area. 
The Boletín de la Oficina Sanitaria Panamericana, which first
appeared in 1922, became an important instrument for the
dissemination of studies.  By 1925 the Boletín was carrying
articles on such subjects as vitamins and prophylaxis for endemic
goiter and pellagra.  In the early 1930s a section was inaugurated
in the Boletín that dealt exclusively with nutrition-related
topics. 
     The Bureau's sphere of action expanded gradually from the
control of certain communicable diseases to encompass the
prevention of morbidity in general.  It was in this context that
interest was awakened in food safety and hygiene techniques.  In
response to the concern expressed at the Pan American Sanitary
Conferences and other international conferences held at the time
about high infant mortality, the Bureau recommended in 1927 that
the Governments give greater attention to modern hygiene practices
and the pasteurization of milk products.  This led to the
preparation, translation, and distribution of a pamphlet entitled
"Ordenanza Modelo para Leche," which was made available to all the
departments of health and served as a basis for legal provisions
at the national and municipal levels.  PASB's efforts to ensure the
safety of milk and milk products continued throughout the 1930s. 
     In Latin America, malnutrition has long been a serious public
health problem and one that has contributed substantially to high
mortality among young children.  In response to this problem, which
was exacerbated by the Depression, and with the growing general
interest in nutritional matters, in 1929 the Bureau undertook an
analysis of dietary habits and began to disseminate information
about good nutrition.  For this purpose it requested statistical
data from the countries on nutritional and digestive diseases as
well as studies on malnutrition.  The VII International Conference
of American States, held in 1930, recommended the establishment
"... de tipos y patrones panamericanos sobre alimentos y drogas,"
and in 1934 the IX Pan American Sanitary Conference recommended
that the Governments create institutes for the purpose of
determining the composition and nutritional value of the foods
produced by each country and studying problems related to the
production, processing, and distribution of foods, with a view to
setting hygienic standards.  In 1936 the Committee on Alimentation
was created as the first permanent technical body to be established
by vote of a Pan American Sanitary Conference.  In the course of
the next few Conferences, the strictly hygienic focus gradually
gave way to a perception of nutrition as a public health concern
closely linked to social well-being.
     The Organization's activities in the area of nutrition prior
to 1940 had a wide and varied impact on policies in the member
countries, which set up government- and industry-subsidized dining
halls and established institutes, laboratories, educational centers
and services of all kinds to improve nutrition; agencies devoted
to nutrition from a health standpoint; and school lunch programs. 
The latter gained momentum during the 1960s and 1970s, when PAHO
focused particular attention on the problems of vulnerable groups. 
Still today, national school nutrition programs, which generally
supply some type of food to every child on a daily basis, occupy
a central place in the social policies of various countries of
Latin America. 
     When the IV Pan American Conference of National Directors of
Health recommended in 1940 that efforts to promote good nutrition
be stepped up, the governments adopted, among other measures, a
system of school gardens.  In Uruguay a national commission was
established to encourage the population to adopt good eating
habits.  Paraguay instituted a balanced dietary regimen for its
armed forces.  In Chile there was increasing recognition that
malnutrition was contributing to the prevalence of tuberculosis. 
These are but a few examples of the developments that took place
in the countries.  Pursuant to other recommendations of the IV
Conference, the Commission on Nutrition prepared a series of menus
for the various countries of the Region based on the local
availability and cost of foods, and, in collaboration with the
School of Tropical Medicine of Puerto Rico, it published the first
Spanish-language manual on food science for use in tropical areas.

Creation of INCAP   

     The founding of the Institute of Nutrition of Central America
and Panama (INCAP) in 1946 in Guatemala City, Guatemala, was an
event of enormous importance.  Established by agreement between six
Central American republics and PAHO, which continues to administer
the Institute, INCAP was created to lay the foundation and foster
further development of nutrition science.  Several other entities
also had a hand in getting INCAP off the ground, including the
Kellogg Foundation and the Massachusetts Institute of Technology. 
The Institute was initially established for a period of four years,
but an agreement reached in 1949 extended its existence
indefinitely.  This decision coincided with the creation of a
Nutrition Section within the Bureau under Dr. Nevin S. Scrimshaw,
who had been the first director of INCAP, for the purpose of
strengthening aid to the countries.
     Since its foundation, INCAP has sought to help the countries
of the Region find practical solutions to their nutrition-related
problems.  Ever mindful of economic and cultural factors in the
countries, the Institute strives to ensure that local produce is
used as efficiently as possible without attempting to impose
arbitrary diets or preconceived ideas based on eating patterns in
the more developed countries.  The early surveys and research
conducted by INCAP, with support from the Bureau's recently
established Nutrition Section, made it possible to determine the
content and physiological effect of foods that are produced and
consumed locally and to introduce dietary changes aimed at
improving the health of the population.  The enhancement of survey
techniques in the 1950s vastly improved the quality of research and
made it possible to obtain data that would serve as a basis for the
design of practically all the regional nutrition programs in Latin
America. 
     INCAP's early efforts to reduce the prevalence of kwashiorkor,
a nutritional disorder associated with high rates of infant
mortality in Latin America and the Caribbean, led to the
development in the 1950s of a low-cost, high-protein mixture, with
a vegetable base.  This new product, called INCAPARINA, rapidly
gained popular acceptance, and industrial production was initiated
in Guatemala and Colombia and later in other countries.  The main
ingredient of the original product was cottonseed, but the basic
formula is adaptable and variations have been manufactured using
local sources of vegetable protein such as soybeans and peanuts. 
While INCAPARINA has been a magnificent source of sustenance for
thousands of children, its primary value lies in having shown that
it is feasible to improve the diet by taking advantage of local
resources.  This approach continues to be the cornerstone of PAHO's
efforts to combat malnutrition.
     Today INCAP is one of the Organization's five specialized
centers and is recognized as a prestigious source of experience and
provider of training and consulting services the world over.  Its
programs are continually being adapted to bring them into line with
the needs of user populations.  Currently the INCAP library
provides services to thousands of people all over the globe.  In
addition, the Institute turns out a series of regular bulletins and
other publications, and its School of Nutrition and Dietetics
offers graduate courses in nutrition and food science and
technology. 

New Era in PAHO History 

     In 1949, PASB became the Regional Office of the recently
created World Health Organization (WHO), and since then it has
endeavored to align its policies on nutrition with those of WHO
while at the same time maintaining the orientations adopted in the
course of its own history.  The ideological panorama of the postwar
period led the Organization to endeavor to bring the countries'
nutritional policies into harmony with their real needs.  To that
end, it provided technical and administrative support for numerous
field research projects and, on the basis of the findings, launched
initiatives to coordinate the actions of national, regional, and
local health planners, as well as those of the agricultural and
other economic sectors.  An event that was illustrative of the
approach followed at that time was the creation in 1950 of the
National Nutrition Institute of Ecuador (INNE), which through the
years has been the recipient of supplies, fellowships, and
personnel from PAHO. 

CFNI and its Activities

     In general terms, the work of the Pan American Health
Organization (the new name given to the Pan American Sanitary
Organization in 1958) in the area of food and nutrition underwent
its most intense phase of development during the illustrious
leadership of Dr. Abraham Horwitz, Director of the Organization
from 1959 to 1975, who labored tirelessly to ensure a high level
of nutrition for the most vulnerable population groups.  In 1967
he was instrumental in founding the Caribbean Food and Nutrition
Institute (CFNI), another of the Organization's specialized
centers, in Jamaica.  Established initially under a five-year
agreement signed by PAHO, FAO, the University of the West Indies,
the Williams-Waterman Fund, and the Governments of Jamaica and
Trinidad and Tobago, CFNI has grown rapidly and is currently
providing services to 17 countries.
     Since its inception the Institute has focused mainly on
supporting interdisciplinary initiatives aimed at finding
practical, economical, and realistic solutions to food and
nutrition problems.  During the 1960s and 1970s many of its
policies sought to reduce the prevalence of protein-energy
malnutrition among children in the Caribbean.  As a result of the
effectiveness of CFNI's strategies, today this type of malnutrition
is no longer a major problem in most of the Caribbean countries and
the morbidity profile has improved enormously.  During the 25 years
of the Institute's existence, the neonatal death rate in the
Caribbean has declined from between 80 and 150 deaths per 1,000
live births to between 11 and 41 deaths.  The rate in children aged
1 to 4 has dropped from between 6 and 37 deaths to between 0.7 and
2.8.
     Through the years CFNI has been very attentive to the
epidemiological priorities of its member countries.  It has
participated actively in the development of numerous strategies and
the formation of many entities concerned with the subject of
nutrition, and it has collaborated in scores of projects with other
organizations.  The nutritional surveys conducted in Barbados
(1969) and Guyana (1971) are outstanding examples of its diligent
efforts. 
     Dissemination of information has also been a central focus of
CFNI.  Through successful radio and videotape series and its
publications Cajanus and Nyam News, it provides the population with
up-to-date information on nutrition.  It also provides support for
training programs offered by various educational institutions in
the Caribbean.  Through a wide range of activities, CFNI is
carrying on its work of the past 25 years, offering an ongoing
testimony to PAHO's valuable contribution in the area of
nutrition.                      

Deficiency Disorders

     Motivated largely by the Organization's promotion efforts in
the area of nutrition, the Governments have focused their attention
on specific deficiencies and on the development of technologies to
enrich and fortify foods.  As early as 1940, pursuant to a
resolution of the IV Pan American Conference of National Directors
of Health, the Bureau was studying the subject of vitamin-enriched
foods and had established scientific standards for their
preparation.  In the years that followed, iodine, iron, and vitamin
A deficiencies, recognized to be important problems in the Region,
became the focus of increasing attention from PAHO and its
nutrition centers.
     The problem of vitamin A deficiency--which is associated with
night or total blindness, impaired immunity, and increased risk of
death among preschool children--came to the fore in Latin America
and the Caribbean as a result of a world survey on xerophthalmia
carried out by WHO in 1962 and of the first and second meetings
(1962 and 1968) of the PAHO Technical Advisory Committee on
Nutrition.  Prior to that time the disease had received little
attention in the Americas, despite its demonstrated frequency among
certain groups, particularly poor children under age 5.  After an
extensive epidemiological study, INCAP determined that the addition
of retinol palmitate to refined sugar was the most promising way
of correcting the deficiency.  In 1974, this method of
fortification was adapted for industrial production.  Its
application in Guatemala produced such good results that within a
few years many countries in the Region, in response to an intense
promotional campaign by PAHO, adopted laws mandating the addition
of vitamin A to sugar intended for domestic consumption.  During
the 1990s PAHO will continue to study the situation in the
countries where vitamin A deficiency is most prevalent and will
support national programs of fortification and surveillance.  These
activities, which will continue through 1999, will form the basis
of a strategy aimed at eliminating vitamin A deficiency as a public
health problem by the year 2000.
     Endemic goiter and cretinism are the two diseases most
commonly associated with a diet low in iodine, although
deficiencies of this micronutrient may cause a wide range of
organic and functional disorders.  These problems occur mainly in
inland mountain regions.  In 1941 Costa Rica imposed the first
legislation providing for compulsory iodization of table salt, and
in subsequent years PAHO was a catalyst for the passage of similar
laws in most of the countries of the Region.  As a result of these
measures, endemic goiter has been significantly reduced in such
countries as Colombia, Uruguay, and Costa Rica.
     Although iodization programs have reduced the prevalence of
goiter and cretinism in many areas, progress has been thwarted by
a number of economic, political, social, and geographical factors,
particularly in remote inland areas.  PAHO has persevered in its
efforts to continually monitor the situation and correct it through
studies of increasing scientific complexity.  It has continued to
investigate practical strategies for the supplementation of local
diets, such as oral or intramuscular administration of iodized oil. 
In 1988 PAHO developed a Regional project for the control of
iodine-deficiency disorders in Latin America, and in 1991 it again
undertook an assessment of the situation in various countries.  By
the end of 1993 all the countries are expected to have instituted
programs for epidemiological surveillance and the evaluation of
salt.  The target of eliminating iodine-deficiency disorders in the
Region by the year 2000, proposed in September 1991 during the XXXV
Meeting of the Directing Council of PAHO, will be promoted through
the Expanded Program for the Control of Iodine-deficiency Disorders
in Latin America.  This effort will involve the provision of
sustained support to the national control programs and the
development of a Plan of Action aimed at strengthening iodization
measures and encouraging public avoidance of non-iodized salt. 
     Anemia has long been an important health problem in Latin
America and the Caribbean.  In the 1960s, PAHO, in collaboration
with FAO, began to apply a coordinated strategy aimed at
investigating the role of various factors in the pathogenesis of
anemia.  In 1963 it was instrumental in establishing a regional
center within the Venezuelan Institute of Scientific Research
(IVIC) in Caracas to train Latin American and Caribbean technicians
and investigators in this area.  Despite the fact that in many
countries the majority of the population has little access to iron
of animal origin, studies have generally failed to confirm that in
Latin America and the Caribbean iron-deficiency anemia, the most
frequent form of anemia, is due chiefly to low levels of iron
consumption.  Rather, the disorder appears to be the result of a
complex set of factors only one of which is insufficient iron
consumption.  The PAHO nutrition centers are continuing to
investigate the role of diet in iron deficiency and to seek ways
in which local foods can be fortified with iron.


New Directions

     In the early 1980s, PAHO began to focus increased attention
on the nutritional needs of infants and small children as part of
its concern for vulnerable groups in general.  It supported the
International Code of Marketing of Breast-milk Substitutes, adopted
by the XXXIV World Health Assembly, and it launched its current-
day campaigns to promote breast-feeding. 
     The Joint PAHO/WHO-UNICEF Nutrition Support Program (JNSP) and
the joint PAHO/WHO-FAO-UNICEF program on food and nutrition
surveillance are examples of the new emphasis on nutrition
surveillance which grew out of the need for more up-to-date
information.  In the face of the economic crisis of the 1980s, in
1988 the Directing Council of PAHO urged the Member Governments to
take steps to improve the availability of food in low-income
populations and groups at high biological risk (Resolution XVI). 
The same year, as an outcome of the International Conference on
Food and Nutrition Surveillance in the Americas, held in Mexico
City, the Regional Training Program in Food and Nutrition
Surveillance was created for the development of human resources in
this area.     
     Today the PAHO Regional Program on Food and Nutrition
continues to carry out its activities through INCAP and CFNI.  Its
publications are a rich source of epidemiological information for
the countries of the Region, to which it provides advisory services
on an ongoing basis.  Some of its recent activities--such as the
development of a computer program for a data base and the review
of the curricula of schools of dietetics and nutrition in various
countries--illustrate the Program's capacity to evolve in response
to changing conditions.  Through these and many other similar
activities, PAHO will continue to encourage its Member Governments
to formulate and put strategies and policies on food and nutrition
into practice with a view to attaining the target of "Health for
All by the Year 2000."








ILLUSTRATIONS FROM MEDICINA NOVOHISPANA
(Distributed along the margin, no caption)

PHOTOS OF ARTICLES FROM THE BOLETIN (collage)
Articles like these are evidence of the Organization's 
early interest in nutrition problems. 

     PHOTO OF THE TITLE PAGE OF EVALUACION DE UN PROGRAMA DE
     ALIMENTACION ESCOLAR:  EL CASO ARGENTINO
     At the invitation of the Ministry of Health and Social Action
     of Argentina and the Inter-American Center for Social
     Development of the OAS (CIDES/OAS), from 1985 to 1987       
      PAHO participated in an evaluation of the school lunch
     program in Argentina.  The study made a valuable contribution
     to world literature on the subject of food and nutrition
     strategies for vulnerable groups.                           


PHOTOS OF CHILDREN RECEIVING MILK
These Guatemalan children are receiving a glass of
milk as part of a national school food program.   

     PHOTOS OF CHILDREN PLANTING SCHOOL GARDENS (collage)
     Students in Chile, Costa Rica, and the United States planting
     vegetables.  PAHO, in collaboration with FAO and UNICEF,
     established a program of school gardens with a view to
     improving the eating habits of children and their families. 
     The aim of activities like these is to promote community
     interest in good nutrition.


PHOTO OF THE FIRST MANUAL IN SPANISH ON FOOD SCIENCE
This useful set of food tables, the first ever published
in Spanish, became a basic guide for nutrition
professionals and technicians in tropical areas.


PHOTO OF THE SITE FOR THE INCAP BUILDING 
Marking the site of the new INCAP building prior to
the ground-breaking ceremony, Guatemala City, 1952.
In 1950 INCAP arranged to move from a site at the
University of San Carlos to this building, which
was completed in 1954.

PHOTO OF THE NEW INCAP BUILDING
INCAP's new facilities opened in 1954.  Its central
laboratories are still located here.  The building
was donated by the Government of Guatemala. 
Although INCAP is funded primarily through quota
contributions from PAHO member countries, it also
receives loans from various agencies concerned with
nutrition, agriculture, medicine, research, and
related fields.




PHOTO OF INCAP LABORATORY WORKERS
INCAP laboratory technicians at work.  The rapid
evolution of techniques in microbiology during the
1950s made it possible to investigate the
biochemical composition of foods, particularly
proteins.

PHOTO OF INCAP WORKER DURING HOUSEHOLD SURVEY
This Guatemalan baby enjoys good health thanks, in large measure,
to the activities of INCAP.  An INCAP dietitian carefully notes the
quantity and type of food consumed every day by the family.


PHOTO OF INCAPARINA
First sale of INCAPARINA in a store in   Palín,
Guatemala, 1960.  This inexpensive product is
similar to milk in nutritional value and has
been a valuable instrument      in the effort
to combat protein-energy malnutrition among
children.

PHOTOS OF THE MAPS OF BARBADOS AND GUYANA
(no caption)



PHOTO OF THE TITLE PAGE OF CAJANUS 
Cajanus, the quarterly journal of CFNI, focuses
on nutritional problems from a perspective that
takes into account the socioeconomic and
cultural realities in the countries of the
Region.

     PHOTO OF THE GUATEMALAN DECREE ON FORTIFIED SUGAR
     The Government of Guatemala was the first to mandate
     compulsory enrichment of sugar with vitamin A.  Sugar was   
      selected for the fortification program because it was widely
     consumed, low in cost, and being produced in well-run, well-
     equipped mills.

PHOTO OF PATIENTS WITH GOITER
Endemic goiter is a major health problem in
mountainous areas, especially in the Andean
countries.  It is characterized by a deforming
enlargement of the thyroid gland and is the
result of a shortage of iodine in the diet.
Thanks to national salt iodization policies,
endemic goiter has been significantly reduced 
in several countries of Latin America.

PHOTOS OF INDIGENOUS IDOLS WITH GOITER (scattered)     
Endemic goiter has existed in the Americas since pre-
Columbian times.  Today it is an acknowledged public
health problem which receives ongoing attention from
PAHO.

PHOTO OF IODIZED SALT
Compulsory iodization of table salt in most of
the countries in the Region has been the
primary weapon in the battle against endemic
goiter, cretinism, and other iodine-deficiency
disorders. 




PHOTO OF CONOCIMIENTOS ACTUALES SOBRE NUTRICION
This extensive classic work, originally published by PAHO
and the International Life Sciences Institute (ILSI) in
1953 and currently in its sixth edition, is a notable
example of the way in which the Organization has
endeavored to provide up-to-date instructional materials
to personnel working in the area of nutrition.


        `IDENTIFICATION` OF VIOLENCE AGAINST WOMEN IN THE
LEGISLATION OF LATIN AMERICA
Mónica Bolis *
Introduction
     Violence is a widespread condition in all societies of the
Region.  Although it affects men as well as women, it affects the
latter to a greater degree.  Aggression towards women assumes
various forms including physical, mental, and sexual abuse, and
creates qualitative and quantitative consequences that differ from
those for men. This is due to several factors; from the perspective
embodied in the existing legal resources that ought to prevent it,
to the possibility of activating the legal machinery destined to
sanction it, violence against women finds favorable conditions in
which to flourish. The fact that most modalities of abuse towards
women are not defined in the legislation makes it impossible to
correct them.  Furthermore, this type of crime has remained, until
very recently, hidden "in the realm of private life, family
intimacy, feelings of guilt and shame, and up to certain point,
traditional customs and culture".  Finally, even in situations
where there is broad legal coverage, "such regulatory progress has
not been accompanied by a parallel improvement of relations in the
sociological arena".  The influence of these sociocultural factors
produces a situation that is disadvantageous for women.  Not only
do they violate a woman's human rights, but they prevent her from
having access to the same opportunities as men, to enjoy health as
"a state of physical, mental, and social well-being".

     The existence and perpetuation of the phenomenon of violence
against women, in addition to constituting a violation of human
rights, is yet another form of discrimination against women, and
a transgression of the principles contained in declarations and
international conventions intended to prevent these aberrations. 
In some cases, the fundamental, basic legal standards of a specific
legal system do not reflect the obligations that the State has
assumed upon endorsement of the international instruments for the
protection of human rights.  In other cases, the adaptation of
national legislation to the international provisions is only
partial, or lacks the enforcement mechanisms necessary to ensure
their application. This is not to imply that the solution to the
problem of violence against women will come strictly from
legislative reform, or from increasing the punishment of persons
committing an offense.  There is an intricate web of social factors
that, together with a supportive legal regime, is required in order
to achieve effective realization of human rights.  However, the
creation of an adequate legal framework is one of the fundamental
mechanisms to establish a system that will ensure that humans live
together in dignity.

     The question then arises, if it is clear that violence against
women constitutes another violation of human rights, why do we
speak of discrimination when referring to it?  Even more so, why
do we refer to international standards as one of the regulatory
mechanisms to adapt legislation on the subject?  Because violence
against a woman is without doubt a consequence of unequal treatment
towards her person, of a restricted conception of her value and the
function that she fulfills in society.  In many cases, these
considerations pervade the legal framework and create situations
that perpetuate the same conditions of violence that the very laws
attempt to prevent.

     The reference to international law is also important. 
Although most of the international instruments on human rights do
not refer explicitly to violence against women, they generally
concur in regard to guaranteeing rights without distinction based
on race, color, sex, language, religion, national origin, birth,
or any another social condition.  By incorporating the
international provisions in its domestic law through ratification
of a particular treaty or convention, the State is committed to
adapting its legislation to the postulates contained therein, thus
ensuring the coherence and logic of its legal system.

     Within the context of these preliminary observations, this
chapter will analyze the legislation of Latin America to identify
the sociocultural factors pertaining to gender that create
favorable conditions for perpetrating violence against women.  It
will also point out those provisions that, in breaking with gender
stereotypes, make it possible to prevent or avoid situations of
violence against women, thus representing effective instruments for
achieving equity between women and men with respect to enjoying the
right to health.  The term gender will refer to "the identity of
men and women as determined by social factors (and that also
explains the relations established between them)".        

     The hypothesis used for the analysis argues that sociocultural
factors create conditions of inequality that can restrict or limit
the opportunities of women to enjoy, on equal terms with men,
health as a state of complete physical, mental, and social well-
being.  It is also argues that the influence of such factors in
legislation limits the State in fulfilling the commitments required
by its endorsement of the international instruments on human
rights, in particular the Convention on the Elimination of All
Forms of Discrimination Against Women, the American Convention on
Human Rights (Pact of San José de Costa Rica) and the Additional
Protocol to the American Convention on Human Rights (Protocol of
San Salvador).  Finally, it is recognized that the solution to the
problem of violence against women cannot be based exclusively on
legislative reformulation, that is to say, it should not be limited
to the penal, litigious, or administrative realms.  What is also
required is a change of attitude regarding the value of women, with
a subsequent elimination of the hierarchical relationship between
the sexes.

     Regarding the methodology used for analysis of the legal
standards, it is important to point out that no attempt is made in
this study to formulate value judgments with respect to the
standards, but rather to determine the extent to which the existing
provisions foster conditions that are conducive to the perpetration
of violence against women.  That is to say, up to what point these
provisions create, taking into account contemporary expectations,
conditions of inequality that allow the exercise of violence
against women.

     Based on the previous discussion, the first items to be
studied in this chapter will be the international conventions
already mentioned, which provide a framework or support for a
series of human rights principles whose validity has been
recognized by the State.  It will then analyze the general
characteristics of legislation in Latin America concerning the
treatment of violence in its different modalities.  Finally,
conclusions of the study will be formulated, and discussion
encouraged to outline a series of principles that could serve as
cornerstones in the reformulation of existing legislation.

1.   International conventions on human rights and violence against
     women

     With the exception of the Convention on the Elimination of All
Forms of Discrimination Against Women, the international
instruments on human rights guarantee indiscriminately to all
persons the rights enumerated within them. They do not specifically
mention violence against women, and when referring to women, the
documents are, for the most part, concerned with the conditions
that stem from family relationships, pregnancy, and social security
benefits. However, the instruments insist on the elimination of
discrimination and on the obligation of the State that ratifies
them to adapt its standards of domestic law in order to enact its
provisions.

1. 1 The Convention on the Elimination of All Forms of
     Discrimination Against Women

     In accordance with this Convention, "discrimination against
women" denotes every distinction, exclusion, or restriction based
on sex whose objective or result is to impair or invalidate a
woman's right to recognize, enjoy, or exercise human rights and
fundamental freedoms, regardless of marital status and on equal
terms with men, in the political, economic, social, cultural,
civil, or any another sphere (article 1).

     Although the Convention does not refer explicitly to abuse of
women, it confirms that the parties to the Convention should adopt
measures to modify or repeal laws, regulations, uses, and practices
that constitute discrimination against women, including the penal
provisions (article 2, literal "f" and "g").  In addition, it
prescribes that the parties take the appropriate measures to modify
the sociocultural patterns of behavior of men and women with a view
to eliminating biases and practices, both customary and of any
another nature, that are based on conceptions of inferiority or
superiority of either sex or based on stereotypical functions of
men and women (article 5, literal "a").  This includes the
elimination of every stereotyped concept of masculine and feminine
roles at all levels and in all forms of teaching (article 10,
literal "c").  Finally, the Convention urges the parties to adopt,
including legislation, appropriate measures to eliminate all forms
of traffic in women, prostitution (article 6), and discrimination
against women in all matters related to marriage and family
relations (article 16, numeral* 1).

     It is interesting to point out, finally, that the Convention
foresees the creation of a Committee for the Elimination of
Discrimination Against Women.  This Committee will examine the
progress achieved in the application of the standard (article 17,
numeral* 1).



1.2  American Convention on Human Rights (Pact of San José de Costa
     Rica)

     The American Convention obliges the signatory nations to
respect the rights and freedoms recognized by the Convention and
to guarantee the free and full exercise of those rights and
freedoms to everyone within its jurisdiction, without
discrimination based on race, color, sex, language, religion,
political opinions, national or social origin, economic position,
birth, or any another determinant (article 1).  In the category of
discrimination in particular, it establishes that all persons are
equal in light of the law, and hence have equal legal rights and
equal access to judicial protection (articles 24 and 25).

     The Convention also guarantees that no one can be subject to
involuntary servitude, and forbids white slave traffic and traffic
of slaves (article 6, numeral* 1).  In addition it establishes that
the parties to the Convention adopt measures to ensure the equality
of rights and obligations of spouses during the marriage and
afterwards, in the event of its dissolution (article 17, numeral*
4).


1.3  Additional Protocol to the American Convention on Human Rights
     Concerning Economic, Social, and Cultural Rights (Protocol of
     San Salvador)

     Like the American Convention, its Additional Protocol requires
that the signatory nations are committed to guaranteeing the
exercise of rights enunciated therein, without discrimination based
on race, color, sex, language, religion, opinions of a political
or any another nature, national or social origin, economic
position, birth, or another social condition (article 3).

2.   Violence in the legislation of Latin America

2. 1.  Concept of violence and modalities

     The concept of violence can be considered from different
perspectives. In the social sciences, it is common to refer to it
as "a state of exploitation and/or oppression within which any
relationship based on subordination and domination is violent.  If
violence is a form of exercising power, then a consequence is the
notion of hierarchy:  power is exercised over someone who is in an
inferior position" [7263].  Violence against women assumes several
forms.  The more notable are domestic or family violence, sexual
abuse--including violence and sexual assault-- prostitution, and
traffic in women. Other modalities build upon these and, for the
most part, tend to go unnoticed in regard to magnitude and
importance because they are not subject to public review and
because the damages that they induce are not immediately apparent.

     Among these last modalities, one should mention the violence
of the mass communications media as well as political and racial
violence.  Although political and racial violence affects men as
well as women, in the case of the women it has a different
connotation due to the factor of gender.  Added to these are other
forms of assault, currently characterized as "violence in health
care", that include situations related to delivery care or
reproductive rights, including unnecessary procedures such as
cesarean sections, and forced sterilizations and family planning
carried out without consent of the patient.  Finally, one should
not ignore the impact that "abuses of economic power" have in the
concept of violence against women.  As a consequence, women are
affected by the use of devices and drugs that have been prohibited
in the developed countries and that lack the controls necessary to
make them safe and effective.  Many of these products are used
without medical supervision, without knowing their effects, and
without the security of adequate sanitary measures.


2.2  Identifying violence.  Characteristics of the legislation of
     Latin America

     Assault in its generic form is subject to treatment in
criminal law as a body of standards directed toward the punishment
of illegal behaviors in society.  In the particular case of
violence against women, the modalities devoted to the protection
of life and health that are defined in the penal code encompass
family relations, public morality, and socially respectable
behavior.  The legal principles to protect the physical and mental
integrity of women appear to be passed over because of this
framework and the need to confer priority to other concepts, such
as the integrity of the family, honor, and modesty, which at a
specific historical moment were recognized as superior. These
factors intervene in defining unlawful behavior and, in most cases,
make it possible for the person charged with criminal action to
have the case dismissed. 
     In addition to the conditions that have already been mentioned
are judicial systems that, supported by stereotyped sociocultural
values regarding gender, become disparaging when addressing the
battered woman.  In most cases the aggressors are not stopped
immediately after the commission of a crime, making it easy for
them to continue their aggressive acts.  Police institutions are
directed for the most part by men who lack the necessary training
to confront charges of abuse or rape. Finally, the judicial
processes often become lengthy and humiliating, and are abandoned
by the victims before a sentence is ever pronounced .

     The sociocultural factors mentioned interfere with the legal
arguments in many cases and create situations that perpetrate the
continuity of the aggressive behavior.  Thus, for example, it is
not unusual for the justice administration to regard cases of minor
injury as incidents of limited social importance which should be
judged benignly.  Further complicating the situation are the
mechanisms of reporting this type of crime and the methods of proof
used.  In order to initiate the judicial process for treating
crimes of private action, it is required that the police report be
filed by the victim, thus reducing considerably the number of
reports filed.  The need for witnesses ignores the fact that these
types of violent assaults may be carried out in the most private
manner or in the privacy of the home.  Finally, forensic
certification of lesions is based on the physical injury without
taking into consideration the psychological harm that is produced.

2. 2. 1 Domestic or family violence

     Domestic or family violence is manifested by a series of
assaults that range from physical and mental abuse to homicide. 
In most of the legislation in Latin America, abuse of women within
marriage, or an arrangement of cohabitation, is not a configuration
expressly defined in penal legislation.  In breaking with this
principle, the new Penal Code of Honduras will punish whoever
batters his wife or the woman with whom he has established a
marital life, even if she does not sustain injuries.  Other legal
arrangements, however, lack this type of foresight.  Such is the
case, for example, in the legislation of Chile, Costa Rica, El
Salvador, Nicaragua, Panama, Paraguay, and Venezuela.  There
exists, indeed, in legislation of Latin America, other criminal
laws that penalize violence in general, and that are considered in
the sections of the penal arrangement corresponding to assault
against the body, life and health, threats and personal injury in
its various types:  simple, mild, serious, or very serious.

     The homicide of the spouse, or uxoricide, as a rule
constitutes a qualified homicide.  The aggravant is based on the
legal tie created by the marriage.  Some legislation also includes
in the aggravant the homicide of the concubine, when she has shared
a marital relationship with a man and they have children together. 
Such is the case, for example, in the legal arrangements of Costa
Rica, El Salvador, Guatemala, Haiti, Mexico, and the Dominican
Republic.  However, the aggravant based on family ties loses
effect in some cases in light of the configuration of adultery. 
Thus, for example, the Paraguayan Penal Code, in the section
corresponding to the crimes against the order of families and
socially respectable behavior, excuses from punishment the husband
that kills, wounds, or abuses his wife if he surprises her
unexpectedly in the act of adultery.  It does not excuse the
behavior of women in the case of malicious abandonment or in the
case of public or scandalous adultery of the husband.  Furthermore,
if the woman commits a similar action upon finding the husband in
flagrant adultery, she would receive the punishment for uxoricide
without any consideration of extenuating circumstances.  The
impunity of uxoricide on the grounds of adultery by the woman is
also envisaged in the criminal justice system of Haiti.

     Venezuelan penal legislation considers extenuating
circumstances in the behavior of the husband who surprises his wife
in adultery, while the legislation of Mexico and Nicaragua consider
extenuating circumstances in the case of homicide practiced by
either spouse.  Finally, the Dominican penal arrangement utilizes
the configuration of the passionate crime among the epithets of
violence against women, referring to this in the section
corresponding to crimes against honesty and modesty. 
Characterizing the crime in this way makes it easy for those
responsible for the crime to be absolved of blame by application
of the exemption for the passionate crime in the cases where women
are murdered by their spouses, ex-spouses, or couples.

     In some legal arrangements, civil legislation provides
resources to address violence against women.  Thus, for example,
in Argentine civil law acts of physical or psychological violence,
together with sexual violence, are considered serious offenses. In
this situation it is possible to remove the aggressor from the home
as a means of protecting the victim.  It also envisages the
abandonment of the home by the abused woman without this course of
action having legal consequences for divorce, custody of the
children, alimony and/or child support, and the right to inherit. 
Costa Rican family legislation also envisages domestic violence as
grounds for divorce and legal separation.  Uruguayan legislation,
among its civil resources to counter assault, grants divorce at the
sole request of a woman so that she may be separated from the
aggressor, and he may removed from the home.  Venezuelan
legislation includes the following behaviors among the grounds for
divorce:  excesses, cruelty, and serious abuse that make life
together impossible.


2.2.2 Sexual abuse:  Rape and sexual harassment 

     Legislative references to rape appear in the sections of the
penal codes devoted to penalizing behavior that offends norms of
social respectability, public modesty and honesty, sexual morality
and freedom, and the structure of the family.  Rape is defined as
sexual activity carried out without consent of the victim.  The
variables utilized in order to determine the gradations of
punishment are based on the age of the victim and on the status of
the perpetrator with regard to the presumption of trustworthiness
or exercise of authority.  Legislative standards generally concur
in utilizing the age of the victim as a determinant for deciding
on the punishment.  Thus some of the factors taken into account are
whether or not the woman is unmarried, married, or a virgin. 
This determinant provides that under some legislation, the fact
that the victim is a prostitute lessens the punishment of the
violator. Such is the case of legislation of Colombia, Paraguay,
El Salvador, and Venezuela.

     Within the category of sexual crimes, the legislation includes
in addition to rape, other modalities such as the rape of a virgin
and seduction.  In general, the laws coincide in regard to the
connotation of each crime. Rape of a virgin is defined as
copulation with a woman who provides her consent, when this is
found to be invalidated by sexual inexperience.  In seduction, the
false promise of marriage is made in order to achieve intercourse. 
Also relevant or applicable in this case are the determinants that
refer to an age limit--which usually fluctuates between 12 and 21
years--and the credibility of the woman.  Use of the legal
configuration of seduction, allows some crimes to be judged in
favor of the delinquent.

     The laws do not identify rape within marriage as a crime,
although sexual violence is in some cases recognized as a serious
offense.  Neither do they refer to sexual harassment in the penal
code or employment regulations.

3.   Conclusions and discussion

     The legislation reviewed is heavily charged with sociocultural
factors relevant to gender that can potentially have damaging
effects on women in regard to their health and physical integrity. 
Important fundamentals that are based on the order of socially
respectable behavior, morality, honor, and modesty act as variables
for defining crime and determining the gradation of the punishment
applicable to the aggressor.  Some legal arrangements grant the
victim of assault civil resources that, in case of marriage, permit
divorce or separation from the person inflicting the suffering
without this action damaging the legal standing in light of the
dissolved union. In most cases these measures, although
significant, do not bring about the expeditious action needed by
the aggrieved person.  The situation is further complicated in the
cases of laws that utilize the configuration of adultery as grounds
for case dismissal of homicide committed by the husband where the
woman is the victim.  The fact that the deed may be committed with
impunity by both spouses does not rectify this anomalous situation.

     The treatment of rape as an unlawful act also suffers from
serious implications of gender.  The characterization of this, and
of other sexual crimes within the category of crimes against
modesty, morality, and socially respectable behavior serves to
reduce the severity of such crimes on the basis of subjective
considerations that invalidate the relevance of the punishable
fact.  It involves a distorted concept which one should consider
as a legal principle to be protected and from which is derived a
set of standards for respectable behavior.  This distortion
perpetuates a hierarchy in which women are found to be inferior to
men.  It also constitutes a manifestation of values that conform
to historical notions of ownership of one sex by another, or to
determined regulatory patterns of proper or improper sexual
behavior that have changed or are in a state of evolution.  As a
result criminal law, which in a social context is maintained as a
regulator of the behaviors that can be considered detrimental to
society at a given time, should seek in order to be valid, to adapt
to the new realities.  In order to be just, the law "should be the
contemporary history of justice that develops naturally within
society and that social law does not create, but rather
sanctions."

     In the case of violence against a woman, the legal principle
must be the protection of her life, safety, and physical and
psychological integrity. Although the implications in regard to the
relationship between morality and the law are not coincidental, it
is not erroneous to affirm that "[The] criminal law should not be
a moral code that contains the enumeration of desirable or
undesirable behaviors from an ethical point of view.  The punitive
text ... included therein should not be an instrument to provide
spiritual salvation to subjects of the law".  Thus, the
intervention of criminal law in the behavior of the individual
should be based on the injury or unjust harm that is caused to
another person or to the community.  In the case of sexual
behavior, for example, this "should be punished when it is imposed
on a passive subject with the use of violence, intimidation, or
through abuse of a dependent relationship".  This is why
considerations such as age, morality, the legal or social condition
of women, whether or not a spouse fulfills the duty of fidelity,
should not excuse or lessen the seriousness of crimes of violence.

     The fact that women remain unprotected in situations of
violence is not only due to the wording of the law. The judicial
machinery also creates impediments.  Instead of protecting the
victim against future assaults, it places her in position of
physical and psychological vulnerability. The processes are lengthy
and tedious, the mechanisms of proof are based on requirements that
are unattainable.  Police personnel without experience in treating
victims of domestic violence and rape, and a judicial culture
usually centered on patriarchal values, are offensive and
discourage the initiatioin of processes that ultimately result in
the denigration of the victim.

     The solution to the problem of violence against women will not
be addressed by a single action.  Although it recognizes that it
is essential to adapt national legislation to the principles of
non-discrimination contained in the international instruments
endorsed by the State, it requires additional factors.  In the
first place, criminal justice should define violence so that the
interests and safety of the victim prevail.  This includes not only
recognizing domestic or family violence among the unlawful acts,
but also of other types of assault such as rape within marriage and
sexual harrassment. Adultery and the passionate crime should be
abandoned as grounds for case dismissal or for reducing the charges
in the cases of homicide where a woman is the victim of her husband
or partner. 

     The processes of reporting and judging the incidents of
violence should be streamlined. The police system should rely on
trained personnel to respond to and process cases of abuse and
rape. Several countries of the Region already report positive
experiences in this regard.  The system of reporting an incident
should be reviewed to remove domestic assault and rape from the
sphere of private action and permit reporting of it by any
interested party.  The mechanisms of proof should be realistic and
take into consideration the special circumstances in which the
incidents of domestic violence and rape occur.

     The review of the current system should not be limited to
penal legislation or to the litigious or administrative realms. 
Other norms such as those found in civil and labor regulations
should, when they represent archaic structures, be relaxed to
eliminate sex hierarchies in society.  Finally, the cultural
standards should be modified.  The vision that is typical of women
as passive and vulnerable in many cultures should be set aside and
replaced by one that values women for the function that they
perform in society as the agents and promoters of economic,
cultural, and social development.  This goal requires public and
private action.  It is necessary to change the stereotypes that
have characterized women from the beginning of time. Restructuring
the educational system and information media constitute an
indispensable mechanism for this purpose.  Several legislative
initiatives have begun to satisfactorily activate changes in this
regard.  The action of the private sector not only is effective
in financing centers for the protection of battered women, but also
as a resource for the education of women in general regarding their
rights and prerogatives.  Finally, it is indispensable that women
become aware of their potential and of their position as a social
class, and rebuild the dignity which is frequently forsaken.















E0237.FIN












PAN AMERICAN HEALTH ORGANIZATION (PAHO)
WORLD HEALTH ORGANIZATION (WHO)








SUBREGIONAL PROGRAM ON
ENVIRONMENT AND HEALTH IN THE
CENTRAL AMERICAN ISTHMUS (MASICA)







PROJECT:
EDUCATION ON THE ENVIRONMENT AND HEALTH






















MANAGUA, NICARAGUA
MAY, 1992
SUBREGIONAL PROGRAM ON "ENVIRONMENT AND HEALTH
IN THE CENTRAL AMERICAN ISTHMUS" (MASICA)

        PROJECT:  EDUCATION ON THE ENVIRONMENT AND HEALTH


EXECUTIVE SUMMARY


     The principal purpose of the Project on Education on the
Environment and Health, which is part of the MASICA Program, is
to contribute to the improvement of health and the quality of
life of the population of the countries of the Central American
isthmus.  This is sought by increasing knowledge of the Man-
Health-Environment relationships of approximately 30 million
people.  They would thus be better able to participate in
identifying and solving both large and small problems in the
household, peridomiciliary, and working environments.

     In this context, special attention will be given to women
and indigenous groups speaking their own languages.

     Over four years the project proposes to coordinate and
orient the formation of mechanisms and infrastructures which
prepare the policies, methodologies, materials, human resources,
and other resources necessary for including continuous teaching
on the health aspects of the Man-Environment relationship in the
educational programs and social communication of the 7
participating countries (Belize, Costa Rica, El Salvador,
Guatemala, Honduras, Nicaragua, and Panama).  Teaching and
information activities will be promoted and supported by the
project during that period.

     Subregional mechanisms for coordination, orientation, and
monitoring will be established under a policy of maximum
utilization of already existing resources and experiences, thus
avoiding unnecessary duplications and jurisdictions.  Greater
emphasis will be placed on the maximum participation of
nongovernmental, community, and union organizations.

     To achieve its objectives, the project proposes to group its
activities in four subject areas which will allow the
participation of the three major channels that exist in the
countries for education and social communication.

     The objective of Subject Area I is to introduce
environmental teaching into the teaching plans and programs of
the formal education system at the pre-primary, primary,
secondary, technical, normal, and university levels.

     Subject Area II will support the execution of research
projects to identify contents, educational models, and techniques
of communication oriented on a priority basis to specific
situations and publics that include women, labor groups, and
minority groups such as the indigenous population speaking its
own languages.

     Subject Area III seeks to create mechanisms of education
coordination and orientation for the agencies and institutions
which deal with nonformal education and social development. 
Among such agencies and institutions are, among others, NGOs,
cultural and social associations, service clubs, sports guilds,
cooperatives, and organized community groups.  The preparation of
specialized materials and texts will be utilized to stimulate the
process.

     Subject Area IV proposes to catalyze installed capacity in
the countries in terms of social communication (radio, TV,
newspapers, etc.)  so that they are systematically devoted to the
dissemination of information on the environment and health, thus
to some extent dealing with the problem of high indexes of
illiteracy in the subregion.

     During the fourth year the project will place emphasis on
the preparation of national and subregional ten-year plans to
ensure that environmental and health education and information
activities have continuity.

     The total budget of the project is US$2,793,510, with
partial allotments of US$660,569, US$1,034,317, US$609,569, and
US$489,055, respectively, in the first, second, third, and fourth
years.








May 1992










FRAMEWORK FOR THE EXECUTION OF THE
EDUCATION ON THE ENVIRONMENT AND HEALTH PROJECT




     1.   Interrelationship of the projects which
compose the MASICA Program.

     2.   Strategies for the execution of the MASICA
Program.

     3.   Coordination between the participating
countries and the MASICA Program.

     4.   Approach of the "Education on the
Environment and Health" Project with respect
to the cultural diversity of the Region.

     5.   Audiences to which the nonformal education
activities of the "Education on the
Environment and Health" Project are geared
and mechanisms for its participation in
them.

     6.   Advances in implementing the projects of the
MASICA Program.
1.  INTERRELATIONSHIP OF THE PROJECTS COMPOSING THE MASICA
     PROGRAM


     The Environment and Health in the Central American Isthmus
Program (MASICA) is designed on the basis of close
interdependence between the seven projects that compose it.  Four
projects (substantive projects) are intended to improve the
capacity of subregional and national management of public and
private institutions to deal with the following situations of
deterioration in environmental health:  pollution of water for
human consumption, inadequate and dangerous accumulation of solid
wastes, growing industrial and vehicle contamination, and
deterioration in the environment and health caused by the
unrestricted use of pesticides.  The three remaining projects are
oriented to strengthening the first four by strengthening
institutional capacity, environmental education for citizens and
professionals, and evaluation of the impact that development
works have on the environment and health.

     The seven projects can be considered a whole in a matrix of
close interrelationships in which there are activities of
synergistic complementarity and strengthening.

     Within this context, and taking as an example the Education
on the Environment and Health Project, the strategic element of
MASICA is to develop and establish plans, programs,
methodologies, and educational activities whose results will make
it possible to increase knowledge and establish habits and
attitudes which guarantee better health status, an increase in
the quality of life, and behavior which promotes rational use and
conservation of natural resources, thus constituting a basis for
conducting the training component of the substantive programs.

     While the Education Project is oriented toward the citizenry
in order to produce changes in behavior which facilitate the
achievement of the objectives of the substantive projects, the
objective of the training component of such projects is to
provide training in the acquisition of specialized knowledge and
skills to learn to "do things" and resolve problems in their
specific fields of action:  water, refuse, industrial wastes, and
sustainable development planning.

2.  STRATEGIES FOR CARRYING OUT THE MASICA PROGRAM


     The fundamental strategy for carrying out the MASICA Program
as a whole is to strengthen interinstitutional coordination of
the counterpart organizations in each project and to take
advantage of already existing structures, jurisdictions, and
facilities rather than to create a new apparatus for execution.

     In the Education on the Environment and Health project, the
principal counterpart institutions in each country will be the
Ministries of Education and Health.  To complete the Advisory
Group of the Project, those institutions which in the judgment of
the national authorities have obligations in carrying out
specific activities within each Subject Area should be included. 
It is expected that such institutions will make a formal
commitment as to any part for which they are responsible in
carrying the Project out.  The Coordinator of the Advisory Group
will be a staff member who will act as the Focal Point designated
by the Ministers of Education and Health of each of the Central
American countries.

     In addition to the two Ministries mentioned above, the
following institutions or their equivalents in each country
should be considered as forming part of the Advisory Group:

Ministry of Natural Resources and/or of the
Environment.
National Commission on the Environment (CONAMA).
Institute of Municipal Promotion.
Universities.
Nongovernmental agencies, including unions of educators
and other professionals.
The official press and public information agencies of
the governments.
The educational research institute (if one exists).

     Each country's annual plans of work (APW) should be prepared
jointly by the Technical Coordinator of the Project, the
Subregional Coordinator of MASICA, and the national authorities
represented in the Advisory Group, and will have to have the
approval of the Focal Point.  Based on this Annual Plan of Work
(APW), which will also contain a timetable and budget, the Four-
Month Plans of Work (FMPW) will be disaggregated in accordance
with the normal practice of the Pan American Health Organization
(PAHO/WHO).  The Technical Coordinator of the Project will make
an evaluative status report on each FMPW, and at the end of the
year a joint general evaluation will be made with the Advisory
Group.  Donors will receive copies of the four-month and annual
evaluations.  Every two years a joint evaluation will be made
with the donors, Advisory Group, and the Technical and
Subregional Coordinators of MASICA/PAHO.

3.  COORDINATION BETWEEN THE PARTICIPATING COUNTRIES AND THE
     MASICA PROGRAM


     Coordination of the efforts in the seven countries
participating in MASICA will be through the Directors-General of
Health of each of the countries.  During the course of each year
the Directors meet several times as subregional circumstances
warrant, but as already established do so formally at least once
a year to prepare for the RESSCA annual meeting (Meeting of the
Health Sector of Central America), which the Ministers of Health
attend.  On that occasion the Subregional Coordinator of MASICA
meets with the Directors-General to report on the progress of the
Program and receive observations and suggestions for future's
planning activities.  This is the highest level of coordination
of MASICA, and at it strategies for attaining objectives are
determined and refined and the execution of activities is
coordinated.  As other MASICA projects in addition to the
Institutional Strengthening one are financed, their Technical
Coordinators will also be included in this meeting with the
Directors-General.  It is important to note that the RESSCA is
the highest decision-making level in the Health Sector of Central
America and as such defines the programming priorities of the
Region.

     The RESSCA has defined Environmental Health as priority Area
IV for the next five-year period (1991-1995); the VIII RESSCA of
1991 issued a ministerial resolution of support for the
MASICA/PAHO projects.

     The Directing Council of MASICA will adhere to the
priorities, orientations, and decisions established by the RESSCA
in the area of its competence.  It will be composed of the
Subregional Coordinator, Focal Points of the projects under way,
and their respective Technical Coordinators.  The council will
determine the principal working directives at the subregional and
country levels, and will guide the Subregional Coordinator's
office by evaluating its reports.

     In technical matters, the Subregional Coordinator's office
currently receives strategic assistance and guidance from the
Environmental Health Program (HPE/PAHO) of the Organization, as
do its specialized Centers, the Pan American Center of Human
Ecology and Health (ECO/PAHO), located in Metepec, State of
Mexico, and the Pan American Center for Sanitary Engineering and
Environmental Sciences (CEPIS/PAHO), located in Lima, Peru.

     Below is a scheme of the agencies of coordination for the
execution of the Project.
MEETINGS OF DIRECTORS-GENERAL OF HEALTH
SUBREGIONAL COORDINATOR OF MASICA
TECHNICAL COORDINATORS OF PROJECTS



DIRECTING COUNCIL OF MASICA
SUBREGIONAL COORDINATOR OF MASICA
PROJECT FOCAL POINTS
PROJECT TECHNICAL COORDINATORS


PROGRAM ON 
ENVIRONMENTAL HEALTH
HPE/PAHO

CEPIS, ECO

SUBREGIONAL COORDINATOR OF MASICA
SAN JOSE, COSTA RICA




COUNTRIES



     MINISTRY OF HEALTH

     FOCAL POINT   LIAISON AND FOLLOW-UP           LOCAL PAHO/WHO
     IN EACH COUNTRY           TECHNICIAN          REPRESENTATION


     ADVISORY GROUPFLOW CHART OF PROGRAMMING/EVALUATION
FOR MASICA/PAHO PROJECTS



DAP/PAHO DONOR


     DECISIONS OF THE RESSCA

ANNUAL PLANS OF WORK (APW)      FOCAL POINT
1 PER PROJECT/COUNTRY           TECHNICAL COORDINATOR
INSTITUTIONS
ADVISORY GROUP



APPROVAL                   DIRECTING COUNCIL
(SUBREGIONAL
COORDINATOR/
TECHNICAL COORDINATORS/
FOCAL POINTS)


EVALUATION     IMPLEMENTATION             SUBREGIONAL COORDINATOR
TECHNICAL COORDINATOR


FOUR-MONTH PLANS OF WORK   FOCAL POINT/ADVISORY
GROUP
(FMPW)                     TECHNICAL COORDINATOR


EVALUATION     IMPLEMENTATION             FOCAL POINT/ADVISORY
GROUP/
TECHNICAL COORDINATOR
HPE/ECO/CEPIS
4.  APPROACH OF THE "EDUCATION ON THE ENVIRONMENT AND HEALTH"
     PROJECT  WITH RESPECT TO THE CULTURAL DIVERSITY OF THE
     REGION


     Central America is a culturally very varied region with
major human conglomerates which have different cultural patterns,
which the Project will take into consideration, especially in the
Subject Areas of Nonformal Education and Informal Education.

     The sociocultural differences in each of the Central
American countries will be reflected in the annual and four-
month programming of activities, in each case by designing
environmental education, training, and participation activities
which are appropriately directed.  The Focal Point and the
Advisory Group in each country should consider this dimension of
sociocultural particularity of the groups toward which the
educational activity is geared.

     In the case of Guatemala, where nearly 60% of the population
is indigenous, local programming will be adapted so that the
activities of the project reach this social conglomerate, which
has its own cultural characteristics, including 22 indigenous
languages and numerous dialects.  This will be carried out in the
activities of Subject Area III of the Project and specifically in
items 2.1.1, 2.1.3, 2.1.4, 3.1, 4.1.1, 4.1.2, 4.1.3, 4.1.4, and
5.1, as well as in item 1.1 of Subject Area IV.

     In Guatemala, and perhaps in Nicaragua if thought desirable,
extension activities and radial campaigns will be carried out in
the languages of the indigenous groups.

     In Honduras, the situation of the ethnic minorities of
Miskitos and Sumu will be considered.

     In Nicaragua, in addition to the Miskitos and Sumu, the
indigenous Rama will be taken into account.

     In Panama, the Kuna, Chocoes, Guaymies, Emberá, and Teribes
groups will be considered.  In all these cases, strategic
attention will be given to training agents of change and
community/educational leaders in each group.

     In programming activities in the countries, in addition to
considering the groups mentioned above, special attention will be
given to certain social sectors such as women, young people,
children, social communicators, and religious groups which work
at the community level.
5.  AUDIENCES TO WHICH THE NONFORMAL EDUCATION ACTIVITIES OF THE
     "EDUCATION ON THE ENVIRONMENT AND HEALTH" PROJECT ARE GEARED
     AND MECHANISMS FOR THEIR PARTICIPATION THEREIN


     The principal social groups which are targets of the
activities of Subject Area III ("Nonformal Environmental
Education") are:  nongovernmental organizations (NGOs) which
carry out activities in the field of Environmental Education,
especially the Network of Nongovernmental Environmental
Organizations for the Sustained Development of Central America
(NETWORKS-CA), organizations of women, young people, social
communicators, community leaders, community health promoters,
mayors and aldermen, municipal promotion organizations, ethnic-
national groups, and farmers.  Such groups, when annual planning
is conducted in each of the countries (APW), will participate in
programming the educational activities involving them as well as
in their execution and assessment.  The principal mechanisms of
participation in the Project will be the following:

     a)   Courses, seminars, workshops, and round tables.
     b)   Strengthening of organizational mechanisms.
     c)   Exchanges of educational experiences.
     d)   Biddings on environmental subjects (paints, texts,
etc.).
     e)   Involvement of the municipal level.
     f)   Involvement through local health systems.

     Points e and f are of much interest since they are based on
the process of administrative decentralization of the state and
the health services in the Central American countries as well as
on growing municipal autonomy.  The municipal level is that which
is most closely linked to the basic social actors whose
relationship to the environment and natural resources is most
intimate.  In this area the Nonformal Education Project will
carry out many of its activities in coordination with and with
the participation of mayors and aldermen.

     At the same time the activities in this area of the
Environmental Education Project will provide contents and
mechanisms so that the health sector can act in line with "Health
Promotion" proposals, mainly in terms of environmental health
promotion and environmental primary health care.
6.  ADVANCES IN THE IMPLEMENTATION OF THE PROJECTS OF THE MASICA
     PROGRAM


     The first project financed in the Program has been that of
Institutional Strengthening, which receives the support of the
Norwegian Development Cooperation Agency (NORAD).  The project
was initiated in March 1991 and among its objectives is creating
the institutional conditions necessary for the execution of the
other MASICA/PAHO projects.  A year after its execution began,
this Project has made it possible for the MASICA Program to have
an active presence and general acceptance in the most important
environmental health forums in the Region.

     Coordination mechanisms have been established with the
principal subregional agencies which operate in these areas,
among which CCAD, CICAD, NETWORKS-CA, UNICEF, UICN, UNEP, AIDIS,
CATIE, ICAITI, CAPRE, environmental NGOs, and international
cooperation agencies deserve to be mentioned.  At the country
level the activities have aimed at strengthening national
capacities for diagnosis, planning, and intervention to preserve,
remedy, or improve the environmental conditions that affect
health.

     Focal Points have also been established and a stage of
coordination has been achieved between different governmental
institutions and the NGOs that interact in the area of the
environment and health by uniting them all in the Project's
Advisory Group.

     The results of these activities are designed to facilitate
arrangements for identifying suitable counterparts, as well as to
arrange for the resources required by the projects on Water
Resources and Drinking Water Quality, Management of Hospital
Solid Wastes, Pesticides, Education for the Environment and
Health, Evaluation of Environmental and Health Impacts, and
Industrial and Vehicle Contamination.

     At the beginning of December 1991, having refined its
mechanisms of administrative coordination with the Ministries of
Health and the PAHO/WHO Country Representatives' offices and
defined the roles of the Focal Points and the Support Groups at
the country level, the subregional headquarters of the Project
was transferred to San José, Costa Rica.

     Among the activities carried out are:

Two subregional courses on environmental toxicology in
Nicaragua and Costa Rica, respectively.

The organization of a MASICA newsletter, with two
issues already published.

The organization of a census of nongovernmental
organizations in the health and environment field in
Central America.  The corresponding directory is
currently being printed.

Collection of all legislation on health and the
environment in the countries of Central America (in the
process of publication).

Collection and classification of methodologies and
techniques for community participation in environmental
and health matters in Central America.

Support for the V Meeting of First Ladies of Central
America on the subject of Environment and Development,
which was held at Managua from 18 to 23 November 1991.

From 13 January to 13 February 1992, MASICA accompanied
a Danish International Cooperation Agency (DANIDA)
mission through Central America whose objective was to
evaluate the "Occupational and Environmental Aspects of
Exposure to Pesticides" project which is currently in
the final phase of review by that Agency.

In the same way, another evaluation mission, this time
by the Swedish Agency for International Development
(ASDI), was accompanied by MASICA in its visit to
Central America from 29 March to 11 April 1992 in order
to evaluate another of its Projects, "Conservation of
Water Resources and Surveillance of Drinking Water
Quality in Central America."  The Agency agrees on the
importance of the topic, and it is now also in the
phase of final review of this important project.

The European Economic Community (EEC) has approved a
project prepared by the Environmental Health Program
(HPE/PAHO) and MASICA/PAHO relative to the control of
dangerous hospital refuse in the Region, which grew out
of the original "Management and Control of Solid Wastes
and their Effects on Health and the Environment/MASICA"
project.  The hospital refuse project will be carried
out mainly in bilateral form and it remains to be seen
what contribution MASICA/PAHO can make to its
execution.

During the third meeting of consultation with the
Nordic countries, the Finnish Cooperation Agency
(FINNIDA) showed some interest in MASICA's "Industrial
and Vehicle Contamination in Central America" project
but made clear that this year it cannot contribute to
carrying the Program out.

Informal conversations have been held with the Central
American Bank for Economic Integration (CABEI) about
the possibility of financing the "Evaluation of the
Impact on the Environment and Health of Development
Works (EIAS)" project since this type of practice is
being promoted by the Bank in its investment proposals.

A more detailed evaluation and new negotiations by the
Program with international agencies will be made during
the I Central American Conference on Ecology and Health
(ECOSAL I), which is being convened by the Ministers of
Health of Central America with the organizational
support of the Organization's Environmental Health
Program (HPE) and MASICA.  This important Conference,
the first of its kind, will be held in El Salvador in
mid-1992.





     The XII Meeting of the Special Subcommittee on Women, Health, and
Development of the Executive Committee was held at the Headquarters of the Pan
American Health Organization, in Washington, D.C., from 6 to 8 April 1992.  The
meeting was chaired by Dr. María Elena de Rivas of Honduras.  Mr. Burton Williams, of
Saint Vincent and the Grenadines, served as Vice Chairperson and Ms. Maritza Tamayo,
of Cuba, as Rapporteur.

     After presentation of the report of on technical cooperation activities, the
Subcommittee discussed the achievements that have been made and suggested that the
leadership role of the Regional Program on Women, Health, and Development should be
strengthened in order to facilitate introduction of the gender approach in the activities of
all technical cooperation programs within the Secretariat.

     The project "Comprehensive Health of Women in Central America" was discussed
and recognized to be a pioneering experience.  The Subcommittee recommended
continued promotion of the processes of co-management involving women's
organizations and health services at the local level and emphasized the need to find
alternative approaches.

     On the topic of women's health and self-care, the Subcommittee pointed out that
this initiative constituted a contribution toward the promotion of women's health and
toward the establishment of a real policy of participation by women in actions to foster
their development and improve their own health.  Recognizing the importance of the
subject, the Subcommittee recommended that further work be done to perfect the
conceptual framework and requested the Secretariat to prepare a proposal of Regional
strategies and concrete lines of action to develop this approach and increase understanding
thereof in the countries.

     Following presentation of the report on the situation of research on women, health,
and development, the Subcommittee endorsed the recommendations contained in the
report and suggested development of a policy to promote research in this area.  It
recommended that the Secretariat support the efforts aimed at presenting and publishing
health statistics with a breakdown by sex and that it promote the analysis of differences
as a means of encouraging research with a gender perspective.

     In response to the report on woman, work, and occupational health, the
Subcommittee pointed out the need for addressing this issue with a gender perspective. 
It was recommended that a special effort be made to promote research and provide a
breakdown by sex of the information that is obtained through surveillance systems in
occupational health.

     Finally, the Subcommittee took up the issue of the status of women within the
Secretariat, placing particular emphasis on the limited numbers of women in positions of
authority.  It suggested that the Secretariat undertake a closer study of the barriers that
limit the recruitment and hiring of women and report on its findings.

     The Executive Committee is requested to examine the report and make any
pertinent observations.  In particular it is asked to comment on the feasibility of the
recommendations made with regard to PAHO's technical cooperation program. 


Project Profile

     CENTERS FOR ADVANCED TRAINING IN OCCUPATIONAL HEALTH
(CEFASO)

I          BACKGROUND

The participants in the Workshop on Human Resources in Occupational Health for
the Region of the Americas, bearing in mind that 1992 was designated the Year of
Workers' Health by the XXIII Pan American Sanitary Conference and aware of the
importance of manpower training, proposed to pool efforts in this area through the
establishment of a network of institutions under the name "Centers for Advanced Training
in Occupational Health (CEFASO)."


II         PURPOSE

To establish mechanisms of collaboration for the promotion and strengthening of
programs and activities to provide advanced training in occupational health for teaching
personnel in the participating Centers, the ultimate purpose being the achievement of
academic excellence.


III        OBJECTIVES

To upgrade the academic levels and the processes of teaching and learning in the
area of occupational health in the Region of the Americas.


IV         COMPONENTS

a) Training

Promotion of the development of high-level events and activities for educators in
the Centers that offer master's degree programs in occupational health and related
sciences, education, and research methodology.

b) Dissemination

Dissemination of information and promotion of participation by the network
Centers in high-level academic activities in the above-mentioned disciplines being
carried out in other Regions of the world.

c) Exchange of Materials

Promotion of the production and exchange of educational materials between the
Centers.

d) Publication

Establishment of a scientific journal to disseminate and promote the results of
research carried out in the Centers, publish articles on topics of interest, and
announce events and activities to be held.

e) Exchange of Data

Creation of a network for the exchange of bibliographies, information from data
banks, etc., between the participating Centers.

f) Research

Promotion of the development of local and collaborative research. 

g) Exchange

Promotion and facilitation of the exchange of educators, investigators, and students
between the participating Centers, as well as with others entities inside and outside
the Region.

h) Collaboration

Establishment of mechanisms to promote collaboration between the network and
universities, organizations of workers and employers, and reference centers with
a view to ensuring attainment of the objectives and targets.

i) Financial Resources

Identification and facilitation of financing.


V          COORDINATION

The initial focal point for the network of Centers will be the PAHO Program on
Workers' Health, with participation by the PAHO/WHO collaborating centers concerned
with occupational health issues.


VI         FINANCING

Possible sources of financing for the activities of the network of Centers are local,
international, binational, or multinational agencies.




SHORT-TERM PLAN OF ACTION

(Period:  weeks)
ACTIVITYFirstSecondThird1. Preparation of profile2. Distribution of profile
    Analysis of Centers3. Preparation of project4. Approval and final selection
      - Centers
      - Universities, etc. 5. Negotiation and
    financing6. Execution of program budgets7. Adjustments and evaluations8.Preparation and approval of biennial                                                                            programs
____________
       - By country
       - Consolidation







REPORTS

SYMPOSIUM ON THE
EPIDEMIOLOGY OF THE
FOOD-BORNE PARASITIC ZOONOSES











     X LATIN AMERICAN CONGRESS OF PARASITOLOGY


        I URUGUAYAN CONGRESS OF PARASITOLOGY


17 to 22 November 1991


MONTEVIDEO, URUGUAY









PAN AMERICAN HEALTH ORGANIZATION
  REGIONAL OFFICE OF THE WORLD HEALTH ORGANIZATION

     PAN AMERICAN INSTITUTE FOR FOOD PROTECTION
AND ZOONOSES (INPPAZ)
VETERINARY PUBLIC HEALTH PROGRAM




Background

     The food-borne diseases continue to be one of the greatest
problems that affect the health of the population of Latin
America and the Caribbean and are consequently a serious concern
of the governments and the health authorities of the countries. 
It is evident that the problem of the parasitic food-borne
diseases, such as toxoplasmosis, taeniasis/cysticercosis,
hydatidosis, angiostrongyliasis, and trichinosis, is of great
interest in Latin America.  The parasitic zoonoses present a
special public health problem; among them are several of the
most prevalent serious human infections which, if not
controlled, will be an increasingly important cause of
morbidity.

     These diseases are the cause of large economic losses,
especially of meat animals, milk, and other food and products
of animal origin, and the greatest impact is on the developing
countries.  The parasitic zoonoses also hamper the rural
development programs, reduce the exportation of meats, and slow
socioeconomic development, in general.

     The complex socioeconomic impact of the parasitic zoonoses
urgently demands an understanding of their true importance in
different countries of Latin America and the Caribbean and the
development of programs for their control.  Comprehensive
knowledge of these diseases will constitute one of the rational
bases for determining the order of priority in the campaign
against the parasitic zoonoses and its incorporation in the
activities of the local health systems and primary health care.


Mandates

1.   The WHO Expert Committee on Parasitic Zoonoses, with the
     participation of FAO (1978), recognized the worldwide
     importance of the parasitic zoonoses and of their great
     impact on health and on the economies of a large number of
     countries and recommended the development of research and
     the preparation of strategies and methods for surveillance,
     prevention, and a campaign against these zoonoses and the
     food-borne diseases.

2.   Resolution VII of the IV Inter-American Meeting, at the
     Ministerial Level, on Animal Health (RIMSA IV), held in
     1985, recommends that PAHO direct its efforts for the
     countries of the Region toward the formulation of policies,
     strategies, and methodologies for the control of the
     parasitic zoonoses, as well as toward the development of
     methodologies for epidemiological surveys, analyses, and
     their interpretation and toward the application of
     techniques for diagnosis.


Justification

     The epidemiology of the food-borne parasitic zoonoses has
been of special interest in the PAHO/WHO Veterinary Public
Health Program (HPV).  It is for that reason and because of the
request by the Congressional authorities that this symposium was
held.   This activity also fulfills the mandates of the
Governing Bodies and falls within the area of food protection
in the Veterinary Public Health Program.  Through this symposium
there is collaboration with the parasitologists from Latin
America and the Caribbean, representing government institutes,
universities, and other institutions in almost all the countries
of the region, to improve the level of knowledge of the subject.


General Objectives

     The objective of the symposium is to discuss the current
situation of the food-borne parasitic zoonoses in Latin America
and the Caribbean for the purpose of preparing intervention and
control measures in accordance with the existing conditions.


Specific Objectives

     The specific objectives are:

     To determine the prevalence of the infections and to
     analyze the epidemiological and social conditions that
     favor the transmission of the parasitic zoonoses,
     especially hydatidosis, toxoplasmosis, distomatosis,
     taeniasis/cysticercosis, trichinosis, and
     angiostrongyliasis, in Latin America and the Caribbean.

     To incorporate some of the multidisciplinary activities
     within the framework of the local health systems, to
     improve diagnosis of the infections, and to provide
     treatment at the primary health care level.

PROGRAM



Date:          19 November 1991

Schedule:      8:00 a.m. to 11:00 a.m.

Area:          Veterinary Public Health

Subject:       Epidemiology of the Food-borne Parasitic Zoonoses

Organizer:     Dr. Primo Arámbulo III, HPV/PAHO/WHO

President:     Dr. Eduardo Lazaneo (Uruguay)


08:00 - 08:05  Introduction
Dr. Eduardo Lazaneo (Uruguay)

08:05 - 08:30  Situation of the Food-borne Parasitic Zoonoses in
Latin America and the Caribbean
Dr. Primo Arámbulo III, HPV/PAHO/WHO
Dr. Amar S. Thakur, HPV/PAHO/WHO

08:30 - 08:55  Trichinosis in Latin America:  Epidemiology,
Prevention, and Control
Dr. Emilio A. Coltorti, HPV/PAHO/WHO

08:55 - 09:20  Taeniasis/Cysticercosis:  Importance in Public
Health and Epidemiological and Social Aspects of
Their Transmission
Dr. Fernando Beltrán, HPT/PAHO/WHO

09:20 - 09:45  Food-borne Toxoplasmosis
Dr. Eduardo Guarnera (Argentina)

09:45 - 09:55  Recess

09:55 - 10:20  Distomatosis:  Epidemiological and Economic
Aspects
Dr. Carlos Eddi (Argentina)

10:20 - 10:45  Angiostrongylosis:  A Public Health Problem
Dr. Pedro Morera (Costa Rica)

10:45 - 11.00  Discussion

AUTHORS

1. Arámbulo III, Primo   Doctorate in Veterinary Medicine and
Master's Degree in Public Health from
the University of Philippines.  Master's
Degree in the Parasitology and Applied
Entomology of Malaysia.  Master's Degree
and Doctorate from the University of
Texas.  Master's Degree in Public
Administration from Harvard.  Currently
Coordinator of the Veterinary Public
Health Program of the Pan American
Health Organization/World Health
Organization in Washington, D. C.

2. Beltrán, Fernando     Graduate of the School of Medicine of
the Autonomous National University of
Mexico (UNAM).  He specialized in
parasitology in the Department of
Microbiology and Parasitology of the
School of Medicine.   He undertook
graduate studies in immunoparasitology
in the Division of Advanced Studies of
that school.  Broad teaching and
research experience in the School of
Medicine of the UNAM.  He worked as a
scientist in the WHO Tropical Disease
Research Program.  He is currently
Regional Adviser in Parasitology in the
PAHO/WHO Communicable Diseases Program.

3. Coltorti, Emilio A.   Doctorate in Biochemistry from the
University of Buenos Aires.  He has
undertaken graduate studies in
immunology at the Pasteur Institute,
College de France.  He has worked on the
immunodiagnosis of parasitic diseases. 
Since 1968 he has been serving in the
PAHO/WHO Veterinary Public Health
Program.

4. Eddi, Carlos S.       He received the degree of Doctor of
Veterinary Medicine in 1975 from the
School of Veterinary Medicine,
University of Buenos Aires, and M. S.
and Ph. D. degrees from Louisiana State
University in the United States of
America in 1987 and 1989, respectively. 
He was Professor of Parasitology in La
Pampa Veterinary School of Medicine from
1976 to 1978 and Investigator in
Parasitology at INTA, Castelar, from
1978 to 1985.  Since 1989 he has been
serving as Coordinator of Parasitology
at INTA, Castelar, Argentina.

5. Guarnera, Eduardo A.  He received the degree of Doctor of
Medicine from the School of Medicine of
the University of Buenos Aires (UBA) in
1972.  He specialized in 1975 in
Infectious Diseases of the UBA
Department of Infectious Diseases, at
Muñiz Hospital.  Diploma in Public
Health from the UBA School of Public
Health in 1984.  He has served as a
parasitologist at the Malbrán Institute
and as section chief since 1981.  He has
been an epidemiologist in the PAHO/WHO
Veterinary Public Health Program since
1985.  Since 1990 he has been serving as
Chief of the Department of Parasitology
in the Carlos G. Malbrán Institute,
Buenos Aires, Argentina.

6. Morera, Pedro

7. Thakur, Amar S.       Received B. V. Sc. and M. V. Sc. degrees
in India in 1956 and 1962, respectively. 
He received an M. S. degree. in Hawaii
in 1966 and a Ph. D. degree from the
University of California in 1970.  He
served as Assistant Professor at the
School of Veterinary Medicine in India,
Principal Investigator in Parasitology
in IVRI, India, and Associate
Investigator in the Department of
Epidemiology of the University of
California.  Since 1975 he has been
serving in the PAHO/WHO Veterinary
Public Health Program.

    TRICHINOSIS:  EPIDEMIOLOGY, PREVENTION, AND CONTROL

Emilio A. Coltorti    
Pan American Institute for Food Protection
and Zoonosis
PAHO/WHO Veterinary Public Health Program
Buenos Aires, Argentina


     Trichinosis is a disease of domestic and wild animals that
is transmitted through consumption of improperly treated meat
from these animals.

     Trichinella is a nematode of low specificity with respect
to its host.  It has been demonstrated experimentally that
almost all mammals can be infected; however, only carnivores and
omnivores acquire the infection naturally.

     The infection is produced by the ingestion of muscle
infected with larvae of Trichinella in the L-1 infective stage. 
These larvae are liberated in the stomach and rapidly locate in
the columnar cells of the epithelium of the small intestine
where they begin their enteral stage.  During this stage they
undergo four alterations in approximately 36 hours, increase
rapidly in size, and are transformed into sexually mature
adults.  Starting from the fifth day of infection the females
begin to release newborn L-1 larvae; that process continues for
approximately 30 days.  Migratory L-1 larvae begin the
parenteral stage, moving through the lymphatic vessels to reach
the general circulation and then locating in the striated muscle
cells where they undergo a series of changes and reach the stage
of L-1 infective larva 20 days later.  At the same time the
muscle cell in which a larva is lodged also undergoes a series
of changes that lead to the formation of a host cell/infective
larva complex.  In that state the larva can remain viable and
infective for months and even years.


Geographical Distribution

     Trichinella is widely distributed in the world, basically
in temperate and cold areas.  In America it is found in Alaska,
Canada, the United States, Mexico, Chile, Argentina, and Uruguay
and in recent years its presence has been reported in Honduras
and Costa Rica.  According to the information available, there
have never been any autochthonous cases reported in Guatemala,
Panama, Colombia, Ecuador, Brazil, Peru, Paraguay, and Bolivia.

     This information is obtained in humans through studies of
autopsies in the general population and in sporadic epidemic
outbreaks; in pigs through the prevalence rates determined by
trichinoscopy in abattoirs; and in special studies carried out
on wild animals.

     Until approximately two decades ago only one species of
Trichinella was recognized:  T. spiralis.  In recent years
comparative studies have been done on isolates of Trichinella
obtained from naturally infected wild and domestic animals to
determine their morphological characteristics; their
infectiousness for different hosts; their capacity for crossed
reproduction; the response of the host; the longevity of the
larvae; and other biochemical, immunological, and genetic
parameters.  These studies have made it possible to establish
differences among some of the populations of Trichinella studied
and they have been provisionally classified as subspecies,
strains, or geographical variants.  Although their taxonomic
assessment is under discussion, it is evident that specific
variations exist within the genus.

     The principal subspecies are:  T. spiralis, var. native,
var. nelsoni, and var. pseudospiralis.

     T. spiralis, var. spiralis:  It parasitizes pigs, rats,
small rodents, and wild carnivores and is universally
distributed.  It is responsible for the domestic and
peridomestic cycles and is the cause of almost all cases of
human trichinosis in temperate areas.

     T. spiralis, var. native:  It parasitizes wild carnivores
and some aquatic mammals in the Arctic region.  It is mildly
infectious in pigs, rats, and other rodents.  It infects man,
producing severe cases.

     T. spiralis, var. nelsoni:  It parasitizes wild canines and
felines and wild swine.  It is mildly infectious in domestic
pigs and adult rodents.  It has been isolated in Africa, in the
temperate areas of Asia, and in eastern Europe.  Few cases of
infection in humans have been reported.

     T. spiralis, var. pseudospiralis:  It parasitizes birds and
occasionally mammals.  It is characterized by the absence of a
capsule in its muscle phase.  There are no known cases of
infection in humans.


Modes of Transmission

     Trichinella has a wild cycle in which the infection is
transmitted and perpetuated among wild animals, which are
occasionally consumed by man and can infect him.  Various
carnivorous species are involved in this cycle; they maintain
the infection through mechanisms of predation and consumption
of the remains of animals that died naturally.

     In the domestic cycle the infection is transmitted and
perpetuated among domestic animals, basically pigs and some
synanthropic species.  Consumption of infected domestic pork is
the principal cause of human trichinosis.  Various transmission
mechanisms have been presented to explain the continuation of
the infection in domestic pigs:  a) consumption of food
contaminated with Trichinella, such as leftover foods, raw
remains from slaughtering establishments, and animal remains
produced in the furrier; b) ingestion of synanthropic species,
especially rats and mice that would be infected through access
to contaminated wastes, remains of infected pigs, and
cannibalism (in some situations these rodents could also be a
linkage with the wild cycle); c) pig to pig transmission through
cannibalism, by tail-eating, or by ingestion of feces from
recently infected pigs.


Prevention and Control

     The objective of a program for prevention and control of
trichinosis is to minimize the risk of infection in man.

     Man is infected by ingestion of improperly treated infected
meat from wild animals and domestic pigs.  In Latin America
almost all the human cases of trichinosis have pork and its
derivatives as the source of infection.  As a result, in
designing a prevention and control program it would be
desirable, at least in the first stage, to concentrate
intervention efforts on the domestic cycle.

     A series of lines of action have been defined whose joint
coordinated application would make it possible to reduce the
risk of infection in man.  These are:  a) the reduction or
elimination of the infection in pigs through improvement in
sanitary conditions and epidemiological surveillance of
production facilities; b) sanitary inspection in the abattoirs
to prevent the distribution and consumption of contaminated
pork; c) adequate control of the pork and pork products that are
marketed raw; d) processing standards that guarantee the
destruction of the larvae in the products or food prepared on
a commercial scale; and e) a plan for education aimed at warning
the small-scale producers of food and the general population of
the risk of consuming pork or pork products without adequate
treatment that ensures the destruction of the larvae and at
modifying culinary habits if that treatment is absent.

     Analysis of the epidemiological situation, identification
of the principal determinants that maintain transmission, and
local characteristics will determine the modality and intensity
of the application of these measures through an
interinstitutional, multidisciplinary participatory program.

     One of the most difficult problems confronting these
programs is the breeding and slaughtering for family consumption
that is carried out on small rural properties where control is
difficult.  In general, these pigs are bred under poor sanitary
conditions and are frequently the cause of a great many small
outbreaks among humans, affecting the family group, friends, and
neighbors.  Local human and animal health systems would appear
to be indicated for collaboration in advising on the improvement
of household breeding conditions and offering the possibility
of trichinoscopic examination to guarantee safety.

     With respect to the wild cycle, it would be desirable to
warn the population at risk of the animal species most
frequently infected in each region and the precautions that
should be taken in their consumption.   


REFERENCES


1.   Acha, P., and B. Szyfres.  Trichinosis.  In:  Zoonoses and
Communicable Diseases Common to Man and Animals.  2d ed.  PAHO
Scientific Publication No. 503.  Washington, D. C., Pan American
Health Organization, 1987.

2.   Quevedo, F., and A. S. Thakur.  Parasitosis Transmitidas
por Alimentos.  Centro Panamericano de Zoonosis, Programa de
Salud Pública Veterinaria OPS/OMS.  Monografía Técnica N 12. 
Buenos Aires, Ramos Mejía, 1980.

3.   Steele, J. H.  Trichinosis.  In:  J. H. Steele (ed.),
Handbook Series on Zoonoses, Parasitic Zoonoses, Vol. II. 
Florida, CRC Press, 1982.

4.   Steele, J. H., and P. V. Arámbulo.  Trichinosis.  A world
problem with extensive sylvatic reservoirs.  Int Z Zoon 2:55-
75, 1975.

5.   Trichinellosis, Proceedings of the Fourth International
Conference on Trichinellosis.  W. Kim and A. Pawlowski (eds.). 
University Press of New England, 1977.

6.   Trichinella  and Trichinosis.  W. Campbell (ed.).  New
York, Plenum Press, 1983.

7.   World Health Organization/International Commission on
Trichinellosis.  Guidelines on Surveillance, Prevention, and
Control of Trichinellosis.  W. Campbell, R. Griffiths, A.
Mantovani, Z. Matyas, and Z. Pawlowski (eds.).  Rome, 1988.

   TAENIASIS/CYSTICERCOSIS:  IMPORTANCE IN PUBLIC HEALTH
 AND EPIDEMIOLOGICAL AND SOCIAL ASPECTS OF ITS TRANSMISSION

Dr. F. A. Beltrán H.
Regional Adviser in Parasitology,
Communicable Diseases Program (HPT/HPD).
PAHO/WHO, Washington, D. C., U. S. A.

     The infection of humans and pigs by Taenia solium is very
widespread in the countries of Latin America.  Recently, active
transmission has been documented with data on the frequency of
taeniasis in humans and/or cysticercosis in pigs and humans in
15 countries of the region (1). In some countries the infection
is almost generalized throughout the territory, while in others
its occurrence is sporadic or localized.  In several countries
of the Americas a growing number of cases of neurocysticercosis
are being diagnosed in individuals that have migrated from
countries where the disease is endemic.  Although the prevalence
of human neurocysticercosis continues to be the severest
clinical expression of this cyclozoonosis, from a strictly
epidemiological point of view it represents only "the tip of the
iceberg" of this problem.  The real prevalence of taeniasis is
unknown and little work is being done in the countries, with the
exception, perhaps, of studies carried out in the last three
years in Honduras, Ecuador, and Mexico.  Recently in Honduras
there have been reports of prevalences of taeniasis of 2 per
1,000 in a university hospital, of 10 per 1,000 in the southern
provinces, and of from 14 to 62 per 1,000, determined through
surveys.  In the university hospital 219 cases of taeniasis were
diagnosed during the period from 1985 to 1989.

     In Mexico, Colombia, Peru, and Ecuador some epidemiological
studies have been carried out in rural communities; they have
demonstrated serological reactivity toward antigens of
cysticerci that varies from 3% to 12%, in association with a
prevalence of taeniasis not greater than 1% to 2%.  In one focus
of transmission all individuals are subject to the risk of
ingesting eggs of T. solium, but it has been determined that the
individuals at greater risk are those that share a room or are
in close contact with a tapeworm carrier.  Thus, it is not rare
to observe the concurrence of groups of cases of human and
porcine cysticercosis in a given locality.

     In addition, it is thought that, on occasion, individuals
staying in rural areas for recreational purposes who have the
habit of eating regional food could acquire taeniasis on eating
undercooked pork and cysticercosis on eating food prepared under
inadequate hygienic conditions.

     The transmission of T. solium between the intermediate and
final hosts is more frequent and more intense in rural
communities, where the cycle is associated with favorable
environmental conditions:  pig-raising on free range that allows
them access to human feces, the lack of latrines, and poor
individual hygienic habits.  In conclusion, this is a parasitic
zoonosis linked to poor socioeconomic and cultural conditions.

     Infection in urban areas may be associated with the
transfer from a carrier of T. solium in a focus of transmission
to an urban area that has all the conditions necessary for
transmission, such as exist in the poverty-stricken areas
located on the peripheries of cities.  A tapeworm carrier in a
highly overcrowded urban area may represent a possible source
of cases of cysticercosis that is even more dangerous than such
a carrier in a rural area, especially if the person works as
food handler.

     Infections of T. solium, both taeniasis and cysticercosis,
are endemic in several countries but may be spread, even
epidemically, when infected individuals are introduced into a
community with no prior infection.

     Traditional, cultural, and occupational customs frequently
influence transmission.  These aspects are related particularly
to ignorance, but it is important to recognize that there can
be groups of individuals that, for economic reasons, promote the
presence of the infection.

     The information available in the countries on the
epidemiological situation of the taeniasis/cysticercosis complex
is incomplete for lack of reporting or underreporting of cases,
for lack of standardized diagnostic techniques and availability
of adequate services to apply them, and for other administrative
deficiencies, among other reasons.  It is, therefore, very
difficult to utilize the published or recorded data in the
countries (Tables 1-3) to describe the problem in quantitative
terms or to carry out a comparative analysis and evaluate the
economic impact for the purpose of planning control measures and
medical care.

     It is evident that there is a need to have basic
epidemiological information, obtained with a single set of
theoretical and methodological criteria, in order to be able to
perform a comparative analysis of the current state of the
problem in the different countries affected.

     To fulfill this purpose an information and analysis system
should be organized to allow continuous evaluation of the impact
of the disease on the population at risk.  The following
information is required for this:

Information on cysticercosis in pigs:

     The prevalence of porcine cysticercosis in official
abattoirs in the capitals and/or other principal cities of the
country.  Simultaneously, a system of registrations should be
organized to establish the source of the infected pigs.

Information on taeniasis:

     The frequency of reports of the presence of the eggs of
Taenia sp. in stools examined in central hospitals or in centers
where stool examinations are usually carried out.

     It is desirable to indicate the coproparasitoscopic method
utilized and the number of examinations carried out on each
patient.  It also is advisable to identify the origin of the
patients.

Information on cysticercosis in humans:

     - The frequency of reports of the presence of cysticercosis
in humans, in necropsies carried out in central hospitals.  It
is advisable to distinguish the frequency of cysticercosis in
patients treated in neurology units or in institutions
specializing in the pathology of the nervous system from that
observed in patients treated in general hospitals.  The data on
the finding of cysticercosis in necropsies done in forensic
medical services could provide orientation in the estimation of
the magnitude of the overall prevalence of cysticercosis in
humans.

     - The frequency with which cysticercosis is reported as a
tumor, in the national tumor registry when there is one in the
country.  If none exists, it would be advisable to promote its
establishment.

     - The frequency with which convulsive repetitive crises are
presented, especially in subjects over 20 years of age.  In some
countries there are national programs on the epidemiology of
epilepsy, which could provide this information.

     - The prevalence of cysticercosis in patients served in
rural and urban hospitals.  With this information an attempt
should be made to identify active foci of transmission.  It is
a given that cases of cysticercosis in humans and pigs are
presented only where there are cases of taeniasis in humans. 
The concurrence of the adult and larva-like phases of the
parasite and their respective hosts in a single area constitutes
what is called the real focus of active transmission.

     There, whenever possible, efforts should be made to learn
the prevalence of taeniasis, especially at the family level,
based on the cases of cysticercosis in humans, or when the
prevalence of cysticercosis in pigs is very high, especially if
these are bred locally, in the immediate environs of the
dwellings.

     When data on the existence of cases of cysticercosis in
humans in areas where the cysticercosis in pigs is very frequent
is not available, it is useful to ascertain whether in that area
there are frequent cases of repetitive convulsive crises, which
could very possibly be due to cerebral cysticercosis.

     Thus, in those areas (localities, municipalities,
departments, or states), where one or more of the aforementioned
factors exist, additional epidemiological studies are justified.

     Under these conditions, it is desirable to carry out, in a
population sample that includes all age groups and both sexes,
an active search for tapeworm carriers and antibodies against
antigens of cysticercus through the immunoenzymatic test (also
known as the ELISA method), the method of
inmunoelectrotransference (IET), or both, in parallel or
sequentially.

     In addition, it would be desirable to consider the
possibility of performing these studies using the risk approach,
which would make it possible to make objective choices of the
priority interventions for control.

     If these methodological principles are adopted and adapted
to the conditions of the infrastructure, both physical and with
respect to existing human resources in the different countries,
it would be possible to produce epidemiological profiles for
every country, which could be compared.  The epidemiological
data would also allow the preparation of maps in which the
prevalences of cysticercosis in pigs and in humans, as well as
the prevalence of positive reactors toward antigens of
cysticerci, could be noted by health jurisdictions or by
departments or states (or municipalities, if information exists
at this level).  This would help to give a clearer idea of the
distribution of the problem in the different countries.

     Having this type of information available and well
documented is considered an urgent need by the Pan American
Health Organization (PAHO/WHO), since this would allow it to
provide timely efficient delivery of the appropriate technical
cooperation requested by the affected countries.

     The situation of porcine cysticercosis in the Americas is
not well documented.  The clandestine sacrifice of pigs without
inspection or sanitary control is very prevalent in most of the
countries of Latin America and the Caribbean and the basic cause
of the lack of notification.  For example, in Colombia there are
approximately 1,300 sites for butchering animals for human
consumption, at only 5% of which the meat is inspected (data
presented in the National Program for Control of Taeniasis and
Cysticercosis).

     The available data on porcine cysticercosis in the
countries are based on limited inspection and registration and
also on data obtained from special local studies.  However, the
utilization of this background plus the information provided in
the FAO/WHO/IOEhepatomegal Animal Health Annual has made it
possible to classify the infection in pigs (Table 3).

     The importance of porcine cysticercosis is reflected, not
only in the fact that pigs are intermediate hosts of the
zoonosis, but also in the economic losses caused by the
retention and destruction of carcasses and the restrictions that
are applied by the international markets.

     One characteristic of the distribution of porcine
cysticercosis in the countries where the disease is endemic is
the existence of many foci, which is closely related to the
socioeconomic and cultural conditions of those who keep pigs,
which influence the ecosystem of the taeniasis/cysticercosis
complex.  This is why the infection is of variable importance
in the different regions of a country.  An example of this is
observed in the case of Colombia, where the Ministry of Health
reported the seizure of from 10,000 to 11,000 pigs per year in
the country (corresponding approximately to 440,000 kilograms
of meat).  In 1988 alone the Department of Cundinamarca
confiscated 3,500 kilograms of pork because of cysticercosis.

     The presentation of incomplete data on this zoonosis in
pigs requires urgent action for the implementation of an
organized permanent information system that would make adequate
development of the surveillance of the cyclozoonoses in the
countries possible.

     The vulnerable points useful for control within the cycle,
based necessarily on specific health education, can be
summarized thus:

     - Safe, simple treatment of intestinal taeniasis.  This can
also be administered to individuals that are suspected carriers
of a tapeworm, especially in active foci of transmission.

     - Use of latrines and education directed toward improving
hygienic habits.

     - Control of the slaughter of pigs with cysticercosis.

     - Promotion of the habit of eating well-cooked pork.

     Some recent research has attempted to demonstrate that the
ingestion of pork with very young forms of cysticerci, could
give rise to cysticerci in whatever ingests them (pigs or man). 
If this were to be demonstrated it would constitute another
mechanism for acquiring cysticercosis, which would have
significant epidemiological implications for control (2).

     In addition to the above, it is useful to note that by the
nature of their work some individuals, such as drivers of
vehicles, are obliged to eat in restaurants established along
highways, including some international highways, where hygienic
conditions are poor, with the consequent risk of acquiring both
taeniasis and cysticercosis because they serve undercooked pork
and because food handlers in those places may be tapeworm
carriers.

     THIS CONSTITUTES A RISK FOR THE SPREAD OF THE PARASITIC
DISEASE, AT BOTH THE NATIONAL AND INTERNATIONAL LEVELS.

     The taeniasis/cysticercosis complex is not only the result
of infection with eggs or larvae of the parasite, but also of
the influence of environmental, social, cultural, and economic
effects in a specific locality.  As a result, the control of the
parasitic disease should involve consideration of multiple
alternatives for solutions that can be applied independently or
together.

     The many measures required for intervention for control
include the adequate use of primary health care based on
community participation and intersectoral articulation within
the affected locality.  Taking the local health system into
account as a modality of action in health, the application of
strategies for the control of taeniasis/cysticercosis in various
geographical, social, and cultural areas is being proposed in
this model.  Within the frame of reference of local health
systems, the basic infrastructure of the medical, veterinary,
and environmental sanitation services will be utilized as a
result.

     The fundamental strategy of the interventions for control
will consist of the interruption of the evolutionary cycle of
the parasite in order to prevent cysticercosis in man and in
animals.  In this regard consideration will be given to the
different cycles that occur in rural and suburban areas where
transmission is as much zoonotic as it is fecal to oral and in
urban areas where the transmission is primarily fecal to oral.

     In addition to the interventions directed toward reducing
morbidity and mortality through specific chemotherapy, the
possibility of treating pigs with albendazole has been
considered.  Some groups of investigators have oriented their
work toward the production of a vaccine for application in pigs. 
An economic analysis, with consideration of usefulness,
efficiency, and costs, is necessary in order to establish its
feasibility.

     In addition, as a result of interprogrammatic actions
(HPV/HPT/HPE), the strengthening and reorientation of activities
in health education are being promoted in the countries in an
effort to comply with the following overall strategic
approaches:

     - The planning should be carried out as a joint task of the
Ministries of Education and Health, with the broad participation
of other sectors and institutions.  In the area of parasitic
zoonoses, the participation of the Ministry of Agriculture and
Livestock Raising is essential.

     - The population to which the messages are going to be
directed should be well characterized.  This will make it
possible to produce educational materials appropriate to the
different potential users.

     - We emphasize the need for simplifying the educational
materials.  In addition, the process of information
dissemination should be conceived so that it can apply to
several parasitic diseases with similar epidemiological
profiles.

     - Multisectoral efforts should be directed toward achieving
sustained changes in the attitudes and behavior of the
population to which the messages are directed.  This requires
the educational messages to have a real impact on the basic
educational actions at the national level.  In the diagram in
Annex I, the flow of information in the educational process is
illustrated.

TABLE 1

        PRELIMINARY CLASSIFICATION OF THE TRANSMISSION
      OF TAENIASIS/CYSTICERCOSIS IN THE COUNTRIES OF THE
AMERICAN HEMISPHERE*

CategoryCountriesActive foci existI.    Taeniasis and
cysticercosis are
prevalent and the problem
is widespread.Bolivia,
Brazil, Colombia, Ecuador,
Guatemala, Honduras,
Mexico, Peru.YesII. The
problem
exists
but the
tran
smis
sion
is
spor
adic
.Arg
entina,
Chile,
Costa
Rica,
Haiti,
Panama,
Venezuela.YesIII.A

ll
c

a

s

es
a

re
i

m

p

o

r

t

e

d.
C

a

n

a

d

a,
C

u

b

a,
U

n

i

t

ed
S

t

a

t

es
of
A

m

e

r

i

c

a

*

*,
G

u

y

a

n

a,
F

r

e

n

ch
G

u

i

a

n

a,
J

a

m

a

i

c

a,
P

a

r

a

g

u

a

y,
S

u

r

i

n

a

m

e,
T

r

i

n

i

d

ad
a

nd
Tobago.NoIV.No
d

a

ta
e

x

i

s

t

.
B

e

l

i

z

e,
El
S

a

l

v

a

d

o

r,
N

i

c

a

r

a

g

u

a,
D

o

m

i

n

i

c

an
R

e

p

u

b

l

i

c,
U

r

u

g

u

a

y.

*    Based both on data published in journals and on unpublished
     data to which the editorial commission had access.

**   There is no data on the situation in Puerto Rico.


TABLE 2

       FREQUENCY OF HUMAN TAENIASIS IN LATIN AMERICA++

CountryYearTaenia spp.% Infection with T. soliumT.
saginataBolivia1977-19862.6 (0.1-8.7)Brazil1986-1989
1965-19683.0 (0.1-5.9)
1.0 (0.2-2.7)Chile1958-19800.2 (0.1-1.7)0.31.9Colombia1968
19860.3
8.36*Costa Rica1978-19870.02-0.09Ecuador1974
1985-1986**1.0 (0.3-1.0)
1.6 (20.0)0.9El Salvador1987-19880.18-0.28Guatemala1964
1914-1953
1986
0.15
0.491.11.7Haiti19640.10Honduras1961-1966
1986-1989**6.7
0.4-6.0
***Mexico1970-1971
1984-19890.6 (0.2-1.1)
2.2 (1.0-3.4)
1.1Panama19600.2Venezuela19610.2 (0.2-0.6)*       History of
expulsion.
**   Epidemiological studies.
***  The ratio of cases of T. solium to cases of T. saginata was
     approximately 3:1.

++   Source:  Official reports and published studies reviewed by
     the editorial commission.

TABLE 3

CLASSIFICATION OF THE SITUATION OF
PORCINE CYSTICERCOSIS IN THE AMERICAS

CategoryCountriesI. Nonexistent.Antigua and Barbuda, Bahamas,
Barbados, Bermudas, Canada, Cuba, Dominica,
Grenada, Guyana, Jamaica, Paraguay, Saint
Lucia, Suriname, Trinidad and Tobago, Uruguay.II.S

p

o

r

a

d

ic
a

p

p

e

a

r

a

n

ce
r

e

p

o

r

t

e

d

.
A

r

g

e

n

t

i

n

a,
C

h

i

l

e,
C

o

s

ta
R

i

c

a,
El
S

a

l

v

a

d

o

r,
H

a

i

t

i,
P

a

n

a

m

a,
U

n

i

t

ed
S

t

a

t

es
of
America.III.E

n

d

e

m

ic
a

nd
m

u

l

t

i

f

o

c

a

l

.
B

o

l

i

v

i

a,
B

r

a

z

i

l,
C

o

l

o

m

b

i

a,
E

c

u

a

d

o

r,
G

u

a

t

e

m

a

l

a,
H

o

n

d

u

r

a

s,
M

e

x

i

c

o,
N

i

c

a

r

a

g

u

a,
P

e

r

u,
Venezuela.IV.E

x

i

s

t

e

n

ce
s

u

s

p

e

c

t

ed
b

ut
n

ot
c

o

n

f

i

r

m

e

d

.
B

e

l

i

z

e,
D

o

m

i

n

i

c

an
R

e

p

u

b

l

i

c.

REFERENCES


1)   OPS/OMS.  Documento:  Epidemiología y Control de la
teniasis/cisticercosis en América Latina.  Preparados por
expertos y editado por Programas HPV/HPT/HPD.  Washington, D.
C., 1992.  (Por publicarse.)

2)   Salazar Schettino, P. M.  Estudio sobre algunos aspectos
biológicos de la cisticercosis.  Cisticercosis humana y porcina. 
Su conocimiento en México.  México, Editorial Limusa, 1989.  pp.
27-30. 


ANNEX I

EDUCATION FOR HEALTH
Flow of Information

1. Professors
2. Family
3. Students
4. School
5. Family
6. Other sectors
7. Health sector
8. Change agents
9. Community
10. Control of Taeniasis/Cysticercosis

FOOD-BORNE TOXOPLASMOSIS

Dr. Eduardo A. Guarnera
National Institute of Microbiology
Dr. Carlos G. Malbrán
Buenos Aires, Argentina

     Toxoplasma gondii is the most extensively distributed
parasite on earth; it is found equally in geographical areas
with diverse climates and in very varied ecological environments
- in urban and rural habitats, for example.

     In addition, it has been verified that it can parasitize
all warm-blooded species - marine mammals, birds, and
terrestrial mammals, among which man is found.  It is capable
of invading any cell of the organism, avoiding only those that
have no nucleus, such as circulating red corpuscles (1).

     However, even though the parasite is so ubiquitous and
prevalent, very seldom does the parasitized organism express any
abnormality at the time of the primary infection or in the
period following.  Only a small fraction of the patients present
some symptomatology in the clinical forms acquired during the
course of an independent life.  Usually, it involves an acute
disease without sequelae.

     On the other hand, primary infections suffered by women
during pregnancy can affect the health of their offspring.  In
this modality of infection various related clinical forms have
been described - all of them in the parasitemic phase or with
generalization of the parasite.  Among the sites with the most
serious consequences are those that affect the central nervous
system, with consequences that include macrocephalia,
microphthalmia, ocular lesions, mental retardation, and
epileptogenic foci, among others.

     T. gondii acquires importance as a zoonosis (2) due to the
pathology, mainly neonatal, that it produces in man and to the
economic losses stemming from the abortions and premature births
in livestock of different species, as was demonstrated in New
Zealand, Australia, and Great Britain, where the prevalence of
antitoxoplasmic antibodies in the principal species of interest
in livestock raising were:  sheep, 35%; pigs, 26%; cattle, 21%;
and horses, 20% (3).  As is known, the parasite can infect man
through the digestive tract where it enters in the forms of
oocysts or bradyzoites.

     The first stage is found free as a biological contaminant
of the environment, while the bradyzoite is found in the
interior of parasitic cysts which are lodged mainly in striated
muscle and the brain of mammals; thus the manipulation and
ingestion of their meat facilitates the transmission of the
parasite.

     Despite the fact that there have been notable advances in
recent years, mainly in the area of immunology, epidemiological
research in the Americas on the prevalence and transmission of
T. gondii in the principal species of agricultural and livestock
interest has not had the same good fortune.

     The animals of greatest epidemiological significance are
sheep, cattle, and swine.

Toxoplasmosis in Sheep

     Sheep are the livestock most susceptible to infection by T.
gondii.  Their meat is the usual source of protein for the
populations located in the rural areas of many countries of
Latin America and an alternative source for the general
population.  Table 1 contains the results of studies on
infection in sheep in countries of the Americas.

     As occurs with the other herbivores, these animals acquire
the infection by feeding on grasses or drinking water
contaminated with oocysts that had been excreted with the feces
of domestic or wild felines (4).

     When sheep are infected during pregnancy they transmit the
infection to their offspring, which carry with them reproductive
disorders that affect the health and productivity of the whole
flock (5, 6).

     It is known that during the first 50 days of gestation the
parasite produces embryonic death and, usually, reabsorption;
on the other hand, infections that occur later also lead to the
death of the fetus, by inducing abortion.

    Table 1.  Studies on toxoplasmic infection in sheep.
Countries in the Americas.

CountryNo. of samplesStudy methodReactors
(%)ReferencesBrazil100Serology392Canada273Serology657Chile64S
erology678U. S. A.66Serology4.59U. S. A.29Serology2410U. S.
A.80Serology23.711U. S.
A.2,164Serology2412Peru14Serology93.813Peru?Serology83.014Per
u100Serology35.015Uruguay62Serology30.616Uruguay44Serology18.22

     The percentage of reactors indicates the risk of
contracting the infection through handling meat or ingesting it
after it has been cooked at a temperature that is not high
enough to destroy to the parasites.

Toxoplasmosis in Cattle

     Although it has been emphasized that cattle are not very
susceptible to toxoplasmic infection, they acquired
epidemiological significance when they became the most important
source of protein for man.  Table 2 presents the results of
studies on infection in cattle in countries of the Americas.

     The principal reason for minimizing their role as
transmitter is that the parasite forms terminal colonies in
bovine skeletal muscle that have a very limited survival
capacity, disappearing from tissues approximately 200 days after
entry (23).  In addition, intrauterine infection is very rare,
from which it can be inferred that in order to become sick, each
animal must acquire its own charge of oocysts from the soil.

       Table 2.  Studies on toxoplasmic infection in
cattle.  Countries of the Americas.

CountryNo. of samplesStudy methodReactors
(%)ReferencesArgentina55Serology
(HAI)4017Argentina105Serology
(*)47.618Brazil350Serology
(IFI)122Canada1,759Serology
(S and F)177Colombia371Serology
(HDI)2419Colombia361Serology
(IFI)29.920, 21U. S. A.110Serology
(HDI)2911Mexico100Serology
(S and F)922Peru (Lima)--1715Uruguay233Serology
(**)23.62
HAI:      Indirect hemagglutination.
IFI:      Indirect immunofluorescence.
S and F:  Sabin y Feldman.
(*)       Direct agglutination with 2-mercaptoethanol and
indirect hemagglutination.
(**)      Indirect hemagglutination with 2-mercaptoethanol.

Toxoplasmosis in Swine

     The pig is the second livestock animal with major
serological prevalence of toxoplasmic infection.  In Table 3 the
results of studies on infection in pigs in countries of the
Americas are presented.

     The persistence of terminal colonies in striated muscle
transform it into a food with a high risk of transmitting the
parasites.

     It can acquire the infection through oocysts from the soil
or by ingesting earthworms that contain them, prenatally, and
through predation of rodents that are usually highly
parasitized.

     Infections acquired during the last third of a pregnancy
are those that can be transmitted to the offspring, which can
be stillborn or be sick at birth and die in a few days or
survive with a chronic infection which can extend the cycle of
the disease (16).


        Table 3.  Studies on toxoplasmic infection in
pigs.  Countries of the Americas.

CountryNo. of samplesStudy methodReactors
(%)ReferencesArgentina20Serology3518Brazil409Serology
(HDI)472Canada671Serology
(IFI)457Chile60Serology
(S and F)568Colombia368Serology
(S and F)3020Peru (Lima)--5015Mexico126Serology
(S and F)4222Uruguay276Serology
(HDI)1316

Prophylaxis of Toxoplasmosis as a Zoonosis

     Transmission to man of the T. gondii that is found in red
meats demands that preventive measures be taken in the
preparation and ingestion of food of animal origin.

     To protect pregnant women that still have not had contact
with the parasite (as evidenced by the absence of circulating
antibodies), they should be advised to:

     -    Handle raw meats with gloves.
     -    Wash the hands thoroughly during food preparation.
     -    Avoid rubbing the eyes or touching the mouth with the
fingers.
     -    Avoid meat dishes that contain raw meat.
     -    Avoid eating lightly cooked or juicy meat.

     Individuals that present positive serological reactions,
even if pregnant, should follow general hygienic practices to
stay healthy, given that toxoplasmosis involves risks only in
the primary infection.

     The same preventive measures should be taken with
individuals that present an increased risk of becoming ill
because they also suffer from some other disease that produces
immunodeficiencies, although in these patients reactivation of
a previous toxoplasmic infection has greater significance than
the primary infection.


REFERENCES

1.   Feldman, H. A.  Toxoplasmosis:  A review.  Bull N Y Acad Sc
1974; 50:110-127.

2.   Freyre, A.  Dispersión de los ooquistes en Toxoplasmosis en
las especies domésticas y como zoonosis.  Universidad de la
República (R.O. Uruguay).  Departamento de Publicaciones. 
Montevideo, Uruguay, 1989.

3.   Blewett, D. A.  The epidemiology of ovine toxoplasmosis. I
the interpretation of data for the prevalence of antibody in
sheep and other host species.  Brit Vet J 1983; 139:537-545.

4.   Hartley, W. J.  Some investigations into the epidemiology
of ovine toxoplasmosis.  N Z Vet J 1966; 14:106-117.

5:   Waldeland, H.  Toxoplasmosis in sheep.  The relative
importance of the infection as a cause of reproductive loss in
sheep in Norway.  Acta Veterinaria Scandinavica 1976; 17
(4):412-425.

6.   Waldeland, H.  Toxoplasmosis in sheep.  Epidemiological
studies in flocks with reproductive loss from toxoplasmosis. 
Acta Veterinaria Scandinavica 1977; 18 (1):91-97.

7.   Tizard, I. R., J. Harmeson, and C. H. Lai.  The prevalence
of serum antibodies to Toxoplasma gondii in Ontario mammals. 
Can J Comp Med 1978; 42:177.

8.   Niedman, G., E. Thiermann, and A. Negme.  Toxoplasmosis en
Chile.  Estado actual de los estudios clínicos y
epidemiológicos.  Bol Chile Parasit 1963; 18 (4):86-92.

9.   Riemann, H. P., C. M. Willadsen, L. J. Berry, D. E.
Behymer, Z. V. Garcia, C. E. Franti, and R. Ruppanner.  Survey
for Toxoplasma antibodies among sheep in Western United States. 
J Amer Vet Med Ass 1977; 171:1260-64.

10.  Eyles, D. E., G. L. Gibson, N. Coleman, C. S. Smith, J. R.
Jumper, and F. E. Jones.  The prevalence of toxoplasmosis in
wild and domesticated animals of the Memphis region.  Amer J
Trop Med Hyg 1959; 8:505.

11.  Vanderwagen, L. C., D. E. Behymer, H. P. Rieman, and C. E.
Franti.  A survey for Toxoplasma antibodies in Northern
California livestock and dogs.  J Am Vet Med Assoc 1974;
164:1034.

12.  Feldman, H. A., and L. T. Miller.  Serological study of
toxoplasmosis prevalence.  Am J Hyg 1956; 64:320.

13.  Contreras, L. O., and A. Tejada.  Estudio serológico sobre
toxoplasmosis en ganado ovino beneficiado en Lima, Perú.  Rev
Per Biol 1974; 1 (2):147-53.

14.  Tejada, A.  Toxoplasmosis en el Perú.  Memorias del
Simposium Interamericano de Toxoplasmosis.  Bogotá, Colombia. 
1 al 3 de Junio de 1984.  pp. 81-83.

15.  Tejada, A., and G. Balvin.  Situación actual del estudio de
la toxoplasmosis en el Perú.  Anals Sem Nac Zoonosis y
enfermedades de transmisión alimentaria.  Lima, Perú.  3-
4 de Julio de 1989.  pp. 107-121.

16.  Osimani, J. J.  Toxoplasmosis.  Arch Pediatr Uruguay 1968;
39:237-256.

17.  Mayer, H. F., and J. K. de Boehringer.  Nuevas
comprobaciones sobre toxoplasmosis animal en la Argentina.  Rev
Med Vet (Buenos Aires) 1967; 48:341.

18.  Mayer, H. P., E. Bakos, and G. Marder.  La serología pro
aglutinación en la detección de la infección toxoplásmica en
bovinos.  Rev Med Vet (Buenos Aires) 1979; 60:81.

19.  Ruiz, O. J., A. C. Arjona, and G. S. Moreno.  Toxoplasmosis
en Colombia.   Bogotá, Colombia, Ministerio de Salud, 1983.

20.  Muñoz Rivas, G.  Toxoplasmosis en Colombia.  Rev Inst
Salubr Enf Trop 1959; 19 (4):351-355.

21.  Villa, R.  Niveles de anticuerpos para Toxoplasma gondii
pro inmunofluorescencia indirecta.  Acta Med Col 1981; 6
(2):225-235.

22.  Varela, G., A. E. Martínez, and A. Treviño.  Toxoplasmosis
en la República Mexicana.  Rev Inst Salubr y Enf Trop 1953;
13:217-242.

23.  Costa, A. J., F. G. Araujo, J. O. Costa, J. D. Lima, and E.
Nascimento.  Experimental infection of bovines with oocysts of
Toxoplasma gondii.  J Parasitol 1977; 63:212-218.

    DISTOMATOSIS:  EPIDEMIOLOGICAL AND ECONOMIC ASPECTS
OF THIS ZOONOSIS

Dr. Carlos Eddi
        Institute of Pathology in Veterinary Sciences.
National Institute of Agricultural
and Livestock Technology (INTA).
Castelar, Prov. of Buenos Aires
Argentine Republic


     Distomatosis or fascioliasis is a parasitic disease of
sheep, goats, and cattle that can occasionally affect other
mammals, including man.  The agent responsible for this disease
in Latin America is Fasciola hepatica, a flat trematode
parasite, 3 cm in length and 1.5 cm. in width, shaped like a
laurel leaf, which lives during its adult phase in the livers
of susceptible hosts (1).

     In areas where the disease is endemic, it represents one of
the most important problems for the breeding of ruminants for
commercial purposes, as well as for public health, since it is
a zoonotic disease (2).

     Distomatosis is a parasitic disease with an indirect
biological cycle that requires snails of the genus Lymnaea as
intermediate hosts.  Although in Europe the snail that is of
importance in the transmission is the amphibian L. truncatula
and in Australia it is the aquatic snail L. tormentosa, in North
America, Central America, the Caribbean islands, and most of the
South American countries the intermediate hosts are the
amphibious snails L. viatrix and L. columella, related both
biologically and taxonomically to L. truncatula.  However, other
species have been involved as intermediate hosts - for example,
L. cubensis, L. peregrina, L. diaphana, and L. palustris, among
others that very probably belong to one of the two species
mentioned above (3).

     It should be understood, therefore, that the presence of
the disease in an area is directly related to the presence of
the intermediate snail from which the infective stage of this
parasitic disease will arise.


EPIDEMIOLOGICAL ASPECTS

     Undoubtedly, man is an accidental host in the distomatosis
cycle, which means that the biological cycle of Fasciola is
maintained in nature, sustained mainly by cattle and sheep and
interaction with the intermediate host snail Lymnaea.

     The primary foci of the disease are all those permanently
moist areas, such as rivers, streams, lakes, lagoons,
reservoirs, and canals, where the snails can live and reproduce
continuously and where the infested animals contaminate the
area.  However, freshets, floods, or strong rains can generate
secondary foci where there is dissemination of snails from the
primary foci or else a reactivation of those snails that had to
pass the summer in the soil during the dry season.

     Given the importance of humidity and temperature in the
life cycle of the snails as well as in the development of the
eggs of Fasciola and the later evolution of the parasitic
stages, both in the snail and in the environment, the warm rainy
periods provide the best conditions for generating a great deal
of contamination with metacercariae and, as a result, are the
most conducive to human and animal infection.

     Infection of animals is produced mainly by ingestion of
grass contaminated with metacercariae of F. hepática.

     Man is an accidental host who is infected mainly through
ingestion of salads made from watercress (Nasturtium
officinale), lettuce, alfalfa juice, or water contaminated with
metacercariae (4).  Although distomatosis does not respect age,
children, because of their habit of putting plants in their
mouths or because they are more likely to be in contact with the
water in streams, are usually affected more than adults.  The
disease in humans is mainly confined to those rural areas near
foci of distomatosis.  Ignorance on the part of the human
population of the risk of consumption of potentially
contaminated plants in areas where animal distomatosis is
endemic is the principal cause of serious infestations.


ECONOMIC ASPECTS

     With respect to the economic losses produced by this
disease the following aspects should be considered:

     1.   Losses due to the disease in commercial livestock.

     The sheep that received 3, 8, and 14 metacercariae of F.
hepática over a period of 22 weeks had a reduction in weight
gain of 26%, 22%, and 33%, respectively (5).

     On the other hand, sheep infected experimentally with 100
to 1,000 metacercariae suffered a significant reduction in
weight gain and a reduction in the quality of the fleece of
approximately 25% (6).

     Some reported cases of mortality in sheep were caused by
acute fascioliasis; others were due to the combination of
Fasciola and Clostridium novyi, type B (7).

     In regard to cattle raised for meat, there have been
reports of reductions in weight gain of between 14% and 20%,
directly correlated with the levels of infection (8).

     In studies done on dairy cattle, a reduction in milk
production of up to 15% in animals infested with Fasciola was
observed (9).

     In addition, it was observed that cattle that had received
treatment for fascioliasis had shorter periods of lactation (352
days) than those observed in animals that had not received
treatment (372 days), a difference of 20 days which represents
a substantial loss of milk production (10).

     Finally, losses due to abortions caused by toxins and/or to
the erratic migration of F. hepática have been observed (11)
along with a significant reduction in fertility in cattle
infected with distomas, which required 2.25 inseminations per
conception in comparison to their uninfested counterparts, which

required only 1.62 inseminations.  Mortality in replacement
heifers affected by Fasciola and Clostridium hemoliticum was
also seen (11).

     In all cases of losses directly caused by the disease one
should add the expenditures for the management and antiparasitic
treatment of the affected animals.
     
     2.   Losses caused by the seizure in abattoirs of the
livers of the affected animals.

     The number of confiscated livers varies according to the
area affected, the annual climatic variations, and the
possibilities for control and registration available in each
country.  In addition, the recorded losses that these seizures
generate are related to the specific price of the meat at the
time of the study.  Many of the data obtained come from the
abattoir records.  However, there are studies done by
investigators during a specific period that provide more precise
information, in which it was observed that the number of
seizures due to this disease is significantly higher than
official records show.

     In Argentina, in studies of abattoirs in the northwestern
provinces - Salta, Jujuy, and Santiago del Estero, of 2,090
livers studied, 271 were infested with Fasciola (12), confirming
data observed previously (13) for the northeastern area,
particularly from abattoirs in the province of Corrientes where,
it was observed, between 9% and 13% of all livers checked were
seized.  The official figures for bovine livers confiscated,
shown in Table 1, fluctuate between approximately 1% for the
years 1988 and 1990 and 4.9% for 1989 (14).

     In studies done in Chile, the prevalence of distomatosis
ranged from 13% to the critical level of 94% (15).

     In the Eastern Republic of Uruguay in the period from 1972
to 1973, of a total of 11,253 bovine livers reviewed, 52.85%
were confiscated due to the presence of Fasciola (16).  As can
be seen in Table 2, the official data for this country indicate
that 54.67% of bovine livers were confiscated in 1981, but the
percentage rose to 59.67% for 1990 (17).

     On the Bolivian altiplano, at an altitude of more than
3,000 meters, levels of prevalence of bovine distomatosis that
varied between 50% and 60% were observed (18).

     In Brazil, the incidence measured by coprology ranged from
61% in adult cattle to 50% in calves in a study done in the
state of Paraná, although the average figures obtained from
abattoir records over the entire country show a prevalence of
seizures on the order of 12% (19).  In particular, in the area
of Rio Grande do Sul a prevalence of 15% was observed (20).

     In Cuba, rates of liver seizures due to Fasciola that
fluctuated between 10.7% and 32.9% were observed (21).

     On the island of Jamaica, in a stool survey done on cattle
it was determined that 22.2% of the animals were infested (22).

     In Puerto Rico, bovine distomatosis is considered
hyperendemic; records show that 82% of the cattle are infested
with Fasciola (17).

     In Mexico, the prevalence varies according to the area
being considered.  Thus, figures for the seizure of bovine
livers infested with distomatosis that range from 6% (23) to 74%
(24) were observed.

     In Costa Rica, using stool analysis a prevalence of
Fasciola in cattle from 23% to 69% was determined, depending on
the region under study (25).

     In Colombia a prevalence of 40% determined by analysis of
bovine feces was reported; the infected cows were less fertile
and a higher proportion aborted than among their uninfested
counterparts (26).

     3.   Economic losses and effects of this disease on public
health.

     Human infection with F. hepática was observed in numerous
countries.  Unfortunately, it is in Latin America where the
greatest number of cases are observed (18).

     To the above-mentioned economic losses that are caused by
this disease should be added those in the area of public health
due to the expenditures for treatment, days of work lost,
technical diagnoses, and hospitalization costs.

     Unfortunately, human distomatosis is a disease that does
not require official notification, which means that records that
show the trends in human infection are not available .

     Studies done in Peru show that in Valle del Mantaro the
prevalence of the disease in children of school age is 15.6%,
while in adults in the same area it is 13.3% (27).

     In Cuba, up to the present there have been epidemics of
human distomatosis in 1944 and 1983; a significant correlation
was observed between increases in rainfall and in the
temperature of the environment and the appearance of the disease
(28). In this country up to 1944 more than 100 verified cases
of human fascioliasis had been recorded.  However, in a single
Cuban clinic 27 clinical cases of distomatosis alone were
observed during the period from 1973 to 1976 (22).

     In Chile, according to the records up to 1959 82 verified
cases of human distomatosis were reported (7).

     In the state of Puebla, Mexico, distomatosis was found in
0.6% of the population (29).

     In Puerto Rico, where bovine distomatosis is considered
hyperendemic, in a health survey done in the area around farms
that produced watercress it was found that 11% of the human
fecal samples examined contained eggs of Fasciola (18).

     In Bolivia, in the region of Kallutaca in the altiplano,
where the prevalence of bovine fascioliasis is approximately
70%, it was observed that 48% of 90 school-age children examined
had eggs of Fasciola in their feces (17), suggesting that the
prevalence of human distomatosis in the Bolivian altiplano is
extremely high and that there is an urgent need for the
attention of the local health authorities.


RECOMMENDATIONS

     The control of human distomatosis is firmly tied to the
control of the disease in animals.  Antiparasitic treatments
against F. hepática, carried out strategically in conjunction
with rational management of the roundup, appreciably reduce the
contamination of the environment and, as a result, the danger
of human infection.

     Health education in the areas of endemicity with special
emphasis on the risks of this disease, its symptomatology, and
the recognition of the infective agent (metacercaria) and of the
intermediate host snail, particularly in the primary and
secondary schools, would undoubtedly reduce the levels of human
infection.

     Special prevention alerts should be implemented in the
rural communities where the disease is endemic after heavy rains
and elevated temperatures so that the population avoids
consumption of potentially contaminated plants and is aware of
the risks of the infection with Fasciola.


      TABLE 1:  Seizures of livers from cattle and sheep
slaughtered in Argentina.

CattleSheepYearNo. of
headNo. seizedPercent seizedNo. of headNo. seizedPercent
seized19889,652,625117,7341.21,421,5958,3230.619892,312,50811
3,9754.91,618,97513,7700.819906,376,82658,4940.91,586,57511,4
671.9
Source:   Ministry of Agriculture and Livestock Raising. 
SENASA, 1991.  Argentine Republic.


      TABLE 2:  Seizures of livers of cattle and sheep
slaughtered in Uruguay.


CattleSheepYearNo. of
headNo. seizedPercent seizedNo. of headNo. seizedPercent
seized19811,616,137883,70054.71,811,288191,88010.619821,821,2651,108,19460.81,415,30
2127,2138.919831,876,0301,030,48455.21,282,690140,22510.919841,205,225692,50357.4719
,60080,62311.219851,306,843731,12755.9847,52895,21211.219861,362,937802,52358.91,575
,381174,10411.119871,056,016578,93454.8919,28685,2129.319881,257,908750.06659.61,146
,803130,47711.419891,625,498973,65257.82,433,109320,27313.219901,398,522834,60759.71
,956,631258,52413.2
Source:   Ministry of Livestock Raising, Agriculture, and Fishing.  Sector Health
Statistics, 1991.  Eastern Republic of Uruguay.



REFERENCES


1.   Eddi, C., M. Carcagno, and R. Dughetti.  La Distomatosis
hepática.  Una enfermedad parasitaria de los rumiantes. 
Acintacnia 1981; 4:16-18.

2.   Boray, J.  Current status of the control of Trematode
infections in livestock in developing countries.  FAO Expert
consultation on helminth infections of livestock in developing
countries. 1991; 23-27 September.  Rome, Italy.

3.   Nari, A.  Personal communication.  1991.

4.   Quevedo, F., and A. S. Thakur.  Food Science.  Food-Borne
Parasitic Diseases.  Series of Scientific and Technical
Monographs Në 12/Rev. 1.  Veterinary Public Health Program. 
PAHO-WHO.  Martínez, Argentina, 1990.

5.   Coop, R., and A. Sykes.  Fasciola hepática:  the effect of
subclinical infection on the food intake and efficiency of food
utilization.  Parasitol 1977; 75:36-37.

6.   Edward, C., M. Al-Saigh, G. Williams, and A. Chamberlain. 
Effect of the liver fluke on wool production in Welsh mountain
sheep.  Vet Rec 1976; 98:372.

7.   Acha, P., and B. Szyfres.  Zoonoses and Communicable
Diseases Common to Man and Animals.  2d ed.  PAHO Scientific
Publication No. 503.  Washington, D. C., Pan American Health
Organization, 1987.

8.   Chick, B., O. Coverdale, and A. Jackson.  Production
effects of liver fluke Fasciola hepática on beef cattle.  Aust
Vet J  1980; 56:588-592.

9.   Guerrero, C.  Fascioliasis: una zoonosis de impacto
económico e importancia en Salud Pública.  IV Reunión
Interamericana de Salud Animal a Nivel Ministerial. 1-3 de Mayo
de 1985. Brasilia, D.F., Brasil.

10.  Hope Cawdery, M.  Review of the economic importance of
Fascioliasis in sheep and cattle.  Irish Vet News 1984; 9.

11.  Contreras, B.  Abortos debidos a fascioliasis en una
hacienda venezolana.  Noticias Med Vet 1976; 2:190-195.

12.  Dwinger R., P. Le Riche, and G. Kuhne.  Fascioliasis in
beef cattle in north-west Argentina.  Trop Anim Hth Prod 1982;
14:167-171.

13.  Lombardero, O., R. Moriena, O. Racioppi, J. Coppo, and H.
Schiffo.  Fascioliasis hepática en bovinos de la Provincia de
Corrientes.  Veterinaria Argentina 1979; 2:21-29.

14.  SENASA.  Datos oficiales obtenidos de los registros de
decomisos de la Secretaría de Agricultura y Ganadería de la
República Argentina.  1991.  Buenos Aires.

15.  Alcaino, H.  Epizootiología de la fascioliasis bovina en
Chile.  Parasitología al Día 1985; 9:22-26.


16.  Nari, A., and H. Cardozo.  Prevalencia y distribución
geográfica de la fascioliasis hepato-biliar en bovinos de carne
del Uruguay.  Veterinaria 1976; 13:11-16.

17.  Nari, A.  Current status of the epidemiology, diagnosis and
control of helminth infections in livestock in Latin America. 
FAO Expert consultation on helminth infections of livestock in
developing countries. 1991. Rome, 23-27 September.

18.  Hillyier, G., M. Garcia Roja, and M. Soler.  Identification
of F. hepática immunogenic molecules with immunodiagnostic and
immunoprophylactic potential.  In:  Basic research in
helminthiases.  R. Elrich, A. Nieto, and L. Yarzabal (eds.). 
Montevideo, R. O. del Uruguay, Logos, 1990.

19.  Over, H.  Current status of liver fluke infection in
developing countries with an assessment of its impact on
livestock production.  FAO Expert consultation on helminth
infections of livestock in developing countries. 1991. Rome, 23-
27 September.

20.  Ueno, H., V. Gutiérres, M. Mattos, and G. Muller. 
Fascioliasis problems in ruminants in Rio Grande do Sul, Brazil.
Vet Parasitol 1982; 11:185-191.

21.  Dobsinsky, O.  Helminthoses of cattle under tropical
breeding conditions.  Helminthologia 1969; 2:167-174.

22.  Bundy, D., P. Arámbulo III, and C. Grey.  La fascioliasis
en Jamaica:  Aspectos epidemiológicos y económicos de una
zoonosis parasitaria transmitida por caracoles.  Bol Of Sanit
Panam 1984; 1:1-17.

23.  Encinas Garcia, R., H. Quiroz Romero, C. Guerrero Molina,
and P. Ochoa Galván.  Frecuencia e impacto económico de Fasciola
hepática en bovinos sacrificados en Ferreira, México. 
Veterinaria México 1989; 20:423-426.

24.  Sánchez Albarrán, A., D. Herrera Rodríguez, and Z. Barrios
Delgado.  Incidencia de la facioliasis y pérdidas económicas
debidas a los decomisos de hígados de bovinos holstein,
sacrificados en el matadero de Tulancingo, estado de Hidalgo,
México.  Técnica Pecuaria en México 1976; 110.

25.  Chang Diaz, E., and M. Cartin González.  Diagnóstico y
control de la fascioliasis bovina en el distrito de Santa Cruz
de Turrialba, Provincia de Cártago.  Cs Veterinarias Costa Rica
1983; 5:118.

26.  Alvaro Castro, H.  Posible efecto de la Fascioliasis en la
reproducción de ganado lechero en la Sabana de Bogotá, Colombia.
Inst Col Agro 1980; 92-97.

27.  Bendezú, P.  Algunos aspectos de la epidemiología de la
distomatosis hepática y su control biológico en el Valle del
Mantaro.  Bol Ext IVITA (Lima) 1970; 4:356-367.

28.  Pérez, O., L. Lecha, M. Lastre, R. González, R. Pérez, and
E. Brito.  Fascioliasis humana epidémica, Cuba, 1983. I.
Caracterización climática.  Rev Cuba de Med Trop 1988; 3:68-
81.

29.  Biagi, F.  Enfermedades Parasitarias.  2d ed.  Mexico, La
Prensa Médica Mexicana, 1974.
   ABDOMINAL ANGIOSTRONGYLOSIS:  A PUBLIC HEALTH PROBLEM

Dr. Pedro Morera
      School of Medicine and Health Research Institute,
University of Costa Rica
Pathology Service,
San Juan de Dios Hospital
COSTA RICA


     Abdominal angiostrongylosis is a parasitic disease caused
by a small nematode Angiostrongylus costaricensis Morera and
Céspedes, 1971 (1) (Morerastrongylus costaricensis Chabaud,
1973) (2).  Despite the fact that the disease began to be
observed in Costa Rican children in 1952 (3, 4), its etiologic
agent was not described until 1971 (1).  Subsequently, the
rodent that acts as the natural final host (5) and the mollusks
that constitute the intermediate hosts (6) were identified and
its life cycle was elucidated (7).  The first non-Costa Rican
case was found in Honduras in 1972 (8) and we now know that the
disease has been observed in most of the countries of the
Hemisphere, from United States to northern Argentina (9) and
including some Caribbean islands.  However, the real
geographical distribution has not been well established due to
the paucity of knowledge about this parasitic disease.  The
first case in Africa was found recently (10), which indicates
that the distribution of the parasite in its natural hosts is
not limited to America.  In Costa Rica, a few more than 500
cases are observed annually, which gives a rate of some 17 cases
per 100,000 population per year; however, it is considered that
this rate could be higher if all physicians had the knowledge
of the disease necessary to suspect its clinical presence.

     Outside Costa Rica, almost all cases are diagnosed by a
pathologist, since there is not sufficient knowledge among
physicians to make a clinical diagnosis.  In addition, very few
pathologists have sufficient knowledge to make the histological
diagnosis, as is demonstrated by the fact that many cases have
been diagnosed in retrospective studies carried out on the files
of the pathology services of several hospitals in Latin America.


MORPHOLOGY AND LIFE CYCLE

     A. costaricensis is a filiform nematode, with the cephalic
extremity rounded and a cone-shaped tail in the female; the
mouth has three small lips.  The female is 32 mm long on the
average and the anus and the vulva are located in the ventral
part of the caudal extremity.  The male measures an average of
20 mm and has a moderately developed copulating sac.

     In the natural final host (rodents of several species) (11)
the adult worms live within the mesenteric arteries of the
ileocecal region.  Here copulation occurs and, subsequently,
oviposition; the eggs are swept by the bloodstream toward the
intestinal wall, where embryonation is initiated.  Once formed,
the larvae of first stage migrate to the intestinal lumen and
reach the soil with the rat's feces.  The intermediate host
(usually a slug of the family Veronicellidae) is infected on
eating the fecal matter of the rodent.  In the mollusk two
alterations occur and in 18 days the larvae of third stage, that
is, the infective form for the mammal, is completely mature;
these larvae can remain alive in the slug for several months or
can leave with the mucous secretion of the mollusk.  The rodent
is infected on ingesting an infected slug.


TRANSMISSION AND EPIDEMIOLOGY

     There is no evidence that individuals intentionally eat
slugs; however, it is possible for small specimens hidden in the
leaves of vegetables to be finely minced in salads and hence
ingested raw accidentally.  We also know of several cases of
ingestion of these mollusks by very young children.  However,
it is probable that most of the infections are produced by
ingestion of larvae that leave with the secretion of the
mollusks and that can contaminate food or objects that are
carried to the mouth fortuitously.  Slugs have been found on
mature fruits that fall to the ground and on plants that are
commonly eaten raw.  The habit, exhibited by children, of
putting things into the mouth could explain why this population
group shows the highest rates of infection.

     The slugs of the family Veronicellidae constitute the most
important intermediate hosts of A. costaricensis.  In a study
carried out in 20 communities in Costa Rica, which ranged from
sea level to an altitude of more than 2,000 meters, it was found
that 50% of 6,025 slugs were infected; more than 16,000
infective larvae were found in a single specimen.

     In Costa Rica, the cotton rat Sigmodon hispidus is the most
important final host, but 11 other species of rodents have also
been found with natural infections.  The coatimundi (Nasua
narica) in Costa Rica, marmosets (Saguinus mystax) of the
Peruvian Amazon, and the domestic dog also have been found with
natural infections.  It is probable that this epidemiological
panorama is different in South America due to the variety of
species of rodents and mollusks that exist there.

     Since the parasite is capable of adapting to a large number
of intermediate and final hosts, the differences in existing
species in distant places in the Hemisphere should not be the
reason that very marked differences exist with respect to
prevalences in the environment; neither is there a special
biological condition that would cause more cases to be observed
per year in Costa Rica than in the rest of America.  In 1991,
through last 31 October, we had verified 513 cases in our
laboratory in examining 1,758 sera that had been sent us because
in those patients there was some reason for clinical suspicion. 
Actually, our country does not have ecological differences great
enough to explain the big difference that exists with other
countries, even those that are closest.  The only explanation
then is the greater knowledge that our physicians have of the
problem, which increases the number of clinical diagnoses that
then are verified or ruled out through immunological diagnosis.


PATHOLOGY

     In infections caused by A. costaricensis two pathogenetic
mechanisms can be clearly distinguished:

     1) The adult worms that live within the arteries damage the
endothelium, inducing the formation of thrombi; as a
consequence, necrosis of the tissues originally irrigated by the
thrombosed vessel is produced.
     2) The eggs, embryos, and larvae, as well as the excretory
and secretory products of the parasite, cause inflammation of
the intestinal wall.

     The combinations of these two phenomena, the susceptibility
of the patient, and the number of parasites and their location
are going to determine the clinicopathological differences which
can range from subclinical cases to those in which only
appendicitis is observed or to the most serious, which require
the resection of large parts of the intestine.

     Macroscopic examination of the surgically excised parts
reveals enlargement and hardening of the intestinal wall with
yellowish spots on the serosal surface and in the mesentery. 
The intestinal lumen is reduced sometimes, causing partial or
total obstruction.  The areas of ischemic necrosis can be
perforated causing peritonitis.  In many cases, despite the fact
that only an appendectomy is performed, the surgeon observes
lesions in the cecum whose severity does not justify resection.

     Histopathological examination shows a granulomatous
inflammatory reaction with marked eosinophilic infiltration, 
especially in the mucosa and submucosa; the serosa and the
muscular layers are often involved but to a lesser extent.  In
the small vessels of the intestinal wall one can observe eggs,
embryos and larvae; on occasion, one can see sterile eggs that
are easily degenerated and are more difficult to recognize;
these structures as well as the deposits of excretory and
secretory antigens can be identified through immunochemical
techniques.  In addition, in the mesenteric lymphatic ganglia
it is possible to observe eggs and larvae together with
reticuloendothelial hyperplasia and eosinophilic infiltration.

     On occasion, the parasite can be located ectopically in the
liver.  The liver lesions caused by A. costaricensis are similar
to those caused by Toxocara canis in the syndrome of visceral
larva migrans (12).  However, the finding of eggs, embryos, and
sometimes of adult parasites in the hepatic parenchyma or a
positive serology with homologous antigen establishes the
correct diagnosis.

     It is also possible for the parasites to migrate to the
arteries of the spermatic cord where they cause occlusion and
hemorrhagic necrosis of the testicular parenchyma (13).


CLINICAL MANIFESTATIONS

     Despite the fact that this parasitic disease is observed in
individuals of all ages, children are most commonly affected by
it.  In a study of 116 patients in a pediatric hospital in Costa
Rica (14) it was found that 53% were schoolchildren, 37% were
preschool age, and 10% were infants.  It was also observed that
men showed a greater rate of infection (64%) than women (36%);
this difference could be due to different play habits.

     In most patients the parasite is located in the ileocecal
branches of the mesenteric artery, just as in the natural host. 
When the worms are located in this habitat, the patients present
pain, usually located in the ileac fossa and/or the right flank. 
Palpation of this area is painful.  Rectal touch is also painful
in almost half of the cases.  There is almost always a fever,
rarely accompanied by chills.  In chronic cases a slight fever
can persist for several weeks.  Anorexia, vomiting, and
constipation may also be observed.  In some cases a very
significant finding for establishing clinical suspicion is the
presence of a palpable mass in the lower right quadrant and it
should be differentiated from a malignant tumor.  Cases with
profuse bleeding that can be confused with several others
pathologies have also been observed (15).

     Despite the fact that in some patients no hematological
changes are observed, the presence of leukocytosis and
eosinophilia is very important in diagnosis of the disease. 
Usually, the white cell count varies from 15,000 to 40,000/mm3
with eosinophilia ranging from 20% to 50%.  Cases have been
observed in which the leukocytes reached a count of 170,000/mm3
with 90% eosinophils.

     A radiological study with a contrasting environment is very
important; the lesions are generally observed in the terminal
ileum, cecum, appendix, and ascending colon.  Through this
method it is possible to observe filling defects and
irritability of the cecum and the colon; the lumen may be
reduced irregularly by the enlargement of the intestinal wall.

     In cases of localization in the liver the patient presents
pain in the upper right quadrant; there is hepatomegaly and the
liver appears smooth on palpation.  In a laparoscopy it is
possible to see small yellowish spots on the surface of the
liver.  In most of the cases, the liver lesions are concomitant
with intestinal angiostrongylosis.

     In Costa Rica several cases of necrosis of the testicular
parenchyma caused by this parasite have been found.  The most
significant findings are acute pain accompanied by reddening of
one of the testes.  Eosinophilia and leukocytosis usually are
very high in these cases.  All the patients with these lesions
were children and the diagnosis was a twisted testis; only after
the histopathological study was the correct diagnosis
established.


DIAGNOSIS

     In infected rats, larvae of first stage can be easily
identified in the feces.  However, this does not occur in humans
therefore a latex agglutination technique has been developed
that is inexpensive, rapid, and highly sensitive and specific.


TREATMENT

     In acute cases surgery is the treatment of choice. 
However, as knowledge of this parasitic disease has increased,
many non-surgical cases have been identified so that the need
has arisen for a medical treatment.  Remission of symptoms after
the use of diethylcarbamazine and thiabendazole has been
reported.  However, there is no scientific evidence that the
improvement was due to treatment with these drugs.  Indeed,
experimental studies in vivo and in vitro demonstrate that the
parasites do not die from these drugs but are excited, migrate
to smaller vessels, and produce ischemic necrosis that sometimes
causes the death of the animals.  Thus, chemotherapy cannot be
recommended until there are new studies to find a drug that is
really effective.


BIBLIOGRAPHY

1.   Morera, P., and R. Céspedes.  Angiostrongylus costaricensis
n. sp. (Nematoda: Metatrongyloidea): A new lungworm occurring
in man in Costa Rica.  Rev Biol Trop 1971; 18:173-185.

2.   Chabaud, A.  Description de Stefankostrongylus dubosti n.
sp. parasite du Potamogale et essai de classification des
Nematodes Angiostrongylinae.  Ann Parasit Hum Comp 1972; 13:312-
317.

3.   Morera, P.  Granulomas entéricos y linfáticos con intensa
eosinofilia tisular producidos por un estrongilideo
(Strongylata). II Aspecto parasitológico.  Acta Med Cost 1967;
10:257-263.

4.   Céspedes, R., J. Salas, S. Mekbel, L. Troper, F. Möllner,
and P. Morera.  Granulomas entéricos y linfáticos con intensa
eosinofilia tisular producidos por un estrongilideo
(Strongylata). Acta Med Cost 1967; 10:235-255.

5.   Morera, P. Investigación del huésped definitivo de
Angiostrongylus costaricensis Morera y Céspedes, 1971.  Bol
Chileno Parasitol 1970; 25:135.

6.   Morera, P., and L. R. Ash.  Investigación del huésped
intermediario de Angiostrongylus costaricensis Morera and
Céspedes, 1970.  Bol Chileno Parasitol 1970; 25:135.

7.   Morera, P.  Life history and redescription of
Angiostrongylus costaricensis Morera and Céspedes, 1971.  Am J
Trop Med Hyg 1973; 22:613-621.

8.   Sierra, E., and P. Morera.  Angiostrongilosis abdominal.
Primer caso humano encontrado en Honduras (Hospital Evangélico
de Siguatepeque).  Acta Médica Cost 1972; 15:95-99.

9.   Strickland, G. T.  Hunter's Tropical Medicine. 7th ed.  W.
B. Saunders Co., 1991.

10.  Baird, J. K., R. C. Neafie, L. Lanoie, and D. H. Connor. 
Abdominal angiostrongyliasis in an African man:  case study. 
Am J Trop Med Hyg 1987; 37:353-356.

11.  Morera, P.  Angiostrongiliasis abdominal.  Transmisión y
observaciones sobre su posible control.  Serie de publicaciones
de la OPS Në1. 1985; 230-235.

12.  Morera, P., F. Pérez, F. Mora, and L. Castro.  Visceral
larva migrans-like syndrome caused by Angiostrongylus
costaricensis.  Am J Trop Med Hyg 1982; 31:67-70.

13.  Ruiz, P., and P. Morera.  Spermatic artery obstruction
caused by Angiostrongylus costaricensis Morera y Céspedes, 1971. 
Am J Trop Med Hyg 1983; 32:1458-1459.

14.  Loría-Cortes, R., and J. F. Lobo-Sanahuja.  Clinical
abdominal angiostrongyliasis:  A study of 116 children with
intestinal eosinophilic granuloma caused by Angiostrongylus
costaricensis.  Am J Trop Med Hyg 1980; 29:538-544.

15.  Silveira, C. T., V. S. Ghali, S. Roven, J. Heimann, and A.
Gelb.  Angiostrongyliasis: a rare cause of gastrointestinal
hemorrhage.  Am J Gastroenterology 1989; 84:329-332.




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

HEALTH PROGRAMS DEVELOPMENT
VETERINARY PUBLIC HEALTH 







MEETING OF GROUP OF EXPERTS ON 
VETERINARY PUBLIC HEALTH EDUCATION IN THE
SCHOOLS OF VETERINARY MEDICINE
IN LATIN AMERICA



FINAL REPORT 












Blacksburg, Virginia
27-31 January 1992


MEETING OF GROUP OF EXPERTS ON 
VETERINARY PUBLIC HEALTH EDUCATION IN THE SCHOOLS OF
VETERINARY MEDICINE IN LATIN AMERICA

Blacksburg, Virginia, 27-31 January 1992



INTRODUCTION


Universities, as training centers for human resources, play an important role
in the development of countries and, as such, they should be involved in the
processes of economic, social, and political change in order to be able to orient
professional training properly.  Involvement means participation in the planning and
carrying out of the actions that are formulated by governments and societies in order
to achieve the desired changes.

Veterinary Medicine has made a significant contribution to the development
of the countries of Latin America; however, its evolution has not been commensurate
with political changes, international animal and animal product markets,
communications, biotechnology, and laws and standards, nor  with the circumstances
of a society that is grappling with unemployment, poverty, and growing violence. 
This situation is the result of lethargy on the part of the veterinary training centers
and of the indifference of those who use the services provided by the profession.  It
is time to reflect upon and analyze the present situation in order to make future plans
that will assist professionals in reassuming their leadership role in society and in the
economy.


OBJECTIVES

1.         To better understand the problem of professional veterinary training and how
it is used by the public and private sectors.
2.        To review and recommend adjustments to the proposal for a situational and
prospective study of veterinary education in veterinary public health in the
schools of medicine.

3.         To define the technical cooperation that is required to support the process of
prospective analysis in the schools of veterinary medicine. 


PARTICIPANTS

Dr.  Frank Anibal                    Dean, School of Veterinary Sciences, Universidad de Buenos
Aires, Argentina.

Dr.  Juan Garza Ramos                        Director, Inter-American Center of Social Security
Studies (CIESS), Mexico.

Dr.  Juan Gay                        Director, Secretariat of Agriculture and Water Resources
(SARH), Mexico.

Dr.  Pedro León Velázquez                               Manager, Empresa Colombiana de Productos
Veterinarios (VECOL), Colombia.

Dr.  Elvio Moreira                   Professor, School of Veterinary Medicine, Universidade
Federal de Minas Gerais, Brazil.

Dr.  Enrique Pérez                   Professor, School of Veterinary Medicine, Universidad
Nacional de Costa Rica.

Dr.  Luis Meléndez                   Virginia-Maryland Regional School of Veterinary Medicine,
Virginia Polytechnic Institute, United States of America.

Dr.  Don Cordes                      Virginia-Maryland Regional School of Veterinary Medicine,
Virginia Polytechnic Institute, United States of America.


Secretariat

Dr.  Primo Arámbulo III                      Coordinator, Veterinary Public Health, PAHO/WHO

Dr.  Alfonso Ruíz                    Regional Adviser, Veterinary Public Health, PAHO/WHO

Dr.  Miguel A. Genovese                      Country Adviser, Veterinary Public Health,
PAHO/WHO

Temporary Advisers

Ms.  Carol Collado                   Health Manpower Development

Dr.  Jorge A. Escalante                      Veterinary Public Health


PROGRAM OF ACTIVITIES


Monday, 27 January

 9:00 a.m.        Opening ceremony
Welcome by the officials of the Regional School of Veterinary Medicine,
Virginia Polytechnic Institute

Orientation by Health Programs Development (HPV), purposes and
objectives of the meeting, methodology of work - Dr. Primo
Arámbulo III, Dr. Alfonso Ruíz, and Ms. Carol Collado

Introduction of participants

10:30 a.m -              Participant panel on "The Situation of Veterinary Public Health in
the
 1:00 p.m         Countries."

 1:00 p.m. -   Lunch
 2:00 p.m.

 2:00 p.m. -   HPV Exhibit on "The Future of Veterinary Public Health"
 3:30 p.m.        Dr. Primo Arámbulo III and Dr. Alfonso Ruíz

 4:00 p.m. -             Group discussion 
 5:00 p.m.

 5:00 p.m. -   Plenary session






Tuesday, 28 January

 9:00 a.m. -  Introduction to the methodology of Prospective Analysis.
10:00 a.m.    Ms. Carol Collado

10:30 a.m. -  Individual exercises
11:30 a.m.

11:30 a.m. -  Discussion in plenary
 1:00 p.m.

 1:00 p.m. -  Lunch
 2:00 p.m.

 2:00 p.m. -  Reading of basic document
 3:30 p.m.

 4:00 p.m. -  Observations on methodology:  Prospective Analysis and Strategic
Planning.
 5:30 p.m.

Wednesday, 29 January

 9:00 a.m. -  Group exercises
10:30 a.m.

11:00 a.m. -  Plenary session.  Observations and orientation regarding the analysis
phase 
 1:00 p.m.

 2:00 p.m. -  Visit to the School of Veterinary Medicine, Virginia Polytechnic
Institute
 5:00 p.m.Thursday, 30 January

 8:30 a.m. -  Suggestions for amendment of basic document
 1:00 p.m.

 1:00 p.m. -  Lunch
 2:00 p.m.

 1:00 p.m. -  Continuation of working group
 3:00 p.m.

 3:00 p.m. -  Discussion:  Presentation of the HPV plan to carry out the prospective
 5:00 p.m.    analysis in the schools of veterinary medicine in Latin America and the
Caribbean

 5:00 p.m. -  Plenary session.  General recommendations
 6:00 p.m.   

 6:00 p.m. -  Closing ceremony
 6:30 p.m.

RESULTS

1.    Inauguration

      During the opening ceremony, held on 27 January at 9:00 a.m., Dr. John Eyre,
Dean of the School of Veterinary Medicine, Virginia Polytechnic Institute,
welcomed the participants and emphasized the importance of the analysis the group
expected to make during the week.  In addition, he stressed the need for academic
integration with the social sectors in order to highlight its concern for the
improvement of public health.  As an example he mentioned certain modalities that
his school had adopted so as to become associated with the socioeconomic
development of the State of Virginia and of the country.

      Dr. Eyre was followed by Dr. Don Cordes, Head of the Department of
Pathological Biology and coordinator for the Virginia Polytechnic Institute for the
event.  Dr. Cordes welcomed the participants and PAHO/WHO, emphasizing the
importance of the meeting for the Virginia Polytechnic Institute and the desirability
of establishing scientific and academic exchange programs with other teaching
institutions in the Hemisphere.  He pointed out the importance that this university
had given to international programs, citing as an example the high number of foreign
students who are currently enrolled in undergraduate and graduate programs. 

      Dr. Primo Arámbulo III then took the floor on behalf of the Program on
Veterinary Public Health of the Pan American Health Organization and thanked Dr.
Eyre and the School of Veterinary Medicine of the Virginia Polytechnic Institute for
its collaboration in hosting the meeting.  He also thanked the Group of Experts that
had been invited to donate part of its time to discussing a medical topic as important
as veterinary medicine training.  Dr. Arámbulo went on to explain the purposes of
the meeting and emphasized the work of PAHO's Program on Veterinary Public
Health. 

2.    Program of Work

      In launching the program of work, Dr. Primo Arámbulo pointed out the purpose
and objectives of the meeting and asked Ms. Carol Collado to explain the
methodology that would be followed during the meeting.  The participants were then
introduced and given the opportunity to speak of their academic training and
professional experience, with particular reference to their participation both in
training and using the human resources in this field.

2.1   The panel on the "Situation of Veterinary Public Health in the Countries" was
      conducted by means of presentations by the experts of their experiences and
      knowledge in their respective countries:  Mexico, Brazil, Costa Rica, Paraguay,
      Colombia, and Argentina.  The experts made a summary of the situation of the
      schools of veterinary medicine, the training of veterinary professionals, and the
      mechanisms of integration employed by the schools in order as a means of
      collaborating with the social sectors, in addition to presenting their ideas on the
      usefulness of such professionals in the development of veterinary public health
      in the countries.  All the speakers referred to the need for a better definition of the
      concept of veterinary public health and for expanding its fields of action for
      inclusion in the school curricula (Annex 1).

      The presentations gave rise to a discussion of the alternatives for the
      improvement of veterinary public health education, and the following conclusions
      were reached:

      a)            It is necessary for the faculties to better define and understand the
concept of veterinary public health prior to proposing changes in the
educational systems of the schools of veterinary medicine.

The group considered that WHO's definition, still in effect, was
desirable, although it pointed out the importance of more extensive
dissemination of the plans of action for veterinary public health that
were presented in the basic document and summarized in the figure
appearing in Annex 2.                    

      b)            Veterinary public health teaching is included in the following courses,
which some schools of veterinary medicine have introduced into their
curricula:

-       Preventive medicine and public health
-       Epidemiology and biostatistics
-       Food protection and hygiene 
-       Comparative pathology, biomedical models
-       Planning and organization of programs
-       Environmental sanitation with regard to animal  production and
animal ownership in urban areas
-       Control of zoonoses
      
      c)            The need was pointed out for enhancing teaching in the schools of
veterinary medicine with experiences derived from sociopolitical and
socioeconomic milieus.  In this regard, certain mechanisms were
mentioned that could be employed in the process of change:

-       Participation of students in in-service training in municipal services.

-       Coordination with the official services and other institutions related
to veterinary public health for the exchange of information and
participation in the processes of planning, development, and
evaluation of programs on food protection and control of zoonoses.

-       Establishment of ties and joint projects with private institutions.

-       Promotion of the dissemination of country socioeconomic
indicators in curriculum subject areas.

      d)            A recommendation was made to use the university as a center for
providing continuing education and maintaining contact with graduates
as a means of maintaining appropriate levels of expertise.  The
following mechanisms were mentioned to achieve this purpose:

      -             Improvement of the quality and orientation of continuing education.

      -             Promotion and improvement of graduate studies at the masters or
doctorate level.

      -             Greater responsibility on the part of the university in supporting the
official services; for example, Mexico's accreditation program, in which
the School of Veterinary Medicine gives short courses on the animal
health campaigns being carried out by the animal health services
provided by the Secretariat of Agriculture and Water Resources for
veterinary physicians in private practice.

      -             The need was noted for establishing indicators to follow up control and
evaluation of the quality of the education being provided in veterinary
medicine at both the school and country levels. 

      e)            It was pointed out that no single model exists for the organization of
activities in veterinary public health.  However, there is no doubt that,
given that veterinary public health encompasses public health activities
that involve the application, skills, and resources of veterinary medicine,
the veterinary public health organic structure should be linked to the
health sector and closely coordinated with the agriculture sector,
particularly in the areas of animal health and animal production.

i.      A focal point -  A veterinarian specialized in public health may be
considered to be one who acts as a catalyst and integrator of public
health activities in the field of veterinary medicine that are carried
out in the health and animal health services in order to provide them
with a programming structure.  This position can be defined as an
advisory function at the Minister level or at the regulatory level. 

ii.     A unit -  The ideal situation would be an administrative unit at the
national level in the Ministry of Health having its own personnel
and resources and a close linkage with its counterpart in animal
health in the Ministry of Agriculture.

      f)            It was recommended that professional veterinary medicine training be
oriented toward achieving a balance of economic and social benefits.

-       It was consequently suggested that the curricula be flexible and
adaptable for the various situations in the labor market.

-       It will be necessary to include in the curricula such subjects as mass
communication, environmental health, and administration and
management.

2.2   Prospective Analysis in the Schools of Veterinary Medicine

      The group analyzed in detail the document "Promotion and Development of
      Veterinary Public Health in the Schools of Veterinary Medicine in Latin
      America," which describes the methodology of the prospective study on
      education in veterinary public health in the schools of veterinary medicine.  The
      instrument for the evaluation was also reviewed and analyzed, and
      recommendations were made for its adaptation (see the corrected methodology
      in Annex 3).

2.3   Visit to the School of Veterinary Medicine, Virginia Polytechnic Institute.

      At the kind invitation of Dr. Peter Eyre, the group of consultants visited the
      School of Veterinary Medicine of the Virginia Polytechnic Institute on 29
      January where they were given the opportunity to observe the latest methods of
      education first hand, particularly with regard to clinical practices. 

2.4   Final Report

      In a plenary meeting a summary was made of the general and specific
      recommendations regarding the documents proposed by PAHO/WHO, and a
      schedule of activities was prepared for carrying out the prospective study (Annex
      4).
3.   Closing Ceremony 

      The meeting was closed at 6:00 p.m. on Thursday, 30 January 1992.



Reflections on the Occasion of an Anniversary 


On 2 December 1992 the Pan American Health Organization marks 90 years
of uninterrupted existence.  It is the oldest international health body in the world. 
This unbroken period has not been a static one by any means; quite the contrary,
it has been highly dynamic in the context of the myriad scientific, political,
economic, and social events of the present century in the Americas.  The
Organization has managed to adapt to all these changing circumstances because
the doctrine that inspires it and governs its task is an enduring one:  to promote
physical and mental health, to prevent disease, to prolong life, and thus to
contribute to the economic and social development of the people of the Western
Hemisphere.

Health, according to this doctrine, is not only a component of economic
development but also an essential element of human capital.  It is a right of all and
not merely the privilege of some, in this case the more well-to-do.  Thus we want
"health for all" because it is a moral principle--because it is accepted with
conscience.  We believe in equal opportunity for all human beings to have access
to the best services of prevention and treatment that a society has to offer.  Herein
lies the great complexity of the challenge that faces the Governments, PAHO, and
the other international organizations.

The creation of the World Health Organization in 1948 gave even greater
scope of action of PAHO.  The Pan American Sanitary Bureau, its executive arm,
in interpreting the policy of the two Organizations in the Americas, sees the human
being as a an integral biological and social unit.  Thus man or woman is
considered to be the object, the end, and the measure of all things.  Health is the
underlying mainstay that enables the individual to contribute creatively to the
sciences and the arts, to produce, to invest, and to consume.  From this it follows
that the actions of prevention and cure are interdependent.  In turn, the same is
also true of well-being and development--the latter understood to be the
application of modern technology to the improvement of living conditions.

We believe that PAHO's 90 years of accomplishments reflect a tradition,
because the value judgments that have inspired them are universal, rooted in the
cultures of the different societies that have come together over time to form the
Americas.  They are inherent in the principles, the precepts, and the customs that
make up the way of life of the men and women of this Hemisphere.

Sir Berkeley Moyniham, a distinguished surgeon of the early 20th century,
spoke about the meaning of tradition.  According to him, those who have learned
from a great teacher should not merely imitate his methods; they should try to
capture his true spirit by seeking new approaches and looking to discover even
deeper truths.  Few virtues are more noble, he claimed, than loyalty to a great
tradition--a tradition that is is kept alive not through routine observance of old
ceremonies or mute obeisance to a worn-out creed but rather through active faith
in the ongoing search for new truths and for new approaches that are in keeping
with the old spirit, with an unshakable devotion to that great ideal that the tradition
venerates.

PAHO has always sought--and will continue to seek--to define the ideal of
health for all the inhabitants of the Americas, which is the most valuable potential
they can count on in forging their destiny.  Above and beyond political pluralism,
which is the basis of democracy, our steadfast purpose should be to humanize
development, because always the men, women, and children who are its
beneficiaries are also its protagonists.

However, today, as yesterday, investments in human beings are usually the
weakest link in the economic development process.  And when the economy is
faced with recessions or depressions, they are the ones that suffer the most from
the redistribution of national income.  There are some--including international
agencies that provide advice to the Governments--who would regard allocations
for health as an expenditure and not a productive investment.  They forget the
years of life that are gained for economic development as a result of health
promotion, prevention, and the timely treatment of frequent diseases.  They forget
that the identification of risk factors for health, a product of epidemiological
research, makes it possible to concentrate actions and resources and thereby
reduce morbidity and mortality.  Convinced that the symbol of a society's progress
is the growth of its gross domestic product, they forget that the real measure is in
fact social well-being--including the state of health and nutrition--without which the
chances of having efficient and equitable economic development are greatly
reduced.

Some of them would hide, for morally questionable reasons, behind the
excuse that it is not acceptable to regard human beings as capital goods that can
be increased through investments.  They forget, as we have pointed it, that the
people are in fact the true protagonists of development.  Without them, it has no
meaning or justification.  We do not live only to be healthy.  We live to realize
ourselves in whatever way the spirit moves us, whether in the sciences, in the arts,
in business, in religion, or in any of the great diversity of human activities.  And we
live also to serve others, especially those who are more in need, with whom we
want to share the same well-being that we enjoy ourselves.  This is the ideal that
inspires--or should inspire--our acts.

We might well ask how we can hope to have an economic common market,
so anxiously sought by many countries of the Americas, without having an
intellectual common market first.  The better the quality of our products, the
greater the possibilities for trade and income.  But we are being held back by a
workforce that is sickly, inefficient, poorly fed, underpaid, and in need of basic
training in order to understand and apply modern technologies without risk.  Even
with highly competent leaders and an entrepreneurial spirit, it will be difficult to
compete as long as labor continues to suffer from these serious limitations, which
will be reflected in the quality and quantity of their output.

The dissemination of the doctrine that inspires PAHO, established by the
Member Governments, accounts to a large extent for the fact that it has continued
to exist for 90 years.  As we see it, this doctrine combines the ideal with the
practical and serves as a basis for the establishment of health policies and
programs in the countries that are geared to their most common problems.

The continuity of PAHO may also be attributed to other reasons.  It has been
a repository for the natural history of health in the Americas.  Because it has lived
through all the stages, it has been in a position to record the evolution of health in
each country and for the countries as a whole.  Over time the language has
become more precise.  The series Health Conditions of the Americas, initiated in
1953, has been increasingly enriched by the quantity and quality of the information
it presents, based on the general and specific indicators submitted by the
Governments.  This information has made it possible to identify national and
regional trends in each of the countries and to make comparative analyses within
and between countries.  Thus a common language has been created.  And in fact
it transcends the Americas because the information is also used by WHO in its
presentations of the health situation in the world.  For every priority problem today
it is possible to report on progress or setbacks, and to identify the determinants. 
It is now possible to justify investments in health on a more solid basis.  By having
increasingly complete and reliable statistics on the magnitude of problems and
available resources, the Governments can plan better--more systematically and
more strategically.  Information of good quality, submitted to decision-makers on
a timely basis, facilitates the essential process of setting priorities and allocating
resources to deal with the problems of greatest frequency and to evaluate
processes and impacts.

The continuity of PAHO is accounted for also because the Governments of
the Americas feel that the Organization belongs to them and they know that they
can rely on it, both in emergencies and for the solution of specific problems.  Its
technicians know how to offer advisory services without interfering with decisions,
and how to generously provide the best scientific knowledge available and share
experiences.  If the Governments did not consider PAHO useful, they would not
have defended its continued existence in 1946 at the Interim Commission that
created WHO.  Nor would they have maintained it up until now through their
contributions.

The Organization does not take credit for the results of the health actions in
which it collaborates.  This belong to the States.  For PAHO, the knowledge that
the ideals which emanate from its doctrine have been transformed into reality in
the form of well-being for a greater or lesser number of human beings is sufficient
incentive to move ahead to the next stage of its mission.

The process of fulfilling the targets in the Ten-Year Health Plans for the
1960s and the 1970s pointed up the need to invest in capital goods that the
Governments did not have.  PAHO has provided advisory services, especially
through the Inter-American Development Bank, which since then has made very
large sums available for improvement or extension of the institutional and
community-based health services infrastructure as well as for water supply and
sanitation, institutional development through the training of human resources,
veterinary public health services, and other challenges.  It is clear that these
contributions have accelerated the attainment of better health--even in the context
of the increasing and sometimes excessive growth of the population and the
negative impact of the economic recession.  The World Bank, the United States
Agency for International Development, and similar agencies in the European
countries have also contributed significantly to the formulation and development
of health programs.

Through its fellowships program and the work of the Subregional and Pan
American Centers that administer it, PAHO has facilitated the formation of a
galaxy of specialists in health who have served as key actors in bringing about a
decline in the indicators of morbidity and mortality in the Americas--a concrete sign
of progress in health.  Also, a considerable number of countries and large areas
of others have made impressive progress in the demographic and epidemiological
transition to a health profile that is more like that of some of the developed nations. 
The chronic and degenerative diseases, many of which depend on the quality and
quantity of the food that people eat, rank among the five leading causes of
morbidity and of mortality.

PAHO has promoted scientific research, especially epidemiological and
operations research, both through direct contributions and through the Centers
that it administers.  There have been many high-level contributions, some of which
are considered classics in the literature of comparative epidemiology, such as the
Inter-American Investigation of Mortality of Childhood, by Puffer and Serrano, and
the study on mortality in adults, Patterns of Urban Mortality, by Puffer and Griffith. 
It has offered the prestigious pages of the Boletín de la Oficina Sanitaria
Panamericana and the Bulletin of the Pan American Health Organization to the
scientists of the Americas, for which the contributions are carefully selected. 
These and other publications of the Organization, considering the demand for that
they enjoy, are another reason for PAHO's continuity.

Dr. Carlyle Guerra de Macedo, the Organization's current Director, has
enriched its visionary doctrine with important conceptual contributions--among
others, the definition of its direction and mission in terms of "management of
knowledge," which includes the generation and application thereof as well as all
the intermediate stages.  This means, in my opinion, that PAHO and WHO should
be in a position at all times to offer validated knowledge, based on the results of
scientific research, for the solution of health problems in the countries. 
Accordingly, the personnel of PASB must be fully up-to-date in the disciplines that
correspond to their responsibilities.  Hence the excellence of the advisory services
offered to the Governments, in which the latest knowledge, tested by experience,
is adapted to each specific situation and circumstance--bearing in mind, of course,
that in any field of science it is difficult today to be omniscient.

Dr. Macedo has interpreted the Organization's doctrine in terms that
transcend the effects of prevention and treatment.  He has proclaimed health to
be a "bridge for peace."  He has called attention to the pointlessness of war and
to the devastation that it wreaks on the physical and economic structure of
countries wherever it occurs--not to mention the resulting breakdown in the
spiritual and moral values of societies.  In the best of cases, innocent human
beings are displaced from their homes and communities, and in the worst, they are
wounded or killed.  The need to treat and rehabilitate these victims on a timely
basis and to prevent malnutrition and infections in mothers and children-
-in other words, the need for health actions--can create a dialogue with the parties
in conflict.  Thus it happens quite often that health does indeed become a bridge
for peace.

The Director of PAHO, in promoting what he calls "new development," warns
against the continued application of worn-out models that have failed in the past. 
The sad heritage of these models has come to form part of our peoples' hard
reality and has contributed to a social debt which by now has reached outrageous
proportions.  We must now create conditions that will make it possible to produce
and be productive once again, but this time with focus on meeting the needs that
have been postponed for so long.  And we must also ensure that the conditions
being created will guarantee lasting development.

Dr. Macedo recommends that health actions be a part of this new
development--which comes from different sectors--because they not only benefit
from its results but also contribute to well-being and to social equity in democratic
countries where there is true freedom of expression and participation in everything
that relates to the common good.  The fact remains that all human beings should
have the opportunity to forge their own destiny and to contribute to social justice
within the nation to which they belong.

During the difficult circumstances of the last decade--which still prevail today-
-PAHO and WHO have continued to cooperate with the Governments of the
Americas in reducing negative health and in promoting positive health.  It has been
a complex process, which certainly has not been facilitated by the economic
recession or the policies of structural adjustment, which have cut deeply into
budgets for health, education, nutrition, and other social areas.  It requires great
imagination, dedication, and decision on the part of leaders to effectively serve a
burgeoning population whose growth is placing a steadily increasing strain on
resources and purchasing power.

If it appears that health indicators have deteriorated less than was expected,
this is explained, among other reasons, by the preventive measures that have
been taken (complete immunization, for example) and by the importance that has
been given to primary health care through emphasis on local health services,
community participation, health education, and the provision of water supply and
basic sanitation services.  It is not easy to measure the effects of formal education
programs, or the impact of agriculture in guaranteeing adequate nutrition for
mothers and children, or the influence of social security--initiatives which have
usually been developed in parallel and have not been integrated with health
programs.

The past 40 years have seen the emergence of a number of international
agencies--multilateral, bilateral, nongovernmental, and philanthropic-- in the area
of financing and technical cooperation which have included health among their
objectives.  These institutions, based in the Americas and other Regions, have
helped in varying degrees to initiate or extend Government-sponsored prevention
and treatment both in institutions and in the communities.  While there is still need
for greater coordination between these entities, progress has been made in recent
years.  Some would think that this process is not going to occur spontaneously. 
Indeed, it is more likely to take place if Governments take the initiative and create
the conditions for effective coordination based on programs involving the
participation of various international agencies--and if evaluations of the processes
and their impacts are taken as the basis for consolidating the joint work of the
participating agencies.

The Pan American Health Organization, thanks to its doctrine of vision and
to its richly constructive past, can look forward to the future with confidence.



   WOMEN AS PRINCIPAL PROVIDERS OF SUPPORT FOR THE ELDERLY:  
THE CASE OF PUERTO RICO


Melba Sánchez-Ayéndez, Ph.D.
INTRODUCTION

     Transcultural studies in the field of gerontology have
demonstrated the importance of family support to the lives of the
elderly.  The elderly person's family members, particularly the
daughters and the spouse, are the principal source of support
both for daily living and at times of crisis.  In cases where one
spouse has died, or where both are older than 75, or where one of
the two is disabled or suffers from a chronic illness that
requires a great deal of care, the children assume responsibility
as the principal providers of support (1-4).  Most often, it is
the daughters who carry out most of the helping functions.

     The daughters represent what has been called "the sandwich
generation" (5) or "the woman in the middle" (6).  These women,
most of them between 40 and 60 years old, face multiple
responsibilities in relation to the generation that precedes them
and those that follow them.  These responsibilities compete among
themselves, and fulfilling them all in a satisfactory manner is
no easy task.  At the same time, many of these women are
experiencing the changes associated with their own aging process
and that of their spouses.

     This article examines the case of Puerto Rico, a country
with a strong Latin American cultural tradition which nonetheless
has close economic and political ties to the United States of
America.  Puerto Rico shares with the rest of Latin America
similar mores regarding the family, regarding masculine and
feminine roles, regarding Catholicism as the predominant
religion, and regarding the relationship between humans and
nature.  It also shares the language, since Spanish continues as
the country's predominant and official tongue despite the long
relationship to the United States of America.

     The elderly population of Puerto Rico has increased
dramatically in less than 40 years.  In 1950, adults of 65 years
and older constituted 4 percent of the country's population. 
Preliminary data from the 1990 census indicate that this group
now accounts for 10 percent of the total population (7). 
Estimates for the year 2000 indicate that adults of 65 and older
will make up 12 percent of the population by then(8), and it is
predicted that this will increase to 18 percent in 2020, when the
so-called postwar generation passes the 65-year mark.

     The cultural patterns of Puerto Rico -- present to a greater
or lesser degree in all the countries of the Region of the
Americas --  have assigned and continue assigning to women the
role of principal providers of care to children, the elderly, and
disabled family members.  The current expectations for self-
reliance increase the burden on women, who are the principal
providers of assistance to their elderly parents.  These
expectations demand greater efforts on the part of women due to
the decreasing size of the Puerto Rican family, a trend which has
limited the number of persons available to participate in
providing support, and due to the increase in the longevity of
elderly persons.

     Puerto Rico also shares with the rest of Latin America
similar values in regard to social concepts of reality, life, and
the family (9, 10).  Family interdependence is still highly
valued, despite the changes associated with migration from the
rural areas to the cities and with the mass migration of Puerto
Ricans to the United States of America.

     Similarly, patterns of inequality continue in regard to 
feminine and masculine behavior and status, despite changes in
the legal sphere which have influenced the formation of public
policies.  These unequal patterns are reflected in the marked
differences between the genders in regard to occupation, income,
working situation, level of autonomy at the workplace, and
functions associated with an occupation (11, 12) -- this in a
country that has the highest rate of female participation in the
formal work force of all the Latin American countries, with women
participating at a rate half that of men at the national level
(13).  Another pattern that Puerto Rico shares with other Latin
American countries is the increase in the number of households
headed by women (13, 14).  This trend may result from the rapid
incorporation of women into the work force, from the increase in
male migration in search of employment, and from the high rate of
divorce (14), factors which are all present in Puerto Rico.

     Notwithstanding these similarities to other Spanish-speaking
countries of the Americas, there are certain structural factors
which set Puerto Rico apart from the larger regional experience
of the continent.  Of particular importance for the health sector
are a higher standard of living; a system of social services
which strongly resembles that of the United States of America and
which depends in great measure on financial and programming
assistance from that country; and greater access to these
services for persons of limited economic resources.

Support Systems for the Elderly

     The rapid social and economic changes which Puerto Rico has
experienced over the last 30 years have affected the patterns of
family and community interaction.  It has been said that the
extended family has given way to the nuclear family, and that the
elderly find no place in it.  However, studies on elderly Puerto
Ricans in Puerto Rico and in the United States of America
indicate that the family continues to be the principal provider
of essential support to the elderly (10, 15-20).

     The findings suggest that in Puerto Rico there exists a
system of modified nuclear family, or modified extended family;
in this system the nuclear family, while not sharing the same
dwelling unit with other relatives, is not isolated, but
maintains patterns of social interaction and mutual assistance
with other nuclear families.  These patterns of support exist
between different generations as well as within a single
generation.  Research on the support networks of elderly Puerto
Ricans shows that they depend more heavily on the support
provided by their families and other members of their informal
support systems than on the services offered by various
government agencies.  Not only do they depend more; they also
prefer to seek support first from these informal systems, before
approaching the formal services.

     The family in Puerto Rico continues to be the primary
institution giving assistance to elderly persons.  The children
and spouse of the elderly adult are his or her principal source
of support (10, 15, 17, 18, 19, 21).  The daughters are the ones
who usually provide the greatest and most diversified support;
when the daughters are not present, then daughters-in-law perform
many of the tasks that the daughters would normally carry out. 
Sisters and nieces are also incorporated into the support
networks, especially during times of crises or when an elderly
person is disabled.
     
     The support that the family offers the elderly person is at
once practical, emotional, and material, both in normal times and
in times of crisis.  It includes functions such as lodging;
transportation and accompaniment; acquisition of food, medicines,
and other necessary items; company, demonstration of affection,
and emotional support; care during illness or disability;
personal hygiene; household cleaning and assistance with other
domestic chores; and provision of other services that the elderly
person needs.  The extent, frequency, type, and form of
assistance offered are subject to the particular dynamics of the
individual family unit and to socio-structural and demographic
factors; these include socioeconomic level, place of residence,
and number, gender, and residential proximity of the children
(10, 17, 20, 21).  The age and the functional and health status
of the elderly person also influence the particular
characteristics of the patterns of assistance.

     Assistance between spouses Usually it is the wives who help
their sick or disabled husbands, seeing to their health care and
their personal cleanliness, and keeping house (10, 20).  When the
elderly woman is not in good health but the husband's health is
relatively satisfactory, it is he who provides the principal
health care.  However, according to ethnographic studies and
studies of cases in small samples selected for qualitative
analysis, the daughters go to the parents' home to supervise the
care, to do housework, and to see to the personal cleanliness of
the mother (10, 21).

     When both spouses enjoy good health, they provide their own
care at home, and in these cases assistance from other family
members is less.  This situation is more common among adults from
60 to 75 years of age; as the parents' age increases there is a
corresponding increase in the help provided by the children
during
health crises, with daily household tasks, and in the provision
of any other type of assistance or service that the elderly
person needs, for example accompaniment on a medical visit.

     Assistance provided by the children Filial support springs
from the cultural principal of family interdependence (10), that
implies a concept of life based on the premise that the
individual is not capable of doing everything nor of doing
everything well, and consequently must depend on assistance from
others (9).  Within this cultural dictate the family stands out
as the principal source of support for all individuals,
regardless of age.  Family interdependence implies standards of
reciprocity that should not be confused with equitable exchanges.

     Two of the handful of qualitative research studies that have
been carried out with elderly persons of Latin American origin
assert that the notion of filial obligation stems from the value
of family interdependence (9, 10).  Assistance from one's
children is viewed in terms of an expected reciprocity, as a
reward for the labors of child-rearing carried out by the parents
and based on filial love.  A good son or daughter is one who
helps the parents to the extent that his or her personal
situation allows.  Empirical studies -- whether quantitative
research at the national level, research on populations which use
specific health services, or qualitative studies on small
subsamples of specific population sectors -- show that nearly 70
percent of elderly Puerto Ricans, when they have a problem they
cannot solve by themselves, go to a daughter or a son to seek
help in resolving it (15, 16, 20, 22).  This is much more
frequent in the case of widowed or disabled elderly persons.

     Cultural dictates on masculine and feminine roles affect the
types of family assistance (10, 21).  Both men and women among
the elderly expect their daughters to be the ones most involved
in providing necessary care.  Members of the current cohort of
Puerto Rican elderly continue to believe in an unequal pattern of
behavior for men and women, and although they accept the fact
that women are educated and work outside the home, they still
expect the man to be the principal breadwinner in the marriage
and the woman to be in charge of the home.  The maintenance of
family relations is seen to be an activity associated with the
home and, therefore, is considered a feminine responsibility;
these relationships include the care of elderly relatives,
especially the parents.

In the case of widowed or disabled mothers, there are greater
expectations for assistance from the daughters.  Elderly women
perceive their daughters to be more understanding, reliable, and
better able than their sons to help them with problems.  They do
not expect their sons to help as much as their daughters, nor in
the same way, and complaints are more frequent when it is a
daughter who decides not to carry out the expected functions of
assistance.  By the same token, it is expected that daughters
will visit or call more frequently than sons.  As women, they are
associated with domestic activity and responsible for the care of
family members.

The maternity of a daughter is an event that lays the foundations
for an inviolable bond between mother and daughter (10).  Once
the daughter herself becomes a mother, it is expected that the
ties that unite her to her own mother will become much stronger. 
This expectation results from a biosocial concept of women. 
Their reproductive biological capacity takes on a psychosocial
dimension that permits them to be more devoted and understanding
with the children than are fathers.  Once a daughter experiences
motherhood, her mother assumes that she can now understand the
sacrifices involved in child-rearing, that traditionally affect
mothers more than fathers, and that are validated socially by the
great majority of women.  The establishment of this inviolable
bond results in further validation of the expectations of love
and of filial support (10, 19).

Sons as well as daughters participate in various activities
related to helping their parents.  However, when the parents are
ill or disabled, it is usually the daughter who becomes the
principal provider of care in the home.  During periods of acute
illness or crises of chronic afflictions, a daughter will
frequently take the ailing parents to her home, or she may stay
in their home in order to be able to provide better care.  It is
also the daughters who, to the extent possible, remain with a
hospitalized parent during the day or night (10).  The sons go to
the hospital, but tend to stay for short periods.  Normally the
daughters, whether they work outside the home or not, are the
ones who spend the most hours at the bedside of the elderly
parent.  In addition, it is usually the daughters who see to it
that the elderly person follows the prescribed treatment, and who
accompany him or her to the doctor's office.  When there are no
daughters, these functions are usually performed by daughters-
in-law.  It is to a daughter's house that the elderly person goes
to live in cases where illness, disability, or very advanced age
prevent him or her from continuing to live alone. 

     Sons, like daughters, take responsibility for the purchase
of medicines or make monetary contributions to defray medical
expenditures and the cost of domestic services, in cases where it
is needed and their economic situation permits it.  But it is the
daughters who visit their sick parents most frequently, provide
their care, and do household chores when the mother is unable do
them temporarily or permanently.

     When the elderly couple or a parent who lives alone needs
assistance with domestic tasks, it is a daughter who takes
responsibility for this.  This dynamic, analyzed in detail in two
qualitative studies on elderly Puerto Rican women, in their
country of origin and in the United States of America (10, 21),
takes place in two principal ways.  If the daughter does not work
outside the home, she goes to the elderly person's house at any
time of day for two or three hours to help with or perform
household tasks.  She might bring prepared food with her, or she
might prepare it in the parent's home; in some cases she takes
home with her the clothes that need washing.  When daughters work
outside the home they offer similar assistance but in the
afternoon, after leaving work.  In these cases, the daughters do
a general assessment of the needs of the home, prepare food, and
perform one or another basic cleaning chore, and then over the
weekend they return to the elderly person's home to carry out a
more thorough cleaning and do the laundry.

     Most of the care given to elderly persons in Puerto Rico,
whether in regard to health, performance of household tasks, or
emotional support, comes from one or two children, principally
women.  However many children the elderly person might have, one
or two take responsibility for providing the care and making the
necessary decisions about it.

The assistance from the perspective of the daughters

     Two qualitative studies on the support networks of elderly
Puerto Rican women found that nearly 76 percent of the daughters
who take active part in support networks for their elderly
parents say that they derive satisfaction from the fulfillment of
what they call their filial duty (10, 21).  Given the central
role of daughters in caring for their parents, it is often
assumed that these activities are cut back when women work
outside the home, but studies on the elderly carried out in
Puerto Rico and elsewhere indicate that this is not the case (21,
23, 24.  Rather, women fulfill their multiple responsibilities by
negotiating flexibility in their daily duties and by sacrificing
their free time.

     It is common for women who work outside the home to use an
afternoon or a day off to take their elderly parent to the
doctor.  In other cases, the daughter drops off the parent at the
doctor's office before she goes to work, or during the lunch
break, and returns to pick him up when she leaves work or during
the lunch break, as the case may be.  Similarly, on occasions
when the elderly person's health condition requires
hospitalization, it is commonly the daughter who takes vacation
or medical leave time so she can stay at the hospital with the
parent.  In many cases, the daughters, daughters-in-law,
grandchildren, sisters, and nieces take turns staying with the
hospitalized elderly person.

     Although the studies do not indicate whether or not this
situation affects women's opportunities in the labor market, it
can be assumed to affect them in some way.  Those women who over
prolonged periods must be absent from their work and whose
attendance records reflect medical leave time, late arrivals, or
early departures, find that this affects their chances for raises
and promotions on special merit, since the fulfillment of their
filial duties conflicts with the interests of the company or
organization.  Not only is there a reduction in the already
limited job opportunities available to women, but in many cases
salaries and wages also are affected.

     Although the daughters express satisfaction with the
fulfillment of their filial obligations, many point out that
performing these helping functions causes them stress, not only
as regards their work situation -- in the case of those that work
outside the home -- but also in their family relations.  This
stress is associated with problems in the relationship with the
husband, with the children, with brothers or sisters who do not
assume responsibilities for the care of the elderly person, and
even with the elderly father or mother; economic problems are
also a cause.  On occasion, the principal provider of assistance
also is plagued by feelings of guilt and impotence.  The
situation is aggravated when the primary care-provider or her
spouse are themselves affected by health problems.

     The provision of needed care for an elderly person whose
health is delicate, or who is physically or mentally disabled,
has repercussions for the health of the woman who is the
principal caretakers.  Depression, low levels of satisfaction
with her situation, and even a deterioration of her own physical
health can result from prolonged situations of health crisis. 
These results are felt as long as the crisis lasts, but also have
repercussions on the future health of these women.

CONCLUSIONS

     The increase in longevity experienced by the population of
Puerto Rico, especially among persons 75 and older, implies the
present and future existence of two generations of elderly. 
Demographic projections indicate that in the future these two
generations will consist for the most part of older women who
will be caring for their elderly mothers.  Puerto Rico is faced
with the need to plan formal services of home care that can
relieve the stress suffered by women who today are the principal
sources of support for their elderly parents.

     The middle-aged Puerto Rican woman who is the principal
provider of care for her elderly parents faces, like her
counterparts in other countries of the Americas, greater
conflicts than did her own mother and grandmother when they cared
for elderly relatives.  A number of factors -- the increase in
longevity and in the number of elderly relatives who require
care; the reduction in the number of family members available to
participate in the care of the elderly person, resulting from
such factors as migration and a declining birth rate; and the
active participation of women in the work force, in addition to
their continuing involvement in the informal economy -- add more
pressures to those already imposed by cultural traditions that
assign women the role of principal providers of health care
within the family nucleus, and by the social expectation of self-
reliance in the performance of these functions.  The
repercussions in terms of the mental and even physical health of
these women, at present and as a future cohort of elderly
persons, must not be overlooked by the planners and suppliers of
social services.  These pressures are often greater in cases
where the woman is herself a head of household.

     Relations between parents and children are based on feelings
of affection and duty.  As a result, the support that daughters
offer their elderly parents is not going to disappear.  However,
it should not be assumed that the family can always provide the
elderly with all the care they require, or with the best care; or
that the provision of assistance to elderly parents who are
disabled, or who require constant attention because of their
advanced age, does not involve tensions, frustrations, and
conflicts.  In the countries of Latin America this situation has
not yet been recognized (25, 26) as it has begun to be in the
United States of America.  The implications of an aging
population in Latin America and the Caribbean have not been
understood in their full magnitude, much less the serious
consequences for the struggle against the conditions of
inequality faced by women, who traditionally provide care within
the family.

     In the International Conference on Aging of the Population
within the Context of Old Age, sponsored by the Population
Division of the United Nations (27), the following needs were
identified:  a) to establish infrastructures and mechanisms that
can supplement and support the care provided by families to the
elderly; b) to provide economic assistance, as necessary, to
families that care for elderly persons in frail health; and c) to
ensure the provision of supplementary services for long-term care
at the community level, in both urban and rural areas, including
"respite" services for the family members responsible for meeting
the needs of disabled elderly persons.  Emphasis was also placed
on the importance of having public policies ensure that the care
that women give to the elderly does not have a negative affect on
the position of women nor on their future opportunities.

     The planning of geronto-geriatric services should start from
the premise of a diverse set of flexible options that facilitate
the sharing of responsibility between the State and the family,
and that make it possible to adequately meet the particular needs
of the elderly and of those persons who assume the role of
principal caretaker in the family, usually women.  This will
promote not only the well-being of the elderly, but also of the
family members or other members of informal support networks who
feel the obligation and desire to assume responsibility for their
care.  Only a flexible set of support measures will ensure that
the needs of these two generations, made up to a great extent of
women, can begin to be fulfilled.








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=====FOOTNOTES/ENDNOTES =====

1. International Fellow in Gerontology, SSM International Center
on Aging, St. Clares Riverside Medical Center, Denville, New
Jersey, United States of America; Associate Professor, Graduate
School of Public Health, Faculty of Medical Sciences, University
of Puerto Rico, San Juan, Puerto Rico.

E0245.FIN



CHAPTER IV.D                                             16/IV/92
PUBLISHED VERSION


Women, health, and development
     The Regional Program on Women, Health, and Development
programmed its activities for the year in relation to the plan of
work approved at the X Meeting of the Subcommittee of the
Executive Committee on this subject, taking into account the
objectives of technical cooperation in this area and the
strategic orientations and priorities for the 1991-1994
quadrennium.
     The Program supported several of the subregional initiatives
and held meetings with different international agencies to agree
on criteria and mobilize financial and human resources.  A
workshop in Mexico on strategies to improve the health of women
doing paid work was supported.  A very special effort was made to
develop the Information System on Women, Health, and Development
(SIMUS) by selecting and processing 1,100 bibliographic records
in the database, and through the selective dissemination of
information to the countries of the Region according to their
requests and specific needs.  In regard to training health
personnel in the gender approach, the development of pedagogical
units on the subject has been carried out.
     As part of the effort to promote the Program, support was
provided to the national initiatives of Colombia and the
Dominican Republic on the World Action Day for Women's Health,
and to those of Cuba and Argentina on Women, Health, and
Development; there was also participation in 10 meetings and
conferences at which the Program was promoted and publicized.
     The meeting of the Working Group on Women, Health, and Self-
Care took place at Cali, Colombia, in November, and from it
resulted a reference document on the subject and strategies of
action for implementation in local health systems.  In addition,
as the Secretariat of the Subcommittee on Women, Health, and
Development of the Executive Committee, the Program put special
emphasis on preparing the meeting and on disseminating its
results.
     In regard to the effort to promote and develop research a
proposal was prepared with the technical advisory services of
Johns Hopkins University (USA) for a community action research
network on women's health and nutrition in Latin America to
obtain necessary financing.  In addition, two research proposals
were approved within the PAHO/WHO Research Grants Program and the
formulation of eight other projects was supervised directly in
the countries.
     Concerning support for subregional initiatives, in addition
to activities to generate subregional projects (in the Caribbean
and Andean Subregion), the Program focused on developing the
Women's Comprehensive Health Project in Central America (SIMCA),
which had financial support from the governments of Sweden and
Norway.  The Project comprises all the countries in the subregion
(Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua,
and Panama).  Subregional coordination has been strengthened
through the collaboration of the Spanish Agency for International
Development.  In addition, a broad consultation process was
carried out in the countries on executing Phase II of the Project
within the framework of the second stage of the Health Initiative
of Central America.  Finally, support was provided for the
initiatives of the countries by identifying needs for technical
advisory services by projects, as in the case of indigenous women
in Guatemala and legal literacy in El Salvador.
     Activities to disseminate information on the
multidisciplinary and gender treatment of the problems of women
resulted in the dissemination of information about this approach
and in the organization of a subregional documentation center on
subjects related to women and health.
     In regard to the review and formulation of laws which
directly or indirectly affect women's health, an analysis of
legislation has been carried out in six countries in the Central
American subregion.  The Subregional Forum on Women, Health, and
Legislation in El Salvador succeeded in bringing national groups
together which were representative of the different sectors
participating in this problem.
     Finally, since violence against women is one of the
principal problems identified in all the countries, research was
initiated to determine the dimensions of the problem and seek
ways to intervene from the viewpoint of public health.


FORTY-FIFTH WORLD HEALTH ASSEMBLY                 WHA45.25

AGENDA ITEM 30.1                                  14 MAY 1992

WOMEN, HEALTH, AND DEVELOPMENT

I.   BACKGROUND

     Resolution WHA45.25 is part of the set of conclusions and
recommendations that came out of the Technical Discussions on
"Women, Health, and Development," held at the Palais des Nations
in Geneva on the mornings of 7, 8, and 9 May.

     Some 400 participants registered for the Technical
Discussions.  These included leading personalities and experts in
the field of women's health, policy-makers, planners, public health
administrators, educators, lawyers, health specialists, and social
scientists.  Also present were government ministers and
representatives, together with representatives of nongovernmental
organizations.

     The discussions during the working sessions revolved around
the health of women throughout the world at all stages of their
lives and included an analysis of the causes and consequences of
women's health problems.  A summary of the discussions, as well as
the proposals for action, are contained in the Final Report,
document A45/Technical Discussions/2 of 12 May 1992.

II.  CONTENT OF THE RESOLUTION

     The resolution urges the Member States to establish a system
for reporting on the extent to which key elements of existing
resolutions of the World Health Assembly on women's health have
been implemented, on the gaps in implementation and the reasons for
these gaps, and on what assistance is needed to ensure fulfillment
of the commitments assumed by the governments.  It also urges the
Member States to implement steps to favor an increased proportion
of women at professional and higher levels in their Ministries of
Health and health sector institutions, and to include at least one
woman in their delegations to the World Health Assembly.

     The resolution requests the Director-General to establish a
Global Commission on Women's Health to produce an agenda for action
and to support the work of the Commission by establishing standards
and criteria to permit regular monitoring of the health status of
women.  It also suggests that the Global Commission report on its
activities at the United Nations Conference on Human Rights in
1993, the United Nationals Population Conference in 1994, and the
Fourth World Conference on Women in 1995.  Finally, it recommends
that a report be submitted on implementation of the resolution to
the Forty-eighth World Health Assembly in 1995.


III. SIGNIFICANCE FOR REGIONAL AND COUNTRY PROGRAMS

     The Director-General of WHO is requested to utilize existing
mechanisms within WHO, at the global and regional levels, more
effectively and fully in order to ensure that proper attention is
given to matters affecting women's health.  This request will have
a direct bearing on the work of the Special Subcommittee on Women,
Health, and Development of the Executive Committee of the Pan
American Health Organization, which will be called on to play a
fundamental role in the regular monitoring and evaluation of
progress in this area, particularly with regard to implementation
of the strategic orientation on women, health, and development
adopted by the XXIII Pan American Sanitary Conference in 1990.

     More effective utilization of the Regional and country
programs by the Secretariat will imply, according to the
recommendations contained in the resolution, the establishment of
activities and the allocation of technical cooperation resources
to promote the development of women in their areas of
responsibility.  The resolution will have a further impact on the
activities of the Regional Program on Women, Health, and
Development in the sense that the Program will need to incorporate
within its plan of work support for the activities of the Global
Commission on Women's Health to be established in 1992.

     The Organization will be called on to begin work on the
definition of criteria and standards that will permit regular
monitoring and evaluation of improvements in the health status of
women in the Region of the Americas.  This will involve the
establishment of concrete targets and time frames for reaching
them, as well as the development of basic indicators, with a
breakdown by sex, and the implementation of a monitoring system at
the Regional level with participation by all the countries.  In
addition, based on the targets proposed, there will be a need to
set dates for the preparation and delivery of progress reports, in
accordance with the time periods established for submission of
reports in the resolutions of PAHO and WHO on this subject.

IV.  RESPONSIBILITIES OF THE REGIONAL COMMITTEE FOR THE AMERICAS

     In accordance with the resolutions of the Governing Bodies of
the Organization, every two years the Directing Council of PAHO
includes on its agenda an item relating to the topic of women,
health, and development.  Accordingly, the Regional Committee of
the Americas will be responsible for reporting to the Executive
Board of WHO in 1993 and 1995 on the progress made in improving the
health status of women, based on the criteria and standards defined
for the Region.
E0249.FIN



CHAPTER I                                                 27/V/92
PUBLISHED VERSION

HEALTH SITUATION IN THE AMERICAS

1.   Socioeconomic and Political Development
     According to the Economic Commission for Latin America and
the Caribbean (ECLA), the economies of the Region resumed their
pattern of growth in 1991, and that growth produced other
favorable trends such as a reduction in the rate of inflation,
some relief in the burden of servicing the external debt, and the
entry of capital as a result of the reduction in interest rates
in the international sphere.

     This represents a major improvement compared to the past
decade, especially if it is considered that the regional rate of
growth in 1991 was more than double the average annual rate of
the previous decade.  In this respect, Chile, Mexico, and
Venezuela led the group of countries of the Region with growth
rates of 8.5%, 5.0%, and 4.0%, respectively.  In regard to the
subregions, it is noted that the oil-exporting countries have
been the dynamic factor in that growth (4.4%), while the non-
oil-exporting countries have had a worse performance, with growth
rates ranging between 1.6% and 1.9%.  In addition, this growth
has been higher than in the previous decade.  At the same time,
there has been a substantial regression in the performance of the
countries that form the Organization of Eastern Caribbean States
(OECS), whose GDP grew only 0.5% during the past year.

     The growth in the total GDP in the 1980s could not be
maintained at the pace of population growth in several countries
of the Region.  The oil-exporting countries experienced a
positive rate of growth in per-capita GDP, but the non-oil-
exporting countries grew at a less negative rate.  Again, the
only exception was the countries of the OECS, which for the first
time in several years had a negative rate of growth in per-capita
GDP in spite of their low population growth rate.  The moderate
increase that most of the economies of the Region showed did not
greatly help increase employment; the index of unemployment
remained constant compared to previous years.

     The new economic basis of the Region is in general
characterized by a stronger orientation toward exports,
liberalization of trade, austerity in fiscal matters, more
prudent management of monetary policy, and greater reluctance to
resort to public regulation of economic activity.  However, these
new public policy rules undoubtedly involve still greater
inequalities in incomes, more precarious employment, a more
restricted fiscal environment, and smaller amounts of freedom to
implement economic policy than in the past.  During the 1990-
1991 biennium many countries made extensive fiscal adjustments
which reduced the financing needs of the public sector to an
amount that fluctuated between 2% and 7% of the GDP.  In many
cases, the adjustment was achieved through an extraordinarily
drastic reduction in expenditures on consumption and investment
which will be difficult to sustain in more normal circumstances,
even if public institutions are restructured to function with
greater efficiency.

     The adoption or intensification of stabilization programs
reduced rates of inflation in 1991 to an accelerated pace.  The
average increase in prices, weighted according to population,
fell from 1,200% in 1989 and 1990 to 200% in 1991.  The pattern
of inflation toward the end of 1991 suggests still greater
progress for the 21 countries for which annual figures exist: 
nine of them had inflation rates lower than 20%, and in seven
they were between 20% and 50% annually.  Only five countries had
rates higher than 50%, and only Brazil, Peru, and Nicaragua
exceeded 100%.

     The net transfer of financial resources changed course and
was favorable for the first time since 1981, since the net
disbursements of $US16 billion in 1990 changed to net incomes of
almost $US7 billion in 1991.  This represented a total of incomes
and expenditures of $US23 billion, equivalent to 15% of the value
of the volume of exports of goods and services of the Region. 
Toward the end of 1991, the external debt of the Region was more
or less equal to that of the previous year of $US426 billion, or
2.87 times the total volume of annual exports.  Although no new
agreements were signed as part of the Brady Plan, the Government
of the United States of America canceled many bilateral
obligations and some countries implemented debt conversion
programs.  Debt was also restricted because of new capital flows.

     Despite everything, the burden of debt has been
significantly relieved in recent years.  For example, the
relationship between payments on earned interest and exports of
goods and services in the Region fell for the fifth consecutive
year to 22%, which represents the lowest level since the 41% of
1982.  External debt service continues to be one of the most
serious structural problems in the Region, however.  The enormous
burden of the external public debt, which represents 80% or more
than the total external debt of Latin America, is another proof
of this.  Finally, the average price of Latin American debt in
secondary markets increased from 35 cents to 44 cents from the
end of 1990 to November 1991.

     It to be expected that the improvements in the economies of
the countries of Latin America and the Caribbean in 1991 will
smooth the path toward the recovery of growth in 1992.  It is
foreseen that with a greater GDP and more confidence in the
economies of the countries in the Region, investment will recover
to the level reached before the crisis and a large part could be
directed toward health and sanitation.  Thus, even a modest
recovery may relieve the situation of the poorer groups in the
population and have a favorable effect on their health
conditions.  But that hypothetical favorable framework has still
not occurred to radically change the structural problems the
Region confronts and which are aggravated by the crisis of the
1980s.

     The subregional processes of economic integration in the
entire Region of the Americas are going through a singular period
which are clearly distinguishable from the weak evolution of
previous decades.  Those processes accelerated in 1991; many of
them tend to exceed the customary geographical framework since in
addition to pacts or agreements between neighboring countries,
such agreements are also proliferating between distant countries. 
The agreements signed go beyond free trade groupings, which was
the operative form up until the past decade.  The terms that are
being established are quite short compared with other
experiences, and represent a serious challenge to their
fulfillment.  The rapprochement between Argentina and Brazil in
1986 appears to mark the beginning of this new phase in the
integration of the Region.  This was reflected in the signature,
in March 1991, of the treaty creating the Southern Common Market
(MERCOSUR), which in addition to Argentina and Brazil includes
Paraguay and Uruguay.  Chile and Argentina foresee the formation
of a common economic area starting in 1995; in 1991, Chile also
signed agreements with Venezuela and Mexico; and for their part,
Colombia, Mexico, and Venezuela form the "Group of Three" leading
to a common market in 1995.  At the same time, protocols are
being prepared for a free trade area between Canada, Mexico, and
the United States.  The Andean countries, signatories of the
Agreement of Cartagena, adopted an ambitious target:  to evolve
toward a community of nations.  Since the political success of
the agreements of Esquipulas, the forums and agreements of
integration among the countries which signed the treaty that gave
rise to the Central American Common Market (Costa Rica, El
Salvador, Guatemala, Honduras, and Nicaragua) have been
strengthened.  Having subscribed to an Agreement Framework, in
January 1991 in Mexico, the Central American presidents met again
at the end of 1991 to reaffirm their commitment to advance toward
a Central American system.  At the very end of the year, an
agreement signed at the United Nations between the government and
the guerrillas of El Salvador put an end to the bloody civil war
in that Central American country.  Finally, the common external
tariff of the countries of the Caribbean Community (CARICOM)
entered into effect in 1991.

     Progress continued in the political field, making possible a
plurality of social life; the exception was Haiti, where
constitutional institutionality was again interrupted.  Suriname,
after the coup d'etat of December 1990, returned to democratic
life between May and September 1991.  In Nicaragua, relations
between the government and opposing political forces which faced
each other militarily a short time ago are being normalized.  In
Paraguay, a National Constituent Assembly was established to
define the new political constitution of the country.  Peru
continues to have an internal political situation of fragility
and quite accentuated insecurity.  In general, other political
crises have been ministerial or cabinet in nature, in many cases
caused by or stemming from differences in economic policy.  The
small capacity for maneuver of the public sectors of health and
the slight political weight resulting from its total dependency,
as with education, in economic policy decisions, is creating
chronic instability for public health authorities.  This is
reflected in the increase in the relief from their positions of
principal public health authorities (Argentina, Brazil, Colombia,
Dominica, Grenada, Haiti, Panama, Peru, St. Kitts and Nevis, St.
Vincent and the Grenadines, Suriname, Uruguay, and Venezuela). 
With exceptions (the eruption of cholera), public health and
medical care did not form part of real political or economic
priorities in Latin America and the Caribbean.

2.   Demographic Aspects
     The population of Latin America in 1991, according to
estimates of the United Nations, was 735 million, of whom 278
million were in North America, 303 million in South America, 120
million in Central America and Mexico, and 34 million in the
Caribbean.
     The demographic indicators for the five-year period 1990-
1995, also from the same sources, are:




North
 America

South America
Central
America
and Mexico


CaribbeanAnnual births (thousands)
Crude birth rate (per
  thousand population)
General fertility
Annual deaths (thousands)
Crude death rate (per
  thousand population)
Life expectancy at birth
  Both sexes
  Males
  Females
Infant mortality rate
Annual growth rate
  Urban (%)
Annual growth rate
  Rural (%)3,916
13.9

1.83
2,441
8.7


76.5
72.9
79.9
8
0.95

-0.043,162
26.2

3.21
2,289
7.4


67.5
64.8
70.3
52
2.56

-0.42
3,590
28.8

3.45
716
5.8


69.4
66.5
72.5
39
2.91

0.71842
24.1

2.85
269
7.7


70.2
68.1
72.3
46
2.33

-0.04

     Several countries carried out population censuses in 1990,
while others have postponed doing so for various reasons. 
Although the final data from the censuses already carried out are
still not known, preliminary information from Argentina, Brazil,
Ecuador, Guyana, Mexico, Panama, Trinidad and Tobago, and
Venezuela and from the National Demography and Health Survey of
Bolivia, makes it possible to formulate a hypothesis that the
observed growth was less than previously estimated.  In recent
years the impact that the reduction in mortality has had on the
decline in fertility has begun to be felt;- this impact shows
that a low birth rate is not occurring while high mortality
persists and that, as a result, declines in mortality are
required for reductions in fertility rates to occur.  The
clearest case is that of Bolivia, whose estimate of general
fertility was 6.1 children per woman during her reproductive life
for 1985-1990 and the value from the survey turned out to be 5.0
for 1989; infant mortality was also reduced, since it fell from
estimates of nearly 200 per 1,000 to less than half thereof, 96
per 1,000, between 1979 and 1989.  Although of lesser
quantitative importance than the overestimates of fertility,
underestimates of emigration are also very important for several
countries, especially Mexico and the countries of Central America
and the Caribbean.  According to the data from the last census in
the United States, carried out in 1990, the Latin American
population in that country grew from 14 to 23 million.  That
increase of 9 million is on the order of 2% of the total
estimated for the entire Latin American region.  Although part of
that growth comes from the vegetative increase of Latin American
groups in the United States and, as a result, it is not migratory
as such, its value is sufficiently important to take it into
account in any demographic analysis made of the Region as a whole
and which makes it possible to include migratory movements. 
Migrations within Latin America and the Caribbean have also
become important; thus, sizable populations have migrated from
the Dominican Republic and Haiti to other countries in the
Caribbean, and from Central American countries to Belize and
Mexico.  The termination of the armed conflict in Nicaragua has
resulted in the return to that country of more 500,000 persons. 
Something similar is foreseen in El Salvador during coming years. 
An important component of the migratory movements among the
countries of Latin America has been refugees; between 1985 and
1990 the number of refugees in the various countries of the
Region grew from 360,000 to 1,200,000.

     With respect to mortality, although few data are available
for 1991, those which exist for 1988 or later make it possible to
state that the trend toward generalized decline continues in the
countries, though at a rate less than in previous years.  This is
valid for both mortality in the first years of life and the adult
population, with ups and downs in the young male population due
to the increase in deaths of violent origin in some countries of
the Region.  After data for 1991 have been obtained, the
hypothesis can be validated that infant mortality, a high
proportion of the total number of deaths, may have fallen in many
countries in the Latin American region as a consequenceÐfavorable
from this point of viewÐof the epidemic of cholera since deaths
due to diarrhea would have diminished.  This would have occurred
either because of the measures taken or changes in hygienic
attitudes in the population itself.  Given the importance of
diarrhea as a cause of death in the first years of life, any
improvement in that regard will result in a fall in infant
mortality, especially in those countries that have high values of
that indicator.  As a specific campaign existed against diarrhea
during the past year, low in cost and carried out in a severe
economic crisis, validation of the hypothesis would show the
potential impact that health activities may have on the most
unprotected groups.

     In summary, the behavior of the principal demographic
variables would be a trend toward reduction in fertility (which
increased in the United States in 1990), especially in those
countries that had high values; a slower reduction in mortality,
and significant migratory currents toward other countries,
especially the United States.

3.   Health Situation
3.1  General appraisal of 1991
     Changes in mortality profiles continue in the countries of
the Region, with a continuous increase in the importance of the
cardiovascular diseases, tumors, and other chronic degenerative
diseases against a background of reduction in mortality in
overall terms and a consequent increase in life expectancy at
birth.  Deaths of violent origin, especially homicides, have
increased alarmingly in several countries, such as Brazil and
Colombia.  In turn, several infectious diseases have increased in
terms of morbidity in the last two years, although with low
fatality rates:  cholera has spread for the first time in this
century; malaria exceeds 1 million of cases a year; dengue
continues causing victims; the AIDS pandemic continues; the other
sexually transmitted diseases are increasing (especially in the
United States); pulmonary tuberculosis is rebounding, in part
when it is combined with infection due to human immunodeficiency
virus (HIV); 95 million people, a fifth of the population, run
the risk of contracting the infection caused by Trypanosoma
cruzi, and yellow fever continues to occur.  It should be noted,
however, that both cholera and the other infectious diseases have
basically affected population groups that live in conditions of
the greatest poverty, lack uncontaminated water services and
adequate sanitation as well as appropriate means to prepare and
store food, and in addition suffer serious limitations on their
access to basic health services.  Despite the economic growth of
1991, the presence of cholera and other diseases is a clear
demonstration of the effects of the economic and social crisis in
recent years, and at the same time of the need to take measures
to protect the most disadvantaged population in the short term
and not to hope for a sustained increase in the gross product.

     Tumors of the reproductive system in women have become one
of the principal concerns and demands, often unsatisfied, of the
female population.  In addition, maternal mortality continues
declining, although it remains high in several countries; part of
that reduction is explained by the clear reduction in fertility,
especially in countries that had high general fertility values.

     The situation of diseases preventable by vaccination is
polarized: although the campaign to eradicate wild poliovirus
continues with success, measles continues to be present and it
has erupted significantly in several countries.

     Major nutritional deficiencies persist and the indicators of
children's growth and development appear to be stagnant or in
deterioration.  Recent information on nutritional status shows a
slight reduction in the prevalence of undernutrition, although
there are still approximately 7 million children under 5 years of
age with moderate or serious undernutrition.  Although dietary
quantity and balance are tremendously important, perhaps no less
so is the quality of food; for example, no less than 70% of
diarrhea episodes may be caused by food-borne agents.  In 1991,
however, two elements occurred which will nevertheless make
favorable development for health possible.  The first is
pressures for the establishment of effective practices of food
quality control to fulfill both requirements of the importing
countries, given the commercial opening abroad, and the
development of subregional markets (external requirements); the
second element derives from the new requirements which are an
outgrowth of the appearance of cholera (internal requirements). 
This has strengthened microbiological analytical capacity and
food inspection services in the countries.  This situation was
reflected in the evaluation and design of the new regional plan
for food protection, approved at the VII Inter-American Meeting
on Animal Health, at the ministerial level, held at Washington,
D.C., in May 1991.

3.2  Cholera in the Americas
     Information about an unusual number of cases of acute
diarrhea in adults in the city of Chancay, Peru, was followed by
the identification, starting on 23 January 1991, of outbreaks of
diarrheal disease in other cities.  A little more than a year
after the first case was reported, 18 countries in the Americas
were affected by the disease.  In 1991 a total of 391,078 cases
were notified in the Region, with 166,188 hospitalizations and
3,996 deaths (Table 1).  The first cases identified were from
Vibrio cholerae 01, biotype El Tor, serotype Inaba.


Table 1.  Cholera in the Americas, 1991



CountryFirst
Report
Total CasesHospital
cases
DeathsPeru23 Jan
322,562119,5232,906Ecuador1 Mar46,32037,342697Colombia10
Mar11,9795,166207USA9 Apr     25     11     0Brazil10 Apr1,431   
93220Chile12 Apr      41     38     2Mexico13 Jun2,690   
83634Guatemala24 Jul3,6741,510    50El Salvador19 Aug     947    
48134Bolivia26 Aug     206    115    12Panama10 Sep  1,177   
27629Honduras13 Oct        11       9    0Nicaragua12 Nov       
1       1    0Venezuela29 Nov        13      9    2French
Guiana
14 Dec
1
      1
    0Total391,078166,1883,996


     The last country to enter the list of the countries with
cholera in 1991 was French Guiana, where a case was reported in
December.
     At the beginning of 1992 the appearance of the first cases
of cholera was reported in Costa Rica and Belize.  The appearance
of cholera was notified in Argentina at the beginning of
February.

     In Ecuador and Peru, studies of cases and controls indicated
the following risk factors for contracting the infection:  (a)
drinking unboiled water from municipal systems and wells; (b)
consuming food and beverages provided by street sellers,
especially beverages containing ice; (c) eating food which has
remained more than three hours at room temperature without
reheating; (d) eating raw fish, mollusks, or shellfish; and (e)
drinking water from a container handled by other persons who may
be infected.  The problem of cholera is a problem of water
culture in its broadest sense.
     
     In all the infected countries in the Americas, cholera has
been predominantly a disease of adults.  In some countries the
disease has occurred in the principal cities; in others, after
starting in rural areas, the disease occurred in the cities with
greater numbers of cases.

     In 1991, overall fatality due to cholera in Latin America
was on the order of 1%; most of the cases are concentrated in
Peru (which has more than 80% of the total number of cases) and,
in second place, Ecuador (with a little more than 10%).  The
highest fatality rate occurred in Bolivia (7%), with 11 deaths in
175 cases.  Variations may have a bias resulting from the
different case definitions used in each country.  In overall
terms the experience in the Americas has been similar to that in
Asia, where the fatality rate is 1.1%, and much lower than the
10% recorded in Africa.

     The almost 4,000 deaths due to cholera in 1991 are a very
small part of mortality, even among adults.  On the basis of the
available data on mortality for the years 1965 to 1990, it has
been estimated that a little more than 6 million deaths occurred
in Latin America during that period due to infectious intestinal
diseases (primarily diarrhea), which include cholera, although in
that period there were no deaths from that cause.  That value
represents 9% of the total deaths.  Twenty percent of those
deaths occurred in adults.  Despite the fact that death rates due
to diarrhea have declined (and in most of the countries the
absolute number as well), the estimate for 1985-1990 is around
130,000 deaths annually due to diarrhea in children under 5.


     In general, case-fatality rates due to cholera have
diminished as the weeks have passed as medical personnel and the
population have acquired greater knowledge of the disease, its
mechanisms of transmission, and the most adequate treatments. 
Special importance attaches to oral rehydration therapy which,
although well established for treating diarrheal diseases in
children, is not always well known or accepted by general
practitioners; the epidemic of cholera strengthened and validated
oral rehydration as one of the principal and most effective
methods of attacking that disease.  A very important factor in
explaining the low fatality rate has been access to and use of
medical services which, in addition to ambulatory treatment, have
provided a very large response in terms of hospitalization of the
most serious cases, with a percentage of cases admitted higher
than 40% of the total reported cases.  In Peru, fatality has
varied from less than 0.5% in the large urban municipios to more
than 4% in remote departments, which have problems of physical
access to the services and a predominantly autochthonous
population.  In several countries deaths have occurred among
those who do not reach or have received adequate treatment very
late at health services.


     It is unquestionable that efforts to limit the extent and
effects of the cholera epidemic were varied in 1991.  This can be
seen in the reduction in cases in the most infected countries, in
the reduction in the case-fatality rate, as well as the control
of its spread.  To control the spread of cholera and limit its
effects during coming years, it is necessary to consolidate the
detection and reporting of cases, support basic diagnosis and
laboratory services, ensure immediate and effective treatment of
diarrhea in all age groups, apply emergency measures to provide
uncontaminated water, treat wastewater in high-risk localities,
and provide for safe food handling.  Even with such commitments
to make emergency interventions, it can be foreseen that cholera
will spread to most of Latin America and the Caribbean.  The
elimination of cholera from the Region, which should be the
maximum target, can only be achieved through significant
investments to improve the availability of water, sanitation, and
health services and extend them to that significant proportion of
the population that so far has not had them.

3.3  Other health problems
     In 1990 it was estimated that 278 million people lived in
malarious areas, with a morbidity of 150 per 100,000 inhabitants,
which was far higher than that in 1974 (49 per 100,000
inhabitants).  The number of cases has increased in the last
four years and surpassed 1 million in 1990.  Of those cases,
37,000 (3.5% of the total) came from areas without continuous
transmission, which reveals the pressure from the advent of
migratory flows in areas of traffic in or receptors of them.  The
Amazon region--Brazil, French Guiana, Guyana, Suriname, and the
southern region of the Orinoco basin in Venezuela--reported
621,000 cases in 1990, of which 269,000 were from Plasmodium
falciparum (78% of all cases in the Region).  Since 1987, the
highest incidence has been in French Guiana.  In 1991 two foci
occurred in Panama, at Darién and Bocas del Toro.  In 1990 the
number of cases increased in Belize and 47,000 cases were
registered in Venezuela and 45,000 in Mexico:  the values
predicted for 1991 were no smaller.  Cases have diminished in El
Salvador, but the presence of the disease is significant in
Bolivia, Colombia, Costa Rica, Guatemala, and Peru.

     With regard to dengue, there is a situation of steady
deterioration in the Region; in 1991, cases of dengue hemorrhagic
fever were recorded in Brazil, Colombia, El Salvador, Guatemala,
Honduras, Mexico, and Venezuela.  In Mexico, 14,400 cases were
reported in 1990.

     Up to December 1991 about 430,000 cases of AIDS had been
reported to WHO.  Of those, more than a quarter-millionÐ58% of
the totalÐcame from the Americas.  Conservative estimates are
that more than 2 million people in the Region may be infected
with HIV:  a million in the United States, 750,000 in Brazil, and
370,000 in the rest of the countries in the Region.  In recent
years the epidemic profile of AIDS has changed in more and more
countries, from the predominantly homosexual and bisexual male
type to a heterosexual one, with a consequent increase in the
number of cases of the disease and of HIV infections in women and
children.  The male:female ratio of cases is still high in some
countries; for example, in the Southern Cone and in the Andean
countries the ratio is 10 men for every woman; but in other
countries, mainly in the Caribbean and Central America, this
ratio is rapidly approaching 1:1.

     Although HIV is predominantly transmitted through sexual
relations, preliminary data from prevalence studies indicate the
growing importance of intravenous drug use as a transmission
route in several countries.  It is thus that in countries such as
Argentina, Brazil, and Uruguay more than 50% of intravenous drug
addicts in some communities may be infected.  Blood transmission
has still not been eliminated in the Region, and some countries
report that analyses of donated blood have not reached
satisfactory levels.

     In synthesis, the situation of AIDS and infection due to HIV
is serious and tends to worsen; to the extent that more persons
are infected and develop symptoms, the social and medical care
services will not suffice.  On the positive side, there is
increasing evidence that healthy changes in behavior are possible
and that specific interventions directed toward groups at
greatest risk are effective in diminishing the transmission of
HIV.  In addition, the strengthening of laboratory services and
the active promotion of the generalization of blood examinations
have reduced though not eliminated transmission by means of blood
transfusions.  In several countries difficulties have been found
in implementing certain promotion and prevention measures in the
public relations campaigns of national programs against AIDS.

     In 1991 vaccination coverage of 75% for the EPI diseases was
achieved.  Only nine cases of wild poliovirus were isolated,
eight in Colombia and one in Peru (the case there was notified in
August in Junín, Peru).  The control of measles in children under
15 years of age was implemented in Cuba, and in the English-
speaking Caribbean a campaign carried out in May achieved
extraordinary coverage.  Other countries are promoting similar
initiatives for coming years in order to achieve measles
eradication by the end of this decade.  The target of achieving
eradication by 1997 in Central America and Mexico thus represents
a challenge for the health services and the living conditions of
the countries.

     The incidence of tuberculosis cases has increased in some
countries (El Salvador, Guyana, Peru, and the United States). 
The close relationship between HIV infection and clinical
tuberculosis will affect the incidence of the latter as the
levels of seropositives to HIV increase.  According to the
estimates made by Murray of the incidence, new cases, and deaths
in two subregions of the Americas, 356,000 new cases and 111,000
deaths occurred in South America and 185,000 new cases and 80,000
deaths (annual values) in Central America and the Caribbean. 
While the estimates of new cases seem appropriate, the mortality
values appear to overestimate the fatality rate since the
experiences of the countries in recent years would make it
possible to estimate between 60,000 and 100,000 deaths annually. 
Tuberculosis continues to be an important cause of death in the
Region, although there are few inexpensive and effective
interventions for controlling it under the most varied
circumstances.

     The final attack phase to eliminate urban rabies continues
and coverage has been extended to medium and small cities; 15 of
the capital cities in Latin America are free from canine rabies. 
Seventy percent of human rabies cases occur in cities of fewer
than 50,000 inhabitants.

     One of the most evident changes in the epidemiological
profiles in the Region as a whole is the ever-increasing relative
importance of external causes of mortality:  accidents of all
types, homicides, suicides, etc., especially in the young and
adult population, are becoming one of the principal causes of
loss of potential years of life and also a source of multiple
disabilities.  The phenomenon occurs in varied ways:  in some
countries, such as Chile and Costa Rica, mortality associated
with accidents, especially automobile accidents, is significant;
in other countries it has been concentrated in certain
minorities, as in the United States with homicides in the black
population.  For Brazil, mortality from external causes
represents 12% of the total number of deaths and has several
characteristics:  young population, in metropolitan areas, male,
and a large number of homicides.  Colombia is perhaps the
country where violence has been most accentuated in recent years: 
mortality from homicides rose from 4,500 in 1965 to 19,000 in
1988 and 24,000 in 1990; with other accidents and violent acts it
reached a total in 1990 of 30,000 deaths (20% of the total number
of registered deaths) and 40% of the potential years of life
lost.  To compare the extraordinary level that such numbers
represent, it suffices to say that in the United States, with a
high homicide rate, the total number of deaths from that cause
was similar in 1990 as well:  on the order of 25,000, but in a
population eight times larger.

     If the rates are compared with respect to the black
population of the United States, the differences with Colombia
would be reduced appreciably.  An aspect of the violence which is
noteworthy is that related to women, whether through violence or
the domestic physical abuse to which they are subject.  The
historical roots of the violence are valid for all countries
which are in that situation:  nonconformity resulting of past
repressions and injustices, social inequalities, a low level of
education, and selective justice.

     Some health problems related to noncommunicable diseases
increasingly deserve attention, and in many countries of the
Region programs have been implemented to modify lifestyles and
cultural patterns:  hypertension, diabetes, smoking.  In recent
years several countries in the Caribbean (Antigua, Bermuda, Cuba,
Dominica, Grenada, St. Kitts and Nevis, St. Vincent and the
Grenadines, Saint Lucia, Trinidad and Tobago, Suriname and the
Netherlands Antilles) have given priority to such health
problems.  Canada, which has several intersectoral programs on
drugs and family violence in operation, continued promoting its
antismoking campaign and in 1991 prohibited all types of public
advertising for tobacco.

     In 1991 no significant natural disasters occurred, although
the border areas between Costa Rica and Panama were affected by
earthquakes at the end of 1990 and beginning of 1991.  Concern
for problems of the environment in the Americas has various
facets; in the United States and Canada the basic concern is for
the ozone layer and its consequences and determinants, as well as
for balance among species; in Brazil it focuses on the
consequences of the deforestation of Amazonia (the world
importance of the subject has succeeded in focusing attention on
that country, where the world conference on the environment will
be held in 1992); in other countries, such as Chile and Mexico,
attention focuses on the very high levels of pollution of
metropolitan areas.  Although the trend of the quality of life in
cities appears to be one of the principal concerns in health
since deterioration in the quality of urban life appeared to be
inexorable, the experience of Curitiba, Brazil, is encouraging;
with simple and economical methods, problems such as abandoned
children, transportation and traffic, and wastes have been able
to be dealt with and controlled and, according to authoritative
opinions, the city has succeeded in becoming "one of the most
pleasant cities in the third world and in the world in general."

     The most recent information available on nutritional status
in Latin America and the Caribbean shows a slight reduction in
the prevalence of undernutrition, although in several countries
there has been no trend toward reduction or it has been so
moderate that it can be considered nonexistent.  It would be
erroneous and even dangerous, however, to assume an attitude of
complacency and limited surveillance.  The achievements may be
reaching the maximum benefit that the developed strategies can
provide.  In addition, the regional prevalence of undernutrition,
estimated at 12%, varies markedly when the countries are
considered individually.  The figures for the Dominican Republic,
Guatemala, Guyana, Haiti, Honduras, and Mexico, with values
higher than 20%, indicate that considerable efforts, including
international collaboration, should be made to reduce
undernutrition by applying policies and programs directed toward
increasing food supply and improving its distribution.  External
dietary assistance from the World Food Program (WFP) and AID
(USA) was 2.2 million metric tons in 1990.  In this respect it
should be borne in mind that external dietary assistance may
sometimes involve changes in cultures and dietary habits, with
effects contrary to what it is desired to achieve.

4.   Development of Services
4.1  Strategies of health for all by the year 2000
     In 1991 the second evaluation of the strategies of health
for all by the year 2000 was carried out in almost all the
countries (the first had been conducted in 1985).  Based on
reports from the countries, a report on the Region of the
Americas was presented to the XXXV Meeting of the Directing
Council of PAHO in September and was approved during the meeting. 
Although the report refers to events in the period from 1985 to
1990, it is pertinent for understanding the current situation
since there were no major changes in that respect in 1991.  The
principal elements presented below have been extracted from the
conclusions in the report.

     The economic policies of adjustment or reactivation have
been characterized by a marked reduction in public spending on
so-called "non-productive activities," such as health and
education.  The application of these measures has led to
reduction or stagnation in the resources available for the
development and operation of the health services.  This has been
shown by the limitations of capital investments for basic
sanitation and the replacement, maintenance, and conservation of
equipment and physical plant.  It has also affected capacity to
maintain an adequate level of current expenditures, which has
impeded the normal operation of programs for dealing with
prevalent problems and restricted administrative development and
the training of personnel in the sector.

     In most of the reporting countries a deterioration in
efforts to put into operation a process of surveillance and
evaluation of the strategy of primary care and health for all is
noted:  no stable programs, structures, and standards dealing
with such activities have been established.  Data for
surveillance and evaluation of activities are obtained
discontinuously, with serious problems of acquisition and without
the participation of the principal authorities in the sector,
except in Canada, Cuba, and the USA where their targets and
progress, as well as proposed new objectives, have been clearly
evaluated; the remaining national reports are responses to formal
commitments to PAHO and WHO more than analyses of and reflections
on what is happening.  Among the latter are some countries whose
effort is greater though not total:  the Bahamas, Belize,
Bolivia, Costa Rica, Haiti, Honduras, and Mexico.  But, broadly
speaking, prospects are not encouraging with respect to future
possibilities for the monitoring and evaluation of PHC and HFA-
2000.

     The availability of data relating to immunization coverage
is timely in almost all the countries, a reflection of the effort
to achieve eradication of wild poliomyelitis virus.  In addition,
information is available in most of the countries on the coverage
of the population with water and basic sanitation services,
although there are still problems of consistency, continuity, and
precision.  In addition, information on nutritional status, low
birthweight, maternal and child care, family planning,
expenditures on health, basic drugs, and local care is reliable
in only a very few countries.  Data on referrals, back-referrals,
physical and mental disability, and oral health and morbidity are
practically nonexistent for most of the countries.

     In all the countries the national health policies and
strategies are coherent and consistent in their declarations with
the strategy of primary care and health for all.  Adjustment of
these policies and strategies has been limited by restrictions on
financial, human, and material resources, and in some countries
by political and social instability.  In addition, in most of the
countries the deficiency or precariousness of comprehensive long-
term strategies for the development of health and especially of
its relations with the socioeconomic situation is noted.

     All the countries state as declared policy the need for
supporting and promoting community participation as an essential
component of primary care.  In the greatest part of cases, the
community is involved in aspects relating to the execution of
some activities at the local level, especially through health
collaborators or volunteers, or through the contribution of labor
and funds for the construction of small local works of
infrastructure.

     Mechanisms have been established in some countries for the
participation of organizations representing communities in the
formulation, execution, and evaluation of policies and programs
at the national level.  Several ministries have created programs,
offices, or departments responsible for the promotion,
coordination, and standardization of community participation in
health programs.

     Many countries have reviewed, are reviewing, or have
modified the institutional and organic-functional framework of
the sector to make way for new management schemes.  The central
levels of the Ministries of Health are coming to have a more
regulatory and coordinating role, and the executive functions and
responsibilities of the components of those institutions or
others which affect the provision of services are being
strengthened.  The responsibilities and spheres of action of the
different institutions that compose the sector have often been
identified with greater precision as a preliminary step to
greater coordination and possible intrasectoral integration. 
These attempts at reform, in a context of major restrictions and
conflicts with personnel, have produced few results up to now in
terms of better efficiency in the services provided, but despite
this legal instruments and standards for decentralized management
have continued to be developed, which probably shows the
political importance attached to them.

     Few countries have a human resources plan to meet the needs
of the strategy of primary care, and no changes have been
observed compatible with that strategy in matriculation and
graduates from the different training institutions.  Few
countries believe there has been progress since 1985 in improving
equity in the distribution of human resources, and some report a
deterioration in equity.  The principal reasons adduced are the
economic crisis, the restriction on financial resources, and the
resistance of health personnel to being assigned to less
developed areas.

     Few countries report the existence, whether declaratively or
in incipient application, of a national policy on the selection
and use of health technology.  Coordination of such activities
is, general speaking, poorly developed.  The same considerations
are valid for the identification and formulation of national
research policies in health.  Several factors block or impede the
effective preparation and application of research and technology
policies:  the scarcity of financial resources, the lack of
enough research personnel to form a critical mass, the
infrastructure, weakness in the mechanisms of interinstitutional
coordination, and limited political willingness to promote
research as an indispensable element for development.  The gap
which is being created between Latin America and the Caribbean
and the rest of the world (except Africa) with respect to the
importance and resources allocated to the area of research and
development of technology is a critical negative element in
future prospects; the foregoing is valid not only for health but
for all cultural and socioeconomic development.


4.2  Policies, plans, and programs
     For the countries of Latin America the response to the
epidemic of cholera was the most important event of the year in
terms of the various goods and services--outpatient care,
hospitalization, rehydration salts, sera, inspection and control
of food and water--provided to the population.  That response in
part explains the low overall fatality rate of 1% which the
epidemic had throughout the year.  The concern that the disease
might become an endemic disease caused almost all the countries
in the Region to implement special programs against cholera.

     As a general rule, the trend of recent years to decentralize
and develop local health systems continued to be strengthened. 
It was thus that Venezuela created by law its National Health
System and the Decentralization and Transfer of Responsibilities,
and as a political priority the strengthening of sanitary
districts.  In Trinidad and Tobago the "Medium Term Macro
Planning Framework" of September 1990 is supposed to change from
a centralized executive to a decentralized system and the
development of a "National Health Insurance System" in 1993; the
National and Sectoral Health Plan of Jamaica created four
Regional Authorities to carry on decentralization; Nicaragua
created Local Systems of Comprehensive Care in Health (SILAIS);
Bolivia made a major reorganization of the central level of the
Ministry of Health to carry out its National Health Districts
Plan; the National Health Plan for 1991-2000 of Ecuador develops
a regionalized network of health services with four basic modules
of organization and establishes Comprehensive Family Health
(SAFI) as a priority; in Colombia, through a major national
effort at consensus, the National Constituent Assembly prepared a
new Constitution which had major repercussions on the
organization of the State.  As a natural corollary the Ministry
of Health was reorganized to provide specific support in the
transfer of resources to the municipios; in Brazil, the municipal
and state stages were carried out as a preliminary to the
National Health Conference of 1992, at which national, state, and
municipal roles will be redefined; in October 1991 the Federal
Health Council (COFESA) of Argentina defined deconcentration as
priority policy.

     The integration of health care services and other social
areas has received special impetus in the two past years, in
addition to what had been generated through the development of
some local health systems.  In this respect, so-called social
emergency funds or social investment funds have been created. 
The resources mobilized, basically from international
cooperation, through these funds are directed toward the
financing of social compensation projects or programs to relieve
poverty and attempt to reach the social groups most affected by
policies of adjustment and with the lowest incomes.  The origin
lies in the much publicized experience of Bolivia with its Social
Emergency Fund in 1987-1989.  Such resources are limited and only
attempt to fill the gaps that the traditional sources of
financing of the State are not able to generate because of the
rigidity of adjustment policies.  The activities related to
health in these projects are basically geared toward programs of
supplementary feeding and nutrition, to construction of
peripheral health centers, and to water supply and basic
sanitation works.  Already created are the Social Emergency Fund
in Bolivia, the Honduran Social Investment Fund, the Health and
Social Investment Fund of Chile, the Social Investment Fund of
Venezuela, the Social Emergency Investment Fund of Nicaragua, the
Social Emergency Program of Peru, the Emergency and Investment
Funds in Guyana, the Compensatory Social Programs of El Salvador,
the Social Front Project in Ecuador, the Economic and Social
Assistance Funds for Haiti, the Social Investment Fund of
Guatemala, the Social Emergency Fund in Jamaica, and the
Emergency Social Investment Fund in Uruguay.  Mexico has
nationally channeled its effort through the so-called Program of
Solidarity, which encompasses the entire social area and whose
financial participation in public spending increased by a third
in 1991.

     In most of the countries of the Region, interagency and
interinstitutional coordination committees were created in 1991
to support fulfillment of the agreements of the World Summit for
Children.  A preliminary step was the formation in May 1991 of an
Interagency Coordination Committee at the regional level by
PAHO/WHO, UNICEF, UNFPA, AID (USA), and IDB.  Various plans were
drawn up in the countries to fulfill the targets.

     The creation of Food and Nutrition Surveillance Systems
(FNSS) has been strengthened, especially in the countries of
Central America.  In Bolivia, Ecuador, and Peru there has been
progress in the control of disorders due to iodine deficiency,
whose prevalence has already diminished.

     Given the high mortality due to tumors of the cervix and the
high prevalence of diabetes in several English-speaking Caribbean
countries, some--Antigua and Barbuda, Bermuda, Grenada, St. Kitts
and Nevis, Saint Lucia, and Trinidad and Tobago--have developed
aggressive programs of prevention and control.  Mexico has done
the same with regard to cervical cancer.

     Progress in the processes of subregional integration has
gone beyond purely economic and commercial aspects; in addition
to the various projects of technical cooperation among countries,
often based on common problems in neighboring countries, whose
development is continuing, progress has begun to be made in
feasible areas to establish common guidelines and standards for
production and marketing.  The major steps with respect to
dietary products have already been mentioned.  In July 1991, the
Ministers of Health of the MERCOSUR (Argentina, Brazil, Paraguay,
and Uruguay) signed an agreement to create a group which will
deal with health and environmental problems related to the flow
of goods and services.  In 1991 two meetings (Andean Group,
MERCOSUR) were held relating to the so-called Convergence
Project, which proposes regional integration to develop health
technology and create opportunities for discussion and
negotiation of projects in that area.  The Central American
countries have also developed various integration projects, many
of them as a part of the second phase of the Plan of Priority
Health Needs of Central America:  "Health and Peace toward
Development and Democracy."

     A modality of care through health services which has
expanded its field of action is that resulting from the operation
of nongovernmental organizations, which act as both financing
institutions and providers of services.  In large areas of
Bolivia and Haiti they are the only institutions that exist. 
Because of their importance, an Interagency Coordinating
Committee was created in Bolivia in 1991 which comprises more
than 500 such agencies.  Given the multiplicity of this type of
organization, several countries are attempting to create a
directory of them as a preliminary step to possible coordination
among them.  In addition, countries such as Jamaica and Trinidad
and Tobago are actively promoting the creation of such agencies
as a strategy for cooperation in health.    

     It is in the area of expenditures on health where the
greatest consensus exists concerning a critical problem, though
with different positions.  For example, in Canada, Cuba, and the
United States the proposals are for containing expenditures
because of the enormous resources they consume and their tendency
to increase.  The United States, which spent 7.3% of its GDP on
health 20 years ago, increased its expenditures by more than an
average of 8% annually (more than twice the rate of inflation) to
reach 12.2% of its GDPÐabout $US800 billion dollarsÐand still has
nearly 30 million uninsured people.  Canada, with a value
similar to that of the United States in 1971, increased its
expenditures on health to 8.9% of its GDP in 1989; that cost
would double were the indirect costs of disease, disability, and
premature death taken into account; the Canadian method of
controlling hospital costs has been to limit the use of expensive
high technology procedures in surgery and diagnosis.  In Cuba the
concern about expenditures on health springs from the high
priority it has had up to now and the costs of maintaining that
level quantitatively and qualitatively in a serious economic
situation.

     In the rest of the countries, generally speaking, critical
proposals deal with the need for maintaining and increasing
expenditures, especially public ones, in view of the trend toward
reductions due to policies of fiscal adjustment.  This
contraction in public spending on health occurs at a time of
deterioration in employment in both volume and real wages.  This
has led to quantitative and qualitative deterioration in medical
benefits from social security, and thus to greater demands on
the public services by groups of the population which at other
times would have had social security coverage.  All this has
meant that the young, from 20 to 30 years of age, have suffered
the most damage due to the scarcity of jobs, which has had as a
direct impact a lack of coverage by compulsory affiliation
systems of such age groups and thus of the age group of children
under 5.  That deficiency in economic resources is translated in
various ways:  lack of maintenance and supply of equipment, which
means that an ever-increasing proportion of fixed investment is
not able to operate; lack of essential drugs, as well as food
services and laundry; reductions in the real wages of personnel,
with consequent union conflicts, retrenchment of non-urgent
services, exodus of qualified personnel from public hospitals,
and malingering in peripheral centers and remote areas.  As
budgets are concentrated almost totally on payment for personnel
services, investment is minimal or null, because of which the
possibility of maintaining up-to-date services becomes still more
remote.  A response to the problems that is being analyzed in the
countries is privatization.  Proposals range from systems in
which the services which can be obtained are directly related to
payment capacity to systems in which the emphasis is not on the
origin of funds but on the characteristics of private
institutions providing services.  The last variant is based on
the supposed inefficiency of the public sector or on their lack
of development.  But what they all have in common is that all
they would leave most of the population without the possibility
of access to specific technologies and treatments.

     An aspect of the greatest importance is human resources.  In
regard to formation, the loss of prestige of the traditional
professions is perceptible and stems from the great fragmentation
of the health professions and in an increase in the inequalities
of professional incomes.  The feminization of the health work
force continues, accompanied by reductions in wages.  There are
warnings of a decline in demand for studies in the health area,
especially in non-autonomous careers such as nursing and social
service.  There is a great scarcity of health workers in
nonmedical areas.  In countries such as Argentina and Uruguay,
where the abundance of medical personnel has reached about 300
inhabitants per physician, university enrollments have begun to
decline.  In addition, the loss of purchasing power by workers in
the public sector has led to the migration of some of them toward
others with more satisfactory rewards.  It is clear that that
migration is quite selective, altering the basic structure of the
personnel in the public sector.  A quite common survival variant
is multiple jobs, which leads to smaller institutional
commitment, loss of motivation, smaller possibilities of
continuing education, medicalized supply, and reduction of the
health problem to a one of medical care.
References

     The principal source for the preparation of this chapter has
been the annual reports sent to the Director by the different
PAHO/WHO country representatives' offices and the annual reports
of the various regional programs of the Organization.


=====FOOTNOTES/ENDNOTES=====


 1.  Cheat.  Section "World of Business" (17 February 1992), p.
     57.

 2.  World Population Prospects 1990.  New York, United Nations,
     1991.  Document ST/THAT/SER.A/120.

 3.  INE/IRD.  Bolivia -  Survey National Health 1989.  Ministry
     of Planning and Coordination of Bolivia (January 1990).

 4.  Chesnaix, Jean Claude.  La transition demographique. 
     Presses Universitaires de France, 1986.

 5   UNICEF.  World Status of Children 1991. pp. 37 and 38.

 6.  Institute for Resource Development, Inc.  Fertility Levels
     and Trends -  Demographic and Health Surveys, Comparative
     Studies No. 2, October 1992.

 7.  United Nations.  Population Newsletter, No. 51, June 1991.

 8.  PAHO.  Food and nutrition situation in Latin America and the
     Caribbean.  Updating of 1991, HPN/91.1.

 9.  WHO.  Application of the world strategy of health for all by
     the year 2000, second evaluation; and eighth report on the
     state of world health.  EB89/10, November WHO.

10.  PAHO.  Boletín Epidemiológico, Vol. 12, No. 4, 1991.

11.  PAHO.  Epidemiological Bulletin, Vol 12, No. 2, 1991.

12.  PAHO.  Situation of the programs of malaria in the Americas. 
     XXXIX Report.  Document CD35/INF/2, September 1991.

13.  Murray, Christopher.  Epidemiological and demographic
     evidence on the levels and trends in tuberculosis.  Draft,
     Seminar on causes and prevention of mortality in adults in
     the developing countries, Santiago, October 1991. 
     International Union for the Scientific Study of Population.

14.  PAHO.  Health conditions in the Americas, edition of 1990.

15.  Ortiz, Luis P.  Violence in the metropolitan regions of
     Brazil.  Draft, Seminar on causes and prevention of
     mortality in adults in developing countries, Santiago,
     October 1991.  International Union for the Scientific Study
     of Population.

16.  World Monitor, March 1992, p. 44

17.  PAHO.  Food and nutrition situation in Latin America and the
     Caribbean.  1991 Update, HPN/91.1.

18.  PAHO.  Food and nutrition situation in Latin America and the
     Caribbean.  1991 Update, HPN/91.1

19.  PAHO.  CD Document 35/19.  August 1991.

20.  PAHO.  Social emergency funds and social investment funds;
     experiences in countries of Latin America and the Caribbean;
     options for policies in the health sector.  Preliminary
     document prepared by R. Suárez for the workshop held at
     Washington, July 1991.

21.  PAHO.  Food and nutrition situation in Latin America and the
     Caribbean.  1991 Update, HPN/91.1.

22.  United States General Accounting Office.  Canadian Health
     Insurance -  Lessons for the United States, June 1991.

23.  Forbes. 3 February 1992, p. 60.

24.  United States General Accounting Office.  Op. cit.

25.  IDB.  Economic and social progress in Latin America.  Report
     for 1991, Special Subject:  Social security.

26.  Argentine Bureau of Health Statistics.  National Institute
     of Statistics.  Survey on utilization and expenditure on
     health services, 1989.

27.  Chronic Diseases in Canada:  Economic Burden of Illness in
     Canada, 1986; Supplement to Vol 12, No. 3, May-June 1991.

28.  PAHO.  Technical cooperation in human resources in the
     context of crisis.  Internal HSM document, 1991.




Technical Report Series No. 8










   The Social Policy of the State:  The Basis for 
Integration of Public Health and 
Social Security Institutions in the English-speaking

Caribbean


by Mónica Bolis, Adviser in Health Legislation 




  Paper presented at the Inter-American Conference on Social Security
XXXV Meeting of the Permanent Inter-American Committee on Social Security

       XV Meeting of the American Juridical Social Commission
Rio de Janeiro, Brazil 4-8 November 1991





Program on Health Policies Development
Pan American Health Organization
Washington, D.C.
April, 1992


CONTENTS


Page


     INTRODUCTION . . . . . . . . . . . . . . . . . . . . . 


I.   THE IMPORTANCE OF COORDINATION BETWEEN SOCIAL SECURITY 
     AND PUBLIC HEALTH INSTITUTIONS . . . . . . . . . . . . 


II.  LEGAL BASES FOR INTEGRATION OF 
     PUBLIC HEALTH AND SOCIAL SECURITY INSTITUTIONS . . . . 


     A. LATIN AMERICA . . . . . . . . . . . . . . . . . . . 


     B. THE ENGLISH-SPEAKING CARIBBEAN. . . . . . . . . . . 


III. SOCIAL POLICY AS THE BASIS FOR INTEGRATION
     OF PUBLIC HEALTH AND SOCIAL SECURITY SERVICES
     IN THE ENGLISH-SPEAKING CARIBBEAN COUNTRIES. . . . . . 


IV.  CONCLUSIONS. . . . . . . . . . . . . . . . . . . . . . 

    INTRODUCTION

     
 The purpose of this study is to formulate guidelines for determining a legal basis
for the integration of public health and social security institutions in the countries of
the English-speaking Caribbean.  The need for this kind of endeavor is evident. 
The vulnerability of health services delivery when it is solely dependent on the
public treasury, as is the case of the traditional systems under the responsibility of
the Ministries of Health, has led to a search for alternative mechanisms, among
which social security appears to be the most appropriate for achieving equity.

     The case of the countries of the English-speaking Caribbean is of singular
importance in this context, since they are characterized by predominance of a
traditional system in which the health services are the responsibility of the Ministries
of Health.  In Latin America, on the other hand, depending on the countries in
question, there has been a tendency to provide health services through social
security.  In each case the rationale for this integration is founded on different
principles.  In Latin America the basis for coordination between the public health
institutions and the social security institutions may be found in constitutional
precepts which, developed by ancillary legislation, create a legal operational
framework of considerable validity, whereas in the legal tradition of the English-
speaking Caribbean such constitutional prerogatives are either nonexistent or at
best are referred to tangentially or abstractly.  This, however, does not mean that
the justification for such coordination cannot be found in other concepts and forms
of recognized universal validity, such as international declarations and instruments,
internal legal provisions that are easier to implement than those deriving from
constitutional precepts, or even the bases of the social policies.

     Now then, why is the legal framework used as an analysis variable?  Because
this framework, through a series of ordered and convergent provisions, makes it
possible to structure laws through which such interaction may be maintained. 
Various conceptions intervene here, of course, that have to do with the legal
tradition involved.  In the constitutional system of Latin America, the sum total of
economic, social, and cultural rights, including the right to health and social security,
may be found in constitutional precepts.  On the other hand, the constitutional
tradition of the English-speaking Caribbean for the most part disregards this
substratum.

     This study includes three sections.  The first defines the importance of
coordination between the public health and social security institutions.  The second
seeks the legal bases for such coordination in constitutional precepts, taking into
account the already indicated diversity in the two systems under study with regard
to the inclusion in the constitution of guarantees that concern economic, social, and
cultural matters.  The third section seeks to find this basis in another variable--
social policy--which in itself was the original rationale for social security as a whole. 
The conclusion summarizes the foregoing sections and provides some reflections
on the topic. 

     The study is concentrated basically on Antigua and Barbuda, The Bahamas,
Barbados, Belize, Dominica, Grenada, Guyana, Jamaica, Saint Kitts and Nevis,
Saint Vincent and the Grenadines, Saint Lucia, and Trinidad and Tobago.  As
regards the analysis methodology, it was considered desirable to compare the two
constitutional systems, both the Latin American and that of the English-speaking
Caribbean, for the purpose of finding legislative support for integration of the public
health and social security institutions at the constitutional level.  However, ancillary
provisions germane to the topic at hand have not been investigated.

I.  THE IMPORTANCE OF COORDINATION BETWEEN SOCIAL
     SECURITY AND PUBLIC HEALTH INSTITUTIONS


     The public sector, through the direct action of the State, has traditionally been
responsible for functions relating to public health.  Thus, it has carried out activities
such as environmental protection and control of endemic and epidemic disease and
has intervened in the regulation and control of food and drugs.  In addition to these
functions, it has carried out other actions, which, although falling within the scope
of health activities, are directed toward ensuring a minimum of health services for
the entire population.  This involves a function that falls into the category of public
welfare or charity. 

     Financing of the health services under the responsibility of the public
subsector is carried out with funds from general State revenues, a situation that
produces instability in that is makes the health services dependent on the capacity
of the public budget and on political decision for the allocation of such funds.  This
situation has been further aggravated by various factors such as the successive
economic crises and the increase in the population, which have brought about a
consequent increase in demand and, consequently, have overwhelmed the financial
capacity of the public sector to provide these services.  For this reason it was
necessary to replace the traditional system and to seek another that would be
capable of responding to these growing needs, of overcoming the crisis, and
moving in the direction of universal coverage.

     Social security as a participant in the health systems emerged as the most
appropriate option for combating the vulnerability of the health services.  This is
because the financing of social security systems is based essentially on a tripartite
mechanism supported by the collective contribution of the workers, employers, and
the State.  In the social security health care systems in particular, the health
services are provided a greater proportion of resources than those allocated to the
Ministries of Health.  This provides social security with its own revenue, whose
effectiveness is, of course, related to the volume of formal employment and the
existing wage level, the efficiency of the tax-collection system, and the increase in
the coverage of risks and of the population.

     Although it is beyond the scope of this paper to enter into details of a
historical nature, it is nevertheless desirable at this point to note that social security
had its origin in the social security model introduced by the German Minister of
Foreign Affairs Otto von Bismarck in 1883.  Social security, whose purpose was to
protect the workers against the risks to which they were exposed in their productive
capacity, assumed a new approach starting in the 1940s.  This new approach,
contained in the Report by Sir William Beveridge, was based on the ideal of
eliminating poverty and providing a complete program of social security.  The
Report promotes the integration of traditional social security programs with public
welfare and health care programs and is based on the principle of universality. 
Social security was thus extended to the entire population regardless of whether it
was used or not.  With reference to health in particular, the Report provides for a
system of comprehensive medical care directed toward the preservation and
recovery of health and the prevention of illness.  It is also directed toward providing
necessary medical services to all.  These include both general and specialized
services, both domestic and institutional.

     The importance of coordination between the public health and social security
institutions, a topic that has been debated extensively during the last decades, has
assumed even greater importance at the present time because of the need to find
solutions to the problems that are looming in the future.  In dealing with the
economic, financial, and social realities that the Region will have to face in the
1990s, it will be necessary to strengthen the interrelationship between the Ministries
of Health and social security with a view to more clearly defining the function that
both institutions should perform with regard to health.  This, in turn, will require an
expansion of the conceptual and operational basis of social security and of its
approach to health in order to achieve equity in providing access by the population
to the services.  This is the particular case of several countries in the English-
speaking Caribbean, where coordination of the services with regard to coverage of
the population has to deal with needs that must be satisfied.  Note is taken in this
regard of the reductions in their health budgets and the consequent negative effects
on their low-income populations.

     The possibilities for extending the coverage of the health services depend on
the existing financing mechanisms, and therein lies a fundamental problem in the
process of interaction between the activities of the Ministries of Health and those
of the social security institutions.  It is well known that the cost of social security has
surpassed the economic capacity of many countries in the Region, since as risk
coverage increases, as does the population to be covered, the capacity for
supplying the sector diminishes.  However, it is not the purpose of this paper to
consider problems of financing.  It is aimed rather at shedding light on the
relationship between the health institutions and the social security institutions in the
countries of the English-speaking Caribbean.  The development of social security
and public health in these countries has followed patterns that differ from those of
Latin America, and they have followed different paths, both historically and with
regard to their foundations. 

     The provision of health services in the countries of the English-speaking
Caribbean has been developed outside the scope of social security--that is, as a
public service in which the Ministry of Health or its equivalent has had exclusive
responsibility for providing health services to the population.  The legal basis of
social security in the countries of the Caribbean is different from the prevailing
pattern in Latin America, where it is derived from constitutional principles which,
although formulated generically, allow for specific regulation in the field. 


II. LEGAL BASES FOR INTEGRATION OF PUBLIC HEALTH AND
     SOCIAL SECURITY INSTITUTIONS

A.   LATIN AMERICA

     The countries of Latin America display a great variety of services that are
provided to the family members of beneficiaries, retirees, and pensioners. 
However, social security has evolved notably in its search for universality.  This
evolution has allowed it to expand from the traditional concepts of insurance that
covered maternity, illness, accidents, and work-related diseases to comprehensive
care for workers and their families.  The consequence of this increased involvement
of social security in community problems is that it is been extended to areas such
as disease and accident prevention, behavior modification, the reduction of
violence, and improvement of the quality of life.

     In Latin America integration of the public health and social security institutions
is provided for in the national constitutions, which form the basis of the national
legal systems.  Although each uses different terminology, they all refer to social
security.  Constitutions in Latin America have dealt with the health as it relates to
social security in diverse ways.  In referring to social security, some of them
explicitly mention health or, on the contrary, disease.  Thus, they guarantee that
social security covers the "contingencies of disease" (Bolivia, 1967); they provide
that social security encompasses "the integrated actions of the Public Powers and
of society aimed at ensuring the rights associated with health" (Brazil, 1988); they
guarantee that social security will protect, inter alia, "against risks of disease"
(Costa Rica, 1949); they recognize that the action of the State in the area of the
right to social security "shall be directed toward guaranteeing the access of the
entire population to the enjoyment of uniform basic benefits" (Chile, 1980); they
establish that the right to social insurance, which includes social security, "has the
objective of protecting beneficiaries and their families in the event of illness..."  and
"care for the health of the population" (Ecuador, 1983); they determine that the right
to social security "shall cover cases of illness..." (Honduras, 1982); they decree that
the law on social security is in the public interest and includes, inter alia, "insurance
... against disease" (Mexico, 1917); they guarantee that "the social security services
shall cover cases of disease" (Panama, 1983); they define that one of the objectives
of social security is "to cover the risks of illness" (Peru, 1979); they establish that
the State will promote the progressive development of social security "so that all
persons shall enjoy adequate protection against ... illness" (Dominican Republic,
1966) or in order to "protect all the inhabitants of the Republic against the
misfortunes of ... illness" (Venezuela, 1961); or they determine that "general
retirement and social security shall be organized so as to guarantee all workers and
employers adequate retirement pensions and compensation for cases of accident,
illness..."  (Uruguay, 1967).

     Other Latin American constitutions refer to social security without expressly
mentioning health; however, they envisage it as a component part of health by
virtue of its integration into social policy.  Thus, for example, the Constitution of
Argentina (1853, amended in 1957) determines that the State "shall grant the
benefits of social security, which shall be comprehensive and inalienable."  The
Constitution of Colombia (1991) stipulates that "Social Security is a compulsory
public service that is provided under the direction, coordination, and control of the
State under the principles of efficiency, universality, and solidarity, as established
by law."  The Constitution of Cuba (1976) provides that by means of the social
security system the "State guarantees adequate protection to all workers burdened
by poor health, disability, or illness..."  The Constitution of El Salvador (1983)
determines that "social security constitutes a compulsory public service," and that
of Guatemala (1985) provides that "the State recognizes and guarantees the right
to social security for the benefit of the population of the Nation."  The Constitution
of Nicaragua (1987) stipulates that "the State guarantees to the Nicaraguan people
the right to social security for comprehensive protection against the social
contingencies of life and of work."  Finally, the Constitution of Paraguay (1967)
establishes that "the State shall institute, insofar as possible, a system of social
security."

     The provisions referred to above, although they set forth general principles
that are to be developed or regulated by other, ancillary laws, constitute, according
to Fuenzalida Puelma "a mandate to future lawmakers in order for the parliament,
if the mandate is directed toward the legislative branch, or for the executive branch
by means of decree, if the mandate is so directed, to make the provisions of the
constitution effective through legal instruments; that is, to make them applicable." 
In this way, by according social security constitutional status and recognizing it as
a right, "the State (ministry/managing institute) intervenes by means of actions of
foresight, insurance, or programs to deal with events that affect the general
population and, ultimately, society."  In addition, these provisions make it possible
to develop the legal framework within which integration is to take place.

B.   THE ENGLISH-SPEAKING CARIBBEAN
     
     Social security in the English-speaking Caribbean countries, in contrast to
Latin America, has experienced alternative development and has been relegated
to the sidelines in the provision of health services.  As Castellanos Robayo and
Frank point out, "In the English-speaking countries of the Caribbean there is a long
and well-established tradition of providing health care as a public service.  As a
principle, the Ministry of Health or the Ministry in charge of health matters, has had
legal and political responsibility for protecting health and providing health services
to all nationals."

     In contrast to Latin American constitutions, the constitutions of the Caribbean
countries do not contain provisions for to integrating the public health institutions
and the social security institutions.  Even the reference to health itself is tangential,
perhaps because, as Harold Lutchman states in citing T. Georges, the jurists of the
Caribbean Commonwealth agree that social and economic rights may lead to
controversy with respect to their meaning, execution, and effectiveness.  The idea
predominates that many of these rights do not possess the validity of true rights,
and consequently should not be considered as such.  This reluctance to define
economic and social prerogatives at the constitutional level has not been an
impediment to recognizing health as a right.  Castellanos Robayo and Frank state
that in subscribing to the Declaration of Alma Ata, the governments of the
Caribbean countries have subscribed to the target of Health for All by the Year 2000
and to using primary health care as the fundamental strategy in order to reach this
target.  In this context, health is generally recognized as a basic human right and
a fundamental component of the national development process.

     In this context, it may be said that the constitutions of the Bahamas (1973),
Antigua and Barbuda (1981), Dominica (1978), Grenada (1973), Saint Kitts and
Nevis (1983), Saint Vincent and the Grenadines (1979), and Saint Lucia (1979)
refer to health tangentially.  As Sir Fred Phillips notes in discussing the matter, "It
is necessary for the reader to feel his way through the labyrinth of exceptions made
to the various other fundamental rights in order to detect the safeguards to the
health of the public."  The Constitutions of Barbados (1966) and Jamaica (1962)
contain no provisions that refer directly to health or its promotion nor to its
correlation with social security.  The same is true of the Constitution of Trinidad and
Tobago (1976).  The Constitution of Belize (1981), on the other hand, recognizes
the need for ensuring a just system capable of providing education and health
services on a basis of equality.  In the same vein, the Constitution of Guyana (1966)
guarantees to all persons the right to enjoy a disease-free life.  It further recognizes
social protection for old age and disability.

     With respect to the provision of the services in particular, "The countries of
the English-speaking Caribbean have developed health public systems, originally
modeled on the British National Health Service.  Private health services are limited,
with few exceptions, to ambulatory care practices and pharmacies; public health
expenditures, primarily supported from general tax revenues, account for relatively
large portions of total government operating expenditures."  This dependency on
a single source of financing has produced, in most cases, an inability to continue
financing the sector.  It has been observed that this situation is further aggravated
by the provision of services through the private sector, with consequent detriment
to needy population groups.

     Social security is still maintained within the traditional canons of insurance for
maternity and for illness deriving from accidents and occupational disease, and is
limited essentially to the payment of cash benefits.  In the Caribbean countries it
has been observed that the social security institutions showed a clear tendency "not
to enter directly into the area of providing or financing medical care.  Traditionally,
the great majority of the inhabitants of all the English-speaking Caribbean countries
obtain their medical care in installations of the Ministry of Health.  A small
percentage of relatively highly-paid, well-to-do individuals can and do utilize private
practitioners and private hospitals but this does not change the general picture. 
Notwithstanding this statement of fact, some of the governments in the Caribbean,
as previously mentioned, have taken steps to investigate the possibility of
establishing a national a national health insurance scheme."
III.SOCIAL POLICY AS THE BASIS FOR INTEGRATION OF THE
     HEALTH SERVICES AND SOCIAL SECURITY IN THE ENGLISH-
     SPEAKING CARIBBEAN COUNTRIES

     
 It has already been pointed that constitutions are one of the fundamental legal
bases for justifying the integration of health institutions and social security
institutions.  This is the case, for example, of the legal framework in Latin America. 
In the countries of the English-speaking Caribbean the lack of these basic precepts
at the constitutional level makes it necessary to resort to an alternative justification. 
The most promising of these has to do with social policy, since social security
generically forms part of the social policy of the State, which provides it with legal
definition, determines its policies, and orients its implementation.

     The basis for the particular relationship of health to social security, supported
by social policy, is found in the Beveridge Report, which recognizes among its basic
principles that social security is only one of the elements of the policy of social
progress.  As such, it cannot be limited to merely providing monetary security to
combat poverty.  In order to achieve social progress as a whole, other elements that
hinder it must be eliminated, among them disease.

     Social policy as a measure of value is important because, as Madison points
out in citing Boulding, if there is something that establishes a common tie that
unifies all aspects of social policy and distinguishes it from mere economic policy,
this nexus constitutes which has been called `an integral system.'  This includes all
aspects of social life that are characterized not by what is obtained in unilateral
terms.  Generally speaking, the objective of social policy is to construct the identity
of the individual in the community with which he is associated.  In order to achieve
this `integral system,' these policies should deal with the numerous and
contradictory aspects of the social environment toward which they are directed. 
As the author adds, most of the investigators agree that the reasoning that is used
in defining these competitive interests is based on personal assessments and on
options and, through them, on the values of the society as a whole.

     Health as a value in the social policy of the countries of the English-speaking
Caribbean, is an element of importance.  As has been pointed out previously, in
subscribing to the Declaration of Alma Ata, for example, the governments of these
countries adopted the target of Health for All by the Year 2000, with all the
implications that a commitment of this nature has for the recognition of health as a
basic human right and a fundamental ingredient in the development process.

     In addition to the aforementioned Declaration, there are other initiatives that
demonstrate the importance of health in the countries of the English-speaking
Caribbean.  Among them are the efforts carried out not only through CARICOM
(Caribbean Community), but also the national efforts carried out through joint
PAHO/WHO efforts and the work of other international agencies, among which are
the United States Agency for International Development (USAID), the United
Nations Children's Fund (UNICEF), the Inter-American Development Bank (IDB),
the Canadian International Development Agency (CIDA), the United Nations
Environmental Program (UNEP), and the European Development Fund (EDF),
which are collaborating for the development of accessible, available, and timely
health services for the entire population.

     The generic existence of these bases, which would make it possible to
coordinate the public health and social security institutions, should not be taken
lightly.  Although law is a mechanism for putting social policies into practice, it also
derives from them the bases for more effective adaptation to the area destined for
regulation and, thus, the legitimacy necessary for the fulfillment of its objectives.


IV. CONCLUSIONS

     
 Throughout this study reference has been made to the need for finding solutions
to the problems caused by the pressures to which the traditional concept of health
services delivery has been subjected--that is, as the exclusive responsibility of the
Ministries of Health.  The need has been pointed out for seeking in the countries of
the English-speaking Caribbean a mechanism for coordination between the public
health and the social security institutions as a means of correcting this deficiency.

     With a view to establishing a basis for such coordination, recourse has been
made to such figures of Latin American law as the inclusion of social rights in the
constitutional framework.  Among these are health and social security.  The lack of
inclusion of either of these modalities in most of the constitutions of the countries
of the English-speaking Caribbean has made it necessary to identify other values
in order to justify such coordination.  Social policy has been utilized for this purpose. 
This constitutes the typical mechanism by means of which concepts are put into
practice which, although not fully developed by means of the basic laws of a
specific legal system, nevertheless find support in the principles that derive from
recognition by the State of universally accepted principles.  These principles are
tacitly incorporated into the legal system.

     The countries of the English-speaking Caribbean have sought to improve the
health conditions of their populations by various means.  These arrangements
range from subscribing to international declarations and instruments up through the
development of joint initiatives and the request for technical cooperation from
international health and credit institutions.  They include, in addition, the search for
new alternatives based on the goal of equity.  Coordination between the public
health and the social security institutions would find support in these modalities,
which make health and the achievement of equity in health a fundamental element
of social policy.



· 

EMB Bol. his

Boletín de la Oficina Sanitaria Panamericana:
Voice of Knowledge and Catalyst for Action

     The 846 issues of the Boletín de la Oficina Sanitaria
Panamericana that have come off the presses during the Bureau's
90-year history represent not only 70 years of uninterrupted
monthly publication but also a long trajectory of direct influence
over the course of public health in the Americas.  In the yellowed
pages of the volumes from the early years the histories of the
Boletín and the Bureau meld into one.  A perusal of these issues
reveals the multiple roles that both the Bureau and the Boletín
have played through the years, providing a flexible and timely
response to bridge the gaps created by the countries' changing
needs. 
     The founding of the Boletín and its inextricable link with the
history of the Bureau itself date back to the VI International
Sanitary Conference, held in Montevideo shortly before Christmas
in 1920.  Among the resolutions relating to the reorganization of
PHOTO OF GUITERAS
the Bureau, one called for the establishment of a bulletin entitled
"Monthly Reports on Pan American Health from the International
Sanitary Bureau," which, together with its corresponding
Spanish-language version, would be published by means of a credit
of $US 20,000, to be prorated among the Member Governments.  The
report for fiscal year 1920-1921 indicates that the Bureau was
reorganized in May 1922, and under the leadership of the Assistant
Director, Dr. J. H. White, work began on the preparation of two
special editions of a Boletín Panamericano de Sanidad, (6,636
copies in Spanish and 2,000 in Portuguese), with articles written
by distinguished specialists from the United States.  The Director
of the Bureau, Dr. Hugh S. Cumming, later explained that
PHOTO OF BOLETIN SEAL/LOGO 
"se renuncio al privilegio de publicarlo en inglés a favor de una
edición en portugués [the decision was made to waive the privilege
of publishing the bulletin in English and to print a Portuguese
issue instead]."  The desire for regular scientific communication
between health officials in the Americas assured the immediate
success of the Boletín, which figures prominently in the annual
reports of the Director during that period, together with abundant
details about its content.
QUOTE 1
     The first issue of the Boletín, which came out in May 1922,
included two articles that proved to contain an almost prophetic
vision of the future.  In an article on the importance of
cooperation between nations in health matters, J. H. White warned
that it would be be impossible to obtain satisfactory results
unless the resolutions of the conferences were adopted as law in
the various countries.  Another article, on the subject of
differential diagnosis and the eradication of smallpox by B. J.
Lloyd, foreshadowed what many decades later would become a joyous
triumph.  The same issue contained a list of cases and deaths from
communicable diseases (cholera, bubonic plague, smallpox,
exanthematous typhus, and yellow fever) reported by the Surgeon
General of the United States.  Such reports were a regular feature
of the Boletín for many years.
     Beginning in July 1923, the journal was given its current name
under a resolution of the V International Conference of American
States, which also decided that the International Sanitary Bureau
would thenceforth be known as the Pan American Sanitary Bureau. 
That year was also noteworthy for the publication in Portuguese of
special issues on syphilis, tuberculosis, leprosy, smallpox,
diphtheria, dental care, mucocutaneous leishmaniasis (buba), and
other subjects.
     Even in its modest initial format, the Boletín already
contained all the elements that 30 years later would justify its
being called the most well-known and widely distributed monthly
journal of hygiene and medicine in Latin America.  Since the
publication consisted of only 26 pages, long articles were
published as series that spanned several issues.  These were
PHOTO OF THE FIRST BOLETIN 
generally written by experts from the United States with ties to
PASB or were translations of articles from prestigious biomedical
journals, although toward the end of the decade the Boletín began
to carry more original contributions by Latin American authors. 
A section that appeared quite regularly was called "Adelantos en
ingeniería sanitaria" (later "Notas y Revistas"), which was
somewhat similar to the current section "Instantáneas" and
contained summaries of texts on sanitation and disease control. 
Another short section that was frequently included was
"Bibliografía," which featured book reviews.  The Boletín also
began to carry reports on the health systems in the countries,
starting with those of Venezuela and Mexico. 
     It soon became necessary to expand the publication's scope to
make room for documents that were of enormous importance for the
countries:  model laws on foods and drugs, texts of the Pan
American Sanitary Code and updates on its ratification, circulars
on seaport quarantines, water purity standards, proceedings of
conferences, and the first translations of Control of Communicable
Diseases in Man.  The texts were embellished with photographs,
tables, and drawings.  Articles that were applicable
COLLAGE OF DRAWINGS USED IN THE BOLETIN  
to specific situations were reprinted and distributed to national
directors of health and newspapers.  The Boletín also began to
carry editorials, which, in addition to reflecting the chief public
health concerns and problems in the Americas and other places
around the world, would have a marked impact on national health
policies.
     Throughout the official documents of the Organization the
importance of the Boletín can be clearly seen.  Pursuant to a
resolution adopted by the first administrative session of the
Directing Council of PASB, the Bureau was requested to continue
giving special attention in the Boletín to the publication of facts
and discoveries which might be of use in the prophylaxis of
tuberculosis and cancer.  In his report for 1927, the Director drew
attention to the articles on public 
QUOTE 2 
health administration in the Americas, calling for completion of
the series on that topic.  He also expressed his satisfaction with
the success of articles on ideal methods of health administration
in a city of 100,000 inhabitants, "Ordenanza modelo para leche,"
and the control of communicable diseases.
     In each era of its history the Boletín has endeavored to paint
a true picture of the health situation.  During its first decade
it focused on the ravages of communicable diseases, including not
only the reportable ones but others such as tuberculosis, leprosy,
and diphtheria.  It also took up concerns that would eventually
become the major public health problems of
QUOTE ABOUT  MALARIA
the future, including sexually transmitted diseases and alcoholism. 
In addition, articles published in the Boletín at that time
provided a glimpse of the problems that would give rise to
important actions many years later.  For example, several of them
anticipated the need to promote preventive health measures among
specific population groups.  A 1923 issue contained a list of
recommendations for tuberculosis patients, and one in 1928 included
articles with advice for mothers on oral health and other matters
under such titles as:  "Dad a vuestros hijos aire y sol  [Give Your
Children Plenty of Sunshine and Fresh Air]," "Alimentae bem vossos
filhos [Feeding Your Children Properly]."  This new selection of
materials aimed at nonprofessional readers was, according to the
Director, intended to increase the dissemination of reliable data
on sanitation, hygiene, and disease.  These early issues also
reveal the growing importance of topics like industrial hygiene,
the specific health needs of women, and the influence of lifestyles
factors, such as weight and sexual behavior, on health.
     By the early 1930s the Boletín was firmly established.  Dr.
Arístides A. Moll, former Editor-in-Chief of the Spanish edition
of the Journal of the American Medical Association had joined the
Bureau as scientific editor of the Boletín and Chief of
Translations.  He later took on the additional responsibilities of
Secretary of PASB.  The Boletín documented, step by step, the
development of a health consciousness in Latin America, publishing
reports that described the improvements in legislative provisions
and health systems.  Articles were included in French and
Portuguese, as were an increasing number of informative features
on different diseases.  Changes in format made it possible to
systematize the presentation of statistics from the countries in
a section entitled "Demografía."  The report on communicable
diseases was shifted to a new publication, the Weekly
Epidemiological Report.  The "Notas y revistas" section kept
readers up to date on the latest news about administration and
organization, new journals and bulletins, meetings and congresses,
awards, and other matters. 
PHOTO OF DELEGATES, NO. 6125
     One of the Boletín's most valued functions was to answer
requests for information on various health problems.  In 1937, for
example, it responded to inquiries about fumigation, disinfection,
poliomyelitis, legislation, medical assistance to industry, and
other concerns.  Among the most noteworthy documents published in
the Boletín during these years were the translations of the United
States Pharmacopeia and the International Nomenclature of Causes
of Death.  The Boletín served the additional function of
communicating the decisions of the Pan American Sanitary Conference
and disseminating data to aid the countries in putting the
Conference's recommendations into effect.  The existence of a
section on the prevalence of diseases led to enhanced data
collection in the countries, which had not always been meeting
their obligation to provide adequate and timely reports.  Although
during the 1930s yellow fever was a primary focus of the Boletín,
especially following the discovery of a jungle type of the disease,
pursuant to recommendations of the Directing Council the journal
began to devote increasing attention to the problems of
tuberculosis and nutrition, including good dietary habits.  Each
year one of the first issues contained a review of the most
important health developments that had taken place in the countries
during the preceding 12 months.  The Boletín had indeed established
itself not only as a fundamental source of reliable public health
information but also as an organ of the Bureau that the member
countries could rightfully claim as their own.
     It was therefore not surprising that the number of subscribers
grew steadily, reaching a total of 8,900 in 1938.  The Bureau
library was receiving some 300 journals a month, many of them in
exchange for the Boletín.  One of the Bureau's targets was to
deliver the publication throughout Latin America to all communities
of more than 2,000 inhabitants and to increase circulation in the
United States.  The journal's popularity is revealed by a repeated
warning to subscribers to keep the Bureau apprised of any changes
of name or address, since each edition of the Boletín was being
exhausted almost as soon as it came off the presses and back issues
were in short supply.
     The 1940's brought major changes to PASB.  The Boletín
chronicled the important events of these years:  the rapid
development of public health and medicine during the Second War
World; the XII Pan American Sanitary Conference of 1947, which
reorganized the Bureau into its current form; the early years of
Dr. Fred Lowe Soper's term as Director; the agreement whereby PASB
became the Regional Office of the World Health Organization for the
Americas; administrative decentralization and the creation of
special area offices; the coordination of health programs along the
Mexico-United States border; and even the transfer of the Bureau
to a new location.  Among the new topics included in the journal
were information on WHO, the new Constitution and the
reorganization of PASB, workers' health, accident prevention,
zoonoses, medical education, nuclear medicine, and a new section
devoted to the improvement of nursing services.
     In 1948 the Organization began to charge a fee for annual
subscriptions to the Boletín, although free distribution was
continued to departments of health and official institutions in the
countries.  Issues from July 1949 onward contained instructions on
the preparation of articles for publication, which undoubtedly
provided an impetus for scientific research in the Americas by
giving contributors the opportunity to submit unsolicited papers
to be considered for publication.  In many cases, these papers
reflected a first-hand view of the health situation in the
countries.
QUOTE 3
     The editorial written for the Boletín of May 1952 briefly
recounted the journal's thirty-year history, pointing out that it
had collected and brought together ideas and knowledge about health
in a single body of information which had helped to unite health
workers throughout the Hemisphere, regardless of the distances
separating them, for a common purpose.  The last issue of the year
QUOTE 4
was devoted exclusively to the fascinating history of the Bureau,
which on 2 December marked its 50th anniversary.  
     In the course of those 50 years the Boletín had published
articles in all four official languages of PAHO (English, French,
Spanish, and Portuguese), although in deference to the composition
of its readership the bulk of them had appeared in Spanish or
Portuguese.  However, every article was generally accompanied by
a summary in English, and later in the four official languages, in
keeping with the aim of reaching all sectors of the inter-American
community through the Boletín.  The editorial service responsible
for putting out the journal had also taken on the publication of
a Spanish edition of the Chronicle of the World Health Organization
as well as translations of various technical works.  By this time
the Boletín had expanded far beyond its initial length of 26 pages
QUOTE 5
and was publishing many more articles based on original research. 
In 1951 it served as the vehicle for a survey on health education
and in 1953 a new section was added on the subject.  The ideas
explored in this section coincided to a large extent with new
developments in the search for health which were being discussed
at major international congresses.  The Boletín gave increasing
attention to statistics, environmental health, and the health needs
of the elderly, and it began to publish essentially monographic
issues devoted almost exclusively to specific subjects, including
poliomyelitis, malaria, nursing, and medical education, among
others.  In 1953, 1955, and 1959 supplements were published that
included scientific material from the Institute of Nutrition of
Central America and Panama.  A forerunner of the current section
entitled "Communicación biomédica" was Selma Debakey's article on
the preparation of medical articles (October, 1955).
     When Dr. Abraham Horwitz was elected Director of the
Organization, the first Latin American to occupy this position, he
became a frequent contributor of incisive articles and editorials. 
At that time the Boletín was reporting monthly on progress toward
the eradication of Aedes aegypti and had begun to publish the first
articles on the new topic of economics and health.  It was also
carrying a growing number of articles on scientific research from
Latin American countries, as well as materials from the Bulletin
of the World Health Organization.  The dynamic events of the famous
meeting of Punta del Este in 1961, and PAHO's role in that
gathering, led to a new emphasis on health as a component of
development, an idea that gained momentum during the administration
of Dr. Héctor Acuña and continues to be an important focus under
the present Director, Dr. Carlyle Guerra de Macedo.
QUOTES 6 and 7
     By 1966 it had been recognized that there was a need to
publish a greater number of articles in English, and the Bulletin
of the Pan American Health Organization was created.  Up to 1970
it came out once a year and featured selections from the Boletín. 
Three issues were published in 1972, and in 1973 the current
quarterly publication schedule was adopted.  Today the Bulletin is
aimed mainly at English-speaking readers in the Caribbean countries
and the articles are selected with that criterion in mind,
independently of the articles published in the Boletín.
     In 1972 the Boletín celebrated it 50th anniversary, the
occasion being marked with the publication of an historical account
in the May issue.  With characteristic foresight, during the
previous year the Boletín had carried several articles on cholera
with a view to preparing the countries of Latin America for the
possibility of a seventh pandemic.  An article by Albert Sabin on
the elimination of poliomyelitis had also been published.  In 1973
the Boletín announced the most dramatic news in its history: 
smallpox had been completely eradicated from the Americas.  A few
years later, in 1978, it published the monumental Declaration of
Alma Ata.
     Under Dr. Acuña, responsibility for the production of several
publications, including the Boletín, was transferred to the PAHO
Representation in Mexico, although the journal's technical content
continued to be decided by the Office of Health and Biomedical
Publications at Headquarters.  In 1982, as the result of a cost-
benefit study ordered by the current Director, Dr. Guerra de
Macedo, the decision was made to return all publication services
to Headquarters.
     In recent decades, the Boletín's focus has shifted away from
general information toward more specific priority subjects.  A new
quarterly section called "Información farmacológica" was
inaugurated in July 1980 and today provides ongoing support to the
national agencies responsible for drug regulation.  With the
creation of new specialized journals such as the Boletín
Epidemiológico, Educación Médica y Salud, and the Boletín
Informativo PAI, as well as the publication of journals by the
various PAHO centers, the Boletín has gradually been relieved of
responsibility for disseminating the type of information carried
by those publications and has been able to turn its attention to
bridging information gaps in other areas. 
     While in earlier days articles were reviewed by the technical
programs of the Organization through an Advisory Committee, since
the 1980s this function has been carried out through a system of
peer review, in keeping with the practices of other international
biomedical journals.   As a result, the quality of the papers
selected for publication has steadily improved.  Since 1989, a
section entitled "Comunicación biomédica" has been offering
technical criteria for research and for the preparation of papers
while at the same time endeavoring to foster the capacity for
critical evaluation among its readers.  The section "Libros"
reviews more than 100 books a year and "Cartas de los lectores"
provides a forum for readers to share their observations.  The
Boletín has a pressrun of 16,500, is listed in various indexes and
electronic data bases, and receives between 350 and 500 articles
each year, 15% to 20% of which are eventually published.  Lengthy
special numbers of the Boletín have examined some of the major
concerns of our time, including mental health, economics and
health, AIDS, drugs, and bioethics.  The dynamic editorials of Dr.
Guerra de Macedo are paving new roads for the consolidation of
Regional solidarity and the search for health and equity as part
of development.
     Over the past seventy years, the Boletín has kept pace with
the unprecedented evolution of knowledge and applications in the
health sciences, from the development of new antibiotics and
vaccines to the spectacular advances in biotechnology.  As a
depository and an organ for the communication of knowledge, and
through its support for scientific research, the Boletín has made
an undeniable contribution to the development of public health in
the Western Hemisphere.  As the voice of the Organization, it has
also guided the Member Governments in the application of
collectively approved health policies and activities.  Above all,
the Boletín has helped to nuture Latin American thinking about
public health and cooperation among countries.  Its pages will
continue to reflect the forward-looking concerns of those who have
devoted their lives to the fight against poverty and disease, and
the Boletín will continue to chronicle both the milestones reached
and the failures and setbacks encountered in the ongoing effort to
achieve well-being for the peoples of the Americas.
QUOTE 1
In addition to the special articles about the cause, prevention,
and control of diseases, the Boletín Panamericano de Sanidad has
published monthly detailed data concerning the existence of
reportable diseases throughout the world but especially in Latin
America.  It has also published information on sanitation and the
maintenance of public health.  This Boletín is sent free of charge
to departments of health, practicing physicians, health officials,
and other concerned individuals in Latin America.  We have received
many commendations on the Boletín as well as numerous assurances
that it is indeed filling a gap.  -- Report of the Director, 1921-
1922


QUOTE 2
It is my ambition and desire to make the Boletín fully worthy of
your confidence and deserving of whatever time you may spend
reading it.  Report of the Director, 1927


QUOTE ON MALARIA
Malaria has long been a dreaded enemy in tropical and subtropical
regions of the Americas.  Not only has it hindered material
progress in the countries of these regions but it has also given
them a reputation as unhealthful and dangerous places, which is the
worst damage it could have done.  Anyone who is concerned with
preventing this scourge should contact the International Sanitary
Bureau.  Notice that appeared regularly in the Boletín beginning
in December 1922


QUOTE 3
The authors of articles solicited by the Director of the Bureau
will receive 20 copies of the Boletín free of charge.  Authors who
submit papers that are accepted for publication will receive 10
copies of the Boletín free of charge.  Reprints may be obtained by
the author for a fee, which currently is US$0.50 per page for 100
copies, with a four-page minimum.  A surcharge will apply to
illustrations that require special paper.  Excerpt from the
instructions for contributors published in the Boletín, 1949


QUOTE 4
The Boletín has now been engaged in carrying out its mission for
30 years.  Its format has evolved as progress has been made in
production techniques, although the emphasis has always been more
on substance than on form.  Conributions by physicians and health
specialists from all the countries have found their way onto the
pages of the Boletín.  This body of thought by the men of the
Americas who are concerned with public health is a valuable
historical legacy that will continue to shape the future. --
Boletín, May 1952


QUOTE 5
One of the primary functions of the Pan American Sanitary Bureau
is to serve as an international center for the collection and
dissemination of scientific information and knowledge about public
health and related sciences.  Boletín, November 1953

QUOTE 6
The Boletín fulfills one of its ineluctable duties by presenting
its readers with the most important information culled from the
documentation available.  --Abraham Horwitz, referring to the
meeting of Punta del Este

QUOTE 7
"As the number of readers increased, the monthly pressrun [of the
Boletín] rose from 11,100 copies in 1966 to more than 14,300 by the
end of 1969.  In the four-year period some 280 articles were
published, from authors in all parts of the Americas as well as
other regions of the world, in addition to the sections devoted to
medical and health news and reports on other items of interest." 
 --Quadrennial Report of the Director, 1966-1969
PHOTO CAPTIONS
Photograph of Dr. Juan Guiteras.  The Boletín de la Oficina
Sanitaria Panamericana came into being as the result of a proposal
made by him at the VI International Sanitary Conference. 

Commemorative seal of the VI International Sanitary Conference,
which was the inspiration for the logo used by the Boletín for a
number of years.

Delegates to the second Pan American Conference of National
Directors of Health, August 1931.  Considerable time during this
meeting was devoted to discussion of how the Boletín would be
distributed to inland cities and populations. 
OBSERVATIONS ON THE DOCUMENT
      "THE MASTER PLAN FOR S. PNEUMONIAE PREVALENCE STUDY"


1.   The title of the document and the contents of the first
     paragraph are not consistent with the language used in the
     proposed protocol, which is aimed at determining the
     prevalence of the various serotypes of S. pneumoniae in cases
     of pneumonia in children under five years of age for the
     purpose of preparing a vaccine.

     A study of prevalence of S. pneumoniae, as the title and the
     first paragraph suggest, should include an overall sample of
     individuals among whom children--and children with pneumonia-
     -would constitute merely a subgroup to be considered.  

2.   Analysis of the remainder of the document will be made in
     consideration of the fact that the objective of the study is
     expressed in the proposal in the first paragraph of Point 1.

3.   A design plan for this objective might include:

     -    A definition of the target population of the study.
     -    An estimate of the size of the sample.
     -    A description of the techniques that will be used.
     -    The duration of the study.
     -    The procedures to be followed in analyzing the results
and drawing conclusions.


4.   The five points above are included in the document under
     study.  Some general considerations on each are presented
     below.

5.   Definition of the Target Population of the Study:

     -    Number of countries:  A hypothesis should be established
on the basis of which the number of countries in the
Region to be included in the study will be determined. 
Given that the vaccines in use in other countries
(Europe) cannot be used in Latin America, since they act
on different serotypes, the possible reasons for these
differences should be analyzed in order to determine how
many and which countries should be studied.  For example: 
Will it be possible to infer the situation in Nicaragua,
Ecuador, and Paraguay from the results obtained in
Brazil, Bolivia, and Mexico?

Epidemiological aspects may be considered in the
selection of the countries, but this does not provide an
answer to the above question.

     -    Age groups:  Although the population should be stratified
by age in order to consider possible variations in the
distribution of serotypes, certain special groups (two
or three-month old infants) in which pneumonia is
especially serious should be taken into account.

     -    Geographical distribution:  In order for the population
to be representative it should include different
geographical areas within the countries.  Consideration
should be given to whether the distribution of the
different serotypes of S. pneumoniae is the same in urban
and rural areas in order to include populations in both
areas.

Consideration of the rural area is important because the
rural population accounts for many of the deaths due to
pneumonia that take place each year because of lack of
access to the health services or because care is provided
too late. 

     -    Case definition:  In accordance with the target of the
study (first paragraph, Point 1 of these observations),
a clear definition of "case of pneumonia" will be
required, and it should be established whether the
definition adopted will be verified with a pattern in
order to confirm the diagnosis.

The criteria proposed by PAHO/WHO are adequate but have
been prepared with another objective (to identify the
greatest number of possible cases of pneumonia in order
to avoid death caused by not receiving adequate
treatment).  The objective of the study requires that the
greatest number of possible cases are really pneumonia,
and consequently these criteria should be supplemented
with other criteria to increase their specificity.

     -    Other factors:  Some of the considerations formulated in
the document under study are of great importance.

The population that is served by hospitals of high or
medium complexity does not appear to be appropriate for
obtaining results that lend themselves to extrapolation. 

Although there are studies that show that a high
proportion of the isolated nasopharyngeal serotypes from
carriers are the same as those that have been found to
produce pneumonia, the role played by carriers in
transmitting the disease is not clearly known.

The availability of adequate infrastructure in the
countries is a very important operational factor for the
success of the study.  However, if countries or areas
within the countries are not included because of these
limitations, decisions should be taken in consideration
of the observations formulated under "Number of
countries" and "Geographical distribution" on this same
point.

Are the serotypes that cause pneumonia in children the
same when they are associated with risk factors such as
malnutrition and environmental pollution exist?

6.   Estimate of the Sample Size:

     Estimate of the sample size should be associated with the
     conclusions that are expected to be drawn and the degree of
     generality to be given them.  To the extent that the groups
     to be studied are stratified, the size of the sample will
     increase.  On the other hand, failure to stratify the study
     may make it impossible to make adequate generalizations.

     Some additional limitations are determined by current lack of
     knowledge of the values of incidence of S. pneumoniae it is
     expected to find in each group and the different serotypes it
     might be possible to find in each.  More information should
     be compiled in this respect.






7.   Description of the Techniques To Be Employed:

     The considerations presented in the document under
     consideration include the principal concerns that can be
     expressed in this respect.

8.   Duration of the Study:

     There are no means available to prepare hypotheses on the
     variability over time of the causative serotypes of pneumonia
     in children.  Consequently, observations cannot be formulated
     for the period of 18 months proposed.

9.   Procedures for Analyzing the Results and Drawing Conclusions:

     The protocol should include details of these procedures.  The
     drawing of conclusions and their degree of generality should
     be closely associated with the decisions that are taken with
     regard to the points referred to above.
     HPM/DRC, difab.mp
UNIVERSAL AVAILABILITY OF ESSENTIAL DRUGS:  
A HEALTH TARGET IN THE AMERICAS

     Of all the spectacular advances that have been made during the
twentieth century, few have benefited humankind as much as the
development of safe and effective drugs.  The continuous search for
new drugs has given rise to a huge transnational pharmaceutical
industry and to thousands of commercial products whose quality,
safety, registration, supply, advertising, and use require careful
regulation.  As a health agency, the Pan American Health
Organization (PAHO) has been a leader through the years, playing
a fundamental and decisive role in setting regulatory policies in
this area.
     Traditionally, technological dependency has made it necessary
for the health sectors in Latin America and the Caribbean to devote
a major portion of their budgets to the purchase of pharmaceutical
products.  At the same time, they have been unable to overcome some
of the difficulties characteristic of developing societies: 
unavailability of drugs to certain groups, lack of information and
false claims about drugs, discrepancies between demand and real
health needs, inappropriate use of products, and ineffective supply
systems.  PAHO, seeking to confront these problems and adapt its
policies to the priorities of the moment, has provided advisory
services to the countries of the Americas on an ongoing basis with
a view to placing safe, effective, good-quality pharmaceutical
products within the reach of all segments of the population.

Early Activities of the Pan American Sanitary Bureau (PASB)
     The United States Pharmacopeia, first published in 1820 and
since updated a number of times, was the officially recognized list
of drugs in the United States at the beginning of this century. 
In 1905, the II International Sanitary Conference proposed that it
be translated into Spanish in order to provide a basic reference
for physicians and pharmacists in the Americas.  The project was
slow to come to fruition, but the translation of the Eleventh
Revision of the Pharmacopeia and its First Supplement was finally
published in 1936.  It was followed three years later by the
translation of the Epitome of the Second Supplement.  This
impressive effort, carried out by the Bureau with the assistance
of auxiliary commissions from Cuba, Puerto Rico, and the
Philippines, is one of the earliest and most outstanding examples
of international scientific collaboration.
     In the early part of the present century all the countries had
independent pharmacopeias and there was a pressing need to
establish a common standard.  As early as 1923, the V International
Conference had recommended that the countries adopt uniform
regulations, and in 1924 the VII Pan American Sanitary Conference
laid the foundation for the corresponding legislation.  The
proposals of that Conference were subsequently adopted by the IX
Pan American Sanitary Conference in 1934, which also designated
PASB to act as liaison between the national commissions of the
American pharmacopeias.  In this connection, in 1938 the Bureau
published a series of 24 articles in the Boletín under the title
"La Farmacopea y el médico." 

Expansion of the Pharmaceutical Industry

     The Bureau's efforts in the area of drug regulation gained 
momentum with the rapid growth of the pharmaceutical industry
during World War II.  In 1947, the XII Pan American Sanitary
Conference recommended the creation of a committee on drugs and
foods to study problems arising from the exportation, importation,
manufacture, and supply of drugs, food, and cosmetics, coupled with
the establishment of standardization measures to facilitate
commercial exchange without sacrificing health objectives.  It also
recommended that the Bureau take steps to ensure the supply of
standards for determining drug potency to official laboratories. 
In response to the proposals of numerous previous Pan American
Sanitary Conferences, the XII Conference ratified the promulgation
of a Pan American Pharmacopeia--a project that never came to
fruition--and recommended that the countries endeavor to repress
the traffic of dangerous or fraudulent drugs, make a general
revision of pharmaceutical products and remove any that violated
the principles of modern therapeutics, and make the manufacturing
licenses renewable for periods not to exceed five years.
Quality Assurance Measures

     When the Bureau became the Regional Office of the World Health
Organization (WHO) in 1949, the World Health Assembly, under the
WHO Constitution, had already been given the authority to adopt
regulations concerning the quality, advertising, and labeling of
drugs moving in international commerce.  Over the next two decades
the Bureau concentrated on ensuring the safety, potency, and purity
of drugs and on setting guidelines for their evaluation.  With a
view to assuring quality from the preparation phase onward, it
approved a set of "good manufacturing practices," with which
manufacturers of pharmaceutical products were required to comply.
These standards have served as a basis for all quality control
activities since then.  To reinforce them, the Bureau has sponsored
numerous courses and workshops, many for its own staff members and
inspectors.
     During the following two decades WHO published the first
International Pharmacopeia, and the measures designed to ensure
legislative uniformity were strengthened.  With the assistance of
the Pan American Union, WHO, and the International Union for the
Protection of Industrial Property, in 1958 the Pan American
Sanitary Bureau [which was known as the Pan American Health
Organization (PAHO) beginning that year] established a food and
drug control program.  At the same time, the Executive Committee
suggested that laws be adopted in the countries giving the
Governments the authority to regulate research activities and all
aspects relating to the purchase, control, registration,
inscription, and distribution of drugs in their territories.  In
support of these measures, PAHO followed the recommendations of the
XV Pan American Sanitary Conference, held in 1958, and increased
distribution of the most recent publications on therapeutics and
pharmacology, organized meetings on the subject, and provided
resources for the training of specialists in control techniques. 
     The 1950s brought increased awareness of the damage that could
be done by irresponsible and false advertising of products.  A
number of strongly worded warnings were issued against "miracle
drugs," and in 1960 the Directing Council recommended the
prohibition of any false and misleading advertising that would
diminish the benefits of drug control laws.  Following a lengthy
study, PAHO determined to undertake a closer examination of certain
aspects of the problem, particularly the potential teratogenicity
of some drugs.  In 1962, the XVI Pan American Sanitary Conference
recommended that congenital defects be noted in certificates of
fetal death and live birth and that all pharmaceutical
preparations, both imported and of national manufacture, be subject
to a qualitative inspection.  Bearing in mind the latter
recommendation, in 1965 PAHO began working toward the establishment
of official international quality control laboratories, which would
later become important centers for research, reference, and
training.  It also began to sponsor annual meetings for the
officials responsible for food and drug control in Central America
and Panama.
     During the 1960s PAHO espoused policies aimed at extending the
drug supply services from the tertiary to the primary care level
while at the same time continuing its efforts to ensure the quality
of food and drugs and strengthening control activities in the
Region.  The first Seminar on Drug Control in the Americas, held
in 1970 and sponsored by PAHO and the Government of Venezuela,
emphasized the importance of adequate training for auxiliary
personnel and clinical pharmacologists and the need to standardize
existing policies.  Consumers were the focus of increasing
attention, as was brought to light in 1972 when the XV World Health
Assembly urged the Member Governments to provide their populations
with information about the use, hazards, and limitations of drugs. 
At the same time it requested them to study the shelf life of
pharmaceutical products and the maintenance of records and a system
of certification to guarantee good quality.

The Regional Program on Essential Drugs

     After the Declaration of Alma Ata (1976), PAHO turned its
attention to the cost and availability of drugs.  It was recognized
that if the target of "Health for All by the Year 2000" was to
become a reality, taking into account the rapid growth of the
population, a larger portion of the limited budget of the
Ministries of Health would have to be devoted to therapeutic agents
as key elements in the control of morbidity.  However, it was also
recognized that there were too many brand-name products in
circulation that did not correspond to the basic health needs and
economic capacity of the countries.  WHO responded to this
situation by preparing a list of essential drugs--using only
international nonproprietary names--based on criteria of cost,
effectiveness, and safety.  Inspired by this example, almost all
the countries in Latin America and the Caribbean succeeded in
preparing their own therapeutic formularies, or basic drug tables,
by the mid-1980s.  These have been reviewed periodically with a
view to adding or deleting products based on an assessment of their
relative benefits and risks.  Since 1978, decisions regarding the
safety and effectiveness of drugs have been published in a special
section of the Boletín entitled "Información farmacológica."
     Following the initiative of WHO, in 1983 PAHO launched the
Regional Program on Essential Drugs, which has two fundamental
objectives:  to support the development and application of basic
tables and to help the countries to create national drug programs
and policies based on their national health needs, their profile
of supply and demand, and the supply capacity of their industrial
sectors.  Between 1984 and 1989, PAHO published a sequence of
important works that included such titles as:  Elaboración y
utilización de formularios de medicamentos [Development and
Implementation of Drug Formularies], Políticas de producción y
comercialización de medicamentos esenciales [Policies for the
Production and Marketing of Essential Drugs], Clasificación
Internacional de Medicamentos [International Classification of
Drugs] (a document prepared in collaboration with WHO), Manual para
la administración de farmacias hospitalarias [Manual for the
Administration of Hospital Pharmacies], and Pautas para el
establecimiento de un programa nacional de control de medicamentos
[Guidelines for the Establishment of a National Drug Control
Program].  Despite the favorable impact of the foregoing measures,
the cost of drugs escalated and problems relating to the
administration of supply systems intensified during the economic
crisis of the 1980s.  In response to this situation, PAHO
concentrated its efforts on improving the efficiency of supply
systems and fostering self-sufficiency in the countries through
promotion of the manufacture of generic products at the national
level and the use of traditional drugs of proven safety and
efficacy.  It also began to provide support for financial and
administrative mechanisms designed to facilitate joint purchasing
of drugs by public sector entities.  Reiterating its traditional
support for regulatory agencies, in 1984 the Organization sponsored
the formation of the Latin American Network of Official Drug
Quality Control Laboratories.  The Network's sphere of action was
extended to encompass drug registration and regulation by the
Ibero-American Meeting on the Registration, Inspection, and Quality
Control of Drugs, held in Madrid in 1991.
     Policies on the production and marketing of essential drugs
were a central focus of the XXIX Meeting of the Directing Council
of PAHO in 1984, an important event at which considerable time was
devoted to discussion of the drug situation in specific countries
of the Region, as well as at the level of subregional markets. 
Today the multinational nature of many PAHO projects in the area
of drugs is an outgrowth of the need to bring regulatory and
normative criteria into line in order to respond to the processes
of economic and political integration that are taking place in the
Region.  Most projects are carried out in the context of the PAHO
subregional initiatives involving the Central American and Andean
countries (the Plan for Priority Health Needs in Central America
and Panama and the Andean Cooperation in Health), which assign
priority to essential drugs.

Rational Use of Drugs

     With the advent of the 1990s, the rational use of therapeutic
agents has begun to occupy a prominent place in the policies of the
Regional Program.  In this context, one of the biggest challenges
facing PAHO is to overcome the enormous resistance of professionals
and the public at large to the use of generic drugs for purposes
of prescription, dispensing, and consumption.  In order to ensure
the correct utilization of therapeutic agents, it will be
necessary, basically, to modify the way in which physicians and
pharmacists are trained and to awaken in the latter an awareness
of their vital role as true experts.  In 1990 the first Pan
American Conference on Pharmaceutical Education was held in Miami. 
The declaration of principles regarding the role of pharmacists
that emanated from that Conference has led pharmacy schools
throughout the Region to undertake an in-depth revision of their
curricula.  In order to enhance education in this area, PAHO has
created various centers in Central America and the Andean area to
disseminate up-to-date information.  The Organization itself is
continually disseminating information through a variety of
publications, many of them widely distributed reference materials. 
Notable among these are the Spanish-language version of the eighth
edition of USP Drug Information for the Health Professional, which
comprises two volumes and is published under an agreement signed
by PAHO, the Convention of the United States Pharmacopeia, and the
Ministry of Health and Consumer Affairs of Spain.  This work is a
prestigious international source of information on drugs for health
professionals.

Looking Toward the Future

     The Regional Program on Essential Drugs continues to grow
rapidly thanks to its capacity and willingness to respond to the
true needs of the peoples of the Americas.  While at the outset the
Program was concerned chiefly with regulation, today its scope has
expanded to include all drug-related matters, from the selection,
purchase, distribution, labeling, and quality control of drugs to
their prescription and use.  Increasing multidisciplinary
involvement in this area poses a challenge for the future,
particularly in view of the difficulty of coordinating the
interests of all the sectors concerned, but it is precisely this
characteristic that will ensure vitality and progress.  The Latin
American Conference on the Economic and Financial Aspects of Drugs,
held in Caracas, Venezuela, in March 1992, was one of the first
clear demonstrations of the way in which the pharmaceutical and
economic sectors today are inextricably linked.
     The Regional Program on Essential Drugs receives ongoing
support from the WHO Action Program on Essential Drugs, the United
States Food and Drug Administration, the Canadian Health Promotion
Branch, the Ministry of Health and Consumer Affairs of Spain, and
the American Association of Colleges of Pharmacy (AACP), as well
as a number of other public and private entities in the member
countries.  The Program is funded mainly through extrabudgetary
funds from WHO and projects with donor agencies.  The
pharmaceutical industry also provides support through its national
and international associations.  It is difficult to predict exactly
what direction the Program will take in the future but its course
will undoubtedly be determined by the technical innovations and
epidemiological, economic, political, and ideological trends that
develop along the way.  It will almost certainly have to grapple
with the challenges created by the biotechnological revolution, for
example, as well as the growing incidence of chronic and
environmentally related diseases in the developing countries.  The
PAHO Regional Program on Essential Drugs has heretofore been, is
now, and will continue to be a valuable instrument for the
Governments of the Americas in their effort to secure health and
well-being for their peoples.
ILLUSTRATIONS FROM THE FLORENTINE CODE
(Scattered, no caption)

 PHOTO OF THE SPANISH-LANGUAGE VERSION OF THE U.S. PHARMACOPEIA 
     The Spanish-language version of the Eleventh Revision of
     the United States Pharmacopeia incorporated a number of
     changes which were the product of study and practice
     during the year and a half that followed publication of
     the original work.

PHOTO OF ILLUSTRATIONS OF "MIRACLE" PRODUCTS
(no caption)

PHOTO OF SLIDES 461 AND 472B
     The consumer is increasingly perceived as someone who
     demands to know what he or she is buying and who desires
     to participate in the programming of development and to
     contribute to the ongoing education process which is the
     basis of progress.  
Dr.  Abraham Horwitz               
Director of PAHO, 1959-1975

PHOTO OF SLIDES 996 and 001009
     Through its initiatives, PAHO is endeavoring to rectify
     the uneven distribution of pharmaceutical products
     between the public and private sectors.
PHOTOS OF SCIENTIFIC PUBLICATIONS 474, 462,
525, PNSP 88-29, PNSP 87-05 & PNSP 89-10
(no caption)

PHOTO OF SLIDES 521, 666
     Proper training of pharmacists is essential to the
     success of essential drug programs.  Training activities
     are currently a major focus of attention for PAHO.

PHOTO OF SLIDE 631
     It is counterproductive to have drugs expire on the shelf
     as a result of administrative inefficiency.  PAHO is
     devoting a great deal of effort to modernizing the drug
     supply and distribution systems in its member countries.
     
     PHOTO OF THE NATIONAL THERAPEUTIC FORMULARY OF COLOMBIA
     Essential drugs formularies are intended to help meet
     therapeutic needs in the health systems.  Consequently,
     they can be prepared for the entire health sector of a
     country, a specific health program, a rural dispensary,
     an urban clinic, a hospital, or any other health service
     unit.  Such formularies have been developed by the
     countries, with the collaboration of PAHO/WHO, in
     response to the need to control costs while at the same
     time assuring quality.

PHOTOS OF SLIDES 596, 599, 601
     Manufacture of pharmaceutical products at the national
     level and the use of generic drugs are two of the
     measures that PAHO is promoting in order to reduce costs
     and improve the availability of products.

E0258.FIN


  EVENTS AND/OR SHORT COURSES IN THE ENVIRONMENTAL HEALTH FIELD
WHICH WILL BE SUPPORTED BY PAHO IN 1992



COUNTRY:                                           


NAME:

OBJECTIVE:





DURATION AND DATE PROGRAMMED FOR EXECUTION:

LEVEL AND CHARACTERISTICS OF THE PARTICIPANTS:



NATIONAL ORGANIZING BODY (IF APPLICABLE):

CAN PARTICIPANTS FROM OTHER COUNTRIES BE ACCEPTED:                
     YES                     NO

IF YES, INDICATE WHERE THEY ARE TO REGISTER:


PAHO COLLABORATION:     1          2          3          4

STAFF MEMBER IN CHARGE:


     1.   Organization and Execution
     2.   Financing
     3.   Presentation of Classes
     4.   Material and Equipment
PAHO/WHO MEMORANDUM

Date: 5 June 1992

From:      H. Otterstetter, CP/HPE   To:  Those mentioned at
bottom*

Our Ref:   HPE/85/1/RC/141           Attention:

Your Ref:                            Subject:  Catalogue of
events and/or
short courses in
environmental
health field
(1992)

Originator:  R. Castro




     For your information, we enclose a copy of the catalogue of
events and/or short courses in the environmental health field
which will be supported by PAHO during 1992.  This document has
been prepared on the basis of the contributions from the
countries which appear in it.

     In order to supplement and keep this information updated,
and possibly to facilitate the participation of different
countries in the courses announced, we plan to publish new
editions next August and October.

     In order to be able to do this, we request your
collaboration in sending us the necessary information by the 15th
of the months indicated.  We will be grateful if you duplicate
and utilize the format which is included at the end of the
enclosed document for this purpose.

     Thank you for your attention.


Attachment
ANNEXES



     1.   Information on the PAHO Regional Symposium on
"Evaluation and Management at the Local Level of
Environmental Risks to Health."


     2.   Information on lodging.


     3.   Matters to consider in obtaining visas to travel to
Cuba.


     4.   Information on the XXIII AIDIS Congress.


     5.   Informative pamphlets on the courses to be given before
the AIDIS Congress.

1.   BACKGROUND

     In July 1972 the United Nations Conference on the
Environment, held at Stockholm, focused the world's attention on
environmental risks which threaten human health.

     Since then many countries and organizations have to a
greater or lesser degree made efforts to minimize such risks. 
Nevertheless, the impact on the environment caused by rapid
urbanization and population growth, together with industrial
development, has resulted in the magnitude of the environmental
problems which have adverse effects on human health increasing
instead of declining.

     In Latin America and the Caribbean, this situation has been
aggravated by the economic and social problems which many of the
countries are facing, negatively affecting their environmental
health policy, which in turn has produced an increase in the
number of health problems related to the environment.  The
epidemic of cholera which is affecting the Region dramatically
illustrates the severity of these problems.

     Although cholera had been identified as a problem of Asia
and later Africa, once the disease was introduced to Latin
America the existing deficient environmental situation provided
ideal conditions for its rapid dissemination.  Thus, the Region
began to pay a new debt, an Environmental Health debt which had
been accumulating during the past two decades through lack of
attention to environmental health problems.  If this situation
persists and increased attention is not paid to solving existing
deficiencies, we can only expect that public health problems
similar to those mentioned above will multiply.

     The European Charter on Environment and Health, signed at
Frankfurt in December 1989 by representatives of the countries of
that Region, points out "the vital importance of preventing risks
to health through the protection of the quality of the
environment."  It also recognizes the right of each individual to
live in an environment that permits him to achieve the highest
level of health and well-being.

     Throughout the developing world, however, the nature of the
problem is broad and complex, comprising multiple and
interconnected causes and many diseases.  For some countries the
greatest challenge in environmental health is lack of drinking
water; in others there are simultaneous and contrasting
situations such as those that occur under conditions of extreme
poverty and those due to intense economic development and
industrialization promoted by the urgent needs of a growing
population.

     Everyone's health is affected by the environment.  While new
concerns are arising in the urban environment, environmental
problems still persist in the rural environment.  Many
environmental pollution problems are not confined to the rural or
to the urban environment:  they know no geographical borders. 
Contamination of natural resourcesÐwater, air, and soilÐaffects
all.  Such problems also affect every social stratum:  rich and
poor eat contaminated food, drink unsafe water, and breathe
polluted air, but deterioration of the environment has a greater
impact on the poor, and women and children are exposed to greater
risk.

     Within this context, to speak of the framework for an
environmental health program is to speak of inter-professional
cooperation and community participation as pillars of activities
which will make it possible to improve public health.

     In view of the foregoing and especially the importance of
community participation for the success of activities which are
adopted to control the environmental risks at the local level,
the Pan American Health Organization has thought it desirable to
devote this Symposium to the subject of "Evaluation and
management at the local level of environmental risks to health."


2.   OBJECTIVES

To identify factors that help the community participate
in solving its environmental problems.

To generate guidelines which for the countries
facilitate the formulation of programs to control
environmental risks at the community level.


3.   PARTICIPANTS

Professionals from Ministries of Health, other sectors
of public and private entities, and ONGs which act to
protect and control the environment in the countries of
the Region of the Americas and the Caribbean.

Representatives from international cooperation agencies
which support the sector.

PAHO/WHO staff members.


4.   STRUCTURE OF THE SYMPOSIUM AND METHODOLOGY OF WORK

     There are three blocks of activities, with the objectives
and characteristics indicated below.

     FIRST BLOCK

     To present the principal environmental risks to human
health; recommend activities for their identification,
evaluation, and control at the local level, and mechanisms
applicable to the mobilization and social participation of
communities for environmental action.

     This block will be made up of conferences followed by a
discussion period.


     SECOND BLOCK

     To determine and analyze local experiences in management and
control of environmental risks, and to identify the factors
which, in such experiences, have contributed to community
participation in solving environmental problems.

     In this block the experiences of several countries and
institutions in developing integrated environmental health
programs at the local level will be presented through
conferences, highlighting community organization and forms of
action.

     In working groups, the participants will then analyze the
experiences presented and will attempt to identify factors
contributing to community participation.

     The final activity in this block will be a plenary session
in which the groups will present and discuss the factors they
identified.


     THIRD BLOCK

     Analysis and discussion in working groups of the items
presented in the two previous blocks.

     On that basis, and with their personal experiences, to
define the principal points which should be considered in
formulating and applying a plan to prevent and control
environmental risks at the local level, and identify recommended
strategies for its implementation, as well as the organizations
which should participate.

     Following the work of the groups, the results will be
presented and discussed at a plenary session and recommendations
will be formulated for intensifying the mobilization of the
community in solving its environmental health problems in the
Region.AGENDA OF THE REGIONAL SYMPOSIUM ON EVALUATION AND MANAGEMENT AT
LOCAL LEVEL OF ENVIRONMENTAL RISKS TO HEALTH
17-19 of November 1992
Havana, Cuba


17 NOVEMBER18 NOVEMBER19 NOVEMBERMORNINGOPENING

BLOCK 1

 Environmental risks

 Their identi-fication, evaluation, and control at the local
level

 Community mobilization for environmental action



 Local experiences in managing and controlling environmental
risks                        BLOCK 3

Work in groups

 Definition of main points of a plan to prevent and control
environmental risks at the local level

 Identification of strategies for implementation

 Recommendations BREAK (12:30-14:00)AFTERNOONContinuation.


BLOCK 2

 Local experiences in managing and controlling environ-mental
risks.                    Work in Groups


 Identification of factors contributing to community par-
ticipation in     solving its environ-mental problems
    


Plenary Session


 Presentation and discussion of results from the working
groups.                  Continuation of 
Work in Groups


Plenary Session


 Presentation and discussion of results from the working groups 


 Recommendations of the Symposium.


CLOSURE
ENCLOSURE II

INFORMATION ON LODGING


     In asking the PWR/Cuba and the Organizing Committee of the
XXIII AIDIS Congress to help reserve lodging for PAHO staff
members and participants in the Symposium which HPE will conduct
during the week before the Congress, we were informed that to
facilitate their transportation to the site at which the
Symposium will be held (the Palace of Conventions) it would be
necessary for all to be lodged in a single hotel.

     The options were analyzed and it was found that the most
desirable would be the Bio-Caribbean Hotel.  This hotel was
opened in 1991 and has very good facilities, and the meeting of
HPE/PAHO staff will be held in its conference room on 20 and 21
November.

     The Bio-Caribbean Hotel has set a special reduced rate for
the participants in the PAHO Symposium and has committed itself
to reserve the necessary number of rooms.  Since there will be
several international events with a high demand for lodging in
Havana in November, however, we were told that we should confirm
the total number of persons for whom rooms are to be reserved by
20 July.

     To be able to meet this requirement, it is necessary that
each PWR advise HPE by 15 July of the number of persons who will
travel to Cuba for the PAHO Symposium.  If PAHO staff members
travel with family members, they should indicate their number and
how many rooms they wish reserved for them.

     To facilitate Symposium participants remaining in Cuba for
the AIDIS Congress, an effort was made to diminish costs for
lodging, transportation, and feeding.  For this purpose, the
Organizing Committee of the Congress was asked to prepare a
"tourist package" including those items similar to the one it
prepared for persons who will attend only the Congress.

     The following pages include an informative pamphlet from the
Bio-Caribbean Hotel and the cost of the tourist package
coordinated by the Organizing Committee of the AIDIS Congress.

     Two options appear in the costs shown, the first for persons
who will attend only the PAHO Symposium, and the second for
persons who will remain in Cuba to the end of the Congress.  In
both cases, the cost of the tourist package has been calculated
taking into account the special rates of the Bio-Caribbean Hotel
for lodging and food, and transportation includes that from the
Hotel Bio-Caribbean to the Palace of Conventions and vice versa. 
The term "meals" in the enclosed information refers to suppers
since at noon the participants will be at the Palace of
Conventions and the cost of meals there will be paid at the time
by each person.  Depending on consumption, that cost may vary
from U$9 to U$20 each time.

     To facilitate coordination of transportation from the
airport to the hotel, the airline and day and hour of arrival of
each participant will have to be reported to the PWR-Cuba a week
before the planned date of arrival in Cuba.
ENCLOSURE III

ASPECTS TO CONSIDER IN OBTAINING VISAS
TO TRAVEL TO CUBA


1.   The PWR Cuba has offered to collaborate in obtaining visas
for all the participants in the PAHO Symposium.  To be able to do
this, it is necessary that each PWR send the PWR Cuba the
following data about each person at least 45 days before the
planned date of the trip:


Name and two surnames
Date of birth
Country of birth
Current nationality
Passport number
Place and date of issuance of the passport
Date of expiration of the passport.


2.   The place and/or way in which visas will be delivered to
participants in each country will vary according to whether a
Cuban Embassy or Interests Office exists in the country.  In
countries without such offices, the PWR in the country should
indicate for each person where the visa is to be delivered when
he or she transmits the data above, taking into account the
explanations in the following paragraphs.


3.   In countries where there is a Cuban Embassy or Interests
Office, the visa will be sent from Cuba to the Embassy or
Interests Office.  In each country, the PWR or the participants
themselves should collect the visa in that Embassy or Office.


4.   In countries in which Cuba does not have an Embassy or
Interests Office there are two options for delivering visas, and
the PWR in each country will decide which he or she considers
most desirable and will send that information to the PWR-Cuba.


4.1  The first option is applicable if the person traveling to
Cuba will make a stop in a country where Cuba is represented.  In
this case, the visa would be sent to the Cuban Embassy or Office
in that country and the participant would have to collect it
there.  Since the office hours of such Embassies or Offices are
Monday to Friday and in many cases only from 9:00 to 13:00 hours,
the PWR in each country should be sure on issuing the passages
that the person has sufficient time to collect his or her visa
before continuing to Cuba.

4.2  The second option is for persons who travel to Cuba
directly, that is, without making a stop in another country in
which they could collect a visa.  In this case, at least a week
before the date planned for the trip to Cuba, the PWR in each
country should advise the PWR-Cuba by telex or fax of the
following:

Name of the person
Name of the airline on which the person is traveling
Flight number
Date and hour of arrival in Cuba

     This will allow a staff member of the PWR-Cuba/International
Relations, Ministry of Health, to take the visa to the airport
and deliver it to the person on his or her arrival.

     Each PWR should pay heed to the fact that if the PWR-Cuba
does not receive the data indicated early enough and as a result
the visa cannot be taken to the airport at the time the
participant arrives, he or she may be returned to his or her
country of origin by the immigration authorities.

     It will also be desirable that the PWRs inform participants
that on arriving at the Havana airport, they may present
themselves at any of the immigration control windows since prior
to the arrival of the flight the staff member of the PWR-
Cuba/Ministry of Health who has their visas will have given their
names to the officials at the windows and will remain nearby. 
When the immigration official receives the passports of any of
the persons on his or her list, he will ask the PWR-Cuba staff
member to deliver the visa for that person.

5.   So that persons who are to be given visas at the Havana
airport do not have difficulties in boarding the airplane on
which they will travel to Cuba, it is suggested:

That the PWR in each country provide them a
document stating that their visa will be at
the Havana airport.  This might be a copy of
the communication sent to the PWR-Cuba
requesting that the visa be obtained or,
better still, a copy of the response from
the PWR-Cuba.

6.   PAHO staff members who plan to travel to Cuba with family
members should send the PWR-Cuba the data specified in item 1 at
least 45 days before the date planned for the trip to Cuba.  To
collect the visa they should take into account the items above,
depending on whether there is a Cuban Embassy in their country.

7.   The Organizing Committee of the Congress advised us that
there is a third option for obtaining a Cuban visa.  This option
is applicable in countries where there are travel agencies that
represent to the Palace of Conventions in Havana.  Since both the
Symposium and the Congress will be held at that site, persons who
will attend them may obtain a visa through such agencies.  For
this purpose they would have to contact such agencies far enough
ahead of time and to make all their travel arrangements through
them (purchase of passages, etc.).

     If this option is exercised, it would no longer be necessary
for the PWRs to send the passport data to the PWR-Cuba as the
travel agency would be responsible for the pertinent
transactions, but they should report to this HQ by 15 July the
number of persons who will travel so that we can make hotel
reservations.  In contacting a travel agency, they should
indicate that reservations are already available at the Bio-
Caribbean Hotel.

8.   The option noted in the item above could be utilized in the
following countries:  Argentina, Barbados, Bolivia, Brazil,
Chile, Colombia, Costa Rica, the Dominican Republic, Ecuador, El
Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Peru,
Uruguay, and Venezuela.  The names and addresses of the agencies
to which they can be directed are given on the next page.

9.   As noted in paragraphs 1 to 6, all information relative to
visas should be sent to the PWR-Cuba.  If it is urgent to
communicate on a Saturday or Sunday to request or send visa
information during the month before the Symposium, however, such
information may be sent by telex to the following number: 
512144-HIGEPCU, attention Dr. Luis Muñoz, Ministry of Health,
Havana, Cuba.  Dr. Muñoz, who is accustomed to go there on
weekends and is responsible for International Relations in the
Ministry of Health though assigned to the PWR-Cuba, will be
responsible for coordinating visa procurement for persons who
will attend the Symposium.ENCLOSURE IV

INFORMATION ON THE XXIII AIDIS CONGRESS
ENCLOSURE V

    INFORMATIVE PAMPHLETS ON COURSES BEFORE THE AIDIS CONGRESS
Provisional Agenda Item 6.3                       CE109/25 (Eng.)
8 June 1992
ORIGINAL: 
SPANISH




INITIATIVE FOR THE ESTABLISHMENT OF
A PAN AMERICAN INSTITUTE OF BIOETHICS,
TO BE LOCATED AT THE UNIVERSITY OF CHILE


     The Director wishes to make the Executive Committee aware of the conversations
in which he has been engaged with the Government of Chile and the University of Chile
in regard to the important and increasingly current topic of bioethics.  In particular, the
dialogue has centered around the interest and possibility of pooling efforts to institute
formal activities in this area within the Organization, in association with the University
of Chile and with the support of the Ministry of Health.

BIOETHICS, THE ETHICS OF LIFE
     
     The technological revolution in the biological and medical sciences has produced
spectacular results while also sparking a revolution in thinking, conceptual traditions,
human values, and the notions of life, health, and death.  Organ transplants, genetic
engineering, artificial means of reproduction, euthanasia, ethics committees, and doctor-
patient relationships are current-day issues that have given rise to moral dilemmas which
are the object of academic and public concern and which are increasingly the focus of
articles in scientific publications, journals, and newspapers.

     The discussion surrounding this scientific-technological and cultural phenomenon
has shaped the field of bioethics (bios life + thik ethics) as a new professional and
multidisciplinary area of study and research.  Bioethics is not a new discipline, nor is it
a specialty within a particular discipline or profession.  No discipline or profession
appears to possess all the resources needed in order to address the political, economic,
social, biomedical, legal, ethical, and value-related dilemmas involved in bioethical
issues.  The development of bioethics is, without a doubt, a manifestation of a universal
cultural movement which in turn is an outgrowth of the concerns awakened by
progress in the area of biomedical technology and by the conflicts created by
progress and its application vis-Õ-vis basic human values, as well as its effect on the
health care of populations.

     Bioethics is being debated in every corner of the world.  In the developed countries
the debate began slightly more than two decades ago, and the proliferation of centers,
institutes, and national commissions on bioethics is clear evidence of the timeliness and
importance of this topic.  In Latin America, within universities, professional schools, and
other nongovernmental entities, there is a growing trend toward the organization of groups
concerned with bioethics.  In an isolated and fragmentary manner and with limited
resources, especially in terms of information, such groups are considering a number of
bioethical issues in response to growing public interest in this area.

     Medicine and health care have heretofore been and will always be social practices
with a profound humanistic and moral content.  As science and technology broaden the
capacity to intervene in the processes that determine or modify the life of individuals and
societies, there will be an increasing need to subject their use to ethical considerations. 
Bioethics is the challenge of the present that will reach into the future.
     
     BIOETHICS WITHIN PAHO

     Over the last several years the Organization has been exploring the subject of
bioethics. Its efforts thus far have been modest but have nevertheless had a significant
impact:

     (a) The publication of special issues of the Boletín de la Oficina Sanitaria
Panamericana and the Bulletin of PAHO devoted to bioethics (vol. 108, nos. 5 and 6, May
and June 1990, in Spanish and vol. 24, no. 4, 1990, in English) with a pressrun of some
11,000 copies, which was quickly exhausted, marked an important milestone in the
Region.  These issues of the Boletín are being utilized as study texts in numerous
universities and are being consulted as essential reference materials.  The content of the
Boletín was reprinted in Scientific Publication No. 527: Bioética - Temas y perspectivas
(1990) (also published in English:  Bioethics - Issues and Perspectives (1990)), which
have been as successful as the Boletín articles.

     (b) Scientific Publication No. 530, Aportes de la ética y el derecho al estudio del
SIDA (1991) (in English:  Ethics and Law in the Study of AIDS  (1992)), financed in part
by a generous contribution from the Federal Centre for AIDS in Canada, contains the
results of a successful Regional Consultation on the subject, held in Santiago, Chile, in
October 1990, with financing from the WHO Global Program on AIDS. 

     (c) Participation in specialized conferences and meetings on bioethics as a very
partial response to the numerous requests and invitations that are received.

     (d) Information and opinions about bioethical issues in response to requests from
government and university entities and individual investigators. 

     (e) Articles in specialized journals.

     (f) Organization of a data base with information on individuals and institutions
concerned with bioethics;

     (g) Institutional contacts with the principal centers and institutes of bioethics
throughout the Region and in the rest of the world.



ESTABLISHMENT OF A PAN AMERICAN INSTITUTE OF BIOETHICS
(BioEtica)

     A fundamental principle in the discussion of bioethics is that the criteria,
approaches, and solutions proposed must be consonant with the cultural context,
traditions, and institutions of each society.  In order to ensure that the conceptual and
applied development of bioethics in Latin America and the Caribbean takes place in an
informed, objective, and fruitful way, it would appear desirable and necessary to establish
an independent and pluralistic institution to carry out the functions of coordination,
cooperation, and support within a framework of international academic cooperation.

     A proposal has been advanced for the establishment of a Pan American Institute
of Bioethics (BioEtica), to be located at the University of Chile.  BioEtica would be a
program of study, research, training, cooperation, and international advisory services in
bioethics, as a Pan American institute under the administration and supervision of
PAHO/WHO, and at the same time it would be an academic, research, and extension
program in bioethics under the University of Chile.  BioEtica's dual role as a Pan
American Institute and a program of the University would be defined under an agreement.


     The Institute's mission would be the conceptual, normative, and applied
development of bioethics and the study of its relationship to health.  It would provide an
international, academic, pluralistic, independent, multidisciplinary, and professional
environment in which to carry out studies, technical discussions, research, education and
training, and dissemination of information on topics relating to bioethics, as well as to
develop and implement intercountry programs, projects, and activities and to provide
cooperation and advisory services in this area.
     
     BioEtica's functions would include the preparation of studies and reports, research,
education and training, dissemination of information, and advisory services and technical
cooperation in bioethics.  The foregoing would involve the analysis of bioethical issues
from a technical and ethical standpoint, taking into account the political, economic, social,
legal, cultural, and value-related dimensions in general and as they pertain specifically to
health care and medicine in the societies of Latin America and the Caribbean. 

     The Government of Chile would act as the host country, with the University of
Chile furnishing the academic and logistic facilities and the Organization providing the
international institutional framework in the form of a Pan American Institute.


     SYNOPSIS
     
     There is no doubt that bioethics is a signal concern of the present decade.  At the
academic and government level, and in the public mind in general, bioethical issues are
attracting more and more attention.  There is an increasingly urgent need for training,
research, dissemination of information, and technical cooperation. 

     The Director considers that this field of study, research, and reflection is
manifested in both the conceptual development and the application of bioethical
principles, orientations, and criteria.  The development of bioethics has a direct impact on
the social practice of medicine and health care, from multidisciplinary and
multiprofessional perspectives.  In this context, bioethics should have a place among the
activities of the Organization.

     The Director requests that the Executive Committee express its reaction to this
initiative for the establishment of a Pan American Institute of Bioethics (BioEtica), which
has the enthusiastic interest and support of Chile and which responds to a pressing need
that is of utmost importance for the health and well-being of the people of the Region.



DEMOCRACY, DEVELOPMENT, AND HEALTH



The relationship between Development and Health in Latin America is a complex one that
is dictated by interactions between the Development Model, the particular type of political
regime, and health.

In order for there to be Development there must be Democracy, since the former concept
is accepted to mean growth in the context of equity.  This in turn means that social
distribution must be a political function and that therefore certain mechanisms are needed
in order to guarantee both social and political participation.

Thus it will be necessary to institute processes to reinforce the social and political actors
who are in a position to generate, at the heart of the State, a negotiation space par
excellence--a balance of power between the interest groups affected in order to ensure that
they will encourage negotiation and the search for solutions based on consensus.

In this sense, liberal Democracy, as a political regime, emerges as a necessary and
sufficient condition for guaranteeing economic and social development in the medium and
long term.

It is desirable that there be a certain degree of development on the part of the various
social and political actors so that out of divergence the need for consensus will arise. 
Whenever the State (an Authoritarian State) imposes constraints that inhibit the
participation of some of its members, this promotes authoritarian-type solutions which in
the long run pervert the mechanisms of distribution and encourage, more than ever,
corporatist policies within the State.

The changes that have taken place in the Region in the last two decades have been the
result of failures in the implementation of developmentalist models which made it
necessary to suspend the development processes under way--processes based on local
industrialization (import substitution) and derived from the concept of a benevolent
redistributory State built on a foundation of liberal democracy.  The CEPALINO models
of the 1950s and 1960s contended that development in the Region necessarily called for
modernization and democratization of oligarchic societies that had found their expression
in populist States and corporatist and clientelist policies.

In order to achieve these objectives, it was proposed to broaden the urban and middle-
class base, and it was recognized that the extension of Social Policies was the means with
which to achieve this goal.

What in fact has happened, according to some authors, is a breakdown of the political-
economic structure that prevailed in many of the Latin American countries from the
beginning of the 1930s up until the 1970s (Cavarozzi, 1991)--the so-called state-
centered model.

From the political standpoint, this meant having to interrupt the political processes that
were keeping changes from being introduced (Argentina, Chile, Brazil and Uruguay), and
establishing what amounted to a new balance of power, which modified the nature of the
State.

At the end of the 1970s a number of factors (which will not be itemized here) came
together to force a reassessment of the democratic processes that would be needed in order
to ensure social peace, political stability, economic growth, investment, and the
development of social policy--concepts that set the tone for elections in Argentina, Brazil,
Chile, Ecuador, Paraguay, Guatemala, Honduras, and Uruguay during the 1980s.

But these Democracies emerged in the context of a series of new requirements:

·    To maintain the country's position in the international market

·    To guarantee social reproduction

·    To provide stability in order to give economic reforms a chance to be explored

·    To promote political reform within the State (reduction of the State apparatus)

·    To guarantee human, civil, and political rights


The responsibility vested in the regimes was great, and even in the partial list above we
can see that some of the objectives are inherently contradictory.

The crisis that arose in the Region during the 1980s was not limited to the economic
sphere; it was also seen in social and political symptoms of a structural nature. 
For example:

a)   The exclusion of certain key actors from the construction of Latin American
     societies;

b)   The inability of others to mount national-level initiatives that would rally the
     majority of the population;

c)   The resistance of traditional political parties to being restructured and democratized
     in order to adapt to the new political and social conditions in their societies, etc.

We should recognize two elements that were crucial to the changes taking place at the
level of the social actors.  The first is the significant contribution of the authoritarian
states--particularly the traditional ones and those associated with the protection of labor
interests such as unions and guilds--to the restructuring process.  The second is the failure
or lack of viability of the alternative social models that were being advanced by these
groups at the ideological level in a process that culminated in the crisis in the East in the
late 1980s and early 1990s.

But these constraints in themselves helped to set the stage for the appearance of other
actors, for a shift in their scene of struggle, and for the introduction of new issues on their
agendas.

Particularly in those countries that emerged from dictatorships during the 1980s, the
democratic struggle has engendered social movements aimed at the assertion of civil and
political rights, and specifically at the extension of individual rights in the areas of health,
education, housing, and the like, to broad sectors of the population--sectors that are highly
heterogeneous in terms of both class and political affiliation.

Thus a sort of interplay emerged involving, on the one hand, the actions of the Political
System, which usually reflect demands that are more structured and more tied to the
assertion of formal rights, and, on the other hand, those of the social movements, which
tend to relate to the substantive nature of the processes.  The outcome was to be a hybrid
that merged the characteristics of both political democracy and social democracy.

It must be acknowledged that this interaction has helped to advance the transition and
even to consolidate many of the claims that have been being asserted for as long as two
decades--e.g., the affirmation of human rights (in Argentina and Uruguay) and the
processes of constitutional reform which have served to broaden the concept of
citizenship, as the case of Brazil and Colombia.

It is often mistakenly assumed that economic decisions are entirely independent of
political decisions, since they are subject to natural laws that are beyond political
intervention.

In this view, the rising foreign debt service, the cutbacks in investments, and the
reductions in external savings are presented as phenomena that simply happen, whereas
in the political and social realms there are decisions that must be made.  These latter, in
turn, lead to increased unemployment, deterioration of public services, progressive loss
of State regulatory capacity, growth of the informal sector, increased violence, and
weakened social ties--all of which, along with other factors, have come together to
produce the serious social symptoms of the crisis.

If we approach this explanatory and analytical process from another angle, making an
effort not to lose sight of the process as a whole, we will see that these alterations have
taken place as a series of chain reactions, each constituting a milestone in the political
social and economic transition that is taking place in the societies of Latin America.  The
rise of authoritarianism, the constitutional-institutional shutdown, the prevalence of neo-
liberal views in the civilian and military leadership, the restriction of civil and political
rights, the trend toward democracy, the so-called "adjustment programs"--each of these
has been a phase in the construction of an alternative development model which is yet to
take final form.  Indeed, what we do see--namely the changes taking place within groups
and in the relationships between the dominant and subordinate sectors of society-
-are merely the tip of the iceberg.

The Latin American democracies, although they are opening up spaces for political
participation, are experiencing problems with regard to social participation, with the result
that in some cases the great majority of the population is excluded, and thus they are
revealing a certain incapacity to achieve not only political but also social stability.

In the words of former Argentine President Raúl Alfonsín, in his address at the opening
session of the Argentine Legislature in May 1988, the great challenge faced by the new
Latin American democracies is to meet the demands of society that have been pent up
over the last decade and at the same time to cope with the crisis and steer the restructuring
of the development models" (PAHO, 1990).

The political parties of today are not always able to serve as effective instruments for the
changes that are taking place in society, and hence it often happens that at the level of the
State the dominant groups govern without mediation.  There are innumerable cases of
cabinet members, advisers, and high-level public officials who have risen to their
positions not through any strong political mandate but rather through long association
with national and international economic groups.

There is yet another facet of the shifting dynamics in the strategies of the groups in power: 
attitudes are pervading the political system, sometimes even through parties of long
existence and tradition, that would tend to set aside populist practices and conceptions in
favor of an increasingly tecnocratic and pragmatic perspective.

The effects of this phenomenon are not measurable, but there appears to be a certain lack
of confidence in the ability of the parties to represent the entire population--as evidenced
by the frequent changes in government, the reduced political participation, and the
reappearance of charismatic leaders outside the party structure (Collor, Fujimori).

In 1991 and again in 1992 there have been a number of alarming signs such as the coups
that took place in Haiti, Peru, and the failed attempt last February in Venezuela.

We believe that the growing dissatisfaction of broad sectors of society and the frustration
of their aspirations in life and in the workplace can lead to the breakdown of institutions
and a loss of confidence in the democratic system.

The new democracies have emerged under the hegemony of neoliberal economic models,
but what is more important, they are also dawning in the context of new international
order.  This latter implies new economic, political, and military relationships between the
developed and the developing nations, and it calls for a world in which the alignments of
power are no longer bipolar but rather multicentric.

Some of the new factors that are conditining the democratic processes that we cited above
and serving as limitations to the consolidation of political and social democracy are:

1.   The budgets of the social sector.

2.   The rate of turnover at the cabinet level.

3.   A shift away from the 1970s concept of a single national health system.

4.   Deterioration of the social security systems.

5.   Emphasis on policies leading to privatization and on programs targeted toward
     groups at risk.

From among these factors, let us take a look at the structure of the System.  In the late
1960s and early 1970s the concepts of a National Health System and a Single Health
Service began to be called into question.  Despite the fact that this discussion was taking
place in several different countries--Brazil, Chile, Colombia, Costa Rica, Peru, and
Venezuela--certain shared aspects are worth mentioning.  First, the question of
reorganizing the sector had not reached the level of political debate; in other words, it had
not gained sufficient momentum to become an organized demand, even though the issue
was being vigorously addressed by state and public health officials who were pressing for
proposals that had been advanced by associations of health professionals and health
workers.

The interruption of democratic life, the economic crisis, and the nature of the project itself
(which was too socializing, inasmuch as it gave the State an important role in financing)
conspired to defeat the chances for this undertaking to become a topic on the countries'
political agenda.  Indeed, only in Cuba was it possible for the proposal to take concrete
form, and that was because the country offered political conditions that were very
different from those prevailing in the the rest of the Region.

Indeed, the restructuring of the sector began to materialize thanks to changes that were
happening on the outside, as a result of actions taken in the context of economic
programs.  In fact, at the end of the 1980s it began to be seen that the organization of the
sector's institutional network was undergoing a change:  it might even be said that there
was a return to the same problems except that this time what was basically being proposed
was a regulatory role for the State coupled with a system of financial and institutional
pluralism that neatly paralleled the trend toward privatization that was being promoted by
several of the governments and which had also permeated the production of services.


Conclusions

If Latin America and the Caribbean manage to find their niche in this context, it will be
thanks to their capacity to negotiate and to achieve an economic position for themselves
within the new order.

Thus the democracies are setting the stage once again to guarantee the existence of these
conditions (conditions that are necessary but not sufficient) and to ensure that there is an
internal reassessment of certain issues, such as health and social education, and of certain
spaces, namely the legislature.
SITUATION OF MATERNAL AND CHILD HEALTH
IN THE REGION OF THE AMERICAS


An epidemiological analysis of the Region of the Americas reveals that
children, adolescents, and women, especially those of fertile age, are the most
vulnerable groups--in other words, those at greatest risk of becoming ill and dying. 
The importance of their health status can be seen when it is considered that:

  ·        The three groups together correspond to 70.6% of the population of Latin
America and the Caribbean, or more than 316 million inhabitants;

  ·        Each year more than 500,000 children under 1 year of age and about 28,000
women are dying from complications associated with pregnancy, delivery,
and puerperium;

  ·        Most of these deaths could be avoided through the use of existing low-cost
technologies that are highly effective.

Although the trend in infant mortality over the period 1950-1985 shows an
overall reduction of 45.5% for the Region as a whole--62% in North America and
49.6% in Latin America--it needs to be emphasized that in the latter area mortality
is 63 per 1,000 live births, or four times greater than the rate of 11 per 1,000 for
North America.  Within Latin America the differences between the countries is very
marked, with extremes ranging in 1990 from 10.7 per 1,000 live births in Cuba to
122 and 100 per 1,000 live births in Haiti and Bolivia, respectively.  There are also
wide variations between the regions within a single country.

The causes of infant mortality are yet another example of the
"epidemiological heterogeneity" that characterizes the Region.  Whereas in Chile,
Costa Rica, and Cuba the leading causes are perinatal complications, followed by
birth defects, the leading causes in the majority of the countries still include
intestinal infections, acute respiratory infections, and diseases preventable by
vaccination.

The intermediate variables that have been identified as factors most closely
linked to infant morbidity and mortality are:  nutrition; those associated with public
health and sanitation; accidents; knowledge, values, and beliefs; condition of the
child at birth; and factors related to the mother (years of schooling, age, etc.). 
These last point to the imporance of considering the two groups together both in the
analysis of their health conditions and in the design of interventions.

As with infant mortality, the situation with regard to maternal mortality is also
varies widely.  In 1988 maternal mortality in North America was 12 per 100,000 live
births, whereas in Latin America it was 200 per 100,000.  In Bolivia the rate is 120
times higher than in Canada, which has the lowest mortality in the Region.

It can be seen that the countries with higher rates of maternal mortality are
also those that have a smaller proportion of institutional deliveries.  In the countries
where this correlation does not obtain, the mortality rates are explained by
deficiencies in the quality of delivery care.

The principal causes of maternal mortality, like those of infant mortality, can
be avoided through the application of relatively simple health actions.  The problem
is lack of equity:  the great majority of the unserved social groups, which are
precisely those most vulnerable to adverse health conditions and those most
affected by the economic adjustments, do not have access to these technologies.

Although it can be seen that infant mortality has declined in the Region in
recent years, the severity of the current economic, political, and social situation and
the outlook for the future imply a serious threat to the progress that has been made
so far.

Obviously, levels of health are largely determined by degree of economic and
social development.  Although the economic crisis of the last decade was partially
offset by real progress in maternal and child health interventions, it is still necessary
to redouble efforts in order to expand coverage and disseminate these low-
cost, high-impact technologies and also to develop new responses to the situation
that looms ahead as a result of the economic adjustments--which do not have a
very "human face"--and to the the changing epidemiological profile in the countries.

Although it has already been said many times before, it is nevertheless still
true that a people's hopes for future development depend on its children.  Not to
care for them is to mortgage the countries' hopes.

16 June 1992


Article for the PAHO Epidemiological Bulletin 
HEALTH PROMOTION 

     Helena E. Restrepo, Coordinator, HPA

     The Program for Health Promotion in 1990 was adopted during the XXIII Pan
American Sanitary Conference as one of the Strategic Orientations for the work of the Pan
American Health Organization (PAHO) during the Quadrennium 1991-1994. (1).

     This orientation is very clear in stressing that health promotion "is increasingly
conceived as the sum activity of the population, the health services, the health authorities,
and other productive and social services, aimed at improving the status of  individual and
collective health." 

     Together with the Ministry of Health and Social Welfare of Canada and the
Canadian Public Health Association, in organizing the First International Conference on
Health Promotion in November 1986, the World Health Organization took the final step,
as it had with regard to Primary Health Care and Health for All by the Year 2000, in
establishing the strategy of Health Promotion in the Charter of Ottawa, (2), a product of
the Conference that briefly summarizes the principles of public health for the development
of health as opposed to medical interventions, which are limited solely to disease.

     In accordance with the definition contained in the aforementioned document,
"health promotion is the process of enabling people to increase control over, and to
improve, their health." 

     Renewal of these concepts in 1986 denotes a landmark in the history of modern
public health in declaring, as fundamental requirements for health, "peace, shelter,
education, food, income, a stable ecosystem, sustainable resources, social justice, and
equity."

     Also worthy of note in the proposal is the recognition that health promotion is not
solely a responsibility of the health sector.  On the contrary, it is only through intersectoral
action that success can be achieved in attaining acceptable health levels among the
population.

     The concept of health promotion encompasses diverse, albeit complementary,
fields and approaches, which include education, information, mass communication,
legislation, policy-making, community organization and participation, and efforts
designed to reorient the health services.

     These principles and approaches are not actually new to public health work.  The
history of medicine and of public health is rich in the contributions made by many
scientists to the social causes of disease or, more precisely, the partial or total loss of
individual and community well-being.  Cabanis, in the period following the French
Revolution, proposed his well-known aphorism:  "Les maladies dépendent des erreurs de
la societé" (3).  A reading of the recommendations made in the last century by Virchow
(4) for eradicating typhus epidemics shows a startling similarity with current proposals
for health promotion:  The remedy is complete and unlimited democracy or education,
freedom and, prosperity.  A great number of authors could be cited who have recognized
the determinants of health in the various social sectors and who have criticized the
solutions proposed by the various political actors.

     The challenge has always involved moving toward action, and even more so
preparing the health sector for such action.  At this point the Ottawa Charter becomes
useful again in defining five operational areas for implementation of the strategy:

     .    Build health public policy 

     .    Create supportive environments 

     .    Strengthen community action

     .    Develop personal skills 

     .    Reorient health services

     Mechanisms and lines of action for work in these areas will assist in reorienting
public health toward reaching targets and objectives more likely to improve the living
conditions and, obviously, the health of the population.  These areas form the bases for
developing work patterns that will contribute to improve the circumstances and lifestyles
that influence health (2).

     Consequently, it becomes clear that health promotion, in the final analysis, refers
to health in development and is a strategy that makes it possible to seek a greater
commitment on the part of all to improvement of the quality of life and of the
environment in which we live.

     Health promotion thus forms part of the political area of the various sectors and
levels, which constitutes one of its greatest successes and a significant advance in
bringing about the action desired; similarly, from a positive perspective, the concept of
work for health is incorporated into the daily life of the individual and the community as
a whole.  In addition, health is considered as a resource for the development of the
peoples of the Americas, and a high value is thus assigned to human capital.

     The responsibility of the health workers should include a search for the general
welfare that extends beyond changes in lifestyles, and it should also include this important
area of positive changes in order to avoid the risks associated with them. 


IMPLEMENTATION MECHANISMS

     Several mechanisms have been identified in the programs and activities for health
promotion with the aim of strengthening the participation of the people in health
interventions at both the individual collective levels.

     Thus, for example, education, as an instrument for changing human beings, plays
an important role in transforming living conditions and bringing about changes in
unhealthy behavior.  However, health education is a problem for the health sector in that
its success also depends on the commitment and effectiveness of the education sector. 
Health and education, jointly, should apply methodologies to inform and educate adults,
and also to create attitudes and less risky lifestyles for the generations to come. 

     In taking into account the importance of health education and information, PAHO
also defined "Using Social Communication in Health" (1) as a complementary and
empowering strategic orientation for health promotion. 

     The provision of health information and knowledge to the population and the
promotion of community discussion on the needs and alternatives to be considered in
seeking the common welfare reinforces the principles of health education and the
democratization of scientific knowledge.  The purpose of this orientation is to capture the
interest of both the specific workers in the sector and of the social and political sectors in
order to obtain their support for the changes that will help the population to attain higher
levels of health.

     One of the major challenges for the health sector today is the design of information
programs and materials for the entire population, those educated formally and those who
have not had the privilege of formal education.  The methods and techniques of social
communication, which were developed for other purposes, have an enormous potential
for application to health.
     
     It is worthwhile mentioning briefly some of the interventions in the industrialized
countries that have been successful in changing the behavior or lifestyles currently
associated with major health problems, such as non-communicable diseases, accidents and
traumas, and addictions to substances harmful to health. 

     Among these interventions are school education, which seeks not only to provide
health knowledge to children and adolescents, but also to change their behavior so that
they will resist external pressures from their peers to lead them to hazardous consumption
and behavior. 

     Another of the successful interventions are the specific activities of social
communication, such as use of the mass media, which is reinforced with interpersonal
communication and "behavior models" selected from within the community to exemplify
healthy behavior.

     Community organization is decisive and involves a process of strengthening the
mechanisms of natural participation of the communities in jointly analyzing health
problems and searching for solutions among representatives of the sector and
representatives of the various formal and informal groups.  In the English-speaking world,
the "advocacy" approach is often used, which in the final analysis seeks to create a climate
of social conscience with regard to a given problem, thereby facilitating political decision
and, above all, supporting its implementation.  The best example of this is the campaign
against smoking, which, inter alia, in creating a collective conscience regarding its effect
on health, promotes regulatory action to protect nonsmokers and enforce legislation
against advertising. 

     Interventions at the community level should be supported by public policies, both
at the national and local levels. 

     Regulatory policies, tax increases, regulation of the food industry, and protection
of the environment, among many others, are indispensable in the task of promoting health. 
This must not be overlooked, and it is very important that it be incorporated into the
health sector and into the actions of health workers in coordinating the efforts of a variety
of sectors.


DEVELOPMENT OF THE STRATEGY

     Development of the strategy of health promotion requires strengthening the health
infrastructure.  The new tasks that are added to public health activities concerned with
noncommunicable disease prevention and associated risk factors, together with the
intersectoral activities that must be carried out to improve health levels, demand both
human and financial resources.  This should be taken into account to an even greater
degree in the developing countries, where the economic crisis has left very little
opportunity for investing resources in preventive activities and where the expenditures for
curative services, which are also necessary, are becoming increasingly burdensome. 

     Reorientation in the training of human resources is urgent in order to devise public
health approaches that are consistent with health promotion. 
     
     Health policies also require important changes, especially with regard to providing
a true response to the most outstanding problems.  Illustrative of this is the fact that in
countries where cardiovascular diseases clearly number among the most urgent health
problems, no policies are being formulated to diminish their frequency.  For this reason,
the need is emerging to correlate health planning with epidemiological analysis to a much
greater degree.

     The resources and approaches of the health programs should be reoriented so as to
utilize epidemiology to a much greater extent, not only for the purposes of planning in the
health sector but also for planning in other sectors that are concerned with the determining
factors of health conditions and, consequently, of development.  Again, the need for
intersectoral action is immediately apparent at all levels of action.


PAHO PROGRAM ON HEALTH PROMOTION 

     In 1991, the Program, theretofore called Health of Adults, became the Regional
Program on Health Promotion, introducing certain structural and functional changes
through the strengthening of the components of social communication and management
of information.

     The mandate for the Program includes application of the strategy of health
promotion in several technical fields that fall within its purview and collaboration with
other units and programs in assimilating operational concepts, principles, and mechanisms
to implement the strategy in the member countries.  Insofar as the specific technical
aspects of the Program are concerned, health promotion is an axis that serves to articulate
approaches to highly prevalent problems in most of the countries in the Region, such as
the noncommunicable cardiovascular diseases, cerebrovascular diseases, cancer, chronic
respiratory diseases, mental disorders, drug abuse, and traumas and accidents.  In addition,
the Program has been assigned the technical responsibility of helping to improve the
quality of life and well-being of special groups, such as the elderly, and to promote human
development through better mental health.

     Generally speaking, unhealthy lifestyles are closely related to the technical fields
mentioned, and consequently any effort to change them is of great importance in this
Program.

     For the purpose of implementing the new orientations of the Program, lines of
action have been formulated that are directed toward garnering support in the countries
for implementing community-based programs aimed at reducing the morbidity and
mortality associated with the problems mentioned above, together with programs that
promote the formulation of policies, plans, and programs to improve the quality of life of
the population, both adult and elderly.  High priority is being assigned to the mass media
and the dissemination of information to mobilize the population in the search for
alternative healthy behavior.

     Approaches and mechanisms for health promotion may also be identified in other
PAHO programs and in interprogram activities that emphasize the role of health in
intersectoral work for the development and improvement of the living conditions of the
population.  Cholera is a good example of this type of work.  The catastrophic situation
revealed to all by the epidemic of cholera, which the Director has framed within the
context of the interrelationship of health development (5), has made it possible for the
Organization to analyze more clearly the fundamental and historical role it should play
in implementing the principles of health promotion in the countries.

     The Healthy Municipios movement that is being organized in the countries with
the assistance of PAHO is another clear-cut example of work for health promotion that
is paving the way to new forms of conceiving and developing public health actions.

     Health promotion, together with disease prevention and the recovery of well-
being, are the challenges that lie before us and for which we must assign rational priorities
and organize resources efficiently and effectively.


REFERENCES

1.   Pan American Health Organization.  Strategic Orientations and Program Priorities,
     1991-1994.  Resolution XIII of the XXIII Pan American Sanitary Conference. 
     CSP23.R13, 1990.

2.   Ottawa Charter for Health Promotion.  An International Conference on Health
     Promotion:  Toward a New Concept of Public Health.  World Health Organization. 
     Ministry of Health and Social Welfare of Canada.  Canadian Public Health
     Association, Ontario, Canada, November 1986.

3.   Cited in Ackerknecht, Erwin H. "Rudolf Virchow:  Doctor, Statesman,
     Anthropologist."  The University of Wisconsin Press, 1953.

4.   Ibid (3).

5.   North-South Center.  Confronting Cholera.  The Development of a Hemispheric
     Response to the Epidemic.  Proceedings of the Conference, A Global Response to
     Cholera, Co-sponsored by the Pan American Health Organization and the North-
     South Center.  University of Miami.  8-9 July 1991.

PAHO-WHO/FAO/USFDA/USAID

       III INTERNATIONAL COURSE ON MICROBIOLOGICAL ANALYSIS
OF VIBRIO CHOLERAE IN FOOD

Martínez, Prov. of Buenos Aires, Argentina
15-19 June 1992

Justification:

The cholera epidemic in the Americas has given rise to more than 300,000 reported
cases, 158,000 hospitalizations, and 3,897 deaths (as of January 1992) in several countries
in the Region.  It is known that cholera is transmitted through contaminated water and raw
or improperly prepared food.  Many experts believe that this disease can recur as an
epidemic disease or that it can be established endemically.  There is concern that the
disease will spread to the entire Region.  With the cooperation of international and
national organizations epidemiological surveillance measures have already been taken,
together with medical treatment, environmental sanitation, and health education measures
for the purpose of controlling the disease.

There is a great deal of concern regarding the risk of transmission of cholera by
food.  The importing countries have undertaken actions to ensure that food imported from
the countries affected by the disease does not pose risks to public health, and they are
allocating substantial resources to inspecting food imports.  The possibility exists that the
importing countries may close their borders to such imports, although the World Health
Organization has declared that the risk of importing cholera through food is very small. 
For these reasons, the exporting countries have serious concerns regarding the adverse
economic consequences they might suffer if food exports are interrupted or reduced.  The
countries of the Region recognize the need for consolidating technical laboratory
procedures in order to guarantee the quality and safety of food products, whether for
export or for national consumption, and they are requesting the technical cooperation
required for improving their capacity to identify Vibrio cholerae.

Objectives:

To provide exhaustive and updated information on the problem of food-
borne diseases and diseases caused by cholera agents, including epidemiological
surveillance activities and the provision of practical training in laboratories to carry out
specialized microbiological analyses in order to detect and confirm food contamination
by V.  cholerae.

Place and Date:

The Course will be given on the premises of the Pan American Institute for Food
Protection and Zoonoses (INPPAZ), Talcahuano 1660, Martínez, Province of Buenos
Aires, Argentina, on 15-19 June 1992.

Participants:

The Course is planned for 10 participants, two each from the following countries: 
Argentina, Brazil, Chile, Paraguay, and Uruguay.

Participants should be laboratory professionals specialized in microbiology who
are currently engaged in official diagnosis of V.  cholerae in food.

Methodology:

The Course will be of one week's duration.  Experienced instructors from the
United States Food and Drug Administration (USFDA), the Pan American Health
Organization (PAHO/WHO), the United Nations Food and Agriculture Organization
(FAO), and the countries of the Region of the Americas will give lectures and
demonstrations of practical laboratory procedures.  Individual exercises will be provided
to ensure the mastery of laboratory techniques.

Program:

The annex contains the Course program, including dates, times, and topics to be
covered. 
PAHO-WHO/FAO/USFDA/USCDC/USAID

       III INTERNATIONAL COURSE ON MICROBIOLOGICAL ANALYSIS
OF VIBRIO CHOLERAE IN FOOD

Martínez, Prov. of Buenos Aires, Argentina
15-19 June 1992



PROGRAM


Monday, 15 June:

 8:00 - 8:45 a.m.                Inauguration.

 8:45 - 8:15 a.m.                Objectives of the Course.

 9:15 - 10:15 a.m.               Historical perspective, public health, and economic repercussions of
cholera in food.

10:15 - 10:30 a.m.               Coffee break.

10:30 - 11:30 a.m.               Risk of transmission of cholera by food.

11:30 - 12.45 p.m.               HACCP concept related to microbiological contamination of food.

12:45 - 2:00 p.m.                Lunch

 2:15 - 5:00 p.m.                Preparation of laboratory equipment and materials; discussion of
sources of supplies and maintenance of laboratories.


Tuesday, 16 June:

 8:30 - 9:45 a.m.                Preparation of samples and typical cultures.

 9:45 - 10:00 a.m.               Coffee break.

10:00 - 12:00 p.m.               Function of the laboratory in epidemiological surveillance of food-
borne diseases.

12:00 - 1:00 p.m.                Lunch


 1:00 - 2:15 p.m.                Need for collecting food samples and data necessary for analysis.

 2:15 -  3:15 p.m.               Interaction of the laboratory with surveillance and control personnel. 
Information on results of samples for authorities responsible for
control and industry.

 3:15 - 3:30 p.m.                Coffee break.

 3:30 - 5:00 p.m.                Inoculation of mediums with typical culture plus eight hours of
enrichment.


Wednesday, 17 June:

 8:30 - 10:30 a.m.               Demonstration of collection of food samples. 

10:30 - 10:45 a.m.               Coffee break.

10:45 - 12:00 p.m.               Handling, dispatch, conservation, and safety of samples.

12:00 - 1:00 p.m.                Lunch

 1:00 - 3:00 p.m.                Analytical methodology for Vibrio cholerae.

 3:00 - 3:15 p.m.                Coffee break.

 3:15 - 5:00 p.m.                Analysis of the results of inoculation, culture for isolating the
microorganism, inoculation of preliminary biochemical tests;
inoculation of mediums for serology.


Thursday, 18 June:

 8:30 - 10:00 a.m.               Discussion of isolation and identification of species of Vibrio in food.

10:30 - 10:45 a.m.               Coffee break.

10:45 - 12:00 p.m.               Laboratory exercises - Isolation and identification of Vibrio species
in food.

12:00 - 1:00 p.m.                Lunch

 1:00 - 5:00 p.m.                Analysis of preliminary tests; inoculation of the remainder of
biochemical tests; preparation of serotypes; preparation of detection
kit for the identification of toxins.

Friday, 19 June:

 8:30 - 10:30 a.m.               Conclusion of laboratory exercises; reading of biochemical tests;
identification of the toxin in sample cultures; discussion of the
characteristics that differentiate V.  cholerae from other species of
Vibrio.

10:30 - 10:45 a.m.               Coffee break.

10:45 - 12:00 p.m.               Preparation of laboratory reports.

12:00 - 1:00 p.m.                Lunch

 1:00 - 2.30 p.m.                Recommendations for application and utilization of the training
program.

 2:30 - 3:00 p.m.                Evaluation of the Course.

 3:00 - 4.30 p.m.                Closing ceremony. 


III INTERNATIONAL COURSE ON
MICROBIOLOGICAL ANALYSIS
OF VIBRIO CHOLERAE
IN FOOD

CERTIFICATE

has attended the III International Course on
Microbiological Analysis of Vibrio cholerae in Food, held at the Pan American
Institute for Food Protection (INPPAZ) in Buenos Aires, Argentina, from 15 to 19
June 1992, with a duration of 40 hours.

     The Course was given under the auspices of the Pan American Health
Organization /World Health Organization (PAHO/WHO) and with the cooperation
of the United Nations Food and Agriculture Organization (FAO), the United States
Food and Drug Administration (USFDA), the United States Centers for Disease
Control (USCDC), and the United States Agency for International Development
(USAID).



Dr. Raúl Londoño
Director, INPPAZ


Dr. Enrique
Nájera                                                                Dr. KatiÛa Cekalovic         
PAHO/WHO Representative in Argentina                                                                   UNDP Representative in Argentina




CE109/27 (Eng.)
19 June 1992
ORIGINAL:  SPANISH



    UNITED NATIONS CONFERENCE ON ENVIRONMENT AND DEVELOPMENT
  Rio de Janeiro, Brazil, 3-14 June 1992.

SUMMARY

The United Nations held the United Nations Conference on
Environment and Development on 3-14 June in the city of Rio de
Janeiro, Brazil.  Delegates from 170 countries participated.  The
Conference culminated with the most highly attended summit meeting
in the history of humankind, a total of 110 Presidents and Heads
of State.

During the Conference four documents of great importance were
adopted.

The first, the Rio Declaration of on the Environment and
Development, establishes a set of ethical principles as a frame of
reference for sustained development that considers human beings as
the primary concern, including their rights to healthy and
productive life in harmony with nature.

The second, the United Nations Framework Convention on Climate
Change, is aimed at preventing changes in the Earth's climate and
the adverse effects they produce through the stabilization of
concentrations of gases that result in a greenhouse effect in the
atmosphere.  Stabilization should be achieved as soon as possible
in order to enable ecosystems to adapt naturally to climatic
change, ensure that food production is not threatened, and allow
economic development to continue in a sustainable manner. 
According to the principal commitments made, the countries agree
to periodically update, publish, and facilitate national
inventories, in addition to carrying out actions and implementing 
programs designed to reduce anthropogenic emissions greenhouse
gases.  The Convention also establishes the commitment to return,
by the end of the present decade, to 1990 levels of anthropogenic
emissions of carbon dioxide and other greenhouse gases not
controlled by the Montreal Protocol.

The third, the Convention on Biological Diversity, recognizes the
intrinsic value of biological diversity and its ecological,
genetic, social, economic, scientific, educational, cultural,
recreational, and esthetic values, and affirms that the
conservation of biological diversity is a common concern of
humankind, and that States have sovereign rights over their own
biological resources.    The Convention also demonstrates concern
that biological diversity is being significantly reduced by certain
specific human activities.  The Conference consequently adopted the
Convention, whose objectives are "the conservation of biological
diversity, the sustainable use of its components and the fair and
equitable sharing of the benefits arising out of the utilization
of genetic resources, including by appropriate access to genetic
resources and by appropriate transfer of relevant technologies,
taking into account all rights over those resources and to
technologies, and by appropriate funding."

The fourth is the Adoption of Agreements on Environment and
Development, Agenda 21, in which it is established that humankind
is at a decisive moment of history, in which we face perpetuation
of the disparities between and within the nations, which results
in the worsening of poverty, hunger, disease, and illiteracy and
the continuous worsening of the ecosystems on which our well-being
depends.  Agenda 21 deals with today's pressing problems and also
attempts to prepare the world for the challenges of the next
century.  It reflects a world consensus and a political commitment
at the highest level to development and cooperation in the sphere
of the environment.  Above all, its successful implementation is
the responsibility of the governments.  National strategies, plans,
policies, and processes are of capital importance in achieving the
aims of Agenda 21, and international cooperation should support and
supplement these national efforts.  In this context, the United
Nations system has a key function to perform.  Other international,
regional, and subregional organizations must contribute to this
effort.  In addition, broader participation of the public and the
active participation of the nongovernmental organizations and other
groups should be encouraged.  Attainment of the objectives of
Agenda 21 will require a substantial flow of new and additional
financial resources toward the developing countries in order to
cover the supplementary expenditures deriving from the measures
that will have to be taken to face the world's environmental
problems and to accelerate sustained development.  Financial
resources are also needed to strengthen the ability of the
international institutions to implement Agenda 21.

Agenda 21 consists of 40 chapters organized into four parts.  Part
I contains the preamble of Agenda 21 and the section entitled
Social and Economic Dimensions.  Part II contains the section
entitled Conservation and Management of Resources for Development. 
Part III includes the section entitled Strengthening of the Role
of the Principal (population) Groups, and finally, Part IV includes
the section entitled Means of Execution.

Among the 40 chapters of Agenda 21 the following are of special
importance for the health sector: 

     Protection and Promotion of Health.  Chap. 6
     
     Protection of the Atmosphere.  Chap. 9

     Protection of the Quality and Supply of Freshwater Resources: 
     Application of Integrated Criteria for the Management and Use
     of Freshwater Resources.  Chap. 18

     Ecologically Sound Management of Toxic Chemicals, Including
     the Prevention of the Illicit Traffic of Toxic and Hazardous
     Products.  Chap. 19

     Ecologically Sound Management of Hazardous Wastes,     
     Including the Prevention of Illicit International Traffic of
     Hazardous Wastes.  Chap. 20

     Ecologically Sound Management of Solid Wastes and Issues
     Related to Freshwater. Chap. 21.

Inasmuch as the XXIII Pan American Sanitary Conference, held in
Washington, D.C., in 1990, adopted Resolution XI on Environmental
Protection, a comparative analysis should be made of its relevant
recommendations and the recommendations made in the various
chapters of Agenda 21.  This analysis will be presented during the
next meeting of the PAHO Directing Council.

 
EBS13204.WPF

19 June 1992

Cholera Situation in the Americas

     Since the previous issue of the Epidemiological Bulletin, the
evolution of cholera in the Americas has been characterized by a
pattern of intense transmission.  Although there are no reports of
new countries that have been affected, the following information
has been received.  In May, Mexico reported twice as many cases
than the average for the previous months in 1992, and the states
of Jalisco, San Luis Potosí, and Sinaloa registered cases for the
first time.  In Central America all the countries, with the
exception of Costa Rica, saw a rise in the number of cases reported
during the period from the end of April through May compared with
the two previous months.  In Honduras and Nicaragua the infected
area increased in size.  In Costa Rica an autochthonous case was
identified as part of a limited outbreak in which nine other
asymptomatic individuals were found to be infected with V. Cholerae
01, El Tor biotype, Inaba serotype.  In the Andean area, repeating
the trend observed last year, Ecuador and Peru saw a reduction in
the number of cases reported during the month of May.  In Brazil
the infected area continued to spread, and as of May 1992 cases had
been reported from more than 300 municipios in 14 states, 73% of
them in the northeastern part of the country.  The United States
of America reported a total of 75 cases associated with an
investigation of cholera among passengers on an Aerolíneas
Argentinas flight between Buenos Aires and Los Angeles, California. 
No information has been provided on the probable source of the
infection.  According to the reports received from the countries,
the trend appears to be one of continued cholera transmission in
the Hemisphere with seasonal peaks in incidence (Figure 1).  As of
6 June, the countries that had reported cases during 1992 were: 
Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica,
Ecuador, El Salvador, French Guiana, Guatemala, Honduras, Mexico,
Nicaragua, Panama, Peru, Suriname, the United States of America,
and Venezuela.

     The recent publication of the World Health Organization, WHO
Guidance on Formulation of National Policy on the Control of
Cholera (WHO/CDD/SER/92.16), which is being translated into Spanish
by the PAHO Program on Diarrheal Disease Control, sets forth the
Organization's position in several important areas relating to the
control of cholera.

     With regard to surveillance and reporting, it is recommended
that following criteria be followed:  suspected case:  (a) a
patient 5 years of age or older who develops serious dehydration
or dies from acute watery diarrhea in an area where the disease has
not been reported;  (b) a patient 5 years of age or older who
develops acute watery diarrhea, with or without vomiting, in an
area where an epidemic is occurring;  confirmed case:  any diarrhea
patient with isolation of Vibrio cholerae 01.

     For reporting at the national level, collection of a minimum
set of data elements is recommended.  Information on sources and
modes of transmission may be obtained through epidemiological
investigation.  With regard to international notification, it is
emphasized that the national authorities in the countries where the
presence of cholera has been confirmed should report to PAHO/WHO
on a weekly basis and include at least the number of new cases and
deaths since the last report, together with cumulative totals for
the year, by region or some other relevant geographical division. 
It is not necessary to distinguish between confirmed and suspected
cases; all cases should be reported as cholera.
     The second area has to do with the use of the laboratory, in
which connection it is emphasized that in the event of a suspected
case a sufficient number of feces samples should be examined to
identify the responsible agent and test its sensitivity to
antibiotics.  Once the presence of cholera in an area is confirmed,
it is not necessary to examine samples from all, or even many, of
the cases or contacts in the area, and in fact it is better not to
promote this practice, since it places an unnecessary burden on the
laboratories.  The evolution of an epidemic in a given area should
be followed through bacteriological tests of samples from a small
number of patients.
     Third, it is reiterated that WHO does not recognize any
situation in which the traditional cholera vaccine should be used. 
     Fourth, with regard to the international spread of cholera,
it is pointed out that at the present time no country requires that
travelers entering its territory be vaccinated against cholera. 
Furthermore, WHO recommends that the countries should not implement
any cordon sanitaire, quarantine, or control of their borders in
their efforts to prevent the spread of cholera.
     With regard to chemoprophylaxis, attention is called to the
fact that mass prophylaxis should not be used in efforts to control
cholera.  Selective chemoprophylaxis may be considered, but only
when surveillance has demonstrated that on the average at least one
of every five family contacts has become ill after the appearance
of the first case.
     In view of the small risk of tourists becoming ill with
cholera, the recommendation on this subject is that tourism should
not be restricted in areas affected by cholera.
     With regard to the water supply and sanitation, it is
emphasized that cholera can only be reliably prevented by ensuring
that all populations have access to adequate excreta disposal and
drinking water systems.  Since large-scale investments are needed
in order to upgrade or build new environmental health
infrastructure that is capable of providing such systems, priority
should be given in the near term to the following interventions: 
Drinking water:  (a) drinking water should be adequately
disinfected; disinfection practices should be improved in
distribution systems and in rural systems;  (b) chlorine or iodine
tablets may be distributed to the population with instructions for
their use;  (c) when chemical water treatment is not possible,
health education should emphasize that is necessary to boil water
before it is consumed;  (d) water quality control should be
improved, surveillance and control of residual chlorine should be
intensified, and bacteriological tests should be implemented and
analyzed at various points in the production and distribution
systems.  With regard to sanitation:  (a) quality control of
wastewater treatment plants should be improved;  (b) the use of
treated wastewater for irrigation should be carefully controlled,
in accordance with national and international standards;  (c)
large-scale chemical treatment of wastewater is rarely justified,
even in emergencies, because of its high cost, unpredictable
effects, and possible negative impact on the environment and
health;  (d) health education should emphasize safe disposal of
excreta.
     The eighth area is concerned with the connection between food
and cholera, and the following general recommendations are made:
When the physical or chemical characteristics or processing of food
are such as to prevent the presence of V. cholerae, there is no
reason to expect any risk of cholera transmission, and hence there
is no justification for actions that restrict the sale,
transportation, or consumption of such foods as measures to control
the disease.
     With regard to food in international trade, the ninth point,
it is noted that although in theory there is a risk of cholera
transmission with some of the food products that are sold on the
international market, this possibility has rarely proven to be
significant, and hence authorities should seek more satisfactory
mechanisms than the application of embargoes on imports.
     Finally, with regard to health education, it is recommended
that those responsible for the mass media should provide the health
authorities with the necessary free time and editorial space to
disseminate information and educate the public on cholera control.




















FINAL REPORT


ROUND TABLE ON TRAINING IN HEALTH ECONOMICS AND
FINANCING IN LATIN AMERICA AND THE CARIBBEAN

Washington, D.C.
7 to 9 January 1992
TABLE OF CONTENTS





Page



FINAL REPORT                                                 1-14

APPENDIX 1LIST OF PARTICIPANTS                              15-23

APPENDIX 2PROGRAM                                           24-27

APPENDIX 3GUIDELINE FOR THE DISCUSSIONS                     28-36

APPENDIX 4COUNTRY REPORTS                                   37-57

.    Argentina                                    38-40
.    Brazil                                       41-42
.    Caribbean                                       43
.    Chile                                        44-47
.    Colombia                                        48
.    Costa Rica                                   49-50
.    Mexico                                       51-55
.    Dominican Republic                           56-57

APPENDIX 5REPORTS OF THE WORKING GROUPS
BY SUBJECT AREAS:                                 58-63

.    Group A:  High-level
Training                                     59-60
.    Group B:  Training of
Resources in Economics and Financing in
Institutions of Higher Education
(Undergraduate and Graduate-level)              61
.    Group C:  Research                              62

APPENDIX 6AREAS OF INTEREST TO INTERNATIONAL COOPERATION AGENCIES
64-68
ROUND TABLE ON TRAINING IN HEALTH ECONOMICS AND FINANCING
 IN LATIN AMERICA AND THE CARIBBEAN


REPORT OF THE MEETING:

     These notes summarize the discussions and recommendations of
the Round Table on Training Activities in Health Economics and
Financing in Countries of the Region of Latin America and the
Caribbean (LAC) organized by the Division of Human Resources of
the Institute of Economic Development of the World Bank (EDI/HR)
and the Health Policy Development Program of the Pan American
Health Organization (PAHO/HSP) in Washington, D.C., from 7 to 9
January 1992.  This is one of the activities to follow up the
series of Sub-Regional Seminars on Health Economics and Financing
held by the two institutions since the end of 1987.

     Professionals from universities, institutes of higher
education, training centers, research institutes, representatives
of professional health economics associations, and personnel from
the public sector and social security agencies in eight countries
of the region participated in the meeting:  Argentina, Brazil,
Colombia, Costa Rica, the Dominican Republic, Jamaica, Mexico,
and Trinidad and Tobago.  The countries were chosen on the basis
of the previous experience of the organizers of the four earlier
sub-regional Seminars and the plans of work of the organizing
institutions.  We know that there are other institutions and
investigators of quality in these and other countries of the
Region which, due to limitations on resources, were not invited. 
However, this round table should be considered the beginning of
an integration process to which we hope that most of the
institutions and investigators in the region will adhere. 
Personnel from other divisions of the World Bank and PAHO, and
representatives of international agencies and cooperation
agencies with programs in the countries of the region also
participated in the meeting:  the Agency for International
Development of the United States (USAID), Inter-American
Development Bank (IDB), and the Association of University
Programs in Health Administration (AUPHA) (see Appendix 1).


I.   OBJECTIVES OF THE SEMINAR

     Considering the needs for high-level training in the
countries of the region and the results of evaluations of the
experiences of the IDE and HSP/PAHO in holding sub-regional
seminars, thought has been given to the development or
strengthening of national high-level training programs and the
formation of a regional network in health economics and finance
as one of the mechanisms for achieving a broader and more
sustained impact for the training programs.

     The central objective of the meeting was to make an
inventory and review the experiences of the countries in carrying
out training programs to identify the degree of development of
such programs, the needs in resources of technical, logistical,
and financial support, and evaluation of the possibilities,
requirements, and operational mechanisms for the formation of a
health economics and finance network to support the development
of national programs.  The development of national capacities to
implement high-level training programs would be supplemented by
the promotion of training activities or academic training in
universities or institutes of higher education, and research on
health economics and finance (see Appendix 2, Summary of
Activities and Program of the Meeting).


II.  PLENARY SESSIONS AND WORKING GROUP MEETINGS

     The three days of the seminar were organized in plenary
discussion sessions (round tables) and meetings of working groups
(Appendix 3, Guidelines for Discussion).  During the first day of
plenary sessions the experiences of the countries in carrying out
activities of training in and research on health economics and
finance were presented and discussed extensively.  These sessions
resulted in an advantageous exchange of experiences among the
participants and the identification of forms of cooperation which
could be carried out among institutions in the region.

     During the second day of the meeting, meetings of country
working groups according to the priority areas of work were held: 
high-level training, training, and research (see Appendix 2: 
Guidelines for Discussion).  The country working groups prepared
a synthesis of their experiences in carrying out activities
related to health economics and finance, and identified some of
the difficulties and requirements for technical and financial
assistance to develop and strengthen national training programs
(Appendix 4:  Country Reports).

     In the meetings of the working groups by priority areas,
areas of interest, proposals of activities, and types of
technical and financial resources required for the formation of a
network to support the national training programs were discussed. 
The proposals of each of the working groups were presented and
discussed at the plenary session at the end of the second day
(Appendix 5:  Reports of the Working Groups).

     In the morning sessions of the third day, the experiences of
IDE and PAHO in organizing regional networks were reviewed and a
synthesis of the conclusions and recommendations on the follow-
up activities and type of support required for the execution and
strengthening of national training programs through the formation
of a regional health economics and finance network was presented. 
At the afternoon sessions, presentations were made on the areas
of technical and financial cooperation by international agencies
and international cooperation agencies:  USAID, World Bank (WB),
IDB, EDI-HR, and HSP/PAHO (see Appendix 6).

     Finally, during the luncheon meetings on the three days of
the seminar, presentations were made on the economic and
financial aspects of the national health systems of Colombia, the
United States, and Canada.  These presentations were by
participants in the seminar and consultants especially invited
for these activities.

     The following sections present a summary of the experiences
and proposals of activities and steps to follow in carrying out
or strengthening national training programs and the formation of
a regional health economics and finance network.  A synthesis is
also included of the areas of interest and forms of technical and
financial cooperation which the agencies and international
cooperation agencies would be interested in supporting.


III. SYNTHESIS OF EXPERIENCES, OBSERVATIONS, AND PROPOSALS

     This section summarizes the experiences and recommendations
from the plenary presentations and the reports prepared by the
working groups.  The synthesis has been organized according to
the three areas of work defined as priorities:  A) high-level
training, B) training of resources in institutions of higher
education, and C) research on health economics and finance.

     Table 1 synthesizes the type of activities in each of the
priority areas by country.  There are a large number and variety
of activities related to health economics and finance in each of
the priority areas.

     In most of countries, some type of activities defined as
high-level training are carried out.  The duration, content, and
type of participants in these seminars is very diverse, however. 
In some cases there are short meetings at which high-level policy
staff members present and discuss specific subjects; in other
cases there are training courses for high-level technical staff
members which may last up to a year.  The content of these
programs ranges from discussions of specific health policies to
workshops on basic economics and health economics, courses on
hospital administration, financial accounting, budgeting, and
preparation and evaluation of projects.

     In terms of training or training in institutions of higher
education, introductory courses on economics and health economics
have been incorporated in graduate-level programs in medicine,
public health, hospital administration, epidemiology, etc., in
most of the countries.  In one case, a course on health economics
is being given in a program on economics at the Autonomous
Technological Institute of Mexico (ITAM).

     In regard to research on subjects of health economics and
finance, some type of study has been carried out in almost all
the countries in the region.  Only three of them have a more or
less structured program of research.  A more detailed summary of
these experiences is presented below.



Table 1

Summary of Activities in Health Economics and Finance by
Countries Participating in the Round Table



SUMMARYABCOF

ACTIVITIES

HIGH-LEVEL TRAINING



ACADEMIC TRAINING


RESEARCHBRAZILR S2        IS       X (P)COSTA RICAS1 S2 CC       
IS       XCOLOMBIA        IS       XCHILER S1 S2 CC        IS     
(X)JAMAICA        IS       XMEXICO        S2EE IS       X
(P)ARGENTINAR S1 CC        IS       X (P)DOMINICAN REPUBLIC      
n                n       nTRINIDAD & TOBAGO       n        n      
n

R:   Discussion meetings (1 to 3 days)
S:   Training seminars (1 to 3 days)
Sz:  Training seminars and courses (1 to 4 weeks)
CC:  Training courses (1 to 12 months)
EE:  Courses on health economics in schools of economics
ES:  Courses on economics and health economics in graduate-level
     schools in medicine, public health, epidemiology, hospital
     administration, etc.
n:   No reported activity.
x:   With experience in conducting research.
(P): With a research program.
():  Activities in fields related to health economics and
     finance.




SUMMARY OF EXPERIENCES

     A)   Training activities in the area of health economics and
finance for senior and middle-level personnel in the
public sector.

i)   Discussion meetings from 1 to 3 days in duration
(R) with personnel from the policy level and
health secretaries of provinces, states, regions,
etc.:  Argentina (on health expenditures,
structure, and distributive impact, and on the
impact of the drug policy), Brazil (systems for
monitoring costs, quality of medical services,
demand and utilization of health services,
public/private mixture in the provision of
services), Chile (on the national nutrition
program).

ii)  Short training seminars (S1) of 1 to 3 days on
specific subjects in health services
administration:  Argentina (Chair of Health and
Medical Economics), Costa Rica-CENDEISS
(administration, accounting, budgeting, etc.),
Chile (hospital administration and health services
administration).

iii) High-level training seminars and courses and
intermediate-level training courses of 1 to 4
weeks (S2):  Brazil (health economics and
finance), Costa Rica-CENDEISS (accounting,
budgeting, and finance), Chile (business
management and administration, preparation and
evaluation of projects), Mexico (elements of
economics and health economics, techniques of
economic evaluation, and special topics).

iv)  Medium-term training courses lasting 1 month to a
year (CC):  Argentina (courses of 8 weeks on
health economics, elements of resource allocation
policies, evaluation of projects).  In Costa Rica,
the Central American Institute of Business
Administration (INCAE Costa Rica) and the National
Institute of Public Administration give training
courses on financial administration and projects. 
Chile (courses on evaluation and preparation of
projects; inter-American course lasting 9 months,
4 regional courses on evaluation and preparation
of projects lasting 1 month).

     The representatives of Jamaica and Trinidad and Tobago
pointed out that since the Seminar on health economics and
finance organized by IDE/PAHO/CDB in 1989 there have been no
similar events in the Caribbean region.  The Dominican Republic
is attempting to organize a "National Forum on the Health Sector"
at which matters related to the organization, efficiency, and
financing of the sector will be discussed.

     B)   Training:  formation of resources in health economics
and finance in undergraduate and graduate-level
programs in universities and institutes of higher
education.

     In several countries of the region the teaching of courses
on elements of economics (micro, macro), health economics, and
courses on financing health services has been initiated in
graduate-level schools of medicine, public health, and
administration.  The teaching of courses on health economics in
schools of economics is still very incipient.

i)   Courses on health economics in Schools of
Economics (CE).  The Autonomous Technological
Institute of Mexico (ITAM) is the only institution
which offers a course on health economics, which
is elective and for students of economics.  In
general, it is noted that in the rest of countries
there is a lack of interest by schools of
economics in offering courses on health economics.

ii)  Courses on elements of economics and health
economics in graduate-level schools of medicine,
health administration, public health, and hospital
administration (IS).  In Argentina there is a
chair of health economics at the National
University of Buenos Aires and at the Argentine
University of Business.  A module on economics 30
days long is included in a course on health
administration at the Catholic University of
Buenos Aires.  In Brazil, a refresher course on
health-sector financing (120 hours) and a
specialized course on social security (360 hours)
are offered at the graduate level.  The University
of SØo Paulo (USP) regularly offers courses on
applied economics, in areas of food and nutrition,
and a graduate course on health economics in the
School of Public Health.

     In Colombia and Costa Rica, introductory courses are offered
on elements of economics (micro, macro, and public finance) in
graduate courses on health administration, public health, and
multidisciplinary programs.  In Colombia there are nine health
administration programs in which courses on economic theory are
included.  Only the University of the North offers specific
courses on health economics.

     In Chile there is a master's degree program in hospital
administration coordinated by the Schools of Economics and
Medicine of the University of Chile, a Latin American course on
Nutrition and Public Health, and a master's degree program in
economics with specialization in social policy in conjunction
with ILADES-Georgetown University, Washington.

     In Mexico, courses on health economics have been included in
the specialized programs in hospital administration and in the
master's degree programs on public health, health systems, and
epidemiology of the National Institute of Public Health (INSP). 
Courses on health economics are also given in the graduate
programs in medicine, accounting, and administration of the
National Autonomous University of Mexico (UNAM) and in the
master's degree in medicine program of the Metropolitan
Autonomous University of Xochimilco (UAM-Xochimilco).

     In the countries of the Caribbean, aspects of the costs and
financing of health services were included in the Diploma in
Health Administration program offered from 1987 to 1989.  Some
aspects of health economics and finance have are discussed in a
few undergraduate and graduate-level courses.      

     C)   Conducting national and regional research on health
economics and finance.

     In several of the countries, research programs have been
conducted on health economics and finance, while in others
research is still in an initial stage.

     In Argentina a synthesis was presented of a research program
agreed upon between the Ministry of Health of the Province of
Buenos Aires and the Professional Council of Economic Sciences of
the Province of Buenos Aires.  The emphasis of the health
economics research program is on analyzing the economic
management of health institutions:  organic structure, property
administration, management of revenue and payments accounts,
management of inputs and labor, administration of funds, and
results of exploitation.

     In Brazil, the National School of Public Health of Rio de
Janeiro (ENSP-Rio de Janeiro) conducts training programs and
research methodologies for managers of health services.  The
Research and Applied Institute Economics (of the Ministry of
Finance and Economic Planning of Brazil) is conducting research
on the areas of financing social security, national expenditures
on health, and the quality and productivity of the medical
services.  Studies and research projects have been conducted at
the University of SØo Paulo (USP) on food and nutrition as well
as malaria control programs.

     In Colombia a series of investigations has been carried out
on national expenditures on health, studies resulting from the
national health survey, and studies on hospital operations,
financing, and costs.  In Chile, several studies on health,
mainly from the perspective of nutrition problems, have been
published in a special issue of the Journal of Economics of the
University of Chile.  In none of these cases is there reference
to a national or institutional research program on health
economics and finance.    

     In the countries of the Caribbean, through the Institute for
Social and Economic Research (ISER), investigations have been
conducted on the financing of the health sector, privatization,
social emergency funds, and the impact of structural adjustment
programs.  In Mexico, the INSP has a portfolio of 14 research
proposals to collect primary data for studies on the demand and
utilization of medical services, decentralization, community
participation in and financing of health services, studies of
costs, expenditures on health, and on investments in health
technology research and development.  There is initial financing
for most of these projects.  The CIESS research program conducts
projects related to the universalization of social security
coverage, the participation of the public, private, and social
security sectors in the financing and provision of health
services, and the problems of social security systems in the
context of economic liberalization and integration.


OBSERVATIONS AND RECOMMENDATIONS:

1.   The experience of IDE and PAHO in the organization of high-
     level training seminars has revealed a growing demand for
     this type of activity. From the organization of the first of
     these seminars, in Brazil in 1987, to the most recent one,
     held in Mexico in March 1991, there has been a growing
     demand for training and research activities in the areas of
     health economics and finance.  However, although the
     authorities of most of the countries in the region perceive
     the need for and importance of this type of activity, this
     perception has not resulted in a commitment to actively
     promote this type of activity.  In other countries the
     leading cause of limited interest in this type of training
     activity appears to be the ignorance or lack of resources of
     the institutions in the public sector.  The IDE and PAHO
     will continue supporting high-level national seminars
     similar to the four already held as one of the mechanisms
     for promoting interest in and demand by national authorities
     for this type of training.

2.   Although the number of countries with professionals
     specializing in the field of health economics and finance is
     limited, most of them have a minimum nucleus of qualified
     professionals working in related subjects whose experiences
     could be rapidly adapted to conducting high-level training
     activities in the field of health economics and finance. 
     This group of professionals can be a basis for national
     training programs.

3.   To achieve greater sensitization of the policy level to the
     utilization of instruments of economic and financial
     analysis in decision making, national training seminars
     should initially be organized to deal with policy problems
     which are of relevance to the country.  For example,
     economic and financial aspects of the processes of
     decentralization and privatization of health services are
     areas of interest in some countries of South America and
     Central America; the financing and viability of implementing
     national health insurance systems is the subject of greatest
     interest in some countries of the Caribbean.  Reform of
     social security systems and analysis of social expenditures
     are the areas of greatest interest in Argentina, Costa Rica,
     and Mexico.  The economic and financial aspects of the
     preparation and evaluation of projects was an area of
     interest for most of countries.

4.   Support for the creation of training courses in graduate-
     level schools, or diploma programs in health economics and
     finance in schools of economics, and support for the
     introduction of courses and advisory services on reviewing
     the content of courses on economics and health economics in
     other graduate-level programs (medicine, public health,
     hospital administration, and other disciplines) are two
     lines of priority work in the area of training in
     institutions of higher education.  The introduction of
     courses on basic principles of economics (micro, macro) in
     graduate-level programs, though received positively by
     students, appear to be inadequate as instruments for
     sensitizing and training in the use of efficiency criteria
     in decision making on the allocation of resources.  A review
     is required of the contents and methods of teaching
     utilized.  Promotion of this type of activity through the
     formation of a regional network for training in health
     economics and finance would be one of the mechanisms to
     support the development of national programs in these areas.

5.   Promotion and improvement of the quality of research on
     health economics and finance is another area which could
     benefit from the formation of a regional training network. 
     This could be obtained through the organization of a
     regional technical research committee formed by
     representatives of the countries and external advisers. 
     Such a technical committee could provide recommendations on
     the contents of high-level seminars and on courses on
     economics and financing in institutes of higher education.

6.   The interdisciplinary character of research and training
     programs in health economics and finance should be
     preserved.  The exchange of experiences about medical,
     epidemiological, economic, and health services
     administration aspects is one of the positive elements for
     improving the quality of training and research programs.

7.   In regard to other technical and financial support needs, it
     was concluded that the lack of bibliographic and educational
     materials and the poor dissemination of studies and research
     is one of the causes of the great ignorance and slight
     interest in the subject of health economics and finance. 
     The needs of the countries for technical and financial
     support to conduct high-level training seminars are very
     varied.  In some of them, initial support is required to
     organize and define the programs and content of high-level
     seminars.  In other countries, financing of the
     participation of international experts and participants is
     the most immediate need.  The common element of need in the
     countries is the scarcity of educational materials, case
     studies, translations of specialized articles, and
     dissemination of studies and research on health economics
     and finance.

8.   The needs of technical and financial support for conducting
     training activities in institutes of higher education is the
     participation of experts in defining programs and the
     content of specialized courses in health economics. 
     Institutional support by international agencies for
     organizing such programs is perceived as highly useful in
     awakening interest and mobilizing national and international
     resources toward that end.  Financial support is required
     for the exchange of educators, fellowships, purchase of
     specialized academic journals, and reproduction of
     educational articles and materials.

9.   The organization of forums or seminars to discuss problems
     in health economics and finance, the establishment of
     fellowships and prizes for professional theses, technical
     advisory services and financial support for the development
     of research protocols, and reproduction and dissemination of
     research results are the types of support that are required
     in the area of research.


IV   REGIONAL NETWORK OR PROGRAM AND AREAS OF COOPERATION BY
     INTERNATIONAL AGENCIES:  SYNTHESIS

1.   Presentations were made of the experiences of IDE and PAHO
     in supporting the formation of regional networks or programs
     to support national programs.  IDE presented some of its
     most recent experiences in promoting the formation of
     specialized institutions (regional networks or programs) to
     support national programs to strengthen local governments,
     poverty relief programs, microbusiness promotion, and
     municipal development programs.  The experience of PAHO was
     in support for the formation of a regional network of
     professionals, based on the promotion of professional
     associations, in the area of urban infrastructure and
     development.  These presentations were illustrative of the
     types of activities and mechanisms which could be utilized
     to mobilize technical and financial resources through a
     regional health economics and finance network.

2.   The development of networks with a regional approach of
     training and technical assistance programs, with medium-
     term programs, for institutional development based on the
     utilization of local institutions and resources were
     identified as the principal characteristics of successful
     programs.  Although financial support by international
     cooperation agencies has been crucial to development of the
     networks, excessive paternalism by and financial dependence
     on international cooperation agencies is one of the most
     common problems in organizing regional networks or programs.

3.   Several agencies and cooperation agencies presented their
     programs and areas of interest in the area of health
     economics and finance, and they identified the type of
     activity and forms of technical and financial cooperation
     which could be utilized to support national programs or the
     activities of a regional network or program in health
     economics and finance.  These presentations covered:  i) the
     IDE/PAHO joint program of training in health economics and
     finance, ii) the regular cooperation programs of the IDE,
     iii) the regular cooperation programs of HSP/PAHO and other
     PAHO programs, iv) the activities of the technical and
     operational units of the World Bank LAT/LAC-HR, v) the
     project analysis department of the health and education
     division of IDB, and vi) the division of population, health,
     and nutrition, office of Latin America and the Caribbean of
     USAID, directly and through its contractors:  the
     Association of University Programs in Health Administration
     (AUPHA) and the Sub-regional Project (Latin America and the
     Caribbean) to Support Health and Nutrition Programs carried
     on by the University Research Corporation/International
     Science and Technology Institute (URC/ISTI), a consulting
     company (see Appendix 6).

4.   The matrix table presented below summarizes the areas of
     interest and types of activities by international
     cooperation institution which could be utilized to mobilize
     technical and financial resources to support conducting the
     activities of national programs or of a regional network or
     program in health economics and finance (see Table 2).
TABLE 2
AREAS OF INTEREST OF EXTERNAL COOPERATION AGENCIES

AGENCY:WORLD BANKPAHOUSAIDAREAS AND
TYPES OF      COOPERATION:
EDI
LAC/LAT-HRHSP & OTHERS
URC/ISTE
AUPHA
IDBA.  High-level
training:
Staff participation :Technicians/expertsXXXXXXInstitutional
supportXXXFinancing:ExpertsXXXXParticipantsXXXTranslationsXXXCase studiesXXXEducational
materialsXXB. TrainingTechnical advisory services:Technicians/expertsXXXXInstitutional
supportXXFinancing:Exchange of educatorsXXFellowshipsX(X)Educational materialsXXXXC.
ResearchTechnical advisory services
/financing:ProposalsXXDevelopmentXXConsultantshipsXXXXFellowships and prizesXXDissemination: 
PublicationXX
Seminars and workshops:  XXX

V.   FINAL OBSERVATIONS ON POSSIBLE AREAS OF ACTION:

1.   The formation of groups, or national committees of
     representatives of universities, research and training
     centers, and other institutions in the public and private
     sectors working in the health sector or of professional
     associations in the field of health economics is one of the
     initial steps in organizing or strengthening national
     training programs in health economics and finance.  The
     definition of plans of work of the national programs and the
     interest of the governments of the countries in supporting
     the development of such programs is an important step in
     facilitating technical cooperation by IDE, PAHO, and other
     international cooperation agencies.  The Country
     Representatives pointed out that they will utilize the
     results of this seminar to initiate this process.  IDE and
     PAHO will support follow-up activities in this direction.

2.   This institutional support of IDE/PAHO for institutions
     supplying training may be an important incentive to
     promoting demand for training by the public sector of the
     countries of the region.  Also, the direct support of
     cooperation agencies of institutions promoting the
     organization of seminars, courses, or research on health
     economics and finance will be instrumental in helping to
     identify high-level training needs which are rarely
     identified as priorities by those responsible for decision
     making.

3.   The great variety in the type and content of high-level
     training programs suggests that the initial support of
     IDE/PAHO of the formulation of the programs and contents of
     such seminars is still crucial to ensuring the achievement
     the objective of sensitizing high-level personnel.  The
     experience acquired by IDE/PAHO in conducting such seminars
     on the application of economic and financial analysis to
     decision making about health policies will be of great
     usefulness in formulating the programs and contents of
     national seminars.

4.   The execution of national research programs dealing with
     subjects in health economics and finance is crucially
     important to adapting training seminars to local conditions
     in the countries.  The diversity of subject areas,
     professional profiles of high-level staff members,
     professional profiles of trainers, and status of discussion
     on subjects in health economics and finance suggests that
     the success of national training programs will depend on
     their adaptation to these realities.  In some countries
     seminars with a high local content may be given; in other
     countries, greater participation by experts from the region
     and international experts will be required.

5.   Initial support of training activities in health economics,
     institutions of higher education and training centers, and
     research on health economics and finance could be carried
     out as a byproduct of PAHO's regular technical cooperation
     programs.  The technical support and institutional
     endorsement of PAHO for training and research activities in
     health economics and finance will be of great usefulness in
     developing such programs.

6.   The IDE and PAHO will support the formulation and
     development of national proposals for training and research
     in order to define a tentative program of activities to be
     supported through a subregional network or program of
     training and research in health economics and finance. 
     Toward this end, EDI and PAHO will contract the services of
     a consultant who will be responsible for processing the
     proposals which are received, for supporting the development
     of national proposals from countries which have developed
     them, and for consolidating such proposals in a sub-regional
     plan of activities, timetable, and estimated budgets which
     will be presented to international cooperation agencies for
     financing.

7.   The support of the operational missions of the World Bank
     and IDB as well as of PAHO's regular cooperation programs
     with the countries in identifying the training, training,
     and research needs of the projects and programs of sectoral
     adjustment is one of the mechanisms for inducing demand by
     these activities.  In addition, specific training, training
     and research activities could be incorporated as
     comprehensive components in the lending operations of the
     World Bank and IDB in the countries of the Region and in the
     technical cooperation programs of PAHO.  The active
     participation of the technicians of the banks, national
     authorities, and professionals in the institutions offering
     the training programs in designing the contents of the
     training programs is a mechanism to be promoted by these
     institutions.

8.   The initiative of international cooperation agencies to
     promote greater participation by national experts in the
     cooperation programs is an element that will help strengthen
     national programs.  The promotion of national forums and
     workshops at which the experiences of national institutions,
     individuals, and international cooperation agencies in
     conducting studies and research on the area of health
     economics and finance are presented is another of the
     mechanisms which may be have a major multiplier effect.

9.   Given the diversity of experiences in conducting activities
     in the countries, there is a potential for gains in the
     exchange of experiences.  Several of the representatives
     from the countries agreed to initiate interinstitutional
     contacts to launch programs for exchanging educators,
     participants, and training materials.

10.  The preparation and dissemination of a directory of
     professionals and institutions working on subjects in health
     economics and finance in the countries of the region may be
     the first step toward supporting the development of national
     programs and the formation of a regional network or program
     in health economics.  A first version of this directory
     could be developed from the data bases on institutions and
     consultants in health economics and finance of PAHO, the
     World Bank, the Inter-American Bank, and other United
     Nations agencies, and AID (including AUPHA and URC/ISTI).
















APPENDIX 1
LIST OF PARTICIPANTS                    APPENDIX 1

ROUND TABLE ON TRAINING
IN HEALTH SECTOR ECONOMICS AND FINANCING
IN LATIN AMERICA AND THE CARIBBEAN


Washington, D.C., 7-9 January 1992



LIST OF ORGANIZERS


Dr. Antonio C. Coelho Campino 
Advisor in Health Economics
Health Policies Development 
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202)  861-3219
Fax:  (202) 861-2647

Ms. Margaret K. Saunders
Population and Health
Specialist
Human Resources Division
Economic Development Institute
World Bank 
1818 H Street, N.W.
Washington, D.C. 20433
Tel:  (202) 473-6448
Fax:  (202) 676-0961

Dr. Armand Van Nimmen
Chief
Division of Human Resources
Economic Development Institute
World Bank
1818 H Street, N.W.
Washington, D.C. 20006
Tel:  (202) 473-6454
Fax:  (202) 676-0961

Dr. César Vieira
Program Coordinator
Health Policies Development
Bread American Organization
Health
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-3235
Fax:  (202) 861-2647
LIST OF PARTICIPANTS


Argentina

Dr. Ginés González García
Presidente
Asociación de Economía de la
Salud
Suipacha 1308
Buenos Aires, Argentina
Tel:  221078/8878


Brazil

Dr. Solón Magalhaes Vianna
Special Projects Coordinator
Instituto de Pesquisa
Economica Aplicada
SBS Edificio BNDES, 14o.
CEP 70076, Brasilia, D.F.
Brasil
Tel:  (55-61) 226.1317
Fax:  (55-61) 321.1597

Ms. Maria A. Dominguez Ugá
Pesquisadora Asistente
Depto. de Administración y
Planificación
Fundación Oswaldo Cruz
Escuela Nacional de Salud
Pública
Ministerio de Salud
Av. Leopoldo Bulhoes No.
1480/708
Manghinhos
Río de Janeiro, RJ 21041
Brasil
Tel:  (55-21) 280.8194
Fax:  (55-21) 280.8194

Ms. Diana Oya Sawyer
Director
CEDEPLAR
Rua Curitiba 832
Belo Horizonte, Brazil
Tel:  201.3253
Fax:  201.3657

Prof. Denise Cavallini Cyrillo
Universidad de SØo Paulo
Luciano Gualberto, 908
SØo Paulo, S.P., Brazil
Tel:  211.0411 - R. 2283


Chile

Ms. Pilar Contreras-García
Subjefe 
Departamento de Inversiones
MIDEPLAN
Ministerio de Planificación y
Cooperation
Ahumada 48, Piso 6
Santiago, Chile
Tel:  672.2033
Fax:  (56-2) 695.2049

Sr. Aristides Torches Lazo
Profesor Economía
Departamento de Economía
Instituto de Economía
Pontificia Universidad
Católica de Chile
Vicuña Mackenna 4860
Casilla 274-V, Correo 21
Santiago, Chile
Tel:  (562) 552.2375
Fax:  (562) 552.1310


Colombia

Sr. Freddy Velandia Salazar
Director 
Unidad Desarrollo Sistemas
Salud
Facultad de Estudios
Interdisciplinarios
Pontificia Universidad
Javeriana 
Carrera 7 #40 Edificio 9, Piso
2
Bogotá, Colombia
Tel:  (57-1) 288.4700
Fax:  (57-1) 288.0861

Sr. Alvaro Olaya Pelaez
Administrador/Comunicador
Social
Departamento de Ciencias
Básicas
Facultad Nacional de Salud
Pública
Universidad de Antioquia
Calle 62-No. 52-19
Medellín, Colombia
Tel:(574) 511.5922
Fax:(574) 511.2506

Dr. Marta Madrid Malo
Economista
Evaluación y Programación
Presupuestal
Ministerio de Salud
C. 1142, #17-31, Apt. 111
Bogotá, Colombia
Tel:  282.4451/3391


Costa Rica

Sr. Jorge Arturo Hernández
Castañeda
Gerente
Gerencia División Financiera
Caja Costarricense del 
Seguro Social
San José, Costa Rica
Tel:  33.3203
Fax:  23.4405

Sr. Juan Manuel Villasuso
Profesor/Consultor
Universidad de Costa Rica
y Prodesarrollo
Apartado 6193
San José 1000, Costa Rica
Tel:  (506) 53.1795
Fax:  (506) 24.3824


Jamaica

Mr. Stanley Lalta
Research Fellow
Institute of Social
and Economic Research
The University of West Indies
Kingston, Jamaica
Tel:  (809) 927.1020
Fax:  (809) 927.2409


Mexico

Lic. Carlos Cruz-Rivero
Director de Investigación en
Sistemas de Salud, 
Centro de Investigaciones en
Salud Pública
Instituto Nacional de Salud
Pública
Av. Universidad 655
Cuernavaca, Morelos, México
62508
Tel:  (91-73) 11.2468
Fax:  (91-73) 11.2219

Lic. Rocío Santoyo-Vistrán
Coordinador Académica 
División de Actuaría
y Planeación Financiera
Centro Interamericano de 
Estudios de Seguridad Social
Calle San Ramón s/n
10100 México, D.F., México
Tel:  (95-202) 595.0011 Ext.
146-147
Fax:  (95-202) 223.5971

Dr. Juan Carlos
Belausteguigoitea
Professor of Economics
Instituto Tecnológico Autónomo
de México
401 Pershing Drive
Silver Spring, MD 20910
Tel:  (301) 585.8147


Dominican Republic

Sr. Miguel Ceara Haaton
Director
Centro de Investigación
Económica
Aplicada (CIECA) 
Calle Respaldo Socorro Sánchez
Plaza Jaragua, Apto. 405,
Gazcue
Santo Domingo, República
Dominicana
Tel:  (809) 686.8696
Fax:  (809) 686.8687

Prof. José Domingo Puello 
Coordinador de Cátedra
Estadística Económica
Universidad Autónoma de Santo
Domingo
Calle Espiral #18
Santo Domingo, República
Dominicana
Tel:566.1806


Trinidad and Tobago

Mr. Karl Theodore
University Lecturer
Department of Economics
The University of West Indies
St. Augustine, Trinidad, W.I.
Tel:  (809) 662.2002 Ext. 2027
Fax:  (809) 663.1334 Ext. 3232


Venezuela

Mr. Thais Maingon
Professor 
Area de Desarrollo Socio
Político
Centro de Estudios del
Desarrollo
de la Universidad Central de
Venezuela
Avda. Neveri, Colinas de
Bellomonte
Edificio ASOVAC
Caracas, Venezuela
Tel:  752.3266 Ext. 37040
Fax:  751.2691
LIST OF OBSERVERS AND INTERNATIONAL AGENCIES

Dr. Samuel R. Aymer
PWR Jamaica
Pan American Health
Organization
60 Knutsford Blvd.
Kingston, Jamaica
Tel:  (809) 926-1990

Dr. Adolfo H. Chorny
Consultant
DRC
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037

Dr. Roberto Capote Mir
Senior Advisor in Health
Services
Health Services Development
Program
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-3226

Sr. Ernesto S. Castagnino
Principal Economist
Education and Health Division
Project Analysis Department
Inter-American Development Bank
1300 New York Ave., N.W.
Washington, D.C. 20577
Tel:  (202) 623-1894
Fax:  (202) 623-1315

Dr. José R. Ferreira
Program Coordinator
Health Manpower Development
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-4310
Fax:  (202) 223-5971

Dr. Gary L. Filerman
President
Association of University
Programs in Health
Administration
1911 - N. Ft. Myer Dr.
Arlington, VA 22209
Tel:  (703) 524-5500

Dr. Fernand Hachette
Economist
Health Services Infrastructure
Area
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-3212
Fax:  (202) 223-5971

Ms. Maureen Lewis
Economist
LA1HR
World Bank
1818 H Street, N.W.
Washington, D.C. 20006
Tel:  (202) 473-9080

Mr. Patricio Márques
LATHR
World Bank
1818 H Street, N.W.
Washington, D.C. 20006
Tel:  (202) 473-6447

Dr. Ricardo Meerhoff
Health Financing Advisor
Latin America and Caribbean
Health and Nutrition
Sustainability
Contract - Technical Support
for
Policy and Health Financing
Assessment to the Bureau for
Latin America and The Caribbean
Agency for International
Development - AID
1129 20th Street, N.W.
Washington, D.C. 20036
Tel:  (202) 466-3318
Fax:  (202) 466-3328

Mr. Philip Musgrove
Economist
Human Resources Division -
LATHR
Technical Department
Latin America and The Caribbean
Regional Office
The World Bank
1818 H Street, N.W.
Washington, D.C. 20433
Tel:  (202) 473-1891
Fax:  (202) 676-0751

Dr. Mr. Horst Otterstetter
Environmental Health Program
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-3311
Fax:  (202) 223-5971

Ms. Matilde Pinto de la Piedra
Health Services Infrastructure
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-3220

Dr. Alberto Pellegrini-Filho
Research Coordination Program
Pan American Health
Organization
525 23rd Street, N.W.
Washington, D.C. 20037
Tel:  (202) 861-4305

Dr. Bernardo Ramírez
Vice President
Latin American Development
Program
Association of University
Programs
in Health Administration
(AUPHA) 
1911 North Fort Myer Drive
Suite 503
Arlington, Virginia 22209
Tel:  (703) 524-5500
Fax:  (703) 525-4791

Mr. Mauricio Silva
Urban Specialist
EDINU
World Bank
1818 H Street, N.W. 
Washington, D.C. 20433
Tel:  (202) 473-6268

Dr. Nicholas Studzinski
Health, Population and
Nutrition Officer
Health, Population and
Nutrition Division
Bureau for Latin America
and the Caribbean
Agency for International
Development - AID
Washington, D.C., 20037
Tel:  (202) 466-3318
Fax:  (202) 466-3328

Mr. Vincent Turbat
Health Economist
Division of Human Resources
Economic Development Bank
World Bank
1818 H Street, N.W.
Washington, D.C. 20433
Tel:  (202) 473-6446
Fax:  (202) 676-0961
CONSULTANTS


Prof. Pran Manga
Masters Program in Health
Administration
University of Ottawa
136 University of Ottawa
Ottawa, Canada K1N6N5
Tel:  (613) 564-4978
Fax:  (613) 564-6518

Dr. Rubén Suárez Berenguela
Economic Consultant
6208 Leeke Forest Court
Bethesda, MD 20817
Tel:  (301) 897-5290
Fax:  (301) 530-5944

Prof. Warren Greenberg
Prof. of Health Economics
George Washington University
4400 Delmont Lane
Kensington, MD 20895
Tel:  H(301) 942-2518
Tel:  W(202) 994-8187

















APPENDIX 2
PROGRAM                     APPENDIX 2

PROGRAM

ROUND TABLE ON TRAINING IN HEALTH SECTOR  ECONOMICS AND FINANCE 
IN LATIN AMERICA AND THE CARIBBEAN
7 to 9 January 1992

FIRST DAY:  Tuesday, 7 January 1992


09.00 h   Welcome:  Dr. Carlyle Guerra de Macedo, Director, PAHO;
Dr. Armand Van Nimmen, Chief of the Division of Human
Resources of the Institute of Economic Development
(IDE) of the World Bank.

·    Background of interest of PAHO/IDE in training in
health sector economics.
·    Purpose of the Round Table.
·    PAHO/IDE Support of national seminars and
networks.
·    Presentation of participants

09.45 h   Objectives of the Round Table.  Antonio Campino, PAHO;
Margaret K. Saunders, IDERH;  Rubén Suárez, Consultant.

·    Objectives and anticipated results of the Round
Table.
·    Preliminary deliberations on the proposal to
establish networks.
·    Open discussion on objectives, anticipated
results, and proposal.

10.15 h   Break

10.30 h   Round Table on experiences concerning training of high-
level staff members.
Moderator:  Armand Van Nimmen, Division of Human
Resources, IDE.

·    Analysis and evaluation of current activities to
train high-level staff members.
·    Definition of the need for this training and
evaluation of existing deficiencies therein.
·    Outline of prospects for national activities to
train high-level staff members.

12.00 h   Luncheon

13.30 h   Round Table on training for undergraduate and graduate
university students.
Moderator:  Matilde Pinto de la Piedra, PAHO.

·    Analysis of current training programs for
undergraduate and graduate university students in
health sector economics in Latin America and the
Caribbean.
·    Evaluation of whether such programs require
greater development and support.
·    Ideas concerning how such development could be
promoted.

15.00 h   Break

15.15 h   Round Table on research concerning health sector
economics and finance. 
Moderator:  Dr. Alberto Pellegrini, PAHO

·    Examination of the type of research currently
conducted in the training institutions and centers
represented on the Round Table.
·    Analysis of the way in which research could be
conducted and supported more extensively.
·    Consideration of how this should be reflected in
future plans for research programs.SECOND DAY:  Wednesday, 8 January 1992


09.00 h   Work in small groups on training of high-level
participants; training of university undergraduates and
graduate students, and research.

·    Separation into groups, according to interest in
each subject, to carry out analysis and
discussions in greater depth.

·    Formulation of ideas on the best way to focus on
training for each of those three groups at the
national level.

·    Presentation of the results of this effort at the
plenary session for its analysis and review.

10.15 h   Break

10.30 h   Continuation

12.00 h   Luncheon

13.30 h   Termination of the group reports

15.30 h   Break

16.00 h   Plenary Session:  Presentation and analysis of the
group efforts.
Moderators:  Antonio Campino, PAHO; Margaret Saunders,
Division of Human Resources, IDETHIRD DAY:  Thursday, 9 January 1992


09.00 h   Presentation of examples of national seminars and
establishment of networks in Latin America.
Moderator:  José R. Ferreira, Coordinator of the Health
Manpower Development Program, PAHO.
Presentations:  Mauritius Silva, Division of
Infrastructure and Urban Development, IDE; Horst
Otterstetter, PAHO.

·    Analysis of elements which have contributed to the
establishment of viable networks and supported the
development of national programs.
·    Examination of negative factors which hinder that
development.
·    Discussion of the way in which such factors are
pertinent to the countries present at the seminar.

10.15 h   Break

10.30 h   Plans for finalizing training programs and establishing
networks at the national level.
Moderator:  Rubén Suárez, Consultant.

·    Synthesis of the principal conclusions of the
efforts of the Round Table's groups and of the
presentation of examples for formulating
recommendations for follow-up.

12.00 h   Luncheon

13.30 h   Exhibits of representatives of international agencies
on support of national programs.

-    World Bank -  Philip Musgrove
-    IDE -  Armand Van Nimmen
-    PAHO -  Antonio Campino
-    USAID -  Nicholas Studzinsky
-    IDB -  Ernesto Castagnino
-    AUPHA (Association of University Programs in
Health Administration) -  Bernardo Ramírez

Determination of how donors could help implement and
support the follow-up recommendations.

15.00 h   Break

15.15 h   Discussion

17.00 h   Deliberations on follow-up.
Moderators:  Antonio Campino, PAHO; Margaret Saunders,
Division of Human Resources, IDE.

·    Closure of the Round Table with an agreement on
measures to be taken in the future.






















APPENDIX 3
GUIDELINE FOR DISCUSSIONS                   APPENDIX 3

Round Table on Training in Health Economics and
Finance in Latin America and the Caribbean
Washington, D.C., January 7 to 9, 1992

GUIDELINES FOR DISCUSSIONS


     This notes summarize the objectives, subject areas, and
mechanics to be followed during the different types of sessions
of the round table on training activities and programs in
economics and financing in Latin America and the Caribbean (LAC).


I.   OBJECTIVES OF THE SEMINAR

     The central objective of this meeting is a review of
experiences and development of proposals on operational
mechanisms to implement national training programs in health
economics and finance.  Proposals of activities and steps to be
followed in forming a regional network or program of institutions
and investigators in health economics which can support the
development of national training programs in the countries of the
Region will be discussed.

     Based on the experiences of the Institute of Economic
Development of the World Bank (IDE/EDI) and the Pan American
Health Organization (PAHO) in the implementation of training
programs, the organization of a regional network has been
identified as one of the most appropriate mechanisms for
supporting the development and strengthening of national training
and research programs in health economics and finance in the
countries of the Region.


II.  THREE PRIORITY WORK AREAS

     To support the development of national training programs in
health economics and finance, three areas of work have been
identified for consideration in forming the regional network.

A)   Training activities in the area of health economics and
     finance for senior and middle-level personnel in the public
     sector.

B)   Training of human resources specializing in health economics
     and finance in undergraduate and graduate-level programs in
     universities and institutes of higher education.

C)   The exchange of experiences in conducting research on health
     economics and finance, and the development of proposals for
     national and regional research to support the development of
     national training programs.

     In each of these areas, the experiences of the participants
were reviewed and proposals of activities which could be carried
out by national programs with the support of the regional health
economics and finance network were developed.


III. PLENARY SESSIONS AND MEETINGS OF WORKING GROUPS

     The sessions of the three days of the seminar have been
organized as plenary discussion and presentation sessions and
meetings of working groups.  For each of the sessions a moderator
and a rapporteur who will prepare a synthesis of the session (see
program) will be named.

     First Day:

     The objective of the plenary meetings on the first day of
the seminar is to facilitate an exchange of experiences on
conducting training and research activities in health economics
and finance.  From the exchange of experiences, needs for
training as well as the resources available therefor at the
national level will be identified.

     Anticipated result(s):  A report summarizing a) the
     experiences of the countries and institutions in conducting
     activities in the priority areas, b) the training needs of
     the countries, and c) requirements for technical and
     financial assistance to develop and strengthen national
     training programs and training in health economics and
     finance.

     Second Day:

     A working group will be organized for each of the three
priority areas.  Each working group will prepare an inventory of
activities, institutions, investigators, etc., which could be
included in national training and research programs and will
formulate proposals for activities and operational mechanisms for
their development.  This will involve identifying requirements
for technical and financial resources which could be mobilized
through a regional health economics and finance network.  The
proposals developed by each of the working groups will be
discussed at the plenary session at the end of the day.

     Anticipated result(s):  Each of the groups will be
     responsible for preparing a report containing a) an
     inventory of institutions and investigators working in the
     corresponding area, b) a description of training and
     research activities which could be carried out by the
     national programs, c) proposals on operational mechanisms
     and technical and financial resources which are required to
     support the execution of the national programs, and d) the
     type of activity and operational mechanisms to be carried
     out through the regional health economics and finance
     network.

     Third Day:

     Plenary presentation and discussion meetings will be held. 
Training experiences of regional networks supporting national
training programs will be reviewed at the morning session.  At
the afternoon session presentations will be made on the areas of
technical and financial cooperation of international agencies and
international cooperation agencies operating in the region.


     Anticipated result(s):  a) a proposal of activities and
     steps to follow for the formation of a regional network or
     program in health economics and finance, b) a synthesis of
     activities and steps to follow to develop and implement
     national training programs in health economics and finance,
     c) a summary of the types of activities (national and
     regional) that the agencies and international cooperation
     agencies would be interested in supporting.


IV.  NOTES FOR THE PRESENTATIONS AND DISCUSSION AT THE MEETINGS:

     The notes and formats presented below summarize the subjects
it is hoped will be covered in the plenary meetings and group
discussions.  These may be modified according to the needs that
arise from the presentations and discussions.

i)        To summarize the efforts at the country or regional
level in terms of training activities for senior and
middle-level personnel in the public sector
(ministries, planning institutes, social security
systems, etc.).

ii)       A list of the institutions currently requesting high-
level training and institutions able to provide
training services.

iii)      The nature of the training programs carried out and
required in terms of:  type of program (national,
international), number of participants, duration,
frequency, contents of programs, materials utilized,
characteristics of the educators, occupational and
academic profile of participants, etc.

iv)       Potential demand for training.  Training needs
considering the current professional and anticipated
profile of personnel in the public sector (and sector
of health) in the country or region.  Type of required
training:  number of participants, duration, frequency,
contents of programs, materials utilized, and
occupational and academic requirements of participants,
etc.

v)        To identify the activities and mechanisms through which
the organization of a regional network could develop
and strengthen national training programs in health
economics and finance; i.e.: exchange of experiences
through seminars and national and regional workshops,
translations and dissemination of materials,
dissemination of studies and training materials
developed locally, promotion of participation or
training in professional associations specializing in
health economics, financing of research, training
fellowships, etc.

vi)       Proposals for alternative activities and operational
mechanisms to establish a regional network of
institutions and investigators in health economics and
finance:  international consortium of institutes of
training in health economics, master's degree programs
in management of social sectors, etc.


vii)      Development of proposed alternative activities and
operational mechanisms to implement national training
and research programs in health economics and finance.
Round Table on Training in Health Economics and Finance
in Countries of Latin America and the Caribbean, January 07-09, 1992.


COUNTRY/INSTITUTION(S):..........  / ...........

AREA A:  Training Programs and Courses for Senior and Middle-level PersonnelEXPERIENCESNEEDSOBSERVATIONS/
RECOMMENDATIONSA.   Type of Activity: 
(Seminar/Workshop/Day   
meeting/Course/etc.)B.    Institu
tions
promoti
ng the
event:
     .    National:
     .    International:
     .    OtherC.    Characteristics (number of participants/duration/content/materials utilized)D.P

a

r

t

i

c

i

p

a

n

t

s

(

n

u

m

b

e

r

)

     .    Public sector
     .    Social Security
     .    Military health
     .    OtherE.    Observations:  On training activities for high-level personnel and
operational mechanisms for the formation of a Regional network or
program in health economics and finance:
Round Table on Training in Health Economics and Finance
in Countries of Latin America and the Caribbean, January 07-09, 1992.


COUNTRY/INSTITUTION(S):..........  / ...........

AREA B:  Training of Human Resources in Health economics and finance
in Institutions of Higher Education (Undergraduate and
Graduate)                               EXPERIENCESNEEDSOBSERVATIONS/
RECOMMENDATIONSA.   Type of activity: 
(Seminar/Workshop/Day
meeting/Course/etc.)B.    Institu
tions
promoti
ng the
event:
     .    Universities
     .    Institutes
     .    Foundations
     .    International agencies
     .    OtherC.    Characteristics (number of students/duration/content
curriculum/materials utilized/books/etc.)D.    Participants (number)
     .    Specialties
     .    Economics
     .    Public Health
     .    Medicine
     .     Sociology
     .     Anthropology, etc.E.Observations:  On academic training activities in institutes
of higher education and operational mechanisms to organize a
Regional network or program in health economics and financeRound Table on Training in Health Economics and Finance
in Countries of Latin America and the Caribbean, January 07-09, 1992.


COUNTRY/INSTITUTION(S):..........  / ...........

AREA B:  Research:  in Health economics and finance
EXPERIENCESNEEDSOBSERVATIONS/
RECOMMENDATIONSA.   Type of activity: 
(Thesis/Consultantships/Workshops/
Nation-al studies/etc.
B.   Institutions promoting the event:
     .    Universities
     .    Institutes
     .    Foundations
     .    Government
     .    International agencies
     .    OtherC.    Characteristics:  (Technical nature/duration/content/resources and
materials utilized/financing.D.Participants (number)
     .    Type of investigators
     .    Specialties:  economics, public health, medicine, sociology, anthropology,
etc.E.     Observations:  On research activities and operational mechanisms to
develop national research programs in a Regional network or program in
health economics and finance which supports the national programs.















APPENDIX 4
COUNTRY REPORTS:
INVENTORY OF ACTIVITIES
IN THE AREAS OF
HEALTH ECONOMICS AND FINANCE
ARGENTINA


AREA A - HIGH LEVEL


1.   SEMINARS:  Expenditures on Health in Argentina, the Economic
     Impact of the Drug Policy, the Distribution of Resources on
     Health and their Relation to Needs, and Expenditures on
     Health as Social Redistributor of the State.

     Organized by the Argentine Association of Health Economics.

     Participants:  40-100 according to seminar, duration 2 to 3
days, public sector 30%, social sector 30%, private sector 40%.

     Members of the Argentine Association of Health Economics and
special guests of the Government participated.  The subjects were
presented by provincial leaders.


2.   COURSES/WORKSHOP:  HEALTH ECONOMICS

     A.   School of Administration and Health Economics.
Participants 30, duration 8 weeks, introductory content
on Health Economics, own materials.

     B.   National University of La Plata, Ministry of Health,
Ministry of Economics, Scientific Research Council.
Participants 30, number of courses 2, total 60, public
sector 15, social security 5, private sector 10.

     C.   Executive staff members from the public, private, or
social security sector.


3.   COURSES/WORKSHOP:  HEALTH AND EQUITY

     Health and Equity:  Elements of Public Policy on Allocating
     Resources according to Needs.

     National University of La Plata, Ministry of Health,
     Ministry of Economics, Scientific Research Council.
     Participants 20, own materials, cases, participants from the
     public sector.
     Observations:  Reserved for provincial, national, or
     municipal staff members.


AREA B:  UNIVERSITY TRAINING

A.   Evaluation of Projects

B.   National University of La Plata, Ministry of Health,
     Ministry of Economics, Scientific Research Council.

     Participants 20, duration 8 weeks.
     Introduction to the Evaluation of Projects with Case
     Analysis and Practical Work.
     Public and Private sector.

C.   Research program -  Action on Health Economics.

     School of Administration and Health Economics.  National
     University of La Plata -  Ministry of Health - Professional
     Council of Economic Sciences.

     Participants 40, own materials, participants:  Graduate
     fellows, graduates in accounting or economic sciences.
     Program is carried out in the institutionsÐ mainly
     hospitalsÐin areas of research (e.g., collection, costs,
     personnel, etc.).

D.   Residency in Social Security.  All the principles and
     techniques of social security.  Includes module lasting 4
     months on health economics.

     School of Administration and Health Economics, University of
     La Plata -  Medical Assistance Institute - Ibero-American
     Social Security Organization.

     Participants 25, duration 2 years, multiple materials.

E.   Chair of Health Economics (UBA).

     National University of Buenos Aires - Graduate
     specialization.


AREA A-B

.    Chair of Health Economics of the UADE (Argentine University
     of Management) organizes International Seminar on Medical
     Economics.

     Participants 300, duration 3 days - once a year,
     participants 20 public, 20 social security, 60 private.

.    Chair of Health Economics.

     Catholic University of Buenos Aires -  Annual Course on
     Health Administration -  Module on Economics 30 days.


AREA C
RESEARCH ON Health economics and finance


     A document on "Research Program on Health Economics,"
Agreement Ministry of Health of the Province of Buenos Aires and
the Professional Council of Economic Sciences of the Province of
Buenos Aires, was presented.


BRAZIL


"HIGH LEVEL":  .     Policy Authority
.     Technical Knowledge


1.   "High policy level"

     State and municipal health secretaries, representatives and
     senators on the Social Security and Budget Committee.

2.   "High technical level"

     Managers:

     .    of the health system (Ministry, State, and Municipal
Health and Planning Secretariats).

     .    of health units.


I.   ACTIVITIES:

     1.   High Policy Level

Half-day meetings coinciding with meetings of the
National Council of State and Municipal Health
Secretaries.  Series of thematic meetings:

For example:

.    Criteria for distribution of resources.

.    systems for monitoring of costs.

.    Public - private "mix".

.    Systems for monitoring quality of the health
services.

.    Needs - demands - utilization of health services.

     2.   Technical Level

a.   Specialist resources coordinated by the Brazilian
Association of Health Economics.

b.   Seminar on Health Economics (40 hours).

c.   Post-graduate:

.     Refresher course on Financing of the Health
Sector (120 hours).

.     Specialized course on Social Security (360
hours).

.     Regional course?

d.   Program of support for the graduate training of
human resources strictu sensu:  ABrES.


II.  NECESSARY SUPPORT

     1.   Financial resources:  per diems, honoraria (invited
professionals), travel, fellowships.

     2.   Teaching material.

     3.   Support for organizing an integrated health information
system.

     4.   Support for ABrES to promote fellowships for master's
degree and doctoral theses in the area of health
economics.
THE CARIBBEAN



HIGH AND MID-LEVEL TRAININGACADEMIC TRAININGRESEARCH1.Experience/
  Current Situation.1989 -  EDI/PAHO/CDB Seminar on training in Health economics and finance - 2 weeks -  About 30 participants.
. Since then, no other program..Diploma in Health Management program was conducted from 1987-89.
. Some aspects of health economics are included in undergraduate and graduate courses at UWI and CAST.  .Specific project research done at ISER and Dept. of
Economics on:
  
  - Financing care health.
  - Privatisation.
  - Social emergency funds.
  - Impact of structural adjustment.2.Needs/Gaps.Managerial and Planning
. Negotiating Technical
  Assistance
. Project preparation/
  Implementation
. Program Budgeting
. Financing Issues in Health
. Information Management.3 levels of training with possibility of advancing upwards:

i)Certificate courses.

ii)Diploma.

iii)MSc./PhD Program.  .Develop Research program rather than isolated projects.
. Specific research on:
  
  - Public policy and health,
  - Trade in health services,
  - Cost effectiveness studies.
3.Observations/
  Recommen-dations.Regional Workshop supplemented by national and in-service seminars.
. Use staff from local tertiary institutions and international organizations.
. Use attachments/short term training in international organizations..Use internships and provide incentives/ scholarships.
. Invest in training of trainers.
. Assistance in networking and development of teaching materials..Support research fellowships in health at University.
. Develop networking arrangements.
. Publish research findings.
. Convene workshops/seminars, etc. to discuss research.CHILE

I.   TRAINING PROGRAMS AND COURSES

     HIGH LEVEL (TRAINING)

     Experience:

     1.   Hospital Administration Seminar, carried out once a
year, convened by the private sector with the
sponsorship of the Ministry of Health.  Its duration is
3 days and it is geared to senior executives from care
centers in the public and private sector.

Around 300 persons participate.

Program:  The seminar includes the following major
subjects:

.    Health policies
.    Administration of human resources
.    Organizational aspects
.    Financial mechanisms
.    Conceptual framework of administration and
economics.

     2.   Day-long meeting of the Ministry of Health with the
Regional Secretaries (SEREMI), carried out 2 or 3 times
a year, convened by the Minister of Health.  Its
duration is 2 days and it is directed toward senior
executives in charge of the regional administration of
the health systems.
Approximately 30 to 40 persons participate.

Program:

.    Review and orientation of health policies
.    Review and orientation of budgetary allocations
.    Identification of operational and financial
problems in the services
.    Orientation on the management of investments to be
made.

     MIDDLE LEVEL (TRAINING)

     1.   PIAS:  Health Administration Program, carried out once
a year by the School of Economics of the University of
Chile.  Its duration is 1 month, and it is
preferentially directed toward intermediate-level
executives.

Thirty-five persons participate.  The program includes
topics in management and business administration and
project evaluation techniques.

     2.   Courses on evaluation of health projects (MIDEPLAN-
MINSAL).  Carried out jointly every 2 years by the
Ministries of Planning and Health.  Its duration is 2
weeks and it is oriented toward administrative chiefs
in the public health sector.

Sixty persons participate.

Program:

.    Includes basic concepts of economics
.    Techniques of project evaluation
.    Study of a practical case.

     3.   Courses on Preparing Health Projects (MIDEPLAN-
SERPLAC).  Carried out once a year in different regions
of the country by the Ministry of Planning.  Its
duration is 2 weeks and it is oriented toward chiefs of
project preparation units at the regional and municipal
levels.

Forty persons participate.

Program:  Identical to course 2.

     4.   CIAPEP:  Inter-American Course on Preparation and
Evaluation of Projects.  Carried out once a year by the
Institute of Economics of the Catholic University with
financing of MIDEPLAN.

Its duration is 9 months and it is oriented toward
chiefs of project evaluation and preparation in both
the public and private sectors.

Forty persons participate.

Program:  4 months of theory, which includes:

.    Principles of economics
.    Accounting
.    Private and social evaluation
.    Preparation of projects
.    Administration and control of projects
.    Special topics
.    Five months of practical work:  prefeasibility
study of a project of national interest.

     5.   Regional Course on Evaluation of Projects:  It has the
same characteristics as the CIAPEP course but is
carried out in regions 4 times a year, with a duration
of 1 month.


II.  TRAINING OF HUMAN RESOURCES IN INSTITUTIONS OF HIGHER
     EDUCATION (UNDERGRADUATE AND GRADUATE)

     1.   Master's degree in Public Health.
Administered by the School of Public Health of the
School of Medicine of the University of Chile.

     2.   Master's degree in Hospital Administration. 
Administered by the Schools of Economics and Medicine
of the University of Chile.

     3.   Latin American Course on Nutrition and Public Health,
administered by INTA (Institute of Food Technology of
the University of Chile).

     4.   ILADES - GEORGETOWN master's degree in economics with
specialization in social policy.


III. RESEARCH

     1.   Specific requests from the public or private sector
(socioeconomic evaluation - PNAC).  Some of this
research is carried out by the Departments of Studies
in the public sector itself.

     2.   Originating from academic interests and financed by
research funds.

     3.   Research carried out by private centers.


NEEDS AND REQUIREMENTS

     The needs will be divided into 3 major categories:  a)
training in short-term seminars basically directed toward
executives; b) training in graduate-level programs emphasizing
health economics; c) research in diagnosis and/or analysis of
economic problems in the health sector.

a)   Training (senior and middle levels):

     Three course levels are distinguished:

     i)   Application of economic concepts to activities in the
health sector directed mainly toward senior executives,
oriented to decision making.

     ii)  Specific health subjects directed toward persons
oriented by experience toward specific matters, e.g.: 
recovery of hospital costs, definition of preventive
programs (AIDS, smoking habit, etc.).

     iii) Study and analysis of specific techniques, e.g.,
target-impact system for evaluating programs;
techniques of analysis of discrete selection, etc.

     We consider with respect to i) that this can be provided by
     the national level, but it would appear interesting to
     utilize the "network" to formulate case studies which can be
     utilized in these seminars.

     Concerning ii), thought should be given to establishing
     regional seminars which deal with some of these specific
     subjects and permit the  exchange of experiences among
     countries.

     Finally for iii), we believe that PAHO could provide
     technical assistance by contracting experts to give seminars
     in each of the countries.

b.   Training (institutions of higher education):

     i)   Inclusion of courses on or subjects within a course
dealing with health sector problems in the economics
and administration curriculum at the undergraduate
level, for example:  in the administration curriculum
of health manpower incentive problems. 

     ii)  Inclusion of an area of study at the graduate level,
for example:  health economics within a master's degree
in economics.

     iii) Creation of a graduate-level program directed toward
problems in the health sector.



COLOMBIA


1.   Proposal of delimiting the subject of health economics

     Three subject areas which can be dealt with by means of
research and training activities are proposed.

     1.1  The relationship between health and Development;

     1.2  The impact of macroeconomic policy measures on the
state of health;

     1.3  Application of microeconomics to the process of
administering health services.  In this area this opens
up the real possibility of a health economics, and it
may include some of the following approaches:

-    Systems of Financing,
-    Development of Economic Models,
-    Project Evaluation and Management.

2.   Identification of Levels of Intervention and Training

     This starts with recognition of the need for acting
differently according to the profile of the groups intended to be
trained.

     2.1  Senior staff members.  Through its formation, which is
not precisely economic, a process is intended of
sensitization and motivation toward the subject through
short seminars with very specific content;

     2.2  Other staff members of the Ministries and hospitals. 
From a diagnosis of its needs in the area, more
specific training is sought to make them more open to
the application of economic tools in the rational use
of resources;

     2.3  Graduate-level students in public health and health
administration.  It is sought to review curriculum
design and to propose courses on health economics which
go beyond what is offered and achieve the application
of effective techniques and models adapted to their
profile.

     2.4  Students in Schools of Economics.  To promote interest
in them in the subject, especially in its thesis and
research efforts.  Stimulus of such efforts is promoted
by sensitizing professors and creating financial
incentives (prizes).

3.   Proposal for Conducting Research:

     3.1  To determine research priorities and establish general
lines;

     3.2  To motivate research centers in universities with
Schools of Economics.


COSTA RICA


Training and Research on Health economics


A.   Training Programs and Courses for Senior and Middle-level
     Personnel.

     CENDEISS (Center for Health and Social Security Education
and Research), Directorate of the Costa Rican Social Security
Fund (CCSS) carries out this task.

     Approximately 50 courses and seminars of varying duration
(from 3 days to 6 months) which are given to staff members of the
Costa Rican health sector are offered annually.  Persons from
other Central American countries also participate in some of the
events.

     The preparation of the annual training program is carried
out in consultation with the directors and chiefs of the
different institutions in the sector, who establish their
concrete demands.

     Among the subject areas are aspects essentially related to
administration (accounting/budgeting/finance, etc.) and
specialties in the medical sciences.

B.   Manpower training in health economics and finance in
     institutions of higher education.

     No courses on health economics exist at the undergraduate
level, either in Schools of Economics or of Medicine.  The only
course on health economics is given in the Master's Degree in
Public Health Program.  It was initiated in 1991.

     The course lasts a semester.  It includes three principal
areas:

     a.   Macroeconomics/Economic Policy,
     b.   Microeconomics/Administration, and
     c.   Social Policy/demography.

     The number of students fluctuates between 25 and 30.

C.   Research on Health economics and finance.

     There is no structured program in the field of research. 
Neither the health institutions (CCSS and Ministry of Health),
the universities, nor private research centers systematically and
organically conduct studies in health economics.

     The few investigations which are conducted deal mainly with
the EVALUATION of programs and projects or with aspects related
to administration (cost/efficiency of health institutions).  To a
great extent, this is because of the lack of resources for
conducting other kinds of studies.

     Of particular importance is the absence of research projects
on macroeconomic topics and their linkage with the health sector
(structural adjustment, devaluation, public finance, etc.), as
well as the impact of macropolicies (commercial liberalization,
reform of the State, privatization) on the health sector and the
demand for services in this field.



MEXICO


      PROPOSAL FOR STRENGTHENING NATIONAL AND INTERNATIONAL
PROGRAMS - MEXICO


AREA A:   TRAINING PROGRAMS AND COURSES FOR SENIOR AND MIDDLE-
LEVEL PERSONNEL.

Experiences:

     a)   Type of Activity:  Seminars and workshop-courses (mixed
technique in which a formal chair is used with
exercises and presentations by participants in case
studies.

     b)   Promoting institutions:  National Institute of Public
Health (6 courses); Inter-American Center for Social
Security Studies (4 courses).

     c)   Characteristics:  Number of participants:  average of
15 students per course.  Duration:  two or three weeks.

Contents:  Basic subjects to be covered, which are
adjusted to the needs of the participants:

     .    Introduction to health economics,
     .    Principal fields in economics and health.
     .    Economic development and health,
     .    Macroeconomics, national accounts, and health.
     .    Determinants of health,
     .    Health as an economic good.
     .    Health systems.
     .    The demand and distinctive characteristics of health
demand (externalities, induced demand, consumer
ignorance, meritorious goods, etc.),
     .    Imperfections in the health care market.
     .    The role of the State and instruments of policy, taxes,
subsidies, controls, and regulations.
     .    The process of producing health services,
     .    The cost of services.
     .    Techniques of microeconomic evaluation, cost-
effectiveness analysis, cost-benefit, and cost-
usefulness.
     .    Selected subjects:  equity, care quality, financing,
and financial diversity.  The role of the public,
private, and social sectors.  Technology.  Human
Resources.  Demographic and epidemiological transition. 
Economic aspects of social security.

Materials utilized:  A basic bibliography is available
for each subject which can be obtained in:

.    Cruz C. Hernández P.  Economía de la Salud. 
Reflexiones en Materia Educativa.  Journal of
Health Administration Education.  Summer 1991.

.    Arredondo A., Cruz C., Hernández P.  Formation de
Recursos Humanos en Economía de la Salud. 
Revista de Education Médica y Salud, OPS.

In addition, original teaching materials, digests,
acetates, and slides are available.

     d)   Participants:

Social security:  (4 courses, 15 participants per
course).
Public Sector:  (6 courses, 15 participants per
course).

     e)   Problem:

e.1  Capacity exists for 30 participants and there are
only 15 students on average because of lack of
financial resources for attending (per diems and
transportation).

e.2  There is now only an introductory course and there
is no serial or continuous training.

     f)   Needs:

f.1  Fellowships to increase the number of participants
in the courses.

f.2  Support for the organization of courses outside
the headquarters which would entail per diems and
travel expenses to the province, for 2 professors.

f.3  Support for the structuring of serial courses:
.     Financing,
.     Costs,
.     Techniques of microeconomic evaluation.

f.4  Support for the final phase of textbook
preparation.


AREA B:   MANPOWER TRAINING IN Health economics and finance IN
INSTITUTIONS OF HIGHER EDUCATION (DEGREE AND GRADUATE-
LEVEL).

Experiences:

     a.   Type of Activity

Four graduate-level programs in which health economics
is one of the central topics.

.    Specialty in Hospital Administration,
.    Master's Degree in Public Health,
.    Master's Degree in Health Systems,
.    Master's Degree in Epidemiology.

     b.   National promoting institutions:

.    National Institute of Public Health.

There are other universities in the country which offer
graduate courses which cover health economics. 
Autonomous National University of Mexico:  (School of
Medicine, School of Accounting and Administration)
Metropolitan Autonomous University of Xochimilco,
Master's Degree in Social Medicine.

     c.   Characteristics:

Number of participants:  MPH 100 students on average;
other programs 10 master's degree students.

Duration:  MPH and Hospital Administration (1 a year),
2 courses on Health Economics, Master's Degree in
Health Systems and Epidemiology (2 years), 3 or 4
courses on health economics.

Contents:  Basic subjects to be covered, which are
adjusted according to the curricula and profile of the
graduate:

.    Introduction to health economics,
.    Principal fields in health economics,
.    Economic development and health,
.    Macroeconomics, national accounts, and health,
.    Determinants of health,
.    Health as an economic good,
.    Health systems,
.    Demand and distinctive characteristics of health
demand (externalities, induced demand, consumer
ignorance, meritorious good, etc.),
.    Imperfections in the health care market,
.    The role of the State and instruments of policy,
taxes, subsidy controls, and regulations,
.    The process of producing health services,
.    The cost of services,
.    Techniques of microeconomic evaluation, analysis
of cost- effectiveness, cost benefit, and cost
usefulness.
.    Selected subjects:  Equity.  Quality of care. 
Financing and financial diversity.  The role of
the public, private, and social sectors. 
Technology.  Human Resources.  Demographic and
epidemiological transition.  Economic aspects of
social security.

Materials utilized:  A basic bibliography is available
for each subject which can be obtained in:

.    Cruz C., Hernández P.  Economía de la Salud. 
Reflexiones en Materia Educativa.  Journal of
Health Administration Education.  Summer 1991.

.    Arredondo A., Cruz C., Hernández P.  Formation de
Recursos Humanos en Economía de la Salud. 
Revista de Education Médica y Salud.  OPS.

In addition, original teaching materials, digests,
acetates, and slides is available.

     d.   Participants:  Social security, 5% of students; Public
Sector, 80% of students; Students from other countries,
15% of students.

     e.   Problem:

e.1  Space is available for 20 students in the master's
degree programs in sciences but there are only 10
students on average because of lack of financial
resources.

     f.   Needs:

f.1  Fellowships to increase the number of participants
in the courses.

f.2  Support for the final phase of textbook
preparation.

f.3  Promotion of master's degree programs in the
region.

f.4  Support for organizing a master's degree in health
planning and financing.


AREA C:   RESEARCH ON ECONOMICS AND FINANCING

Experiences:

     a.   Type of research:

.    14 investigations from 1987 to 1991.
     
     b.   Promoting institutions:

National:  National Institute of Public Health.
Regional:  PAHO, World Bank, UNICEF, Kellogg
Foundation.

     c.   Characteristics:  Technical nature:  Analytical and
propositive research to obtain primary data.

Duration:  from two to three years.

Contents:

.    Demand for health services.
.    Community participation and financing of health
services.
.    Decentralization of health care and economic
crises.  Research of the effect on health.
.    Patterns of utilization of services in the infant
population in the Federal District of persons
entitled to IMSS services.
.    Allocation of resources for research and
development of drugs in the pharmaceutical
industry in the United States and Mexico.
.    Research on the supply of medical equipment in
Mexico.
.    Planning and financing of the health services
under decentralization.
.    Economic crisis, public spending, and health in
Mexico.
.    Socioeconomic level and utilization of health
services.
.    Development and application of a methodology to
analyze health service costs in Mexico.
.    Ambulatory vending as a risk factor for the health
of women and their children.
.    Analysis of demand by women of reproductive age.

Material resources:  Computer support is available for
each investigation.

Human resources:  Each investigation relies on a
principal investigator, from three to four associate
investigators, and a technical support team
(interviewers, coders, compilers, programmers, and
administrative support).

Financing:  Each investigation has external financing
of $20,000 on average.

Participants:  Each investigation is led by a health
economist and its multidisciplinary group is composed
of physicians, sociologists, geographers,
nutritionists, accountants, psychologists,
statisticians, etc.

Problem:  Greater financial resources are required to
carry out quasi-experimental pilot projects using
alternative forms of financing.

Needs:

1.   Greater resources to conduct quasi-experimental
investigations.

2.   Financial support to organize a program of serial
publications of research results like "Discussion
Documents" (Discussion paper of the York
University type).




DOMINICAN REPUBLIC


Premises:

     The development strategy which the country follows
     conditions sectoral dynamics.

     1.   A good sectoral policy may be completely defeated by
the economic policy which flows from the development
strategy.

For example:  competitiveness based on wages or
devaluation results in deterioration of public services
because of the fall in real incomes of the population.

It is necessary to demonstrate that health is something
that goes beyond the clinical area.  The health of the
population affects the strategy of development itself.

     2.   The health of Dominicans can only improve when if there
is a commitment by civilian society.  In a democratic
society, that society should create surveillance
mechanisms involving all social groups:  entrepreneurs,
unions, development NGOs, the press, opinion molders,
etc.

Objectives:  Seminars on Health economics and finance.


     .    To remove the subject of health from the area of
physicians.
     .    To create a National Health Forum.

     The objective of the National Health Forum will be to
     discuss the problem of health in the framework of the
     strategy of development.  To see that the subject of health
     is part of the agenda of the sectors that make decisions or
     that influence social policy and economics.

     "Health to the extent that it helps promote the basis of
     competitiveness, from wages to productivity, is a much too
     important subject to leave in hands of the physicians."

     A set of activities can be included in the framework of the
     forum which do not exceed more than 4 or 5 hours per
     completely self-contained session, in which the basics of
     health economics are presented.

     In addition to this, studies should be conducted on very
     concrete aspects concerning the situation of hospitals,
     public spending on health, measurements of efficiency, etc.,
     which would be presented at the Forum.

     The end result of the Forum should be the formulation of a
     Development Plan for the Health Sector, using the same
     methodology followed in drawing up the National Education
     Plan.

     PAHO, the World Bank, and other international agencies can
     contribute experts and technicians to support the work of
     nationals as well as support through the financing of the
     Forum.
APPENDIX 5















REPORTS OF THE WORKING GROUPS
BY SUBJECT AREAS



Group A:  High-level Training; Alicia Uga (Brazil), Pillar
Contreras (Chile), Marta Madrid (Colombia), Jorge A. Hernández
(Costa Rica), Rocío Santoyo (Mexico), Ginés González (Argentina),
Rubén Suárez (Consultant).

Group B:  Academic training; Denise Cavallini (Brazil), José
Domingo (Dominican Republic), Arístides Torche (Chile), Alvaro
Olaya (Colombia), Juan Carlos Belausteguigoitea (Mexico), Matilde
Pinto (PAHO).

Group C:  Research; Diane Oya (Brazil), Freddy Velandia
(Colombia), J. M. Villasuso (Costa Rica), Miguel Ceara (Dominican
Republic), Karl Theodore (Trinidad and Tobago), Carlos Cruz
(Mexico), Stanley Lalta (Jamaica), Antonio Campiño (PAHO).

GROUP A:  HIGH-LEVEL TRAINING


I.   Two types of seminars:  (for high-level policy staff
     members).

TYPE I SEMINARS:  Sensitization courses for high-level staff
members.

     These are short-term (1-2 days) and at the national level. 
They deal with economic aspects but are oriented toward showing
cases, experiences, and processes which support the decision-
making role that these staff members fulfill.


TYPE II SEMINARS:

     Informational or training.  They are international in nature
and based on the exchange of experiences from different countries
or on the study of a specific case.


PROPOSED SUBJECTS:

     1.   Financing of the Health Sector:

a.   Organization of the system of financing and its
relation to the organization of the system of
providing services,

b.   Study of proposals for privatizing services,

c.   Analysis of equity in the system of financing.

     2.   Health and Development

a.   Analysis of equity in terms of the distributive
impact of the organization on the provision of
services,

b.   Economic growth and health:  for example, to study
the economic impact of certain diseases such as
malaria, AIDS, etc.,

c.   Impact of macroeconomic adjustment policies on the
health sector.

     3.   Decentralization

Exchange of experiences between countries which are
carrying out or have advanced processes of
decentralization.

     4.   Processes of Economic Integration and their
Relationship to Health Systems and Social Security.


II.  Support Needs of Financing Agencies:

     1.   Strengthening of regional information in general,
support for the creation of an information system based
on exchanges between countries.  This information
should also deal with research which is being carried
out or has been carried out and the documentation
available on different subjects in health economics.

     2.   Contracting of experts, both international and
national.

     3.   Translation and publication of documents.

III. Seminars directed toward High-level Technical Persons.

     Among these could be some on various methodologies for
     evaluating projects in the health sector.


GROUP B:  MANPOWER TRAINING IN ECONOMICS AND FINANCING IN
INSTITUTIONS OF HIGHER EDUCATION (UNDERGRADUATE AND
GRADUATE-LEVEL)

     The group dealt with the subject of training for graduates
and postgraduates in gradual form which starts with the creation
of an academic area in universities for health economics and
eventually generates new courses which would be offered to health
professionals in graduate-level programs.

     The levels of intervention would be the following:

1.   Students of Economics and Administration

     1.1  Offers of optional courses on health economics.  There
are doubts about the levels of motivation of students
toward this discipline.  It is suggested that health
agencies stimulate Schools of Economics by creating
openings for student practice and thesis possibilities
related to health.

     1.2  To take advantage of the space that the current
programs have in courses on social policy, public
finance, and human resources economics (in Brazil) to
introduce elements of health economics.

2.   Graduate-level training

     After analyzing the feasibility of creating specific
     graduate-level studies in health economics, the group does
     not think it feasible to create master's degree or
     specialized programs in the countries.

     It is perhaps more feasible to design courses or areas of
     emphasis in graduate-level programs on economic policy,
     economic development, and evaluation of projects currently
     offered in the universities.

3.   Training of professors

     We think it of crucial importance both to motivate and
     prepare groups of professors who will be vitalizing agents
     for this discipline in our universities.  For this purpose
     the following strategies are suggested:

     3.1  Advisory services of experts so that courses are
offered and research proposals promoted in the
countries,

     3.2  Training of nationals in universities abroad with joint
financing from the countries and international
agencies,

     3.3  Internships or fellowships among countries of the
Region with economic assistance from PAHO, IDE, or
other agencies.  Such internships would be of short-
term (3 or 4 weeks), with visits to programs and
meetings, and access to bibliography.


GROUP C

1.   Necessary Conditions

     1.1  Information

To raise the level of awareness of health institutions
which compile information on research needs.
     1.2  Investigators

Research cannot be conducted without investigators.

a)   Allocate resources to train investigators.

b)   PAHO should collaborate in the formation of a
critical mass at the country and regional levels. 
This could be done in different ways.  To bring
investigators together.

2.Institutional Framework

     2.1  Divorce between health and research institutions.

Health institutions do not request research other than
in specific areas (isolated and operational areas)

Research institutions do not generate research
proposals.

3.   Subject Areas/Lines of Research

     3.1  What are the major questions of policy which are
relevant to each of the countries?

2 Areas:   i.   Trade and Health Services
ii.  Reform of the State

-    Long- and short-term studies
-    Large and small studies

4.   Financing

     4.1  Great competition for resources
     4.2  To get ahead of problems is a way to obtain financing
     4.3  Private sector/Few possibilities

4.3.1The current system reproduces the inequality.

PAHO:  To help identify sources of financing
Cofinancing

5.   Strategy

     To elevate the status of "health economics" (status).

     Conducting National Forums to discuss aspects of health
     economics and finance.




















APPENDIX 6
AREAS OF INTEREST
INTERNATIONAL COOPERATION AGENCIES
APPENDIX 6

        AREAS OF INTEREST OF EXTERNAL COOPERATION AGENCIES


IDE - WORLD BANK:

     The IDE has identified three mechanisms through which
activities of the national programs of health economics and
finance could be supported:  i) promotion of the demand for high-
level training through the operations of the bank, ii) direct
support for conducting activities to develop consensus about
health policies, and seminars and workshops on specific topics in
health economics and finance, and iii) promotion of the
fellowship programs administered by the EDI and the World Bank
(World Bank Scholarship Program, and Robert MacNamara Fellowship
Program).

     Direct support of national programs could be given in the
form of:  reproduction and production of training materials,
financing the participation of experts in seminars or national
training workshops, direct participation of staff from EDI and
other divisions of the World Bank in activities of national
programs, logistical support for the preparation of seminars and
methodologies of training, and support for the exchange of
educators and participants from different countries in the
region.  EDI, in coordination with PAHO, is considering the
possibility of contracting a consultant to support the
development of national programs and formulate a regional program
of support for national programs to be presented as a regional
project to international financing agencies.


PAHO - HSP

     There are three areas of work in the Health Policy
Development Program of PAHO (HSP/PAHO) which could be utilized to
strengthen national training programs:  i) the research area, ii)
training seminars, and iii) dissemination of materials on health
economics and finance.

     In research, HSP has promoted and financed research on the
financing and economic impact of the economic crisis on the
health sector, on the social security systems in the countries of
the region, and on the experiences of the investment funds and
social compensation programs in countries of the region. 
Discussions (policy papers) have also been conducted on the
relationship between health and development, the exchange of debt
for health projects, and sectoral adjustment programs.  The
development of a data bank containing household surveys
(demographic and family budget surveys, continuous household
surveys, and national health surveys) and to promote research on
accessibility and expenditure of households on drugs and health
services is programmed in the program of work for 1992-93.  The
creation of a regional prize for the best graduate-level theses
(MA or PhD) on health economics is being planned as part of the
research promotion program.  Another source of financing for
research proposals by national programs or of a regional program
is PAHO/WHO's research grants program.  This program finances (or
cofinances) around 50 projects per year, up to the sum of
US$20,000.

     With EDI/World Bank, HSP/PAHO's program of training
activities will continue supporting seminars on health economics
and finance.  It will continue giving support to two-week
seminars on Planning and Development of Health Projects, which
will be changed into International Courses on Planning and
Development of Health Projects lasting a month.  It will continue
supporting national training programs through the participation
of personnel and financing of experts and participants.

     PAHO can also support national programs by facilitating
institutional publications on health economics and finance
(PAHO/WHO publications), facilitating educational materials
developed by the division for project seminars, and financing the
development of materials and case studies for national training
seminars.


USAID:

     The Division of Population, Health, and Nutrition in USAID's
Office for Latin America and the Caribbean has been supporting
the execution of studies on health financing since the middle of
the 1980s.  Research proposals and cooperation programs are
financed at the central level, at the level of the regional
offices, and at the level of the country representations of AID
in the countries.  At the country level, technical and financial
support is requested directly from the representation or through
it.

     At the central level, the Division of Health, Population,
and Nutrition for Latin America and the Caribbean channels
technical cooperation to or through the Country Representations
to the governments of the countries through the project called
"Latin America and Caribbean Health and Nutrition
Sustainability - Technical Support for Policy, Financing, and
Management" "Project of Technical Support and Self-sufficiency in
Policy, Financing, and Health Administration and Nutrition for
Latin America and the Caribbean" (LAC-HNS).  This project is part
of a larger worldwide project entitled "Health Financing
Sustainability."  LAC HNS is carried out under contract with two
private consultants:  University Research Corporation (URC) and
ISTI (International Science and Technology Institute).  LAC HNS
is conducting studies on recurring costs of primary health care
and nutrition programs in Belize, Bolivia, Guatemala, Nicaragua,
and Peru, and will soon begin to carry out a similar study in
Paraguay.  AID promotes and conducts research on alternatives for
financing health programs, resource allocation policies, cost
control and recovery, and private alternatives for providing and
financing health services.  The LAC HNS project has experience in
carrying out sectoral studies, holding workshops, and research
for decision making.  Research and technical cooperation
activities with the countries and to support the development of a
regional health economics and finance network could be
coordinated with URC/ISTI.

     AUPHA is the international consortium of programs of
education in health services administration.  This consortium
includes more than 150 universities, 400 organizations supplying
health services, individuals, and representatives from
governmental institutions, professional associations, and the
health industry.

     AUPHA's network of programs includes participants in more
than 35 countries and is very extensive in the United States,
Canada, Latin America, and the Caribbean.  Its mission is to
promote excellence in education, training, and research in the
field of the health services administration.  Since 1948, AUPHA
has promoted and coordinated the responses of the academic
community to the policy, management, and administration needs of
the health services.  It contributes to the local development of
university programs and in-service health training; it has
developed methodologies applied to this discipline such as the
use of chaos and the remote education of executives; AUPHA
publishes two journals and a newsletter in Spanish containing
articles which include subjects on economics and financing of
health services.  In North America it has established a network
of experts in economics and financing of services who can
facilitate the activities of the Latin American network.  It
participates actively in training programs and recycling of
professors.

     URC/ISTI, a private consultant executing the Support of
Health Programs and Nutrition project, has experience in
conducting sectoral studies, workshops, and research for decision
making on policies of financing and management of health and
nutrition programs.  URC is carrying out studies on recurring
costs of primary health care and nutrition programs in Belize,
Bolivia, Guatemala, Nicaragua, and Peru, and is initiating
another study in Paraguay.  USAID is sponsoring country studies
on the public-private mixture in providing health services. 
Investigations are being promoted and carried out on alternatives
for financing primary health care and nutrition programs,
resource allocation policies, cost control and recovery policies,
and the public/private mixture in the financing and provision of
health services.  Research activities and technical cooperation
with the countries, and activities to support the development of
a regional network or program could be coordinated with URC/ISTI.


IDB

     The financing of studies through consultantships is the most
direct way of obtaining resources from IDB.  However, IDB has
also participated in financing regional studies, such as that on
crisis and health carried out jointly with PAHO, is responsible
for studies to prepare the annual report on economic and social
progress in Latin America, and supports activities of some
graduate-level programs of countries in the region (University of
the Andes, Colombia; Torcuato DiTella Institute, Argentina, and
the Institute of Nutrition of Central America and Panama (INCAP). 
Through the ECIEL (Joint Studies of Latin American Economic
Integration) regional network or program it has promoted several
regional studies.

     The following were identified as areas of interest for the
development of consultantships:  i) studies on equity in health
systems which contribute to better focalization of health
projects, ii) studies on demand for health services which help
identify the payment capacity and willingness of consumers and
the shaping of the provision of health services, iii) analyses
and studies of costs which can be included in managerial
information systems, iv) analysis of health units as economic
units producing services, v) studies which contribute to
developing national investment and technology selection
strategies, what health services to offer, to whom, how much, and
what technologies to utilize, and, vi) studies on current and
anticipated impact on health services.


WORLD BANK LAT/LAC-HR

     The World Bank saw a rapid growth in operations in the area
of human resources.  Individual and institutional consultantships
are one of the mechanisms through which some of the activities of
national programs could be supported.  Technical cooperation by
experts in the area of health economics and finance is another of
the lines of cooperation that could be utilized by national
training and research programs.

     Among the areas of interest that the LAT/LAC-HR division of
the World Bank would be interested in supporting were:  i)
proposals of sectoral reforms in financing and organization of
the health sector, ii) technical support in developing investment
proposals, and iii) post-evaluation of investment and
institutional development proposals in the health sector.  Also,
through the operational areas of the World Bank, training and
research activities of the national programs could be actively
promoted.  Dissemination of information on the activities of
national programs through the regular publication of the LAT-
HR division (LAC Newsletter) and dissemination and exchange of
research reports are other mechanisms which could be utilized to
promote and strengthen the national programs.

     It was also pointed out that a coming issue of the annual
report on World Economic Development will deal specifically with
the subject of health.  This has required and will require
research projects which could be carried out by institutions or
investigators in the region.
INSTITUTIONAL STRATEGIC PLANNING MODULE

CASE STUDY:  PLAES

1    Introduction

The case study of strategic analysis for the Caieiras health area
is a combination of information on real situations, fictitious
elements, and variables.  The annex contains the references and
bibliography that served as a basis for preparation of the case
study.  However, it is important to point out that development of
the conceptual elements has been based on the material
investigated and presented by Dr. Stephen L. Tucker, D.B.A. (1)
in the course given on Strategic Planning and Marketing at the
Department of Health Services Administration of Trinity
University, San Antonio, Texas, USA.  Similarly, the physical
location and demographic information is partially derived from a
case study of the SØo Paulo Metropolitan Health Program in
Brazil, which is part of the Physical Planning Module in the
Seminars on Health Development Projects prepared by HSP/PAHO/WHO.

The objective of the case study is to provide professionals with
some of the techniques and methodologies that are used in the
strategic planning of health services, with special emphasis on
hospital units and ambulatory centers.

The techniques presented include:

-    Analysis of competitive advantages and disadvantages,
     opportunities, and risks (ADOR).

-    Segmentation of the programs into Strategic Health Service
     Units (SHSUs).

-    Analysis of the portfolio of strategic programs and
     projects.

-    Strategic physical location of the SHSUs.

-    Segmentation of the markets and physical location of the
     SHSUs.


2    Terms of Reference of the Working Group

A multidisciplinary Working Group was appointed by the manager of
the Caieiras Regional Health System (CRHS) to formulate and
implement a strategic plan of action.  This plan will make it
possible for the institution to operate on an equal footing with
the various health sector actors within the area served and thus
ensure fulfillment of its mission.  As part of this plan, several
studies of an epidemiological, demographic, sociocultural,
economic, financial, institutional, and marketing nature were
carried out.  The results of some of studies are presented here
and will serve as a basis for the Working Group to:

1.   Formulate development strategies for one or more of the
     SHSUs.

2.   Decide on the physical location of the Unit(s). 

The institution's mission was reformulated as the main thrust of
the strategic plan of action, based on a participatory process
that involves both the CRHS executive board and members of
representative community groups.

Mission of the Caieiras Regional Health System

The CRHS is a public nonprofit state institution which was
established for the purpose of providing health services to the
population in the municipios of Mairipora, Francisco Morato,
Franco da Rocha, Caieiras, and Cajamar.  Together with the active
participation of the community and the other public, private, and
corporate health service providers, the CRHS undertakes to meet
the basic health needs of the population in the area served.  For
this purpose it is expected to provide preventive services
together with diagnosis and treatment at the primary, secondary,
and tertiary levels through programs, services, health centers,
and referral and counterreferral mechanisms. 

3   Analysis of the Situation

Epidemiological studies and projections of possible health
scenarios prepared by the Group have made it possible to
determine the frequency of health problems in the region and
develop the following profile of the demand:

a)   Sixty-five percent of the problems can be treated at the
     outpatient level or through preventive community action. 

b)   From 15% to 30% of the cases require immediate action and
     should be treated in emergency outpatient centers or in
     emergency surgery centers that have capacity to handle the
     basic specialties.

c)   Ten percent of the cases should be admitted to general or
     specialized hospitals.

In order to meet the demand for hospitalization in the area
served, the CRHS has a hospital located in the Juqueri sector
(see Annex Map).  This hospital, recently established by the
State Health Secretariat, has a capacity of 142 beds.  The
distribution of the beds by specialties and the corresponding
annual budget are shown in Table 1.

3.1   Profile of the Competition

With a view to characterizing the competitive position of the CRHS in
the hospital field, the Working Group analyzed both the internal and
the external situations and developed the following profiles, tables,
and charts.

The Club Quirúrgico Hospital, an institution established by a group
of surgeons from the clinical specialties, provides tertiary level
hospitalization, emergency care, and specialized outpatient service. 
More than 50% of its installed capacity is permanently occupied by
beneficiaries of the social security system.

The GrÞmio Médico Hospital, founded by the State Physicians
Association, contracts services with private businesses in industry
and trade and provides outpatient and emergency services for the
social security system.

The Grupo Pró-Saúde [Pro-Health Group] has a comprehensive system of
outpatient, laboratory, and hospital units and provides preventive
and curative services to its beneficiaries through a pre-payment
system.  Under capitation agreements with private medical groups, its
sphere of action covers the region and extends to other regions of
the State.

The Santa Maria Hospital is a nonprofit university hospital run by a
religious group.  It provides outpatient and inpatient services in
the basic specialties and also has diagnostic imaging equipment and
specialized laboratories.

3.2  Analysis of Advantages, Disadvantages, Opportunities, and Risks
     (ADOR)

Chart 2 shows the results of the Working Group's analysis of the
internal and external factors that constitute advantages,
disadvantages, opportunities, and risks (ADOR) for the CRHS Juqueri
Hospital.

Terms of Reference of the Working Group

Based on its analysis of the situation of the CRHS Juqueri
Hospital, the Working Group is supposed to propose key strategies
to the CRHS Executive Committee for making the health system
competitive within the region that it serves.  Accordingly, it is
recommended that the Group carry out the following activities:

-   Assess the performance of the clinical programs offered, broken
    down by services.  Based on the information available on both
    the external environment of the sector in general and the
    internal environment of the CRHS Juqueri Hospital, the data in
    Annex Table 1 will assist the Working Group in analyzing the
    mix of programs offered by the Hospital and formulate
    recommended alternatives for development.

-   Based on opportunities and risks in the internal and external
    environment, select the service areas that offer the greatest
    potential for successful fulfillment of the CRHS's mission and
    formulate the corresponding development strategies.


Part I:  Analysis and Selection of the Strategic Units (SHSUs)

Once it has analyzed the different variables presented, the Group
will assign a position to each of the programs within the matrix
shown in Annex Table 2.  Based on its position in the matrix and
the guidelines provided in Chart 3 (see Hax & Majluf, Strategic
Management, An Integrative Perspective), the Group will then select
one of the following lines of action for each of the clinical
programs:

Chart 3.

I.   Invest in expansion of the program with
     a view to achieving a dominant position
     in the sector.

II.  Identify the areas that are strongest
     and break them down in order to
     selectively target the investment while
     at the same time maintaining a
     competitive position.

III. Invest selectively in the
     infrastructure and resources needed in
     order to maintain the competitive
     position achieved and also obtain
     maximum results.

IV.  Reap the benefit of seeds sown in the
     past and get the best possible results
     from the program while monitoring its
     performance.  Minimize investment and
     leave the possibility open to close
     down the program if necessary.


Part II:  Segmentation of the Market 

In its formulation of possible development
strategies, the Group is considering decentralization
of some of the mergency services, since it has been
determined that only 15% of the cases attended in the
Hospital's Emergency Unit actually required emergency
medical care.

The basic data for Part II of the case study will be
processed during sessions in the microcomputer
laboratory.  The Working Group should access the
PLAES file through Lotus 1-2-3.  Below are some of
the criteria that should guide the Group in deciding
on the desirability of one or another alternative and
on the possible physical location of the Ambulatory
Emergency Center(s) (AECs).

Definition of the Area Served

For the purpose of selecting the population to be
captured through the AECs, the Group defined the area
to be served as follows:

The Ambulatory Emergency Center will provide primary
emergency care to the covered population within a
radius of 3 km around the Center for approximately
80% of the visits.

Since the centers are supposed to capture patients
who require emergency medical care and refer them to
the CRHS Juqueri Hospital, the centers should be
located primarily in the municipios in the Caieiras
region that are not directly served by the Hospital. 
The Grupo Pró-Saúde has a network of similar centers
in the municipio of Caieiras.

Characteristics of the Market

Studies have shown that this type of service results
in a demand of between 200 and 300 visits per 1,000
population.  Moreover, it has been found that in
order to justify the investment in terms of
cost/effectiveness, a minimum of 30 visits per day is
required.  Each center must have a minimum of 10,800
visits per year and will have to attend at least
28,400 inhabitants within the area served.  Of these,
it will have to capture about 19% of the primary care
visits in order to meet the target of two visits per
inhabitant.

Among the characteristics to be considered in
deciding on the location of the AECs, the following
criteria were included, inter alia, for breaking down
the population into groups:

-    Percentage of population under 30 years of age: 
     Surveys and operations research have shown that
     young families are the single largest group of
     subjects, given the need to establish a pattern
     of medical and health care for their children. 
     Accordingly, it is recommended that areas be
     selected that have high percentages of
     population age 30 or under.

-   Number of residents per housing unit:  The high
    incidence of disease in population groups living
    in overcrowded conditions, coupled with the more
    likely presence of high-risk groups (mothers,
    infants, and elderly persons) in high-density
    dwellings, suggested that it would be desirable
    to select areas that are characteristic of such
    conditions.  This indicator also makes it
    possible to select areas that have larger numbers
    of workers who are covered by social security.

-   Number of minimum wages per family:  In order to
    provide the low-income population with access to
    emergency services, priority has been given to
    municipios in which 50% or more of the population
    had five or fewer minimum wages per family.

3   Selection of the Project Site

In deciding on the location of the center(s), the
Working Group is supposed to analyze the information
available from the various municipios in terms of the
above criteria and then take the following steps:

a)  From Lotus 1-2-3, recover the PLAES file from the
    diskette given to the participants.

b)  On the basis of the information in Table 2,
    calculate the percentage growth of the population
    over the period 1980-1990.  To facilitate this
    exercise, the following formula is suggested: 
    (1990 population - 1980 population/1980
    population.  The Lotus 1-2-3 copy feature should
    be used to reproduce this formula in each
    municipio (consult with the instructor in the
    microcomputer laboratory).

-   To see a graphic representation of the population
    growth trends, enter the following sequence from
    the Lotus menu:  /GV.

c)  To calculate the percentage of population to be
    captured in order to meet the cost/effectiveness
    criteria indicated above, the following formula
    should be used:  10800/(2*1990 population).  To
    reproduce this formula in each municipio, use the
    Lotus 1-2-3 copy feature (consult with the
    instructor in the microcomputer laboratory). 

d)  Based on an analysis of the population data
    obtained in II and III, together with the other
    indicators in the Table, the Group is supposed to
    make the decisions which in its judgment justify
    locating the AEC(s) in the corresponding
    municipio(s).  This decision, as well as the
    conclusions from Part I of the Case Study, will
    serve as a guide for the formulation of
    strategies to be presented in the next plenary
    session, using the format indicated in Part III.


Part III:  Formulation of Development Strategies
 
    Based on the SHSUs that have been identified
    as having priority and on the results obtained
    in the PLAES case, the Group should focus, as
    it sees fit, on the strategy or central
    strategies to be implemented through the
    Strategic Plan of Action for the CRHS.  The
    tables and charts in the visual presentation,
    included in the annex hereto, can serve as a
    guide for the selection of strategies.


DEVELOPMENT STRATEGIES OF THE CRHS


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Bibliography

l/  Tucker, Stephen L.  (Trinity University, Dean of
    the Division of Administrative and Behavioral
    Studies).  "Strategic Planning and Marketing of
    Health Care Services."  Trinity University,
    Course material and assignments. San Antonio,
    Texas (January 1990). 

2/  Ibañez, Nelson, et al.  "Módulo de
    Planificación Física, Estudio de Caso: Programa
    Metropolitano de Salud, Estado de Sao Paulo,
    Brasil." Seminars on Health Development
    Projects, Program on Health Policies
    Development, HSP/PAHO, Washington D.C. (1987).

3/  Booz, Allen & Hamilton. "The Spring Valley
    Hospital: Case Study."  Planning Engagements. 

4/  Hanna, Nagy. "Planificación y Gerencia
    Estratégica, Análisis de la Experiencia
    Reciente."  Working Documents of the World Bank
    Staff, No. 751, IBRD, Washington D.C. (Feb. 
    1985).

5/  Has, Arnoldo C., and Nicolas S. Majluf.
    Strategic Management: An Integrative
    Perspective. Englewood Cliffs, New Jersey: 
    Prentice-Hall, Inc. (1984). 

6/  Hillestead, Steven G., and Eric N. Berkowitz.
    "Health Care Marketing Plans: From Strategy to
    Action."  Homewood, Illinois: Dow Jones-Irwin
    (1984). 

7/  Kotler, Philip, and Roberta N. Clarke. 
    "Marketing for Health Care Organization."
    Englewood Cliffs, New Jersey:  Prentice-Hall,
    Inc. (1987). 

8/  Parsons, Robert J. William K. Willson, and David
    Youkstetter.  "Applied Feasibility Analysis for
    Urgent Care Centers."  Journal of Ambulatory
    Care Management (Nov. 1985). 

9/  Porter, Michael E. "From Competitive Advantage
    to Corporate Strategy." Harvard Business Review
    (May/June, 1987). 






RESEARCH

     PAHO's role in the support and promotion of scientific
research in medicine, biology, and other sciences directly related
to health problems in the Region of the Americas has evolved
gradually over time.
     In its research activities, the Organization initially gave
preference to health problems of international importance.  In the
beginning stages, during the late 1950s and early 1960s, the
research sponsored by PAHO focused mainly on ecological and
biological concerns that had social implications.  For example,
during that early period studies addressed such topics the
interrelationship of acute infections, nutritional status, and
hygiene as factors in infant mortality; action of simuliid vectors
in the causation of onchocerciasis; and ways to derive high-value
dietary protein from plant sources--to mention but a few.  Soon the
scope of research was expanded to include the testing of new drugs,
studies on vaccine effectiveness (for example, attenuated
poliomyelitis vaccines), the development of simple techniques for
the iodization of salt and prevention of endemic goiter, etc.  Even
comparative epidemiology--represented, for example, by studies on
the frequency of atherosclerosis in ethnic groups from different
continents--was included in the list of research topics of the
time.
     As these early studies progressed, responsible authorities
became aware of the need to formulate long-term plans to coordinate
the research being carried out in the Hemisphere.  Numerous
obstacles were impeding research in the area of health and limiting
its application to health services planning.  The most frequent
problems were lack of clearly defined national research policies
and fragmentation or lack of articulation between the various
institutions engaged in health-related research--all stemming from
failure to plan and coordinate at the intrasectoral level.  It had
become clear that it was up to the Organization to assume a role
of coordination and leadership in this area of scientific endeavor.
     A major catalyst for the new ideas that were emerging in the
field of health-related research was an agreement signed with the
U.S. Public Health Service which made funds available starting in
1961 to finance the establishment of a research coordination unit
at the Washington, D.C. headquarters of the Pan American Sanitary
Bureau (PASB).  Later this unit was given permanent status and
entrusted with the responsibility of coordinating the research
activities being carried out under the Organization's other
programs and collaborating with them in the promotion of studies
that would respond to priority health problems.  More recently the
unit has cooperated directly with the member countries in the
formulation and implementation of policies for health science and
technology development as well as in the strengthening of their
scientific and technical infrastructure.

QUOTE

     The complexities of nature both foster and limit the knowledge
     of humankind, and in so doing they make the search for truth
     more challenging.  It is in scientific research that humanism
     reveals its purest forms and purposes; it has no point at all
     unless it leads to the good of the human race.
     Dr.  Abraham Horwitz, Director of PASB, 1959-1975
     
     While the Organization was looking at the formulation of a
long-term plan, at the same time it began to encourage the
presentation of proposals on specific research topics in the
Region.  The first two, for which funds were obtained from the U.S.
National Institutes of Health, were a study on the economic impact
of malaria eradication in various countries of the Americas--
carried out by the University of Michigan School of Public Health
with the collaboration of PASB--and an investgation into the causes
of mortality in 12 major cities of the Americas.
     Within a short time research in biomedicine had progressed
more rapidly in the Region than research in other fields.  Both its
impetus, in terms of number of projects, and its steady growth were
the fruit of State intervention in the planning of scientific
activity.  This intervention began to take place in Latin America
in the 1950s.  Such was the momentum that within a few years the
Hemisphere could boast that it had world-renowned investigators,
teams, laboratories, or institutions in almost all facets and areas
of research.
     One of the characteristics of biomedical research in Latin
America, especially in universities, was the focus on basic
research to the neglect of applied research.  The recommendations
of both internal and external working groups that looked into the
situation agreed that it was necessary to give more attention to
applied research in the area of public health.  Fortunately, the
years that followed saw support provided by governments,
international agencies (e.g. PAHO, the World Bank, the United
Nations Development Program), and other agencies for research that
would have immediate practical application.  By the end of the
1960s the volume of research being carried out in Latin America had
increased impressively--and the phenomenon was not limited to of
health; it was also taking place in the social sciences.
     
     The Organization's efforts in this area led to the formation
of the PAHO Advisory Committee of Medical Research (ACMR), which
in 1984 became the Advisory Committee on Health Research (ACHR). 
Since its creation, the Committee's membership has included
renowned scientists from countries throughout the Region, among
them several Nobel laureates.  For the first 14 years the meetings
of the ACHR were held at PAHO Headquarters in Washington, D.C., and
starting in 1976 the venue began to alternate between Washington
and other countries of the Region.
     At its first meeting, which took place in 1962, Dr. Abraham
Horwitz, Director of PASB, announced that the Committee had been
created for the purpose of analyzing the proposed research program
and making suggestions and recommendations on long-term research
policies.  This meeting affirmed the Committee's primary concern
with research and the related areas of research training and
education.  As Dr. Horwitz pointed out in a subsequent meeting,
"research has a clear and very important place within the framework
of the Organization's programs for the improvement of health of the
Americas," and he enjoined the Committee to base its work on the
mandate contained in the Charter of Punta del Este, which calls for
intensified scientific research and the application of its results
more fully and effectively to the prevention and cure of disease.
     The years that followed saw expansion of the Organization's
Research Program, a concerted effort to adapt research proposals
to the needs of the member countries and the requirements for
scientific excellence and rigor being imposed by the donor
agencies, increased focus on multinational research programs and
collaboration between important centers in different countries,
and, finally, creation and/or strengthening of the Organization's
collaborating research centers.
     The approach adopted by PAHO was compatible with priorities
in the field of health such as the strengthening of health services
and the expansion of their coverage to rural and neglected areas,
disease control (especially communicable diseases), manpower
development, family health and family planning with emphasis on
maternal and child health, and environmental health.  In other
words, it involved identifying problems and finding solutions
within the socioeconomic environment of the Region.
     In the 1970s the ACHR began to participate much more actively
in the detailed evaluation of research under way.  At the same
time, conditions and health needs in many of the countries in the
Region were forcing the members of the ACHR to take a careful look
at other types of biological, epidemiological, social, and
administrative research that might be needed in order to improve
on or expand the existing disease control programs.
     An important meeting of the ACHR was held in Caracas on 25-
28 April 1982 under the joint auspices of PAHO and the Venezuelan
Government.  It brought together ministers and representatives of
universities, research councils, international agencies, and
foundations, and its objective was to promote the acceptance and
application of research policies as an integral part of national
health development plans.  The members of the ACHR expressed their
views on priority issues affecting research in the Region and
reaffirmed their responsibility to review research being carried
out within the Organization, to advise the Organization on matters
of policy relating to research, and to establish subcommittees to
examine areas that might require special attention and possibly
strengthening.  This last function has led to stepped-up research
in the areas of communicable diseases, maternal and child health,
environmental health, veterinary public health, medical education,
health planning and policies, and the organization of scientific
activity.
     The mid-1980s saw a change in the Organizaion's approach to
the promotion of health research.  Whereas in the past the emphasis
had been on strengthening the supply, concern began to shift to
cooperation with the countries with a view to organizing scientific
activity so that it would respond more closely and effectively to
the people's needs.  The concept of knowledge management--defined
by the Director of PASB, Dr. Carlyle Guerra de Macedo, as
"promoting the generation of knowledge, compiling it, critically
rethinking and renewing it, disseminating it, and helping the
countries to use it"--became the cornerstone of PAHO activities in
this area.
     Also on this occasion the ACHR recommended that the scope of
PAHO cooperation in health science and technology should go beyond
strengthening the countries' capacity to establish their research
policies and priorities and that cooperation should focus on
strengthening the scientific and technical infrastructure in two
strategic areas:  biotechnology and health services systems (ISSS). 
Shortly thereafter the ACHR created subcommittees and entrusted
them with with the responsibility of orienting the policies and
programs to be developed in these two areas.  The work of these
subcommittees is now fully under way.

PHOTOS




PHOTO 1.  Research is essential to the future of health care in the
Americas.  PAHO has collaborated in the establishment and
updating of laboratory systems so that they can meet the
growing demand for services generated by the expansion
of health programs.


PHOTO 2.  Cytology--the study of cells--is important for the
control of cancer of the cervix.  Some of the staff in
the PAHO collaborating centers are paraplegic.


PHOTO 3.  A meeting held in Caracas on 25-28 April 1982, sponsored
by PAHO and the Venezuelan Government, addressed priority
issues relating to research in the Region.


PHOTO 4.  Data collection is an essential step in many research
projects.  PAHO has always made an effort to ensure that
surveys achieve maximum coverage.























     
AIDS


     In a relatively short period of time, human immunodeficiency
virus (HIV) has spread throughout the world.  The number of HIV-
infected adults is estimated to be between 9 and 11 million,
including 3 to 4 million women.  More than a million cases have
already been recorded in the United States and Canada, and almost
a million in Latin America and the Caribbean.  According to
conservative estimates, by the year 2000 there will be almost 10
million cases of acquired immunodeficiency syndrome (AIDS) among
adults worldwide and a total of 30 to 40 million people will be HIV
infected, 10 million of them children.    
     To combat AIDS and strengthen national AIDS programs in the
member countries, the PAHO Program on AIDS has consistently
employed Regional strategies of surveillance, research promotion,
dissemination of information, direct technical cooperation,
resource mobilization, training, and international coordination. 
     During the period 1980-1984, 9,145 cases of the disease were
registered.  In light of this figure, in 1984 PAHO requested that
the member countries formally report all diagnosed cases.
     In 1985, taking into account the advances made in the
epidemiology of the disease since discovery of the human
immunodeficiency virus in 1983, the Organization distributed a
publication containing preliminary guidelines for the control of
AIDS.  The Caribbean Epidemiology Center (CAREC) responded to the
growing concern of the Governments with control measures, advisory
services and education, and a research program carried out in
collaboration with the United States National Institute of Allergy
and Infectious Diseases.  The causative agent of AIDS was known,
a test to detect the virus had just been put on the market, and the
international scientific community had exchanged experiences and
knowledge about the epidemic at the first international conference
on AIDS, held in Atlanta, GA, in the United States.  Without an
effective treatment for HIV, essentially the only way to deal with
the epidemic was to prevent transmission.  The Organization was
called on to act rapidly and effectively to address a problem that
threatened to reach unprecedented proportions. 
     In response to this situation, in 1986 an attempt was made to
consolidate the system of epidemiological surveillance that had
been proposed to the countries.  In December an expert group
meeting was held to revise and update the PAHO guidelines on AIDS.
     The Organization provided ongoing technical support to the
countries through the preparation and distribution of guidelines
and audiovisual materials and through direct advisory services,
especially in regard to diagnosis, surveillance, and research.  In
addition, a standardized information system on the disease was
established.
     At the request of the member countries, CAREC provided
laboratory support for research in Trinidad and Tobago and studied
migrant farm workers from Saint Lucia and from the Grenadines who
had worked up to six months in Florida.  In addition, it examined
migrant workers in Dominica and took blood samples from donors in
Grenada, Saint Lucia, and St. Vincent and the Grenadines.
     It was clear that the strategy to combat AIDS hinged on
reducing HIV transmission, basically through modification of the
behavior of infected persons and those at risk of contracting the
infection.  That strategy needed to be bolstered through the
distribution of accurate, timely, and clear information to the
general public in order to raise the population's awareness of the
magnitude of the problem, explain how to avoid infection, and
dispel unjustified fears.
     In the wake of technical and scientific advances in prevention
of the disease, a group of experts from the Region prepared
technical guidelines for prevention.  These guidelines were widely
distributed and then subsequently revised, first in December 1986
and again in April 1987.
     Up to that time most of the people affected by AIDS in the
Region had been homosexual men, bisexual persons, and persons who
had received blood transfusions or blood derivatives.  In the
United States, intravenous drug addicts had also contributed
notably to the spread of the epidemic.  However, there was growing
alarm in some countries at the increase in the number of cases
being reported among heterosexual persons, a phenomenon which had
the potential for significantly increasing the rate of HIV
transmission. 
     The magnitude of the estimates and the need to care for all
those affected by AIDS was placing an increasingly heavy burden on
the health systems of the Region, which were already overburdened
and financially strained.  This situation pointed up the pressing
need for effective prevention, control, and treatment programs. 
Emergency action was imperative.
     In 1987 the Organization's efforts to cope with the epidemic
crystallized in the consolidation of epidemiological surveillance
systems and in joint research activities with the National
Institutes of Health.  At the same time, significant advances were
made in the development of national plans of action and in
establishment of the Global Program on AIDS at the level of the
Americas.  The Organization also provided support for laboratory
services for the diagnosis of AIDS and, in particular, for the
training of laboratory personnel.  In addition, in 1985 the PAHO
Research Grants Program had been transformed into an instrument of
technical cooperation aimed at spurring the production of knowledge
that might lead to the solution of priority health problems.  The
incorporation into this program of an area on priority
technological developments made it possible to support research
proposals on the development and evaluation of methods for the
diagnosis of AIDS.
     In the economic sphere, more than US$2 million in WHO
extrabudgetary funds were mobilized to assist in the rapid
development of national plans to fight AIDS in the Region. On the
education front, personnel from the Program on AIDS collected and
disseminated health information with a view to offering health
education services and scientific and technical information.  The
Organization played a key role in the establishment of the first
clearinghouse for educational information on AIDS within CAREC, and
it also began to work on the creation of another clearinghouse in
Mexico.
     In addition to these activities, Program personnel
participated in numerous meetings and consultations throughout the
Region as well as in the first PAHO/WHO Pan American Teleconference
on AIDS, which was held in Quito, Ecuador, on 14-15 September 1987. 
This teleconference, broadcast by satellite in four languages to
650 sites in the countries of the Americas, demonstrated that the
telecommunications media could be used to deliver important health
information to a large audience and have a greater impact than
would be possible through conventional media.  In addition, it
pointed up new ways of cooperating with the member countries, the
private sector, and other organizations.  That same year
preparations began for the Second Pan American Teleconference.
     Finally, in collaboration with the Organization's Communicable
Diseases Unit, the Program organized training workshops for
laboratory personnel in several countries and also served as a
liaison for WHO with the United States Congress.
     During 1988 considerable headway was made in the prevention
and control of AIDS.  Most of the countries in the Region that had
developed AIDS or AIDS-related programs committed themselves to
putting the plans of action formulated by the Organization into
effect as quickly and efficiently as possible.  The AIDS Prevention
and Control Program was reorganized and consolidated within the
Program on Health Situation and Trend Assessment.  That year
brought a difficult challenge:  the Organization had to find the
way to meet the urgent requests for technical collaboration and
financial support being presented by the Member Governments to the
Governing Bodies.  In this context, a special Information,
Education, and Communication Unit (IEC) was created for the purpose
of providing support to the countries to enable them to strengthen
the AIDS education component in their national plans.
     Considerable attention was devoted that year to the planning
and delivery of technical assistance to the countries and to
strengthening interprogram collaboration within PAHO/WHO. 
Moreover, financial support to the countries was increased through
regular contact with the Global Program on AIDS and the United
States Agency for International Development (AID), the European
Economic Community (EEC), the Canadian International Development
Agency (CIDA), and the United Nations Fund for Population
Activities (UNFPA), among other agencies.
     The organization of numerous workshops, meetings, and
conferences at the local, national, and subregional levels also
made it possible to put governmental, nongovernmental,
multilateral, and bilateral agencies into contact with one another
and aided efforts to develop national plans for the prevention and
control of AIDS.
     CAREC stepped up its activities in the area of training in
laboratory practices.  A standardized report form was developed to
compile data from the member countries.  This information was then
published in monthly epidemiological reports on the AIDS situation
in the Americas in response to the crucial need for up-to-date
information.  Throughout the year, collaborative efforts were
undertaken with such nongovernmental organizations as the
International Red Cross and the International Lions Club.
     Program staff also participated extensively in scientific
meetings during 1988.  They attended the World Summit of Ministers
of Health on Programs for AIDS Prevention in London in January and
played a major role in organizing and subsequently evaluating the
First International Symposium on Communication and Information on
AIDS, held in October in Ixtapa, Mexico.
     The Program on AIDS has continually worked in collaboration
with other programs of the Organization.  This joint action has
yielded numerous results, including the publication of an issue of
the Spanish-language Boletín de la OSP devoted entirely to the AIDS
epidemic and a volume entitled AIDS:  Profile of an Epidemic
(English and Spanish editions, PAHO Scientific Publication no.
514).  In addition, together with the Program on Communicable
Diseases, it has organized several international seminars on
laboratory technology for the diagnosis of AIDS and other
communicable diseases.
     Thanks to the unflagging efforts of the IEC Unit, the
distribution of scientific information on the syndrome increased
notably.  Periodical publications were combed regularly for
pertinent articles, which were then reproduced and sent to the
corresponding office in each country for distribution.  An
innovative approach was the distribution of compact disks
containing MEDLINE-AIDS bibliographies and articles on AIDS
extracted from major biomedical journals.
     Finally, another decisive step in the Organization's efforts
that year was the transmission of the second Pan American
Teleconference on AIDS via satellite from Rio de Janeiro to a
widespread audience in all the countries of the Region, as well as
Portugal, Kuwait, and five African countries.
     During 1989, workshops for teaching personnel continued to be
held on topics such as counseling, health promotion, marketing of
condoms, the role of nurses in the prevention and control of HIV
transmission, ways to ensure balanced media coverage of the subject
and to mobilize youth in the campaign against the disease. 
     The Organization has promoted the WHO Global Program on AIDS
in the Americas since the Program's inception.  As a result of the
intensive work that had been carried out in preceding years,
epidemiological surveillance had been substantially improved by
1990 and it had become possible to detect and report a much larger
proportion of AIDS cases.  As heterosexual transmission of the
infection increased, the Organization modified the prevention
strategies being employed in the Region.  It was necessary, among
other things, to expand the scope of AIDS control measures to
include other PAHO health programs.  It was also essential to find
a way of effectively meeting the difficult challenges posed by the
disease through interprogram and collaborative work, ensuring, at
the same time, the necessary coordination with other international
agencies.
     The common denominator in the Organization's actions during
1990 can be summarized under four headings:  technical cooperation
to the countries for development; execution and evaluation of
national programs for the prevention and control of AIDS;
collection, dissemination, and exchange of scientific and technical
information on the disease; and expansion of national research
capabilities.
     The member countries instituted national programs for the
prevention and control of HIV infection, which underwent
substantial changes.  These changes were the catalyst that
transformed the emergency and short-term control programs into
medium-term prevention programs.  The principal result of the
introduction of these modifications was that, by the end of the
year, medium-term programs had been developed in almost all the
countries of the Region.
     In 1990 and 1991, all the activities planned for each year
were carried out.  An important event was the broadcast of the
third Pan American Teleconference on AIDS, held in Caracas,
Venezuela, on 13-15 March 1991.  The conference was particularly
noteworthy for its technical content and for the relevance and
importance of the topics discussed.  Its most significant merit,
however, was the degree of multisectoral participation achieved and
the involvement of political and governmental levels in the member
countries. 
     Work also began on an inventory of AIDS-related research in
the Americas with a view to determining the Region's capacity to
conduct research of major scientific importance.  This inventory
was published in mid-1992.  In addition, various research projects
were completed or continued in collaboration with the United States
National Institute of Allergy and Infectious Diseases. 
     During 1991 the Organization provided a total of 244
consultant/weeks of direct technical cooperation to the member
countries (compared with 121 in 1990), including 60 weeks in the
area of management; 98 in the area of surveillance; 49 in support
for education, health promotion, and research; and 36 in laboratory
strengthening.  Regional personnel and those who carry out
international activities devoted more than 200 weeks to
collaborating directly in the field with the national AIDS
programs, and PAHO allocated a total of US$60 million to support
the activities of these national programs. 
     In the course of the same year the PAHO Global Program on AIDS
was restructured, and both the biennial plan of work and the
targets for 1992-1993 received the support of the XXXV Meeting of
the Directing Council of the Organization.
     PAHO and its Member Governments have committed themselves to
applying the global strategy with a view to achieving the goal of
preventing and controlling AIDS in the Americas.  The principal
objectives of this strategy are:  to prevent HIV infection, to
reduce its personal and social impact, and to mobilize and unify
national and international forces against AIDS.
     Ultimately, AIDS must be considered not only a health problem
but also a social, economic, and political problem that will have
long-term repercussions in the communities and countries of the
Region.  At the national level, the fight against AIDS and the
reduction of the epidemic's social consequences will require a
sustained and concerted effort with participation by, inter alia,
the ministries, the social security institutions, the
communications media, the private sector, and all types of
organizations and community groups.
     In order to achieve this objective it will be necessary to
obtain political support at the highest levels, technical
leadership from the health sector, financial resources from
national and international agencies, and, above all, the
unconditional commitment of local health systems and communities.
PHOTOS

PHOTOS 1, 2, 3.     Intravenous drug addicts, prostitutes, and
prisoners are among those at high risk of
becoming infected by the human immunodeficiency
virus.  In its campaign against AIDS, PAHO has
concentrated its efforts on meeting the
priority needs of these groups. 

PHOTO 4.  The PAHO Program on AIDS has organized and promoted
numerous workshops and courses to train laboratory
personnel in the principal methods for diagnosing HIV
infection. 

PHOTO 5.  One of the principal aims of the special Information,
Education, and Communication Unit (IEC) of the Program
on AIDS, as well as the Program on Scientific and
Technical Health Information of PAHO, is to deliver
accurate and rigorous scientific information on the AIDS
epidemic to the general public and to health
professionals. 

PHOTO 6.  The battle against AIDS must be waged on different fronts
and at various levels.  The activities of health workers
at the local level are indispensable to the success of
national AIDS programs. 

PHOTO 7.  Extreme poverty, among other conditions, contributes to
the mounting number of homeless children who are at high
risk of contracting HIV infection, as well as reported
cases of pediatric AIDS.  Among other measures, PAHO has
sponsored several meetings and workshops in the Region
to address this problem.

PHOTO 8.  Appropriate language, media, and channels of
communication must be used in tailoring messages on the
prevention of HIV infection to the idiosyncrasies of the
many different communities in the Region of the Americas. 
PAHO has taken into account these factors in
disseminating information on the disease.

POSTER.   UNIVERSITY OF CALIFORNIA AT BERKELEY (Student Health
Service).     
 IMPROVEMENT IN THE NUTRITIONAL STATUS OF COLOMBIAN CHILDREN
BETWEEN 1965 AND 19891

     A study was carried out in order to compare the
anthropometric measurements obtained by the Ministry of Public
Health of Colombia in three nutritional surveys (1965-1966,
1977-1980, and 1986-1989) of comparable, representative,
country-wide samples of the population under age 5.  Similar
methods of analysis were used to determine the trend in the
prevalence of global malnutrition (low weight-for-age), chronic
malnutrition (low height-for-age), and acute malnutrition (low
weight-for-height) as well as the trend in a series of
socioeconomic development indicators during the period 1965-
1989.
     The results revealed a decline of almost 50% in the rates
of global and chronic malnutrition in children under age 5 and
a reduction of 25.7% in the rate of acute malnutrition.  They
also show a marked improvement in numerous indicators of
development, including gross national product, income
distribution, level of education and literacy (especially among
women), women's participation in the labor force, housing
conditions, food production, and per capita dietary energy and
protein supplies.  These improvements appear to be the outcome
of sustained economic growth and governmental policies aimed at
promoting social development, increased primary health care
coverage, and specific nutrition programs.  Several persistent
nutritional problems and possible measures for solving them are
mentioned.


PRIMARY HEALTH CARE IN ECUADOR:
MINISTRY OF HEALTH AND
RURAL SOCIAL SECURITY SERVICES

     The present study will examine three common premises in the field of international public health:  that the
primary care services offered by agencies of the Ministries of Health (MH) are less costly than those offered by
Social Security institutions, that the services of the former are inferior to those of the latter, and that in the MH
centers, funds are distributed more equitably among the various recipient populations.  In 1986, we compared the
costs, quality, and equity of the services in 15 primary care centers in Ecuador--eight Ministry of Health centers and
seven rural Social Security (RSS) centers--examining budgetary data from 1985 and obtaining information through a
questionnaire and interviews with the personnel at these centers.
     Standardized accounting techniques were applied to determine the average costs, and it was confirmed that
for several important services, especially medical consultations, these costs were much lower in the Ministry centers
than in the Social Security centers.  However, no differences in the cost of dental care were detected.
     The evaluation of quality, based on an analysis of the structure and process of production, did not yield
uniform results.  On the one hand, the distribution of personnel and the allocation of funds for drugs and other
supplies indicated that the RSS agencies provide better quality services.  On the other hand, a questionnaire revealed
that the MH health workers' knowledge of various principles of primary care was superior to that of the RSS
workers.
     Upon comparing the per capita budget of the two entities, it was confirmed that the Ministry of Health has
more equitable per capita coverage than rural Social Security.  Finally, we discuss the implications of our findings
for Ecuador and other developing countries and make several recommendations. 






Mortality Due to Intestinal Infectious Diseases
in Latin America and the Caribbean, 1965-1990


     The influences that have transformed the health situation in the countries of Latin America and the
Caribbean in recent decades, especially with respect to mortality, have brought an increase in life
expectancy at birth from 51.8 to 66.6 years in Latin America and from 56.4 to 72.4 years in the non-Latin
Caribbean over the period from 1950-1955 to 1985-1990 (1).  In general, the greatest impact of these forces
has been seen in reduced mortality due to infectious diseases; their second greatest impact has been on
acute respiratory infections.  According to McKeown (2), these effects are the result both of direct influences
(improved nutrition, immunizations, availability of drinking water and waste disposal, and safer food
handling) as well as indirect influences (control and lowering of the birth rate, increased literacy rates
especially among women, mass outreach of the communications media, etc.).  While these improvements
have had an unquestioned impact, they have not been distributed equitably throughout the entire
population.  One need only point to the current epidemic of cholera and to the persistence of a risk which is
one of the most preventable and yet still one of the most common:  the intestinal infectious
diseases--basically, the diarrheal diseases (3).  While it is true that in some places and times other risks
have caused more deaths, in Latin America in both the recent and distant past such other risks have been
far less important than the diarrheal diseases.  The latter have killed and continue to kill, in particular, a
serious proportion of children in their first years of life.  Moreover, in many countries diarrhea has been and
remains an important cause of death in other age groups as well.

     Table 1 shows the evolution of mortality due to intestinal infectious diseases in most of the
countries of Latin America and the Caribbean.  The period under study has been divided into five five-year
segments, and for each of these the average annual values for certain indicators have been estimated
wherever the existing information permitted (4).

     In nearly all the countries that have data available for more than one of the five-year periods there
has been a decrease in the number of deaths from intestinal infectious diseases for all ages and for children
under 5 (columns 1 and 3, respectively).  The decline has been more pronounced in some countries than in
others:  in Costa Rica and Chile, for example, the number of deaths from intestinal infections decreased by
approximately 90% for all ages, and by 93% and 95%, respectively, for children under 5.

     Inasmuch as the population in all the countries has grown considerably in the period analyzed, the
trend toward fewer deaths from intestinal infections does in fact mean a reduced risk of dying from this
cause.  The falling trend is also seen indirectly in the decline of proportional mortality--that is, the relative
importance of deaths from intestinal infections as a percentage of total deaths from all defined causes
(column 2).  Moreover, since overall mortality from all causes has also gone down (5), it would appear that
the downtrend in mortality from intestinal infections has been much greater than that seen for all other
causes combined.  If the remaining causes had declined to the same degree as diarrhea, the percentages
of proportional mortality (column 2) would not have changed over the course of the five-year periods in
question.  From this it may be concluded that reduced mortality from intestinal infectious diseases has
alone, as a single cause, contributed substantially to the decline in mortality from all causes and therefore to
the increase in life expectancy at birth.

     The percentages of reduction have a different impact in terms of lowered rates, and thus increased
longevity, depending not only on the age at which the deaths occur but also on the level at which mortality
already stands.  For example, in Chile the number of deaths in children under 5 decreased by 95% (from
4,840 to 240 deaths), resulting in a decline in the specific death rate for that age group of from 3.72 to 0.17
deaths for every 1,000 children under 5 (column 6), whereas a smaller reduction in Mexico had an even
greater impact:  in that country, the decline in deaths among children under 5 was less, 64%, but the rate
fell from 7.46 to 2.17 per 1,000.  The difference translates into the prevention of 355 child deaths per
100,000 in Chile versus 529 in Mexico.  However, Mexico still has a long way to go, since the rate of 2.17
per 1,000, which represents 25,000 deaths each year in children under 5 during the last five-year period, is
still excessive.

     While the relative weight of deaths due to intestinal infectious diseases is greatest among children
under 5, nevertheless some variations can be seen depending on the relative importance of this cause
vis-Õ-vis total deaths in all age groups (columns 2 and 4).  When proportional mortality from diarrhea is very
high in all age groups--i.e. in excess of 20% of all deaths--mortality is high not only in children under 5 but in
the other age groups as well.  On the other hand, when the importance of diarrhea relative to all causes
begins to decrease, then the deaths tend to occur more in infancy--which would suggest that gains from the
reduction of deaths due to intestinal infections have been greater in the other age groups.  And finally, when
proportional mortality due to diarrhea is lowest, then mortality from this cause is mostly in the other age
groups.

     A study of changes in mortality due to diarrhea in the first 5 years of life vis-Õ-vis levels of
proportional mortality (column 5) and specific death rates for that age group (column 6) shows the following: 
if the rates decreased while the percentages of proportional mortality remained relatively unchanged (as in
Guatemala, Honduras, Jamaica, Mexico, Nicaragua, and Peru), then the reduction for the other causes
taken together was of the same general magnitude as for intestinal infectious diseases.  On the other hand,
if the rate fell but proportional mortality increased, as in Ecuador, then the remaining causes decreased to
an even greater extent.  (The low figure for Ecuador in 1965-1970 suggests a problem with the
underregistration of diarrhea during those years, which correspond to the changeover from ICD-7 to ICD-8.)

     All this suggests that the death rates for intestinal infectious diseases in children under age 5 are
the most useful indicators for analyzing changes in mortality from these diseases.

    In order to assess the trends over the 25-year period in terms of the reduction in death rates from
diarrhea per 1,000 children under 5, a five-level scale has been established, Level 1 being the least serious
and Level 5 the most serious, as follows:

     Rate                    Category

Lower than 0.5           Level 1
Between 0.5 and 2.0      Level 2
Between 2.0 and 5.0      Level 3
Between 5.0 and 10.0     Level 4
Higher than 10.0         Level 5

     Note that the lowest range on the scale starts with a rate of 0.5 deaths per 1,000 children under 5,
which even so is seven times higher than the rates prevailing in the United States of America and Canada
at the beginning of the period 25 years ago.

     When the countries are grouped according to the progress in their rates between the first and the
last of the five-year periods, the following distribution is seen:

Evolution in rates           Countries

Level 4 to Level 1  Costa Rica
Level 3 to Level 1  Argentina, Chile, Trinidad and Tobago
Level 2 to Level 1  Cuba, Uruguay
Level 4 to Level 2  Colombia
Level 3 to Level 2  Belize, Brazil, Jamaica, Panama,                
Venezuela
Level 5 to Level 3  Dominican Republic
Level 4 to Level 3  Ecuador, El Salvador, Mexico
Level 5 to Level 4  Guatemala, Honduras, Nicaragua

     The remaining countries with information for more than one five-year period (all except Guyana)
stayed at the same level:  Peru at Level 4, Paraguay at Level 3, and Suriname at Level 2.

     A comparison with the situation in the United States of America and Canada between 1965 and
1970, where deaths from diarrhea stood at 0.07 per 1,000 children under 5, shows that none of the Latin
American and Caribbean countries under study currently has a rate lower than the figure for these two
countries 25 years ago.  Moreover, from 0.07 the rate in these countries has continued to decline and is
now close to zero (in Canada two children under 5 died from intestinal infectious diseases in 1987 and two
in 1988, making for a rate of 1 per 1,000,000 children under 5).  From this it can be said that it is possible to
reduce all mortality from intestinal infectious diseases in the under-5 age group to zero not only with the
technology of today but even with the technology that existed more than two decades ago.  If 10% mortality
in children under 5 is taken as the criterion for high risk (column 5), then 16 of the 23 countries listed,
representing the great majority of the Region's population, would be in this situation.  The reduction of
diarrhea in infancy is quite feasible, as shown by the trends in Argentina, Chile, Costa Rica, Cuba, Panama,
Trinidad and Tobago, and Uruguay, where the percentages have declined to less than 10%.  The drop has
been particularly notable in Chile, where the rate has fallen from 17.2% to 3.4%--the lowest of all the
estimated values.

     Despite the progress that has been made, it is evident that a very severe problem persists in the
developing countries of the Americas.  Between 1985 and 1990 these countries had approximately 130,000
deaths each year from diarrhea in children under 5.  This number is several times greater than the 25-year
cumulative total of 38,000 deaths from intestinal infections for all ages in the United States of America (5).

     Based on the figures in Table 1, estimates of mortality from intestinal infectious diseases have been
calculated for the entire 25-year period both for the countries individually and for the countries a group (6). 
These figures appear in Table 2.

     Column 1 gives an estimate of total deaths from this cause; column 2, the subtotal for deaths in
children under 5; and column 3, the percentage represented by the latter column with respect to the former. 
Column 4 gives estimated proportional mortality from intestinal infectious diseases vis-Õ-vis total deaths
from all causes, and column 5 gives the relative importance of mortality due to intestinal infectious diseases
in children under 5 expressed as a percentage of mortality from all causes.

     If the figures in Table 1 gave cause for concern, the estimate of 6 million deaths for 1965-1990 is a
clear numerical expression of the serious risk that diarrheal diseases present for Latin America and the
Caribbean.  The other figures give further details on the magnitude of the problem.

     These 6 million deaths correspond to nearly one out of every 11 deaths from all causes--almost
9%--in the countries of Latin America and the Caribbean.

     Almost 5 million of the deaths from diarrhea occurred in children under 5, amounting to 80% of all
deaths from intestinal infections in all age groups and 7% of the deaths from all causes at all ages.  This
means that in the period studied, in the countries of Latin America and the Caribbean taken together, one
out of every 14 deaths in the general population was from an intestinal infection in a child under 5.  In some
countries the proportion is even greater, reaching as high as one child death from diarrhea for every six
deaths from all causes at all ages.

     Mortality figures for the 25 years in the United States of America (7) show that the cumulative
number of deaths from all causes before age 45 during the same period was 5.8 million.  And this figure is
lower than the 6 million deaths caused by intestinal infectious diseases alone in Latin America and the
Caribbean.  Moreover, the number of deaths from diarrhea among children under 5 in Latin America and the
Caribbean, namely 4.8 million, was higher than all cumulative deaths in the United States of America in the
population up to age 35 for the same period, or 4.1 million from all causes.  And it was more than 100 times
greater than all cumulative deaths in the United States from intestinal infections in all age groups, which
was only 38,000 for the entire 25 years.



Notes and References


(1) Health Conditions in the Americas, 1990.  Washington, D.C.: Pan American Health Organization, vol. 1,
p. 28, based on estimates by CELADE and the United Nations.

(2) McKeown, Thomas, The Origins of Human Diseases, Barcelona: Critical Publishing House, 1990, p.251.

(3) The intestinal infectious diseases correspond to categories 001-009 in the International Classification of
Diseases, Ninth Revision (ICD-9):  cholera, typhoid and paratyphoid fevers, other salmonella infections,
shigellosis, other food poisoning (bacterial), amebiasis, other protozoal intestinal diseases, intestinal
infections due to other organisms (specified), and ill-defined intestinal infections.

(4) The figures in columns 2, 4, and 5 were calculated from data in the Technical Information System (TIS)
of the Pan American Health Organization.  Only deaths from clearly defined causes were considered for this
purpose.  The percentages were calculated by averaging the percentages for the different years in each of
the five-year periods, as long as there were at least two years.  Once these annual averages were obtained
(column 1), the number of deaths from intestinal infectious diseases was estimated by multiplying the figure
in column 2 by the estimated average annual number of deaths in the five-year periods as calculated by
CELADE (Boletín Demográfico 23(45), Santiago, 1990) and the United Nations (World Population
Prospects, 1988, ST/ESA/SER.A/106, New York, 1989).  Once column 1 was obtained, column 4 was used
to calculate column 3, namely deaths from intestinal infectious diseases in children under 5.  These values
were then combined with population estimates for children under 5, derived from the same publications, in
order to obtain the specific death rate from this cause in children under 5.  The latter figures appear in
column 6.  The numbers obtained for columns 1, 2, and 6 are, on the whole, higher that those registered
and reported by the countries.  This is due to the underregistration of deaths and causes of death. 
Accordingly, the calculated estimates do not necessarily reflect the reality, since it is not possible to know
the distribution of causes for the deaths that were not registered.  Given this fact, the estimated values may
be regarded as minimum levels--and in fact they are intended to be such--since the real values, if they could
be ascertained, would be still higher.  The line of reasoning which supports this conclusion--valid for
intestinal infectious diseases but not necessarily other causes--is that in any population the
underregistration of deaths is greater in those subgroups for whom the necessities of life, above all the
adequate supply and utilization of drinking water and sewerage services, are more precarious and in many
cases nonexistent.  Such subgroups, which may in fact correspond to the majority of the population, have
higher mortality.  In particular, the proportion of deaths due to intestinal infections is bound to be greater for
such subgroups than it is for population subgroups for which deaths are registered accurately.  Therefore, in
terms of the population as a whole, the real values of the indicators associated with these diseases should
be at least equal to if not greater than those obtained using registered mortality.

(5) The figures for 1966 to 1988 were obtained from the PAHO TIS, and for 1989 and 1990 from estimates
by the National Center for Health Statistics, Monthly Vital Statistics Report 40(1), May 1991.

(6) In oder to estimate figures for those five-year periods for which information is not available, as shown in
Table 1, calculations have been made using the percentages for the nearest five-year period and the
CELADE and United Nations estimates of total deaths corresponding to that five-year period.

(7) Idem. (5).




LOCAL STRATEGIC ADMINISTRATION


A PROPOSAL FOR DISCUSSION

(PRELIMINARY VERSION)




PAHO/WHO
Washington, D.C.                                        July 1991


     
RESTRICTED CIRCULATION
TABLE OF CONTENTS
Page
PRESENTATION                              

PART I THE CONTEXT OF LOCAL HEALTH SYSTEMS
Chapter I   GENERAL ASPECTS
   1   Health and Its Determinants:  Health and Living
       Conditions                              
       1.1  Health and the Environment             
       1.2  Health Promotion                   
   2   Health in Development                       
   3   Intersectoral Development
       3.1  General Aspects of Intersectoral Development        
       3.2  Institutional and Administrative Aspects            
       3.3  The Political Process                  
       3.4  Human and Financial Resources              
       3.5  Methodological Constraints    
   4   Health Legislation                      
   5   The Role of the State in Responding to
       the Health Needs of the Population              
   6   The Role of Society and of Health Organizations
       6.1  Social Movements                   
       6.2  Health Workers                
   7   The Transformation of National Health Systems:
       the Local Health System Strategy            
   8   Social Processes and their Relationship to
       Health System Administration                
   9   The Role of Science and Technology              
       9.1  The Role of Epidemiology               
       9.2  The Application of Knowledge:
Role of the Health Programs                
   10  Analysis of the Planning and Programming 
       Process                            

PART II     LOCAL STRATEGIC ADMINISTRATION
 
Chapter II  CHARACTERISTICS OF LOCAL STRATEGIC ADMINISTRATION
   1   Local Strategic Administration in Local Health Systems      
   2   Fundamental Characteristics of Local Health Systems
       that
       Affect Local Strategic Administration           
   3   The Phases of Local Strategic Administration


Chapter III     LEADERSHIP IN LOCAL STRATEGIC ADMINISTRATION
   1   Characteristics of the Leadership Process            
   2   Steering and Leadership in Local Health Systems      
   3   Relationship of the Local Health System to Other
       Political
       and Administrative Levels of the Health System           
   4   The Identification of Health Problems
       4.1  Conceptualization of Health Problems            
       4.2  The Identification of Priorities and Assumption of
Commitments
       4.3  Negotiation and Concerted Action                


Chapter IV  PROGRAMMING IN LOCAL STRATEGIC ADMINISTRATION
   1   Local Health System Programming and the Integration of
       Knowledge                          
   2   Selection of Technologies and Programming and Operating
       Standards                               
   3   The Programming Process                     
       3.1  Identification of Health Problems:
Application of the Epidemiological Approach         
a)  Population                     
b)  Resources                      
c)  Health Status                  
d)  The Political, Social, Economic, and
Physical Environment                   
       3.2  Allocation of Resources       
       3.3  Execution at the Applied Level             
a) Organization of the Services Network         
b) Hospital Programming            
c) Environmental Concerns                  
       3.4  Financial Programming              
       3.5  Budget Negotiation                 
       3.6  Program Implementation:  Application Strategies
       3.7  Evaluation and Adjustment                  

Chapter V   MANAGEMENT IN LOCAL STRATEGIC ADMINISTRATION
   1   Conceptualization of Management in the Context of
       LSA                            
   2   Evolution of the Management Concept             
   3   The New Management and the Processes of
       Decentralization                            
       3.1  Team-oriented Organization         
       3.2  Atomized and Modular Organization          
       3.3  Characteristics of Atomized and Modular
Organization                           
       3.4  Recommendations for Achieving Organizational
Flexibility                   


Chapter VI  PARTICIPATION OF SOCIAL ACTORS IN THE LSA PROCESS
   1   Definition of Problems
       1.1  The Definition of Problems and Identification
of Social Actors                   
       1.2  Modalities of Social Participation in the
Definition of the Health Problems          
   2   The Role of Specialists                     
       2.1  The Specialist and Leadership              
       2.2  The Specialist and Programming             
       2.3  The Specialist and Management                   

PART III    INSTRUMENTS, TECHNIQUES, AND
       PROCEDURES FOR LOCAL STRATEGIC ADMINISTRATION            

FOREWORD

     This document seeks to retrieve from the historical
process and experiences occurring in health planning and
administration in the Region of the Americas the conceptual
and instrumental elements that enable support for policies
and strategies relating to the decentralization of health
systems, provide the basis for promoting dialogue and
discussion among the different interested sectors, and
facilitate the agreements necessary for implementing the
Strategic Orientations and Program Priorities jointly with
the member countries, in particular those pertaining to the
reorganization and decentralization of national health
systems through the establishment and development of local
health systems.

     The ideas presented should be taken as a basis for
discussion and promotion of the concepts underlying the local
health system strategy and its implementation. 
Hypothetically, none of them can be considered ready for
implementation without an analysis of the particular
circumstances in each country.  There has been no effort to
cover concepts still being discussed or not yet fully
developed.  An attempt has been made, whenever possible, to
indicate the level of knowledge attained.

     The concepts in this document are of potential use to: 
directors of national health systems and political and
technical experts responsible for the promotion,
dissemination, and execution of the strategy involving the
development and consolidation of local health systems both at
the central level and in local management and operations; the
academic sectors, which seek to promote and enrich their
dialogue and ideas regarding health services; and finally,
organizations at the health district level that are
interested in participating or are already involved in the
improvement of the health conditions, the achievement of
equality, and increased effectiveness and efficiency in the
health services.

     It is the local area that is being considered, and the
discussion of the administrative process takes place in this
context, without overlooking the necessary relationship that
must exist between local levels and regional and national
levels.  Within this context, consideration is also given to
dividing the local system into units and operational
programs.

     It is sought, moreover, to generate agreement in order to
facilitate and favor methodological advances and develop
procedures, techniques, and methods aimed at providing the
local health systems with instruments for taking action based
on their situation, in accordance with their capabilities and
resources.

     Since the intention is to facilitate the adoption of
institutional positions, the perspective of the social actors 
that comprise the organization is generally assumed.  For
this reason, even though there are problems in the entire
area of decision-making and sectoral action, the discussion
is geared toward official health institutions.  This does not
mean that the other participants out of the picture; they
will be discussed from the perspective of State institutions,
based on the assumption that they are the ones who must
assume responsibility for orienting the process.

     As part of the effort to capture the experiences that the
countries of the Region have accumulated in the planning and
management of health systems and adapt these to the current
situation in the Region, elements are provided to facilitate
the linking, within the local context, of strategic
approaches to planning and administration using knowledge
from the social sciences
In so doing, it is hoped that a contribution will be made to
increasing the instruments available for learning about
sectoral processes and that therefore we will be in better
situation to attain the target of Health for All by the Year
2000.

     Historically, local health programming begins when health
services, concerned with the need to increase coverage,
assume two types of responsibilities.  At the central levels
they set standards and procedures, and at the local levels
they provide information for decision-making and application
of the standards--which have been defined, without any
participation in the process, so that they are almost never a
reflection of local reality.  Today, programming is regarded
as an ongoing process involving all levels of organization
and ranging from decision-making and the orientation of
sectoral policies to the execution and assessment thereof.
     
     This approach is called local strategic administration
[LSA].  We would like to emphasize that it is geared toward
the execution of actions in local health systems while at the
same time not overlooking the need to deal with all aspects
of health planning at the provincial and national levels.  In
developing the concepts and methods, an effort has been made
to capture and incorporate existing experiences within a more
comprehensive approach that seeks to reconcile strategic and
normative actions.  Management is also a part of it and is
the fundamental strategic element responsible for
interpreting, adapting, and implementing general directives
for the sector based on current situations in the particular
locale.

     Given the fact that the diversity of a local area makes
it impossible to have uniform procedures, the present
document is not a proposal for any given method of
programming or local administration but rather a guide that
can facilitate local strategic developments by applying
social science and health knowledge in an effort to attain
equality, effectiveness, and efficiency in responding to the
health needs and demands of the population.

     The concepts developed should be taken only as
indications that may serve as support for the processes of
orientation, programming, and management that are generated
in each country, taking into account the peculiarities of
each national, regional, and local situation.

     In this context, it is hoped that LSA makes it possible
to reveal the underlying logic of each social management
situation, enabling groups within society and the health
system to create an area where the understanding and the
harmonization of interests are established based on mutual
understanding and the definition of common objectives, since
one of the objectives behind this proposal is to create the
conditions necessary for the full exercise of social
participation.

     The innovative contribution stemming from this exchange
will give LSA all the experience and knowledge relative to
persons who are involved in and committed to the
transformation of the health systems, in order to make
equality, effectiveness, and efficiency a reality and social
participation an ongoing practice in every local area. 

     Finally, it should be pointed out that, given the
strategic nature of the proposal, an effort has been made to
present, whenever possible, an approach that is aimed at
being broad and generic, with the prescriptive approach being
avoided.  If this is not apparent from the reading of the
document, or if at any time a normative approach is used, it
should be attributed to deficiencies in handling the language
but never to a deliberate intention in that regard.


PART I
THE CONTEXT OF LOCAL HEALTH SYSTEMS

     In this part, the general aspects of the health/disease
process are presented, together with the conditions and
determinations that are involved.  Although this type of
discussion is often viewed as unproductive and not useful in
practice, it is firmly believed that the proper development
of local strategic administration requires ongoing reflection
and reconstruction of the knowledge that supposedly exists at
the national level.  Theory and practice should always be
actively linked in order to provide the elements and inputs
required for the transformation of national health systems.



CHAPTER I
GENERAL ASPECTS

     1.     HEALTH AND ITS DETERMINANTS:  HEALTH AND LIVING
CONDITIONS

     Health, both individual and collective, is the result of
complex interaction between the biological, ecological,
cultural, and socioeconomic processes that take place in
society.

     To a large extent, health is a product of dominant social
relations, determined by a historical process of which it is
one of the manifestations.  The health profile of a social
group results from the objective conditions of life
itself--that is, it depends on the series of processes that
reproduce the particular form of integration of that group in
the process of social production at a given point and in a
given place.  The objective conditions of life represent a
particular way of integrating into the productive process, of
participating in consumption, of relating to the environment,
and of participating in the political process and
decision-making.   Health is not a matter of equilibrium; it
is tension and conflict in the search for better living
conditions in an ongoing effort to attain higher levels of
well-being.  As a result, it is not possible, theoretically,
to define an acceptable level of health, since each group and
each individual establishes, in its own situation, whatever
best suits its aspirations and real and specific
possibilities.

     Health/disease is a concept that is built collectively
and socially.  This notion obeys a complex logic in which
social and individual views are brought together to create an
image of what is desirable.  Reflection on this complex
problem is hardly something to be dealt in the field of
biology or the clinical area; it transcends such limits and
is fully complemented with the introduction of the social
dimension.
     The foregoing makes it possible to outline the possible
role of the sector in determining the health/disease process,
based on acceptance of its limitations and recognition of its
responsibility in providing leadership to all sectoral
groups, especially institutional groups, with a view to
achieving the target of HFA/2000 and facilitating effective
linkage between all resources in order to carry out the
actions necessary in that area, to which the strategy for the
decentralization of national health systems gives priority
through support for the development and strengthening of
local health systems.

     Based on this approach, two aspects are particularly
important in the present situation:  health and the
environment, and efforts to encourage the promotion thereof
as one of the fundamental elements signaling a change of
perspective in the sector.  The next two sections will be
devoted to these issues.

     1.1  Health and the Environment

     Environmental health is essentially an intersectoral
field of action, since it involves all the components of the
human environment.  The control of environmental pollution is
only one aspect of this problem.  Others are water supply and
sanitation, sanitary housing, food safety, and occupational
health, all which highlight different specific dimensions of
the more general problem.  And this is not an exhaustive list
of the factors associated with environmental pollution; in
addition there are the environmental aspects associated with
vector-borne diseases, heart disease, cancer, etc.  In
addition, there is agriculture, energy production, mining,
forestry, and tourism.  Other types of natural resource
exploitation are closely tied to environmental health
conditions.

     In particular, health personnel and social groups should
develop the capacity to rethink health problems in ecological
terms, thereby creating the necessary conditions for
efficient and effective participation in actions aimed at
preventing and responding to adverse effects on health
resulting from the interaction of changes in population and
patterns of settlement, production processes and the waste
therefrom, the generation and transportation of energy, the
depletion of basic resources, changes in the overall
environment, and the approaching point of saturation in the
resistance capacity of the environment.

     Diseases caused by contaminants are often difficult to
identify in precise terms.  It is known, however, that
persons who live in unsafe environments are subject to
greater risks of falling ill and having seriously morbid
symptoms than those who live in more healthy environments.

     The range of environmental factors that bear on health
make the situation much more complex, since most
environmental problems are linked to multiple causes and
affect various aspects of the health of persons, families,
and social groups.

     Some of the negative factors associated with deficient
environmental conditions are:
     * Communicable diseases caused by the insanitary
       elimination of excreta and parasitic diseases
       associated with the importation of pathogens by
       migrants from endemic rural areas and settlement of the
       poor in swampy areas on the outskirts of urban areas;
     * Among communicable diseases, the spread of
       gastrointestinal and parasitic diseases, caused in part
       by the inadequate elimination of solid waste and in
       part by the obsolescence and deterioration of drainage
       systems, which facilitates the accelerated           
       reproduction of vectors;
     * Noncommunicable diseases and traumas resulting from
       inadequate protection against the elements, dwellings
       that are unsafely designed, inadequate protection
       against natural disasters (earthquakes, hurricanes,
       floods), and the use of hazardous building materials;
     * The increase in mortality due to diseases that are
       exacerbated by air pollution (certain types of cancer,
       influenza, pneumonia, bronchitis, emphysema, etc.);
     * Increased risk of work-related accidents and
       occupational diseases that comes with the processes of
       industrialization;
     * Health problems caused by low-level and long-term
       exposure to hazardous chemical wastes (lead,
       trichloroethylene, chloroform, toluene, benzene, PCB,
       phenol, arsenic, etc.).

     The foregoing factors, together with increased community
participation as a result of democratization, have
strengthened the address health problems from an ecological
perspective.

     There is growing social awareness of environmental risks,
which is affecting how policy-makers respond.  It is in this
context that efforts are being made to optimize
across-the-board intersectoral cooperation and promote the
creation and strengthening of local structures with a view to
ensuring community participation in the protection of
environmental health in local areas.

     In order to ensure greater coherence and coordination for
sectoral and intersectoral policies and programs, and to
reduce organizational fragmentation, the health sector should
prepare conceptual and practical strategies that take new
risk patterns into account.  Such strategies need to regard
the environment and health as social resources, which means
that they need to be protected by the entire community.

     For this purpose, national, regional, and local health
systems should develop the following functions, in the
specificity and scope best suited to their tasks and
responsibilities:

     * Advocating preventive measures to protect individuals,
       families, social groups, and the environment against
       environmental risks;
     * Fostering the capacity of persons, families,
       communities, and social groups to promote environmental
       health, thereby encouraging the decentralization of
       tasks and responsibilities;
     * Maintaining epidemiological surveillance of diseases
       related to the environment;
     * Formulating and implementing programs for emergency
       preparedness.

     1.2    Health Promotion

     Health promotion is understood to be all the actions of
society, including the health services, health authorities,
and other social and productive sectors, which are geared to
the development of better conditions of individual and
collective health.

     The promotion of health is of fundamental importance to
mothers and children and also to adolescents, adults, and the
elderly, since health conditions are related to risk factors
that stem from individual and group behavior as well as to a
variety of factors associated with other sectors of
development.  In order to control these, it is indispensable
to promote and channel the participation of social groups
into health promotion, particularly when it comes to
decisions to change conditions in the environment, collective
ways of living, and behavior patterns that endanger health
(tobacco, diet, alcohol, sedentary lifestyle, stress,
environmental exposure to hazardous substances, violent
behavior).  Accordingly, health actions to eliminate these
risks are the shared responsibility of several sectors.

     The central points around which the health promotion
strategy is organized are:

      *The promotion of health and changes in lifestyle;
     * The organization and transformation of health services
       so as to address existing health problems of specific
       risk groups (mothers and children, adolescents, adults,
       the elderly, workers, etc.);
     * Development of a rational approach to the selection and
       use of technologies that are costly and highly complex.

     Based on the priority areas of action, the following have
emerged as strategic activities aimed at promoting and
encouraging change:

     * The dissemination of pertinent information;
     * The provision of incentives to the information media so
       that society as a whole and each of its communities
       will become aware of, discuss, and accept or reject the
       risks associated with certain lifestyles that are
       considered unhealthy;
     * The training of health workers and social groups in the
       use of participatory approaches to prevention and
       health promotion, and
     * Epidemiological research aimed at increasing knowledge
       about problems and the results of interventions.

     The changes to be made in the organization of health
establishments, which are necessary so that they can assume
the new commitments arising from the adoption of prevention
and health promotion as basic strategies for the improvement
of health conditions, should be aimed at achieving:

     * Application of the risk approach in programming;
     * Earlier attention to problems in order to prevent death
       and disabilities, and
     * Changes in the organization of the health services so
       that they will be more active in the search for and
       early treatment of priority diseases.

     The strengthening of local health systems as a basic
strategy for the transformation of health systems in the
direction indicated is the principal frame of reference
within which health promotion activities must be conducted. 
In order to secure the equality and effectiveness that are
sought through the local health system strategy, it is
essential to train health workers in the use of new
techniques that will foster participation by the community
and the use of epidemiology.

     Given the conditions that exist in most countries of the
Region, it is clear that the areas that deserve particular
attention if the health problem is to be effectively
addressed are:

     * Drug abuse;
     * Health of the elderly;
     * Mental health;
     * Women's health; and
     * Workers' health.

     The possible emphasis on these areas does not mean
ignoring other problems, which, given the peculiarities and
specificity of different local conditions, may also warrant
priority treatment.

     With regard to the problems indicated, the search for new
models for health promotion, the prevention of risks, and the
recovery of health--ones that offer alternatives to
institutionalization and that strengthen the role played by
families and social groups--deserve special attention.

     Finally, other types of actions that continue to be
important in health work should be pointed out, in particular
the prevention of chronic noncommunicable diseases and
elimination of the risk factors that condition them,
combating cancer in women, and the prevention of disabilities
and deaths due to accidents and violent behavior (including
violence in homes and within the family).

     2.     HEALTH IN DEVELOPMENT

     This subject is by nature intersectoral, since it refers
to the challenges posed by new realities at the world,
regional, and national levels in the area of health. 
Throughout the history of the Pan American Health
Organization and each national experience in the Region,
there has been a growing awareness that health cannot only be
the work of the so-called health services, systems, and
institutions.

     Health is the best indicator of conditions of well-being
and the rationale for any social initiative, including
productive activities.  Thus, instead of speaking of health
and development, or health versus development, it is
preferable to speak of "health in development," because
development has no meaning without participation by the
sectors most closely associated with the living conditions of
social groups--that is, the so-called social sectors.

     Health in development gives meaning and purpose to
development.  Without this objective--that is, the well-being
of persons, families, communities, and society as a
whole--the notion of development is devoid of meaning.

     However, the relationship between health and development
is not limited merely to this goal-oriented and therefore
ethical proposition.  Health is both a factor and a result. 
In its relationship to what are known as productive
activities--i.e. what might be called economic
growth--health, rather than being simply an object of
expenditure or a "non-productive" sector, is an essential
condition for enabling those activities to be developed
within a framework of stability, peace, and social progress.

     In order for productive activity to be carried out
properly and to enlist the commitment and effective
participation of all social actors, a social environment must
be created in which the productive process is perceived as
being beneficial to all.  Conditions need to be created for
society to feel involved in the way economic activities are
organized.  There is no more efficient way to bring the
benefits of production to social groups, workers, and their
families than through the satisfaction of their basic needs.

     There are two fundamental aspects of health relations in
the development process.  The first is defined by the purpose
of the process itself, which is that beyond its ethical
dimensions it is a fundamental requirement for the creation
of a psychological and social environment that is adequate
for the productive process.  The second has to do with the
interdependence between the different social sectors,
particularly between health and the so-called productive
sectors.  However, the union of these two aspects cannot be
addressed using the mechanisms of development theory and the
methodological tools that have been developed so far for
implementing it.  The union of the ethical and economic views
of development can only be achieved through political action. 
It is only through politics that ethics and production can be
brought together.  This means that health in particular, as a
result or consequence of social processes, is both the result
of and a part of the political process.

     In the Region, generations have lived through a history
of constant shortages, repeated failures, disillusionment,
and broken promises.  Even during the periods of accelerated
economic growth, the processes of development in the Region
proved to be profoundly inadequate to meet the ultimate
objective of development itself:  achieving the well-being of 
   societies.  The crisis of the 1980s was not, therefore,
the root cause of the problems currently being experienced. 
It only underscored the inadequacies and deficiencies of the
development models adopted in the past and the need to give
thought to the forms and styles of development that are most
appropriate for the Region in today's world and in the
immediate future.

     Development is undoubtedly the greatest challenge that
the Region has to face.  It will not be enough to start
growing again if the increases in production are not evenly
distributed and if the benefits of growth fail to reach all
individuals in the societies and populations of the Region. 
To meet the challenge of development, new approaches will
have to be devised.

     From the perspective of health, the development that is
needed for Latin America and the Caribbean has to have at
least the following characteristics:

     Production and productivity.  Development implies and is
sustained by increased production.  It is necessary,
therefore, to create conditions for production to increase in
tandem with productivity.  If in fact adjustment policies are
necessary, an institutional framework for mobilization of the
needed internal and external resources has to be created in
order to increase efficiency and productivity.  Adjustment is
meaningless if it is not aimed at achieving the ultimate goal
of every development process:  the well-being of the people.

     Orientation towards well-being and equity.  The
fundamental characteristics of the new development are
political commitment, policy-making, and a commitment to
dedicate economic production to the well-being of the people
and to peace and social justice.

     Regional and world-wide integration.  Efforts to
introduce into the economies adjustments and structural
changes that envisage well-being and justice must be
undertaken in a context of increasing insertion of the
Region's economies into the new economic order being created
in the world.  If this insertion is to take place under
satisfactory conditions, individual action by the countries
is not enough.  If it is to sustain an adequate level of
development and achieve effective, useful, and meaningful
insertion into the world order, the Region faces the
extraordinary challenge of first of all integrating itself
internally, or at least establishing internal links.  The
force of national commitment must be joined with the strength
arising from common effort and a fully united front. 
Regional integration is not merely an ideal passed on to us
by those who brought about the independence of the countries
of the Region; it is a necessity.

     Freedom and democracy.  Development must take place in a
context of complete freedom and participation, which implies
democracy beyond its formal aspects.  Democracy that is
translated into a permanent way of life, which is present
everywhere on a daily basis, which makes it possible to
achieve one of the most valued of all human rights, namely
the right of individuals to participate in decisions relating
to their own future, is within the reach of all.

     Sustainment.  Development should be based on conditions
that enable it to be self-sustaining and not merely be the
manifestation of aspects of individual situations.  In
creating this self-sustainment, two factors are important: 
on the one hand, protection of the environment and
intelligent use of available natural resources, with the
preservation of this common heritage for future generations,
and on the other, changing the values that permeate and
sustain our cultures.  Over time, for reasons that will not
be explored here, values have been developed that undermine
efficiency, participation, and hard work and deny the
importance of unity, solidarity, and regional integration. 
These values, which are divisive, create inertia, work
against efficiency, and foster corruption (in the
sociological sense of the term), should be replaced by new
values that uphold the importance of productivity,
participation, efficiency, solidarity, and integration.

     A new State.  The development that is needed implies a
new role for the State and a change in its relationship to
society.  This does not mean that the State should disappear,
or even that there should necessarily be any less involvement
by the State.  A political commitment to ensure that
development leads to greater social justice, well-being, and
the satisfaction of basic needs, thereby resulting in equity,
requires a State that is active, efficient, flexible, and
therefore more involved and efficient in terms of decisions
leading to the channeling, orientation, and mobilization of
its resources.  This is not to argue in favor of the State as
a producer of goods or a bureaucratic State that is
inefficient and serves vested interests.  It is a matter of
recognizing that in order to ensure social cohesion, in order
to ensure the creation of those conditions that will make for
productivity and efficiency, and especially, in order to
ensure equity and the application of democratic precepts,
values, participation, and work, a new State is necessary.

     In all aspects of this development, health is essential: 
this is so in terms of its objective and also in terms of the
activities and actions that make it possible.  Not only does
it benefit from the new development; it can also become a
powerful instrument in shaping and promoting it.

     As we approach the end of the century, Latin America and
the Caribbean are facing a host of new challenges in the
health field.  There must be a continued effort to address
the problems of the past and, at the same time, to face new
and greater problems more effectively.  Services need to be
increased for a population that grows at an ever-faster rate
despite the reduction in fertility.  The older and more
urbanized population is exposed to increased risks in an
environment which is steadily becoming more of a hazard to
health and having a greater incidence of chronic degenerative
problems.  Thus health itself must also be changed.  Any
change occurring in relation to development, in its turn and
in the same way as development, should be oriented
essentially toward ensuring equity.

     In order for equity is to be a possible, with universal
access to coverage and health services, efficiency and
effectiveness must be increased through the improvement of
quality and the upgrading of care.  A sense of mutual
responsibility must be established between health services
and individuals, families, and communities, and mechanisms
must exist through which the health of every individual
everywhere is subject to a specific allocation that he can
claim from those responsible for the care of this health.

     Historical evolution has created a growing separation
between health systems and society, especially between the
former and the lowest-income social groups.  In order to
correct this situation, reorganization of the health systems
should have as one of its fundamental elements the process of
decentralization and the creation of local health systems
where persons cease to be merely numbers and acquire identity
as individuals.  This change that is needed in the health
sector and in the health services system can only occur
through the mobilization of all persons responsible for the
well-being, and the health in particular, of everyone.  It
cannot be an exclusive responsibility of those involved in
health; it is a responsibility of governments, of those who
define economic policies and orient the productive process,
of those who plan, of persons, communities, and families. 
This implies solidarity, social integration, and cooperation.


     3.     INTERSECTORAL DEVELOPMENT
     3.1    General Aspects of Intersectoral Development

     Intersectoral development is defined as the broadest set
of relationships between the different economic and social
sectors.  It encompasses both the coordination of efforts
among government agencies and the coordination of links
between sectors.  It is a process in which the objectives,
strategies, activities, and resources of each sector are
considered in terms of their effects and of their
repercussions on similar elements in the other sectors.  From
the point of view of the health sector, intersectoral action
constitutes a means for attaining fully integrated
development at the national, regional, and local levels in
the phases when policies are being established and projects
and programs are being developed, executed, and evaluated.

     The importance of intersectoral development lies in the
well-recognized fact that the results of one sector's
policies and actions depend to a great extent on the progress
made by the other sectors.  The increase in literacy and the
development of skills and competencies, the improvement of
living conditions and urban areas, agricultural development
and nutritional self- reliance, and economic growth with
equitable redistribution of benefits are some of the
fundamental requirements for creating better health
conditions.

     In order to effectively implement processes of
intersectoral development, a number of obstacles need to be
overcome.  They may be characterized as institutional and
administrative, political, human and financial, and
methodological.  Perhaps the greatest obstacle lies in the
national models of development themselves, since they give
priority to the economic aspect and do not take into account
the repercussions that decisions in this field can have on
social aspects--that is, on individuals, families, and social
groups that historically have been marginalized.

     3.2    Institutional and Administrative Aspects

     Application of the intersectoral development concept
calls for a prior analysis that will yield knowledge about
the institutional and administrative structures of the
different political jurisdictions in the country (national,
regional, local), the legal spheres of competence of the main
institutions, and the mechanisms of contact between them.  In
addition, there is need to examine the procedures whereby
policies are fixed, decisions adopted, priorities set,
resources identified, and programs and projects implemented.

     This analysis of institutional characteristics seeks to
identify the administrative spheres of competence of the
central government, the degree of
centralization/decentralization (formal and real) at the
various levels of authority, the interdependence between the
powers, and the way in which the development model determines
and conditions relationships between the public and private
sectors.

     3.3    The Political Process

     The existence of institutional and administrative
structures can represent the formal acceptance of the concept
of intersectoral development.  However, if there is no firm
political commitment with respect to coordination between
sectors or any recognition of the need for just economic and
social development, the institutional structures established
will have few opportunities to obtain significant or even
noteworthy results.

     One way in which this political commitment can be
manifested is through a national development strategy which
considers priority social goals within a framework of
instrumental policies that promote this strategy.  In
particular, the existence of well-established objectives and
intersectoral goals--especially the definition of
intersectoral financial and budgetary mechanisms--is the
objective manifestation of political commitment.

     However, political commitment expressed in the different
phases of orientation is not enough.  The local level must
recognize and understand the real relations of power between
the participants of the process (from the national, to the
regional, and to the local area itself), as well as their
legal status, mission, and the degree of real power that they
possess.

     In this type of analysis, it should be borne in mind that
the political process is not limited to the formal sphere of
competence of the public authorities.  The interests of
pressure groups and their political influence, the existence
of other social actors that can acquire great importance in
specific situations when their interests are directly
affected, and the way in which other groups and actors define
and fix their goals and objectives are also essential
elements to be considered in an analysis of the sector and in
the establishment of a strategy to be followed with a view to
obtaining the conditions necessary for a multisectoral
approach in conditions that favor the attainment of
satisfactory and effective development.

     3.4    Human and Financial Resources

     One of the obstacles to the strengthening of
intersectoral policies is the shortage of adequate human and
financial  resources.  The chances for the success of
intersectoral development proposals will depend to a great
extent on the creation of technical capability within the
health sector itself, especially at the regional and local
levels, which will make it possible to detect the capacity to
respond flexibly and creatively to local problems, calling on
solutions that go beyond the limited framework of the
traditional public health perspective.

     With regard to financial matters, within the framework of
budgetary restrictions currently existing in the Region,
there is a clear need not only to make better use of sectoral
public resources but also to take advantage as much as
possible of opportunities that may arise as a result of
effective intersectoral coordination, in order to avoid or
minimize the impact that programs or projects of other
sectors can have on health.

     Intersectoral development, however, can be a conduit for
the financing of health actions by the fact that the sector
can call for the inclusion of health components in the
investments and activities of the other sectors.  One of the
principal challenges to be addressed by local actors is to
identify opportunities for establishing complementary
projects and manage to participate in their preparation using
an integrative approach.

     3.5    Methodological Constraints

     From a methodological point of view, intersectoral
coordination begins with coherence between the objectives of
the different sectors, some of them being subordinated others
being combined, with a view to achieving a common objective.

     The viability of the actions planned will only be
achieved through by formulating general and specific support
policies that are assumed by all the participants of the
process.
     A necessary and important step to be taken is arrive at a
common (intersectoral) understanding regarding the nature and
direction of change--that is, regarding the characteristics
that will define the development project and, in accordance
with this, the profile of well-being and living conditions
being aspired to.

     Together with this process, programs for the operation of
the sector have to take into account both the incorporation
of interventions needed by the other sectors and the possible
negative impact on health of interventions needed, or not
needed, by these other sectors.  The determination of
interventions is linked to the analysis, understanding, and
identification of the critical elements of economic
development that influence health conditions and well-being,
and to a better understanding of how intersectoral actions
can contribute to improving the health of individuals,
families, social groups, and the environment.

     4.     HEALTH LEGISLATION

     The best place for the development of local health
systems is in the context of democratization and expanded
social participation.  One of the most effective mechanisms
of social participation in the formulation and execution of
health policies is interaction between the interests of the
different groups that make up society.

     Legislation, as the ultimate expression of this process
of participation, is the proper means for transforming health
into the fundamental ingredient of the development process. 
In this regard, not only does it constitute the medium
through which the health sector should be restructured in
order to permit the proper operation of local health systems
but it also generates the conditions that provide for the
full physical and mental development of the individual and
the person's integration into the aforementioned process as
both actor and beneficiary.  For this reason, consideration
must be given to the real dimension of development--that is,
its overall and interrelated nature.  Legislation should be
regarded as one of the means that will allow this to be
achieved.  It should be considered and analyzed in three
contexts:  the international, the national, and the local.

     From an overall perspective, a proper international
policy-setting approach will facilitate the process of
regional integration.  Therefore, in order to achieve the
kind of development that will guarantee well-being and
equity, the importance of health legislation should be
recognized, not just in the area of service delivery but in
its true broad, multisectoral context.  This process of
regional integration will affect the domestic legislation of
the States, which, in turn, will become the vehicle par
excellence for the harmonization of development strategies
having the aforementioned characteristics.

     At the national level, it is through legislation that an
institutional reformulation will be feasible.  Structures
that favor the active participation of the State will be
generated with a view to achieving equity.  In this context,
legislation should facilitate the creation of proper
mechanisms for guaranteeing the extension of coverage to all
social groups and creating the appropriate legal framework
for the proper exercise of institutional pluralism in the
provision of health services.  Finally, it should permit the
structuring of an efficient mechanism of control on the part
of the society.

     In the specific context of LSA, proper health legislation
should be capable of structuring the normative framework
through which coordination between different national and
local levels takes place effectively and on the basis of an
efficient process of decentralization.  As has been stated
earlier, each local reality is different.  However, the
decentralization process responds to a qualitative rather
than quantitative concept.  It is based on social
participation in the management of public matters with a view
to achieving greater equity and effectiveness.  For this
reason, local or municipal legislation should include
regulations regarding the services that are provided.  In
addition, it should not be limited to the sectoral context
but rather be oriented toward the intersectoral context with
a view to also including those actions that are related to
the other sectors of economic and social development.

     From the point of view of the legal instruments that
facilitate decentralization and the execution of health
actions at the local or municipal levels, legislation
supporting cooperation between municipal or departmental
systems in the field of health will have to be reviewed.  In
other words, the structure of this cooperation will have to
be examined--how it is structured and whether it has been
considered in a manner that will permit its effective
implementation instead of stopping at mere statements or
declarations.  In this regard, it is important to point out
that most of the national Constitutions contain provisions
for regional decentralization.  In other cases, the matter is
regulated by norms that come under the Constitution and
which, without contradicting it, serve to fill the
constitutional gap.

     However, even in those cases where provisions have been
made for decentralization at the level of supreme law, the
provisions that pertain to it are usually vague and refer to
the health aspect without considering the overall
intersectoral implications of the concept of primary care. 
It is therefore important to examine the laws that regulate
the municipal or departmental system in order to determine
their true scope and proceed with appropriate adjustments
depending on the legal situation in each case.  Importance
should also be given to norms that provide for economic
decentralization for the purpose of determining assigned
functions.  Finally, in the particular case of federated
states, since the decentralization of functions should not be
limited to States but should also be geared toward the
delegation of authority at the municipal level through the
State Constitutions, it will be important to review these
instruments to determine whether they are capable of
permitting effective decentralization at that level.

     5.     THE ROLE OF THE STATE IN RESPONDING TO THE HEALTH
NEEDS OF THE POPULATION

     Local health systems are being developed in a context of
crisis that affects the political, economic, and cultural
spheres.  The main characteristics of this crisis, which has
many dimensions, is persistence and permanence; it takes the
form of cycles more than an abrupt and short-term break.

     In most countries of the Region, the crisis is
accompanied by a series of questions concerning the role
historically played by the State and the appearance of new or
renewed forms of involvement of units and elements in the
social dynamic.

     In this context, the success of LSA depends on and is
conditioned by the following:

     * Effective participation by citizens from all social
       groups in all its dimensions, and;
     * The development of mechanisms of solidarity and social
       justice at the national, regional, and local levels;
     * Full political and social participation;
     * Just conditions of access to production and
       consumption.

     In addition to these are the conditions arising from the
needs created by a proposal of this kind, namely the
existence of processes of decentralization and social control
of State management.

     Assuming that the foregoing conditions are reasonably
fulfilled, the State would have to perform the functions of
orientation, regulation, redistribution of the socially
produced surplus, and promotion of cooperation, from a social
perspective, between the different groups that make up the
population.  It would also have to guarantee the necessary
conditions for just participation by the various social
actors.

     Within the State, various levels of sectoral public
administration are responsible for carrying out political
directives that form part of the national health project.  In
that regard, some conflict does arise between two roles that
have to be harmonized within the State apparatus itself.  The
first arises from the fact that the organs of government are
responsible for carrying out the policy of the majority in
power at a given time and the second is determined by the
long-term social project that characterizes and gives a
specific society its identity.  The two do not always
coincide, creating contradictions and points of friction that
serve as obstacles to achievement of the objective of a more
profound transformation of the existing situation.

     Recognition of the role of sectoral organs of the State
as political and administrative instruments of the government
has implications that call for an open-minded, vigilant,
creative, and flexible approach to the analysis of problems,
the design of the options undertaken to solve these problems,
and administration of what has been agreed to.  It requires,
in addition, getting rid of beliefs and harmonizing
conflicting interests in the midst of situations of great
uncertainty and within very short periods.  One method of
contributing to this process is to give local groups the
possibility to participate fully in the overall management of
the national project.

     It is critical to differentiate between the function of
government and strategies and contingent actions arising
therefrom in the short and medium terms,.and between the
substantive and the ongoing responsibility of the sectoral
organs of the State, whose institutional mission is to design
and implement long-term strategies for the reduction of
social inequities and the improvement of standards of living. 
This is an inherent requirement of processes aimed at
consolidating democracy, the fulfillment of which implies
other horizons and solutions that transcend the situation and
are part of the development of the national project.

     The activities of the State health sector agencies that
serve as conduits for the development and fulfillment of
policies require that efforts be focused on the development
of strategic leadership capacity and administration of the
system and its organizations, with a view to finding creative
alternatives that produce results quickly and are feasible
and viable.

     At the national level, the Executive Branch is
responsible for devising policies and global strategies with
which to address national problems, and through its political
and administrative instruments (ministries and secretariats),
designing and implementing appropriate sectoral and
intersectoral policies.  This effort also involves the
Legislative Branch as a critical protagonist, assisted by the
process of consolidating democracy in terms of its
responsibility to act as the mediator in the dialogue with
civilian society and the State--that is, as the formal
vehicle for the social control of public management at the
decision-making level, facilitating, in this context of
negotiation and agreement, a management style that is open
and governed and regulated by persons who represent the
interests of the different sectors of society.  In addition,
parliament provides an effective avenue for the incorporation
of new social actors into the policy-making arena, thereby
permitting the process of increased participation by
individuals to be improved.

     Today, when political elements in pluralistic democracies
gather into organized social groups, the parliament and the
political parties are responsible for enabling the
participation of social groups that have been overlooked and
hence have fewer possibilities for organization and
expression of their needs and aspirations.  Health
legislation involves the establishment of joint forms of
coexistence on which the living conditions of vast sectors of
the society depend.

     As a result, in order to assume their responsibilities,
the Executive and Legislative Branches must strengthen their
respective areas of discussion and cooperation.

     With regard to the role of the sectoral organs of
government, the translation of the views expressed above
regarding the development of strategy and specific policies,
given its specificity, is a task that should be thought
through and undertaken in the light of each national
situation and reality.  However, a number of operational
contexts and strategic groupings can be identified which
could orient or at least systematize the proposal under
discussion.  These operational phases and strategic groupings
do not really constitute isolatable categories or formal
sequences.  Their identification can only can be useful in
facilitating comprehension of the process being outlined.

     Within the framework of those limitations, it is useful
to regard an operational phase as one in which the sectoral
organs of the government identify and evaluate the needs and
demands of the sectoral groups that are most affected.

     This operational phase is critical not only because it is
during this phase that the objective of the policies and
strategies to be developed by sectoral agencies is defined
but also because it is strategic to development of the
capacity for negotiation, cooperation, and leadership, which
are vital to fulfillment of the responsibility assigned to
the sectoral organs of government.

     The development of strategies for combating the health
problems of the social groups identified on the basis of the
health/disease phenomenon considered as a historical,
biological, and social process is another operational phase
of strategic importance, since it provides the sectoral
organs of government with the central argument for the
development of interinstitutional coordination with society,
based on their expertise in the technical field, since it
provides them with the opportunity to create options for
negotiation and coordination.  In turn, these attack
strategies constitute, from the time they are developed, a
central argument for creating structures, communication, and
development within the institution itself.  They fall into
three strategic groups:  coordination at the level of design
and social control, interinstitutional articulation (health
system, other sectors, and civilian society) through specific
joint actions in which the specific demands of specific
public and private institutions are negotiated and
coordinated, the legalization of government monitoring and
control (giving legitimacy to regulation), and the creation
of a unifying option capable of fostering the environment
necessary in order to successfully implement strategic
institutional leadership.

     With due regard for the specificity of each national
situation, it seems possible to assume that at the
institutional level this strategic approach, with the
variations involved in each case, will revolve around
maximizing the effectiveness and efficiency of the health
care network, the extension of its coverage to marginalized
social groups, and democratization of the management thereof.

     6.     THE ROLE OF THE SOCIETY AND OF HEALTH ORGANIZATIONS
     6.1    Social Movements

     Three sets of actors that deserve special treatment
because of their importance to health activities are social
movements, women, and nongovernmental organizations (NGOs). 
Although the last two may be considered subsets of the
former, they are listed separately because of their rapidly
growing importance on in the health area.

     Social movements in general, and women and NGOs in
particular, are actors in health which to date have had
little or no representation.  They are now calling for legal
recognition in new areas of debate and for cooperation within
the sectoral organs of government at the levels of social
structure and organization in which they are involved.

     The presence of new participants in the social process
leads to a reconsideration of actions and a redefinition of
established powers.  One of the results of this new scheme is
the generation of strong movements that are making demands on
local management.  These demands have contributed in part to
the movements for the decentralization of State power.

     One particular type of social movement is neighborhood
groups that get organized in response to problems affecting
poor living conditions.  Some of the main demands of these
groups are in the area of health.  These groups will
undoubtedly be called upon to play a fundamental role in the
decentralized management of health services, serving as the
counterpart to local health system management.

     The confluence of those different factors creates the
conditions for the (re)acquisition of knowledge and for
health actions by local social groups that had been
marginalized or alienated over time.  Accordingly, we are now
witnessing the active reassumption of responsibilities by
populations and individuals with regard to their health.

     In this context, the participation of women and their
movements is of special interest, since they are they ones
who historically and socially have played a fundamental role
in the health care of their families and who quite often
assume a leadership role in health action.

     While economic and social development is leading to the
incorporation of increasingly large numbers of women into the
labor force, at the same time their historical role is being
jeopardized because of the dispersion of their energies in so
many different directions.  However, the formal participation
of women at almost all levels of decision-making is bringing
to the fore approaches in relation to health that are
concrete and pertain to real situations--approaches which
until quite recently were thought to belong to a frame of
reference that was almost exclusively female.

     This growing role of women's and other social movements
in the health area makes it imperative to open up
opportunities for them to participate on an equal footing and
to find new approaches and solutions for dealing with the
needs and demands of the population.

     Of particular importance is the integration of women into
the processes of health in development, since it is urgent to
redress the imbalance in relationships between the sexes as
an integral part of human development and of the health of
the population as a whole.

     This move toward the real integration of women into
society includes the mobilization and coordination of
decisions by the health sector agencies in the local context
taking women's and other social organizations into account so
that specific actions can be developed for the solution of
health problems that are specific to women and for the
redress of discriminatory situations to which they are
subjected in most social spheres, even within the family.

     To the extent that local health systems are capable of
incorporating these new expressions of society organized in
this manner, they will be capable of generating, from the
bottom up, the changes expected in the national health
systems.

     6.2    Health Workers

     Given the fact that the health sector is labor-intensive,
the manner in which the question of health workers is handled
is very important in terms of both the training and
utilization of human resources.

     With regard to the former, there appears to be a loss of
prestige of the traditional professions.  This is the result
of increased segmentation in health professions and the
accentuation of inequities between health professionals.  For
physicians, and perhaps dentists as well, their category has
been segmented into different strata each with a separate
social function.  The increasing feminization of the health
work force is contributing to this process, one of whose
characteristics is the reduction in compensation for work
performed.  The most recent result of this process, which is
pertinent to the present discussion, is the decline that can
already be seen in some of the countries in course enrollment
in the health fields, especially in non-autonomous careers
such as nursing and social work.

     With regard to the integration of professionals into the
salaried labor market, a reduction can be seen in the
purchasing power of workers in the public subsector.  This is
being translated into a movement of certain segments of the
health work force toward other areas of activity where
salaries are higher.

     However, given the high degree of specialization in some
of the professional sectors, which makes a professional
choice almost irreversible, the migration is taking place
selectively through changes in the distribution of health
manpower.

     The large discrepancies in compensation between the
different professional categories and within the same
categories accentuate the disparities and imbalances between
health workers and make it more difficult to organize the
work.

     In many cases, health workers have resorted to holding
more than one job.  At the same time, essential activities
such as continuing education, training incentives for
professionals in other centers, rotation of health teams,
etc., are suffering serious setbacks in this context.

     With regard to the strategy under consideration, the
factors just outlined have made for a body of professionals
with increasingly less vocation and motivation, alienated
from their work, with little or no awareness of the worth and
dignity of what they do.  The situation is being aggravated,
moreover, by increasing medicalization and reduction of the
health problem to medical care.

     As a result, health workers who have the potential of
being fundamental force in the transformation process are
fragmented and divided into multiple actors bound together by
short-term interests but in general alienated from their true
commitment and responsibility.  Regardless of the
circumstances, it is imperative that mechanisms be created at
the local level that will bring health workers closer
together on the basis of their shared concerns and at the
same time bind them to the social groups they are meant to
serve.


     7.     THE TRANSFORMATION OF NATIONAL HEALTH SYSTEMS: THE
LOCAL HEALTH SYSTEM STRATEGY

     Local health systems are the concrete expression of the
basic strategy for reorganizing and reorienting the health
sector with a view to achieving equity, effectiveness, and
social efficiency through maximum participation by community
groups and implementation of the primary care strategy.

     The concept of local health systems is in fact a proposal
for the division of labor within national health systems
based on geographic and demographic criteria.  It has emerged
in response to the needs and demands of social groups and of
society as a whole, in light of the injuries and risks to
which they are exposed.

     In principle, the municipio is the preferred area for the
establishment of local health systems, although the area may
also be larger (several municipal jurisdictions combined) or
smaller (neighborhoods or other subdivisions of large urban
areas) if the circumstances so require.

     The local health system is responsible for serving the
individual, the family, and the community, and it seeks to
coordinate all resources for this purpose, both sectoral and
extrasectoral, within its jurisdiction and to promote the
broadest social participation.

     The strategy provides for local health systems to be the
basic units in the organization of national health systems. 
However, the local system should not be thought of as the
most simple functional unit, since it is not correspond to a
particular level of care but rather the minimum political and
administrative structure capable of responding to the needs
and health demands of a sector of the population, to the
extent considered equitable and just in a given society. 
Thus a local health system should include everything, ranging
from the least sophisticated resources (for example: lay
midwives, health auxiliaries) to the most complex
(hospitals), forming a network makes it possible to address
all major health problems for a given geographical and social
group.  The services network must be structured in such a way
that all its various levels are aware of the different health
needs of the population.

     However, local health systems do not end with individual
care; their philosophy also implies care of the family, the
community, and the environment (approached through the home,
places of recreation and employment, and any other settings
where the health of individuals, families, and social groups
is directly affected).

     However, because not all needs and demands are met in the
same manner, consideration will have to be given to the most
appropriate way of resolving each type of problem
effectively.  While some problems will be solved within the
local health systems, others will have to be dealt with
outside the local context.  This fact is important, because
it dictates the scope and limitations of local solutions.

     It should also be pointed out that when the local level
is strengthened, the possibility is also being created for
other problems to be solved at the other levels of the
national health system.  This process seeks to reverse the
usual practice of defining problems at the central level and
then later identifying them at the local level.


     8.     SOCIAL PROCESSES AND THEIR RELATIONSHIP TO HEALTH
SYSTEM ADMINISTRATION

     A social process is an ongoing construction and
reconstruction of reality by a social group whose members
share experiences and cultural practices that give them a
sense of belonging, lend identity to the group, and encourage
joint behavior in the face of developments and events that
arise.

     The following are some of the characteristics that define
social participation:
     *   It takes place in the context of shared experiences. 
It is not decreed, regulated, or defined in terms of
time or physical space;
     *   It promotes learning, because its actors share,
either explicitly or implicitly, a common set of
needs, objectives, and approaches for prioritizing
and solving their problems;
     *   It demonstrates, on an ongoing basis, that the
sharing of a common task by members of a community
gives better results than tasks done independently by
groups working in their own interest, motivated only
by the attainment of their own objectives;
     *   It breaks down stereotypical behavior that hinders,
invalidates, or blocks social and individual growth;
     *   It promotes dialogue and creative approaches to the
study and solution of problems and conflicts, and it
helps people to channel their anxieties and deal with
crises;
     *   It respects and makes use of the schemes of reference
(experiences, knowledge, and feelings) of its actors,
promotes the analysis of practical experience and
theory, and recreates knowledge;
     *   It collectivizes individual knowledge and builds and
enriches shared knowledge;
     *   It coordinates and brings about consensus regarding
ideologies, integrates them, and enriches them based
on positive and conscious practical experience;
     *   It encourages a better quality of criticism, views
that are substantiated and justified, affirmations
and negations, reflection, and decision-making;
     *   It forms a constructive context, a point from which
to perceive the world.  It is a dynamic system marked
by interpersonal relations; an integrated
communication network; a time for discussion,
reflection, expression, analysis, and action; a forum
for collective and cooperative endeavor; and a
setting for participation and socialized and
contextualized learning that leads to a common
outcome in which all have a share.

     In order for the overall context to be able to promote
participatory processes, it is necessary to think about
behaviors and attitudes to be displayed by those directly
involved in the social processes such as:
     *   Personal commitment
     *   Honesty of opinions
     *   Cooperative and collective attitudes
     *   Self-control
     *   Capacity to listen and rigor of expression
     *   A critical approach to analysis, reflection, and
decision-making
     *   Perception of others as being jointly involved in
construction of the reality
     *   Ability to be, speak, listen, and act in harmony with
and not against others
     *   Open-minded approach to learning.

     Local health systems provide the appropriate forum for
social groups to participate in management of the health
system, from the definition of problems and the determination
of strategies for their solution to the execution, control,
and evaluation of activities, outcomes, and effects.  This is
because of their small size, since they establish more direct
social relationships between representatives and the
represented, and because they are committed to becoming
increasingly autonomous vis-Õ-vis the central levels.

     The health sector actors and civilian society participate
jointly in local health systems.  The simultaneous presence
of persons whose experiences are mutually influential
requires an organizational structure and rules that permit
individual decisions to be incorporated into collective
decisions.

     Participation creates political conflicts, since it
implies shifts in the distribution of power, which impacts on
grass-roots organizations and strengthens their political and
organizational profiles.

     Understood as a basic human right, participation in the
field of health, when fully exercised, is equivalent to
reappropriation by the population of all institutions that
regulate health actions."


     9.  THE ROLE OF SCIENCE AND TECHNOLOGY

     The complex interrelationships that are established
within the health system, together with the many factors that
bear on the health of individuals, families, social groups,
and the environment, create a favorable climate for the
development of scientific and technological knowledge.  In
the search for new solutions to the health problem, it is
important to establish the closest possible linkage between
health workers, social groups, and scientific and
technological advances being achieved.  It is clear that this
linkage cannot be viewed only as a task for the central
agencies of the health system.  It must be reflected at each
of the different levels of its organization and in society
itself.  It will have to seek to develop the mechanisms that
facilitate that linkage as well as the flow of knowledge in
the opposite direction, that is, from society toward the
institutional sectors that are responsible for generating
knowledge and techniques.

     For purposes of this discussion, four types of knowledge
in the field of health sciences are outlined.

     One is clinical knowledge, or knowledge of medical
sciences, which focuses on the individual.  This knowledge is
directed predominantly towards the diagnosis of disease or
problems, their organic or biological cause, and the
definition of what should be done, how it should be done, and
what should not be done, using the resources of medicine as a
biological science.

     This knowledge is applied by the health worker--the
doctor, nurse, or other professional in the area--to the
patient or family to indicate the actions to be taken and the
behavior to be adopted based on the specialized knowledge of
the professional.

     The second type of knowledge, which may be considered a
subset of the first but which is usually rejected by leaders
in the field of the scientific knowledge, is popular
knowledge--the heritage of the people, which is applied by
persons, families, populations, and has its roots in history,
in age-old experiences, and in traditional cultures.

     The third type of knowledge basically uses biological
knowledge and does not totally reject all the contributions
of popular knowledge, which it applies to a different object,
namely the population.  This is epidemiological knowledge,
which builds upon what has to be done and how it should be
done at the individual level by analyzing the causes that
predispose and account for the problems at the community
level and identifying the populations at risk, whether
biological, economic, or social.

     The fourth type of knowledge includes the previous three
and combines them with knowledge about the organization and
management of resources.  Its object is not only individuals
or populations but also health services and the processes
carried out within these services, between the services and
the people, and between the health services and other social
services.  It is concerned with the implementation of
decisions and consideration of options, institutional and
social organization, the financing of services, etc.  It is
at this level of knowledge that an attempt can be made to
relate the formal knowledge of the services with that of
social groups.  In terms of the concept of LSA, the
programming process can greatly facilitate the establishment
of this coordination between institutional knowledge and the
knowledge of social groups.

     Existing knowledge can be organized according to its
purpose under some of the following non-exclusive
categories:

     1.  CLINICAL KNOWLEDGE:  what to do, what not to do, how
to do it.  Target:  individual.
     2.  EPIDEMIOLOGICAL KNOWLEDGE:  identification of social
groups exposed to different risks.  Target:  social
groups.
     3.  POPULAR KNOWLEDGE:  attitudes, beliefs, and behavior
based on experience and historical and cultural
practices.  This type of knowledge cannot be
formalized or governed by standards that apply to the
so-called scientific method.
     4.  ADMINISTRATIVE KNOWLEDGE:  with what resources, at
what costs, and using what type of organization. 
Consideration of technologies.  Target:  health
services, institutions, and their organization and
interrelationships.

     LSA undertakes to relate these types of knowledge and
establish the most appropriate method of coordination in each
case.

     9.1 The Role of Epidemiology

     The central mission of epidemiology, within the services
system, is to produce knowledge that will enable it to
broaden the explanation of health/disease processes in order
to facilitate decision-making for the formulation of health
policies, the organization of system, and the actions aimed
at resolving specific problems.  Consequently,
epidemiological research should be oriented toward the
identification, description, and interpretation of those
processes which, at the individual and collective levels,
determine the frequency and distribution of health problems,
thus providing a critical perspective of the health
situation, helping to rank priorities among the population
groups and the determinants of their problems, and selecting
strategies for action and evaluating their impact.

     The theoretical reconstruction of the processes that
dictate the health profiles of social groups seeks to
identify laws and general principles as well as the many
processes that mediate between the objective conditions of
life and health problems.  The description and explanation
are acts of knowledge and acts of investigation.  Decisions
regarding the utilization of this knowledge for the
transformation of health conditions constitute political acts
that involve not only knowledge but also the ability to
control the system, the capacity to administrate, the
available technical and financial resources, and the context
for the exercise of power within the framework of the
projects and interests of the different social actors. 
Accordingly, the production of knowledge about the health
situation and its determinants should be closely articulated
with the decision-making with regard to priorities and the
allocation of resources.  It is very important for this to
involve the health team as a whole, as a systematic ongoing
activity for evaluating and reorienting decisions.

     Based on these concepts, a general consensus has been
reached on the identification of four broad areas of action
for epidemiology within the health systems:

*  Studies of the health situation in different
population groups, its determinants and trends;
*  Epidemiological surveillance of diseases and other
health problems;
*  Causal and explanatory research on priority health
problems;
*  Assessment of the health impact of the services and
other actions on individuals, the environment, and
living conditions, and the evaluation of technology
in terms of its safety and impact.

     Studies of the health situation can no longer be limited
to recitations of the main categories of mortality and
morbidity and a few demographic indicators.  These studies
provide the means of identifying and accounting for priority
problems with a view to implementing change.  They should
therefore be oriented toward the systematic evaluation of
health problems and their determining processes with a view
to providing information for the adoption of the necessary
decisions and actions in order to reduce the risks of disease
and death.  The population is not homogeneous, and priority
health problems may vary considerably from one group to
another.

     Health needs represent problems for sectoral
decision-making, to the extent that they are perceived and
viewed by a social actor in whose collective conscience they
are organized, ranked, explained, and built into a mobilizing
force.  Therefore, the identification of priority problems
requires, in addition to the technical effort of health
workers, the utilization of methods and techniques that will
permit and promote participation by the different sectors of
the population and make it possible to grasp and understand
the underlying subjectivity in assigning degrees of priority
to the problems.

     9.2 The Application of Knowledge:  Role of the Health
Programs

     One of the fundamental objectives in the development of
the local health systems is to maximize the impact of health
actions.

     The achievement of a greater impact requires the
incorporation of all successful experiences in the area of 
health actions in a comprehensive and coordinated way.  In
order to obtain an adequate response to this challenge, the
social actors involved in local health systems must be able
to define joint programs.

     It is generally accepted that health actions are those
that are carried out through the application of knowledge of
the health sciences and implemented by institutions,
organizations, or individuals in order to try to resolve the
specific development and health care problems of individuals,
families, social groups, and the environment.  However, from
the perspective of LSA, it is not merely a matter of applying
knowledge from the health sciences.  In addition, it involves
the knowledge generated by health institutions and the
different sectors of the society, as the product of their
experiences.  One of the concerns of LSA is to capture
knowledge regarding the health/disease processes in different
population groups based on their culture, beliefs, and
traditions.

     The reconstruction of clinical knowledge in the
particular health science specialties and in public health,
corresponds to what is usually known as Health Programs.

     The method of defining the population groups to which
these programs are targeted varies.  The criteria used for
the classification may be age or age groups (e.g. children,
adolescents, adults, the elderly), sex (e.g. maternal care),
or the persons involved in the productive process (e.g.
workers' health).  The categories may also be defined in
terms of diseases or a groups of diseases (e.g. programs for
tuberculosis, leprosy, mental health, communicable diseases,
etc).  Regardless of the approach used to address a problem,
steps should be taken to avoid conflicting approaches at the
time of application, in which, instead of being mutually
reinforcing, they compete for resources and clientele.  It is
at the local level where, based on joint programming, the
different types of knowledge can complement one another in
comprehensive health actions.  The programs suggested for the
purpose of solving problems among population groups
identified on the basis of shared risks seem to be those that
manage to be most effectively integrated and to achieve the
best results.


     10.    ANALYSIS OF THE PLANNING AND PROGRAMMING PROCESS

     In the mid 1960s, a planning method emerged in the field
of public health which was to have a long-term impact on work
in the Region's health sector--namely the CENDES/PAHO
method.

     Taking efficiency in the use of resources as the central
area of concern and focusing on the achievement of this
efficiency through basic concepts and principles of economic
science, a methodological context was developed in which
precepts from the physical and natural sciences prevailed.

     The most important of those precepts, because of its
methodological consequences, is that there be an external
observer who is not related to the phenomenon being studied. 
The translation of this precept to the field of health
planning meant that the planner was viewed as someone who has
no interest in the system being planned or in society as a
whole.  Both were treated as system/objects that were to be
controlled through the rational processes of the planner, and
this was considered to be science.

     Since the system/object was expected to perform in a
manner that was only barely reactive, its different states
could be considered predictable and reasonably well-defined. 
The system did not create, it reacted.  Its rationale
followed laws that can become known and which at the very
most are based on probability.

     Laws and objective conditions for making determinations
led to the demand for a universal and depersonalized
diagnosis that would make the individual identification of
problems possible.  It was always assumed that a scientific
solution to these problems existed.

     At the end of the 1960s, health planning was invoking the
coordination of services and the expansion of coverage as
watchwords.  This was reflected in the discussions held at
the III Meeting of Ministers of Health and was reflected in
the Ten-Year Health Plan for the Americas approved at that
meeting.  The plan, which embodied recognition of the
universal right to health, assumed the extension of health
coverage to the rural areas and to poor urban areas.  Through
emphasis on integration or coordination of the many
institutions working in the sector, the role of the State was
strengthened in terms of its responsibility for the
formulation of health policy.  An important antecedent for
LSA, there was already a proposal for participatory planning
which called for incorporation of the population into the
organization and execution of health activities.

     At the end of the 1970s and the beginning of the 1980s, a
different approach to problems emerged in the area of health
planning.  This new approach, the "strategic" approach, is
based on the recognition, inter alia, of the criticisms and
failures observed in the normative approach to planning.

     The strategic approach has different interpretations,
each of which is given a special identity.  However, they all
have a series of common elements that make it possible to
characterize this approach to health planning as innovative.

     The first common element in the strategic approaches is
the recognition that there is more than one way to interpret
reality, each associated with a specific interest group. 
This leads to a conflict, real or potential, between the
different approaches for obtaining the most desirable
solution.  Thus, since there is no single solution, the one
to be implemented must be chosen on the basis of agreement,
cooperation, consensus, or other forms of coordinated
opinion.

     A second element is the recognition of opposition and
hence of opponents whose actions are not merely reactive but
also, and to a great extent, creative.  The path of resulting
actions is not decided by the person who does the planning
(individual, social actor, institution, or organization) but
is the result of transactions throughout the process, in each
of which the different participants seek to maximize their
gains or minimize their losses, depending on the conditions
imposed by the situation.  There are no laws that make it
possible to easily foresee the results, and most of the time
there is no room for any predictions at all.

     Another distinctive element is the treatment accorded to
the planner.  In strategic planning, the planner is a social
actor who is part of the system being planned and with whom a
relationship is formed based on determinations and
conditions.  The planner is longer an observer outside the
system but rather someone who occupies positions both in the
process and in the system, which, together with his
background, determine his perception of the problems and the
solutions.

     Since the person who does the planning is only one of the
actors, and since his "truth" is one of several possible
"truths," this means that there cannot be only one process of
diagnosis.  There is more than one explanation of social
reality, and therefore the determination of problems and
solutions will depend on the affiliation of the person who
decides in favor of a given system of ideas.

     LSA, which attempts to incorporate local perspectives and
concerns into all its approaches to the national endeavor,
falls within this strategic context and is a natural
outgrowth of thinking as it has evolved in the field of
planning.



PART II
LOCAL STRATEGIC ADMINISTRATION

     This section presents the specific aspects of local
strategic administration--orientation, programming, and
management--which constitute the basic nucleus for the
undertaking that local health system development seeks to
facilitate.
CHAPTER II

CHARACTERISTICS OF
LOCAL STRATEGIC ADMINISTRATION

     1.     LOCAL STRATEGIC ADMINISTRATION IN LOCAL HEALTH
SYSTEMS

     As a first approximation to defining the concept, LSA may
be seen as a way of relating the problems and health needs of
social groups living in specific geographical areas to
available knowledge (clinical, epidemiological, social,
administrative) and institutional and community resources so
that priorities can be defined, alternative actions may be
considered, and the process can be guided toward resolution
or control of the problem.  Resources and knowledge should be
allocated with a view to maximizing equity (ensuring equal
opportunity in terms of access and coverage for all social
groups, based on their relative risks), effectiveness
(achieving the best possible results and the highest quality
compatible with the resources available to the health system
and which social groups are prepared to dedicate to that
objective), and social efficiency (maximizing the resources
offered by the population, the health system, and the other
social sectors involved), while at the same time promoting
and facilitating social participation in all the phases of
the process.

     The relationship between the problems and needs of social
groups, on the one hand, and the knowledge and resources
available, on the other, should be established with
sufficient flexibility to allow for analysis of the
advantages and limitations of various options and also to
create a climate for dialogue and the negotiation of
agreement at the intra- and intersectoral level while
involving society and the different sectors that comprise it.

     The knowledge of the health sciences, systematized with a
view to fulfilling the purposes indicated, should be
channeled through instruments of self-same organization and
administration in order to reach the population and permit
the attainment of the objectives sought.

     LSA is proposed as the means for providing the conceptual
and methodological elements needed in order to systematize
the knowledge and resources of the different social actors
involved, enabling them to be more effectively applied to the
solution of problems that affect social groups in the health
area.

     Social groups must play the role of protagonists in the
organization and management of local health systems--a
process that should incorporate the knowledge generated over
time both within the health system and by the various sectors
of society.  Hence, instead of defining, as is usually done,
a scheme to be adapted to different areas of health
knowledge, it is proposed to reverse the process--that is,
to base it on the needs of the groups, which should serve to
reorient the contributions of the respective areas of health
knowledge, and then to devise strategies for addressing the
problems and arriving at the most appropriate LSA approach in
each case.

     The challenge, which this new approximation attempts to
deal with, is to apply health knowledge--based on maximum
social participation by the groups and institutions
involved--with equity, effectiveness, and social efficiency
through a comprehensive approach to actions that takes into
account promotion, prevention, cure, and rehabilitation.

     The strategic approach attempts to avoid haphazard health
actions and takes as its fundamental unit or main object of
concern a multivariate and complex grouping that corresponds
to an individual/family/social/environmental system and also
takes into account the integration and complementarity of
various possible approaches to the solution of health
problems.

     The proposal maintains that both the resources and the
necessary knowledge can be found in the community, in the
health services, or even in services or areas outside the
realm of public health.


   2.  FUNDAMENTAL CHARACTERISTICS OF LOCAL HEALTH SYSTEMS
       THAT AFFECT LOCAL STRATEGIC ADMINISTRATION

     The basic characteristics of local health systems as they
are regarded in the context of LSA are as follows:

*   The local health system is responsible for identifying all
    health problems among the entire population living in its
    area of intervention and for channeling them toward a
    solution.  In terms of LSA, this means that instruments
    need to be devised that will make it possible to identify
    all social groups and the health problems that affect
    them.  This may not be possible in the beginning, but it
    is important to bear it in mind as a goal to be reached at
    some time in the evolution of the process.  In the
    meantime, steps can be taken to develop instruments that
    will make it possible to identify those problems
    considered to be the most important in the area of local
    health system intervention.  A possible point of departure
    might be to utilize the indications gained from the
    problems that have the highest priority in the Region,
    subregion, country, province (or analogous division), or
    local health system jurisdiction.

    Identification of the most relevant health problems, to
    the exclusion of others, does not imply a definitive value
    judgment concerning their importance or priority in the
    local context, since, within the flexibility and
    adaptability characteristic of strategic processes, it is
    always possible to revise priorities and reconsider topics
    which, at the time of the initial problems were
    identified, corresponded to gaps in knowledge. 

*   In order to be able to address all health problems, local
    health systems encompass the entire population living in
    its area of operation, with no group excluded.  This does
    not mean, however, that all of them will receive equal
    treatment.  The public subsector would have to undertake
    redistributive intervention in order to begin to approach
    the goal of equity, assigning the necessary resources and
    responsibilities so that those sectors of the population
    that have less access to health services will be capable
    of finding adequate solutions to their problems and can
    meet their needs and demands in ways that, based on the
    prevailing ethical standards in that society, are
    considered socially just.  Unless this is done--based on
    the argument that it is essential to universalize care in
    equitable terms--then what may well happen is that
    problems are dealt with uniformly (homogeneously) when in
    fact they are intrinsically different (heterogeneous).

*   Given the fact that local health systems seek to integrate
    all resources in their area of intervention, as well as
    all social groups involved, an attempt needs to be made to
    identify, for each of the risks to which a specific social
    group is exposed, the resources and types of solutions
    that are needed, establishing institutional responsibility
    for providing care to that group and assigning the
    resources available in that institutional jurisdiction. 
    An attempt will also be made to establish relationships
    between the different subsectors so that all groups in the
    population will have equal access to available health
    resources, in terms of their risks and specific needs. 
    Accordingly, the public subsector should coordinate the
    mechanisms that link the different subsectors in so that
    the resources of the health system can be used by everyone
    who needs them.  This is especially important in view of
    the fact that local health systems do not necessarily have
    to exist at all levels of technological complexity; 
    relations need to be established within the health system
    that will make it possible to guarantee all the
    inhabitants of the country access at equal levels of care.

    The joint determination of appropriate mechanisms and
    procedures calls for knowledge about the policy, social,
    economic, and administrative areas, which bears out the
    need for interdisciplinary teamwork.

*   Technical capacity and decision-making authority at the
    local level are determined by the local social and
    political culture and by the scope and complexity of the
    local health systems under consideration.  These elements
    delimit the technical possibilities for local action and
    indicate which cases should be covered by other components
    of the health system, since local health systems are but
    one part of larger systems of relationships at the
    national, regional, and provincial levels.  However, the
    problem-solving capacity of local health systems is not
    uniform.  It is possible to find local health systems
    consisting only of basic care units, while others have
    units with a high level of technical and administrative
    complexity.  The same is true in the case of environmental
    health, where the technology available within local
    health systems can vary in relation to the magnitude of
    the problems to be addressed and the possibilities for
    application of economies of scale.
    It is expected that, in the definition of procedures for
    the identification of health problems among social groups
    living within the local health system area, the
    problem-solving level for which they were designed will be
    specified.  It would be highly desirable to define, for a
    given problem, indicators geared to different levels of
    problem-solving capacity in the local health systems.

*   Local health system development takes place in a context
    of democratization and broad social participation.  The
    current processes of democratization are characterized by
    emphasis on decentralization and the importance of demands
    by social groups for greater participation in the
    decisions that concern them.  It should be recognized that
    this reaffirmation movement at the local level is capable
    of generating an area of conflict within the State, the
    solution to which lies in striking a balance between the
    conflicting interests at least in the short term:  local
    versus central, individual versus collective, public/state
    versus private, etc.  These are only a few--perhaps the
    most outstanding--of the false contradictions that can
    lead to precipitate attempts to get on with the proposal. 
    Overcoming these false contradictions involves
    establishing areas of competence that will be socially and
    nationally effective in resolving the problems of the
    population in general at the least possible social cost. 
    In affirming the need for decentralization, it should not
    be forgotten that at the same time the central level needs
    to be strengthened as well.

       In summary, it can be said that LSA is conceived on the
assumption that the local health system is:

    *  Is part of the national health system and hence
       included in some of its levels (municipal, provincial,
       and national). 
    *  Is based on the principle of institutional pluralism in
       health care services and attempts to coordinate all
       available resources from the State, private sources,
       social security, nongovernmental organizations (NGOs),
       etc.
    *  Is responsible for extending care both to individuals
       and to the environment.
    *  Extends care to the entire population in its area of
       responsibility, including actions requested by persons
       referred from other local health systems and the
       monitoring and coordinating of care needed by persons
       sent to other local health systems.
    *  Provides comprehensive care, based on the approaches of
       promotion, prevention, treatment, and rehabilitation.
    *  Uses the epidemiological approach to emphasize the
       channeling of resources in terms of the needs of social
       groups in order to ensure that the requirements for
       greater equity, effectiveness, and efficiency are met.*Regards dialogue between social groups and health
       institutions as a fundamental aspect of the management
       process, which makes it possible to allow for different
       options and select those that are most favorable for
       attaining the objectives of equity, effectiveness, and
       efficiency.
    *  Takes into account not only direct activities aimed at
       individuals or the environment but also logistical
       aspects, including those related to supplies, the
       maintenance and conservation of physical resources, 
       the information system, and financing.

    3. THE PHASES OF LOCAL STRATEGIC ADMINISTRATION

     Three phases can be identified in LSA:  orientation,
programming, and management.

     The term phase, as it is used here, refers to moments or
situations in the course of an uninterrupted process, which
do not allow for the identification of necessary sequences
among them, since each can be carried out at any point or
repeated more than once throughout the process.

     In specific circumstances, the actions and activities of
one phase will prevail over others.  In such a case, that
phase of the process is given the name of the activity
prevailing at that time.

     One point should be clarified, to avoid future
misunderstandings.  The phases are given names that
correspond to the prevailing administrative functions
(information, decision, execution, control).  Therefore, when
decision-making is the dominant activity, the term leadership
phase is used.  Similarly, when information and control
activities are dominant, the term programming phase is used. 
With regard to the management phase, an additional
clarification is in order.  Management involves the functions
of planning, execution, and control, but according to
established practice it is usually reserved for the
designation of management personnel for the administration of
execution.  For this reason, the phase in which program
execution is dominant is called the management phase.

     The leadership phase is the central axis and at the same
time the most distinctive aspect of the strategic approach. 
Based on the recognition that different social actors are at
work, none of which speaks for the essential and ultimate
truth, it becomes necessary to provide direction for social
processes, the health field in particular.  Local health
systems provide the context for the coexistence of different
organizations and institutions whose primary task involves
the health of those who live in that area.  However, although
health is the rationale that binds them together, the
essential objective will be different for each of the
individuals involved.  For some it will be an end in itself,
for others it will be a means to an end (for example: to
obtain gains by working in this area), and still others will
view health as the object of their institutional mission (for
example: sectoral public institutions).  Beyond the different
essential approaches, the way in which health problems are
broached and managed will also depend on a variety of
determinants and conditions are rooted in cultures, beliefs,
knowledge, and other dimensions which broadly and generically
may be regarded as ideology.

     The intricate web of actors and interests calls for a
strategic approach, and in particular it call attention to
the need to build a process of leadership throughout the
entire health care process.  Thus leadership, agreement,
negotiation, cooperation, and consensus are notions that are
central to LSA.  The leadership phase therefore assumes a
protagonism that is lacking in the approaches referred to as
normative planning.

     How should leadership be provided?  Who should lead? 
Based on what interests or agreements is leadership
established?  How is leadership built?  Who are the actors
that participate in the steering process?  These are some of
the questions that take on fundamental importance when it
comes to characterizing LSA.  These are the questions that
always call for decision-making on the part of the actors
involved in the process--decisions that will depend on the
configuration of power based on the relations between the
actors and therefore cannot be determined a priori.

     In any case, given the magnitude of the task being
undertaken, it is impossible to pose the issues from all
perspectives.  Accordingly, henceforth only one perspective
will be adopted, namely that of the actors in the State
health organizations, and specifically those in sectoral
agencies.  It should be made clear that this focus on the
State subsector is in no way intended to rule out or
subordinate the other actors in the process.  It merely
recognizes the dimension that predominates in the
institutional setting in which this analysis is being carried
out.

     The programming phase encompasses all activities that
have to do with foreseeing the courses of action to be
followed.  Programming should not be merely a ritual that is
the responsibility of a single institutional actor, usually
the State.  Rather, it should involve all the actors that are
in a position to plan their actions for the attainment of
their objectives, which is different  their actions for the
achievement of their objectives.  What will differ is the
level of formalization achieved.  However, for reasons
already indicated, the description will correspond, in its
first approximation, to the perspective of the public health
subsector.

     The programming phase ranges from the identification of
health problems to the design of the actions and activities
considered necessary for attaining the goals proposed. 
Throughout this process, leadership will be a fundamental
element in obtaining the consensus needed in order for the
different actors to join efforts in working toward the agreed
objectives.

     The explanation of the health situation, which involves
the use of information and the evaluation of processes and
results, is provided by each of the actors in terms of their
interests and specific perspectives.

     In particular, in the area of public institutions, the
identification and explanation of problem situations is
predominantly done by specialists from every particular
branch of health knowledge.  This activity should lead to
the formulation of options as a basis for determining
priorities for intervention.

     It should be borne in mind that the identification of
problems in this context implies, if the channels of
communication with other actors are to be kept open, clearly
stating the knowledge available and being utilized in
presenting and solving problems that are detected, given the
fact that they are part of the culture of one of the actors
and do not necessarily represent a consensus.

     Agreements in these areas will make it possible to
determine which resources or technological tools should be
available for solving the problems in each specific situation
and for promotion, prevention, diagnosis, treatment, and
rehabilitation, as well as those that are not provided for as
part of health services for individuals--including
environmental health, manpower planning, and the creation,
maintenance, and recovery of physical resources.

     For this reason, it is essential to identify or recognize
the relationship between problems and causes, and between
problems and the resources needed for their solution, at each
of the levels and in each area under consideration.

     These different types of information will make it
possible to strike a balance, at the local level, between
needs and existing resources in terms of quantity and
response capacity, which in turn will guide the determination
of different possible courses of action for solving problems
as well as the steps necessary for their implementation based
on the priorities set.

     In order to carry out the activities planned,
consideration needs to be given to the application and
utilization of methods, techniques, and procedures for
managing and administering the resources required in order to
solve problems and respond to demands.  Consideration should
also be given to the areas of monitoring, surveillance,
supervision, and evaluation, determining which indicators
could be used in the process and the outcomes thereof,
depending to the problem and the level of intervention.  The
activities required in order to carry out the foregoing
correspond to the management phase.

CHAPTER III

   LEADERSHIP IN LOCAL STRATEGIC ADMINISTRATION 

     1.-   CHARACTERISTICS OF THE LEADERSHIP PROCESS 

      LSA takes place in a scenario that is characterized, at
any given moment, by the configuration of relationships
between the various actors in the society--relationships that
are established in the midst of tensions between the actors. 
This means that local health systems, as social systems, are
enmeshed in environments characterized by conflicts of
interest, power struggles, institutional fragmentation, and
uncertainty as to the outcome of any actions that are carried
out.

      Thus there is justification for emphasizing a strategic
approach and for recognizing the importance of leadership. 
In particular, in the process of leadership in LSA, care must
be taken to:

    * recognize and deal with pluralism, multiple choices,
      negotiation, uncertainty, conflict, fragmentation,
      dependency, and complexity;
    * take into account and integrate, as well as analyze and
      address, existing social, political, economic, and
      cultural contexts;
    * consider and recognize the component elements in the use
      and distribution of political, administrative, and
      technical power;
    * continuously relate the short term to the medium and
      long terms;
    * consider consensus, agreement, and negotiation as
      fundamental instruments for making proposals viable;
    * seek to create the conditions necessary for extensive
      participation by all the involved social actors and
      groups;
    * relate and evaluate normative and strategic
      considerations.

    2.-    STEERING AND LEADERSHIP IN LOCAL HEALTH SYSTEMS

      Since in most of the countries of the Region the
operating capacity of the health system is under the
authority of the Ministries of Health, or their national
equivalents, the maintenance of control by these institutions
over that capacity and the achievement of maximum efficiency
and effectiveness are the strategic keys to establishing
leadership in the system.

      Increased efficiency in the networks of services,
including hospitals, should be accompanied by a
democratization of the steering process, allowing for social
participation in the service-providing units and in each of
the control/information/decision-making levels into which the
networks are organized.  In this connection, the
decentralization of institutional management, which leads
toward social control of management, should be accompanied by
a strengthening of the capacity for leadership of the system
within the decision-making spheres where national policies
are mapped out.

      Leadership, programming, and management in this context
necessitate development of the capacity to administer and
negotiate complex and conflictive processes; monitor
privileged social groups and control the health system in
accordance with concerted strategy; and adjust, orient, and
control external assistance, which in crisis situations can
become essential, at times with negative side effects.  All
of this requires highly developed strategic leadership.

      Leadership in the sectoral organs of government will
emerge as the process evolves, but this can happen only to
the extent that they gain credibility in the eyes of society
and the government in general.  Such credibility develops as
a result of concrete actions in their respective areas of
responsibility and through democratization of the system at
its various levels.  According to the concepts and notions of
strategic administration, leadership becomes apparent when
there is a situation of crisis that threatens institutional
survival and at the same time there is a strategic argument
that suggests a way of getting around the perceived threat.

      Because leadership involves an ongoing process of
negotiation from an unstable position of authority, it is
possible to expect that authority will be achieved by gaining
credibility and, consequently, the capacity for negotiation,
concerted action, and monitoring through the design and
administration, in conjunction with civil society, of
effective actions that will mobilize all actors in the health
system according to their spheres of action and effective
capacity.  These actions with regard to the short term must
be carefully considered, implemented, and reviewed so they
can yield to long-term actions that will constitute the
contribution of the health sector to higher standards of
living and fewer inequities, as an integral part of the
development of a national project of democratic coexistence
that will transcend immediate political/administrative
management concerns.

      The determination of institutional jurisdiction over
leadership and coordination of the process is a necessary
condition for the subsequent development of activities. 
Indeed, this can be seen as the first step in the
establishment of a local health system.

      The local health system should lead the process of
negotiation and agreement between the various social actors
that coexist in the local jurisdiction (public and private
subsectors, social security institutions, NGOs, social
groups) and take the initiative in the process of
programming, with the participation of those responsible for
the services, members of the local health teams, and social
groups.  This process must receive sustained support from the
regional and central levels of the health system.

      An important aspect within the organization of
leadership is coordination.  This can take the form, for
example, of a collegiate body with representation from
sectoral and extrasectoral institutions and social groups or
a working group established by the appropriate
political/administrative authority.  The degree of
development achieved by the social actors and groups involved
in the local health systems will determine the level of
complexity and formality attained in the organization of
administration and coordination.

      While the role of those who assume responsibility for
leadership cannot be ignored, it is important to emphasize
that this process does not take place in a vacuum. 
Leadership occurs in a specific society and situation, which
means it is essential to recognize that society (i.e., the
actors and social groups that form it) should carry out a
basic function:  the exercise of social control over the
system.  Monitoring and strategic evaluation should occur in
every local health system in order to ensure that social
participation is not reduced to its caricature form:
community participation as cheap or free labor to meet the
demands and needs of specialists and technicians in the
sector.

    3.-    RELATIONSHIP OF THE LOCAL HEALTH SYSTEM TO OTHER
POLITICAL AND ADMINISTRATIVE LEVELS OF THE HEALTH
SYSTEM

      The process of developing and strengthening a local
health system requires a guiding principle expressed in the
form of policies and various strategic alternatives that can
be used to make them viable and feasible.

      Policies for the development and strengthening of the
local health system should be consistent and congruent with
overall policies for development of the national health
system, since the local health systems are part of this
system, not independent and isolated units.

      Because the local health system is located in a
geographical area (and is responsible for the population
living in it) that is or is part of a political subdivision
of a territory, strategies for developing and strengthening
the system should be designed in light of the models of
political, administrative, economic, and sociocultural
behavior that characterize the region where it is located and
the modalities or styles of articulating their administration
within the corresponding local government.

      At the same time, the local health system is part of a
whole whose other levels of organization also have defined
and important roles in its leadership, programming, and
management.

      These other levels of organization--the intermediate or
regional and the national levels--should program their
support and functional articulation with the local health
system.

      The intermediate level assembles and analyzes the
requirements defined by the administrative entity of each of
the local health systems operating in the regional area, and
originates:

      - recommendations in regard to the adjustments needed to
      place these requirements within administrative and
      financial guidelines, adapting them to any budgetary
      ceilings and technical standards for the operation of
      physical resources in the health care field (physical
      plant, facilities, and equipment) and for
      recommendations for responding to health problems;
      - regional programs, timetables, and budgets;
      - demands that will be channeled to the national level.

      The national level brings the demands of the regions
into line with the standards, guidelines, and procedures of
the sector, carrying out in its sphere the same procedures as
those that fall to the regional level.  With regard to this
adaptation, the same considerations pertaining to demands
should extend to the appropriate international or
multinational agencies.


    4.-    THE IDENTIFICATION OF HEALTH PROBLEMS
    4.1.-  Conceptualization of Health Problems
    
      From the perspective of the health system, a problem or
problem situation can be said to exist when one or more
indicators deviate negatively from the values considered to
be acceptable or desirable.  The definition of the indicator
as well as its "acceptable" or "normal" values is context-
specific and should be determined in each individual area in
accordance with the objectives pursued.

      For those who carry out the evaluation, the negative
distance between the actual situation and what was expected
or desired, when properly measured, is a first indication of
the magnitude of the problem.  However, the problem, from a
social perspective, is always associated with the values,
needs, and expectations of some social group.  Thus the
definition established by the health system must be analyzed
in light of the definitions of other actors in order to
arrive at a concerted interpretation of sectoral problems. 
However, given that a problem manifests itself at a specific
time, its definition, and the assignment of priority to it,
is an ongoing process with neither a beginning nor an end.

      In reality, it is impossible to speak of or treat health
problems as if they were isolated occurrences.  Social
problems form complex and related systems that are mutually
conditioned and determined.  Identification of one of them
does not imply automatic identification of the system to
which it belongs.  Taking this into account and given the
power of the instruments of intervention that are available,
it is necessary to identify the greatest number of problems
and their components, as well as the systems to which they
belong, in order to be able to specify their causes and
determine the best interventions, based on available
knowledge and resources.

      On the basis of these reflections it is possible to
state the conditions that must be met in order to be able to
identify a health problem or set of problems. 

    - Define the characteristics of the phenomenon or
      situation that is considered normal or desirable. 
      Whenever possible this definition should consider the
      establishment of indicators, both qualitative and
      quantitative, that make it possible to identify problems
      in different areas;
    - Specify known causes of the phenomenon and, whenever
      possible, the characteristics of these causes that might
      be associated with various degrees of magnitude of the
      phenomenon or process;
    - Identify the social groups for which different values of
      the indicators define a problem.


    4.2.-  The Identification of Priorities and Assumption of
Commitments

      Priority expresses the order of importance of health or
health-related problems.  The term commitment, on the other
hand, expresses a political content, a responsibility for
guidance in order to ensure the implementation of a political
process aimed at achieving the desired objectives.

      Priority and commitment define an area of negotiation in
which the local health system leadership should seek to
ensure that the resources for solving health problems are
adequately balanced with those allocated for other sector
projects aimed at achieving more immediate political
purposes.  In other words, health should acquire political
importance. 

      The definition of priority problems and their acceptance
as political commitments brings up a two-fold consideration-
-who makes the decisions, and how and by whom are resources
assigned? 

      The identification and selection of priorities for
action are carried out in relation to the main problems
detected in health, the epidemiological factors that
condition or determine their appearance, and the population
groups at greatest risk of being affected by them, as well as
the technologies required to solve them and the assessment of
the various technical options available based on the
anticipated cost/benefit ratio. 

      In this process, the participation of all involved
actors is essential.  It is in the local area that the
promotion of social participation mechanisms can be most
successful and can bring about, in the most spontaneous,
creative, and integrated manner possible, the generation by
social groups of ideas, explanations, and solutions to deal
with problems.

      Each of the three levels of leadership (national,
regional, and local) has the authority to assume commitments. 
The national level, for example, makes international
commitments, hence the decisions to eradicate wild
poliovirus, establish a global AIDS program, extend coverage,
etc.  The intermediate level enters into regional commitments
within a country or commitments with regard to borders
between countries for the solution of common problems.  The
local level makes commitments for the solution of health
problems and the optimization of available resources in its
geographical area of authority in terms of both leadership
and implementation.

      The sum of these commitments constitutes the set of
health priorities that must be negotiated in order to arrive
at a decision.  National commitments obligate all the local
systems; intermediate-level commitments obligate all the
local systems under that level; and the problems identified
at every local level obligate all service-providing units in
that area.  This ensures the participation of all levels in
the definition of local priorities, and the local health
systems do not become into isolated entities with no
functional programming relation to the national health
system.


    4.3.-  Negotiation and Concerted Action

      The appropriate strategies for promoting social
participation in local health systems are the processes of
deliberation and agreement on concerted action.  Deliberation
signifies a joint assessment of the health situation,
incorporating the knowledge of technicians and social groups. 
This assumes recognition of the fact that knowledge is a
social product that is not static but rather historical and
subject to change.  Agreement is the process of establishing
concurrence between the various actors on what should be done
or what can be done to solve the problems on which a
consensus exists.  In the course of this process,
responsibilities are assigned for carrying out the activities
that have been agreed upon.

      The need for agreement arises when it becomes evident
that the various actors involved in the process have
different interests and exercise different degrees and types
of power.

      In health, as in other social fields, supply is more
organized than demand, and it is more powerful as well.

      Faced with this situation, civil society has not
attained a sufficient level of organization to bring about a
more balanced dynamic of power.  Moreover, society is not
homogeneous; on the contrary, groups with the least resources
are the most vulnerable and least organized and, therefore
have the least relative power.

      In each specific case it will be necessary to analyze
the structure and distribution of local power, as well as the
restrictions imposed by the overall system of power on local
self-determination.  The existence of adequate room for
participation will depend to a great extent on the
restrictions imposed by higher levels and their dominant
political features.

      Frequently the participatory process at local levels is
limited to deliberation, since it is more likely that there
will be room for deliberation than real room for concerted
action.  There have been experiences involving management
committees that began with great expectations but took shape
in formal or bureaucratic environments where their members
lost representative capacity, and attempts at agreement and
concerted action ended in frustrated.

      Negotiation is a process of discussion that seeks to
achieve a coherent commitment from the various social forces
and groups, with a view to conferring viability and realism
on proposed changes.

      Following the identification of health problems by the
various social actors and groups, a process of negotiation is
initiated with a view to creating an option for intervention
that can be taken up by society as a whole.  In order for
this to happen, the option that arises out of negotiation
must be given viability and feasibility.

      To a certain extent, the establishment of viability
originates with strategic negotiation of the option.  The
analysis and establishment of viability comprise a process of
reasoning and political action that takes place during
decision-making in a more or less implicit and asystematic
way.

      The elements included in the analysis of viability can
be systematized as follows:

      - identification and analysis of favorable, unfavorable,
      and restrictive factors that will come into play during
      the period allowed for establishment and implementation
      of the option;
      - analysis of the possibility and opportuneness of
      removing restrictive factors during the period allowed
      for the option.  Identification, selection, and
      articulation of the possible effective actions for this
      purpose;
      - analysis of the negative impact that the restrictive
      and unfavorable factors could have on any strategy and
      option selected.  Evaluation of the possible impact on
      directionality of the process; and
      - analysis of the immediate situation and proposed
      actions that give short-term viability to the negotiated
      option. 

      The identification of factors should not be limited to
an analysis of the moment or initial situation but should
also take into account those factors that might reasonably be
expected to appear during the process of change.  In
considering time periods, it is important to bear in mind
both the period during which the factors may come into play
and the time of maturation of the actions aimed at overcoming
the obstacles.

      At every level negotiation is marked by different
characteristics.  Within a social group (whether it is
institutional or not), what is discussed is the establishment
of an image-objective that is shared by the members of the
group.  But they must also agree on final goals (the intended
outcome of a cycle of programming), as well as intermediate
objectives acceptable to the social group in question.

      Similar negotiations should be carried out between
social groups in order to establish a sectoral proposal. 
Both processes of negotiation take place in the midst of
conflicts, agreements, and alliances.  Power is lost and
power is gained. 

      Negotiation between institutions focuses on arriving at
an agreement in regard to the options suggested by each of
them.  The aim is to bring into line the various conflicting
viewpoints and interests in order to develop a single
proposal for the sector.  Such negotiation may or may not be
take place within a specific arena, such as an
interinstitutional council or commission, but in practice it
always takes place.  If the institutional option is developed
taking into account both final objectives and the degree of
power and strategic options of other institutions, it will
have a greater degree of political realism and will therefore
be more liable to emerge successfully from the process of
negotiation.  It is in this connection that political maps
can come to play an essential role.

      Once interinstitutional negotiation has been carried
out, there will be a series of demands from the sector with
regard to other sectors of the government apparatus and civil
society.  This creates room for intersectoral negotiation,
the goal of which is agreement on the various demands and,
circumstances permitting, the implementation of a process of
joint programming of pertinent intersectoral activities.

      The last level of negotiation is negotiation with the
central government.  Here objectives and priorities of
national scope are defined, funds are allocated on the basis
of agreements between local and national interests, and the
concordance between local policies and those of a general
nature is consistently and coherently made explicit. 

      The process of negotiation is neither linear nor well-
defined, and it does not admit of rules or models, since if
this were the case it would imply the existence of a supra-
rationality, and the negotiation process would lose its
meaning and become a confrontation of conflicting values
based on a scale of measurement that would solely determine
the best solution.
CHAPTER IV

  PROGRAMMING IN LOCAL STRATEGIC ADMINISTRATION 

     1.-   LOCAL HEALTH SYSTEM PROGRAMMING AND THE INTEGRATION
OF KNOWLEDGE

      Local programming should be considered an instrument to
facilitate decision-making aimed at ensuring coverage,
equity, quality, and efficiency in the use of resources, as
well as to facilitate the processes of negotiation and social
participation within the frame of reference established by
global policies and strategies.

      Programming in the local health system encompasses
actions intended to determine and rationally order the type,
number, and intended purpose of the services of promotion,
recovery, and rehabilitation of direct care for
individuals/families/social groups that are required to solve
their problems and meet their priority needs.  Also included
in programming is the definition of the administrative and
managerial activities needed to support these actions.

      The programming area is the geopolitical area
established for the local health system, encompassing the
population which lives in it or which, through work or for
some other reason, is exposed to health risks in this area. 

      However, the local health system is responsible for more
than programming in its jurisdiction.  It must also, where
necessary, adapt to local conditions the general guidelines
established as a frame of reference for policies and
strategies, as well as the operational standards and
procedures that emanate from the national or regional level.

      Because the local health system is located in a
political/administrative jurisdiction where a group of social
and technological resources must be coordinated in order to
improve the population's health conditions, one of the
central concerns of those who establish it should be the
application of knowledge relating to the social sciences and
health.  The application of this knowledge, if it is to be
effective, must follow a series of guidelines and fulfill a
series of conditions that are defined in the process of
programming.

      Integration of the knowledge to be applied to concrete
situations and problems is a necessary step, and one strategy
for accomplishing it is to determine the knowledge needed to
contend with problems on the basis of population groups
defined according to social, economic, and geographic
characteristics.  This makes it possible to envisage
comprehensive care for population groups with similar risks
of becoming ill in terms of their spatial (geographic)
distribution.

      The aim of this approach is to first identify population
groups, and then determine the knowledge necessary to address
the risks and damages to which they are exposed.  In this way
attention will be focused on food and nutrition; promotion
and prevention; and in particular comprehensive care with
regard to communicable, infectious, and parasitic diseases,
chronic diseases, and conditions related to oral health;
environmental concerns; the control of animals and the
prevention and control of rabies; food safety; veterinary
public health in general; and support for systems of supply,
drugs, laboratory, diagnosis through imagery and other
technologies.

      An attempt will thus be made to integrate the different
types of knowledge and the health problems of population
groups defined by age, sex, working conditions, or
socioeconomic conditions taking into account risks from
diseases and from environmental factors.  Technological
proposals will allow the local level to complete the process
of establishing comprehensive programs of action in order to
ensure the greatest possible quality and efficiency.

      To make all this possible, guidelines must be developed
to support programming processes at the local level, taking
into account at least some of the following considerations:

      1.   What information will be necessary and which
indicators will make it possible to identify the
damages, risks, and causal factors that determine
and predispose the appearance and continued
existence of a health problem in a population group?
      2.   What are the possible ways of defining priorities?
      3.   What knowledge and technologies are available for
promotion, prevention, cure, and rehabilitation? 
Detail the various options for each problem and
technology, their advantages and drawbacks in so far
as flexibility, acceptance, cost, etc.
      4.   Which resources or technologies are necessary and
available for resolving problems?
      5.   What are the proposals for achieving effective
coverage, quality care, concentration of care, and
the outcome proposed for every resource or
technology in terms of achieving greater efficiency?
      6.   What are the proposals for differentiated care for
the population?
      7.   What are the acceptable environmental standards and
how can the local health system act in every case to
achieve better control and assessment of the
technology in use?



    2.-    SELECTION OF TECHNOLOGIES AND PROGRAMMING AND
OPERATING STANDARDS

      It is advisable to consider the development, adoption,
and adjustment of standards to guide the process of
allocating resources toward the resolution of problems.

      A standard of care characterizes a process of work,
which involves a definition of what knowledge is to be
applied and which technologies and inputs are necessary in
order to carry out the process.  The standard also provides
direction, implicitly or explicitly, as to the
characteristics, in terms of type and qualification, of the
human resources to be used.

      In this connection, it is advisable to bear in mind the
concepts of hard standard and from soft standard.  The former
refers to the use of technologies according to scientifically
proven procedures, which do not generally allow for any
variation in their application (for example, vaccination
schemes and the number of doses of a particular vaccine that
can be considered effective).  The soft standard refers to
the use of knowledge that has been experimentally proven and
applies to the use of resources (for example, concentration,
performance, and type of personnel).  It allows for variation
without detracting from the quality or outcome of care,
depending on the resources available and the specific
characteristics of the population to which the standard is
applied.  It is the local level that should develop or adapt
this soft standard in accordance with its resources, needs,
and previous experiences.

      If local programming is to be successful, it is
essential to have human resources who are trained and aware
of their mission and who have sufficient power of action to
enable them to respond creatively to the various problems
that arise at the local level, making use of a wide range of
resources in order to find the best possible solution.  Hence
the fundamental importance of establishing a local standard.

      For every priority or commitment it will be necessary to
select and make use of the most appropriate technologies for
promotion, prevention, recovery, and rehabilitation, as well
as to decide on the standards that will be used in
programming and operation.  Also it is important to determine
the criteria for identifying the population group that is to
be the object and subject of the program, the services that
should be provided and with what frequency and in what
quantity, as well as matters relative to the structure and
organization of the support system (maintenance,
conservation, and other considerations) that should be
modified to ensure, in practice, better conditions for the
achievement of the objectives pursued.


      The development of standards comes about through a
process that involves the participation of all levels--
central as well as local--of the health system.  The central
levels contribute by providing information on existing
technical consensus in regard to the intervention processes
and options available for dealing with specific problems. 
The local levels participate by adapting and reorienting
these processes on the basis of analyses of the viability and
feasibility of implementing them in light of local conditions
and experiences.

      Within certain limits, the degree of freedom for the
application of a standard can vary in relation to the
different levels of equity, effectiveness, and efficiency of
the health services.  It is within each of the local health
systems that the process of negotiation defines the courses
of action to be followed.  It is also at this level that it
is possible to develop comprehensive actions to address sets
of problems rather than isolated actions to contend with
individual problems.  Instead of developing programs aimed at
providing care for isolated pathologies, it is preferable to
establish programs to provide comprehensive care for groups
with defined risks so as to gear actions toward a set of
health problems that arise concurrently and possibly
synergistically as a result of a similar set of causal
factors.

      The degree to which programs are integrated cannot be
defined theoretically; rather, it will be within the local
health system during the programming process that the best
way of integrating resources and efforts will be sought in
order to resolve health problems in the most efficient and
effective manner.   The process should also endeavor to
foster technological innovation, applying the standard so
that is possible to evaluate such innovations at the local
level.  This is yet another area in which the creativity of
social groups can become apparent, provided the necessary
steps have been taken to ensure the effective delegation of
responsibility and a corresponding assumption of
responsibility for the functions of leadership, programming,
and management in the local health systems.


    3.-    THE PROGRAMMING PROCESS

      The activities mentioned below should not necessarily
occur in the order in which they are listed, although some
may need to take place before others.  It should again be
emphasized that in practice the various activities can be
carried out simultaneously.  What usually happens is that
some activities temporarily take precedence over others,
however this should not be taken to mean that they are closed
and unique sets to be completed as separate stages and not to
be repeated until the next cycle of programming.

    1.     Identification of health problems by the social
groups and professionals of the sector. 
Establishment of the pertinent initial appraisal for
the respective local level (this is also part also
of the process of leadership).
    2.     Validation of the principal health problems and
establishment of a tentative list of local
priorities according to the affected social groups
and subjects (health problems).  (Also included in
the process of leadership.)
    3.     Identification of the susceptible population,
defining as such the groups of persons, things, or
situations in which the phenomenon or the problems
may occur.
    4.     Determination of the knowledge and technologies
available for solving the problems identified.
    5.     Selection of the most adequate technology based on
criteria of availability, viability, feasibility,
costs, effectiveness, and acceptability.
    6.     Assignment of population groups and problems to be
solved to the various institutional sectors, taking
into account the availability of all types of
resources.  Establishment of programs and
subprograms (process of negotiation).
    7.     Determination, for all the subsectors that are
participating organically and functionally in the
activity of the local health system, of the number
of activities needed based on the application of
standards of coverage, concentration, and resource
productivity by social or population group for every
institutional resource.  This determination will be
theoretical at the outset when it is made by the
administration of the local health system and will
then become operational at the level of the service-
providing units. The final outcome should be the
result of negotiations and compromises.
    8.     Analysis of the balance between required and
available resources.  Consideration of different
options for different priorities.  This activity
also occurs in the leadership process in the local
health system and in each service unit.  It makes it
possible to adjust requirements and ensure that the
activities complement one another more fully and
effectively. 
    9.     Modification of preliminary proposals and
preparation of final proposals.
    10.    Preparation of the budget.  Determination of
available funds.  Cost studies.  Consideration of
the implementation of alternative activities.
    11.    Budgetary negotiation.  Approval of the actions to
be carried out.
    12.    Execution and continual adjustment of programming.
    13.    Supervision, control, and evaluation.  Social
control of management.  Accountability.  Adaptation
of leadership and programming guidelines and
strategies.  Revision of the initial assessment and
appraisal of the situation.  Establishment of
priorities.

      The local programming guide for each local health system
should come about through a flexible process of participation
that allows for the incorporation of each and every
experience that occurs in light of different types of
knowledge within a common framework that lends the
consistency and coherence necessary for their generalization.

      Because this is a process that develops and advances
over time, it should never be considered that what has been
achieved constitutes a new model of programming.  The guide,
or guides, should always be viewed as a consolidation of the
state of the art, subject to changes and alterations in form
or substance, based on the new knowledge and options that
will inevitably be generated throughout the process. 
Presented below is a possible sequence of some--though by no
means all--of the activities that may be carried out during
the process of programming.  It must be emphasized that these
activities can also be carried out simultaneously.


    3.1.-  Identification of Health Problems:  Application of
the Epidemiological Approach

      The identification of health problems is based on a
description and assessment of the health situation in
relation to the theoretical and methodological approach
adopted by whoever provides the assessment.

      However, the identification of problems depends not only
on who does the assessing, but also on the purpose of the
identification (why are they being identified?), the level or
position from which the problems are being identified (where
are they being identified?), and the group that is chiefly
affected by the problems identified.

      Within the approach that has been adopted, it is assumed
that the identification of problems, and the consequent need
for promotion, prevention, recovery, and rehabilitation of
the health of individuals and families, social groups and the
environment, occurs during the process of leadership in the
local health system (including the participation of all
involved social actors), the objectives being transformation
of the health system and health conditions and the
achievement of equity and greater effectiveness and
efficiency.  The final beneficiaries of this whole process
are the social groups, and therefore all the individuals, who
live within the sphere of action of the local health system.


      The process involves the participation of health service
technicians (from the public and private subsectors and from
social security institutions), political authorities,
professional associations, and representatives of population
groups, all of whom identify, discuss, and analyze health
problems.  In order for this to be possible, steps must be
taken to facilitate and promote social participation at all
levels so that the analysis, discussion, and determination of
the existing health situation is carried out by the
appropriate social actors.

      The initial assessment attempts to identify health
problems and their causes, with a view to providing the
elements necessary for programming the intervention of the
local health system, determining the actions that will be
required at other levels of the national health system, and
coordinating with other sectors the activities that, although
they affect health, require interventions that fall outside
the scope of the sector.

      The preliminary list of problems and needs should be
subject to a review in which specialists, applying the
appropriate specific knowledge, act as advisers in the
overall process of programming in the local health system. 
This review and adjustment may, and usually does, give rise
to new rounds of discussion involving social actors.  The
discussions should continue until there is fairly general
agreement as to the assessment of the health situation, as
well as its determining causes, within the area of the local
health system.

      To facilitate discussion, the following characteristics
of the population, resources, health status, and context
might be taken into consideration: 


    a)     Population.  The characteristics of the individuals
in certain social groups by sex, age group, socioeconomic
status, geographical area, and other variables that influence
or determine the epidemiological situation.  Families should
also be typed on the basis of several of the preceding
variables, as well as variables related to habits that can
affect health.   There should also be consideration of the
characteristics of family members, such as pathologies or
differentiated behavior, that can affect the family group.

      Information on persons who work in productive processes
and who are therefore subject to the influence of a work
environment that affects health, both individual and
collective, in terms of the type of process and the
integration and position of these individuals in the
productive system.

      It is also important to take into consideration
information on population groups in terms of the communities
they live in and the characteristics of their habitat, since
health conditions are influenced by surroundings and the
peculiarities of social and economic development.

      For purposes of discussion in regard to social groups,
it may prove useful to consider the following information: 

      *    distribution by age group, sex, and localities;
      *    distribution of the working population by type of
occupational risk;
      *    number of urban and rural dwellings by
characteristics such as availability of drinking
water, excreta and refuse disposal, and others
related to health;
      *    other basic data on programs for environmental
sanitation and workers' health, including aspects of
human ecology;
      *    principal causes of mortality and morbidity by
social group, municipio, or other relevant spatial
divisions.

      This activity requires instruments for identifying the
social groups that are to receive priority attention in the
local health system.  To assist in this task there are two
simple and practical tools:

      * sketches (maps, plans) of the area of the local health
      systems, in order to determine where people live and
      show the location of urban areas, suburbs, work areas,
      housing, etc. 
      * censuses of population, dwellings, and families
      (population size and geographical area permitting) that
      record the relevant demographic, economic, and social
      attributes for purposes of the programming process under
      way.

      These two tools make it possible to obtain basic data on
social groups, as well as their location and relationship to
the physical, economic, and social environment.

    b)     Resources.  Information on all the resources
allocated for health care (for the environment, social
groups, work environments, individuals, etc).  It is also
important to obtain information on the network of services
and the model or models of care that are being used in the
area of the local health system.  These categories of
analysis are important in order to identify current problems
in relation to the provision of services and care, as well as
the possibilities and characteristics of alternative
solutions and the areas where development is required in
order to improve them.  Strategies for problem-solving should
contemplate the use of heterogeneous care models in dealing
with equally heterogeneous problems, since in the reality
these are the most common type, even in local health systems.

      With regard to resources, the following information may
be used:

      *    the location of resources and social groups that
have access (legal, geographical, financial) to each
of them, as well as the population groups that do
not have access to any type of health resource;
      *    the number and type of health establishments by
administrative level, and identification of the
market for each of them;
      *    the distribution of benefits (general and
specialized consultations, payments, auxiliary
services, and other services that are considered
relevant) by cause and social group; 
      *    available health personnel and their training;
      *    the characteristics of the physical plant,
facilities, and available equipment by establishment
and administrative level, as well as the conditions
of maintenance and conservation;
      *    production, performance, and expenditure of the
establishments and resources in general.  Sources
(origins of financial resources by establishment and
administrative level);
      *    service coverage by social group and health problem.

      An important concept that should be borne in mind in the
collection and analysis of data on resources is that of
function of production.  In general, such information is
collected and processed following each of the variables that
apply to the resources (type of personnel, type of equipment,
type of establishment, etc.)  but these variables are rarely
grouped in a set of resources for a common purpose, the
result being isolated data, characteristic of census
processes, that say little or nothing about the actual
capacity for real production.  Function of production
establishes the participation of each of the different
resources in the production of a unit, or set of units, of a
particular service.  It serves to identify the combination,
in real terms, of various resources (human, material,
equipment) required to produce, for example, a consultation,
thereby making it possible to evaluate the quality of the
production and discuss the standard or pattern that is most
appropriate for each activity.

    c)     Health Status.

      The process of decentralization and transformation of
health systems has helped to underscore the need for methods
and procedures that can be utilized with small groups and, in
general, at levels of observation and analysis where
registries and other traditional techniques have limitations
in terms of the type, quantity, and quality of the
information.  In the local health system there should be
combined use of registries, surveys and participatory
techniques, as well as enhanced capacity to interpret the
information obtained through both quantitative and
qualitative techniques.

      Nevertheless, it is important to get away from the idea
that an assessment of the health situation necessitates the
collection and processing of a large volume of information. 
It can be much more useful for decision-making to have
analyses based on a limited number of highly relevant
indicators selected on a sound theoretical basis, which will
produce information that is reliable and which can be
evaluated in terms of their sensitivity, specificity, and
predictive capacity through epidemiological techniques that
are within the reach of most of the services at the local,
regional, and national levels.  Such indicators will be all
the more useful to the extent that they are closely linked to
the purposes of the analysis and the decision-making spheres
within the various areas of the health system.

      Epidemiological surveillance should be closely tied to
the function of disease and risk control, especially the
response capacity of the services.  It must become a basic
function of all services and programs at the local, regional,
and national level, and the active search for the required
information must therefore be promoted.  Surveillance
techniques should be appropriate for the epidemiological
characteristics of the problem and the conditions, needs, and
response capacity of every country and health system, in
particular the local health systems.

      In addition to improving the capacity for early
detection of acute situations, in which it has been observed
or is suspected that there is a concentration--in time and
space--of an unusual number of cases or symptoms, and
adapting the services in order to ensure the capacity for
investigation and immediate response that is required in such
emergencies, surveillance should extend to problems such as
chronic diseases, accidents and violence, drug abuse, and
others conditions that require medical services of increasing
complexity.  Surveillance procedures in general are not
suited to the detection of situations of this nature, and it
will therefore be necessary to determine the data that are
needed and the most appropriate mechanisms for collecting,
processing, and analyzing them.  It will also be necessary to
promote within the local health system the habit of
periodically evaluating the magnitude and tendencies of these
types of problems and the effectiveness of control measures
in order to facilitate the planning of increasingly efficient
and timely interventions.

      Evaluation of the impact of health actions is another
basic function of epidemiology in the health services,
particularly in circumstances where resources are scarce.

      The potential impact of health actions is limited by the
frequency and behavior of the problem that they are designed
to address, its degree of relation to the factors targeted by
the action, the prevalence of such risk factors and
processes, and the managerial effectiveness of the strategies
and techniques used.  Intervening between the potential and
actual impact are administrative processes related to the
availability and effective utilization of resources. 

      Every action has a cost in terms of human resources,
time, finances, and power.  Its implementation must
necessarily be evaluated in regard to cost and social benefit
in comparison with other strategies and modalities of
intervention.  Despite their demonstrated potential, the
epidemiological techniques developed in order to evaluate
relative risk, attributable risk, and the potential impact of
actions--in combination with information on the health
situation and the changes that have taken place in it--are
still insufficiently utilized for this purpose.  Their
systematic incorporation should facilitate management in the
health services, especially in view of the limited
availability of resources and the varied and complex range of
options that can be established for the execution of
comprehensive and intersectoral programs designed to address
priority health problems in the different population groups.

    d)     The Political, Social, Economic, and Physical
Environment.  In the development of different scenarios
(political, administrative, socio-epidemiological) it is
necessary to take into account that the time and dynamics of
each of them will be different by reason of the
characteristics that are unique to them and give them
identity.  Given that the scenarios mutually influence one
another, they must be viewed with sufficient flexibility to
allow for adjustment in response to changing circumstances in
any of them.   Because of the uncertainties inherent in them
it is essential to ensure that they can be adapted to the
changing realities of every situation.  The consideration of
local scenarios (microscenarios) can prove to be very
relevant, since it is important that local initiative and
creative imagination in the use of resources (whether they
are allocated or produced locally) be directed toward the
resolution of problems that affect the local population. 
This is also valid when discussing the participation of
social groups in the identification of problems, decision-
making, and in the management of health services and systems.


    3.2.-  Allocation of Resources

       This is the stage at which the various resources, both
from the organizations in the sector and the social groups,
are allotted for the implementation of planned activities, at
which time proposals are also made regarding alternative uses
for these resources in order to maximize social efficiency.

      At this point resources are identified, selected, and
assigned through programming packages intended to resolve the
main health problems of the population groups on the basis of
degrees of need and risk.

      The allocation of resources is carried out taking into
account the main health problems that have been detected; the
use of technologies based on comprehensive actions of
protection, promotion, recovery, and rehabilitation; and the
population groups at greatest relative risk.

      In order to allocate resources, it is necessary to have
theoretical tools and practices that make it possible to:

      *    acknowledge national, provincial, and municipal
commitments;
      *    evaluate, with the participation of the sectors
involved (institutional and social groups), local
priorities and commitments;
      *    carry out the appropriate epidemiological analysis
that will make it possible to identify:
-   causes of disease and death
-   risk factors
-   high-risk groups
-   other elements related to the health of social
groups who fall within the field of action of
the epidemiological method.

      These data, if they are adequately analyzed and
interpreted, together with the technical specifications of
the technology that might be used, make it possible to
delimit the population to be served; to establish schedules
for work; and to formulate a timetable of supply needs,
including parts and materials.  It should be pointed out that
in programming the activities of the end services, as well as
the diagnostic and treatment services, it is important not to
overlook the need to program the logistical support required
in order to carry out these services.  Programming of the
activities of support services and systems such as, for
example, systems of supply, maintenance and conservation,
information, supervision and control, communication and
transportation, and budgeting, will serve to determine the
type and size of the environments, facilities, equipment, and
inputs.  It will thus be possible to adapt them to the
programming needs imposed by the different operational
schemes required to accomplish specific objectives.

      In this connection, an essential consideration in the
allocation of local health system resources is the possible
diversity of the institutions that provide those resources,
which will inevitably make it necessary to carry out specific
actions in order to obtain the best outcome in the allocation
and use of resources.  In other words, one approach must be
used in relation to resources that are obtained from the
public subsector where authority is clearly identifiable,
while a different approach will be required in dealing with
the private subsector, and within this subsector there are
also different approaches, depending on whether or not the
source of funds is a profit-making enterprise. 

      The foregoing is especially important if it is
considered that in programming the implementation of
strategies there may be responsibilities that are shared by a
single population group, in relation to the different risks
and the various levels of complexity and resolution of the
resources of the subsectors that comprise the service network
of the local health system.

      Finally, it should be clarified that the way in which
problems are identified will not automatically determine the
way they will be solved, although it may sometimes suggest an
approach.  The identification of problems is a task of
analysis and disaggregation, while the design of a solution
involves synthesis and the combining of activities and
resources.


    3.3.-  Execution at the Applied Level

      The applied level is represented by the units of
service--physician's offices, health centers and posts,
mobile units, hospitals, clinics and laboratories, and
sanitation and environmental protection services.

      At the time that programmed actions are established, an
agreement should be reached with the social groups involved
regarding the strategies and forms that their participation
will take.

      In the transition from the programming stage to the
implementation of operations and activities by the applied
level, three main topics are considered:  organization of the
network of services, hospital programming, and programming
for environmental concerns.

      a) Organization of the Services Network.  The extension
of health services coverage to the entire population through
an increase in access for deprived groups, is the axis of the
primary care strategy and, consequently, the local health
systems.  The consideration of primary care as a strategy
implies reorganization of the network of services as a
necessary condition for attaining equity and social
efficiency.  This reorganization, carried out to improve
accessibility, affects both the network of the local health
system and that of the national or regional system.

      One of the conditions required in order to achieve
maximum effectiveness and efficiency in the use of resources
is the organization of the health network by degrees of
complexity that are structured according to levels of care
defined on the basis of production functions aimed at
optimizing the social use of resources, ensuring their
productivity and impact.  Therefore, one of the fundamental
phases in programming is the definition of the levels of care
in the network of all the services available in the local
health system, regardless of their administrative level. 

      The development of the concept of levels of care is
based on two fundamental considerations:  (1) the existence
of a need for care originating from a specific health
situation or problem, and (2) the degree of complexity
required in order to achieve an adequate response capacity in
the health system, i.e., delivery of the type of service that
should be offered to meet that need.  This implies the
existence a relationship of effectiveness and efficiency
between the complexity of a specific health situation and
that of the methods and techniques required to meet the need.

      In general, problems or needs that arise most frequently
require simple technology, while those that occur less
frequently necessitate more complex technologies.  When
health needs exceed the technological capacity of one level
of care, it becomes necessary to refer to a level of greater
complexity.  This way of progressively adapting resources and
technology to needs is also related to the size of population
groups and their geographical location, with the relatively
simplest technologies being employed nearest those
populations who seek the greatest geographical and cultural
access and the most complex and expensive resources being
concentrated in hospital establishments, which seek the
greatest efficiency in their use.

      The systematic ordering of the service delivery based on
the classification and the degree of priority of health
demands and needs and the functions of the corresponding care
in fact implies the organization of a referral system to
ensure timely and universal access to the level of care that
is appropriate for the health problem that needs to be
solved.  It is not possible to establish a single way of
ordering these resources, since in every country the network
of services is organized differently.  It is through the
programming process in every local health system that it will
be possible to facilitate the functional ordering of
resources in accordance with their complexity and response
capacity, as well as to respect the particular operational
features and diversity of interests of the various
administrative levels of the services.

      Local programming should also be carried out in every
service-producing unit, which should have a defined target
population and area of geographical responsibility.   This
programming is consolidated in the process of leadership in
the local health system.  Thus, the programming of activities
for the local health system is defined by the set of
activities programmed by the service-producing units.  To
these activities are added those that originate at the
central and provincial levels but whose area of application
is the local health system.  Also included in this
consolidation are the activities that arise out of agreements
established in regard to the responsibility of the different
subsectors comprising the system for specific population
groups or other agreements on the use of available
technologies in the local health system by population groups
living in the area of another local system that does not have
such resources.

      The extension of health services coverage, and its
organization based on criteria of increasing complexity
depending on needs, makes it essential to achieve an
effective integration of knowledge and technologies in the
establishments of the health system.

      The coordination and integration of resources among
establishments of varying degrees of complexity is
fundamental, given the need to organize first level care and
the scarcity of resources available for this purpose.  It is
at this level where the most frequent health needs should be
met through a combination of simple and easily accessible
resources.  The staff of the less complex establishments is
usually made up of one or at most a handful of health agents
with little or no preparation for the health actions to be
carried out, which underscores the importance of selecting
activities and using technical resources that will permit
such agents to achieve maximum efficiency.

      Local operational programming should seek to ensure that
the specific knowledge, and technical proposals for solutions
that are based on this knowledge, are adapted to and
compatible with existing resources.  It is at the first level
that attempts should be made to achieve a maximum integration
of actions, avoiding isolated activities and favoring
measures to address problems with common causal factors.


      b) Hospital Programming.  The hospital establishment as
an integral part of the local health system should
participate in programming in two different ways:

*   as a service-producing unit, 
*   as one of the core units for the care of
referrals within the network of services.

      Hospitals are resources in the area of services and
should therefore be considered as elements in the system of
care, with responsibility for a specific geographical area
and population (the population in the area it is responsible
for), in addition to patients it receives as a result of
referral and back-referral agreements in relation to its role
in the network.

      In programming its activities the hospital must consider
its responsibility to provide comprehensive health services
for a geographical area and the social groups who live in it. 
However, it must also provide for the programming of
activities and resources required by the population that it
serves through referrals.

      In addition to programming medical care, the hospital
should engage in more detailed programming of its operation
as a service-producing unit.  Based on the population to be
covered it should establish the expected production of its
end services and should also undertake an assessment of
productivity and costs.  At a later stage, it will be
necessary to determine the intermediate and general services
that will be required in order to ensure that the end
services can carry out their activities smoothly and in
accordance with the time frame established.  In order to
systematize and order these activities it will be necessary
to prepare a hospital programming guide, which will be an
indispensable complement to programming in the local health
system.

      Hospital programming should include the following
general considerations:  

      1.   Analysis of the situation of determining and
predisposing factors in the health status of the
social groups living in the hospital's area of
influence.
      2.   Analysis, from an epidemiological perspective, of
the health conditions of the social groups in its
area.
      3.   Determination of the activities that should be
carried out in the unit to address the health
problems and their causal factors.
      4.   Selection of the technologies to be employed.
      5.   Estimation of the end service production required to
carry out the proposed activities and serve the
expected referrals.  The latter will require that
the hospital work articulatedly with first level
care units and units at other levels, which are
responsible for such referrals, based on the roles
established in the network.
      6.   Estimation of the production of intermediate and
general services that will be required to provide
technical and infrastructure support for the
expected end activities.
      7.   Calculation of the resources needed to carry out the
planned activities.  In order to make these
calculations it will be necessary to have standards
of production and operation.
      8.   Preparation of a balance sheet showing the amount of
resources required and the amounts that are likely
to be available at the moment of execution.
      9.   Adjustment of programmed activities depending on the
viability and feasibility of the proposals.
      10.  Calculation of the budgetary needs, identifying
sources of funding and quantifying anticipated
operating receipts.
      11.  Negotiation of the budget and of the required
resources, tailoring programming to the resources
actually available.
      12.  Selection of alternative courses of action to be
taken in response to any changes in anticipated
situations.
      13.  Determination of indicators and procedures for
follow-up and monitoring of the process.

      c) Environmental Concerns

      If the strategy of primary care is to be truly
effective, environmental concerns must be addressed in order
to protect the health of the entire population living in the
area of the local health system.

      In order to program and develop coordinated and
concerted efforts between institutions and social groups, it
is necessary to understand that environmental problems have
multiple origins that require multisectoral interventions. 
In light of the intricate network of interrelationships
between populations and the environment, it can be affirmed
that individuals, and therefore families and social groups,
will not be healthy if the environment is not healthy.

      Hence, in order to be able to develop effective actions
in this respect, it is necessary to establish a strong
foundation in the social groups based on recognition of the
strategic dimension of ecological considerations in the
determination of the health conditions.

      In addressing environmental concerns it is also
important to understand that, in general, environmental
problems extend beyond local limits and jurisdictions,
regions, and even countries, and thus may produce effects and
consequences on other continents.   It is therefore necessary
to develop a system for dealing with environmental problems
at the local, regional, and national levels, depending on the
degree of complexity, technology required, and risk of the
problem.  LSA should constitute an important tool in this
process.

      LSA seeks to facilitate the participation, commitment,
and responsibility of the local level in providing
surveillance and protection of the ecology in order to ensure
adequate quality of life.  Through LSA the organizations
representing social groups will participate not only in the
prevention of environmental risks in the area of the local
health system, but will have the opportunity to channel their
demands and opinions concerning the projects or activities
that the regional and national levels are or are planning to
carry out in the local area.

      LSA will also facilitate an understanding of the
interdependence of environmental health with other areas of
health and will permit a complementarity of resources, while
optimizing their utilization.

      The two essential components of environmental health
are:  sanitation services and environmental protection, which
may be divided into the following specific areas:

    Sanitation Services
*   Provision of drinking water supply services
*   Management and sanitary disposal of wastewater
and excreta
*   Surveillance and control of the quality of
drinking water intended for human consumption
*   Provision of drainage systems
*   Collection, transportation, and final disposal
of solid waste and urban sanitation
*   Food safety
*   Control of arthropods and rodents that may
affect health
*   Improvement of housing and human settlements
*   Sanitation in public places
*   Sanitation in recreational and touristic areas
*   Sanitation in mass transit services 
*   Control of zoonoses
*   Planning for sanitation in urban development 


       Environmental Protection
*   Control of toxic and dangerous substances
*   Control of atomic radiation
*   Noise control
*   Occupational hygiene and health
*   Control of surface and underground water
pollution, sanitary reuse of wastewater
*   Control of soil and subsoil pollution       
*   Control of air pollution
*   Control of contamination of flora and fauna
*   Forecast, identification, and assessment of the
impact of development projects on the
environment and on health .

      Attention should also be given to sanitation problems
and measures in exceptional cases such as natural and
technological disasters, migratory movements, epidemics,
nuclear accidents, etc. in order to safeguard the environment
in general and ensure that the health of individuals,
families, and social groups is shielded from risks.

      LSA seeks to create favorable conditions for the
development of coordinated environmental health actions
within the process of development of the local health
systems.  In order for the programming required for this type
of activity to be viable it is necessary to form
multidisciplinary teams including participants from
governmental organizations, the sectors linked to the
environment, NGOs, and organizations representing the social
groups in the local health system.  Where circumstances
merit, the participation of representatives from the
appropriate regional and national levels should also be
obtained.

      In order to ensure the participation of extrasectoral,
public, and private organizations concerned with
environmental matters, it is important that there be
sufficient political conviction to make it possible to
propose integrated solutions to environmental problems
through intersectoral actions and extensive social
participation.

      LSA should help to facilitate the organization, both
institutional and financial, of a national environmental
health system whose point of departure is the local level,
through the strengthening and the development of the local
health systems.  This process will make it possible to
define, from an institutional viewpoint, the organizations or
institutions responsible for carrying out the main functions
in the field of environmental health at the national,
regional, and local levels, as well as to establish, from a
financial perspective, the mechanisms to ensure a sufficient
flow of resources to the system so that its responsibilities
and functions can be fulfilled.  From the standpoint of
planning, it will be necessary to define the mechanisms of
coordination, programming, control, and evaluation required
to facilitate and articulate coordinated and concerted
development at the local, regional, and national levels.

      These mechanisms will make it possible to determine
whether environmental problems are best addressed through
sanitation services or environmental protection measures.

      When a problem falls under the area of sanitation
services, it must be determined whether it is a problem of
quantity, quality, or both.  In any case, the process must
begin with a basic assessment, including general information
on the social groups in the local health system, as well as
specific information concerning the sources of service: 
installed systems, functioning or operation of these systems,
quality of the service provided, service administration,
forms of social participation in the local area, etc.

      If the problem is one of environmental protection, it is
also necessary to initiate the process with an assessment
that includes a characterization of the pollution,
identification of sources of the pollution, monitoring,
harmful effects, criteria for quality, technology, health
troubles and risks, community perceptions, education, etc.

      Through these assessments, problems will be defined as
either sanitation and environmental protection matters, and
this in turn will make it possible to study and propose
coordinated and concerted solutions together with those
responsible for environmental concerns at the local,
regional, or national level, as appropriate, since there are
a number of functions in relation to sanitation services and
environmental protection actions that are outside the realm
of the local health system.

      The institution or body responsible, at each level, for
environmental matters will program the actions and resources
required to resolve the problem identified, setting the
objectives and goals to be reached.  These programs should be
integrated and coordinated with other sectoral activities.

      The utilization of the standard for calculating the
resources needed has, in general, the same orientation as
discussed in the case of personal health care, with logical
adaptations for each specific case.

    3.4.-  Financial Programming 

      With regard to the subject of financing, it is important
to consider with due specificity the two main types of
resources available to the sector.  On the one hand, there
are funds from sources in the public sector (Ministries of
Health and/or their equivalents in national, regional, and
local jurisdictions), which are committed through the
formulation of annual budgets and derived from national
treasuries.  On the other hand, there are a wide range of
resources, some of them considerable, from sources such as
social security, public and private institutions (including
NGO's), and contributions from individuals and families
themselves through payments for services or some types of
insurance.

      In view of the foregoing, it is clear that sectoral
leadership exercises control over part of the financial
resources allocated to health.  What is important is that the
management of these resources must be carried out in such a
way as to make it possible to channel other resources outside
its area of jurisdiction.

      The following paragraphs will deal only with resources
that come from a well-defined source and over which there is
a delegated authority responsible for their allocation (this
is equivalent to saying that the private sector and personal
expenditure will not be considered).

      Once the problems, priorities, and needed resources have
been identified the annual budget of the local health system
is prepared.  This should be done in accordance with the
prevailing standards in every country, although whenever
possible it is desirable that it be done by the health
establishments, whatever their level of complexity, since
this is the best way of getting them to commit to the real
and effective decentralization of health actions.

      Coordinated and articulated programming around the needs
of the target population of the local health systems makes it
possible to define functions and institutional coverage;
rechannel resources; and make a coordinated decision as to
how the funds are to be spent, how financing is to be shared,
and how existing resources are to be disbursed to cover the
needs of the population.

      With the incorporation of an operational strategy for
the consolidation of national health systems, for which the
local health systems are the cornerstone, as an alternative
to the strategy that focuses on health programs, it becomes
necessary to review traditional sources of financing and
design new modalities that will permit better use of
financial resources as new sources of financing are being
explored.

      The decentralization of decision-making and resource
management, together with a greater commitment on the part of
the levels that are the targets of decentralization to
addressing health problems in the geographical area of the
local health system, will serve to incorporate the local and
intermediate levels of government, which heretofore have had
little or no involvement in the sphere of financial sources. 
The appearance of new sources of financing does not imply a
move away from earlier sources; on the contrary, they should
be seen as adding to the volume of financial resources that
can be made available for health actions.

    3.5.-  Budget Negotiation

      This is the stage at which the desires and aspirations
expressed in the budget are evaluated on the basis of
financial viability and feasibility.  Negotiation between the
local health system and the various institutions,
organizations, and financial agencies is the crucial element
that can determine to what extent it will be possible to
proceed with the proposals included in the operating plan. 
Essential to this process are sectoral leadership and social
participation, which are the two pillars holding up the
negotiations that will culminate in the approval of an
operating budget for the local health systems.


    3.6.-  Program Implementation:  Application Strategies

      Here the merit of the programming process is put to the
test.  Strategic administration and management form the basis
of support and, together with the processes of strategic
evaluation and monitoring, make it possible to continually
adjust programmed activities in light of the activities that
are actually being carried out.  In the final analysis, it is
reality that will determine the road to be followed.  The
program is only an indication of the desired direction, but
cannot become an end in itself.  What should take precedence
over every other consideration is the response to the needs
and demands of the social groups that live in the area of the
local health system.  In order for this to happen, it is
essential that, when the program is prepared, due
consideration be given to the strategic options available for
carrying it out. 



    3.7.-  Evaluation and Adjustment

      This stage consists developing and applying mechanisms
to supervise and evaluate the activities carried out, as well
as adjusting the programmed actions on the basis of the
results.
      
      So that monitoring and evaluation can be carried out in
as timely and precise a manner as possible, it will be
necessary to have a managerial information system to support
decision-making, since control over the management of the
process is essential in order to continually ensure that
activities are proceeding as planned.  Evaluation and
monitoring are not sporadic activities, carried out once a
year in compliance with standards or provisions alien to
local interests.  They are an integral part LSA, since they
can determine the success of a program by allowing it to
adapt to changing circumstances of the social reality in
which it is occurring.

      The processes of supervision, monitoring, and evaluation
should be carried out bearing in mind their necessary
articulation with the development, training, and continuing
education of human resources.  The process of supervision and
evaluation can thus become an instrument of ongoing training.


      At this juncture, it is crucial to ensure the
participation not only of health personnel but of social
groups, determining to what extent objectives have been
accomplished and deciding how to correct the course when
reality departs from what was anticipated.

      Evaluation of the progress of activities programmed by
the local health system is a shared responsibility of the
social actors and groups involved and will therefore be joint
endeavor.

      To evaluate implies judging the performance observed
against what was expected.  This necessitates the definition
and establishment of indicators to measure performance in
specific areas and according to specific parameters that
establish the ranges within which performance will be
considered acceptable.

      For this to be feasible, it is necessary to define:

* the subject of evaluation
* the performance measurement indicators 
* the range of performance acceptability 

      Selection of the subject of evaluation should be viewed
as a process that is related to the operating capacity of the
system and the priorities selected for development and
strengthening.  This implies a process of gradually
incorporating subjects to be evaluated and establishing
indicators and parameters of comparison.  Once the point of
departure has been established, the process of development
and strengthening itself will take care of expanding of the
horizon of evaluation.
CHAPTER V

MANAGEMENT IN LOCAL 
STRATEGIC ADMINISTRATION 

      1. -     CONCEPTUALIZATION OF MANAGEMENT IN THE CONTEXT
OF LSA

      The organization and coordination of resources for
carrying out programmed activities and their evaluation are
part of the management process.

      One of the functions of management is to promote
achievement of the sector's social mission--equity--and not
to focus attention on "efficiency-ism."   Productivity is a
means to the social end.  Efficiency is a necessary condition
for transformation, but in itself it is not sufficient
justification for sectoral strategic action.

      Management, in the context of local health systems,
extends beyond the simple application of administrative
techniques or the mere administration of resources.  Since
management evolves in the public area, its activities are
framed within the management of public policies and it seeks
to respond to the problems emerging in its field of action in
accordance with national development projects and in terms of
the interests of the social groups within its jurisdiction.
      The satisfaction of basic health needs for neglected
population groups is directly related to achieving its
objectives, which, in addition to presupposing efficiency in
the use of the resources necessary for undertaking health
actions, demands that economic development be accompanied by
concomitant social development.  This challenge requires more
integrated health management, capable of including and making
use of the close ties between economic and social factors,
showing partiality to neither and according each its proper
place in determining the effectiveness of health actions.

      Each country and each region establishes appropriate
priorities for meeting the basic needs of their social
sectors and the paths and means for achieving this end, with
due regard to the resources available, the aspirations of the
inhabitants involved, the political will of the governments,
and the various capacities of the organizations and
institutions, in addition to the complexity of the
requirements for interaction, the extent of decentralization
desired and attained, and the degree of social participation
achieved.

      This process, in addition to increasing the operating
capacity of the health services and efficiently organizing
the use of resources, aims at achieving the goal of universal
coverage in order to ensure health to all with equity,
effectiveness, and efficiency.

      Management finds one of its principal fields of action
in the local health systems, since it is precisely there
where the appropriate conditions are generated for the
production and delivery of health services to individuals as
well as to the environment.

      Management in the local health systems, as an integral
part of LSA, refers to action that makes for viable and
feasible optimization of resources for the achievement of the
social objectives sought through an ongoing decision-making
process based on defining and analyzing problems and
allocating the resources for their solution in such a manner
that these decisions translate into effective actions.

    2. -   EVOLUTION OF THE MANAGEMENT CONCEPT

      The term management is used as a synonym for
administration and guidance.  If special importance is given
here to the use of the word management, it is in an effort to
break with a conviction rooted in public health practice that
has led to subordinating the administrative function and
making it equivalent to routine management lacking in
imagination with regard to things or to individuals
considered as things.  This state of affairs, explained by
the administrative concepts that preceded the formulations of
scientific administration, has led to a practice whose
momentum has strengthened the initial appreciation of
administration.

      Renewal of the various areas of knowledge has also come
to the field of management, although it has not yet resulted
in substantial alterations in the practices of the health
organizations in the Region, since these organizations
customarily employ the most traditional concepts in the
field.

      The point of departure in considering management in
local health systems is accepting that the administrative
function is an essential element in achieving the objectives
pursued, provided that it is allowed to emerge from the
narrow boundaries defined by traditional patterns and take up
the paths opened by the new conceptions of management, which
are the result of the changes produced in the social,
political, economic, and cultural spheres that profoundly
affect the manner in which the organization of work and
production are understood and analyzed.

      Whereas traditional administration was concerned with
organization on the basis of prescriptions involving rigid
elements and principles that sought universality, modern
administrative approaches are concerned with themes that are
more fluid and less precise.   Communication, adaptation,
agreement, decision, creativity, and flexibility are a few
examples of the matters that concern present-day
administrators. 

      In the health area, until not too long ago, the
prevailing concepts of administration had emerged in a world
where change was slower and foreseeable, which made it
possible for bureaucratic ideals and the belief in the
possibility of administrative control over reality to set the
pattern for organizations.  As a result, models based on
order, uniformity, and the existence of a higher rationality
found fertile ground for application.

      However, the successive crises that convulsed the world
in the 1950s, combined with the vertiginous growth of
technological innovation, the expansion of markets, and the
heightening of internal and external competition, led to the
belief that the existing organizational models had run their
course.  Administrative theory then set out to find new
organizational models that would take into account the
demands imposed by the new circumstances and generate the
contingent systematic proposals of which strategic
administration is a part.

    3. -   THE NEW MANAGEMENT AND THE PROCESSES OF
DECENTRALIZATION

      Organizational models reflect an arbitrary division of
labor, authority, and responsibilities.  However, in order to
be able to function and reach its objectives, organization
requires a structure that determines the relationships
between individuals.

      While structure is a necessary condition for the
operation of an organization, at the same time it sets the
stage for the rigidities that limit the organization's
possibilities for adapting to situations that arise in the
socioeconomic context.  The crystallization of roles and
routines--the formal consecration of standards and procedures
based on those that at one time were flowed from the
structure--constitute one of the principal obstacles to
achieving the flexibility required in order to grow and
survive in today's conflictive world. 

      Thus, what was at one time an arbitrary decision has
been transformed into a procrustean bed in which the
organization thrashes about but cannot free itself.  The
structure should be viewed as a simple option and not as a
rational determination--the result of the intangible laws of
administration.

      In order to provide the organization with the
flexibility it requires, other means must be sought for
establishing internal relations that are based on congruent
goals and policies.  In this process the concepts discussed
below may be useful.

    3.1. - Team-oriented Organization 

      The division and specialization of labor in accordance
with the goals of the organization constitutes the first
phase and the backdrop for all the functions of management. 
Only after defining the structure of the tasks is it possible
to establish the competencies and abilities that are required
in order to carry them out, and only then can individuals be
sought to fulfill these requirements.  The tasks are defined
independently of the characteristics of those who are to
perform them.  In consequence, most of the capabilities of
individuals fail to be fully utilized, if at all. 
Individuals are prevented from developing their professional
abilities creatively, and work routines are designed that are
generally boring, repetitive, and lacking in motivation,
thereby leading to professional dissatisfaction and low
productivity.

      Many of the limitations with regard to both individuals
and the organization, which are commonly attributed to lack
of efficiency and creativity, actually lie in the
bureaucratic specification of the tasks. 

      In order to escape structural determination, it is
important to allow for greater individual freedom within the
organization so as to raise the level of professional
satisfaction and efficiency, without at the same time totally
abandoning task-based structurization.  However, ignoring
structure by tasks.  Nevertheless, most recent proposals have
undertaken to alter this basis by setting up teams,  even
before the definition of tasks.

    3.2. - Atomized and Modular Organization

      Since in principle there is no "best way" of structuring
or predetermining the format of the organization, ambiguous
and less clear-cut limits of authority and hierarchy may be
accepted in order to better deal with variations in its
socioeconomic environment.   Simplicity is being sought
through decentralization, and more direct and more accessible
information systems are being set up to improve external
communications and increase the internal and external clarity
of the information provided.

      The new proposal for organizations is essentially
characterized by atomization and a modular approach. 

      An attempt is made to create decentralized organizations
or strengthen those that already exist with autonomous units
which in principle reproduce and project the entire
organization, now based on a teams approach, reduced
hierarchical power, shared responsibilities, and a balance of
dynamic power throughout the decision-making process.  The
decentralized units are modular, autonomous, and independent,
and their interdependence is ensured by a minimum set of
shared values and a system of intensive communication.  These
new organizations require central coordination and are
characterized by overlapping job descriptions and the absence
of intermediate levels of management.

      The system is transformed into a set of smaller
organizations that are administered with a maximum of
interdependence.  The connections between the parts are
maintained by a system of intense communication by means of
which information is at the same time distributed to all the
parts so that each has a vision of the whole and is apprised
of what is going on in the other sectors.

    3.3. - Characteristics of Atomized and Modular
Organization

    * Decentralized and autonomous
    * Redundant
    * Differentiated by objectives
    * Based on intensive communication            
    * Based on a team approach

    Decentralized and autonomous.  This means that the
organization is structured as a conglomeration of modules or
units with specific objectives, autonomy, decision-making
power, and self-organization capacity.  This autonomy of
sectoral and local management offers the possibility of
greater flexibility in adapting to changes in the environment
in which the organization operates.
      The basis of these independent and self-managed units is
decentralization.  Command, authority, and responsibility at
the local level, enhanced by full and timely communication,
is shifted to the levels that were traditionally regarded as
peripheral or subordinate to those where decisions and
important moves are made.  To decentralize means to locate
decision-making as near as possible to the user and the place
where the action is to be carried out and where the required
information exists so that decisions may be taken.  If this
premise is accepted, the appropriate move is to decentralize
to the greatest extent possible and transfer as many
decisions as possible to the local units in order to
accelerate the decision-making process, reduce costs of all
kinds, and see to it that decisions are more congruent with
the aspirations, demands, and needs of the local
organizations.

      It is of special interest to stress the importance of
having congruity between the decisions and the needs and
demands of the local area.  This congruity exists when those
who interact with the users in decision-making enjoy
favorable conditions for creativity and innovation, a power
which when recognized by the public encourages organizations
and individuals to contribute to improving current
conditions.  This is the opposite of what happens when
decision-making is centralized and the community does not
participate, since they know that their spokesmen would have
no power.

      The fact that the modular units are more autonomous and
decentralized does not mean that they are free of all
control.  Central controls will exist, but their nature will
be different and they will be reduced to the indispensable
minimum.  They will be established essentially in terms of
overall and sectoral results, and minimally with regard to
procedures.  The emphasis of the control will be on the
critical values (mission) of the organization, since they
constitute the indispensable minimum values for ensuring
cohesion, survival of the overall system of the organization,
and adherence of the parts to the system.  Maximum freedom,
without breaking off from the system of the organization, is
obtained through rigorous respect for these values as a means
of having maximum flexibility in all other areas.  
    Redundant.  Functional redundancy is the direct
consequence of decentralization, modularization, and
differentiation by areas and objectives.  Redundancy allows
each sector to perform its functions autonomously, thereby
eliminating large units of bureaucratic control. 
Reinstantiation of the concept in each unit of the whole
means that both planning and control can be decentralized. 
It should be borne in mind that attempts to eliminate
overlapping of tasks and activities almost always end in
centralization, which is more costly and more inefficient
than the supposed dysfunctions they seek to correct.

    Differentiated by objectives.  The structure, no matter
how sophisticated, becomes a more or less unstable coalition
of power with a minimum of common interests among the
elements of which it is comprised.  Therefore, the design of
structures should first take into account the objectives and
their division according to substantive criteria--always in
relation to the mission of the organization.

      The division of labor in terms of objectives promotes
more autonomous decision-making, decentralization, and
flexibility.  Consequently, it is desirable to avoid to the
utmost the assignment of work by functions, processes,
techniques, or clients.

    Based on intensive communication.  In organizations of
the type described, interdependence and coordination between
the component parts are ensured through a broad system of
intensive communication in which modern information
technologies are of fundamental importance.  The ideas that
lead to change are:  the disappearance of most of the
bureaucratic systems, and the limitation of channels of
restricted access and confidentiality to an absolute minimum
in order to undercut power based on the control of
information.

      It is anticipated that in this way the organization will
be transformed into a broad-based processor of information,
which is the true foundation of the system it replaces in
view of its importance both to the structure and to
bureaucratic decisions--because it is from the communications
system that the relations between the component parts, as
well as their coordination and mutual integration are
derived. 

    Based on a team approach.  A team-based structure by work
teams is characterized by flexibility with regard to job
assignments.  The organization continues to maintain its
previous system, now no longer exclusively in terms of job
specialization but rather in terms of teamwork. 
Organizational patterns for the differentiation and
specialization of tasks arise naturally from group activity
and are determined less by the organization's previous
design.  The first consequence of this fact is the
recognition that individual and group potential exists that
can be assessed and integrated beforehand, based on
objectives.  Individual capabilities and interests are
considered and utilized in a proper distribution the work,
which is going on continually.  New needs are compared with
existing capabilities and competencies that need to be added,
but group evaluations are always made.  Any "redundancy of
competencies" is assessed, and a greater number of
individuals may acquire the same knowledge, techniques, and
skills as a means of permitting substitution and rotation
within the group.  No effort is made to build homogeneity or
insist on conformity in the definition of common objectives;
but rather, an attempt is made to encourage and expand the
variety and diversity of individual skills in order to create
more alternative ways for attaining the common objective.

      A second consequence of the team-based approach to
organization is that leadership of the group is shared,
pluralistic, and rotational.  Shared authority and
responsibility undermine the sense of uniqueness of
leadership, which develops circumstantially according to the
nature of the work.  However, the fact that leadership is
pluralistic does not mean that the leadership lacks power or
that there are no leaders with broad and permanent
recognition.  What happens is that leadership is more a
product of the group itself than of an authority or capacity
previously defined by the bureaucratic system.

      The third consequence is the greater decision-making
autonomy of the group, based on the prior definition of the
organization and also on the power achieved through the
reinforcement of growth and individual and collective
development.  In an organization, one way of transferring
power to another sector or to higher hierarchical levels is
not to resolve conflicts in the area in which they occur. 
Unresolved conflicts usually shift power toward higher
hierarchical levels.

    3.4. - Recommendations for Achieving Organizational
Flexibility 

    1. -   Restructure only in terms of objectives
and strategies.  The structure depends on
the objectives and on the strategy, but
the reverse is not true--although on an
everyday basis this reality has to be
accepted because of the power system
implicit in the structure of the
organization.  What is important is to
guide the organization toward structural
flexibility and to test internal
structural conditions in the formulation
of objectives and strategies.
    2.-    Locate decision-making capacity as near as
possible to the place of the action. 
Since the lowest hierarchical and
decentralized levels have the information
needed in order to make the decisions,
these are the levels that should be
responsible for them.  Avoid unnecessary
centralization merely aimed at
strengthening the central bureaucratic
power.
    3.-    Avoid the existence of numerous vertical
hierarchical levels.  The numbers of
levels should be kept to the indispensable
minimum, and hierarchical distances should
not be created that separate the local
decision-making level from the central
level.
    4.-    Reduce the number of intermediate
authorities to a minimum.  Work with the
principle of minimum specialization of
tasks in defining administrative
positions.  Diffused authority, both
vertical and horizontal, becomes a basic
motive for centralization,
"processualism," bureaucratization, and
high administrative costs.
    5.-    Assign greater decision-making power over
the means to those responsible for the
ends.  Development of the logic of
objectives and their division by
substantive criteria enormously
facilitates the availability of means for
those responsible for the ends.
    6.-    Seek systematic consistency through
objectives and rather through power and
authority.
    7.-    A reasonable overlapping of activities is
normal in a flexible and decentralized and
flexible structure, and it is also much
less costly than any centralization with
rigid job assignments. 
    8.-    Overall lines of command are normally
appropriate for important decisions but
tend to be obstacles for routine
decisions, for which direct contacts are
more effective.
    9.-    Structural complexity promotes inertia and
conformism.  A network of informal
communication should be accepted and
promoted.
    10.-   Maximize the use of ad hoc working groups
for the development of innovative
projects. 
    11.-   Creativity and innovation require a
certain degree of functional freedom and
therefore tolerance of what may appear to
be chaotic and somewhat irrational
conditions compared with the existing
formal structure.
    12.-   Always decentralize, relying on the
institution and its personnel.
    13.-   It is structural flexibility, or even the
relative lack of structure, that
guarantees ongoing adaptation to shifting
circumstances.  In a world of rapid
change, an organization as immense a
health system is too complex to be
administered through manuals, directives,
or service orders. CHAPTER VI

PARTICIPATION OF SOCIAL ACTORS
IN THE LSA PROCESS

     1. -  DEFINITION OF PROBLEMS
      1.1.-    The Definition of Problems and Identification of
Social Actors

      According to the strategic approach,  at least two large
groups of actors should participate in the definition of
problems:  those who belong to the health system (including
health workers), and those who make up what is customarily
understood to be civil society (including the corresponding
social groups).

      It is not only in the steering of local health systems
that problems are identified; this process also takes place
in civil society (community organizations, churches, trade
associations, industries, providers of supplies and drugs,
etc.). 

      It is the responsibility of the health teams in the
local health systems to identify the various sources that can
or do define health problems in order to relate them to one
another and situate them within the context of the health
services action, take the statements and rationales of such
problems to the negotiating table in order to analyze and
implement actions aimed at solving the problems within the
appropriate fields of intervention.

      An instrument that may prove to be very useful in
identifying the key social actors in the local health systems
is known as a "political map."  This makes it possible to
single out the social groups and actors who should be
consulted and who have a supporting or opposing opinion on
each area of development.  It also makes it possible to
determine the origins and causes of such attitudes, and it
facilitates description of the present situation and the
charting of future strategies by presenting a political
microscenario of the local health system.

      The microscenario is based on the real conditions and
situations of each local health system, not only
epidemiological but also historical and political, which
makes it possible to develop a new concept of programming
that goes beyond the former rigid schemes and sets the stage
for the participation of sectoral institutions and local
social groups in the entire process.  In order for this to be
feasible, the management level of the local health systems
should promote the concerted agreement required for the
development of local creativity for identifying problems,
organizing and ranking the use of their resources, and
evaluating the results.

    1.2.-  Modalities of Social Participation in the Definition
of The Health Problems

      In order to provide the social groups that make up a
society at a given time with the opportunity of coming
forward and being represented at the local level, making
their claims heard, and presenting their ideas on the
problems and their possible solutions, flexible strategies
must be proposed that will make it possible to give these
groups a voice and encourage them to participate in preparing
and, if appropriate, implementing concrete proposals.

      Any strategy that pursues this end should lead to the
following actions:
    
    a)     Deliberation between groups of organized actors
    (community and institutional) on health problems and
    their solution.  This means that the local community
    should participate fully in analyzing and identifying
    health problems and share its perceptions and
    experiences.  It also means that specialists and
    institutional participants should recognize the validity
    of other opinions, perceptions, and interpretations that
    may arise from other points of view, even if they have
    not been subjected to validation by science and the
    scientific method.

    The democratization of knowledge, and its appropriation
    by the various social actors (community and
    institutional), requires that it be formalized as a
    practice in which the various subjects that participate
    in it observe reality, address the different perceptions
    thereof, and, recognizing these differences, develop new
    knowledge and ways of acting vis-Õ-vis the world, in
    order to thus understand it and transform it.

    b)     Negotiation of Concerted Agreement between the
    various social groups and actors on what should be done
    to improve health, the means of achieving it, and what
    commitments and roles each of the participants in the
    agreement assumes to ensure that the proposed objectives
    are attained.  The agreement process presupposes that
    those participating in it are legitimate representatives
    of the parties involved (social groups as well as
    institutions), so that any decisions agreed upon may be
    put into practice.  If such is not the case, the
    agreement makes no sense and is merely an empty exercise.

    c)     A rendering of accounts, following creation of the
    necessary formal mechanisms, in which the various
    participating actors present what has or has not been
    accomplished toward the commitments assumed in the
    agreement.  This process is the germ of another, more
    ambitious one, the social control of public affairs--that
    is, the objective pursued to ensure the permanence and
    strengthening of democracy.      

    2. -   THE ROLE OF SPECIALISTS

      The definition of problems by health professionals is
also a component of the strategic administration of local
health systems.

      This definition is made on the basis of clinical,
epidemiological, and public health knowledge, combined with
other knowledge from the fields of organization,
administration, and management, and based on an analysis of
health, disease, and death indicators.  This approach should
then be contrasted with the definitions given by the social
groups, which bring out what people actually think and feel
with regard to their health.

      In both approaches to the definition of health problems-
-that of the health professionals and that of the social
groups--there are differences that should be considered, and
although these differences make the process more complex,
they also give it greater reality.

      The health professionals who define the problems are
usually those who work in official institutions.  Problems
are also identified by those who work in unofficial services,
academic institutions, or union organizations in the health
sector.  They all define health problems according to their
particular social or group perspective. 

      An important contribution to the identification of
health problems is the knowledge accumulated by the health
services on the measurement of collective health phenomena. 
However, it is the task of the health specialist to provide
the technical and scientific information needed in order to
identify the magnitude and characteristics of the problems.      

      In the systematization of knowledge, it is the task of
the specialists in health science and technology to
participate in each and every phase of the LSA process by
proposing the elements for identifying the specific problems
in their fields of endeavor and determining the type and
quantity of resources required for dealing with them.

      The participation and intervention of sectoral
specialists is essential for proper development of LSA, since
the contribution of their knowledge is of the greatest
importance in formulating and implementing the processes of
leadership, programming, and management.

    2.1.   The Specialist and Leadership 

      Since leadership is a political process that takes into
account the context, conflicts, and uncertainties involved,
it requires a steady flow of information is required on
political elements, especially the local social actors, their
positions for or against sectoral transformation, and their
interests, alliances, and conflicts.  Here, the specialist
contributes knowledge and experience that make it possible at
the administrative level to:

    * identify social actors in the local area and other
      related areas who have similar interests in the field of
      health and who can intervene positively or negatively in
      the transformation process;
    * identify the position of each actor and his or her
      relative influence in the development of the policies
      and strategies for the local health system;
    * identify the health problems in the area covered, using
      epidemiological and community-based approaches;
    * make an overall assessment of the resources needed and
      those already available; 
    * facilitate decision-making for the assignment of
      priorities.  The specialist should contribute the
      elements required in order to identify the health
      problems, their magnitude, the cost they represent for
      the community and for the services, the manner in which
      the health problems affect or are related to the
      processes of development, and the implications for the
      various social groups if these problems are not dealt
      with;
    * have health promotion, prevention, treatment, and
      rehabilitation alternatives available to facilitate the
      appropriate use of the existing technology, and be able
      to estimate the costs, including opportunity costs, of
      incorporating or replacing technologies, bearing in mind
      the lowest level of complexity and the greatest degree
      of accessibility compatible with suitable resolution of
      the problems;
    * identify the population at greatest risk, having
      developed the indicators required for this purpose;
    * decide on the characteristics of the resources required
      for resolving the problem, including personnel (in type
      and quantity), physical infrastructure, facilities, and
      equipment, and specify possible strategies for more
      appropriate use of existing resources;
    * initiate dialogue with the local administration and the
      community and furnish for this purpose the information
      necessary for facilitating decision-making and ongoing
      adaptation of the process;
    * have a better flow of information from the central and
      regional levels and provide the scientific and technical
      elements required to adapt the knowledge of his field of
      specialization to the specific local setting.

    2.2.-  The Specialist and Programming

      The programming process includes proposing the
functional relationships that should exist between knowledge,
the available resources, and the social groups and their
health problems in light of the policies and priorities
defined.

      In order for this to take place in the most effective
manner in terms of the equity and quality of the care
provided, the specialist contributes his or her abilities to
enhance development of the programming process.

      It is expected that the specialist will contribute to
the preparation of standards for technical--standards
relating to health promotion, prevention, treatment, and
rehabilitation--by determining:

    * for each of the priority health problems, what to do and
      how to do it  indicating, when appropriate, alternatives
      for action;
    * who should do what, specifying the human resources and
      skills needed and indicating, when appropriate,
      alternative resources and competencies;
    * how much of the resource should be used and how often--
      that is, determination of the intensity and
      concentration of resource utilization;
    * the conditions that will ensure appropriate use of the
      available technology, identifying the most appropriate
      levels of care and technological complexity to for
      dealing with the severity and intensity of the problem.

      In addition, it is expected that in contributing to the
process the specialist will:

    * specify the factors that should be considered in
      identifying the population at greater relative risk
      according to specialty and type of problem, and develop
      practical procedures for specific spheres of action;
    * disseminate the technical information in a manner that
      is appropriate to each local situation and will permit
      fuller participation of the social groups in the
      sectoral decision-making process;
    * provide information on the type and characteristics of
      the inputs and equipment needed for implementation of
      the proposed solutions.

    2.3.-  The Specialist and Management

      In management, which refers to the process of organizing
and coordinating the resources for carrying out and
evaluating the activities programmed, it is the task of the
sectoral specialist to:
    * determine what information is needed in order to be able
      to monitor and evaluate compliance with the
      requirements of equity, quality, efficiency, and
      coverage from the standpoint of the best use of the
      resources and technical procedures;
    * prepare "sentry" indicators for early detection of the
      health problems of the social groups;
    * define indicators for measuring the results of
      intervention in the case of each health problem;
    * determine what information should be obtained on the
      characteristics of the resources and their use, with
      emphasis on the data required in order to monitor
      operation of the human resources and the physical
      infrastructure;
    * participate in the design of information systems;
    * participate in defining means of providing continuing
      education for health and support personnel;
    * collaborate in preparing and carrying out cost studies
      on the proposed interventions and, based on the results
      of such studies, propose more efficient and effective
      alternatives.
PART III.
    INSTRUMENTS, TECHNIQUES, AND PROCEDURES FOR
LOCAL STRATEGIC ADMINISTRATION

       The general topics presented in Parts I and II provide
the framework necessary for adapting, developing, and
creating the instruments, techniques, and methods required
for implementing the concept of LSA in local health systems.

      The list presented is not exhaustive; it illustrates
only some of the kinds of instruments that are currently
available and may be of assistance in the local process.  It
is hoped that each local, regional, or national experience
will provide new elements to be included on the list in order
to make it a useful indicator for those searching for new
ways of implementing proposals in connection with the
decentralization of health systems, whose underlying premise
is the local health system concept.
      Below are listed some of the instruments and areas that
could be developed or applied in the LSA process.  It should
be understood that in the current state of preparation of the
document they are merely a kind of aide-mémoire to promote
the active participation of those who feel they are involved
in the proposal, and consequently they should be detailed and
analyzed more carefully in subsequent versions of the present
paper.

      *    POLITICAL MAPS
      *    OPERATIONS RESEARCH MODELS
      *    PROSPECTIVE ANALYSIS
      *    COST ANALYSIS (COST/BENEFIT, COST/EFFECTIVENESS,
ETC.)
      *    MODELS FOR DIAGNOSIS OF THE SITUATION 
      *    EPIDEMIOLOGICAL METHODS AND TECHNIQUES
      *    STANDARDS OF CARE
      *    INTEGRATED PROGRAMMING MODELS
      *    ADMINISTRATIVE METHODS AND TECHNIQUES
      *    MANAGEMENT INFORMATION SYSTEMS 
      *    PROCEDURES FOR THE DEVELOPMENT OF INDICATORS
      *    HUMAN RESOURCES DEVELOPMENT 
      *    MEDICAL AUDITING 
      *    QUALITY ASSURANCE
      *    MODELS FOR HEALTH PROMOTION 
      *    INTEGRATED INTERSECTORAL DEVELOPMENT
      *    OTHER
XXXV Meeting                                        XLIII Meeting
Washington, D.C.
September 1991

CD35/INF/2 (Eng.)
16 August 1991
ORIGINAL:  SPANISH














STATUS OF MALARIA PROGRAMS IN THE AMERICAS
XXXIX REPORT

    INTRODUCTION

     This document is the XXXIX Report on the Status of Malaria
published by PAHO.  It describes the situation of malaria in the
Region in 1990, summarizing the information obtained from the
Governments in response to the questionnaire sent to them annually.

     The situation of malaria in the world refers to 1989, and has
been taken from publications of the World Health Organization.

I.   STATUS OF MALARIA IN THE WORLD

A.   Population at risk

      More than 40% of the world population, i.e. more than two
billion people, are still exposed to some degree of risk of malaria
in approximately 100 countries and territories (Map 1).  Of a total
world population of some 5.16 billion, 1.4 billion (27%) live in
regions where there has never been malaria or when it disappeared
with no antimalarial intervention; 1.65 billion (32%) live in
regions where malaria was eradicated through malaria campaigns and
have stayed free of this disease; 1.62 billion (31%) inhabit areas
where endemic malaria was reduced considerably or even eradicated,
but then was transmitted anew, with an unstable or deteriorating
situation.  These regions include areas where malaria poses the
most serious problems as a result of major ecological and social
changes.  Such areas encompass only 1% of the world population. 
Areas where endemicity remains practically unchanged, where there
is intense transmission in many areas, and where antimalarial
programs have not been fully implemented, are inhabited by 490
million people (almost 10% of the world population).  This
situation is encountered primarily in tropical Africa (Figure 1).

B.   Reports of malaria cases to WHO

     Every year WHO receives information from the Member States on
the number of malaria cases recorded by the national surveillance
programs.  These cases are usually defined as those requiring
treatment and confirmed by microscopic examination; however, in the
countries without microscopic examination services at the
peripheral level, most cases are diagnosed by the clinical signs.

     It is estimated that world incidence of malaria comes to some
110 million clinical cases per year, and that approximately 280
million people are carriers of the parasite.  These figures should
be considered approximate in view of the difficulty obtaining
precise information.  Reporting is quite fragmentary and irregular
in the very endemic regions.  For example, the countries of
tropical Africa, which are estimated to account for approximately
80% of all clinical cases and more than 90% of all carriers of
parasites, report only 2% to 6% of the estimated world number.

     Excluding Africa, in 1989 5.2 million of cases were reported
to WHO; 95% came from just 25 of the more than 100 countries or
territories with endemic malaria.  Half of all cases were
registered in India (39%) and Brazil (11%), while approximately one
fourth were from Thailand, Sri Lanka, Afghanistan, Vietnam, China,
and Myanmar (in decreasing order).

     A general description of the malaria situation runs the risk
of concealing the large variations among and within countries; this
is the case of the information provided by India and Brazil, whose
data account for half of all registered cases.  In India, with 2
million cases reported in 1989, nearly 55% of all cases are from
3 states:  Gujarat (599,000), Orissa (261,000), and Madhya Pradesh
(253,000).  In the Americas, where the incidence of malaria
increased from 270,000 cases in 1974 to 1,100,000 in 1989, Brazil
accounted for 52% of the total.  In the interior of Brazil, the
Amazon region accounted 97% of all cases, the majority in three
states.  Even within these states, the cases were concentrated in
specific areas.

C.   World trends

     From 1975 to 1979, there was a reduction in the number of
cases of malaria reported, due largely to the control measures
taken in India against an outbreak of the disease.  Since 1985, the
number of reported cases in India has stabilized, at present it
continues to climb.  Malaria incidence in China has continued to
decline thanks to the positive results in integrating the malaria
campaign into the primary health care system.  Excluding India and
China, it appears that the malaria situation is deteriorating. 
Among the areas particularly susceptible to this deterioration are
the "peripheral regions" of Southeast Asia and South America.  The
situation has not changed a great deal in the highly endemic areas
of Africa, but large-scale epidemics have been reported in areas
with less endemicity (see Table 1).
II. STATUS OF MALARIA IN THE AMERICAS, 1990

     In 1990 it was estimated that 278 million people in the Region
of the Americas lived in malarious areas.  The rate of morbidity
due to malaria was 149.67 per 100,000 population, while in 1974
morbidity was only 49.37 per 100,000 inhabitants.  As can be
observed in Table 2, in the last four years more than one million
cases have been registered in the Region; this figure reflects a
worsening of the problem in the Region.

     In the 21 countries with active malaria control programs,
1,042,817 cases were confirmed as of the end of the year, with an
Annual Parasite Incidence of 2.53 per 1,000 population, as
described in Table 3 and Figure 2.

     French Guiana continues to have the highest annual parasite
incidence, as it has since 1987; in 1990, the API was 64.23 per
1,000 population; Guyana and Belize had an API of 21.81 per 1,000
and 16.57 per 1,000 respectively.  The annual blood examination
rate (ABER) was highest in French Guiana and Belize.  The
malariometric rates of 21 countries in the last five years are
shown in Table 4; the regional total for the last 30 years is shown
in Figure 3.


III.CURRENT SITUATION OF MALARIA PROGRAMS IN THE AMERICAS

A.   General Information

     In 1990 it was estimated that the population of the Americas
was 698,199,000, of which 278,600,000 lived in areas originally
considered malarious, i.e. 39.8% of the total population, living
in 50.60% of the total area of the Hemisphere (see Tables 5, 6, and
7).

     During the year there were 1,045,808 cases of malaria in 36
countries of the Americas.  Of this total, 7,221 cases were
detected in areas considered non-malarious and 29,550 in areas
where transmission has existed or has been interrupted for more
than three years (maintenance phase), for a total of 36,771 cases
(i.e. 3.51% of the total) diagnosed in areas without permanent
transmission of malaria (see Table 8).

     These figures reflect the constant pressure for transmission
in areas still vulnerable.  In these areas the development of
institutions for social protection is still deficient, making it
difficult to detect epidemics.  Usually, these vulnerable areas are
characterized as areas of traffic or reception of migratory flows, 
be they organized or spontaneous, from areas with permanent malaria
transmission.

     In 1990, the transmission of epidemics by P.  vivax in
vulnerable areas of Brazil (Foz do IguaÛu and Manaus), and of
Mexico (Guerrero, Michoacán, and Oaxaca), was controlled through
the implementation of integrated control measures.  These actions
have been adapted to the particular characteristics of these areas,
strengthening the concept of that the transmission of malaria is
a focal problem, for which solutions and successful intervention
measures depend on local planning and execution, as described below
in the individual country descriptions.  

     The countries used different epidemiological surveillance
systems.  Thus in Cuba, where 801,946 blood samples of travelers
who entered the country were examined, 462 cases were detected. 
In the United States of America, where detection depends on
spontaneous demand, 877 cases were detected (Table 8 and Map 2). 
Of the 7,221 cases registered in non-malarious areas, 378 cases
were registered in the Bahamas (4), Barbados (3), Bermuda (3), and
Canada (368); and 6,843 in other countries with originally non-
malarious areas (Table 9).

     Among the 21 countries of the Region of the Americas where
transmission of malaria now occurs, 1,044,069 malaria cases were
registered in 1990 (see Table 9 and Figure 4).  Based on the
situation in that year, the 21 countries with active malaria
programs can be divided into the following subregions.  

Mexico, Central America, Belize, and Panama.  

     This subregion, in which we include the eight contiguous
countries of Middle America--Belize, Costa Rica, El Salvador,
Guatemala, Honduras, Mexico, Nicaragua, and Panama--has 59,990,000
inhabitants living in areas originally malarious, i.e. 54.80% of
a total population of 109,482,000 inhabitants.  In Mexico, 49.3%
of the population lives in malarious areas.  In the other seven
countries, 19,990,000 individuals, or 70.3% of the total
population, live in such areas (Tables 10 and 11).

     Nonetheless, taking the annual parasitic incidence (API) as
an indicator of the magnitude of the malaria problem, it is
observed that the risk of these population groups becoming ill of
malaria in these countries ranges from 0.16 cases per 1,000
population exposed in Panama, to 16.57 per 1,000 in Belize.  In
addition, the distribution of risk varies from country to country
(see Map 3).

     In 1990 Belize had the highest annual parasitic incidence for
the subregion, with areas as the Cayo district having an API of 45
per 1,000 inhabitants.  Despite the notable flow of population from
El Petén, Guatemala to Chiapas, Mexico through Belize, 98.5% of the
cases diagnosed have been due to P.  vivax infections.

     In Costa Rica 1,146 P.  vivax infections were registered, as
were five cases due to P.  falciparum.  The malarious area of the
country encompasses 69.6% of the national territory; but the
transmission of malaria is concentrated in three provinces, where
85% of the cases were detected.  Costa Rica has attained a high
degree of control over the endemic disease, reflecting the
country's high level of social development.

     In El Salvador the trend to control malaria that was initiated
in the 1980s has been maintained, after developing a work process
based on epidemiological stratification and the integration of
diagnostic, treatment, and epidemiological surveillance services. 
Of the 9,269 cases registered during the year, 80% were detected
in 62 of the country's 262 municipalities, which are considered to
constitute the hyper-endemic area.

     Guatemala has reported the diagnosis of 41,711 cases of
malaria (97.6% P.  vivax).  Even though the distribution of risk
is well-known, i.e. that five of the country's 22 departments
accounted for 65% of all cases registered, very little progress was
made in controlling the endemic disease.

     Honduras, with 288 municipalities, has reported the diagnosis
of 53,095 cases (98.8% P.  vivax) in 64 municipalities located in
six departments.  Honduras continues to use universal spraying and
medication with antimalarial drugs, but has yet to attain a
positive impact in controlling the endemic disease.  Although
efforts to analyze the malaria problem were stepped up in 1990,
changes in intervention strategies have not yet been carried out. 

     In Mexico the epidemiological situation improved
significantly, with a turnaround in the trend toward uncontrolled
spread of the transmission of P.  vivax, which began in 1983.  The
reduction of the magnitude of the malaria problem from an API of
1.17 per 1,000 population in 1989 to 4 per 1,000 in 1990, reflects
an intense mobilization of resources allocated to strengthening the
technical capability of states with transmission and those where
tourism is important.  Furthermore, the epidemiological conditions
of southern Mexico continue to generate foci of transmission; and
P. falciparum persists in the jungle (logging) region of the border
with Guatemala and Belize.

     Nicaragua reported 35,785 cases of malaria (95.6% P. vivax)
in 1990, maintaining an API of 9.24 cases per 1,000 inhabitants. 
In 49 of the country's 143 municipalities, where 29.3% of the
population lives, the risk of becoming infected with malaria is
three times greater than in the rest of the country.  

     The country has operational contrasts that are noteworthy. 
The municipality of León, through the efforts of the local health
authority, has reduced the transmission of malaria by 80% from 1988
to 1990.  This achievement has been attained through a careful
study of local stratification of transmission and a precise
definition of the risk factors associated with the area generating
cases.  In the context of intersectoral municipal actions, vast
breeding sites hitherto unknown have been drained.  In other
smaller breeding sites, traditional cleaning treatments and
application of larvicides were used.  In the municipality of El
Viejo, characterized by the production of cotton and sugarcane with
involving the intense application of pesticides, the national
control program continues to use traditional measures, i.e
intradomiciliary spraying of insecticides and active case detection
and treatment.  Even with these measures, this municipality still
had the highest API in the country in 1990 (71.7 per 1,000
population).

     In Panama persistence continues in three areas that are
generating cases.  These are the province of Darién, the San Blas
District, and the Bayano region.  These areas account for 32.3% of
the national territory and 3.4% of the population of the country;
transmission is detected in 72 localities, i.e. 0.74% of all
localities in the country.  Despite the low total number of cases,
27.56% of the infections are by P.  falciparum (Table 6).

Caribbean Area

     In the Caribbean region, the island of Hispaniola (Haiti and
the Dominican Republic) continues to constitute an area of
transmission by P. falciparum.  Haiti launched a program financed
specifically for the integrated control of malaria; it is detailed
in the section on specific countries.

     In the Dominican Republic epidemiological surveillance has
been maintained.  A total of 297,599 blood slides were examined,
with a positive result in 356 cases; 22 were by P. vivax, and were
probably imported.

Andean Area

     In the Andean subregion, Bolivia, Colombia, Ecuador, Peru, and
Venezuela reported 254,803 cases of malaria, with a population of
54,339,000, or 58.3% of the total population of the malarious
areas, in the original malarious area.  These cases represented an
increase in 13.54%, driving the annual parasitic incidence of the
subregion up to 4.7 cases per 1,000 population (see Maps 4 and 5).

     Considering that in Colombia, Ecuador, and Venezuela more than
one-fourth of the cases registered were infections by P. 
falciparum, the situation should be considered serious.

     Infections by P. falciparum in Colombia (35,490) and Ecuador
(21,871) showed a proportional distribution different from the
classical epidemiological picture.  The cases in Colombia, which
had been concentrated in the northeast (Sarare Region), came to be
concentrated in the west (Pacific Coast); the Middle Magdalena
remained relatively unchanged.  In addition, four provinces of
Ecuador (Esmeraldas, Manabi, Guayas, and Los Ríos) accounted for
92.45% of cases registered of P.  falciparum (19,081), reflecting
the same pattern of the neighboring country.  This contrasts with
the classical Ecuadorian distribution of P.  falciparum in the
valleys of the Putumayo along the border with Colombia and the
valley of the Napo river in the Amazon region. 

     Venezuela continued to have the highest proportion of
infections due to P. falciparum in jungle areas of its Amazon
region (federal territory of Amazonas and the state of Bolívar). 
(See description under Amazon Region together with Brazil and the
Guianas).

     Bolivia registered 19,680 cases and Peru 28,882 (up to October
1990), of which 3.31% and 0.45% respectively were diagnosed as P. 
falciparum.  This situation is characterized by apparent endemic
stability.  The relative increase in the diagnosis of cases due to
P.  falciparum in Peru, from zero in 1988 to 131 in 1990, has
originated mainly in the region of Piura, Tumbes.  This region has
the known focus of San Lorenzo, which challenged the interruption
of transmission in Peru during the eradication period.  The
reinitiation of transmission by P.  falciparum in a country that
had interrupted it completely and for many years is dispiriting. 


Amazon Region

     For the purpose of studying malaria, we consider as a part of
this region to be constituted by the macroregion of the political-
administrative division known as the Amazonia in Brazil, French
Guiana, Guyana, Suriname, and the area south of the Orinoco river
basin in Venezuela (state of Bolívar and federal territory of
Amazonas) (see Map 4).

     This region is characterized as an "area of malaria that
cannot be reached" by the old strategy of eradication.  In these
areas traditional control measures such as intradomiciliary
spraying and case detection and treatment did not present the
results attained in areas with greater population density, where
the basic indicators for social and economic development were
higher.

     However, in this region the last decade has seen the opening
of "great frontiers" as part of a model of economic development
that does not attribute sufficient priority to the development and
social protection of man.  These frontiers of economic development
have generated large-scale human circulation, with a high capacity
for mobilization created by the opening of roads and air and river
transport facilities, creating serious ecological imbalances.  In
addition to the foregoing, there are large numbers of susceptible
persons but the expansion of the parasitic reservoir, as well as
the increase in population density of the vectors, favored by the
ecological changes.

     In the context of state lack of social protection, the
traditional control programs were taken by surprise with malaria
control measures that were inappropriate for the region and without
a specific possibility for developing intersectoral social
protection measures, sometimes due to the absence of institutions
in the area and other times due to the lack of a technical strategy
for generating new measures of a broader social nature. 

     This Amazon region has reported the diagnosis of 622,160 cases
of malaria, of which, 278,421 were infections due to P. falciparum. 
They were originated mainly in the jungles of the Amazon area,
which account for 80.6% of all diagnosed cases of P. falciparum in
the Region of the Americas.

Southern Cone

     In this area, which as regards malaria is represented mainly
by Paraguay and Argentina, is very affected in certain areas by the
population flow from southern Brazil through Paraguay (see Map 5).

     These two countries, with a population in malarious areas of
7,947,000 inhabitants, registered 4,572 malaria cases (API of 0.39
per 1,000 and 0.79 per 1,000 population respectively).

     The traditional reservoir of cases in Paraguay (Amambay) has
expanded considerably due to agricultural development, particularly
since the creation of the Itaipú reservoir, which has forced the
country to reactivate areas of "attack" as part of its eradication
strategy.  Furthermore, the construction of the reservoirs and dams
along the border with Argentina merit special attention.  Thus
engineering works should work to keep to a minimum the creation of
conditions that are optimal for expanding vector density, because
of increased relative moisture in the air caused by falling water. 

B.   Status of Malaria in Countries with Transmission of the
     Disease

      Table 12 shows a comparison between the passive and active
search of cases in each of the countries.  In general the largest
numbers of malaria patients continue to be detected through passive
search.  However, seven countries have yet to change their system
for finding malaria cases.  These countries, Argentina, Bolivia,
Costa Rica, Panama, the Dominican Republic, Paraguay, and
Venezuela, continue preferring active searching, though less cases
are discovered with this method than through passive searching. 
Thus in 1990, the efforts and costs of these countries for taking
a total of 861,733 blood samples by active search produced barely
15,721 positive slides, for a positive slide index (PSI) of 1.8%. 
By contrast, 414,431 blood samples taken by passive search (half
of active search) came up with 45,501 positive cases, i.e. three
times more than those discovered by active searching. 

Field Operations 

      Use of insecticides continues to be the principal control
measure.  Table 13 shows the number of insecticide sprayings during
1989 and 1990 in the malaria programs.  Table 14 shows the
insecticides used in 1990 in each country and the estimate for
1991.  Table 15 lists the quantities used from 1987 to 1990.  DDT
is still the insecticide most used, though in several countries,
especially Central America, they are no longer used. 

     Antimalarial drugs are used for continuous presumptive
treatment in most of the countries.  Table 16 shows the quantities
utilized, country by country, for 1990 and the estimated figures
for 1991.  Table 17 shows data on the total quantities of drugs
consumed from 1986 to 1990.

     Table 18 contains information on personnel used in the malaria
programs in 1989 and 1990.

Problems in Developing the Malaria Programs

      The problems that face the malaria programs are summarized
in Table 19.  Although information is lacking on five countries
that have both technical and administrative problems, the table
shows the population, area, insecticides used, and number of cases
registered, the principal vectors, and the causes of the problem. 
In the 13 countries that appear in that table, 621,722 cases were
diagnosed, i.e. 59.6% of all cases registered in the 21 malarious
countries of the Americas.


Country Information

      Below is a brief description of the malaria situation in each
country, including a table and a graph showing the malariometric
rates from 1960 to 1990.


ARGENTINA 

     The malaria control program reported that:

     a) fulfillment of coverage programmed for epidemiological
surveillance was 87.2%; 

     b) intradomiciliary spraying was 62.5% of coverage programmed;

     c) the fulfillment of coverage programmed is insufficient, due
mainly to the lack of funds, or the fact that the funds needed by
services are not available; 

     d) the resources available were oriented to covering areas at
greater risk;

     e) during the year there was a significant reduction of
personnel (authority, laboratories);

     f) no evidence was observed of resistance to the insecticides
and/or drugs.

BELIZE 

     In 1990, 3,033 cases of malaria were registered; 98.5% were
infections by P.  vivax.  The API declined in 1990 to 16.57 per
1,000 population as compared to 18.46 per 1,000 for 1989.  As in
previous years, the transmission of malaria continued to be high
in the districts of Cayo and Toledo, with 40 and 47 cases per 1,000
population respectively.  The districts of the north continued to
have a similar prevalence; only the district of Belize registered
a lower number of cases.

     The Ministry of Health of Belize adopted the strategy of
"Integrated Control" with the support of other ministries, such as
Agriculture, Natural Resources, and Education.
BOLIVIA 

     Currently there appears to be better integration of the
specific activities for detection and treatment of cases by the
general health services, which detected 69% of all malaria cases. 

     A comparative analysis of the last decade demonstrates the
trend of malaria through the classical indicators.  In 1980 there
was a PSI of 11.6%, which fell to 4.0% in 1983 and began to rise
in 1989, when it reached 22.5%.  However, in 1980 the PSI was
16.2%, which indicates a relative reduction of positivity in
febrile persons.  This contrasts with the poorer performance of
case-finding indicated by the ABER, from 7.2% in 1980 to 4.6% in
1990.  Indeed there was a 15% reduction in case-finding (active and
passive) that is also related to the system of reporting,
participation of the health services, and an active search on the
part of the operational personnel, which yielded just 31% of total
cases detected.  Based on the total population of the country
estimated in 1980, the API was 2.83 per 1,000 population; its
lowest point was in 1982, when it fell to 1.14 per 1,000
population.  In 1990 it was back up to 2.69 per 1,000 population.
BRAZIL 

     The population of the country, estimated for 1990, came to
154,235,703 inhabitants, of which 67,341,152 (43.7%) are considered
to live in originally malarious areas; 43,492,501 of latter group
(64.6%) live in areas where the transmission of malaria has been
interrupted.  The rest of the population, i.e. 23,848,651 people,
(35.4%) live in areas where transmission continues.

     In 1990, 560,396 cases of malaria were registered; of these,
252,191 were caused by P.  falciparum, 308,184 by P.  vivax, and
21 by P.  malariae.  These data show a reduction in malaria cases
since 1989 (577,520), and the decline of P.  falciparum in the
parasitic form.  

     Of the three macro-regions into which the country can be
divided, the region with the greatest transmission is the Official
Amazonia, which encompasses nine states and territories:  Acre,
Amapá, Amazonas, MaranhØo, Mato Grosso, Pará, Rondonia, Roraima,
and Tocantíns.  This region has moist tropical forests, very heavy
rainfall, and high temperatures, and is mostly near sea level.  The
states of the official Amazonia account for nearly 99% of all
malaria cases.  The main vector species is A.  darlingi, but
malaria parasites have been found in other species of mosquitoes.

     The three states that accounted for most malaria transmission
in the Amazon region in 1990 were Rondonia (33.4%), Pará (20.1%),
and Mato Grosso (25.0%).  The analysis by municipalities showed
that 30 of the nation's 2,278 municipalities, all located in the
endemic area, accounted for 67.2% of the cases.  These
municipalities include 6.46% of the national population and 11.03%
of the malarious area.

     One could observe that during the year the trend in the states
of Mato Grosso and Roraima was upward, while in the other states
malaria incidence declined.  The increase in malaria cases in Mato
Grosso is due mainly to increased mining in the northern part of
this state; in Roraima rising incidence of malaria continues to
stem from the arrival of miners to regions where access is
difficult.

     The rest of the country can be divided into two regions with
little malaria transmission.  The northeast region is arid and
semiarid; it includes the states of Bahia, Ceará, Paraiba,
Pernambuco, Piauí, Rio Grande do Norte, and Sergipe.  It is also
characterized by high temperatures and is periodically afflicted
by long droughts.  The southern region is made up of the states of
Espíritu Santo, Goiás, Mato Grosso do Sul, Minas Gerais, Paraná,
Rio de Janeiro, Rio Grande do Sul, Santa Catarina, and SØo Paulo,
and the Federal District.  This is the most developed region of the
country, and has a temperate climate.  Some local areas have
experienced outbreaks of malaria, such as in early 1989 at Foz de
IguaÛú, in the state of Paraná.  This resulted mainly from growth
of the A.  darlingi population in the area, and the migration of
malarious persons from the states of the Amazonia.  In 1990, this
outbreak was contained by control measures carried out by the three
countries affected (Brazil, Argentina, and Paraguay).  In 1989 more
than 1,000 autochthonous cases were detected on the Brazilian side,
while in 1990 only 200 cases were detected there.

Causes Affecting the Persistence of Malaria

     The states that account for most malaria cases, particularly
in the official Amazonia, constitute the two "great frontiers" that
exist in this area.  The first frontier is the mining area with the
presence of garimpeiros (miners), who come from remote areas of the
Amazon region in search of gold, cassiterite, and other minerals. 
Most of these garimpeiros live in subsistence conditions, without
walls and with only improvised shelter.

     Control activities in these areas are very precarious due to
the difficult access, which is predominantly by private or rented
airplane.  In the state of Pará the national control agency (SUCAM)
initiated activities known as "microzonage."  In each microzone a
guard is placed who serves a segment of the population in a
specific area.  Yet despite the difficulties, the migratory flow
continues in large numbers, since the garimpeiros move continually
from one locality to another.  In the closed garimpos, or mining
sites, such as Serra Pelada in the state of Pará, malaria was never
a serious problem, due to the control activities of the government. 
In this case control was kept of who was coming and leaving.  In
contrast, in the open garimpos no type of control is exercised.

     The mining activities destroy the ecological balance, since
the mining mechanisms are totally predatory, destroying the forest
through the complete deforestation of extensive areas, and
diverting small watercourses, which become stagnant with the
reconfiguration of land use.  Thus pools and water holes are formed
that become vector breeding sites.  The region's very heavy
rainfall contributes to the formation and maintenance of breeding
sites and spreads them over time.  Separating gold with the
assistance of mercury has polluted the rivers; the fish become so
contaminated that they cannot be consumed.  Direct contamination
of the garimpeiros with mercury is also a problem.

     The second frontier expanding malaria transmission in the
Amazon region is the agricultural frontier, which is most
predominant in the states of Acre and Rondonia.  In these frontier
areas, the colonists inhabit lands that are often inaccessible
during rainy periods.  In the first years these colonists devote
most of their time to clearing land and planting subsistence
harvests, devoting little time or effort to building rooms with
walls.  As a result, they live in houses without walls or with
incomplete walls.

     The state of Rondonia accounted for more than 31.1% of total
cases in the country, although there was a reduction of 23.5% with
respect to 1989.

     The state of Acre is divided into 12 municipalities, four of
which reported 95% of malaria cases in 1990.  The other
municipalities produced 687 cases in the entire year.  The
municipality of Rio Branco is among the 30 municipalities with
highest incidence of malaria nationwide, while the municipality of
Plácido de Castro produces almost as many cases, and has the
highest API in the state (198.9 per 1,000).  The municipality of
Senador Guiomard has an API of 101.9 per 1,000 population.  The 4
municipalities that generate most of the cases are also those with
the highest APIs in the state.

     The state of Amapá is divided into nine municipalities, three
of which accounted for 81% of malaria cases in 1990.  The other
municipalities registered 2,074 cases in the entire year.  The
municipality of Macapá is among the 30 with highest incidence of
malaria nationwide.  The municipality of Tartarugal has the highest
API (125 per 1,000); the other municipalities, with the exception
of Laranjal do Jari, have high API, ranging from 25 to 90.

     The state of Amazonas is divided into 62 municipalities.  Ten
had a higher incidence of malaria, accounting for 62% of all cases
registered in 1990.  Of the 30 municipalities with the highest
incidence of malaria in the country, Manaus has the lowest API, 5.2
per 1,000, due to the large population of this municipality, which
is also the state capital.  Of the other 61 municipalities, three
have an API greater than 100, two of them (Apuí and Barcelos) have
the greatest incidence of malaria in the state, and 19 have an API
ranging from 25 to 99 per 1,000 population.

     The state of Maranhao is divided into 136 municipalities.  The
10 with the greatest incidence of malaria generated less than 50%
of the malaria cases registered in 1990.  Only the municipality of
Imperatriz is among the 30 with highest incidence of malaria of the
country, with an API of 13.0.  The municipality of Pindare Mirim
registered the highest API, 26.8 per 1,000 population, while the
other municipalities have an API of less than 22 per 1,000.

     The state of Mato Grosso is divided into 22 municipalities. 
The 10 with greatest incidence generated less than 92% of malaria
cases in 1990.  Nine of these are among the 30 with greatest
incidence of malaria, with APIs ranging from 129 per 1,000
population to 3,924 per 1,000.  The APIs of the other
municipalities of the state are lower; the lowest API is 20 per
1,000 population.

     The state of Pará is divided into 105 municipalities.  The 10
with the greater incidence of malaria accounted for 66% of all
cases registered in the state.  Five are among the 30 with greatest
incidence of malaria in the country; all have an API  ranging from
26.6 to 583.8 per 1,000 inhabitants.  Some of the municipalities
in this state did not report cases during 1990.

     The state of Rondonia is divided into 23 municipalities.  The
10 with the highest incidence of malaria generated 90% of the cases
state-wide.  Seven are among the 30 municipalities with the highest
incidence of malaria nationwide; in two the API was greater than
100 per 1,000 population.

     The state of Roraima is divided into eight municipalities. 
The five with the greatest incidence of malaria generated
approximately 95% of the cases in the state.  One, Boa Vista, is
among the 30 municipalities with greatest incidence of malaria in
the country.  Boa Vista's API was 79.5 per 1,000.  The APIs of
three municipalities were greater than 100; the other ranged from
14 per 1,000 to 93 per 1,000.

     The state of Tocantíns is divided into 80 municipalities.  The
10 municipalities with the greatest incidence of malaria generated
62% of the cases.  Three had an API ranging from 25 to 68 per
1,000, while in the others it was less than 17 per 1,000.  Some did
not report any cases of malaria during the year.  None of the
municipalities of Tocantíns is among those with the highest
incidence the country.

     Migrations of colonists and miners are also responsible for
the occurrence and re-establishment of malaria in other regions of
the country where transmission had been interrupted.

     In some cases, urban transmission is still a serious problem
in the Amazon region.  In localities such as Porto Velho, capital
of Rondînia, the incidence of urban transmission has been reduced
with the use of adulticides, in ULV, applied weekly.  In contrast,
in the city of Manaus, where urban transmission was interrupted in
1974, transmission was reestablished in 1989, with the expansion
of the city.  Efforts have been made in the area to reduce sources
of transmission in some peripheral neighborhoods. 

     One of the major deficits the country is facing is in manpower
training, particularly in the areas of epidemiology, entomology,
and vector control.  During the year several courses were developed
and prepared to enhance personnel in these areas.  In the cities
of Belém, Pará, and Manaus, Amazonas, 15 persons participated (two
from abroad, one from Colombia and one from Portugal) in the
"International Course of Malariology"; it lasted three months.  A
course on medical entomology was also offered, in Rio de Janeiro,
with a duration of one month.  Another course was given on
Entomology in Public Health and Vector Control for upper-level
personnel in Manaus, Amazonas, of three months duration, with the
participation of 12 students, one of who came from abroad
(Ecuador).  
Malaria Control in International Border Areas

      Among the existing international agreements with other
countries is the Southern Cone Pact, which includes Argentina,
Bolivia, Brazil, Chile, Paraguay, and Uruguay.  Malaria is endemic
only in Paraguay, Bolivia, and Brazil, and in a small part of
northern Argentina.  In intercountry technical meetings it was
recommended that exchange actions be increased in the areas of
human resources, research, epidemiological surveillance,
documentation, and acquisition and supply of inputs, material and
equipment, in order to obtain effective and lasting control of
disease.
COLOMBIA

     The status of malaria has gradually and continuously worsened. 
Even though it is considered one of the country's health
priorities, the results of control efforts have not been
satisfactory, and prevalence of the disease has increased over the
last ten years.

     The Bureau of Direct Campaigns (DCD) registered a total of
99,489 malaria cases in 1990, of which 35,322 (35.5%) were
diagnosed as P.  falciparum.

     The greatest transmission of malaria continues to occur in the
Pacific Coast, Lower Cauca, Urabá, Amazon, Sarare, and Middle
Magdalena regions.  In these six regions 79,962 cases of malaria
were detected in 74 municipalities, accounting for 80.4% of the
99,489 cases registered in the country.  Of these 74
municipalities, 28 registered 64,735 cases, equivalent to 65.1% of
the national total, and 80.9% of all cases detected in the six
regions.

     However, the limited number of localities in the malarious
area that have information (4,629) is noteworthy; this represents
only 12% of the total number of localities in the malarious area. 
No information was received from the remaining 87.9% of the
localities.

     In contrast, the Sectional Health Service of Antioquia
reported mortality due to malaria at two per 100,000 population,
which represents a very significant reduction, compared to the
figure for 1983 of 34 per 100,000 population, and 1984, 19 per
100,000 population.  This reduction is the fruit of actions carried
out by the Sectional Health Service since 1984, based on diagnosis
and timely treatment.  The Health Service of Antioquia also
reported taking 211,826 blood samples, in which it detected 80,936
malaria cases in 1990.

     In summary, the malaria situation in Colombia had the
following characteristics:

     Stability in the 1988-1990 period, with approximately 100,000
cases per year.  Slight reduction in infections due to P. 
falciparum in the regions of Sarare, Catatumbo, the Orinoco river
basin, and the Amazon basin, and a deterioration of that situation
in the Pacific Coast, Urabá, Lower Cauca-Nechí, and Upper Sinú
regions.

     There is considerable underregistration of mortality due to
malaria.  In some communities of the Pacific Coast there have been
findings of up to 20% apparently healthy carriers, with confirmed
parasitemia.

     Of all cases registered in 1990, 46% were detected in 13
municipalities, and 18% in three of these.  Of the total of cases
by P.  falciparum in 1990, 50% were concentrated in eight
municipalities; of these, four accounted for 38% of the cases
registered.

     Infections by P.  falciparum of the An.  darlingi, An.
albimanus, and An. neomacutipalpus, and by P. vivax of the An.
albimanus and An. rangeli, were detected using immunological
methods. 

Causes Affecting the Persistence of Malaria

     Reservoir-related factors.  Large concentrations of population
in newly-occupied tropical colonization zones have established new
human settlements that do not have the health services required for
care delivery.  In addition to the foregoing are the different
types of migrations specific to agricultural, stock-raising, and
mining activities; problems of public order, which limit the areas
in which timely control measures can be taken; and the risk factors
associated with the physical environment (very heavy rainfall and
relative moisture, and high temperatures).

     Other factors to be considered have to do with the knowledge,
attitudes, practices and behavior of the population in relation to
their ecological and cultural adaptation to factors that alter
susceptibility and degree of exposure to the risk of malaria.

     The hemorrhagic dengue emergency in 1990 caused a major
reduction in the activities programmed for malaria control at the
national level, due to the diversion of resources to address that
emergency.

Decentralization

     In accordance with the provisions of Law 10 of 10 January
1990, the offices and respective employment of the current Bureau
of Direct Campaigns (DCD) should be assumed by national or
territorial entities.  Accordingly, the municipal governments must
assume responsibility for the actions to control malaria and other
vector-borne diseases (VBD).  The process of decentralization
called for in that law has been initiated by the Bureau of Direct
Campaigns through a survey of the epidemiological situation in each
community (locality) over the last five years, reviewing the
résumés of each staff member; taking stock of resources, especially
lots, buildings, and transportation; and assessing resources
available and human resources needed for the operational levels in
the municipalities.  

     In addition, workshops and meetings were held with mayors of
the municipalities, in which malaria was examined as a problem in
the framework established through the creation of the Committees
for Community Participation.  

Epidemiological Stratification

     The process of stratification in Colombia has made it possible
to identify and group the areas with the greatest transmission of
malaria, using as the principal indicators the annual parasite
incidence (API) and the annual P.  falciparum incidence (AFI).

     The utilization of these two indicators has made possible
improved use of resources, which are concentrated in those areas
where the API is highest.  Three levels of risk have been
established based on API:  below 0.5, low risk; 0.5-10.0, medium
risk; and greater than 10.0, high risk.

     In the area where control actions are focused, which is
considered high-risk, 94,190 cases of malaria were registered in
1990, for an API of 17.8 per 1,000 population.

     In the low-risk area (area being consolidated), 5,299 cases
were diagnosed, for an API of 0.3 per 1,000.  This situation
reflects the knowledge available as to the magnitude and intensity
of malaria transmission in Colombia.  However, identification of
the risk factors at the local level is still deficient.

Malaria Control in International Border Areas

     Together with the armed forces of the bordering countries,
periodic visits continued to the populations of the localities
located along the shores of the Putumayo and Amazon rivers, as part
of the Civic-Naval Plan of Action.  In addition, as a result of the
Colombian-Venezuelan border meetings, joint actions with Venezuela
were carried out for malaria control in the Sarare and Catatumbo
regions.

     In the region of the Putumayo river, along the border with
Ecuador, the problem of malaria has been reduced by actions agreed
upon in border meetings.  This region has a network of
microscopists, thus reducing the time between taking samples and
their diagnosis, and between diagnosis and treatment.
COSTA RICA 

     The principal objective of the Malaria Program in Costa Rica
was to consolidate the process of interrupting the disease in the
national territory.

     The malarious area of the country includes 35,446 km2, which
represents 69.6% of the country's area, and a population of
835,485.  In 1990, 113,167 blood samples were examined, of which
1,151 were positive (1,146 P.  vivax, and 5 P.  falciparum).

     The epidemiological analysis indicates that the most affected
provinces were Limón, with 779 cases; Alajuela, with 105; and
Guanacaste, with 92.  These account for 85% of total cases in the
country, and resulted from epidemic outbreaks.  Of the 1,151 cases
registered, 117 were classified as imported from abroad, with 107
from Nicaragua, three from Panama, one from Honduras, two from
Guatemala, two from Colombia, one from India, and one from Brazil.

Causes Affecting the Persistence of Malaria

      One of the cantons that is most problematic due to the
dispersion and persistence of transmission is Limón, with 280
cases, most of which were in areas of difficult access and/or where
there has been migration.

     The most recent outbreak was in the canton of Siquirres, with
221 cases.  This area is suffering drastic changes due to the
presence of unstable and scattered populations, and also due to the
reactivation of banana-growing on many farms.

     The prevailing climatological conditions also favored
increased transmission in the area, making control measures
difficult.  In many cases treatment had to be interrupted due to
continuous high waters and floods.  The excessive rain during the
year facilitated the increase in anopheline density,  which
established transmission in places where it had already been
interrupted.

Malaria Control in International Border Areas

      With a view to preventing malaria and dengue in the border
region between Costa Rica and Nicaragua, a cooperation agreement
was signed with the Governments of Sweden and Finland in August
1988.  This facilitated the joint work, with coordination of tasks
not only for malaria and dengue control, but also for the primary
care program.  In this context shared goals were established,
common problems identified, and coherent solutions devised to
address local health problems with available resources.

     In August 1990 the proposal for financing the Second Phase of
the Project for Strengthening the Operational Capacity of the Local
Level of Health Care was prepared; it is based on the prevention
and control of vector-borne diseases in border areas between Costa
Rica and Honduras, and Costa Rica and Nicaragua.

     The Basic Technical Councils (local health systems) are
responsible for carrying out activities at the local level,
including surveillance and control of malaria, dengue, and A. 
aegypti.  The upper levels of coordination are constituted by the
Regional Technical Councils.  This regional and local structure is
supported by the normative programs of the central level.

     The actions carried out in 1990 were set forth in the context
of the policies and strategies defined in these by the health
program component of the National Plan for Economic and Social
Development for 1990-1994. 
ECUADOR 

     Ecuador reported 71,690 cases of malaria, of which 21,871 were
infections by P.  falciparum (30.5%).  Of these cases, 91.5%
occurred in the provinces of Esmeraldas, Manabi, Guayas, and Los
Ríos.  This area constitutes the new frontier of development in
Ecuador; it includes new zones vital for agriculture and mining.

     This characteristic is reinforced by the continuity of the
greatest prevalence of P.  falciparum in the Province of Esmeraldas
along in the border with Colombia along the Pacific coast, where
40% of all cases of P.  falciparum were registered.  However, the
classical scenario of high prevalence changed in the valley of the
Napo river in the Amazon region, where the number of cases declined
to 15% of the total.
EL SALVADOR

     Again, for the third consecutive year, the transmission of
malaria continues diminishing in El Salvador.  In 1990, only 9,269
cases were registered.  Infections by P.  falciparum are the lowest
figures ever registered, with 18 cases, or 0.2% of all cases
diagnosed in 1990.

     Since 1980, when the highest figures of malaria were detected
(96,000 cases, including 16,000 by P.  falciparum), the situation
has improved continuously for 11 years.  Thus there was a 90%
reduction in the number of cases in general, and in the specific
case of P.  falciparum, a 99.8% reduction.

     These achievements resulted from the development of an of
integrated control strategy, with a purely epidemiological
approach, based on stratification of the problem and its constant
adaptation to the evolving malaria situation.  This required the
development of a computerized information system for immediate
decision-making.  In addition to the foregoing, the
decentralization of diagnosis at the rural level and by local
medical services made possible more timely treatment of cases. 
Finally, training of the program personnel, the 2,700 voluntary
collaborators, the health services personnel, and others involved
has been extremely valuable in developing the aforementioned
strategy.
GUATEMALA 

     In Guatemala, during the 1959-1976 period, there were an
average of 10,325 malaria cases annually; from 1977 to 1990 this
number increased to 57,274 cases.

     During 1990 total malaria cases came to 41,711, which was a
decline of 742 cases (1.7%) with respect to the 42,453 diagnosed
in 1989.  The 305,791 blood examinations done in 1990 declined by
26.01% and 8.0% with regard to those done in 1988 and 1989,
respectively.

     Annual parasite incidence (API) was 4.54 per 1,000 population
in the country, very similar to that of 1989 (4.75 per 1,000).  The
distribution by parasitic species of the 41,711 cases was 40,703
(97.6%) cases of P.  vivax, 890 (2.1%) of P.  falciparum, and 118
(0.3%) mixed infections.

     In the distribution of cases by health regions, it was
observed that Regions II, VI, and VIII contributed 12,438 (30.1%),
7,986 (17.0%), and 5,567 (13.0%) cases respectively.  In sum, these
three regions accounted for 25,991 cases, or 62.3% of the total
registered in the country.  These same regions contributed a
similar percentage (59.0%) in 1989.  Of 22 departments, five (El
Petén, Alta Verapaz, Escuintla, Izabal, and El Quiché) accounted
for 67.6% of total cases in the country.  In El Petén, Alta
Verapaz, San Marcos, and El Quiché the APIs were above average.  

     In the distribution of malaria by ecological areas, the
northern ecological area registered 25,314 cases, which or 60.6%
of the total.  This area encompasses 55,210 km2, i.e. 50.7% of the
national territory, and a population of 1,050,468 inhabitants
(1967), or 11.7% of the country's total population.  The high
receptivity of this area is a consequence of the favorable
climatological factors, such as the abundant rainfall and average
temperature of 25o C.  An. albimanus is the principal vector,
although An. pseudopunctipennis and An. vestitipennis are also
present.

     In addition to the ecological factors, there are migratory
movements that affect the agrarian development of the region and
contribute to disorganized colonization, with unprotected
dwellings, mainly in the departments of Alta Verapaz and El Petén.
Sociopolitical problems are present in most of the departments of
the northern area, hindering adequate epidemiological surveillance
and implementation of the respective control measures.  There are
also other factors, such as inaccessibility, distance to the
localities, and lack of resources and equipment in good condition.

     The southern ecological area has conditions that are very
propitious for malaria transmission, especially in the coastal
strip, at 400 meters above sea level.  The region, with 11,471 km2,
is not all that extensive; it comprises 10.5% of the national
territory.  Yet it is the most densely populated, with 1,109,158
inhabitants, or 12.05% of the total population.  The topography is
flat and with abundant rivers; the principal vector is the An.
albimanus.

     In this area over the 10 last years the malaria problem has
diminished considerably.

     Possible explanations have been given to account for this,
such as the suppression of cotton and banana crops, and the
predominance of sugarcane.  This has contributed to a reduction in
internal rural migrations and the indiscriminate use of
insecticides.

     The eastern central ecological area includes 13,864 km2, which
is 13.0% of the total area of the country, and has a population of
1,269,601 (1987), or 14.0% of the total population.  This area is
characterized by high temperatures, little precipitation, and low
relative moisture, in addition to a broken topography with little
vegetation.  The irrigation systems are the main source promoting
and maintaining breeding sites of the An.  albimanus.

     This area is characterized by its high vulnerability due to
the constant flow of population to and from El Salvador.  However,
this epidemiological situation is offset by the area's low
receptivity.

Epidemiological Stratification

     The Malaria Division has used stratification, drawing on the
annual parasite incidence (API, per 1,000) as an instrument for
identifying priority areas.  Thus the malarious area has been
divided into two major groups of municipalities:  a) those that
account for 80.0% of the cases; and, b) those in the remaining
20.0%.

     The group a) municipalities, in turn, are subdivided into
three strata:  a) localities with an API greater than 100; b)
localities with an API from 50 per 1,000 to 99.9 per 1,000; c)
localities with an API under 49.9 cases per 1,000 population.  This
approach has made possible the improved use of available resources.

     Having determined this stratification based on API, the next
steps are to:  a) identify and measure the risk factors; b)
determine the epidemiological strata; c) select the principal
measures of intervention; and, d) ensure participation of health
services in implementing the actions.  For example, the services
of the Ministry of Health performed only 0.5% of the 305,791 blood
samples examined.  Of the samples, 99.4% were examined by the
voluntary collaborators, reflecting active community participation; 
only 204 positives were reported by the hospitals.  The limited
participation of establishments of the first level of care in the
epidemiological surveillance of malaria is noteworthy.

Causes Affecting the Persistence of Malaria

     Economic and administrative problems are compounded by
migrations.  Agricultural labor migration in Guatemala is not a
recent phenomenon.  Due to the lack of major mineral resources, the
economy of the Central American region was based on use of the land
and work force.  After the rise of coffee, banana-growing was
introduced in Guatemala and became a major export product.  Then
cotton and stock-breeding have expanded.  In the 1960s and 1970s,
sugar and cardamom began to be cultivated as export products.  By
the late 1980s other new exports added to this list included
sesame, okra, and some others.  These products currently represent
more than 60.0% of exports.

     Migrant workers face several problems that affect their
health.  These include:  a) poor nutrition, c) prolonged work days,
d) lack of medical services and environmental sanitation,  and e)
lack of legal protection in general.  

     As a result of the problems described, this population has
health deficiencies such as malnutrition, infectious diseases,
respiratory and gastrointestinal diseases, occupational accidents,
intoxications, and premature aging.  The transmission of malaria
and the permanence of endemic areas and the high prevalence of the
disease in the northern part of the country, is closely associated
with these internal migrations.

The Current and Potential Problem  Posed by Development Projects

      Development projects affect the surrounding ecology and
consequently the biology and ecology of malaria transmitters.  Such
projects thus increase vector receptivity as well as vulnerability,
due to the increase in labor, especially the labor of peasants. 
This results in an increase in the demand for the health services
to serve these new population nuclei. 

     The country has 25 irrigation projects under way and 24 under
study.  These projects under way cover a population of 16,250; and
those under construction or under study are to cover a population
of 51,252 inhabitants.

Malaria Control in International Border Areas

     The 46 municipalities that share borders with Honduras, El
Salvador, Belize, and Mexico cover an area of 51,089 km2, or 47.0%
of the national territory, with a population of 1,134,300.  During
the 1985-1990 period these municipalities registered an annual
average of 19,528 cases of malaria.  In 1990 the number of cases
was of 18,756, or 45.0% of total malaria cases.

     The border area with Belize includes six municipalities
belonging to the departments of El Petén and Izabal.  It includes
an area of 9,346 km2, with a population of 111,370.  In the last
six years the annual average has been 4,597 malaria cases.  In
1990, 5,139 cases were registered; of these, the municipalities of
Dolores, San Luis, and Livingston accounted for 1,563, 1,169, and
1,007 cases respectively, i.e. 72.7% of total cases in the area.

     Eleven municipalities of the departments of Jutiapa and
Chiquimula are located in the border area with El Salvador.  This
area encompasses 2,418 km2, with a population of 203,176
inhabitants.  During the last six years the annual average number
of cases was 1,190.  In 1990, 928 cases were registered; the
municipalities of Asunción Mita and Moyuta in the department of
Jutiapa accounted for 57.0% of all cases.

     The border area with the Republic of Honduras is formed by
seven municipalities located in the departments of Chiquimula,
Izabal, and Zacapa.  It includes an area of 5,008 km2 and a
population of 351,849.  The average number of malaria cases per
year in the 1985-1990 period was 2,460; in 1990, 1,349 cases were
registered, with the department of Izabal contributing 83%. 

     The 23 municipalities of the border area with Mexico encompass
34,317 km2 and 467,905 inhabitants.  During the 1985-1990 period
the average number of cases was 10,279; in 1990, 11,340 cases of
malaria were registered, with the department of El Petén
contributing 67.0% of this total.

     The Malaria Division has based its control efforts on
intradomiciliary spraying, antilarval measures, and collective
treatments.  In other border areas 25 of 75 municipalities have
been sprayed (33.3%), providing protection to 93,093 houses with
150,183 inhabitants.  Fenitrothion, deltamethrin, and propoxur were
the insecticides used for intradomiciliary spraying; Fenitrothion
was used most frequently.

     The fact that the municipalities along the borders with
Belize, El Salvador, Honduras, and Mexico accounted for 45.0% of
all malaria cases in the country points to the need for the health
authorities involved to follow-up on the different border
agreements; to date these agreements have resulted in little in the
way of operational activities related to malaria.  
FRENCH GUIANA 

     In 1990, 5,909 cases of malaria were registered, for a 6.0%
reduction with respect to 1989.  The areas with greatest
transmission continued to be the Maroni and Oyapock river basins,
with an API of 204 per 1,000 and 546 per 1,000 population
respectively.  Although in the Maroni river area there was a 45%
reduction in cases registered, in comparison with the previous
year, P. falciparum was the predominant species in the area,
accounting for 50.7% of all cases registered in the year.  In
addition, 10 cases of P. malariae were detected, which is
noteworthy, since the species had not been diagnosed in this region
since 1978.

     Transmission continues to increase in new settlements around
Cayenne, where there was a 30% increase in case-finding from 1989
to 1990.  In other areas, transmission continues to be limited.
GUYANA 

     The almost exponential annual growth of malaria cases
registered from 1984 to 1988 has come to a halt.  The achievements
of 1989 were maintained in 1990.

     Of the country's ten administrative regions, Region I, along
the southern border with Venezuela, continues to have the highest
incidence of malaria.  Its API was 417, practically unchanged from
the previous year; 37% of the cases reported in the country were
detected there.  Regions VII, VIII, and IX contributed with 10%,
13%, and 12%, respectively, of total cases.  The corresponding APIs
were 251 per 1,000 population (for regions VII and VIII combined)
and 168 per 1,000.

     In Region IV, which includes Georgetown, the capital, 3,775
cases were registered (17% of the total).  Epidemiological research
revealed that 39% were from Region VII and 44% from Region VIII;
the immense majority were migrant gold and diamond prospectors.

     With the reduction of the vector prevention and control
measures, there is much greater reliance on the diagnosis and
treatment of malaria cases.  Microscopy services had 54 staff in
39 fixed and six mobile laboratories for the diagnosis of malaria. 
Chemotherapy was administered by primary health care personnel, as
well as personnel from the malaria campaign.

Causes Affecting the Persistence of Malaria

      The search for gold and diamonds by migrant workers,
especially in Regions VII and VIII, has had a considerable impact
on the epidemiology of malaria in Guyana.  The precarious housing
conditions in camps alongside the rivers have furthered
transmission by the An. darlingi.  The difficult access to many
remote places delays diagnosis and adequate treatment.  This has
combined with the absence of walls that can be sprayed; the lack
of measures of protection from the vectors; the deficient self-
administration of drugs in febrile patients; and the resistance of
P. falciparum to the antimalarial drugs to aggravate the problem.

     Spraying coverage has declined notably, from more than 11,000
houses in 1987 to less than 3,000 in 1990.  This reduction, as well
as the low coverage in the forest settlements with indigenous
population, have contributed to the continuation of transmission. 
In some regions, mainly the Rupununi region (Region IX), the
seasonal agricultural practice requires the building of provisional
dwellings outside of the villages.  In these circumstances the
factors previously described with regard to the gold prospectors
are also present.

     The local introduction of malaria in the coastal areas by the
migrant mineral prospectors when they resupply with provisions,
and/or receive visits to their homes by persons from the interior,
provide a constant source of infection for the coastal vector, An.
aquasalis.  However, in the coast region only 36 autochthonous
cases were reported in 1990.

Malaria Control in International Border Areas

     An agreement signed by Guyana and Venezuela provides for a
joint team that will collaborate in making routine visits to the
remote border settlements to make diagnoses, administer treatments,
spray dwellings, and promote self-care measures.  No official
cooperation program has been established in the border area with
Brazil, although there is a some exchange of information between
the two countries.  The project for building roads from the
northern border to Georgetown is increasing mobility of the
population through malarious regions of the interior.  Over time
colonization of the forests may accelerate in areas with a high
potential for transmission by virtue of improved access to them.

     Periodically meetings are held of a bilateral commission with
Suriname to study cooperation mechanisms and promote the exchange
of information on several health questions, among them malaria; but
there is no operational collaboration between the two countries.
HAITI 

     Malaria control is one of the priority programs of the
Ministry of Health.  The disease is endemic in the country,
affecting most of the territory, with perennial transmission in
some coastal areas and seasonal transmission in others during the
rainy seasons of April-May and of October-November.  The collection
of epidemiological information is a responsibility of the health
services.

     In 1989, 63,528 blood samples were examined, of which 23,231
were diagnosed as positive, for a PSI of 36.5 per 1,000 population.

     The available data on 1990 correspond to only two (2) of the
fifteen (15) districts in the country.  Some 13,743 blood samples
were examined; of these, 4,806 were positive (35.0% PSI). 

     The control strategy adopted by the health authorities
considers malaria to be a high priority public health problem. 
Responsibility for control of the disease has been delegated to the
health services, which should incorporate it into their regular
plans for providing health care to the population.  This strategy
requires that all health, governmental, and nongovernmental
institutions (NGOs) offer the community curative services using the
appropriate antimalarial drugs.  The health promotion services
provide information on methods of personal protection and control
methods for implementing preventive measures at the community
level.  During 1990, a total of 1,250,000 chloroquine tablets (150
mg bases) and 14,000 primaquine tablets (15 mg bases) were
distributed to the health institutions in malarious areas.

     P. falciparum is currently the only parasite prevalent in the
country; there is no evidence of that any strains are resistant to
chloroquine.  The use of insecticides regularly and periodically
as a means of vector control is not part of the control strategy. 
The Ministry of Health does not have specialized personnel for this
activity.

     A unit of specialists in malaria, made up of three (3)
physicians, one (1) sanitary engineer, one (1) entomologist, and
one (1) technical expert in vector control is charged with
analyzing the epidemiological situation and giving technical
orientation to the health institutions on implementation of the
strategy (strategies) for more adequate control.

Decentralization

      Malaria control has been decentralized since 1988;
responsibility for this activity has been delegated to the General
Health Services.  The semi-autonomous institution in charge of
malaria control was abolished in 1988.  In late 1990, the
Government, with the PAHO/WHO assistance, obtained from the UNDP
approval of a project of US$ 1,000,000.00, which will be carried
out by PAHO/WHO.  This project makes available to the Ministry of
Health the resources needed for training personnel of the general
health services, including NGO personnel, to ensure successful
implementation of the strategy (strategies) selected.  AID/USA
contributes with the equivalent of approximately US$ 250,000 for
malaria control in problem areas.  The Japanese International
Cooperation Agency (JICA) has donated equipment and vehicles.

Malaria Control in International Border Areas

      During the year no special activities were undertaken in
border areas.  However, preparations are under way to renew the
agreement with the Dominican Republic for carrying out certain
joint border activities, especially follow-up on sensitivity of the
vector to the insecticides.
HONDURAS 

     Malaria is endemic in Honduras; in 1990 it was third among
notifiable communicable diseases, with a morbidity rate of 1,072.5
per 100,000 population.

     The country has an area of 112,088 kmÉ and a population of
4,950,633, for a density of 44.2 inhabitants per kmÉ.  The area
from 0 to 1,000 meters above sea level is considered malarious; it
covers 100,071 kmÉ (89%) and 4,620,633 inhabitants (93.3%).  It is
estimated that this area includes 11,000 localities.  Some 62% of
the population resides in rural areas.

     The parasite responsible for infection in 98.8% of the cases
is P. vivax; in the remaining 1.2%, it is P. falciparum.  The
mosquito vectors are the A. Albimanus, A. darlingi, and A.
pseudopunctipennis.  The case-finding network was made up of 5,604
posts staffed by voluntary collaborators, and 822 health services
workers.

     In 1990, of the 418,513 blood samples examined, 53,095 were
positive; of these, 52,436 were P. vivax (98.8%), and 659 P.
falciparum and associates (1.2%).

     Since 1989 there has been an upward trend of cases, with the
API increasing from 9.22 per 1,000 population in 1989 to 10.33 per
1,000 in 1990.  The same occurs with infections by P. falciparum,
with annual P. falciparum incidence (AFI) rising from 0.07 to 0.13
per 1,000 population.  This situation could be attributed to the
extensive floods that occurred from October to December 1990,
especially in the Sula and Dilute valleys, and the incomplete and
non-uniform operational measures.

     The departments with the greatest incidence of malaria in the
year were:  Yoro, 13,562 cases (3.8 API); Choluteca, 8,339 cases
(2.7 API); Colón, 7,483 cases (4.8 API); Cortés, 7,165 cases (1.0
API); Valle, 3,166 cases (2.5 API); and Atlántida, 1,930 cases (0.8
API).  Total cases numbered 41,644 (82.3 per 1,000 population). 

     Most of these departments have an area of moist tropical
jungle, high rainfall, temperature above 28ëC, and an altitude
mostly 200 meters or more above sea level.  Malaria affects all age
groups and both sexes equally.

     In general, 51.4% of the cases occurred in persons under 15
years of age; and 52.7% of the patients are males.  Of the total
samples taken in 1989, 75% were done by the voluntary
collaborators, who detected 84.7% of total cases.

Causes Affecting the Persistence of Malaria

      Biological, environmental, social, and economic factors
intervene direct and indirectly in the transmission of malaria. 
Most of the Honduran territory has environmental conditions
favorable to transmission of the disease, such as jungle areas, a
rich hydrography, the appropriate climate, high rainfall, and high
relative moisture, among others.  Some social and economic factors
currently influencing increased incidence of the disease are the
internal and external migratory movements; the presence of
displaced persons and refugees due to the war situation in the
neighboring countries, seasonal internal migrations in the planting
and harvest seasons, and spontaneous colonization with the
construction of temporary dwellings in precarious conditions. 

     The operational and technical factors that favor the
transmission of malaria in the country are the existence of
localities in the malarious area that for several years have not
received attention, the result being lack of knowledge regarding
the epidemiological situation; the use of irregular and incomplete
control measures; low coverage of intradomiciliary spraying with
insecticides; physiological resistance of the mosquito vector to
the insecticides; delay in the diagnosis of blood samples; and
insufficient and low-quality field supervision.

Decentralization

      Beginning in 1990, the Division of Vector Control (DVC) began
to operate as the Division of Vector-Borne Diseases (DVBD). The
purpose of this change was to simplify the organization of this new
Division, which has been assigned, at the central level, the role
of serving as a technical and normative unit to provide support for
the health regions.  The structure was transformed, and resources
decentralized. 

     The process of decentralizing and incorporating activities for
the control of malaria and other vector-borne diseases (dengue,
Chagas' disease, and leishmaniasis) into the local health services
was begun.

     At the central level, the DVBD was restructured in such a way
that it maintains adequate levels of communication with the health
regions so as to be able to advise them on the control of the
transmission of vector-borne diseases.  Since some of the personnel
in the health regions did not have sufficient information or
knowledge of malaria prevention and control activities, it was
necessary to update their knowledge and train them to carry out
comprehensive health activities.  At the same time a great deal of
emphasis was placed on obtaining community participation in the
prevention and control of malaria and other vector-borne diseases,
and an expansion in the network of voluntary collaborators,
especially in localities to which access is difficult.

     The Ministry of Health facilities as of 1990 consist of 724
establishments, distributed as follows:  23 hospitals, two maternal
and child clinics, 178 health centers with physicians, and 521
health centers without physicians.  In addition, there are 5,664
voluntary collaborators for malaria control, health guardians,
trained midwives, and others.  To support diagnosis, there is a
network of 72 clinical laboratories, with a national reference
laboratory in the capital, offering microscopy, hematology,
clinical chemistry, bacteriology, virology, and other services. 
In addition, the DVBD has 37 microscopists located in the service
provider units who perform microscopic examination of the blood
samples taken by voluntary collaborators and Division personnel. 
It has been established that the general health services should
take at least 10 blood samples daily, which would represent 35% of
the projected figures.  It is hoped that with integration health
personnel will be more productive in the epidemiological
surveillance of malaria.

Epidemiological Stratification

      The malarious areas of the country include shores, valleys,
and areas at average altitudes.  Malaria is present in 256 of the
country's 288 municipalities (88.9%); the remaining 32
municipalities are considered non-malarious (11%).  The risk to the
inhabitants is not uniform, as there are some municipalities where
100% of the population is at risk, while in others less than 10%
of the inhabitants are exposed. 

     In 1989 the criterion was established for stratification by
municipalities in accordance with their malariogenic potential
during the six years of the 1984-1989 period.  This made it
possible to group the 288 municipalities into three strata in
accordance with the mean values of the API for the period
mentioned.  

     The stratum considered high-risk for malaria includes 64
municipalities whose API in the six years ranged from 8.0 to 51.9
cases per 1,000 inhabitants, with a population in 1989 of
1,200,000; these municipalities accounted for 79.5% of all cases
in the country.

     The stratum considered average risk includes 58 municipalities
with an average API over the six years ranging from 3.0 to 7.9 per
1,000 population, with a population estimated at 1,000,000, i.e.
25% of the national population; the positivity of malaria was
15.4%. 

     The third group or stratum, low-risk, includes 166
municipalities whose API ranged from 0.0 to 2.9 cases per 1,000
population, with an estimated population of 2,300,000.  This group
includes the 32 municipalities considered non-malarious, with a
population of 838,200, including the Metropolitan Region.  This
group registered 5.1% of all cases in the country.

     High Risk Stratum.  The environmental characteristics include
the coastal plains of the Atlantic and Pacific, low valleys, moist
tropical forests, warm climate, temperature above 26ëC, relative
moisture greater than 70%, rainfall greater than 2,000 mm3 per
year, and abundant hydrography.  In this stratum malaria has a
tendency to become epidemic:  there is high endemicity from
continuous malaria transmission, abundant carriers not treated, and
the API is greater than eight per 1,000 population, with prevalence
of the P.vivax (99%) and P.falciparum (1%); the vectors are A.
albimanus and A. darlingi.  The 64 municipalities of this stratum
(22.2% of the total) include 27% of the population.

     The social and economic characteristics of this stratum are
those typical of a region that has experienced development in the
agroindustrial and livestock sectors; has limited urban
development; and receives insufficient support for basic services
such as water, refuse collection, and excreta disposal.  There are
extensive plantations of bananas, African palm, rice, and
sugarcane, and intense labor migrations, especially during the
planting and harvest seasons.

     Average Risk Stratum.  The environmental characteristics for
this stratum are those of a mountainous region, with numerous
medium and small interior valleys located from 800 m to 1,200 m
above sea level, subtropical moist forests, a temperate climate,
temperature varying from 18ëC to 20ëC, rainfall of 2,000 mm3 to
3,000 mm3 per year, usually from May to October, relative moisture
of 60% to 70%, and numerous tributaries and rivers coming together
to constitute the country's large rivers.  The epidemiological
characteristics include unstable malaria, with frequent outbreaks
limited to small interior valleys, an abundant migrant reservoir
that has not received adequate treatment, an API from 3.0 per 1,000
to 7.9 per 1,000 population, and P.vivax in 99.9% of the cases. 
The vectors are the A. pseudopunctipennis and A. albimanus.  The
58 municipalities of this stratum account for 20.2% of the total,
with 22.5% of the population and 15% of malaria cases.

     The social and economic characteristics include cultivation
of tobacco, coffee, and grains, livestock raising, and frequent
labor movements on the part of peasants.  

     Low-risk Stratum.  The environmental characteristics in this
stratum are those of a mountainous region with abundant high and
narrow valleys more than 1,000 meters above sea level, subtropical
moist forest, subtropical climate, temperature of 16ëC to 24ëC,
relative moisture of 50%-70%, rains of 1,000 mm3 to 2,000 mm3 per
year, usually from May to October, and an abundant hydrography.

     Malaria transmission is sporadic, but numerous cases come in
from the high and average risk strata.  The API is less than 2.9
cases per 1,000 population; 99.9% are P. vivax.  The vector is the
A. albimanus.  The 166 municipalities in this stratum constitute
57.6% of the total number; the population is 50.5% of the national
figure; and malaria positivity is 5.1% of the total for the
country.  

     The social and economic characteristics are those of a rural
population in regions characterized by slopes and high altitudes,
with grain production and livestock raising; there is also an urban
population engaged in industrial and commercial activity in the
urban areas.  There are major migratory movements.

     The process of epidemiological stratification of malaria with
a view to its control has yet to implemented.  Currently studies
are under way for this purpose in two health regions (4 and 6);
this process will be initiated in the course of the second semester
of 1991 in accordance with the results obtained.
MEXICO 

     In Guerrero, Michoacán, and Oaxaca the Plan of Simultaneous 
Intensive Actions was implemented beginning in the second semester
of 1989.  In 1990 this plan was strengthened with human resources,
materials, and financial resources, facilitating the reduction of
transmission, of cases, and of the number of localities with
positives.  The foregoing made it possible to contain the trend the
disease had shown up to 1988.  In 1990, 44,513 cases were
registered in 11,008 localities which, compared with 101,241 cases
and 16,102 localities in 1989, represented a reduction of 56% and
31% respectively.  The number of blood samples examined rose from
1,484,565 in 1989 to 1,503,208 in 1990.

     The API for the entire country was 1.17 per 1,000 in 1989 and
0.50 per 1,000 population in 1990.  The PSI was 6.8% in 1989 and
declined to 2.9% in 1990.  The ABER remained at 1.71 per 100
inhabitants both years.

     In 1990, 62 cases were diagnosed caused by P. falciparum in
the states of Tabasco, Chiapas, Quintana Roo, and Yucatán.  The
case diagnosed in Yucatán was imported from Angola.  The outbreak
registered in the state of Tabasco in 1990 was associated with
migration from Central American countries, which means that
international coordination needs to be strengthened to improve
control.

     The feasibility and results of the program depend to a great
extent on strengthening the quantity, timeliness, and quality of
resources, as well as on improving training of the personnel whose
role in the program has been of capital importance. 
NICARAGUA 

    A total of 35,785 malaria cases were registered with laboratory
confirmation.  The annual parasitic incidence for the country as
a whole was 9.3 cases per 1,000 population, down from 1989, when
it was 12.3 per 1,000 population, with a PSI of 7.7% and an ABER
of 12%.  The distribution of the relative incidence of parasites
remained at 5% for P. falciparum and 95% for P. vivax.

     Region II is the source of 60% of malaria cases in the
country; its area is 9,686 km2, and it has 695,000 inhabitants. 
This Region includes two departments (León and Chinandega) and 23
municipalities.  Those with the greatest incidence are:



Municip.   PopulationArea       Cases/90  A.P.I./90
x1000    


El Viejo    68,900 H.1,271 Km2. 4,937    71.7        
León       150,100     852      3,144    20.9        
Chinandega 108,800     625      2,817    25.9        
Chichigalpa 48,800     252      1,960    40.2        
La Reynaga  30,300     834      1,140    37.6        
Somotillo   25,600     928      1,069    41.8        



     These six municipalities account for 70% of the cases in the
Region.

Malaria Control in International Border Areas

     The activities carried out in the border areas with Honduras
and Costa Rica were based on epidemiological surveillance, which
consists of case-finding.  Most cases were detected by voluntary
collaborators, accounting for 60% of the blood samples taken.  The
treatment of positive malaria cases was done by personnel of the
program, with an average coverage of 80% (radical treatments).  In
1990 no spraying cycle was programmed, and antilarval actions were
very irregular.  In addition, intercountry coordination meetings
were not held.  Although most of these localities do not have a
high incidence of malaria, there is a potential danger of an
increase in cases due to migration and new settlements.

     Region II, León and Chinandega, has had the greatest
development in integrating the malaria control program with health
services.  This resulted from the need to solve the problem.  In
the other border regions, there was still no defined and stable
integration of the malaria program with health services.PANAMA 

     Malaria continues to persist in the province of Darién, the
San Blas District, and eastern Panama, in the Bayano region.  These
areas include 3.4% of the national population, distributed in 32.3%
of the national territory, for a population density of 3.5 per km2. 
Cases have been detected in 84 localities; in 72 of them local
infections were registered, accounting for 0.74% of the localities
existing in the malaria area.  With 23,114 blood samples less than
1989, 46 malaria cases (10.8%) were discovered.  Since 1985 there
has been no registered mortality due to malaria; morbidity has
declined in the last five years from 47.6 to 15.8 with a slight
increase in 1987.

     The control activities consist of intradomiciliary spraying
with Fenitrothion as the only measure of intervention for
preventing the disease.  In 1990 spraying coverage was 21.7% of
what was considered necessary.

      The origin of 90% of the cases nationwide was investigated; 
83.2% turned out to be autochthonous.  The health services detected
32.8% of the malaria cases by taking blood samples.  Medication
with chloroquine/primaquine for P. vivax and Fanasil for P.
falciparum were used for disease control, in accordance with
current standards.  Radical curative treatment was administered in
90.3% of the cases; the remaining cases were persons in the country
temporarily.

     In 1990 an Interinstitutional Committee on Water, Sanitation,
and the Environment (CYASMA) was created, made up of the Ministry
of Health (MS), the Institute of National Water Supply and Sewerage
Systems (IDAAN), the Metropolitan Bureau of Cleanliness (DIMA), the
Institutes of Renewable Natural Resources (INRENARE), the National
Commission on the Environment (CONAMA), the Ministry of Planning
and Economic Policy (MIPPE), and the Bayano Development
Corporation.  This Committee was formed to facilitate the
coordination of disease prevention and control actions in the
context of environment and health.

Causes Affecting the Persistence of Malaria  

     In the San Blas District, the existence of the indigenous
population, with close commercial and political-tribal relations
with the indigenous groups of Colombia from Caño Caimán in the Gulf
of Urabá, and religious-social relations with the reserves of
Madugandí, Wala, Nurra, and Mortí in the mainland part of the
District, has been a cause of persistence.  To this is added the
frequent arrival of non-indigenous Colombian merchants without
migration controls (imported cases), and incomplete and untimely
intervention measures, both for cultural reasons and due to lack
of resources (NMES).

     In the province of Darién, the population movements are from
Juradó, Chocó, and Antioquia, Colombia (Pacific Coast) and from the
area around the Gulf of Urabá.  In addition, incomplete treatments
have resulted from human mobility; insufficient intervention
measures; and asymptomatic carriers.

     In eastern Panama (Upper Bayano), persistence has been caused
by the uncontrolled colonization by a population highly susceptible
to malaria from regions free of the disease (the central
provinces); the culture shock between the traditional medicine of
the Kunas and the traditional control methods; the relocation of
Kuna indigenous populations due to the construction of the of the
Bayano hydroelectric dam, and the resulting ecological changes; and
timber exploitation.  To the foregoing are added the movements of
indigenous population to and from San Blas and from Colombia (Gulf
of Urabá).

Malaria Control in International Border Areas 

      There is close border coordination with Costa Rica in the
Pacific and Atlantic regions, where joint actions and exchange of
information are carried out, and where supplies have been exchanged
when one of the two countries has deficiencies due to untimely
supplies.  In contrast, with Colombia, the country from which the
largest number of imported cases come, there is an inoperative
agreement at the upper levels; exchange of information has been
maintained at the local level.
PARAGUAY 

     The situation of malaria in Paraguay has evolved favorably. 
During the year semiannual spraying was done in some areas, while
in others the localities with highest positivity were covered.

     In 1990, 98,417 blood samples were examined, 9,154 more than
in 1989.  The number of positives declined considerably, from 5,247
in 1989 to 1,660 in 1990, resulting in a reduction of the API from
1.26 to 0.39 per 1,000 population.
PERU 

     As of October 1990, 90,040 blood samples had been examined;
28,882 were diagnosed as positive.  Of these, 99.35% were by P.
vivax, 0.45% by P. falciparum, and 0.20% by P. malariae.  However,
the number of cases by P.  falciparum registered a notable increase
from zero in 1988 to 65 in 1989, and 131 in 1990.
DOMINICAN REPUBLIC 

     In 1990, the incidence of malaria showed a notable
improvement.  The number of cases was barely 27% of those
registered the previous year.  A drought from January to May,
traditionally rainy months with high malaria transmission, may have
helped to limit cases through the decline in anopheline density in
areas that had a higher incidence during the 1980-1985 period
(eastern region of the country).

     The age group most affected by malaria, accounting for 63.8%
of all cases, was that of 15 to 49 years (which is basically the
economically active population).   Of all cases, 21.4% occurred in
children from 5 to 14 years; this is explained in part by the rural
preference of the pathology (73.9% of all cases).  In those areas
children participate in agricultural work from a very early age.

     An important factor in the incidence of malaria was the
Haitian immigration, which is related to the sugarcane crop.  This
migratory factor plays a preponderant role in the transmission of
malaria, even more so after the malaria program in Haiti was
suspended in March 1988.  In 1990, for the beginning of the
harvest, the National Malaria Eradication Service coordinated the
antimalarial measures to be carried out in border areas and in the
inlets jointly with the State Sugar Council, with a view to
avoiding increased incidence of malaria.  Unfortunately, there was
a mass entry of Haitians during the month of December, which
obliged the Malaria Program to expand coverage of epidemiological
surveillance nationwide, to ensure that the immigrants were given
the treatment of combined antimalarial drugs and registered by the
field staff of the NMES.
SURINAME 

     Due to hostilities in the interior of the country, where
transmission of malaria continues to be high, the control program
planned was not carried out; there was only a series of house
sprayings in areas where the hostilities diminished in intensity.

     During the year, 18,594 blood samples were examined, of which
1,608 were positive, while the previous year 23,364 blood samples
were examined, with 1,704 positives.VENEZUELA 

     Of the 46,910 malaria cases registered in Venezuela in 1990,
26,602 (56.7%) were from the state of Bolívar, for an annual
parasitic incidence in that state of 29.5 per 1,000 population. 
Of the malaria cases diagnosed in the state of Bolívar, 85% were
from the jungle areas, where mining activities are under way.  In
these areas the presence of the vector is permanent, dwellings are
precarious, access is difficult, and health services infrastructure
is lacking.  Preliminary data obtained in four indigenous and four
mining communities located in the mining region of the state of
Bolívar indicated a general prevalence of parasitemia of 4.1% (5.9%
among the indigenous population and 2.9% in the miners); nearly 70%
of the 1,353 persons interviewed had a history of malaria in the
last two years; one-third of the people who became ill with malaria
received treatment through the national control service.  The
others did not get treatment, or did so consulting with
pharmacists, healers, neighbors, or private physicians.

     The state of Sucre accounts for 14.6% of malaria cases in the
country; it has an API of 10.1 per 1,000 population.  Incidence is
still high because operational and administrative problems persist
that stand in the way of proper application of the antimalarial
measures in the entire state.  The largest share of the cases come
from the municipality of Santa Fe.

     The federal territory of Amazonas accounted for 10.6% of the
cases; it registered a 71.4% increase the number of cases from the
previous year, and annual parasitic incidence of 89.1 per 1,000
population.  This area represents the malarious area that cannot
be reached because of the problems of communication and access to
the jungle.

     The state of Apure (API of 6.5 per 1,000 persons), with 3.9%
of the cases, had an increase of 67.4% in relation to the previous
year, mainly from the process of colonization in the southwest
Andean region, in the municipalities of San Camilo and Urdaneta. 
The corresponding percentages for the states are:  Táchira 2.7%,
API=1.6; Monagas 1.7%, API=1.7%; Anzoátegui 1.7%, API=0.9; and
federal territory of Delta Amacuro 1.1%, API=5.9.

     It should be noted that a large proportion of the cases
diagnosed in the states in the maintenance phase are in general
imported from the states of Bolívar and Sucre.

     The treatment routinely provided by the program consists of
Chloroquine + Primaquine for infections by P.vivax and Amodiaquine
+ Primaquine for infections by P. falciparum.  Resistant cases of
P. falciparum are treated with Sulfadoxine + Pyrimethamine or
Quinine. 

Causes Affecting the Persistence of Malaria

     A series of biological, social, and administrative factors
have helped maintain the transmission of malaria.  Among the
biological aspects are the following:

·    The vector An. nuñeztovari, with exophilic and exophagic
     habits, avoids contact with the insecticide administered
     through intradomiciliary spraying, resulting in partially
     refractory malaria (north of Apure, Barinas, and Táchira).

·    An. darlingi is present in the jungle.  There it is found both
     within and outside of dwellings, which makes it less
     vulnerable to the insecticides.

·    The An. aquasalis vector mosquito in the state of Sucre is
     refractory to traditional spraying measures. 

·    The presence of infections caused by P. falciparum resistant
     to the four aminoquinolines, and to the association of sulfa
     drugs and pyrimethamine.

The social aspects that merit mention are:

·    Major migratory flows in the western part of the country,
     along the border with Colombia (Cúcuta-San Cristóbal and
     Táchira and also Puerto Carreño-Puerto Ayacucho), of day
     laborers who are carriers of parasites from malarious areas.

·    Areas characterized by foci of malaria that cannot be reached
     with rudimentary dwellings and a nomadic population, making
     difficult all protective measures with insecticides or drugs
     (southern malarious area).  The entry of infected and
     susceptible human population produces explosive outbreaks.

·    Unstable and uncontrolled colonization from the southwest
     Andean region (western malarious area).  Rejection by the
     community of intradomiciliary spraying measures.

·    Limited community participation in the control program.  The
     program does not rely on voluntary collaborators.

The administrative aspects indicated are:  

·    Labor problems have had a negative impact on the pace,
     quality, and coverage of actions.

·    There is a need to broaden the agreement between the Ministry
     of Health, the Cooperacíon Venezolana de Guayana and the
     governments of the two federal territories so as to be able
     to increase surveillance and control actions, which are
     limited due to lack of resources, materials, and equipment.

·    Limited national budget for malaria control.  In 1987 the
     budget earmarked for the malaria program was 207,887,802
     bolívars, and in 1990, 225,529,312 bolívars.  This was an 8.5%
     increase during a period in which inflation was approximately
     90%.

·    There is a need for collaboration from the regional health
     offices, Armed Forces, and the regional executive, to make
     control measures more effective.

Malaria Control in International Border Areas

     The agreement initiated in November 1988 for a joint
operational program between the governments of Venezuela and Guyana
continues.  The objectives are to prevent mortality due to malaria;
to reduce morbidity; to strengthen the health infrastructure; and
to improve knowledge of socioeconomic conditions in the affected
areas.  The area of action is delimited by the Barima river from
the Orinoco delta to the mouth of the Kaituma river, and from the
mouth of the river Kaituma to Port Kaituma; the Sedai river; the
Aruka river, from its mouth to the Kumuca river; the Amacuro and
Yarabita rivers.  The Venamo river from Kaikan to the Cuyuni river;
and from this point to Corotoko.  In 1990, the Second Technical
Meeting on Malaria Control was held in Georgetown, Guyana.

     A Colombian-Venezuelan border meeting was also held in Cúcuta,
Colombia, to discuss strategies of the control programs.  In
addition, an informal cooperation activity has been developed along
the border with Colombia, mainly in Cúcuta and the state of
Táchira, with the supply of drugs and insecticides.


IV.  PROBLEMS FOR MALARIA PREVENTION AND CONTROL IN THE AMERICAS

A.   Socioeconomic Problems in the Vector Control of Malaria and
     Management of Man-Vector Contact

     In 1990, the control programs continued to run up against
sociocultural and socioeconomic forces that favor persistence and
expansion of malaria in the countries of the Americas.

     There is recognition of the importance of health education and
community participation in vector and malaria control.  The
affected communities need to understand better the bases of malaria
transmission through mosquitoes, and to become familiar with simple
measures for controlling both adult mosquitoes and larvae.  The
experience in the Americas and in other regions indicates that
vector and disease control efforts usually have limited long-term
success if they lack active and substantial community
participation.  Participation can include the use of vector control
aides who are members of the community (for example, technical
personnel for spraying or eliminating sources), participation in
personal protection from vectors (for example, use of mosquito
nets), or the active selection of workers from the community for
primary health care with an emphasis on malaria surveillance and
control.

     Medical anthropologists have noted that human behavior is
based on belief systems, and that such behavior can both
intentionally and unintentionally improve or worsen health.  Social
and behavioral factors play an important role in the use of
residual spraying, personal protection, environmental management,
community participation for vector control and surveillance,
prophylaxis, and treatment of malaria.

B.   Use of Residual Spraying

     In the Americas, most national programs malaria control use
residual insecticides.  However, in several countries of the region
sprayers continue experiencing rejection on the part of the
residents of dwellings and of the community in general.  This
rejection persists for several reasons:  problems caused by the
odor of the insecticide; social problems, such as language barriers
and sociocultural conflicts between the communities and the
sprayers; conflicts over the time available to community members;
and local and practical beliefs regarding the diseases and their
control that conflict with those of the malaria control services.

     Social anthropologists and rural sociologists have noted that
contrary to common belief, women in the rural communities do not
have much free time during the day (for example, to be able to
respond immediately to requests from the spraying teams, which
arrive in the communities suddenly and without prior notification). 
Actually, the women are very busy with routine activities such as
commerce, collecting water and fire-wood, working in the kitchen,
performing manual work (for example, weaving), and caring for the
children.  In some rural economies, when poverty increases so does
the pressure to participate in several activities necessary for
family subsistence.  This makes women's time become very valuable
and less available.  A similar situation exists in the community
for working men.  Under these conditions, the risk of community
rejection of the spraying team is a reality.

     The odor of the insecticide, which both adults and children
sometimes find unpleasant, induces rejection.  Similarly, the
removal of stored food, deposits of drinking water, and some other
accessories from the dwellings prior to spraying may be perceived,
to a greater or lesser extent, as a drawback by the family or the
community.  Particularly in remote rural communities, it is
difficult to notify residents in advance of the visit by the
spraying team, yet it is necessary to do so.  In any event, it is
possible to modify the behavior towards and negative perception of
the sprayers through health education, explaining the purpose and
effect of spraying with residual insecticides.

C.   Use of Mosquito Nets, and Metal Curtains and Screens

      People use different instruments to protect themselves from
the bother of being bit by mosquitoes.  Thus they burn herbs and
spirals to combat mosquitoes in infested houses; they cover their
arms and legs with repellents made from local plants or plants
purchased commercially; and they impregnate their clothes and
mosquito nets with insecticides.  In Suriname it has been shown
that two communities, the Maroons and the Amerindians, used
mosquito nets over long periods.  Although the impact of mosquito
nets in the transmission of malaria varies among communities and
from season to season, their use has caused a major reduction in
vector-man contact in dwellings.  Also, some gold prospectors use
domestic mosquito nets in the Amazon region in Brazil.  However,
we do not yet have systematic and specific knowledge on what other
communities and populations in the Americas use mosquito nets,
curtains, screens, or some other method of personal protection.

     Distribution of mosquito nets, treated or not, is a potential
tool for integrated vector control in the Americas.  Some
communities that have no previous experience with mosquito nets
were prepared to pay for mosquito nets after a community with only
a few inhabitants was provided mosquito nets for personal
protection and found them useful.  The risk of rejection by the
community is reduced by this strategy.  Rejection can also be
reduced by adapting local materials and designs and making the
mosquito nets in appropriate sizes (Rozendaal and Curtis, 1989); 
community participation can be used to impregnate the curtains with
insecticides or repellents.

D.   Environmental Management and Community Participation for
     Vector Control

     Prior to the use of insecticides, malaria control was done
through drainage, filling areas of impounded water, installation
of screens in houses, larvicide oils, and water flow control. 
However, since 1950 the developing countries of the Americas have
limited their experience in the use of environmental management for
vector control of malaria.  Often when this is done, it is directed
and promoted in a centralized and vertical form, with minimal
community participation.

E.   Problems in Surveillance and Control of Malaria Parasites in
     the Human Reservoir

     Sometimes, routine and special malaria surveillance activities
in a community run up against or give rise to social barriers.  The
beliefs of several communities in the region do not foster the
taking of blood samples from community members as part of
antimalarial activities.  Fortunately, these community behaviors
can be modified through careful education and the establishment of
confidence and credibility in malaria control personnel.  In
addition, it is necessary to overcome deficiencies in some
programs, such as the failure to inform the local communities on
the nature of malaria (for example, through demonstrations with the
microscope of the presence of malaria parasites in the red
corpuscles), and failing to report results of the blood samples.

     The personnel of the control program must avoid the pitfall
of ridiculing people who have such beliefs and behavior, and must
not try to eradicate such views and practices.  Rather, they should
patiently create a new explanation of the belief structure in the
community, in which the traditional beliefs are modified and
brought into line with up-to-date knowledge on disease prevention
and treatment through health education.

     In an attempt to increase the coverage of malaria services,
some countries have recently integrated government antimalarial
activities into the local health systems.  If this strategy is to
be successful, it is necessary to win the trust and cooperation of
the local communities for residual spraying, case detection, and
treatment.

F.   Economic development projects and infrastructure projects: 
     their impact on malaria

     The countries in the Region of the Americas continue to
develop and expand their economies with new investment in the
traditional economic and nontraditional sectors.  The projects in
the traditional sectors often include or are accompanied by the
building of new dams and reservoirs, colonization of new lands, and
construction of roads, ports, and sewerage projects.  However, the
national development policies and development projects based in the
sector are associated with several public health problems.  Some
of the main adverse impacts of development projects include
breaking down of local ecosystems, displacement of human
populations, incomplete or sluggish provision of primary health
care, and new or aggravated resistance to the insecticides.

     The alteration of local ecosystems induced by development
projects may result in the introduction or worsening of malaria and
other vector-borne diseases.  New breeding sites may be created
accidentally, especially as the result of road and dam
construction.  The movement of persons susceptible to or infected
by malaria within and outside the project area (for example, the
work force, merchants, colonists), together with changes in the
vector populations, may create a risk of introducing and furthering
the transmission of unstable malaria within and around the area in
question.  This phenomenon has been observed particularly, but not
exclusively, in projects for the development of water resources,
especially in their early years.

     Urban and rural development projects may also cause
displacement and compel communities to relocate to new lands, with
the subsequent risk of exposure to malaria and other diseases. 
Many displaced communities are made up of economically marginal
populations to begin with; their economies and health conditions
worsen as a result of their displacement.

     The lack of intersectoral and inter-ministerial cooperation
in the planning and implementation of development projects has
increased the incidence of malaria in the displaced and resettled
communities, where vector control services, primary health care,
and basic water supply and sanitation are inadequate.  Appropriate
coordination of the Ministries, such as those responsible for water
supply, electric energy, rural and agricultural development,
housing, etc. with the Ministry of Health, could impede malaria
epidemics associated with the development projects.

     The use of agricultural insecticides continues to rise in the
Americas.  In the areas where malaria is transmitted, where crops
are based on irrigation, there is a risk of inducing or aggravating
resistance of the malaria vectors to the insecticides, since the
breeding sites receive surface water contaminated with insecticides
used in agriculture.  The resistance of An. albimanus in Central
America and An. quadrimaculatus in the United States and Mexico has
had to do with the use of insecticides in irrigated cotton and rice
fields.

G.   Environmental Degradation and Problems of Malaria

     The developing countries of the Americas continue to
experience very high population growth.  The population increase
creates basic demands on limited local resources, such as drinking
water, fire-wood, food with high caloric or protein content,
fertile land, and water.  The economies of the region continue to
grow in response to the social market forces, and governments are
working to stabilize their debts and inflation.  Structural
adjustments to the national economy have been common; they have
resulted in temporary or long-term displacement of the urban and
rural work force.  Those populations, displaced from their means
of production (work, lands), also lose access to capital, and are
sometimes competing with other poor people for critical government
services, such as health care.  Economically displaced populations
can return to a system of subsistence, thus creating a new
generation of migrants and colonists, of gold prospectors and
migrant workers, who struggle to survival.  Those who migrate to
rural areas to secure and establish new lands, or to work as
farmers and miners, may not be immune and thus are very susceptible
in areas of malaria transmission, or may themselves introduce
malaria in new areas.

H.   Problems of Malaria in the International Context

     International migratory flows have been associated with
problems of malaria in the sugarcane planting areas in the
Dominican Republic, and with malaria epidemics in the area of San
Diego, California, in the United States.  In the Dominican
Republic, migrant workers from the neighboring Republic of Haiti
supposedly introduce malaria in the sugarcane crops.  In
California, most cases of malaria have been among migrant workers
from Mexico who live outside provisional shelters near breeding
sites, while a few cases were also found in communities of
permanent residents who live near provisional fields.

     In the 1980s, political instability and internal civil
disturbances in countries such as Guatemala, Nicaragua, and El
Salvador led to the establishment of refugee camps in Honduras and
Mexico, and the migration of refugees to neighboring countries of
Central America, Mexico, and the United States.  Malaria has become
a major problem in some refugee camps.  Nicaragua registered
greater incidence of malaria in the areas of conflict than in non-
conflictive areas.  In Peru and Guatemala, the internal civil
conflicts have limited or prevented access of malaria control
personnel to the areas of conflict.

     The problems stemming from the illegal production of cocaine
and the associated international drug trafficking have turned
certain regions into areas where it is difficult if not impossible
for governmental agencies to carry out actions for malaria
prevention and control. 

VI.  PERSONNEL TRAINING

      Personnel training continues to be a priority component for
most of the countries of the Region, not only for malaria but also
for controlling other vector-borne diseases.  This has made all the
more evident the need to prepare a strategic plan of action, with
the participation of the countries, aimed at overcoming the
problems that have traditionally caused the results in this area
to be modest.

     Less than 20 individuals graduate each year as specialists and
master's degree holders for whom teaching, research, or control of
communicable diseases is a priority.  These include those who
receive training subsidies from the Special Program for Tropical
Disease Research and Training (TDR).  Unfortunately, most often
success results from individual plans and efforts, sometimes
supported by institutions of the health sector and, more commonly,
by universities, institutes and research centers.

     In summary, in 1990 the following training activities on
malaria and related subjects were held:



     Figure 5 also summarizes the data that we receive on courses
offered in the countries, in the subject areas of greatest
interest.  It is apparent that interest in the training of human
resources in epidemiology, biology, vector control, and
parasitological diagnosis is on the rise.  In addition, there is
interest in training personnel who participate in control
activities in strategies and methods that make it possible to
achieve the committed participation of the communities in the
tasks.   






Key:    PAR = Parasitology.  EPD = Epidemiology.
        ENT = Entolomogy.    EQU = Control Team.
        MGM = Management.    VBC = Biology and Vector Control.
        P. COM = Community Participation.






     In addition, as an example of what is occurring in a large
number of countries where malaria continues to constitute a serious
public health problem, Figure 6 illustrates the distribution of
students by course, in the above-mentioned subject areas.  It is
evident also that in the countries indicated, interest is focused
on the epidemiological training of personnel.  This will no doubt
make it possible to achieve more rational management in the
countries suited to the particular epidemiological circumstances
of each country.


Figure 6


=====FOOTNOTES/ENDNOTES =====

*. WHO Wkly.  Epidem.  Rec.  No. 22, 1991, pp. 157-163, and No. 23,
      1991, pp. 167-170.

*.See Rozendaal.  Trop.  Dis.  Bull. 86:  R1 and R41, 1989. 
Rozendaal and Curtis.  J. Am.  Mosq.  Cont.  Ass. 5:500, 1989. 
Rozendaal et al. the.  Med. Vet. Entomol. 3:353, 1989.

**.  See Rozendaal.  Trop.  Dis.  Bull. 86:  R1 and R41, 1989. 
Rozendaal and Curtis.  J. Am.  Mosq.  Cont.  Ass. 5:500, 1989. 
Rozendaal et al., Med. Vet. Entomol. 3:353, 1989.




PROGRAM ON MATERNAL AND CHILD HEALTH 
PROGRAM ON FOOD AND NUTRITION 













        REPORT OF THE REGIONAL ADVISORY GROUP
ON THE
PROMOTION OF BREAST-FEEDING

Washington, D.C., 19 -  21 June 1991


















PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION










CONTENTS

Page
     


I.   INTRODUCTION  3


II.  OBJECTIVES  4


III. SYNOPSIS OF PROGRAMS AND PROJECTS IN PROGRESS  5


IV.  RECOMMENDATIONS:
- Document of Agreement:  "Regional Response
to the Declaration"  15


V.   ANNEXES  23
- Agenda  24
- List of Participants  29
- Programs and Projects in Progress * *






     **Because of their length, the programs and projects are not
     included in this report; however, they may be requested from
     the authors, whose addresses appear in the list of
     participants.I.INTRODUCTION

     The promotion and protection of breast-feeding and safe
practices of infant feeding constitute an area of great concern
within maternal and child health programs.

     The advantages of exclusive breast-feeding during the first
four to six months of life, followed by the gradual introduction
of other foods, are recognized as very important factors for the
promotion of child growth and development and protection against
infections, as well as increased spacing between pregnancies,
among other benefits.  In addition, breast-feeding offers a way
of providing sufficient, nutritionally balanced food to children
of low-income families, who have suffered the repercussions of
the economic crisis that is currently affecting most of the
countries in the Region.

     However, much remains to be done and many challenges will be
faced by the health sector and other social sectors in their
efforts to carry out effective programs that will have an impact
at the national level.  The broad spectrum of activities to
promote breast-feeding include the encouragement of community
participation in joint activities sponsored by various community
health agents, the provision of adequate health services at
different levels and in varied forms, the enactment of
appropriate legislation to effectively support working women, and
the monitoring of practices of international and national
manufacturers of breast-milk substitutes.  These are only a few
of the important activities being carried out in connection with
this complex issue which has such profound human implications. 

     This Regional Advisory Group, composed of experts and
officials from international agencies and countries in the
Americas, convened in order to:  first, analyze the present
situation regarding breast-feeding practices; second, identify
and analyze the activities currently in progress; and finally,
propose lines of action that might serve as a frame of reference
for the implementation or enhancement of initiatives in the
countries of the Region.

     In developing lines of action, the group considered all the
recommendations and resolutions that have been passed in recent
years by the United Nations specialized agencies and ratified by
the Governments.

     This report assigns priority to the activities currently in
progress and recommends the lines of action defined in the
document "Regional Response to the Innocenti Declaration" and
affirmed by participants in the Advisory Group.



II.  GENERAL OBJECTIVE

     1. To bring together a group of experts and officials from
     agencies concerned with breast-feeding in order to formulate
     a regional plan of action for coordinated activities in this
     area.

     Specific Objectives

     1. To exchange knowledge and compare experiences in order to
     increase the practice of breast-feeding in the countries of
     the Region.

     2. To analyze available information on the prevalence of
     breast-feeding and determine whether the services seek to
     promote and increase it, and to incorporate indicators for
     monitoring trends in maternal and child health and infant
     feeding.

     3. To discuss coordinated activities in breast-feeding
     education and training for health personnel, as well as in
     schools of medicine, nursing, and nutrition.

     4. To discuss appropriate activities for the promotion of 
     breast-feeding in the community and in the mass media.

     5. To analyze the educational and instructional materials
     that are available and agree on their use and application in
     the different services and social settings of the Region.

     6. To identify and characterize the centers and units that
     provide breast-feeding education, research, and support
     services in order to incorporate them into the plan of
     activities and include financial support for their
     operation.

     7. To help strengthen regional activities for the promotion
     of breast-feeding in light of the decision of several
     formula manufacturing companies to discontinue the free
     supply of breast-milk substitutes.

     8. To establish interagency coordination mechanisms so that
     the Plan of Action of the World Summit for Children will
     become the operational handbook to be used by the agencies
     in their cooperation with the countries.



III. SYNOPSIS OF BREAST-FEEDING PROGRAMS AND PROJECTS IN PROGRESS

     The projects and programs presented during the meeting
attest to the interest and commitment of the Governments,
international organizations, NGOs, and academic institutions to
the promotion of breast-feeding, and they also reflect the actual
experiences of several countries in the Region.

     The following is a brief synopsis of the experiences
reported during the meeting of the Regional Advisory Group.  The
annexes include summaries of the reports presented.  The original
documents are available from the Maternal and Child Health
Program of PAHO/WHO in Washington, D.C., USA.

1.   Activities in the Countries of the Region

1.1. Brazil

     In Brazil, two institutions, the Center for Breast-feeding 
Education in Santos and the Pernambuco Maternal and Child
Institute in Recife, are actively involved in the promotion of
breast-feeding.

     The Center for Breast-feeding Education in Santos offered
three two-week courses for multidisciplinary health teams,
combining breast-feeding theory with clinical practice.  Thanks
to these courses, five health teams were trained and are offering
breast-feeding education at several clinics in the area.

     Lessons learned as a result of this program include the
following:

     · It is possible to organize quality training courses at a
     low cost;

     · Training for breast-feeding education should be done in
     collaboration with the services that promote and support
     breast-feeding; and

     · If the training center pools its efforts with those of the
     national and local programs that promote breast-feeding, the
     process of participant selection is enhanced (see Annexes).

     The Pernambuco Maternal and Child Institute (IMIP) in Recife
is one of five reference centers in Brazil.  Its principal
activities include personnel training, the creation of milk
banks, the promotion of exclusive breast-feeding, and research. 
In the last four years the IMIP has created 52 milk banks,
trained 22 multidisciplinary health teams, organized numerous
seminars, and supervised the promotion of exclusive
breast-feeding in the Region with great success.

     In addition to the reports on these two experiences, there
was a presentation on the program "Promotion of Breast-feeding
Through Social Mobilization," which was initiated in Brazil in
1981 by the Ministry of Health through the National Institute of
Food and Nutrition with support from UNICEF and PAHO/WHO.  The
lessons learned from this program include the following:

     · The importance of a multisectoral approach;
     
     · The advantages of promoting community awareness through
     the use of mass media; and
     
     · The importance of having international support for
     compliance with the provisions of the International Code of
     Marketing of Breast-milk Substitutes at the national level.


1.2  Guatemala

     The National Commission to Promote Breast-feeding, created
by governmental agreement in order to promote, advance,
coordinate, and streamline the programs and activities geared
toward establishing the widespread practice of breast-feeding,
constitutes an effective initiative at the national level which
is consistent with international guidelines for the promotion of
breast-feeding.

     From its inception, the National Commission, which includes
the participation of 13 public and private Guatemalan
institutions, with UNICEF, INCAP, PAHO/WHO, and the La Leche
League serving as advisory institutions, has been instrumental in
ensuring compliance with health sector legislation and standards
and promoting hospital practices and educational actions to
encourage breast-feeding (see Annexes).


1.3  Mexico

     The National Program on Breast-feeding, initiated in Mexico
in 1990, was created through an effort on the part of
institutions and international and private organizations.  The
Government has enacted standards and guidelines in order to
promote breast-feeding, including application of the
International Code of Marketing of Breast-milk Substitutes.  In
addition, it has given priority to carrying out a comprehensive
information campaign aimed at motivating service providers, the
public, and public opinion leaders. 

     The 1991-1993 plan contains specific objectives to be
carried out through four operational strategies:  epidemiological
surveillance, institutional strengthening, educational
information, and community participation.

     The National Nutrition Institute in Mexico, in collaboration
with the National Committee on Breast-feeding, is carrying out
breast-feeding research and promotion activities, including
studies to determine trends in breast-feeding.  In addition,
through the Center for Training in Ecology and Health, and
working together with the International Baby Food Action Network
(IBFAN),  the National Nutrition Institute has been instrumental
in creating a network to promote breast-feeding in the south of
Mexico.


1.4 Argentina

     The Family Action Foundation in Argentina is a public
interest group devoted to promoting family values within the
context of respect for natural behavior.

     Among its activities are the study and promotion of
breast-feeding.  From 1987 to 1990 the Foundation was funded by a
partial grant from the Pérez Companc Foundation.

     In 1987 the Foundation carried out research on insufficient
weight gain in infants breast-fed during the first three months
of life.  This work received the 1987 Award of the Argentine
Society of Pediatrics. 

     In January 1959 the Foundation published a book titled
Orientación Profesional del Amamantamiento [Professional
Guidance for Breast-feeding] with the support of the Pérez
Campanc Foundation.  This book serves as a bibliographic
reference for courses that train professionals in breast-feeding. 
The Ministry of Health of Nicaragua purchased 300 copies, which
are being used for this purpose.

     In 1990 the pamphlet Breast-feeding was published to
complement the Program to Promote Breast-feeding.  The pamphlet
is  written in practical language and serves as a quick review
for mothers of what they were taught during pregnancy and the
postpartum period.  The Bank of Boston Foundation underwrote the
printing of 1,000 copies to be used in additional training
courses.

     A written script was prepared for an 18-minute videotape
aimed at teaching women who are pregnant or have recently
delivered, primarily through visual images.

     In 1989, three training courses for professionals
(pediatricians, physicians, psychologists, and nutritionists)
were held with seven participants in each course, using the
Breast-feeding Training Module prepared that year under PAHO
auspices.

     In 1990 the Module was used by Dr. Rosa Streinterberger in
Paraná, Argentina, where she directed a course with seven other 
professionals (two pediatricians, two nurses, two obstetricians,
and one psychologist).

     In the evaluation of the course, as in that of the 1989
course, the participants said they had acquired greater knowledge
of the subject in terms of theory and techniques, as well as
methods for persuading mothers.  They suggested that the course
could be enhanced by the addition of more activities relating to
pregnant women and women who have recently delivered, as well as
follow-up care until weaning. 


Project for 1991-1992

     Ten courses will be offered to train 100 professionals in
Argentina using Module No. 20 in the Paltex Series for Medical
Technicians and Auxiliaries.

     The courses will be offered in maternity services and at
primary health care posts.

     Before each course begins, the services will be asked to
respond to the 1989 WHO/UNICEF Questionnaire on the Evaluation of
Maternity Services.  The cost per participant is estimated at
US$350.


2.   Cooperation Activities of International Agencies


 2.1 Pan American Health Organization/WHO

     As the organizers and sponsors of the meeting of the
Regional Advisory Group on the Promotion of Breast-feeding, the
directors of the PAHO/WHO Programs on Maternal and Child Health
and Food and Nutrition underscored the importance of commitment
by the Governments and international agencies to reaching the
targets for the promotion of breast-feeding established at the
World Summit for Children and set forth in the Innocenti
Declaration on the Protection, Promotion, and Support of
Breast-feeding.

     In addition to the need to emphasize the advantages of
breast-feeding, it was pointed out that there is a need to
evaluate the costs of these activities and assess the impact and
effectiveness of the various interventions carried out in the
Region.

     The annexes include the summary of an evaluation of
breast-feeding support programs in the Region, which was carried
out during 1988 and 1989 by the PAHO/WHO Program on Food and
Nutrition.  The evaluation focused primarily on efforts to: 
promote and support breast-feeding; promote and support
supplementary feeding at the appropriate time (weaning);
strengthen education, training, and information about the feeding
of infants and small children; improve the social and health
status of women; and monitor the marketing and distribution of
breast-milk substitutes.

     This assessment reflects the importance of implementing and
institutionalizing an adequate surveillance system within
breast-feeding programs in order to determine the effectiveness
of these efforts through simple basic indicators.


2.2  UNICEF

      Since the inception of the strategy for child survival in
1982, breast-feeding has been a priority of UNICEF.

     The World Declaration on the Survival, Protection, and
Development of Children, approved by the World Summit for
Children in September 1990, together with the Plan of Action,
which sets specific targets, and the Innocenti Declaration on the
Protection, Promotion, and Support of Breast-feeding, constitute
a body of standards and recommendations that give new impetus to
the development of national programs in this field.


2.3  United States Agency for International Development (USAID)

     Since the 1970s, breast-feeding has been an important
component of USAID's health, population, and nutrition programs. 
 Along with vaccines, oral rehydration, and family planning, it
has been considered a priority area in efforts to regulate
fertility and reduce infant mortality and malnutrition.

     In the last 20 years, USAID has supported a broad range of
interventions in various countries of the Region.  It has
provided support to institutions in Costa Rica, Honduras, Panama,
Guatemala, El Salvador, and Colombia, as well as United States
groups such as Wellstart in San Diego, California, and Georgetown
University in Washington, D.C.

     The current USAID strategy for the promotion of
breast-feeding in developing countries gives priority to a rapid
expansion of interventions designed to have a significant impact
on influencing the key behaviors that result in exclusive
breast-feeding during the first four to six months of life and
satisfactory infant feeding practices during the first two years
of life.

     During the meeting of the Regional Advisory Group, there
were reports on experiences that have received financial support
from USAID.


2.4  Role of the Latin American Center for Perinatology and Human
     Development 
     (Current Center proposals that might be incorporated)


Research and Breast-feeding

     The Center's efforts have involved standardization,
information science, and evaluation.  

     As a basic element in maternal and child health,
breast-feeding should be an integral part of comprehensive
perinatal and pediatric care.  Health care standards related to
childbirth (prenatal, delivery, and postnatal care, as well as
care of the child from 0 to 5 years), should promote and support
breast-feeding. In addition, the instruments used for basic
health care determination (clinical history, identification cards
for the mother and child) should document these activities. Local
health systems should implement such standards, use health care
identification cards, and be capable of analyzing information
using basic indicators and generating basic statistics that
reflect the perinatal and pediatric situation, including
information on breast-feeding. 

     The Center has developed a set of basic (simple)
technologies, including perinatal and child information systems,
which will facilitate these tasks. 

     The psychosocial aspects of mental health have been included
in these instruments, owing to the need to integrate into the
overall care of the mother and child elements that will permit a
better understanding of the environment, family dynamics, and
child-rearing practices that affect the physical and emotional
health of the child and mother.


Evaluation of Technologies

     The health services in our countries are characterized by a
scarcity of resources, enormous demand, and an overabundance of
proposals for health-related actions or technologies.

     It is essential that there be a preliminary appraisal of
proposed technologies with a view to rationalizing the use of
resources.

     In this connection, the Center is conducting studies in
three areas:

     · Educational technologies and community participation in
     prenatal care, promotion of maternal and fetal health, and
     care of the newborn and breast-feeding. 


     · Participation of the mother in caring for the premature
     baby during the initial phase with regard to feeding and
     optimum growth.

     · Impact of "Early Hospital Release" (12-24 hours after
     delivery) on the health of the mother and normal newborn,
     including successful breast-feeding. 


2.5 INCAP

     INCAP is carrying out a wide range of research activities,
including the following studies:

     - Basic research on:     Immunology.
Protection against V. cholerae
Nutritional aspects of breast milk.

· Use of contaminants -  pesticides
· Prevalence of breast-feeding
· Role of the mother's occupation 
· Knowledge, attitudes, and practices regarding
breast-feeding. 
· Influence of breast-feeding on amenorrhea
· Influence on nutritional status

     - Manpower training: 

Physicians
Other professionals
Auxiliaries

     - Intervention programs

     - Bibliographic information

     INCAP also provides technical assistance to the countries of
Central America and, especially in recent years, has been
involved in the promotion of breast-feeding in Nicaragua.


2.6  Wellstart - International Breast-feeding Education Program

     Since 1977, Wellstart, formerly the San Diego Breast-feeding
Program, has provided breast-feeding education and support,
consultations, and clinical and information services.

     In 1983, with the support of USAID and INCS, Wellstart began
to offer its program to teams of health professionals in
developing countries.

     This well-designed program, which continues to be financed
by USAID, trains professionals to conduct breast-feeding
education programs in their own hospitals and countries.

     Courses in Breast-feeding Management

     Since 1983:

     · Hundreds of health care professionals from developing
     countries have participated in Wellstart courses.

     · Wellstart has done follow-up work and provides support for
     its graduates in their places of work.

     · Its educators include instructors who are invited to
     workshops and local seminars attended by several thousand
     health care professionals.

     The Wellstart International Breast-feeding Education Program
is much more than a course.  It employs a multifaceted approach
with seven components, which has ensured consistently good
results. 

     The program components are:

     · Selection of participants,
     · Education -  motivation,
     · Intervention strategy, 
     · Support materials,
     · Implementation of the intervention,
     · Follow-up,
     · Expansion of activities.


2.7  Institute for International Studies on Natural Family
     Planning, Georgetown University

       Since 1985, the Institute has promoted activities to
increase the awareness of breast-feeding services, as well as
their effectiveness, acceptability, and availability.  These
activities include biomedical, social, and educational research
and the development of manuals for health care and health service
leaders and professionals.  One of the Institute's priorities is
to promote breast-feeding as a natural method for spacing
pregnancies.


2.8 Breast-feeding Education for Health Care Professionals

     This is a regional project with various Latin American
universities whose objective is to introduce a breast-feeding
module into the academic curriculum for health care
professionals.  A book on breast-feeding education for health
professionals was published by PAHO in 1990, and the
breast-feeding module included in the book is being tested at 13
sites.  The results will be published in a case study format. 
The objective of the third and last phase of the project is to
bring about a change of policy within academic institutions so
that the module can be officially integrated into their
respective curricula.  This project is being financed by
Georgetown University.


2.9  Regional Project with Academic Institutions: 
     "Breast-feeding Education for Health Professionals"

     
      The book on breast-feeding education for health
professionals is one of the results of a regional project on
education research that began in 1989 with the objective of
introducing a breast-feeding module into undergraduate programs
for health professional(s). 

     The conceptualization of this project began in early 1987
with the collaboration of AID, PAHO, and colleagues in Latin
American universities. 

     An evaluation of university courses and the breast-feeding
education materials in certain professional programs of Latin
American universities brought to light the following:

     · The curriculum materials that have been published are
     offered as guides, but no mention is made of whether or
     where they have been used, nor what the results have been. 

     · The curriculum materials used in programs of documented
     quality are available only to those who participate in these
     programs.  Moreover, the materials are aimed at the training
     of in-service personnel. 

     · In the different countries, either there is no
     breast-feeding education program at all or the information
     included is incorrect, incomplete, or outdated.

     Based on this information, and in response to the interest
expressed by several universities, especially nursing schools, a
research project was implemented in three countries with a view
to:

     I.   Developing a curriculum on breast-feeding (15 units of
theory and practice).

     II.  Testing the curriculum and documenting the results. 
(Publication of case studies).

     III. Bringing about a change in policy at the university
level to ensure that the breast-feeding module is
officially integrated into university programs.

     Phase II of the project has recently been completed.  The
breast-feeding module has been tested in 14 places:  one in
Chile, one in Costa Rica, two in Ecuador, four in Peru, two in
Colombia, two in Honduras, one in Mexico, and one in Washington,
D.C.  The case studies are being evaluated for publication.


IV.  RECOMMENDATIONS

      The most important recommendations of the Regional Advisory
Group on the Promotion of Breast-feeding are expressed in the
attached document entitled:

"Regional Response to the Innocenti Declaration and the Lines of
Action to Fulfill the Goals of the World Summit for Children for
the Protection and Promotion of Breast-feeding in the Region of
the Americas."
        REGIONAL RESPONSE TO THE INNOCENTI DECLARATION 
AND THE LINES OF ACTION TO FULFILL THE GOALS OF THE WORLD SUMMIT
FOR CHILDREN FOR THE PROTECTION AND PROMOTION OF BREAST-FEEDING
IN THE REGION OF THE AMERICAS.


I.  BACKGROUND

      There have been a number of recent developments in
connection with efforts to promote and protect breast-feeding as
the child's right to breast milk and the mother's right to nurse
her child, including: 

     - The joint WHO/UNICEF statement of 1989 on "Protecting,
promoting, and supporting breast-feeding:  The special role of
maternity services, which set out the "Ten Steps To Successful
Breast-feeding."

     - The Innocenti Declaration of August 1990 on the
Protection, Promotion, and Support of Breast-feeding, approved by
national Governments and international agencies, which recommends
the adoption of the measures needed to:


· Ensure adequate nutrition of the mother and her
family, as a requirement for optimum health.

· Establish policies, objectives and a plan of action
in order to promote breast-feeding in the 1990s as a
part of maternal and child programs at the national
level.

     - The World Summit for Children, held on 30 September 1990,
which approved the World Declaration on the Survival, Protection,
and Development of Children, as well as the Plan of Action to
reduce deaths, which set as a specific target "the empowerment of
all women to breast-feed their children exclusively for four to
six months and to continue breast-feeding, with complementary
food, well into the second year." 

     - Resolution 45/104, passed by the United Nations General
Assembly on 14 December 1990, regarding the Convention on the
Rights of the Child, which underscores the importance of the
World Summit agreements, as well as the commitment of governments
to supporting the practice of breast-feeding.

     - The role of UNICEF in the promotion of breast-feeding,
established by the Executive Board in 1991, and the agreement
reached by the World Health Organization during its 44th General
Assembly in May 1991.

     - The Memorandum of Interagency Collaboration, signed by the
regional directors of PAHO/WHO, UNFPA, UNICEF, IDB and USAID on
17 May 1991, which supports health activities for children,
adolescents and women.

     - The meeting of the Regional Advisory Group on the
Promotion of Breast-feeding in the Americas, held at PAHO/WHO
headquarters from 19 to 21 June 1991.

     In light of this background and the fact that breast-feeding
should be an integral part of efforts to improve maternal and
child health, the Regional Advisory Group proposes the adoption
and implementation of the following lines of action at the
national and regional level.  Fulfillment of these agreements
will require the support of the Governments, international
cooperation agencies, NGOs, academic institutions, and other
social groups. 



INNOCENTI DECLARATION, OPERATIONAL TARGETS All governments by the
year 1995 should have:

· appointed a national breast-feeding coordinator of appropriate
authority; and established a multisectoral national breast-
feeding committee composed of representatives from relevant
government departments, non-governmental organizations,  and
health professional associations; 
· ensured that every facility providing maternity services
practices all ten of the Ten Steps To Successful Breast-feeding
set out in the joint WHO/UNICEF statement "Protecting, promoting,
and supporting breast-feeding:  the special role of maternity
services";
· taken action to give effect to the principles and aim of all
Articles of the International Code of Marketing of Breast-milk
Substitutes and subsequent relevant resolutions of the World
Health Assembly; and
· enacted imaginative legislation protecting the breast-feeding
rights of working women and established means for its
enforcement.

We also call upon international organizations to:

· draw up action strategies for protecting, promoting, and
supporting breast-feeding, including global monitoring and
evaluation of their strategies; 
· support national situation analyses and surveys and the
development of national goals and targets for action; and
· encourage and support national authorities in planning,
implementing, monitoring, and evaluating their breast-feeding
policies.
     


II. LINES OF ACTION

     1.   LEGISLATION AND INTERNATIONAL CODE OF MARKETING OF
BREAST-MILK SUBSTITUTES 

     - Promote the actions needed in order to ensure that by the
end of 1992 at least 10 countries of the Region will have adopted
and implemented the International Code of Marketing of
Breast-milk Substitutes.

     - Monitor compliance with the Code in the countries that
have adopted it by the end of 1992.

     - Promote the actions required in order to ensure that by
the end of 1995 all Governments of the Americas will have
accepted the principles and objectives of the Code and will have
taken measures to adopt, implement, and monitor it. 

     - Revise the Articles of the Code as needed to reflect any
changes in international trade regulations. 

     - Promote a revision of labor legislation in all countries
of the Americas in order to protect the breast-feeding rights of
working women. 


     2. TEN STEPS TO SUCCESSFUL BREAST-FEEDING

      - Provide favorable conditions so that by the end of 1992
at least one reputable maternity service in every country of the
Americas will have taken steps toward enabling all mothers to
practice exclusive breast-feeding.
     
     - Promote the activities needed in order to ensure that by
the end of 1995 maternity centers in all the countries will have
taken steps toward enabling all mothers to practice exclusive
breast-feeding.

     The activities aimed at full implementation of the Ten Steps
To Successful Breast-feeding should be carried out as part of the
maternal and child health activities of the health services and
should include the following actions: 

     ·    Determination of the existing situation at the start of
activities.

     ·    Development of a specific plan of action for every
institution.
     
     ·    Promotion of appropriate training for personnel.

     ·    Monitoring and evaluation of advances and results in
implementation of the "Ten Steps."

     - Identify and support service providers such as lay or
traditional birth attendants, health promoters, community
workers, and other public and private sector institutions, with a
view to promoting and protecting breast-feeding at the country
level.

     - Include breast-feeding promotion modules in the training
programs of these groups and institutions.

     - Promote dissemination of the message contained in the text
"For Life" and other educational materials, as well as the
exchange of experiences between health promoters and all parties
concerned with breast-feeding.

     - Promote the establishment of breast-feeding support groups
and the referral of mothers to such groups.

     - Engage community organizations (mothers' clubs, unions,
and others) in efforts to support breast-feeding.


     3. EDUCATION OF PROFESSIONALS AND TRAINING OF HEALTH
     PERSONNEL

     - Take steps to ensure that by the end of 1992 a survey will
have been carried out to determine the status of breast-feeding
education in the training schools for health professionals
(medicine, nursing, nutrition, and others) and the training
programs for health personnel in the Americas.

     - Support academic institutions so that by the end of 1992
at least 10 of the most prestigious institutions in the Region
will have implemented measures to incorporate breast-feeding
education, technical assistance, and research into their
curricula.

     - Support academic institutions so that by the end of 1995
at least 25 of them will have implemented measures to incorporate
breast-feeding education into their curricula.

     - Take steps to ensure that by the end of 1992 at least five
breast-feeding education and research centers will have been
established at the national or subregional level and that the
number of such centers will have increased to 15 by the end of
1995.

     - Enlist scientific and professional societies to aid in the
training of health personnel with regard to breast-feeding.


     4. MONITORING AND EVALUATION AT THE NATIONAL LEVEL

     - Carry out, beginning in 1991, the necessary basic studies
to enable health professionals to assess the existing situation
and establish monitoring mechanisms that will make it possible to
measure the impact of the proposed breast-feeding promotion
actions.

     - Promote the development of indicators to evaluate
compliance with the principles and objectives of the
International Code of Marketing of Breast-milk Substitutes.


     5. RESEARCH

      - Support efforts aimed at carrying out studies, beginning
in 1991, in order to obtain basic data for the purpose of
monitoring the impact of actions to promote breast-feeding.
     
     - Support the development of basic, simple technologies of
standardization, information science, and evaluation in order to
permit a better understanding of family dynamics and
child-rearing practices, which affect the physical and emotional
health of children and mothers.

     - Evaluate appropriate technologies that will lead to a more
rational use of resources in the following areas:

· Education technologies and community participation in
prenatal care, the promotion of maternal and fetal
health, and care of the nursing newborn.
    
· Participation of the mother in caring for the
premature and low-birthweight newborn, dissemination
and replication of methodologies for outpatient care.

· Impact of routine "early hospital release" (12-24
hours after delivery) on the health of the mother and
normal newborn, including the success of exclusive
breast-feeding. 

· Models for the promotion of breast-feeding.

     - Promote a study of the breast-feeding attitudes,
knowledge, and practices of the population.


     6. INFORMATION AND EDUCATION

      - Support the development of educational communication
strategies to promote, utilizing the mass media, the
incorporation of breast-feeding as a priority component in
maternal and child health care.

     - Promote the dissemination of information on the legal
rights of breast-feeding women.

     - Design and develop, within maternity services in the
countries of the Region, an educational communication strategy
aimed at avoiding "missed opportunities" to promote and protect
breast-feeding.  This strategy should foster the development of
positive attitudes among health care personnel and those who come
into contact with the health services.

     - Promote the establishment of national and regional
networks to facilitate the exchange of information, data,
materials, and reports on the outcome of breast-feeding promotion
activities.


III. METHODS OF IMPLEMENTATION 
     
     In order to support implementation of the lines of action
and activities described in this document, the Regional Advisory
Group proposes that:
     
     - The Regional Interagency Coordinating Committee,
comprising representatives from PAHO/WHO, UNICEF, UNFPA, US/AID,
and IDB, include in the agenda for its next meeting the
discussion and adoption of these recommendations, and that it
extend an invitation to participate to other institutions that
endorse and promote breast-feeding.

     - The Governing Bodies of PAHO/WHO and other international
cooperation agencies adopt and ratify the world declarations on
the promotion and protection of breast-feeding and adopt the
Code.

     - The Interagency Coordinating Committees at the country
level provide technical assistance and help to obtain the
resources needed in order to carry out the proposed actions for
the protection and promotion of breast-feeding, working in close
collaboration with the respective authorities and/or National
Commissions.

     - The estimated costs of planned activities be included in
national maternal and child health care plans with a view to
determining the amounts needed and mounting efforts to obtain
sufficient financing.

     - A follow-up meeting of the Regional Advisory Group on the
Promotion of Breast-feeding be held at the end of 1992.     
ANNEXES



     1.    Agenda of the Meeting


     2.   List of Participants


     
REGIONAL ADVISORY GROUP ON
THE PROMOTION OF BREAST-FEEDING

AGENDA





I.   PLACE:         PAHO headquarters, Washington, D.C.
Room C (Second floor)


II.  DATE:          19-21 June 1991


III. OBJECTIVES

     The meeting began with a discussion of the objectives of the
     Regional Advisory Group on the Promotion of Breast-feeding. 
     The group agreed on the following objectives:

     3.1  General Objective

1. To bring together a group of experts and officials
from agencies concerned with breast-feeding in order to
formulate a regional plan of action for coordinated
activities in this area.

     3.2  Specific Objectives

1. To exchange knowledge and compare experiences in
order to increase the practice of breast-feeding in the
countries of the Region.

2. To analyze available information on the prevalence
of breast-feeding and determine whether the services
seek to promote and increase it, and to incorporate
indicators for monitoring trends in maternal and child
health and infant feeding.

3. To discuss coordinated activities in breast-feeding
education and training for health personnel, as well as
in schools of medicine, nursing, and nutrition.

4. To discuss appropriate activities for the promotion
of  breast-feeding in the community and in the mass
media.

5. To analyze the educational and instructional
materials that are available and agree on their use and
application in the different services and social
settings of the Region.

6. To identify and characterize the centers and units
that provide breast-feeding education, research, and
support services in order to incorporate them into the
plan of activities and include financial support for
their operation.

7. To help strengthen regional activities for the
promotion of breast-feeding in light of the decision of
several formula manufacturing companies to discontinue
the free supply of breast-milk substitutes.

8. To establish interagency coordination mechanisms so
that the Plan of Action of the World Summit for
Children will become the operational handbook to be
used by the agencies in their cooperation with the
countries.



IV.   ORGANIZERS 


 Dr.  Néstor Suárez Ojeda, HPM/GDR
 Dr.  Miguel Gueri, HPN
 Dr.  Juan Urrutia, HPM/CDD
 Dr.  Melba de Borrero, HPM/CDD

V.    SECRETARIAT

 Dr.  JoØo Yunes, HPM, Washington
 Dr.  Margaret Kyenkya, UNICEF
 Dr.  J. Aguilar, UNICEF
 Dr.  Marina Rea, WHO/Geneva
 Dr.  Carlos H. Daza, HPN, Washington


VI.   TENTATIVE AGENDA 

Wednesday, 19 June 1991

 9:00 -  9:30        Opening Remarks:         Dr. JoØo Yunes

 
 9:30 - 10:30        Objectives and Agenda:   Dr. Néstor Suárez Ojeda
Dr. Juan Urrutia

10:30 - 11:00        Coffee break


11:00 - 12:30        PAHO and WHO Presentations on Breast-feeding,
including the International Code of Marketing
Breast-milk Substitutes:  

Dr.  Miguel Gueri
Dr.  Marina Rea 
Moderator:     Dr.  JoØo Yunes


12:30 -  2:00        Lunch


 2:00 -  3:30        Group Discussion:  Exchange of Information on
Activities Being Carried Out by Various Agencies
 
Moderator:     Dr. Néstor Suárez O.

 3:30 -  4:00        Coffee break


 4:00 -  5:30        Group Discussion 



Thursday, 20 June 1991


 9:00 - 10:30        "Breast-feeding and      Dr. Cutberto Garza
Nutrition"
"Breast-feeding and      Dr. J.L. Díaz            
Bonding"             Roselló

 
Moderator:     Dr. Audrey Naylor

10:30 - 11:00        Coffee break


11:00 - 12:30        Panel on "Activities to Promote Breast-feeding in
Official and Non-governmental Agencies"
    
Dr.  Marcos Arana
Dr.  Teresa Toma
Dr.  Ruth de Arango
Dr.  Carlos Beccar Varela

Moderator:     Dr.  Giorgio Solimano


12:30 -  2:00        Lunch


 2:00 -  3:30        Presentation and Discussion of Teaching Materials
Prepared by Various Agencies

Moderator:     Dr.  Juan Aguilar


 3:30 - 4:00    Coffee break


 4:00 - 5:30    Education and Training Activities for Health Services
Personnel

Moderator:     Dr.  Carlos Samayoa



Friday, 21 June 1991



 9:00 - 10:30        Health Education Activities and Social
Participation.  Use of Mass Media.

Moderator:     Dr.  Mary Ann Anderson


10:30 - 11:00        Coffee break

11:00 - 12:30        Breast-feeding Research

12:30 -  2:00        Lunch

 2:00 -  4:00        Plan of Action:  Coordination of Activities. 
Formation of Networks.  Outlook.

Moderador:  Dr.  JoØo Yunes


 4:00 -  5:00        Presentation and Discussion of Draft Report
























PARTICIPANTS 

 

Dr. Mary Ann Anderson
Deputy Chief, Health Service Division
Office of Health Bureau for Science and Technology
Agency for International Development
Washington, D.C.  20523


Dr. Marcos Arana
Centro Capacitación en Ecología y Salud
Instituto Nacional de Nutrición
Insurgentes 39-B
San Cristobal de las Casas
Chiapas 3200 - México
Ph. (967) 81596
Fax       81512


Dr. Ruth de Arango
Comisión Nacional de Lactancia Materna
Via 5 4-50 Zona 4, Edificio Maya
60 Nivel, Guatemala, C.A.
Ph. Off. 315128 - Home 740188


Dr. Carlos Beccar Varela
Fundación Acción Familiar
Estanislao Diaz 347
1642 San Isidro, Buenos Aires
Argentina


Dr. Vilneide Braga Serva
Instituto Materno Infantil Recife, IMIP
Banco de Leite Humano
Rua dos Coelhos 300-Boa Vista
50.000 Recife, PE - 
Brazil
Ph. (55-81) 221-2832 Off.
268-4638 Home


Dr. Carol Dabbs, AID, USA
Office of Health Bureau for Science and Technology
Agency for International Development
Washington, D.C.  20523






Dr.  J.L. Diaz Roselló
CLAP
Casilla de Correo 627
Montevideo, Uruguay
Ph. (598-2) 802929
Fax         802573
Uruguay


Dr.  Cutberto Garza
Division of Nutritional Science, 
Cornell University
Ithaca, N.Y.  14850


Dr. Gayle Gibbons
Director, Clearinghouse on Infant Feeding & 
Maternal Nutrition
1015 Fifteenth St., N.W.
Washington, D.C.  20005


Dr. Miriam Labbok
Georgetown University, Dept. OB/Gyn
Medical School
3800 Reservoir Rd. N.W.
Washington, D.C. 20007
Ph. (202) 687-1392
Fax       687-6846


Dr. Audrey J. Naylor
President and Co-Director Wellstart, San Diego, CA.
4062 Firstove, San Diego, CA 9103
P.O. Box 87549
San Diego. California 92138
Ph. (619) 295-5192


Dr. Rosalía Rodriguez Garcia
George Washington University
MPH Program
2150 Pennsylvania Ave. N.W.
Washington, D.C.  20037






Dr. Carlos Samayoa
INCAP
Calzada Roosvelth
Zona 11. Apartado Postal 1188
Guatemala, Guatemala, C.A.


Dr. Giorgio Solimano
CORSAPS
Viña del Mar 12
Santiago, Chile
Ph. (562) 222-5520
Fax        34-6118


Lic. Yolanda Senties
Directora Nacional de Salud Materno Infantil
San Pablo 13, Centro Histórico,
Mexico, D.F.


Dr. Miguel Torrealday
Ministro de la Secretaría de Salud
de la Provincia de Entre Rios, Argentina
Corrientes 172, Paraná (043)
Provincia Entre Rios, C.P. 3.100


Dr. Tereza Toma
Coordinadora de Entrenamiento
Centro Lactancia Materna, Santos, S.P. Brasil
Instituto de Saude 
R. Santo Antonio 590- 2o. A
CEP 01314 - B. Vista,
Sao Paulo, Brazil
Ph. (011) 359-047  Off.
832-6889 Home


Dr. Humberto Vargas Flores
Director Normatización SMI, Mexico
San Pablo No. 13, Centro Histórico
Mexico, D.F.


Dr. Martita Marxs
PRITECH
1925 North Lynn St., Suite 400,
Arlington, Va.  22209



Dr. Rodrigo Arboleda
UNICEF, México
Paseo de la Reforma 645
México, D.F.
Ph. 202 3233


Dr. Manuel Manrique
UNICEF, México
Paseo de la Reforma 645
México, D.F.


Dr. Ho Sang
UNICEF, New York
3 United Nations Plaza
New York, N.Y.  10017


Dr. J. Aguilar
UNICEF, Colombia
Oficina Regional de UNICEF
para América Latina y el Caribe
Carrera 13, 75-74
Bogotá, Colombia
Ph.  (571) 217-2200
Fax        211-4071


Dr. Marina Rea, WHO/Geneva
CDD
WHO-CH 1211
Geneva, Switzerland
Ph. 791-2633


Dr. Martha López de Montero
OPS/OMS PERU
Los Cedros 269, San Isidro
Lima 100 - Perú
Ph.  409-200


Dr. Susan Anthony 
Agency for International Development
AID
SA-18, Room 413
Washington, D.C.  20523






Dr. JoØo Yunes
Pan American Health Organization
Program Coordinator 
Maternal and Child Health 
525 23rd. St. N.W.
Washington, D.C. 20037
Ph.  (202) 861-3250
Fax        223-5971


Dr. Néstor Suárez Ojeda
Pan American Health Organization
Regional Advisor
Maternal and Child Health Program
525 23rd. St. N.W.
Washington, D.C. 20037
Ph.  (202) 861-3262
Fax        223-5971


Dr. Miguel Gueri
Pan American Health Organization
Food and Nutrition
525 23rd. St. N.W.
Washington, D.C. 20037
Ph.  (202) 861-3200
Fax        223-5971


Dr. Juan Urrutia
Pan American Health Organization
Regional Advisor
CDD, Maternal and Child Health Program
525 23rd. St. N.W.
Washington, D.C. 20037
Ph.  (202) 861-3254
Fax        223-5971


Dr. Melba Franklin de Borrero
Pan American Health Organization
CDD, Maternal and Child Health Program
525 23rd. St. N.W.
Washington, D.C. 20037
Ph.  (202) 861-3254
Fax        223-5971









Castella                                                           22.VIII.91



LIVING CONDITIONS AND SURVEILLANCE OF THE HEALTH SITUATION


     The profound social, economic, and political changes that have taken place in recent years at the
international level and in Latin America in particular, coupled with the changes that have occurred in the
organization, financing, and accessibility of the health services and the promotion, prevention, and
restoration of health, have resulted in a marked deterioration of living conditions for broad sectors of the
population and a further deepening of inequality in terms of living conditions and health.  In light of this
situation, there is a growing need to develop procedures for evaluating the status of health and living
conditions among the different sectors of the population based on instruments that will be sufficiently
sensitive to identify both long-term trends and short-term situational changes and at the same time assess
the impact of various social responses.

     The concern for reducing the excessive inequities in health and living conditions that are afflicting
the peoples of the Americas is long-standing.  In August 1961 the Charter of Punta del Este1 affirmed the
importance of achieving "maximum levels of well-being, with equal opportunities for all," and, accordingly, of
setting targets that will take into account "not only ... average levels of real income and gross product per
capita" but also "a more equitable distribution of national income."  To this end, it urged that development
programs incorporate targets aimed at "improving living conditions ... including better housing, education,
and health," and at the same time identify short-term measures designed "to concentrate efforts within each
country in the less developed or more depressed areas in which particularly serious social problems exist."

     In 1972 the Ministers of Health of the Americas, at their III Special Meeting, formulated the
Ten-Year Health Plan for the Americas,2 whose principal goal was to increase the life expectancy of the
Region's peoples.  Accordingly, it was recommended that steps be taken to "begin installing machinery
during the decade to make it feasible to attain total coverage of the population by the health service
systems in all the countries of the Region."  In 1977 the World Health Assembly3 decided that "the main
social target ... should be the attainment by all citizens of the world by the year 2000 of a level of health that
will permit them to lead a socially and economically productive life."  That same year, in their IV Special
Meeting,4 the Ministers of Health of the Americas identified and defined primary health care as the principal
strategy for achieving the targets that had been set within the intersectoral context of economic
development.

     Subsequently, at Alma-Ata in 1978, the International Conference on Primary Health Care5
established that primary health care is "the key to attaining the target [of Health for All by the Year 2000] as
a part of development in the spirit of social justice," and in 1979 the World Health Assembly6 called for "the
formulation and implementation of national, regional, and global strategies" for achieving this goal.

     In 1980 Pan American Health Organization7 formulated strategies, targets, and specific objectives
for the Region of the Americas and defined the minimum indicators for evaluating progress at the country
level.  These objectives were "aimed at ensuring that the health sector makes a specific contribution to
reducing social and economic inequalities."  The document states that the target and strategies of Health for
All "involve the entire population," that priority should be given to "the population living in extreme poverty in
rural and urban areas," and that "the improvement of national levels of well-being is a necessary condition
for attaining the goal."

     Finally, at the XXIII Sanitary Conference (1990)8 the Ministers expressed concern over "the
disparities in the distribution of wealth" and the exclusion of broad sectors of the population from the most
elementary levels of social well-being.  The fight against inequality needs to be taken on as a fundamental
component of development, with priority given to essential human needs, including health, and the
elimination of extreme poverty.  It is also urgent "to document and analyze the effects of stagnated growth,
the general economic crisis, social inequities, and the spread of extreme poverty" on the health conditions
of the people and therefore to develop the sector's capacity to apply an epidemiological approach to
knowledge about the population's state of health.

     In recent years, concern over the relationship between inequalities in the health situation, on the
one hand, and living conditions, on the other, has been translated into numerous international studies.  In
the Latin American context there have been works on the seriousness of poverty in Latin America in the
1980s,9 essential health needs in Mexico10, the social determinants of mortality,11,12 and, more recently,
health inequalities in Ecuador.13  Another important undertaking was a project carried out by WHO on health
inequalities in Europe.14  The Ottawa Charter15 cites the close correlation between the health situation and
the living conditions of different population groups and therefore the need to develop comprehensive
multisectoral actions in order to bring about changes in living conditions and in health.  It declares that "the
fundamental conditions and resources for health are peace, shelter, education, food, income, a stable
ecosystem, sustainable resources, social justice, and equity."

     In the Region of the Americas, in addition to deep inequalities both between and within the
countries, the deterioration in the economic situation has meant that larger numbers are living in relative or
extreme poverty.  Despite the considerable reduction in mortality that has been achieved in the last 35
years, mortality at early ages and morbidity and mortality due to diarrheal and acute respiratory diseases
and other communicable and preventable conditions continue to be major problems for many sectors of the
population.  In several instances, diseases that had declined significantly have now recrudesced, and there
have been epidemics and serious problems with communicable diseases such as cholera and AIDS, which
translate not only into violence and drug addiction but also into a deterioration in living conditions.16

     In the context of the world economic crisis, most of the countries of the Region have seen their
economies undermined and have had to resort to adjustment processes in an effort to combat inflation and
stimulate growth while at the same time seeking new windows through which to become integrated into the
international economy.  But the adjustment policies have served to aggravate the social, political, and
institutional breakdown which to a greater or lesser extent had begun to take place as far back as the
1970s.17,18  In most of the countries, public health services are degenerating, the public sector's per capita
expenditure on health is declining, and the limited and increasingly scarce resources are being
concentrated on curative actions.19  At the same time, within the framework of the adjustment policies,
significant changes have been introduced in the organization of these services, especially in how they are
financed, with a prevailing trend toward privatization and the transfer of operational costs to users.

     With support from international agencies, the governments have been devising intervention
strategies for sparing the most impoverished social sectors from the negative impact of the crisis.  In several
of the countries, social development funds have been created or are in the process of being created, and
almost all of them have begun to define social intervention programs aimed at the most vulnerable sectors. 
In an effort to minimize red tape and reach the population more directly, most of these programs have been
set up outside the traditional structures of the Ministries of Health using new, ad hoc institutions developed
by the official sector or nongovernmental organizations.  In some cases, part of the financing previously
allocated for official services has been diverted from traditional structures to support these new initiatives,
thus adding to the financial problems of the former.  Most of these emergency or social investment
programs focus on just a few lines of action and are directed toward a small number of specific problems in
the population groups that are considered to be most affected by the crisis.

     So far, there has not been enough knowledge or information available to document a correlation
between the deterioration in living conditions and health services coverage and quality, on the one hand,
and the health/disease problem, on the other.  As a result, the health systems have had only a limited role
in decision-making and the planning and evaluation of actions to promote health and well-being.  It is
therefore urgent that methods and techniques be developed that will measure the effect of the crisis on
different sectors of the population, identify the chief problems of these groups, and assess the impact of the
social responses.

     It is not enough to look only at the historical trends in living conditions and health at the national
level.  It is also necessary to evaluate the health of specific population groups, and, especially, to monitor
the patterns of inequality in different groups.  Moreover, it is essential to evaluate the impact of the actions
taken, in terms of units of time spent, for purposes of decision-making, so that the deployment of resources
and actions can be confirmed, or rechanneled, so as to achieve the greatest possible impact.  It is
becoming increasingly necessary to develop the capacity to evaluate change in the short term, to
supplement medium- and long-term trend assessments.

     It is more than just a matter of finding a "new" group of indicators with greater or lesser
discriminatory power to be applied universally to all population groups and in every country:  what seems to
be needed is an entire conceptual redefinition of the field of health, the incorporation of more appropriate
methodologies to capture the dynamics of the changes, and the development and application of techniques
for assessing the health situation which have not been widely used up to now.

     Accordingly, it has been decided to encourage the development of national systems to evaluate
and monitor health and living conditions in the different sectors of the population.  Such systems should
have the capacity to detect shifting trends and assess the impact of socioeconomic changes and
interventions for health and well-being on different groups of the population while at the same time
gathering knowledge on long-term trends.

     The study of inequalities in the health situation and their relationship to living conditions poses
major conceptual, methodological, and technical challenges that extend to the very concepts of health,
living conditions, and inequality, which have already been examined in a variety circumstances and
contexts.20,21,22  This will require a critical review of the different conceptual models that have been applied to
date, including the ecological model proposed by Morris23 and the models used by Blum,24 Lalonde,25
Dever26,27 and others.  It is time to move toward a reformulation within an integrative conceptual framework
that will operationalize the study of the health situation as part of the whole gamut of social processes that
generate living conditions in their different dimensions (biological, ecological, psycho-cultural, economic)28
and the different levels at which they are manifested (as individual, group, or societal phenomena), always
bearing in mind that a wealth of processes are involved.

     This entire undertaking--the reconceptualization of health in its relationship to the living conditions
of each population group; the redefinition of the units of analysis, the variables, and the relevant indicators;
and the articulation of the process of understanding the health situation with the processes of making
decisions and assessing the impact of interventions--raises issues of great epistemological complexity that
cannot be resolved by dealing with reality in compartmentalized and fragmented pieces and avoiding the full
theoretical construct.

     Different scientific disciplines have addressed the need to reduce complexity in their object of study
at the point where the cognitive and decision processes meet, and they have produced a number of
conceptual and methodological approaches such as the notion of hierarchical and nearly descomposible
systems,29,30 complex and poorly structured problems,31 and latent structure.32  In the area of research
methodology, renewed interest in the development of comprehensive methods has been translated into
tools such as methodological triangulation33,34 and data matrix systems,35 among others, which can be very
useful for the articulation of units of analysis, variables, and indicators of different levels and for the
integration of different quantitative and participatory methods within a single study.

     Finally, in order to facilitate the design of specific projects in the countries, it will be important to
enlist such techniques as the use of space-population units, which have been widely applied in geography
for the stratification of the population according to living conditions.  In addition, techniques based on the
concepts of sentinel populations and the tracing of problems and indicators, adapted to the needs of the
projects in each country, might help to increase the sensitivity of the surveillance system while at the same
time reducing the number of indicators and the operational costs.

     To facilitate the discussion and enrichment of these concepts, PAHO's Health Situation and Trend
Assessment Program has prepared a working document that summarizes many of the developments cited
here, based on which steps are being taken to promote specific operational proposals that are geared to the
national reality in each country.  The document is not prescriptive, nor is does it call for reaching a
consensus; rather, the hope is that it will contribute to the particular process in each country and facilitate
local cooperation by PAHO, based on a participatory approach, in the design of systems that are suitable,
viable, feasible, and capable of responding to the needs at stake in terms of national criteria.  In the first
attempts at this process, which have been limited to four countries so far, it has been possible to
incorporate the scientific and technical capacity of the institutions involved, which has been translated into
the particular characteristics of each undertaking and has considerably enriched the initial working
document while at the same time facilitating evaluation of the proposals in terms of their viability and
feasibility.

     It is hoped that this effort will be lead to relatively simple operational proposals, applicable to the
countries' particular conditions in terms of technical and financial resources, which can be turned into
ongoing activities by the institutions involved, complementing and strengthening the existing information
systems and closely tied to the decision-making processes at the point where the institutions of government
and civilian society interact.

REFERENCES


1Charter of Punta del Este, Establishing an Alliance for Progress within the Framework of Operation Pan
America, Titles I and II and Appendix to Title II.

2III Special Meeting of Ministers of Health of the Americas (Santiago, Chile, 2-9 October 1972), Ten-Year
Health Plan for the Americas, Pan American Health Organization, Washington, D.C., Official Doc. No. 118,
1973.

3Resolution WHA 30.43, World Health Assembly, Geneva, 1977.

4IV Special Meeting of Ministers of Health of the Americas (Washington, D.C., 26-27 September 1977).

5International Conference on Primary Health Care (Alma-Ata, USSR, September 1978), WHO/UNICEF.

6Resolution WHA 32.30, World Health Assembly, Geneva, 1979.

7Pan American Health Organization, HFA/2000: Strategies, Washington, D.C., Official Doc. No. 173, 1980,
reprinted in 1983, pp. 152, 153.

8Pan American Health Organization, XXIII Pan American Sanitary Conference (Washington, D.C., 1990),
"Strategic Orientations and Program Priorities for the Quadrennium 1991-1994."

9Comisión Económica para América Latina y el Caribe/Programa de las Naciones Unidas para el
Desarrollo, "Magnitud de la Pobreza en América Latina," Doc. LC/L.533, May 1990.

10Coordinación General del Plan Nacional de Zonas Deprimidas y Grupos Marginales, "Necesidades
esenciales de salud en México: Situación actual y perspectiva al año 2000," México, Siglo XXI Ed., 1982.

11H. Behm, "Determinantes económicos y sociales de la mortalidad en América Latina," paper presented at
the UN/WHO Meeting on Socioeconomic Determinants of Mortality and Their Consequences (Mexico,
1979).

12H. Behm, J.M. Guzmán, A. Robles, and S. Schkolnik, "Factores sociales de riesgo de muerte en la
infancia," Santiago, CELADE, 1990.

13J. Breilh, E. Granda, et al., "Deterioro de la vida," Quito, Corporación Ed. Nacional/CEAS, 1990.

14"Health Inequalities in Europe," Soc Sci Med 31(3):223-420, 1990.

15I International Conference on Health Promotion (Ottawa, November 1986), "Ottawa Charter for Health
Promotion," WHO, Ministry of Health and Welfare of Canada, Canadian Public Health Association.

16"La práctica epidemiológica en los sistemas de servicios de salud." Bol Epidemiol (OPS) 11(3), 1990.

17Sistema Económico Latinoamericano (SELA), "Las consecuencias sociales del endeudamiento externo de
América Latina," Caracas, 1988.

18G.A. Cornia, R. Jolly, and F. Stewart, "Ajuste con rostro humano," Madrid, UNICEF/Siglo XXI Ed., 1987.

19Pan American Health Organization, Health Conditions in the Americas, 1990 edition, vol. 1, Washington,
D.C., 1990.

20R. Illsley and D. Baker, "Contextual Variations in the Meaning of Health Inequality," Soc Sci Med 32(4):
359-366.

21D. Vagerð, "Inequality in Health: Some Theorical and Empirical Problems," Soc Sci Med 32(4): 367-372.

22D. Lundberg, "Causal Explanations for Class Inequality in Health: An Empirical Analysis."

23J.N. Morris, Uses of Epidemiology, 3d ed., Edinburgh, Churchill Livingston, 1975.

24H.L. Blum, Planning for Health: Development Application of Social Change Theory, New York, Human
Sciences Press, 1974.

25M. Lalonde, "A New Perspective and the Health of Canadians," Office of the Canadian Minister of National
Health and Welfare, April 1974, cited in Dever op. cit.

26G.E.A. Dever, "Holistic Health: An Epidemiological Model for Policy Analysis," in: Community Health
Analysis, Gaithersburg, Maryland, Aspen Pub., 1980.

27In the second edition of this book, the author confirms the model and points out that quality of life has
become a basic concern in the analysis of health problems.sis de los problemas de salud (G.E.A. Dever,
Community Health Analysis, 2d ed., Gaithersburg, Maryland, Aspen Pub., p. 18).

28P.L. Castellanos, "Sobre el concepto de salud/enfermedad: Descripción y explicación de la situación de
salud," Bol Epidemiol (OPS), 10(4), 1990.

29H. Simon, Ciencia de lo artifical, Barcelona, Ed. ATE, 1979.

30H.A. Simon, Models of My Life, Basic Books, Harper Collins, 1991.

31I. Mitrov I, Methodological Approach to Social Sciences, San Francisco,  Jossey-Buss, 1978.

32P. Lazarfeld and H. Menzel, Relaciones entre propiedades individuales y propiedades colectivas,
Barcelona, Ed. Laia, 1966.

33T.D. Jick, "Mixing Quantitative and Qualitative Methods: Triangulation in Action," Admin Quarterly 24(12),
1979.

34J. Samaja, "Triangulación metodológica: Pasos para una compresión de la dialéctica de la combinación
de métodos."  V Congreso Latinoamericano de Medicina Social (Caracas, March 1991).

35J. Samaja, Dialéctica de la investigación científica, Buenos Aires, Helguero Ed., 1987.










107th Meeting
Washington, D.C.
June 1991

Provisional Agenda Item 5.8                CD35/20  (Eng.)
22 August 1991
ORIGINAL:  SPANISH

CHOLERA IN THE AMERICAS

      For the first time in the current century, epidemic cholera
struck the Americas in January 1991.  During the past seven months,
over 270,000 cases have occurred in Peru, Ecuador, and Colombia,
with additional cases in Chile, Brazil, the United States of
America, Mexico, and Guatemala.  Although there has been some
decrease in the number of cases during the month of August, it
cannot be considered that the epidemic has subsided permanently. 
Since cholera will have epidemiological periodicity, other countries
can be expected to experience epidemics in future months and years,
and cholera may become endemic in some areas of the Region. 
Therefore, it is essential that all countries prepare for the
possible introduction of cholera by developing national plans for
cholera control.  Such national plans should include elements of
surveillance, crisis management, financial planning, case
management, epidemiological investigation, environmental sanitation,
food safety, health education, laboratory studies, and information
management.  

      PAHO should support the development and implementation of
national plans, prepare a plan at the Regional level, and identify
potential external resources for national and regional prevention
and control efforts.  

      The Organization has divided its response to the epidemic into
two phases:  the emergency phase, which will last three years, and
the investment phase, which will continue for 12 years.  It is
expected that US$ 610 million will be required during the emergency
phase to finance national plans and at least some subregional and
Regional activities.  During the investment phase, US$ 200 billion
will be needed in order to correct deficiencies in the environmental
and health infrastructure that have contributed to the spread of
cholera.  The countries will need to provide a significant share of
the resources, with the remainder to be requested from international
organizations.  As of mid-August, PAHO had participated in the
mobilization of more than US$ 12 million, which were donated by
various countries, the European Community, and the Inter-American
Development Bank (IDB).  The Organization is discussing projects
with other organizations, since there is an obvious need to rapidly
mobilize additional financial resources.

      Discussions during the Meeting of the Executive Committee
Meeting focused on the role of national cholera control commissions,
alternative strategies for dealing with the problem, the
prioritization of studies on new vaccines, the desirability of
strengthening diarrheal disease control, the importance of public
information, ways to encourage community involvement, the need to
report and share information on the problem, control actions, and
the amount required for investment in the immediate future.  As a
result of these discussions, the document presented to the Executive
Committee (see Annex) has been revised to clarify the role of the
national commissions, underscore the importance of supporting the
new vaccine studies, point out the need to step up programs for the
control of diarrheal diseases, and emphasize the importance of
public information and community involvement.  Updated information
has also been added with regard to the epidemic and the status of
resource mobilization.

      Resolution XI, adopted by the Executive Committee and included
below, suggests a draft resolution that encompasses the policies
proposed for consideration by the Council.  Members of the Directing
Council are asked to review this document for purposes of
discussion, decide on the policies to be implemented, and provide
guidance for the Secretariat and recommendations for the countries.CD35/20 
(Eng.)
ANNEX























CHOLERA IN THE AMERICAS


CONTENTS


Page

I.    Historical Background...................................

II.   Epidemiological Situation...............................

III.  Response of the Pan American Health Organization........

IV.   Planning for the Future.................................

V.    Conclusion..............................................CHOLERA IN THE AMERICAS


I.    HISTORICAL BACKGROUND

      Most countries of the Americas were affected by the second
through the fifth pandemics of cholera that spread widely between
the 1830's and the 1890's.  Fortunately, the Americas were free of
epidemic cholera for the first 90 years of this century, which has
been attributed, at least in part, to the installation of water
treatment in virtually all major cities of the Americas beginning at
the turn of the century.  Water filtration was widespread by 1870
and chlorination by 1910.  The Americas succeeded in being the only
region free of cholera during the first 30 years of the seventh
pandemic, which began in Indonesia in 1961 and reached much of the
world during its first 10 years, including West Africa in 1970. 
Cholera spread rapidly through Africa from 1970 to 1973 and has
remained endemic in several countries since then.   Epidemics also
occurred in Italy, Portugal and Spain in the 1970's, but cholera was
eliminated from these countries after appropriate control measures
were implemented.   Imported cases were reported by Canada and the
United States, and since 1973, the United States has also reported
occasional autochthonous cases related to the consumption of
poorly-cooked seafood caught along the Gulf coast.  However, the
strains of Vibrio cholerae serogroup 01 isolated from autochthonous
cases in the United States were distinct from the pandemic biotype,
V. cholerae El Tor.

      During the month of August, the Region has experienced a
reduction in the number of cholera cases.  However, this decrease
should not be considered a sign that the epidemic has abated
permanently, since cholera will certainly have epidemiological
periodicity, with a frequency as yet undetermined.  PAHO continues
to work under the hypothesis that the epidemic will spread to most
countries and will become endemic in several of them. 

II.  EPIDEMIOLOGICAL SITUATION

A.  Peru

      The first cases of cholera in Peru were reported on 23 January
in Chancay, on the coast near Lima, and almost simultaneously in
Chimbote, a major port 400 km to the north.  V. cholerae, serogroup
01, biotype El Tor, serotype Inaba was isolated and identified by
the National Institute of Health in Peru and subsequently confirmed
by the U.S. Centers for Disease Control.  Over the next week, cases
were reported in Lima, Piura, and other communities along the 1200
km coast north of the capital.  Since then, the epidemic has spread
south and to the interior departments, including Iquitos, which has
a major port on the Amazon River.  Cuzco was the final department to
be affected during May.  As of 6 August, a cumulative total of
238,261 probable cases and 2,387 deaths had been reported (Table 1),
with the highest attack rates in the coastal departments (Figure 1). 
The weekly incidence of cases has declined since 15 April (Figure
2), at least in the most heavily affected departments.  More than
80% of cholera cases have occurred in persons over 10 years of age,
a pattern opposite to that of other diarrheal diseases in Peru.  The
case fatality ratio in Peru has been remarkably low throughout the
epidemic, averaging 0.1% of all cases, in large part as a result of
a well-organized diarrheal disease control program that has made
oral rehydration salts readily available and has promoted the
correct management of diarrhea patients through continuous training
activities.  However, the case-fatality ratio has exceeded 2% in
several interior departments where educational campaigns have been
less effective and health care is less readily available (Figure 3).

      Epidemiological investigations in Peru have revealed several
mechanisms which are responsible for the spread of cholera.  The
major risk factor in the cities has been drinking untreated or
unboiled water.  Environmental studies in the earlier stages of the
epidemic found high levels of fecal coliforms and no residual
chlorine in several municipal water systems.  Vibrio cholerae was
isolated from at least three water systems, as well as from multiple
environmental samples, including river and coastal waters.  Other
risk factors include consumption of food and beverages, especially
ice, from street vendors, eating food left for more than three hours
without refrigeration and without reheating, and placing hands
directly into drinking water stored in household containers. 
Additional factors considered important in Peru have been raw
seafood consumption, principally as ceviche, and the discharge of
untreated waste into rivers and the ocean.

B.    Ecuador

      The first case of cholera in Ecuador was reported on 1 March,
approximately one month after the epidemic's onset in Peru, and
occurred in El Oro Province among a group of shrimp fishermen who
worked in Peruvian waters.  The community probably spread its
infection through a well which was contaminated by a septic tank
that overflowed at high tide.  Since then, cholera has reached 19
provinces of Ecuador with 31,881 cases and 505 deaths (Table 2). 
The highest attack rates have been along the coast.  The incidence
of cases at the national level is declining (Figure 4).

C.  Colombia

      Colombia reported its first case on 10 March, when an adult
male living on the Mira River 20 km south of Tumaco, in Nariño
Department (located on the Pacific coast at the border with Peru),
was confirmed to have V. cholerae infection.  He had no history of
travel or apparent connection with Ecuador or Peru.  Subsequent
cases were reported on and after 26 March from Tumaco and Salahonda. 
Since then, the infection has spread to 12 other departments: 
Cauca, Valle, Chocó, Tolima, Cundinamarca, Huila, Santander, Caldas,
Córdoba, Amazonas, Guaviare, and Meta.  Colombia has registered a
total of 4,292 cases and 76 deaths.  As of 30 July, 3,991 cases had
occurred in the departments of Nariño, Cauca, and Valle (Table 3 and
Figure 5).

D.    Brazil

      The first case in Brazil was detected on 10 April in an
individual from the Island of Santa Rosa in the Amazon River at the
border with Colombia and Peru.  Subsequently, 31 more cases have
been confirmed, 28 of which have been in the same area of Amazonas
State (Tabatingá, Atália do Norte); six of these cases were imported
(Table 4).  The most recent case in this area occurred on 28 May. 
Two additional cases were identified in Pontes-e-Lacerda in Mato
Grosso State, but it is unclear whether there is any association
with the other cases (Figure 6).

E.  Chile

      Chile reported its first case on 12 April in an adult male
living in the metropolitan area of Santiago.  Since then, Chile has
confirmed 41 cases and two deaths, all in persons 10 years of age
and older.  All except 6 cases were in the Santiago area and 35
cases occurred in April (Figure 7).  The latest case occurred on 27
May (Figure 8).  The most important risk factor has been the
consumption of raw vegetables.  Measures to restrict the
distribution of vegetables irrigated with sewage-contaminated water
have been implemented to control the cholera epidemic in Chile.

F.    United States

      The first case of cholera in the United States in 1991
occurred on 9 April in an individual who attended a medical
conference in Lima.  Subsequently, 13 additional cases have been
confirmed in the United States, one in a person who travelled to
South America and 12 in persons who ate meat from two different
crabs brought in noncommercially by travelers returning from
Ecuador.  There has been no evidence of subsequent spread in the
United States.

G.    Mexico

      The first case was detected on 13 June in San Miguel de
Totomoloya (Table 5), a rural community with 1,100 inhabitants where
there were 27 cases.  Health authorities carried out prevention and
control campaign that included visits to all households.  Later,
still more foci of cholera infection were identified, and as of 5
August there had been 257 confirmed cases and two deaths in the
states of Mexico (32), Hidalgo (183), Veracruz (7), Puebla (11), and
Chiapas (24).  Figure 9 shows 65 cases in the states of Mexico and
Hidalgo.

H.    Guatemala

      The first case of cholera was reported on 24 July in a male
patient residing in La Gloria in San Marcos Department, near the
Mexican border.  As of 10 August, nine cases of cholera had been
reported.

III. RESPONSE OF THE ORGANIZATION

A.   Overall Response

      When cholera cases were first detected, the PAHO/WHO
Representative (PWR) Office in Peru and the Pan American Center for
Sanitary Engineering and Environmental Sciences (CEPIS), located in
Lima, immediately became involved in assisting Peru confront the
epidemic.  At PAHO Headquarters, a Cholera Task Force was formed to
coordinate the international response, identify human and financial
resources to address the emergency, and provide essential
information to Member Countries and other agencies.  The Task Force,
which meets several times each week, includes representatives from
the PAHO Programs dealing with diarrheal diseases, laboratory,
emergency preparedness and disaster relief, information,
communicable diseases, environmental sanitation, food safety,
research, and epidemiology; the focal point is the Health Situation
and Trend Assessment Program.

      One of the first concerns of the Organization was to assure
that Peru had the means to provide the necessary medical attention
for cholera cases.  Shipments of additional oral rehydration salts
(ORS), intravenous fluids, antibiotics and other essential medical
supplies were arranged, and external resources to meet the disaster
were sought.  PAHO served as the focal point for the international
response based on an initial request for $3.84 million which was
prepared by the Peruvian Ministry of Health.  PAHO has processed
$2.09 million in external assistance to Peru, of which about half
has been for medical supplies and ORS.

      Another immediate concern was the economic impact of the
initial restrictions placed on the importation of Peruvian products
by some Governments.  A special effort was to provide information
about the low level of risk and to clarify the situation, in order
to avoid or remove restrictive policies and ameliorate their impact. 
PAHO has continued to advise against restrictions on imported
products as other countries have become infected.

      As efforts to control the epidemic broadened, approximately $1
million in external funds have been used for environmental
sanitation, health education, laboratory support, and related
interventions.  The PWR Office has been extremely active in
supporting the local purchase and distribution of supplies and
acquiring needed technical expertise.  All PAHO offices have been
involved in dissemination of health information through television
and newspapers, including special supplements on cholera prevention.

      It should be mentioned that considerable assistance, both in
material and personnel, has been provided to Peru by other Member
Countries, and PAHO has regarded this as an excellent example of
technical cooperation and collaboration.  The PWR Office has
actively coordinated much of the bilateral assistance to Peru.

      In the other Latin American countries affected by cholera, the
response of the PAHO/WHO Offices has been as prompt and
comprehensive as in Peru.  PAHO epidemiologists and other staff have
been involved in field investigations and have assisted the
governments in instituting control measures.  Headquarters-based
staff have provided technical assistance in many areas, including
case management, environmental sanitation, food safety, and others.

B.   Emergency Response and Res







FINAL REPORT*







TRAVELING SEMINAR ON
      THE TRAINING AND UTILIZATION OF FELDSHERS
     FOR PRIMARY HEALTH CARE IN THE SOVIET UNION



8-23 May 1991







J. R. Ferreira
M. H. Malo



PAHO-AMRO/WHOINTRODUCTION

      Prior to the present seminar, six similar ones were held,
five in English and one in French.  From the cumulative
experience of these seminars, it is clear that the training and
utilization of feldshers in the Soviet health system provides an
excellent framework for exchange and comparative analysis of
similar experiences which are taking place or being promoted in
other countries.

     This year's seminar was held in Spanish for participants
from countries of the Region of the Americas.  There were eleven
participants representing eight countries of the Region, all of
them holding high-level positions in different areas of public
health in their countries (see Annex #1).  In addition, two
officials from PAHO/WHO-AMRO accompanied the group: Dr. José
Roberto Ferreira, Coordinator, Health Manpower Development, and
Dr. Miguel Malo, associate consultant in international health. 
Unfortunately, for reasons of force majeure, the representatives
from Guatemala, Colombia, and Nicaragua who had been expected to
attend were not able to do so.

     Personnel from PAHO and WHO in Geneva assisted in drafting
the document which served as the basis for planning this year's
seminar, and which was also sent to Moscow for its corresponding
approval.  Because of difficulties with travel arrangements, it
was not possible to hold a meeting between Dr. Ferreira and the
members of CIAMS to wrap up final details in preparations for the 
seminar.  The important role of WHO Geneva in facilitating
communication with CIAMS and handling travel arrangements should
be duly noted.

Objectives

     The following objectives were defined for the seminar:

1.   Analysis of the policy of utilization of feldshers at the
     level of primary care, and differences between this type of
     personnel and other alternatives employed in the
     participants' countries;

2.   Critical analysis of the educational system and
     instructional methodologies used in training the different
     categories of feldshers;

3.   Analysis comparing the system of continuing education for
     the feldshers to systems of continuing education utilized in
     the participants' countries;

4.   To suggest techniques for ensuring a continuing exchange of
     experiences and cooperation among countries for manpower
     development, particularly in terms of middle-level
     technicians.


Program 

     The program began in Moscow with an introductory plenary
session that provided an overview of the Soviet Union's public
health system, including manpower development, and gave a general
description of the training of middle-level technicians.  Field
visits were included to the "intermediate-level medical schools"
for the training of feldshers and to the headquarters of
emergency services for the city.

     The seminar continued in the province (oblast) of Vladimir,
where participants met with the directors of Public Health for
the province and had the opportunity to visit a rural hospital, a
feldsher's post in a rural community, a polyclinic located in a
tractor factory, a feldsher working in a school in the city, and
the headquarters of health and epidemiology for the district
(rayon) of Suzdal.

     The third part of the seminar was held in Leningrad, where
the participants visited the city's Health Director, an
"intermediate-level medical school," and one of Leningrad's
institutes of medicine.

     The last day of the seminar, in Moscow, consisted of the
session for evaluation and closure, held at the local office of
CIAMS.

     In order to provide for greater flexibility and creativity
in the participants' contributions, and in order to facilitate
the exchange of ideas, it was requested that each participant
submit a brief written report after each phase of the seminar:
phase one in Moscow, phase two in Vladimir-Suzdal and phase three
in Leningrad.  The reports were to include the participants'
analyses of what they had observed, an attempt at comparative
analysis in relation to the experience of each country, and the
usefulness of these observations in terms of their potential
application to the participants' specific work in their
countries.

     These written reports, along with material from the general
secretary and the documents distributed by the organizers, served
as the basis for drafting the present report.

     This report does not attempt to provide a chronological
description of the seminar program, but rather, discusses under
its several headings those aspects which the participants
considered to be of greatest importance:

     -    country context 

     -    characterization of the feldsher - educational process
- working process

     -    comparative analysis

     -    conclusions and recommendations

CONTEXT

      One of the participants from Brazil wrote in his report:
"This seminar offers an exceptional opportunity to make contact
with the health system of a great country, the Soviet Union, at a
time when it is undergoing a process of extraordinarily rapid
change."

     The seminar was indeed held under conditions of profound
economic, political and social transformation, affecting the very
foundations of Soviet society.  Without a doubt, the general
uncertainty facing Soviet society at this moment in its history -
- in particular at the time of the seminar, which was held in a
pre-electoral period -- was the underlying scenario which shaped
the seminar as a whole.  

     As a result, each activity planned for the seminar --
including the visits to the feldshers' workplaces, the formal
presentations by public health officials, the conversations with
staff members of both the services and the training schools --
reflected, in one way or another, some level of uncertainty as to
the present and potential impact that these changes may have on
the health services.

     The opening that perestroika and glasnost have created for
new forms of social organization in Soviet society implies, as
well, the need to review the conception and organization of the
health sector.  The participant from the Dominican Republic wrote
in his report: "This moment of profound change in the Soviet
Union, which our group is privileged to witness, is also
reflected in the field of health."  Examples ranged from the
proposals for decentralization mentioned by Dr. Vartanian,
director of CIAMS, in his introductory presentation on the Soviet
health system, to the problems of financing which were mentioned
on various occasions by different speakers.

     As the participants from Mexico expressed it, "In our
opinion, although the basic principles of a socialist
organization of the health system may not be affected in the
short term, the economic and political changes will eventually
alter the means of financing and delivery of services."  On the
basis of what the participants observed, the debate appears to
revolve around two points, which in a sense represent the
greatest uncertainty about changes in the health services:

.    the financing of the health sector

.    the planning of human resources for the sector

     Privatization, which is now a possibility in every area of
Soviet society, is also being given serious consideration for
application to the health services.  The fact that health workers
(feldshers, physicians) can practice outside the state sphere is
further evidence of the trend toward privatization.  The medical
cooperatives, consisting of groups of physicians who sell their
services to the state, are a first step in this direction. 
According to various officials, privatization is seen as a means
of improving the efficiency of the health sector by improving the
quality of care; it would also be important as an alternative
mechanism of financing the health sector in the future.

     Moreover, as regards the development of human resources,
there is likely to be a gap between the accelerated pace of
change in the financial structure and the response by agencies
responsible for training human resources.  The possibility of an
open labor market for health workers outside the state structure
creates conflicts with planning which is centralized and
controlled by the state.  It was not possible during the seminar
to evaluate mechanisms for dealing with potential conflicts
between the reorganization of the services and the training of
human resources.

     The progressive reduction in the centralized power of the
Ministry at the state level along with greater autonomy for the
republics is causing problems such as the difficulty in filling
medical posts in rural areas.  This is an example of how the
growing flexibility in managing human resources creates new
problems, to which neither the services nor the training
institutions have yet responded.  It was clear, for example, that
the generation of new health workers such as the family doctor
and the nurse practitioner do not fit well into the current
structure of the health services but might better serve as
initial responses to the new dynamic in the health sector in the
sense of creating a profile for the physician in private
practice, on the one hand, and on the other hand, one for a
health worker to whom the state would have recourse once the
physicians are practicing autonomously. 

     The extensive use of feldshers in different job categories,
which appears to respond more to a policy of full employment than
to a criterion of efficiency, could take a different course with
the changes to come, when concerns such as efficiency and
effectiveness from the perspective of the West cause questions to
be raised about the number of people employed in the services.

     It is interesting to note in this regard that the areas of
knowledge concerned with financing the health sector and managing
human resources in health are not well developed in the Soviet
Union, on account of the particular way that the health services
are managed in socialist society.  At a time when this
organization of services is being redesigned from the ground up,
this creates a major theoretical gap.  This is being filled, as
the participants understand it, in a manner substantially
influenced by the perspectives of certain other health systems
(the United States of America, Germany, the Netherlands).  The
contribution to theoretical development in these fields can be
considered as an interesting area for the development of
cooperation with the countries of Latin America.

     Finally, it was of particular interest to the participants
to observe the marked socio-economic and political differences
among the different regions visited in the course of the seminar.

     In Moscow, there was discussion of alternatives for the
organization and financing of the health services, among them the
creation of the so-called "medical cooperatives."  However,
concern was also expressed for the need to retain the basic
principles of socialist organization in the health services.  In
Vladimir and Suzdal, meanwhile, universal coverage, the level of
participation by the community and the trade unions, and the
cooperation with other community entities reflected a socialist
organization of the health services which remained relatively
intact.  Finally, in Leningrad it was apparent that steps toward
privatization of the health services were proceeding at a more
rapid rate.

     Without a doubt, the chance to observe the dynamics of the
health sector in the different geographic areas of the country
contributed valuable elements to the analysis of the extent to
which the changes taking place in the country are affecting the
health services in the various regions.

     Although the seminar enabled the participants to deepen
their understanding of how the feldshers are used, certain
concerns, related above all to the future of the Soviet health
services as a whole, could not be adequately dealt with given the
general uncertainty about the future created by the profound
changes taking place in Soviet society.

CHARACTERIZATION OF THE FELDSHERS WITHIN THE HEALTH SYSTEM

     The program for the seminar basically consisted of an
overview of the system for training the feldshers and their uses
at the different levels of the health system. 

     From the material distributed prior to the seminar,
participants learned of the feldsher's role in providing primary
health care at the local and district levels, in both urban and
rural areas.  Within these services the feldsher acts as a
"bridge," providing a liaison between the peripheral health
service and the first level of referral.  The feldsher is also
referred to as a medical assistant, or as a "high-level nurse,"
which would place the feldsher's role between that of the nurse
and the physician.

     The participants emphasized the fact that this initial
definition of the feldsher was much closer to the job profile of
the feldsher observed in the rural health post near Suzdal.  As
the participant from Belize put it, "The feldsher's role in the
rural health post matches my preconception and expectations for
this group of health workers."  In this case the feldsher works
in a small rural health post together with a midwife and nurse,
with responsibility for a specific population group and working
under the supervision of a physician at the nearby rural
hospital.  This organization of services begins at the level of
the feldsher's post, which serves around 700 persons, and then
moves to a secondary level in the rural hospital, which in turn
serves a population of around 3,000 inhabitants.  The feldsher's
practice -- encompassing activities in health promotion and
prevention, a basic level of curative care, house calls, follow-
up to medical treatment, ongoing medical supervision, and
referrals to higher levels of the system, all with a significant
degree of community participation -- would reflect, as the
participants understood it, the characteristics of the model of
primary health care proposed by Alma Ata.  In the words of the
participant from Bolivia, "[In Suzdal] we could see that many of
the Alma Ata postulates on primary health care are being
fulfilled."

     The characterization of the feldsher becomes more
complicated, however, when one looks at the health services in
the cities, where there is an apparent tendency to expand the
concept of the feldsher to cover other professional categories. 
In Moscow, as in Vladimir and Leningrad, it appeared that the
schools for training middle-level medical personnel referred to
different types of feldshers as stomatologists, laboratory
technicians, physiotherapists, x-ray technicians, and
anesthesiologists.

     This tendency to expand the concept of feldsher is
reflected, for example, in Vladimir province, where 60% of the
feldshers are found in the cities rather than in the rural areas. 
The feldshers in Vladimir work at the level of health posts
located in factories and schools, and have no role in hospitals. 
In the case of Moscow, there is a greater diversity in the
concepts covered by the term feldsher, and thus one finds
feldshers working at the hospital level as technicians in
anesthesiology, physiotherapy, and laboratory, and performing
electrocardiograms; and outside the hospital in the emergency
stations, providing emergency care in ambulances.

     In other words, the term feldsher -- which comes from the
German "feld" (field), and thus implies the idea, as understood
at the beginning of the seminar, of personnel providing primary
health care in outlying areas -- does not correspond to a single
category of health personnel in the Soviet Union, but tends to
encompass a number of categories.  Some of them differ
substantially from primary health care personnel and really
correspond to more specialized and restricted job categories, a
point mentioned by Honduran participant in his report.

     In an effort to systematize the observations from the
seminar so that one can establish criteria for comparison with
the experiences of other countries, it is useful to think in
terms of three broad categories of feldshers:

     a)  the feldsher working in primary health care, especially,
     as mentioned above, the feldsher working in a rural post;
     and the feldsher providing emergency care in the major
     cities whose job profile is specific and well-defined within
     the city's primary health care system;

     b)  the feldsher primarily concerned with preventive care,
     whose job profile would be that of a sanitary feldsher;

     c)  other types of feldshers who do not play a role in
     primary health care, but whose jobs involve performing
     complementary services under the direction of the physician,
     as is the case with feldshers who are stomatologists,
     laboratory workers, physiotherapists, radiologists, or
     anesthesiologists.
     
     However, it is necessary to add yet another job category to
cover those feldshers working in rural hospitals, factories, and
schools.  This is the one which the participants found difficult
to understand, since it is a role quite limited in scope and
completely subordinated to the authority of the physician, making
it difficult to distinguish from the role of the nurse.

     This issue becomes still more complicated in light of the
proposed creation of new job categories such as the professional
nurse and the family doctor, whose roles would appear to overlap
to some degree with some of the functions of the feldsher.

TRAINING OF THE FELDSHERS

     The system of institutions for training middle-level
technicians consists of around 600 schools providing basic
training and 17 post-graduate schools, which are distributed
throughout the entire country.  These schools are considered to
be institutions of specialized secondary training, and they train
12 types of specialists, including feldshers, midwives, and
nurses.

     From the group's observations, it appears that the system
for training feldshers in the Soviet Union is based on a solid
infrastructure.  The schools visited had abundant human and
material resources.

     The training of a feldsher begins after 11 years of basic
schooling, in contrast to the training of a nurse, which can
begin after only nine years.  Students are admitted on the basis
of their previous qualifications, the results of entrance
examinations, and their place of residence.  Steps are taken to
encourage the admission of persons from the rural areas, on
condition that they return to practice in their home area.  There
is also a type of career guidance through which students in the
intermediate school attempt to generate interest among students
in the basic schools.

     The intermediate-level medical schools appear to fulfill
three principal functions:  1) the basic training of the
different types of feldshers;  2) the process of continuing
education;  3) the pedagogical and technical training of the
professors.

     1)  The duration of the training for feldshers depends on
     the specialty and on the number of years of basic school
     completed.  It lasts on average two years and six months,
     while that of a nurse lasts one year and six months.  An
     interesting aspect of this training is the fact that it
     begins with a level of basic training apparently intended to
     address inequalities produced at the basic school level.

     The teaching materials appeared to be of high quality, at
     once simple, inexpensive, and highly effective in a
     pedagogical sense.

     2)  Without doubt, the aspect which most impressed the
     participants was the importance given to continuing
     education.  The educational process is structured so as to
     ensure the continuous updating of knowledge for all
     personnel.  The feldsher must take a refresher course every
     five years, and this process is ensured by closely
     coordinated planning between the institution providing
     services and the institution which trains personnel.

     3)  The participants reported a similarly positive
     impression of the importance given to the pedagogical
     training of teaching personnel, who, in addition to
     receiving specialized training in teaching, also undergo
     continuous pedagogical updating.

     The acceptability of this updating process is clearly
enhanced by the associated policy of economic incentives which
accompany continuing education.  The feldsher who completes a
refresher course acquires a new job title which entitles him or
her to a higher salary.

COMPARATIVE ANALYSIS

     Although the trends appear to be changing, at this time the
Soviet health services are still organized basically along a
socialist model; in other words, the dynamics of production and
utilization of health manpower are subject to different
determinants than in the participants' countries.  Although this
reality limits the scope for comparison, it creates, in turn, a
framework of differences that can stimulate analysis in countries
with different types of social organization.

     The socialist health system of the Soviet Union is based on
principals of universal access, services provided free of cost,
and participation, and the state organizes the services so as to
guarantee the fulfillment of these principals in practice.

     One aspect of this organization which the participants
commented upon frequently was the relationship between the
institutions providing services and those concerned with training
human resources.  The type of manpower planning where training
institutions implement their programs according to the needs of
the services is not found in the participants' countries.  In
this regard, some participants referred to a "divorce" between
the health services and the institutions which train human
resources.  This leads to situations in which some personnel,
such as nursing technicians are trained in private institutions;
the result, according to one of the Peruvian participants, is
disorder and chaos, since these institutions are responding to an
unreal demand that fails to match the requirements of the health
institutions that receive their graduates.

     Nonetheless, among the concerns raised by the participants
was their perception of a marked separation between the directors
of the educational institutions and those persons involved in
policy-making and planning.  This appears to create a top-down
dynamic in which the educational institution transmits standards
issued from the top level, without possibility for feedback.  In
the words of the participants:  "The health system appears to use
a highly standardized approach that is reflected in the training
offered by the schools, where activities are carried out under
strictly established standards and where the teacher-student
relationship apparently maintains the same hierarchical rigidity
that is seen throughout the system."

     A further concern about the educational system was the
apparent lack of integration between teaching and service.  It
appeared that in the schools the so-called "practical classes"
were based primarily on simulation exercises.  Although there was
mention of mechanisms for training the feldshers within the
services, visits to some did not reveal any clear organization of
this integrated teaching-service process.  The fact that the
professors are predominantly physicians and not feldshers also
reflects this evident lack of integration between teaching and
service.  This was of special concern since it does not make
sense that the refresher courses should be given outside the work
setting and without any process of reflection or evaluation of
the student's practice.

     Another difference noted by the participants concerned the
diversity of factors which regulate the labor force in societies
like their own, factors which obviously are not present in a
socialist society.  One such factor which was mentioned
repeatedly was the role of professional corporations.  In the
case of both Costa Rica and Brazil, for example, professional
corporations were cited as among the principal obstacles to a
more rationalized process of manpower planning by the state.

     Unfortunately, the discussions did not permit greater
clarification of the importance of other factors which influence
the dynamics of health manpower in Soviet society.  Factors
related to the sex distribution in the different professions,
geographical distribution, the role of the wage scale, and the
social prestige of the different areas of health work, could not
be discussed in adequate depth.

     With respect to the organization of the services, one of the
aspects emphasized by the participants -- since it is not
necessarily present in other countries -- was the importance
granted to the worker.  Examples include the organization of
service around productive units such as factories or agricultural
cooperatives, and the fact that a large part of the service
infrastructure is dedicated to physiotherapy.  Another positive
aspect was the organization of services by geographic area, with
responsibility for a defined population and with guaranteed
mechanisms for making referrals to higher levels of care.  These
conditions generally are not present in the participants'
countries.

     It should be noted in this regard that the participants'
greatest concern was that the changes taking place in Soviet
society may profoundly affect this organization of the health
services.

     In terms of the relationship between the profile of the
feldsher and that of middle-level technical personnel in the
participants' countries, the following points were raised.

     In general, it appears that the job profile of the primary
health care worker in the participants' countries does not
correspond to that of a middle-level technician.  It most often
resembles the profile of a nursing auxiliary and/or health
promoter, with a much lower level of qualification than a
feldsher.  Training is less extensive, and the functions are
almost exclusively preventive and educational rather than
curative.  An example is the case of the Dominican Republic,
which has recent experience with training middle-level
technicians in rural health, with a higher level of training than
an auxiliary or promoter, but more oriented toward education and
environmental sanitation.

     Curative coverage at the primary care level, in the case of
certain countries such as Mexico and Peru, is the responsibility
of the rural physician.  This is typically a recently graduated
physician who must perform compulsory service for a specific
length of time in the rural health services run by the state.

     Of special interest to the participants was the job of the
sanitary feldsher.  One of the participants wrote: "The activity
of the sanitary position is especially important for validating
the experience in my country, since the functional integration of
basic sanitary control, epidemiological control, dietary
supervision, and their relation to the health services, would
permit the coverage of certain public health actions by a single
person."  In the case of Peru, it was noted that the sanitary
epidemiologist collects data but lacks the sanitary feldsher's
authority to intervene.  In Belize, similarly, there is a "public
health official" with a job profile which is similar but more
limited than that of the sanitary feldsher.

     On the other hand, the epidemiological-sanitary position is
limited in that its role is confined to sanitary surveillance of
the environment (water, air, food contamination), but does not
include epidemiological analysis of the health situation.

     In respect to the feldsher working in emergency care, it was
noted that no job profile with these characteristics exists in
the participants' countries.

     With regard to the other types of feldshers included in
category c), it was noted that these are the ones which would
most resemble the middle-level technician in the participants'
countries.  During the meeting on general guidelines for the
training of middle-level technicians which was sponsored by PAHO
in Washington in 1984, the following definition of middle-level
technician was proposed: a health worker who carries out his
functions under the supervision of a professional within a
particular specialty, and who has completed a post-secondary
training course which permits him, on the basis of broader
knowledge and greater practical experience, to carry out more
complex techniques in his specialty and to supervise the work of
the health auxiliary.

     This definition encompasses different types of middle-level
technicians, in the countries of the Region, which correspond to
some of the job profiles of the feldsher (middle-level
technician) in the Soviet Union; for example, technicians in
laboratory, anesthesia, pharmacy, and physiotherapy, as well as 
stomatologists and radiologists.  However, there would still be
differences in the type of training.  In the case of Bolivia, for
example, it was noted that the middle-level technicians do not
undergo a phase of general training, as do the feldshers; rather,
their training is oriented to their specialty from the outset. 
In the cases of Peru and the Dominican Republic the middle-level
technicians undergo longer training, giving them a more
professional status within the health services.

     The feldsher's role in schools, rural hospitals and
industrial polyclinics, by contrast, resembles more closely the
job of a nurse, while the nurse in the Soviet system is more
comparable to the nursing auxiliary in the participants'
countries.

     As mentioned above, the group's unanimously positive
impression of the continuing education process generated concern
among the participants that this aspect should be reviewed in
their own countries: "The role of the intermediate-level medical
schools is significant, it appears to be a very interesting
experiment in continuing education ... I will raise this idea for
discussion in my country."  "This experience encourages me to
review the system for training our middle-level technical
auxiliaries in order to try to improve its organization and offer
new alternatives where necessary."  "I believe this experience
may be feasible in my country both from the standpoint of
planning and policy in rural health, and in terms of the training
itself."  "The system of continuing education for middle-level
technicians could be applied in the Ministry of Public Health
through the School of Public Health, and the universities could
collaborate in updating other professionals."  

     None of the countries has a system of continuing education
as well established as that of the Soviet Union; Soviet
knowledge, therefore, provides an important reference point in
each country's search for alternatives.  

CONCLUSIONS AND RECOMMENDATIONS

     It should be pointed out first of all that the seminar
experience went beyond its objectives to give the participants a
privileged opportunity to observe close at hand the rapid changes
taking place in Soviet society, which will have repercussions
well beyond that country's borders.  From the perspective of
public health in the countries of the Region, it was of great
interest to be able to observe the impact of these changes on the
organization of the health services.

     The seminar unquestionably provided a fine opportunity for
the participants, in becoming familiar with the Soviet health
system and especially the training and utilization of the
feldshers within the system, to begin a process of reflection and
analysis on the use of middle-level technicians in their own
countries.  Elements such as the organization of primary health
care in rural areas, the system of emergency services in the
cities, and the organization of services in the workplace, are
external reference points that provide interesting points of
comparison for analysis of the situation.  Furthermore, the
system of continuing education seen in the Soviet Union raised
concerns among the participants in terms of viable alternatives
for each of their countries.

     The objectives defined for this year's seminar, as set forth
in the UNDP project document, establish a predominantly
analytical and conceptual orientation which, by providing an in-
depth understanding of the factors that determine the dynamics of
the health sector, permit an analysis comparing the Soviet
experience to the experience of each of the participants'
countries.  In their evaluations, including the reports on
individual phases of the trip as well as the sections dealing
with the seminar as a whole, the participants nonetheless noted
certain limitations:

     -    The seminar activities, including the planned site
visits to feldsher training schools and feldsher
workplaces, were organized on a rather tight schedule. 
On the one hand, this had the effect of curtailing
activities aimed at stimulating exchange among the
participants; on the other hand, on certain occasions
it also impeded a higher level of exchange between the
participants and Soviet personnel.  The impossibility
of going beyond the descriptive level in discussions
with Soviet personnel, along with the lack of time for
sharing concerns among the participants, hindered
efforts to develop a deeper critical analysis of what
was seen and an exchange among the participants aimed
at comparing these observations with experiences in
their respective countries.

     -    A second limitation was linked to the fact that the
great majority of persons who addressed the group
during the seminar did not hold positions at the same
hierarchical level, within the structure of the health
services, as the participants held in their respective
countries.  As a result, most of the Soviet speakers
limited their presentations to a basically descriptive
approach.  This meant that many points related to the
rationality and criteria for policy-making could not be
dealt with satisfactorily, hindering a deeper exchange
and discussion of the factors underlying the
development of policies governing health manpower and
the feldshers in particular.  

     -    The organization of the seminar, which was focused
almost exclusively on the feldshers, could be seen as
another obstacle to the full utilization of this type
of exchange.  The seminar organization tended to
present the feldsher in a manner isolated from the
dynamics of the health services as a whole.  This
created difficulties in understanding the roles of
other health personnel in relation to the role of the
feldsher.  Participants felt they needed to examine the
job profiles of other health personnel in order to
better understand the feldshers, and as a result, they
requested a visit to the medical training schools which
had not been planned as part of the program.

     Furthermore, the context in which the seminar took place,
one of intense changes in all areas of Soviet society, created
great uncertainty regarding the impact on the field of public
health.  This uncertainty meant that some questions remain
unanswered, since only time will tell what the impact on the
services will be.  Nonetheless, certain general trends could be
seen in the evolution of the services and were perceived by the
participants as worrisome, above all the trend toward
privatization.  The manner and intensity with which privatization
may affect the socialist health system is of great interest as an
external reference point for the health services in the
participants' countries.  In this regard, it is of special
concern that these steps toward privatization are proceeding in
the absence of theoretical references in Soviet public health,
especially with respect to the financing of the health sector.

     In this regard, it may be possible to increase technical
cooperation between countries of the Region and the Soviet Union,
particularly in matters related to the financing of the health
services, an area where the Latin American countries have
extensive experience and a strong theoretical base, offering a
potentially valuable contribution to the Soviet health services
as they take their new course.

     On the basis of these considerations, the following changes
are suggested for future seminars:

     .    the seminar could be planned so as to provide a broader
and deeper understanding of the health system in its
entirety;

     .    expand the scope to include all the different types of
personnel providing primary health care, and not only
the feldshers;

     .    raise the level of dialogue so that the participants
can hold an exchange with officials in charge of
setting policy;

     .    arrange for the program to include workshops where the
participants can discuss and debate what they have
observed and deepen elements of comparative analysis;

     .    plan the seminar program with enough flexibility to
allow deeper debate with certain speakers when this is
felt to be needed.

     Two concerns were raised about the logistical aspects of the
seminar.  One was the need to improve the system of translation. 
The participants felt that the intensity of the seminar required
the presence of more than one interpreter, avoiding the risk of
overloading a single interpreter with work and thereby
diminishing his efficiency.  A second suggestion was that the
audiovisual materials be translated into the official language of
the seminar.

     Finally, it was suggested that for future events of this
type, ways be found to facilitate the arrangement of travel and
visas in the respective countries.  The majority of the
participants reported having had serious delays in making their
travel arrangements on account of problems related to airfare and
visas.  Indeed, one of the three countries which did not send
participants dropped out because of delays in securing visas and
fares.
EBS12302.WPF                                            6/IX/91  
  
Cholera in the Americas -  Update

     Since publication of the previous update, cholera cases have
been identified in three more countries of the Region--Guatemala,
El Salvador, and Bolivia (Epidemiological Bulletin, Vol. 12, No.
2, 1991).
     From the beginning of the epidemic in Peru at the end of
January, cholera has attacked a country a month:  Colombia in
March, Chile in April, Brazil in May, Mexico in June, Guatemala
in July, El Salvador in August, and, most recently, Bolivia.
     The total number of cases reported to PAHO as of ---- 1991
was ------, with ---- deaths.  This number is more than four
times the total number of cholera cases reported worldwide in
1990.
     In Chile the epidemic has virtually ceased, the last case
having been reported on 22 May of this year.
     In Peru the incidence of cholera has diminished from a total
of 15,000 to 20,000 cases registered per week in February to ---
-in August.
     In Ecuador the provinces most affected during the month of
August were -----.  The average number of reported cases per week
in the country during July and August was ---- compared to ---
reported in -----.
     In Colombia cholera has spread to the departments of ----
since the last update.
     Cholera in Brazil continues to be confined basically to the
State of Amazonas.  As of the last report received, cases had
occurred in the municipios of Jutai, Atalaia do Norte, and SØo
Paulo de OlivenÛa (in Medio Solimïes), in addition to Tabatingá
and Benjamin Constant.  An isolated case was reported in the
State of Mato Grosso and an imported case was registered in the
city of SØo Paulo.  No associated cases were registered.  Brazil
reported ---- cases during the period 30 June-30 August compared
to 18 reported cases in the two previous months.  In this country
cholera cases are considered to be only those confirmed through
laboratory identification of V. cholerae 01, El Tor, Inaba.
     The last report on the cholera situation in Mexico covers
the period 28 June-6 August.  During this interval -----
additional cases were reported by the states of ------------.
     In Guatemala, in the third week of July 1991, Vibrio
cholerae 01, El Tor, Inaba was isolated in a Guatemalan man from
the Department of San Marcos (on the border with Mexico).  During
the next five weeks, up to --- August, there was a rapid spread
of the disease from rural areas toward the capital.  As of that
date, ----- cases had been reported in the departments of San
Marcos, Suchitepéquez, Retalhuleu, Guatemala, Quetzaltenango,
and Sololá.
     In El Salvador the first two cases of cholera were reported
on 16 and 21 August.  Both patients were indigent men living in
Colonia Esmeralda, Barrio San Jacinto, in the capital city, San
Salvador.  Neither had a history of having traveled outside the
area.  The laboratory isolated Vibrio cholerae 01, El Tor, Inaba
from the feces of both patients.  Since the first reported cases,
there have been a total of --- cases and one death, all occurring
in the metropolitan region (14 neighborhoods) and surrounding
area (Zacatecoluca).
     Bolivia reported the occurrence of four cholera cases
confirmed by laboratory on 27 August.  All the patients were
adult residents of two communities located along the Choqueyapu
River in the Río Abajo region, 20 km south of La Paz.  As of --
--August, two additional cases had been reported, one in the same
region and another (a death) in the El Alto region, also near La
Paz.
     In the United States of America, four cases of cholera have
been identified in addition to the fourteen previously reported
in 1991.  All were imported, two of them from other regions of
the world (Cambodia and India) and two from Latin America
(Ecuador).  No secondary cases of transmission have been
registered within the country.
     In assessing the situation in the Region on the basis of
data reported by the aforementioned countries, it should be borne
in mind that clinical manifestations of V. Cholerae 01 infection
have ranged from asymptomatic infections (75%) and mild diarrhea
up to the severest clinically identifiable forms (5%).
     Given the evolution of the cholera epidemic in Latin America
over the past seven months, both in terms of its magnitude and
the way in which it has spread, it is feared that the disease may
extend to other countries in coming months and become endemic in
some areas of the Region.  It is therefore essential that all the
countries take steps to prepare for a possible attack of cholera
and formulate or review their national plans for contending with
this disease.

ADVISORY MEETING ON THE DISPOSAL OF EXCRETA
AND WASTEWATER
IN LATIN AMERICA AND THE CARIBBEAN


Washington, D.C.                               22-24 October 1991



Guidelines for Working Groups


GENERAL INFORMATION


-    The participants will be divided into two groups, each of
     which will work independently, carrying out the activities
     outlined in the guidelines for Blocks 2 and 3.


-    The composition of each group is indicated on a separate
     sheet.  At its first working session each group should elect
     a moderator-rapporteur from among its members.

-    The results obtained by each group will be presented and
     discussed at the Plenary Session scheduled to coincide with
     completion of the activities under Blocks 2 and 3.  The
     presentation will be made by a representative designated by
     the group, who may be supported by other group members in
     order to respond to any questions that arise.

-    In addition to the oral presentation, each group will deliver
     its recommendations in writing.  At the least, the group is
     expected to complete the forms provided at the start of its
     work. 

-    The composition of the working groups will remain the same for
     the duration of the meeting.




ADVISORY MEETING ON THE DISPOSAL OF EXCRETA
AND WASTEWATER
IN LATIN AMERICA AND THE CARIBBEAN

Washington, D.C. -  22-24 October 1991


Block 2 of Activities--Guidelines for Working Groups


1.   ACTIVITIES

Based on the presentations made the previous day, as well
     as the information contained in the reference document
     distributed for discussion at the Meeting, each of the groups
     should do the following:

     -    Analyze the most critical problems in excreta and
wastewater disposal in the countries of the Region, and
identify the most appropriate measures for their
solution.

     -    Identify specific institutions and activities to support
the development and execution of programs for the sector.
     
     -    Suggest strategies and means for mobilizing resources to
finance programs for the sector, and propose mechanisms
of coordination between agencies with a view to
optimizing interventions in this area.


2.   PRESENTATION OF RESULTS

     -    Each group will have of a maximum of 20 minutes to
present its work to the Plenary Session, which will meet
from 3:30 to 5:00 p.m.  Following the presentations there
will be a discussion period.

     -    The group should also provide the information requested
on the attached forms and should deliver them to the
Coordinator of the meeting upon completion of the group's
work.

     -    If necessary, the group will also deliver a summary
report of its work, indicating its principal
recommendations.


Critical Problems in the Disposal of Excreta and Wastewater in the
Countries of Latin America and the Caribbean, and Measures
Recommended for their Solution.


Block 2                                   Working Group No.      

Critical Aspect and/or ProblemMeasure Recommended for
its Solution







































Identification of Specific Institutions and Activities to Support
the Development and Execution of Programs for the Treatment and
Disposal of Excreta and Wastewater in the Countries of Latin
America and the Caribbean.


Block 2                                   Working Group No.      

Institution/
     AgencyActivities or Aspects in which it Can Provide Support
for Programs in the Countries





































     
Recommended Strategies and Means of Mobilizing Resources to Finance
Programs for the Treatment and Disposal of Excreta and Wastewater


Block 2                                  Working Group No.       

Activity or Program 
for which Financing
is RequiredRecommended Strategies and/or
Means of Mobilizing
Resources


































Recommended Mechanisms of Coordination to Optimize the
Interventions of Institutions that Support and/or Carry Out
Programs for the Treatment and Disposal of Excreta and Wastewater
in the Countries of Latin America and the Caribbean

Block 2                                   Working Group No.      

Institutions InvolvedRecommended Mechanisms of
Coordination




































Advisory Meeting on the Disposal of Excreta and Wastewater in Latin
America and the Caribbean


Block 2                                    Working Group No.     

    Complementary Observations on the Work Carried Out under
Block 2 of Activities








































ADVISORY MEETING ON THE DISPOSAL OF EXCRETA
AND WASTEWATER
IN LATIN AMERICA AND THE CARIBBEAN

Washington,D.C. -  22-24 October 1991


Block 3 of Activities--Guidelines for Working Groups


1.   ACTIVITIES

Based on the work carried out under Block 2 of
     activities, as well as the information contained in the
     reference document distributed for discussion at the Meeting,
     each of the groups should do the following:

     -    Identify coordinated strategies of action that will help
to increase and optimize the support provided by
different agencies to the Governments of the countries
of the Region for the solution of problems in the
treatment and disposal of excreta and wastewater.

     -    Recommend matters and/or actions in this sector to be
included in PAHO technical cooperation programs in the
countries of Latin America and the Caribbean.


2.   PRESENTATION OF RESULTS

     -    Each group will have of a maximum of 20 minutes to
present its work to the Plenary Session, which will meet
from 3:30 to 5:00 p.m.  Following the presentations there
will be a discussion period.

     -    The group should also provide the information requested
on the attached forms and should deliver them to the
Coordinator of the meeting upon completion of the group's
work.

     -    If necessary, the group will also deliver a summary
report of its work, indicating its principal
recommendations.


Strategies Recommended by the Group to Optimize and/or
Increase the Support Provided by International Cooperation Agencies
to the Countries in the Field of Treatment and Disposal of Excreta
and Wastewater


Block 3                                    Working Group No.     


Recommended StrategyInstitutions/
Agencies Involved



































Matters that the Agencies and Participants in the Advisory Meeting
Recommend that PAHO Include in its Technical Cooperation Programs
related to the Treatment and Disposal of Excreta and Wastewater

Block 3                                   Working Group No.      

Matter that is Recommended to
PAHO for Inclusion in its
ProgramOther Agencies that Include this Matter in their Programs
and Type of Coordination that is Suggested.


































Complementary Observations on the Work Carried Out under Block 3
of Activities.














































   
AMRO Contribution to the
Director General's Report
on the Work of WHO, 1990-1991

CHAPTER 18.  REGION OF THE AMERICAS

     Most of the countries in the Region of the Americas have
entered the 1990s in a state of serious economic and social
deterioration.  The pervasive economic crisis of the past decade
has sharply eroded the average standard of living of the
population in Latin America and the Caribbean, adding to the
number of previously unmet social needs.

     Real decline in per capita production in the Region,
together with high levels of inflation, falling terms of trade,
and growing unemployment and underemployment are only some of the
ways in which the crisis has been manifested in the national
economies of the Region.  These factors, combined with lower
levels of domestic saving and investment, have reduced the
availability of goods and services.

     This situation has been reflected in the social sector,
where the crisis has resulted in a marked decrease in public
spending, which in turn has aggravated the persistent
deficiencies in basic infrastructure and services.  In most of
the countries, expenditure on new investment has been extremely
limited, and the flow of resources available for the operation of
services has been reduced or cut off entirely.  This has been
manifested in limited investment in basic sanitation and the
replacement, maintenance, and conservation of equipment. 
Moreover, it has proved impossible for many of the countries to
maintain current levels of expenditure, which has impaired the
operation of programs aimed at addressing their most prevalent
problems and restricted administrative development and personnel
training in the sector.  The cholera epidemic that began in Peru
and has been rapidly spreading since early 1991 has attested to
the deterioration of the sanitary infrastructure in the affected
countries of the Region.

     Cholera has been incorporated into the long-standing
epidemiological profile of most of the countries in the Region,
where there continue to be high death rates and morbidity from
communicable gastrointestinal diseases, as well as respiratory
diseases, diseases preventable by vaccination, and diseases
related to malnutrition.  The epidemiological situation has been
exacerbated by an increase in the prevalence of chronic
diseases--particularly cardiovascular diseases, cancer, and
diabetes--and the consequences of demographic changes, especially
urbanization, which alter lifestyles and lead to deterioration of
the environment.  Moreover, there has been an increase in
disability and morbidity due to accidents, mental disorders, and
drug and alcohol addiction.  The epidemic curve of acquired
immunodeficiency syndrome (AIDS) has also shown a rapid increase
in Latin America and the Caribbean, with rates similar to those
that were seen in North America five years ago.

     The difficult conditions under which the countries of the
Region have entered the last decade of the twentieth century
imply an enormous challenge for PAHO/AMRO.  In the face of these
needs, the XXIII Pan American Sanitary Conference resolved to
approve the document "Strategic Orientations and Program
Priorities for the Pan American Health Organization during the
Quadrennium 1991-1994," which gives general guidelines for the
Organization's policy during the period.  The policy is premised
on the understanding that health is a fundamental part of
development, and health initiatives must therefore assume a
promotional and political role in development efforts. 
Accordingly, PAHO/AMRO has consistently endeavored to guarantee
involvement of the various social actors in discussions of
health-related problems so that health sector policies will be
the result of a concerted multisectoral approach.

     PAHO/AMRO has carried out a number of activities to
strengthen and develop local health systems, which have been
recognized as a valid response to the need to prepare health
services to a deal with the ever-increasing restrictions being
placed on the sector.  Efforts have been focused on reorganizing
the health sector through the local health systems so that
external financing, resources, and actions will be channeled
toward the high-risk population groups.  As a result, there is
now better functional coverage, less fragmentation of sectoral
actions, and greater equity in the distribution and accessiblity
of health services.

     Within the framework of local health system development,
immunization programs in the Americas have increased their
coverage, attaining for the first time in history a level of over
70% for all the vaccines included in the programs.  In 1990,
30,000 deaths from measles, whooping cough, and neonatal tetanus
were prevented, as were 5,000 cases of poliomyelitis.  During the
same year, only 14 cases of wild poliovirus were detected among
the more than 2,000 specimens examined, which signified a
reduction of 40% with respect to 1989.  All the indicators show
considerable progress toward the eradication of poliomyelitis in
the Western Hemisphere.

     When the first cases of cholera were detected in Peru,
PAHO/AMRO formed a cholera study group to coordinate the
international response, identify human and financial resources,
and provide essential information to the Member Countries and
other concerned agencies.  PAHO/AMRO has promoted the
strengthening of national capacity for the rapid mobilization of
resources, intercountry and intersectoral cooperation, and
emergency logistics and communications under the emergency phase
of the strategy for cholera prevention and control in the Region. 
Together with USAID and UNICEF, PAHO/AMRO has helped all its
Member Countries--both those affected by cholera and those where
the epidemic has not yet struck--to develop an extremely
effective program for the control of diarrheal diseases.  Efforts
in this connection have included the development and distribution
to all the countries of a training module on cholera which
describes the epidemiological and clinical characteristics of the
disease as well as laboratory and control procedures.  This has
led to the standardization of actions to combat cholera, which
will result in a more efficient and effective campaign against
this disease.

     AIDS continues to be a major concern for PAHO/AMRO.  Top
priority has been given to direct technical collaboration with
the Member Countries in the development, execution, financing,
and evaluation of their national programs for the prevention and
control of AIDS.  During 1990, a total of 80 consultant-months
were mobilized in support of national and subregional programs. 
The national programs have been structured around four principal
strategies:  prevention of the sexual transmission of HIV,
prevention of the transmission by blood and blood products,
prevention of perinatal transmission, and reduction of the impact
of the epidemic on individuals and social groups, with special
emphasis on the prevention of drug addiction, sex education for
children and adolescents, the strengthening of laboratories, and
quality control of blood and blood products.

     Activities in environmental health have continued the
directions taken during the International Drinking Water Supply
and Sanitation Decade (1981-1990).  September 1990 marked the
adoption of a Regional declaration on "Water Supply, Sanitation,
and Health," which proposed strategies for achieving universal
coverage by the year 2000.  PAHO/AMRO has also supported the
development of national water supply programs in coordination
with IDB, UNICEF, UNDP, and bilateral cooperation agencies.  In
1990, 259 courses and seminars were offered on water supply and
sanitation in 18 countries of the Region--a marked increase in
training at the national level.  PAHO/AMRO has promoted
certification programs for non-professional personnel in the area
of environmental sanitation in some of the countries of the
Region and has provided support for the creation and/or
consolidation of Regional networks of institutions to facilitate
efforts in various areas, including the treatment and recycling
of refuse, toxicology, environmental epidemiology, and the
assessment of environmental impact.  In addition, the
Organization has collaborated in the strengthening of the Pan
American Network of Information and Documentation in Sanitary
Engineering and Environmental Sciences.

     Throughout the biennium PAHO/AMRO stepped up efforts at the
subregional level.  In light of the important role played by the
Central American Health Initiative known as "Health, a Bridge for
Peace," the XXIII Pan American Sanitary Conference resolved to
support the second stage of the initiative approved in Belize by
the Ministers of Health of the subregion under the title "Health
and Peace for Development and Democracy in Central America." 
PAHO/AMRO's cooperation has been aimed mainly at the development
of national and subregional capacity to mobilize resources for
national and subregional projects in four priority areas:  health
infrastructure, health promotion and disease control, attention
to special groups, and protection of the environment.

     In the Andean subregion, PAHO/AMRO has provided support for
important advances in health sector coordination.  Since May 1990
there have been periodic subregional meetings of directors of
social security institutions.  In 1991, for the first time in the
subregion, comprehensive coordination agreements were signed
between the Ministries of Health and the social security
institutions.  With the ongoing support of the Andean Cooperation
in Health (ACH), arrangements were made to mobilize considerable
resources for the Plan of Social Emergency for combating cholera.


     The health sector will face enormous challenges during the
last decade of the century.  If it is to meet these challenges,
health must be assigned greater importance in the formulation and
implementation of social policies and must be seen as a
fundamental component for the sustained development of the
countries.

     The principal task confronting the sector is that of its own
modernization.  Modernization will mean developing the sector's
capacity to make effective use of epidemiology in order to
identify priority problems and establish functional coverage for
the population groups that are at greatest risk.  In order to do
this it will be necessary to increase the efficiency and
effectiveness of the sector through the improvement of managerial
capacity in the services and the implementation of qualitative
and quantitative changes in the patterns of service production. 

     All of the foregoing should help to reduce disparities in
the health status of different social groups and guarantee all
citizens access to services so that their basic health needs can
be met.
      










Provisional Agenda Item 5                   SPP17/4 (Eng.)
30 October 1991
Original:  Spanish








DEMOCRACY AND HEALTH:

   PAHO/WHO COOPERATION WITH THE LEGISLATURES OF THE AMERICAS 






















  PAHO/WHO COOPERATION WITH THE LEGISLATURES OF THE AMERICAS 


  1.    Background

  Several factors have been instrumental in the development of the
project "Democracy and Health," which began in the early 1990s. 
From a socioeconomic perspective, opportunities have arisen to
offset some of the negative effects that the crisis of the "lost
decade" has had on social development in the Americas, especially
its impact on health.  Aggravated by the economic adjustment
policies adopted by many countries in response to the crisis, these
effects have been manifested in growing inequity between the
different social strata in the Americas in terms of the risks for
disease and death and access to health services.

  From a political standpoint, the trend toward democracy that has
been evident during the last decade in Latin America and the
Caribbean has generated favorable conditions for interaction by the
Pan American Health Organization (PAHO/WHO) with the legislatures. 
It has been through the revitalization of democracy that the
legislatures have recovered their pivotal role in the political life
of the countries, a role which for many years they had lost.  This
phenomenon carries singular importance, since the legislative
sphere, where conflicting groups and interests converge and validate
one another, provides fertile ground for the examination of health
issues and the formulation of new social policies to contend with
the crisis.  The authoritarian state tends, by its very nature, to
formulate restrictive legislation, which emphasizes national
security at the internal level and leads to isolation and seclusion
at the international level.  The constitutional state, on the other
hand, attaches special importance to distributive legislation,
oriented toward social welfare and the achievement of equity, while
in regard to external relations it emphasizes integration and
cooperation with the countries that are its counterparts.

  Within the Organization, the countries of the Americas have
recognized that health is not only a basic component of development
but also one of its objectives.  Inasmuch as it is influenced by
political, social, and economic factors, health should not be the
exclusive responsibility of the health sector; rather, it requires
participation by society as a whole and by all the entities of
government, including the legislature. Such thinking inspired
several events during the decade of the 1980s which pointed up the
desirability and timeliness of incorporating the issue of "Democracy
and Health" into the dynamics of the legislatures in the Americas. 
Among these events were the meetings held in Antigua and Montelimar,
as well as the I and II Madrid Conferences of 1985 and 1988, which
shaped and set in motion the Plan for Priority Health Needs in
Central America and Panama.  These occurrences suggest that health,
together with peace and social justice, are basic components in the
effort to further development and implement democracy.  Moreover,
they illustrate the need to adopt new strategies in order to
strengthen the capacity of the legislatures to define more equitable
policies, channel more resources, and control public management of
health, as well as to promote closer ties between the legislatures
of the Region.

  The Organization's first contribution in support of this
initiative was the creation of the Project on Health Legislation
(HLE) under the program chapter of Health Policies Development
(HSP).  The aim of the Project is to manage information and provide
technical cooperation in this area.  As part of this Project, work
has begun on the LEYES data base, which will index the national
health legislation that has been passed by the countries of Latin
America and the Caribbean since 1978.  The data base will be
available to governments, legislatures, and academic institutions
throughout the Region on the compact disk (LILACS/CD-ROM) produced
by the Latin American and Caribbean Center on Health Sciences
Information (BIREME).  The Latin American legislation is being
catalogued on the basis of the Index to Latin American Legislation
prepared by the Hispanic Law Division of the United States Library
of the Congress.  The compilation of legislation from the Caribbean
countries is being carried out under an agreement between PAHO/WHO
with the School of Law of the University of the West Indies (UWI).

  This data base, which is more current and complete than similar
collections in other areas if WHO, will give our Member Countries
access to the body of comparative health legislation in the Region,
which in turn will serve as an incentive and source of information
in the updating of their respective national laws.  At the same
time, efforts are being made to encourage the compilation of health
legislation at the sub-national level utilizing the same methodology
as that employed by LEYES, as in the case of the agreement with the
"Centro de Estudos e Pesquisas de Direito Sanitário" [Center for
Study and Research in Health Law] at the University of SØo Paulo. 
This agreement envisages the compilation and inclusion of health
legislation at the national, state, and municipal level with a view
to bringing it into conformity with the provisions of Brazil's new
Constitution enacted in 1988.




  2. Objectives

  PAHO/WHO is postulating the improvement of health as one of the
objectives of economic and social development, with a view to
reducing the inequalities in health conditions and in access to
health services among the different social segments of its Member
Countries.  The XXIII Pan American Sanitary Conference, held in
September 1990, adopted this position when it approved the Strategic
Orientations and Program Priorities for PAHO during the Quadrennium
1991-1994.  Among other targets that it establishes for the
quadrennium, this document calls on the countries and the
Secretariat to endeavor to improve the relative priority assigned
to health on their political agendas and in decision-making for the
allocation of resources, both at the national and international
level.  The thrust of this objective is to restore the social
visibility and political relevance of health in the societies and
Governments of the Americas.  To this end, it is essential to
promote the active involvement of the social and political actors
who are most influential and have the greatest decision-making
capacity in efforts to solve health problems and to safeguard the
achievements in this area to date.

  Among other measures, it is considered essential for the
Organization to work more closely with the legislatures of the
Region to promote the growing interest in health within the
respective countries, as well as to support them in carrying out
their legislative and control functions in this area.  Health is
considered to be one of the most propitious areas for achieving
agreement on the objectives of equity, democratic consolidation,
and Regional integration.  This is the rationale behind PAHO/WHO's
promotion of the Project "Democracy and Health."  The legislatures
have a key role to play in the Project inasmuch as they are
regaining the central position in the political life of the Region
that they had temporarily lost during periods of recess, cloture,
or dissolution.  This reactivation of the legislatures implies an
effort to recover lost time, notably through constitutional reforms,
sectoral reorganization, and the updating of sanitary codes--
measures that have been taken recently by several countries of the
Region.

  For many countries this new presence of the legislature has
signified a move away from a tradition of strong primacy of the
executive branch toward an acceptance of the equalizing role of the
legislative branch in the formulation of policies, the allocation
of resources, or management of the state apparatus.  More important
still, the legislature provides a forum for negotiation and
cooperation between the various interest groups involved in the
health sector and in health issues.  It is precisely through the
power and effectiveness of the democratic system that it is possible
to turn this negotiation and cooperation into clear-cut action
mediated and regulated by those who represent the interests of the
people as a whole.  Thus, the legislature plays an important role
in the definition of health policies, especially when there is a
need to reorder health care, rechannel financing for it, or regulate
the actions of those who produce health inputs and services. 
Moreover, it provides a favorable environment for making health more
than merely a sectoral concern and for strengthening its links with
other levels of political and socioeconomic development.  To
accomplish these tasks, the legislative branch will require
technical information and advice, in addition to exchange and
cooperation between legislatures, in order to enable it respond
more expeditiously and effectively to the social demands that it
is called upon to meet.

  The Project "Democracy and Health" was initiated in 1990 under a
cooperation agreement between PAHO/WHO and the Organization of
American States (OAS), on the basis of which four subregional
meetings of legislators were held.  In addition to seeking to
establish closer relations between PAHO/WHO, the OAS, and the
legislatures of Latin America and the Caribbean, these meetings had
the following objectives:

  a.    To contribute to the consolidation of democracy through
        greater equity in the area of health;
        
  b.    To strengthen the role of the legislature in dealing with
        health issues; 

  c.    To promote greater knowledge and information on the health
        situation among lawmakers as members of the Hemisphere's
        political leadership; and 

  d.    To identify the challenges and priorities for health that
        will orient futures actions in the legislative area and in
        technical cooperation.

  With regard to this last objective, the Project has undertaken to
involve the legislatures in the technical cooperation process at the
Regional, subregional, and national level in coordination with the
respective national authorities and with the support of other
international agencies.  This cooperation is intended to
progressively encompass legislatures at the national, provincial or
state, and municipal levels.

3.Evolution of the Project "Democracy and Health"

  3.1.  First stage:  Subregional Meetings of Lawmakers in 1990

  The first stage of the project began with the following
subregional meetings, the sites and dates of which are indicated
below, together with the number of lawmakers in attendance:

  ´ First meeting:  Tegucigalpa, 28-30 May, attended by 21
  lawmakers from Belize, Costa Rica, El Salvador, Guatemala,
  Honduras, Nicaragua, and Panama.

  ´ Second meeting:  Caracas, 18-21 June, attended by 24 lawmakers
  from Bolivia, Colombia, Cuba, the Dominican Republic, Ecuador,
  Mexico, Peru, and Venezuela.

  ´ Third meeting:  Kingston, 22-24 October, attended by 35
  lawmakers from Antigua and Barbuda, Aruba, Bahamas, Dominica,
  Grenada, Guyana, Jamaica, Netherlands Antilles, Saint Kitts and
  Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname,
  and Trinidad and Tobago.

  ´ Fourth meeting:  Santiago and Valparaiso, 7-9 November,
  attended by 28 lawmakers from Argentina, Brazil, Chile, Paraguay,
  and Uruguay.

  The meetings brought together a total of 108 lawmakers from both
legislative chambers (in the case of countries with bicameral
legislatures) with recognized interest and a relevant background in
social and health policies.  Two to five lawmakers were invited from
each country with a view to ensuring that every delegation had a
politically pluralistic composition.  Participation by women
lawmakers was strongly encouraged.  Each of the meetings was opened
by the Head of State of the host country, or his representative, and
a number of important figures, including Ministers of Health and
other governmental authorities, were in attendance.  The Central
American meeting coincided with a special meeting of Ministers of
Health from the subregion.  The PWRs participated in the meetings
in support of the delegations from the respective countries. 
Excellent press coverage, both oral and written, conveyed an
awareness of the significance of the event to citizens of the host
country.

  The sessions of the meeting were devoted to an examination of
topics having to do with the relationship between democracy and
health, including the following:

  ´     The role of the legislature in the health field;
  
  ´     Crises, adjustment policies, and their impact on health;

  ´     Financing problems in health systems development;

  ´     Women, health, and development

  ´     Technical cooperation:  priorities and prospects


  In preparation for discussion of the meeting's agenda, reference
documents were drawn up in accordance with specific suggestions
received from the various PAHO/WHO programs and from the OAS units
involved in the project.  In addition, various publications produced
by the sponsoring organizations were made available to the
participants. The documentation was sent to the delegations in
advance in order to allow them sufficient time to prepare their
contributions to the discussions, which resulted in well structured
interventions and a productive discussion of the proposed agenda.

  At these meetings, the lawmakers agreed on a series of points
which formed the basis for formal declarations and which have served
to orient the interaction of PAHO/WHO with the national
legislatures.  These points of agreement are described below.

  In economic terms, the legislators focused on the negative impact
that the crisis, external debt, and economic adjustment programs had
had in the Region, especially in the social and health areas.  There
was also agreement on the need to seek effective mechanisms to
respond to the situation and, with this objective in mind, to
integrate resources and efforts being undertaken by welfare
agencies, social security institutions, and private medical care.

  On the political level, they reaffirmed that there is a need to
consolidate the processes of democratization and peace-making, in
order reaffirm the right of citizens to health, to be accomplished
through legal provisions that go beyond merely paying lip service
to the idea and actually ensure access to good care and the
achievement of increasingly satisfactory levels of health for the
entire population.  The most important manifestations of this
process have been the constitutional reform initiatives aimed at
guaranteeing the right to health and defining the responsibility of
society and of the State in this regard.  The lawmakers also
recognized the importance of streamlining the work of the executive
and legislative branches with a view to ensuring more effective and
efficient policy-making in the area of health and giving the
legislature its rightful degree of control over this process. 

  The participants recognized the important contribution that the
legislature could make toward the attainment of equity, particularly
in light of its role in setting policy on fiscal and budgetary
matters.  Finally, they emphasized that there is a need to promote
the processes of regional integration as a means of responding to
pressing problems in the countries of the Region and presenting a
common front in the global system of international relations.

  In regard to women, the lawmakers underscored the importance of
involving them in the process of development in light of the
important role that women fulfill in society.  They also affirmed
the need to make the utmost use of women's capacity in the
promotion, protection, and recovery of health, as well as in the
prevention of disease.  It was agreed that it was therefore
necessary to include women, in their dual status as both
beneficiaries and promoters, in the development and implementation
of health policies.    

  Finally, it was recognized that there is a need to promote
cooperation between the legislatures of the Region in health
matters, as well as to enter into agreements and promote the
participation of legislators in events where social and health
issues are debated.  In addition, the lawmakers requested that the
sponsoring agencies establish lines of cooperation in the area of
health, stressing the need to update health legislation through an
approach that combines the principles indicated above.  It was also
emphasized that in order to attain these objectives it would be
indispensable to have mechanisms that would not only facilitate the
dissemination of knowledge on health legislation but would also
provide the lawmakers with access to the training needed in order
to address the challenge of health management at the legislative
level.

  In this connection it was recognized that the legislative
infrastructure is quite limited, making it difficult for the
legislatures to adequately fulfill the functions that have been
consigned to them in the prevailing Regional situation.  Moreover,
as yet there has been little interaction between legislatures,
health authorities, and international agencies in the area of
health, and there is still no clear awareness of the possibilities
for reciprocal cooperation.  Events such as the subregional meetings
can therefore be a means for them to become better acquainted with
one another and establish ties that will make for better utilization
of the potential of all parties concerned.


  3.2   Second stage:  Establishment of direct cooperation with the
        legislatures in 1991

  For the sponsoring organizations, the subregional meetings
generated a series of tacit commitments for technical cooperation. 
In the case of PAHO/WHO, the events made it possible to view the
legislatures in their political and technical dimension, which
resulted in a line of work that began to be implemented during the
second year of the Project.  As will be described below, this
cooperation has involved diverse activities, including agreements
for technical cooperation, promotion and support for subregional
meetings, and response to specific requests for advisory services
in relation to legislation, in addition to the establishment of
relations with Regional and subregional legislative organizations. 


  3.2.1 Technical cooperation agreements between PAHO/WHO and the
        legislatures

  The need manifested by the lawmakers for access to information
and training in the management of health issues led PAHO/WHO to sign
an agreement of technical cooperation this year with 20 legislatures
in the Region.  The legislatures included in this first stage are
those of Argentina, Barbados, Bolivia, Brazil, Chile, Colombia,
Costa Rica, Ecuador, El Salvador, Guatemala, Haiti, Honduras,
Jamaica, Mexico, Paraguay, Peru, Saint Lucia, Trinidad and Tobago,
Uruguay, and Venezuela.  The agreement provides for the following
types of cooperation:

  a) Provision of the technology required for use of the LILACS/CD-
ROM, including, in addition to periodic delivery of the compact
disk, a microcomputer with a printer and a CD-ROM reader.  This
technology permits access to the data bases of Latin American and
Caribbean literature in the health sciences (LILACS), human ecology
(ECO), environmental sanitation (REPIDISCA), and health legislation
(LEYES), all of them produced by BIREME;

  b) Subscription to the publications of the Organization that are
considered relevant for the development of health-related
legislation; and

  c) Opportunity for the legislatures to participate in the
Regional initiatives promoted by the Organization, as well as in
cooperation activities at the country level under agreements
concluded with the respective national authorities.

  The agreement also provides for the designation of an official
from the legislature who will take responsibility for coordinating
cooperation and providing information on the proposed laws under
discussion, as well as on the composition and activities of the
health commissions.  This information, in turn, will be placed at
the disposal of the other legislatures through a special data base
that should become available during 1992.

  The ties established with legislators have also generated a
series of requests for advisory services to aid in the updating of
health legislation.  These requests have generally been addressed
through two complementary modalities, both of these in consultation
with the corresponding technical program.  The first is the supply
of comparative legislation on the subject in question, organized
into compendiums prepared by information contained in the LEYES data
base.  The second involves carrying out advisory missions to the
health commissions of the legislatures.  Noteworthy among these has
been the advisory mission that collaborated in updating the Sanitary
Code of the Dominican Republic, in response to a request by the
Health and Population Commissions of the Congress of that country.

  The subregional meetings have also led to several interprogram
activities to support the development of health legislation on
specific issues.  Worthy of mention in this regard are the advisory
missions to Colombia and Ecuador on mental health, which came about
as a result of the reform process generated by the Declaration of
Caracas,  and the updating of legislation on the control of tobacco
use.  Both missions were carried out in cooperation with the Program
for Health Promotion (HPA).  Also noteworthy is the study on the
implications for health of the Treaty of Asunción, which created
the "Common Market of the Southern Cone" (MERCOSUR). Implementation
of this agreement will require the harmonization of various aspects
of the health legislation of the signatory countries. 

  The PWRs are gradually including the legislatures, especially
their health commissions, among the counterparts in the cooperation
provided by the respective Country Representations.  At the same
time, from Headquarters there have been initiatives to establish
closer ties with the legislatures as counterparts in cooperation. 
The Director has been regularly including the legislatures in the
contacts that he makes during official visits to the countries. 
There have also been efforts on the part of the Regional programs
to include the legislatures in the activities that they oversee. 
Finally, in their missions to the countries, HSP professionals have
held meetings with the Health Commissions in Argentina, Brazil,
Costa Rica, Peru, Venezuela, and Uruguay as follow-up on the
activities spawned by the Project "Democracy and Health."  These
activities have served to confirm the interest of the legislatures
in PAHO/WHO cooperation, as well as to define concrete cooperation
activities in response to specific requests for support for projects
that the lawmakers are promoting in their respective countries.

3.2.2   First Meeting of Legislators from the Southern Cone

        The First Meeting of Legislators from the Southern Cone
brought together delegates from the countries that were signatories
to the Treaty of Asunción, namely Argentina, Brazil, Paraguay, and
Uruguay.  Delegates from Chile also participated.  The meeting was
held in Brasília from 29 to 31 July 1991 simultaneously and in
coordination with the Meeting of Ministers of Health from the same
countries.  PAHO/WHO's contribution to this the meeting of lawmakers
included the preparation of a document on the incongruities and gaps
in the health legislation of the participating countries that might
hamper or impede execution of the Treaty.  The areas analyzed during
the meeting were:  quality control of food, drugs, equipment, and
medical devices; environmental protection; industrial promotion,
protection, development, and integration; social security systems;
the health of workers, and the rights of children.  Following the
same approach used for the subregional meetings of 1990, the
reference material on these subjects was sent in advance to the
lawmakers, who had the support of the corresponding PWRs in
reviewing the information and preparing their respective
contributions. 
    
    In the meeting the lawmakers expressed concern over the
possibility that economic problems might displace those of a social
nature with the consolidation of MERCOSUR.  The also agreed on the
need for the integration process stemming from the "Treaty of
Asunción" to revitalize the system of participatory democracy and
guarantee protection of the environment and the preservation of
natural resources.  In this connection, it was agreed that, of all
the issues under discussion, environmental protection was the one
in which there was the most pressing need for integrated action on
the part of all the participating countries.  With respect to
quality control for food, drugs, and medical devices, the
legislators emphasized the importance of reconciling trends toward
deregulation with the need to protect consumers and stressed the
importance of adopting international standards such as the Codex
Alimentarius. 

    The legislators concurred in recognizing the right to health as
an integral part of democracy and a condition for the exercise of
citizenship.  Workers' health was viewed as an essential element for
the achievement of comprehensive development, and a detailed account
was given of the crisis currently affecting the social security
systems and the need to propose appropriate measures to reform and
modernize them.  Finally, at the request of the Director of
PAHO/WHO, the delegates agreed on the importance of setting
"legislative agendas" in health, with a view to furthering the
process of integration engendered by the Treaty of Asunción.  To
this end, the legislators of Argentina and Paraguay requested
advisory services from PAHO/WHO in order to reformulate the
legislation applicable to the subjects covered by the treaty.  The
Paraguayan delegation in particular asked for cooperation from the
Organization in determining the treatment to be given to health in
the National Constitution that is soon to be drawn up. 
3.2.3   Meeting of the Health Commissions of the Andean Legislatures

        Members of the Health Commissions of the legislatures in
several countries of the Andean Area met recently in Lima at the
invitation of PAHO/WHO.  This meeting coincided with another being
held in the same city of the members of the Commission for Latin
America of the European Parliament.  The objective of the meeting
was to identify areas of common interest for the harmonization and
updating of health legislation in every country of the Andean
subregion.  At the same time, the meeting sought to create an
opportunity for supranational coordination and discussion, which
will lay the foundation for the creation of the Health Commission
of the Andean Parliament in the near future.

    The lawmakers described the health issues currently on their
agendas and also affirmed their commitment to work toward
reactivation of the health commissions in their respective countries
and to support implementation of the cooperation agreements between
PAHO/WHO and the legislatures.  They agreed to maintain a minimum
level of coordination with a view to achieving an articulated effort
among the countries of the Andean group, including Bolivia and
Colombia, which were not represented at the meeting.








    3.2.4  Activities with regional and subregional legislative
organizations

1. European Parliament   

    A working meeting was also held in July with the members of the
Commission for Latin America of the European Parliament during their
visit to the Andean Parliament.  The visit of the Europeans was
coordinated by the Representation of the European Economic Community
in Lima, and it was PAHO/WHO's responsibility to arrange for
inclusion of the health issue on the agenda for the meeting.  The
objective of this gathering was to define possible lines of
cooperation between the American and European parliaments with a
view to strengthening the Project "Democracy and Health" in the
following areas:

    a) political support from the European Parliament for the
    resolutions passed by American legislatures on health-related
    issues, both in regard to their legislative and control
    functions;

    b) support for projects and activities of interparliamentary
    cooperation promoted by PAHO/WHO in the countries; and

    c) participation by the European Parliament in the Inter-
    American Parliamentary Conference.

        2. Meeting with the Latin American Parliament

    The Organization has proposed to the Latin American Parliament,
or "Parlatino," that an Inter-American Parliamentary Conference be
organized in order to define a Regional legislative agenda on
health-related issues.  This Conference, to be held in 1993, would
be attended by representatives from all the legislatures of the
Region, in addition to a delegation from the European Parliament.

    At the same time, the Brazilian Group of the Latin American
Parliament has proposed that PAHO/WHO hold a Regional Meeting on
Environment, Health, and Development, which will serve to promote
participation by legislators from the Region in the United Nations
Conference on Environment and Development (ECO/92).

    It should be noted that at present the Latin American
Parliament is organized into the following commissions:  Political
Affairs, Economic and Social Affairs, Cultural and Educational
Affairs, Legal Affairs, Environmental Affairs, and Science and
Technology.  Until recently, health issues were included on the
agenda of the Commission on Social Affairs.  However, at its last
Conference, held in Cartagena from 31 July to 3 August 1991, the
Parliament created a Health Commission, which will be responsible,
inter alia, for promoting the Conference proposed by PAHO/WHO.



    3.  Meeting with the Andean Parliament
    
        The Andean Parliament has manifested its interest in
supporting the Project "Democracy and Health" through the
establishment of a line of direct cooperation with the legislatures
in the Andean countries in the area of health.  This assembly was
created in 1979 and ratified five years later through a treaty
signed by Bolivia, Colombia, Ecuador, Peru, and Venezuela.  For the
time being, the Andean Parliament fulfills an indicative function
in regard to budgetary matters and serves as a political forum for
discussion and amalgamation of ideas, thereby helping to strengthen
Regional integration.  At its last meeting this subregional
Parliament examined the Initiative for the Americas proposed by the
President of the United States.


    3.3 Third stage:  1992 and thereafter - Establishment of
        legislative agendas at the regional, subregional, and
        national level

    The process resulting from the subregional meetings on
Democracy and Health and the cementing of cooperation with the
legislatures augurs well for the future.  It is anticipated that
there will be opportunities for action that will transcend the
national framework and have an impact at the subregional and
Regional levels as well.

    The processes of subregional and regional integration require
uniform normative support that will not only validate them but also
facilitate them.  This is the rationale behind the promotion of
"health agendas" to guide the legislatures in the harmonization of
their respective national laws.  For this purpose, PAHO/WHO, through
its Regional programs and PWRs, will seek to identify gaps in
legislation and will urge the legislatures of the Region to consider
them.

    At the same time, the Organization intends to step up direct
technical cooperation through implementation of the technical
cooperation agreements signed in 1991.  It is hoped that new
agreements will be signed in the coming year to aid the legislatures
of other countries, namely: Antigua and Barbuda, the Bahamas,
Belize, Dominica, the Dominican Republic, Grenada, Guyana,
Nicaragua, Panama, Saint Kitts and Nevis, Saint Lucia, Saint Vincent
and the Grenadines, and Suriname.  There are also plans to
consolidate the cooperation provided through the country APBs, in
addition to continuing with advisory services to the legislatures
within the framework of the legislative agendas that are established
by common agreement at the different levels.  For this purpose,
experts and specialized information have been made available to the
PWRs which can be supplemented if necessary with contributions from
the programs at Headquarters.

    At the supranational level, there are opportunities for diverse
types of action, including: 

    a) Support for promptly naming members to the recently created
    Health Commission of the Latin American Parliament, so that
    there will be a platform for promoting the establishment of
    "health agendas" at the national, subregional, and Regional
    levels;

    b) Continued support for coordination efforts with the Andean
    countries with a view to ensuring creation of the Health
    Commission of the Andean Parliament and increasing the
    Parliament's initiatives in this area;

    c) Broadening of the coordination activities with subregional
    interlegislative bodies, including the initiation of contacts
    with the recently created Central American Parliament at a
    meeting in late October in Guatemala;

    d) Initiation of discussions aimed at involving the
    Commonwealth Parliamentarian Association in this program of
    activities, with a view to also involving the Caribbean
    countries.  

    e) Close attention to evolution of the proposal to create a
    Caribbean Parliament so that, should the initiative become a
    reality, health issues will be considered by this body from the
    outset;

    f) Support for the meetings convened by the health commissions
    of the legislatures to examine and discuss health issues with
    representatives of the legislative bodies of the Member
    Countries.  In this regard, the efforts of PAHO/WHO will be
    directed at organizing the Meeting on Environment, Health, and
    Development within the framework of ECO/92, as well as the
    Inter-American Parliamentary Conference, to be held in 1983.



    4.  Conclusion:  A Preliminary Evaluation

    It can be said that the Project "Democracy and Health" has thus
far made satisfactory progress, as is evidenced by several
developments.  First, there has been an increase in the number of
requests for technical advisory services by the legislatures,
resulting from greater awareness of PAHO/WHO's cooperation
strategies and our experience, both in technical areas and in health
legislation.

    At the same time, there have been a growing number of
cooperation initiatives originating with the national legislative
bodies themselves or their Regional and subregional counterparts. 
Such undertakings free PAHO/WHO from intervening in these stages and
allow it to focus on supporting other, autonomously generated
initiatives that coincide with its objectives.

    Progress has also been made in opening new areas and
identifying additional collaborators, which will contribute to
political reinforcement of PAHO/WHO activities with the legislatures
at the national, subregional, and Regional level.  In addition, new
channels of communication have been created between the executive
and legislative branches which will lead to a better understanding
of the viewpoints and priorities of each of these bodies in the area
of health.  One result of this will be a strengthening of the health
sector thanks to speedier implementation of real and effective
solutions to the problems that plague the great majority of
populations in the Region.

    As a consequence of the foregoing, there has been an evolution
in PAHO/WHO cooperation with the legislatures toward the definition
of legislative agendas in the areas that the Organization considers
to be priorities and away from the diversity of subject matter that
is often associated with spontaneous requests for cooperation. 
Finally, a project has been initiated to organize the Meeting of
Legislators on the Environment, Health, and Development, within the
framework of ECO-92.  This proposal is being promoted by the
Brazilian Group of the Latin American Parliament with the support
of ECLAC, UNDP, and other organizations of the United Nations
system.  There is also a proposal to hold an Inter-American
Parliamentary Conference that will bring together representatives
from all the legislatures of the Americas, with the participation
of the European Parliament.








SEMINAR ON HEALTH TECHNOLOGY IN MEXICO






INTERNATIONAL COOPERATION IN HEALTH TECHNOLOGY











Jorge Peña Mohr
PAHO/WHO Regional Adviser in Health
Policy and Technological Development

_____________
This document does not constitute an official publication.  It should not be subject to reviewing, summarizing,
or quotation without the authorization of the Pan American Health Organization (PAHO).  The statements in
signed articles are the exclusive responsibility of their authors.


INTRODUCTION

Prediction of the future, however obscure and uncertain the results are, is
needed to promote awareness of the trends and to anticipate future events. 
Simón Ramo (1) states that at present we are witnessing a rapid increase in the
impact of technological progress on social, economic, and political structures
throughout the world.  However, its implications are far from having been
explored.  Moreover, the effects of the technological changes are
underestimated in the short term, while the problems associated with the
successive crises monopolize the attention of most of the leaders of the world. 
A severe imbalance is being created between the accelerated technological
progress and the delay in the social process.

Rarely do the governments include science and technology among the
categories of priority problems.  There is still no awareness that all the social,
economic, and political problems that are usually labeled as having priority are
interrelated with technological progress.  Technological development is
intertwined with the processes of development; it can sometimes be the cause
of serious problems and, at other times, be part of the solutions.  This
presentation explores five subjects that we consider crucial in the relationship
of international technical cooperation and technological progress.  It is our first
incursion in this complex area and naturally the ideas expressed are not
completely developed.


I.         DOES THE PRINCIPLE OF THE SUPREMACY OF NATIONAL
SOVEREIGNTY CONTINUE TO BE VALID?

To the extent that the countries become closer through communications,
transportation, and alliances the paradox of the separation of the domestic from
the international becomes more evident.

The supremacy of national sovereignty is recognized in Art. 2, No. 7, of the
United Nations Charter which states that no provision of that Charter authorizes
the United Nations to intervene in matters that are essentially under the
domestic jurisdiction of the states.  In indicating that that principle should not
prejudice the application of measures to enforce the provisions of Chapter VII
the Charter recognizes the difficulty in separating the domestic from the
international (2).

As A. LeRoy Bennett points out (3), in general, the international level is
characterized by less development of integrating factors than is found at the
national level.  The international cooperation and financing organizations and the
bilateral agencies pay special attention to technical cooperation centered on
countries individually.  The emergence of blocks and of the processes of
integration require reframing this approach and revising the concepts of national
sovereignty in the face of what could be called the sphere of international
sovereignty.

The movement toward geographical integration of the markets and the
financial structure has been especially pronounced in the European Community. 
Latin America and the Caribbean are experiencing similar movements. 
Integration is not simply an economic operation, but a delicate political
operation, according to Rafael Calderón (4).  The national political forces have
been obliged to readjust their agendas and platforms to accommodate the new
subjects of discussion that arise from these alliances which prior to this were
centered on the negotiation of conflicts and are now directed more toward
negotiating cooperation.

The Member States have not granted the international agencies
independent decision-making power over national sovereignty.  The exception
that proves the rule is the experience of the European Community where there
are examples of the cession of sovereign power to an international organ.  Since
1979 the European Parliament consists of members elected directly by the
voters of each nation.  Its power is not legislative; it is the supervisory  body of
the Council.  However, its influence on the internal matters of all of the countries
is considerable.  It must be consulted in cases of trade treaties and of
cooperation; this occurred with the cooperative agreement between the
European Community and Central America which entered in effect in July 1987
(5).

In Lima, Peru, on 16 November, the plenipotentiary representatives of
eighteen countries signed a treaty which institutionalized the Latin American
Parliament, established in Lima on 10 December 1964, fixed its principles and
objectives, and discussed, among other subjects, the mechanism for the
selection of its members (6).  In 1989 Javier Silva R. (7) called for a free
democratic election in every country for the selection of the representatives to
the Latin American Parliament.

This treaty is an expression of the political dynamics that are emerging,
which are establishing new interrelationships and new spaces of power. 
Different than its European counterpart, the Latin American Parliament is not
formed by direct election and is not linked to an inter-American organ.

The last World Development Report from the World Bank ends by stating
that with strong international cooperation, the opportunities for development will
be more promising.  There is more agreement today than at any other time in
recent history on what should be done and how it should be done.  What is
lacking is putting these ideas into practice everywhere (8).

The role of mediator played by the international cooperation system in the
transfer of slogans, doctrines, approaches, models, and, in general, structures
of thought on fundamental aspects has not been sufficiently emphasized.  In
International Capital Markets, published by the International Monetary Fund (9),
in referring to the reentry of the developing countries into the international
capital markets the catalytic role of the Fund is emphasized.  This role of the
international organizations can be played through simple persuasion or through
powerful mechanisms of influence.

Jessica Mathews, in an editorial in the Washington Post on 26 October of
this year, reported that the International Monetary Fund and the World Bank had
announced that in their loan policy they would pay considerable attention to
those countries that spend too much on defense.  She stated that success in
altering the governmental priorities would not come easily; twenty-four
developing countries had already warned the two institutions of the sensitivity
of this area.  The lenders have a powerful instrument in their hands in the
attention that this new policy will generate in the countries in which the priorities
are manifestly out of line with the social needs - countries where the gross
national product reaches one dollar per day per capita while 20%, 30%, and even
40% of the government budget is for military expenditures (10).

Although there is some influence favoring or restricting access to
resources or markets, the states do not appear to yield their sovereignty nor
have they transferred explicit power to define or implement policies.  In practice,
the capacity of the international agencies to exert influence by bureaucratic,
diplomatic, economic, and political means is considerable.

The dividing line between national sovereignty and the influence of
international cooperation is being blurred, particularly in the areas of interest of
the strongest states.  The replacement of tariff barriers by nontariff barriers,
particularly regulatory instruments for food, drugs, and medical devices along
with the aggregate of the products resulting from biotechnology, and legislation
protecting intellectual and industrial property are clear examples of the complex
international process of establishing the rules of the game.

In the framing of the understanding and basic consensus on the principal
elements of the final package of the Uruguay Round of Multilateral Trade
Negotiations it is stated that the great majority of the countries of Latin America
and the Caribbean have adopted severe adjustment programs at significant
social cost; these include the autonomous liberalization of their markets.  This
has not yet received due recognition by the developed countries (11).

The General Agreement on Tariffs and Trade (GATT) is one of the
international forums where these interests come into play.  Many other rules of
the game are negotiated bilaterally or within international agencies associated
with the interests of the industrialized countries.  The coordination of standards,
regulatory mechanisms, pricing systems, mechanisms for subsidies, legislation
on intellectual and industrial property, and other normative packages is
considered as a part of process of international cooperation.  The next meeting
to coordinate the names of medical devices in the United States of America,
Canada, and the European Community, to be held in Brussels, and the eventual
establishment of an international system of regulatory information demonstrates
how matters falling withing the realm of each state are being transferred to the
orbit of international negotiation (12).

The concern for environmental problems has become transnational.  Such
problems do not respect borders.  The transnationalization of this agenda, which
makes it possible to define new rules of the game for this matter on a global
scale, is of interest to the most powerful countries, which are those that have
assaulted the environment the most.  On the other hand, it is much more difficult
for the problems of greatest priority for the developing countries to be
accommodated on international agendas, particularly those of the multilateral
agencies.

The World Bank report mentioned above points out that in the time it takes
to read a paragraph on its back cover approximately one hundred children are
born - six in industrialized countries and ninety-four in developing countries.  It
notes that more than one billion persons or one quarter of the population of the
developing countries lives in extreme poverty on less than a dollar a day and it
concludes that whatever the prospects of the industrialized economies, the
world will find lasting prosperity and safety only if the developing countries can
raise their standard of living.  This is the challenge of development.

Is the challenge of development the struggle of each country to raise its
living conditions, or is this a global challenge?  In order to introduce the concern
for the environment the earth has been pictured as a space ship which we all
share.  When one refers to population, poverty, and standards of living, one is
speaking about two separate worlds.

Will the principle of the supremacy of national sovereignty prevail in the
negotiation of the rules of the international game?  Will the path to be followed
be that of international sovereignty established through a representative process
by the world population with the power to enforce the standards of international
coexistence?  Can a system of international relations capable of coping with
present and future challenges for humankind be constructed on the basis of
strict adherence to the historical principle of national sovereignty?  Can a new
international order be established on the basis of the current structure of
national power or is it necessary to consider advancing toward democratic
systems of representation similar to those of the European Parliament at the
global level?

The vision of a human brotherhood is not new.  The Greek and Roman
philosophers who witnessed the historical transition from the preeminence of
the Greek city-states to the expansion of the Roman empire had a cosmopolitan
vision.  The cynics essentially denied and rejected patriotism and the need for
separate states.  The stoics believed in a universal society based on one
essential element:  reason.  History is witness to the efforts of many thinkers to
find a theory of international relations.  In each age, these visions reflected the
particular conditions of the moment.  War, imperialism, colonialism, dependency,
and other themes have been central to international thought and have played a
paradigmatic role.

Gustavo Lagos (13) maintained, in 1965, that integration involved the
assumption that, along with the loyalty of the citizen to the nation, a new loyalty
and identification with a greater community would emerge, formed by the
countries that are integrated.

Twenty-five years later Liliana de Riz (14) maintains that the construction
of a political vision - of a community project over the entire region - is a task that
falls mainly on the political parties.

The constitutional expression of this reframing is expressed in the
Constitution of Guatemala of 1985 (15) which states that that nation, as a part of
the Central American Community, will maintain and will cultivate cooperative
relationships and solidarity with the other states that form the Central American
Federation and should adopt measures for establishing, partially or totally, the
political or economic union of Central America.  There is also a requirement that
the competent authorities strengthen Central American economic integration on
the basis of equity.

Enrique Barón Crespo (16), Spanish chairman of the European Parliament,
pointed out that in a context of globalization of the economy and society, the
nation states do not have a structure that is adequate to confront the problems,
which means that there is a tendency in every region and on every continent
toward the formation of communities.  The time of emerging nationalism is over. 
Today, the most creative formula, with the most decisive consequences on the
configuration of the future world, is one of regional areas.

Despite these significant advances in thinking, today the forces of
fragmentation continue to dominate and the movement toward political
internationalism continues to be weak.


II.        WHO ADOPTS THE ORPHANED VALUES?

Reflections on war and peace and on the nature of international relations
have a long history.  Kant distinguished two sides of human behavior, the selfish
and the rational.

In today's world it appears that the political advantages, economic
prosperity, and military power that are obtainable in the short term are the
dominant interests.  The history of international relations is full of examples of
conflicts generated by this selfish desire to dominate others and it is difficult to
associate this behavior with significant collective benefits.  Humanitarian
sentiment has not succeeded in penetrating the conscience of the nations much
less in generating the revolutionary changes that are required to modify the
prevailing international order.

Equity as the synthesis of humanitarian values has been very weakly
present in development policies in Latin America and in the world.  The
inequities are very marked, as can be seen in Figure 1, which shows the varied
relationships between economic growth and distribution existing in a group of
countries.

Figure 1.            Inequities in income and growth of the gross domestic product in
selected countries, 1965-1989.

Growth of GDP per capita (percent).






















Inequity in income (a)

a)         Ratio of incomes of the 20% richest to the 20% poorest in the population.  Data on the distribution
of the incomes come from surveys conducted mainly at the end of the 1960s and the beginning of the
1970s.
Source:  World Bank data; Berg and Sachs, 1988.


Life expectancy, infant mortality, and per capita expenditure on health are
examples of indicators that show how different the living conditions of the
populations in different regions and countries of the world are.  The differences
are increasing, the gap is widened, and the prospects for a more equitable
international order appear to be dimmer or even an impossible dream.

Poverty is the tragic result of failed development processes on top of
ineffective redistribution policies and an international solidarity that still
operates under the concept of a "safety net" to protect capital investments
without one to protect the population.

The World Bank report mentioned above notes that several studies have
found that education is the individual variable that has the greatest power to
have an effect on inequitable income.  Investments in education, health, and
nutrition - if they are well designed and carried out - can improve the distribution
of income and at the same time promote development in various senses.

There is a strong association between an increase in the educational level
of mothers and a reduction in infant mortality, as is shown in Figure 2.

Although in many cases economic growth appeared to favor a better
redistribution of income, it is the social policies that have a more direct impact. 
The evidence shows, the above-mentioned World Bank report states, that a
heavy investment in individuals makes sense, not alone in human terms, but
also in hard-headed economic terms.  Investment in individuals is the
development proposal that is being propounded today by the international
cooperation agencies and banks.  Development with equity and development
with a human face are the expressions used for this proposal by ECLA and
UNICEF, respectively.  For its part, Canada states its position in the report
"Sharing the Future" (17), pointing out that the fundamental objective of our
efforts is to help the poorest countries and people in the world.

Are these proposals the idealistic manifestation of the idea that investment
in individuals is justified in itself, or are they derived from a pragmatic thought
that considers that investment in individuals is a means to achieve other ends?

In the health community it has always been known that investment in
individuals is essential and desirable, because they are perceived as an end to
themselves, equal to or higher in the hierarchy than the goals of economic
prosperity.

Figure 2.           Female education and reduction of infant mortality in selected
economies, 1960 to 1987

Annual average in the reduction
of infant mortality (percent)

Female Education
Low       

























Female Education
High


Note:      The economies are mentioned in ascending order according to the level of female education, defined
as the average number of years of schooling, excluding later education, of women between 15 and
64 years of age.
Source:  World Bank data.


The lost decade of the 1980s, the deterioration of the terms of exchange,
the increase in the external debt, the reduction of public spending, the export of
capital, and other evils that afflict what is called the third world served as an
introductory litany in the evaluative discourses of end of the decade.  It is
possible that this tragic panorama is motivating the valuational reframing that
appears to be occurring.

In an environment in which government policies are placing more
emphasis on market forces, competition, and privatization, these valuational
expressions are fundamental.  It can be tragic that the governments and
international cooperation abstain from fulfilling their basic humanitarian role. 
The market can be responsible for efficiency, but who will be responsible for
equity?

The Director of PAHO/WHO, Dr. Carlyle Guerra de Macedo (18), in pointing
out that one of the missions of that organization is to promote understanding,
solidarity, and peace, is making the commitment to these values explicit and is
indicating, in addition, that this is not only a matter of bilateral, but also of
multilateral, concern.  Health is a field that is especially vulnerable to the
absence of government policies that ensure the access of the entire population
to the health services and guarantee homogeneous quality.

We would like to think that it is the mission of the international agencies
and, in particular, the agencies of the United Nations system, to incorporate
these values of solidarity, humanism, and humanitarianism in their operation. 
Frequently, these values remain orphaned when competitive interests are
discussed and negotiated even in the current favorable environment of
integration and discussion of the social debt.

Unfortunately, these proposals have still not achieved sufficient support
through international policy and international cooperation.


III.       IS ONE GREAT INTERNATIONAL ALLIANCE FEASIBLE?

The gestation period of the United Nations (UN) was several years, as was
that of the League of Nations.  Both organizations arose as a result of postwar
initiatives.  The enormity of the effort to launch the UN can be appreciated in the
participation of 50 states, 283 official delegates, 1,400 designated advisers, 1,000
secretariat staff members, and 4,000 aides at the San Francisco Conference on
25 April 1954.  The history of the public and private organizations and the
conservative and progressive political efforts that forged this great joint venture
of the states that signed the charter is testimony to one of the most significant
works of civilization.

The United Nations is not alone.  There are approximately 400 public
international agencies and more than 5,000 private international organizations.

An interesting phenomenon has been the emergence of regional agencies
in greater numbers than global ones.  In Latin America the following are worthy
of note:  the Organization of American States (OAS); the Latin American
Economic System (SELA); the Organization of Central America States (ODECA);
the Latin American Association of Integration (ALADI); the Latin American
Association of Institutions of Development (ALIDE); the Latin American Export
Bank (BLADEX); the Economic Commission for Latin America (ECLA); the
Committee of Action of Support for the Economic and Social Development of
Central America (CADESCA); the Andean Corporation of Promotion (CAF); the
Latin American Federation of Banks (FELABAN); the Board of the Agreement of
Cartagena (JUNAC); the Latin American and Caribbean Program of Commercial
Information and of Support for the Foreign Trade (PLACIEX); the Association of
Latin American Industrials (AILA); the Conference of Latin American Authorities
of Information Science (CALDI); the Caribbean Community (CARICOM); the
Center for Latin American Monetary Studies (CEMLA); the Latin American
Commission of Science and Technology (COLCYT); the Central American
Institute of Research and Industrial Technology (ICAITI); the Andean System of
Technological Information (SAIT); the General Treaty of Central American
Economic Integration (SIECA); the Inter-American Development Bank (IDB); and
many others that are to numerous to mention.

Another group of institutions of growing importance, listed in the Directory
of International Organizations, consists of the nongovernmental international
organizations, which reach 4,500 in number.  To this one can add the nearly
10,000 nongovernmental institutions with an international orientation.  The
Economic and Social Adviser of the United Nations has granted consultant's
status to more than 800 international nongovernmental organizations.

The foundations constitute another group of institutions of particular
significance through their programs in health in Latin America and their
interrelationships with the international agencies.  The Rockefeller and W. K.
Kellogg Foundations deserve special mention in the field of health.  Today new
foundations are emerging, such as those in Mexico, that will play a role of
growing importance.  The countries, and even some universities in Latin
America, are creating foundations oriented toward international action in order
to establish linkages and expand their activities.

Recently, there has been an upsurge of international cooperation
organizations created by consortiums of academic institutions, by industry, and
by the health services with central support from state and municipal
governments.  Two good examples are Swede-South in Malmo, Sweden, and
Med-Tech in London, Ontario, Canada.

Multinational corporations constitute another category differentiated from
the nonprofit international organizations.  These transnational corporations,
which handle large resources, greater in some cases than the gross domestic
product of most of the countries of Latin America, have concentrated the interest
of scholars in international relations.  Apart from the philosophic orientation with
which the role of the transnational corporations is analyzed, there is not doubt
that their influence in the field of international cooperation is extraordinarily
strong.

I have left for the end mention of international cooperation through the
bilateral organizations, which has been the object of review by SELA (19, 20, 21,
22, 23).

The 1990 OECD report on development assistance (24) summarizes the
official assistance of the industrialized countries in percentage of gross national
product and in absolute terms (see Figure 3).

Figure 3.            Official assistance for the development of the industrialized
countries in 1989.

Percentage of GNP                                                        $US billions










Of the total of $46.7 billion, $34.2 billion have corresponded to bilateral
assistance and $12.5 billion to cooperation through multilateral agencies.

Cooperation from the countries not belonging to OECD has been
declining, reaching $6.7 billion in 1989.

Official assistance for development is a part of the flow of international
financing.  Official assistance, which comes from many sources, has been
stable, while other forms, such as bank credits and export credits, have been
decreasing.

It is interesting to note that only a portion of this cooperation is oriented
to health and population.  Denmark directed 10.2% of its cooperation to this
category and at the other, low, extreme, Austria devoteed only 1.1%; the United
States allocated 7.7% in 1989.  Latin America and the Caribbean received official
assistance that reached $5.6 billion in comparison to Africa which received $18
billion and Asia, $15 billion.  Mexico received 0.3% of the total of the assistance,
which equaled 0.1% of its gross national product, while for Bolivia assistance
reached 10.7% of its gross national product.  An extreme case is Mozambique
where 76.1% of the gross national product corresponded to official assistance.

With regard to official cooperation from the United States, Israel receives
12.5%, followed by Egypt (9.5%) and Pakistan (3.9%).  El Salvador (3.3%),
Guatemala (1.5%), Honduras (1.4%), Costa Rica (1.4%), Jamaica (1%), Bolivia
(0.8%), the Dominican Republic (0.7%), Peru (0.6%), and Haiti (0.6%) are also
among the recipients receiving the largest amounts of this financing.

Japan, in turn, makes its greatest contributions to cooperation in Latin
America to Brazil (1.1%), Paraguay (0.7%), and Bolivia (0.6%).  Of the total, 13.1%
is concentrated on Indonesia.

Germany, Austria, Belgium, Denmark, Finland, Holland, Italy, Norway,
Sweden, and Switzerland provide official assistance to some countries of Central
America and the Andean Group in very low proportions, as can be evaluated in
the following table:



Germany                        Brazil                         1.0
Peru                           0.9
Bolivia                        0.8

Austria                        Nicaragua                      0.7
Guatemala                      0.6

Belgium                        Bolivia                        0.6
Ecuador                        0.5
Peru                           0.5
Chile                          0.3

Denmark                        Nicaragua                      0.9

Finland                        Nicaragua                      2.6
Peru                           0.8

Italy                          Argentina                      2.4
Peru                           1.6
Ecuador                        0.8
Brazil                         0.7
Guatemala                      0.7
Bolivia                        0.6

Netherlands                              Bolivia                        1.3
Suriname                       1.2
Nicaragua                      1.1
Peru                           1.0

Norway                         Nicaragua                      2.2

Sweden                         Nicaragua                      3.2
Costa Rica                     0.3

Switzerland                    Bolivia                        2.9
Nicaragua                      1.2
Peru                           1.0
Honduras                       1.0


As can be seen in these data, Latin America receives official assistance
from the industrialized countries amounting to $5.5 billion of which a small
proportion (5%) is directed toward health.  On the other hand, the Region is
importing biologicals, drugs, and medical equipment whose value is higher than
the total of all official assistance for development.

A thorough review of these flows of assistance should enter into the
balance in future negotiations; to be considered on the other side are debt
payments, the export of capital, the injury derived from unjust terms of
exchange, and also trade flows.

It would be too pretentious to attempt to examine the political, economic,
and social effects that stem from the increasingly complex range of actors and
the linked relationships among them.  The conclusion, which may appear
obvious, is that in this scenario significant interests play and will play an
increasingly significant role.  The states that are strong protagonists and the
alliances among them will continue to be dominant while the interests of the
countries that represent the large population majorities that have remained
marginal in the processes of development are not organized.

Can the substitution of cooperation for conflict free resources?  The World
Bank and the International Monetary Fund announced, according to a report in
the Washington Post (10), that the cut in military expenditures is by far the
largest source of available funds which the countries can use to meet their own
needs.  Camdessus and Preston have taken a first spirited step.  Now it is matter
of support from the bilateral donors, particularly the United States, and from the
recipient countries themselves.  All the parts need a target:  the year 2000 is not
very close for cutting the military expenditures of the third world, now $150
annual billion at the half-way point.  If half of the saving went to reduce the debt
and the rest to education, health care, family planning, and caring for soils,
forests, and water, the burden of human misery on the planet would be
dramatically relieved.

Is it feasible to have the developed countries contribute 1.04% of their
gross national product to international cooperation, as Norway does?

If this occurred, the contribution of Japan would increase by
approximately $9 billion to around $30 billion and that of the United States from
approximately $7.7 billion to around $46 billion, which added to the increase in
cooperation from the other countries and to the reduction of military
expenditures in the third world and in the industrialized world would make it
possible to increase international cooperation and deescalate conflicts.  We are
far from an international alliance of this magnitude, but we should advance in
that direction.


IV.       IS TECHNICAL COOPERATION IN TECHNOLOGICAL DEVELOPMENT
DIFFERENT?

The fundamental mission of technical and economic international
cooperation in the future will be the administration of interdependence from the
technological cycle to cooperation between countries and blocks.

Scientific investigation leads to the segmentation of knowledge in
increasingly specialized branches.  In another dimension, the advances in
knowledge occur scatteredly in an ever-widening range of institutions.  With the
elevation of the strategic value of knowledge as a factor in the production of
goods and services, it has been transformed into the critical variable in
development.  Every product or service that enters the market has incorporated
in it a package of knowledge and information associated with the processes that
generated it and led it to its final destination and use.

We live in an environment that is segmented and divided.  Our institutions
are fragmented within, which limits the coordination and integration of the
processes that do not recognize structural divisions.  The process that
transforms scientific knowledge into information, designs, prototypes, and
eventually products used in health and their incorporation into the practice until
they project their effects onto the health of the population require thorough
evaluative scrutiny and detailed planning.  The institutional and normative
structures to articulate this range of increasingly interdependent processes need
to be coordinated.  We should learn the Japanese recipe for technological
innovation, which is to uncover and develop a profitable market.  Technology
that remains at the conceptual level does not generate development (25).

The management of the innovation within every institution has become a
task of a higher order.  The research institutes as well as productive enterprises
and the health services are feeling the need to incorporate this new capacity to
manage technological innovation.  To be able to compete, the institutions require
favorable economic, industrial, and technological policies.  They also should
overcome the problems of technological management (26).

The traditional state, composed of sectors with centralization of decision-
making, is yielding to reforming processes.  Decentralization is the order of the
day in these reforms.  As André Franco Montoro points out, when the
dictatorships in Latin America are eliminated there will be dialogue instead of
authoritarian monologue; instead of the concentration of power,
decentralization; and instead of paternalism, participation.

But this process does not necessarily simplify the articulation of the
scientific, technological, industrial, and marketing processes at the macro level. 
They do make it possible to invigorate new public, state, and municipal organs,
emerging universities, and industrial sectors far removed from the central
power.

Intersectoral articulation is an old proposal.  In the field of science and
technology, where intense interrelationships and negotiations are required to
establish a sustainable policy in the long term and orchestrate the relationships
among many institutions, the states have been gaining experience but sectoral
isolation continues to prevail.  At this level, the health sector needs to keep its
proposals within the framework of the national policies on science and
technology and development and to be assured of space for active
interrelationship.  According to Ralph Landau and Nathan Rosenburg, the
governments cannot decree a successful development strategy, but they can
coordinate their various policies if they understand the real objectives involved
and promote the infrastructure that microeconomics requires for innovation (27).

Mexico, like the other countries of the continent, is promoting progressive
processes of integration with renewed vigor.  Markets, production, scientific and
technological development, and investment are becoming transnational.  In
addition, the instruments of national policy on scientific, technological,
industrial, commercial, and other development are being submitted to demands
for articulation and harmonization.  In negotiations involving the
interdependence among countries the instruments of weak informal agreements
will be replaced by contracts, treaties, joint ventures of various types, company
mergers, and other forms of strong alliances.  The proliferation of this
multiplicity of alliances will create new patterns of international relationships to
compete for markets and to gain access to critical elements in production (28).

Among these elements, access to knowledge becomes vital.  The systems
for intellectual and industrial property become central instruments in the play of
power in substitution of the traditional protectionist barriers.  The initiatives for
harmonization of regulatory instruments among the developed countries run
parallel to the pressures on the other countries to adopt the predominant
standards.

Technical cooperation has traditionally focused its action on a country by
country basis.  This has occurred in both bilateral a and multilateral cooperation. 
In the reemergence of the processes of integration, the opportunity arises to
orchestrate the interrelationships among countries in order to take advantage
of the relative development potential of each country and to forge lasting
strategic alliances.  This process of integration in health technology
development needs to be the object of detailed programming to establish
effective mechanisms to negotiate and manage cooperative projects.  The great
task is to orchestrate the interdependence to allow access to profitable markets,
to knowledge, and to other critical resources.  The challenge is to integrate and
to continue to integrate.


V.         IS TECHNICAL COOPERATION AMONG COUNTRIES A ROAD TOWARD
INTEGRATION?

The concept of technical cooperation among developing countries (TCDC)
arose as a proposal from the countries of the third world and was incorporated
into the agenda of the international agencies in 1978 (29).  As occurs with the
concepts that do not have sufficient political and financial backing, TCDC came
to be more bureaucratic rhetoric than strategic action.  Nevertheless, the
proposal is increasingly valid, especially on a continent that is progressing
toward integration.  TCDC should and can be one of the forces in the
introduction of the innovations required in the structures and processes of
international cooperation.  In light of this conviction, the plan for technical
cooperation among countries for health technology development is emerging.

The Convergence Project (30) was launched in 1991 through a joint effort
of the Pan American Health Organization (PAHO/WHO), the Latin American
Economic System (SELA), and the United Nations Development Program
(UNDP).  The XV Council of SELA selected health to initiate an exercise of
technical cooperation among developing countries and requested the
collaboration of PAHO/WHO.  After the proposal presented by PAHO/WHO was
approved by the XVI Council of SELA in 1990, both institutions submitted the
project to the Special TCDC Unit of the UNDP where it was approved.

This project has as its objective the promotion of the development of
health technology in the Americas through technical cooperation among the
countries of the Region.  It aims at the activation and strengthening of the
potentials of the national institutions to design and produce technologies
adapted to the specific health needs of the population of the Region.

This project extends the joint collaboration of government agencies,
research institutions, and industrial enterprises in the member countries.  It
interacts with these institutions in the planning, negotiation, and execution of
specific projects within the field of health technology.

In every country there has been promotion of the organization of working
groups representing the Ministries of Health, social security, organs of science
and technology and agencies to coordinate international cooperation, other
organs of government dealing with the industrial, trade, and education sectors,
the private sector, and international cooperation agencies.  These groups
identify the potentials of the national institutions and prepare the portfolio of
projects for the negotiation of cooperation.  The countries, through their
negotiators, interact in bilateral negotiations.

The project foresees the realization of four subregional forums that make
the establishment of seventy-nine negotiating tables possible.  See Figure 6.

In addition to the bilateral negotiations, in a process of strategic planning
the countries in each subregion select and develop the profiles of projects that
they consider to have priority for that group of countries.  These joint projects
are a strong force for integration.

Figure 6.  Convergence Project:  Subregional negotiating tables.

Convergence Project.
Subregional meetings.

Bolivia
Colombia
Ecuador
Peru
Venezuela
Argentina
Brazil
Chile
Uruguay
Paraguay
Costa Rica
El Salvador
Guatemala
Honduras
Nicaragua
Panama
Belize
Bahamas
Barbados
Guyana
Jamaica
Suriname
Trinidad and Tobago
Haiti
Dominican Rep.
Cuba
Mexico
Canada
U. S. A.

In a regional encounter, negotiations are produced among the countries
of the subregions through a joint negotiating table and satellite tables in order
to adjust complementary negotiations between two or more countries, as is
shown in Figure 7.

Figure 7.  Convergence Project:  Regional negotiating tables.

Convergence Project.
Regional encounter.

Bolivia
Colombia
Ecuador
Peru
Venezuela
Argentina
Brazil
Chile
Uruguay
Paraguay
Costa Rica
El Salvador
Guatemala
Honduras
Nicaragua
Panama
Belize
Bahamas
Barbados
Guyana
Jamaica
Suriname
Trinidad and Tobago
Haiti                          C
Dominican Rep.                            C A
Cuba                                      S C 
Mexico                                    S C 
Canada
U. S. A.

From this process agreements among subregions emerge.  In the next
phase, all of the countries participate jointly in a process of strategic formulation
to rank, to select, and to agree on cooperation based on the projects submitted
for consideration by each subregion.

The cooperative agreements and the strategic projects constitute the
portfolio of cooperation in the various configurations of countries.  This portfolio
is subject to joint management and the support of the international agencies. 
The search for national and international resources becomes a shared task in
which the organs for coordination of international cooperation have a very
important role.

In the processes of negotiation and strategic formulation information and
communication are intensely involved; for this a support system, which is shown
in Figure 8, is being designed and developed.

Figure 8.  Convergence Project:  The information system.

Convergence Project
The information system

Linkages                                 Data bases                     Users

CC                             Codes                                               L
MDR
FDA/WBD                        
Country profiles                                    D
UNDP                 Government institutions                                       D
INRES SUR                      
RESLAC                         Investment and                                      D
development institutions
UNIDO                          Industries                                          D
ECRI
Hospitals                                           D         BIDNET
CC                             Technologies                                        D
MRD
ECRI
SELA/ECLA                      Projects                                            D
Agreements                                                    D
Treaties                                            
Experts                                             D
Investment bankers                                  D
FDA                            Regulation                                          D
WBD


The first meeting, held in Quito (31) this past October, is a clear
demonstration of the potential of the national institutions, of the existing talent
and leadership, and of the political will of the countries to advance rapidly
toward integration.  TCDC is without doubt a good mechanism for triggering the
process for seeking agreement through negotiations and for mobilizing the
existing talent and capacities.  The headlines in the press "Integration in Health,"
"Andean Integration in Health," and "Andean Agreement in Health" are images
that reflect the sense of this new generation of forms of cooperation.

The consortium to produce vaccines and biologicals, the research network
in this field, the Association for Extraction of Active Principles from Medicinal
Plants, and the Association of Producers of Medical Equipment, together with
institutes of biomedical engineering, are examples of the first cooperative
projects among the countries of the Andean Group.  The more than sixty bilateral
agreements and the 144 project proposals presented by the institutions of the
five countries are examples of the vitality and a clear sign of the interest in a
process of regional convergence.

It remains to be seen whether the community of international cooperation
agencies provides the necessary political and financial backing for this
emerging process which will serve to incubate TCDC projects with high strategic
value for the support of stable alliances.  SELA, with the support of the UNDP,
is actively promoting this process which was initiated in the area of hydroponics,
is being implemented in health, and will continue in international trade and
subsequently in industrial development.  The annual meeting of the international
agencies in SELA to consider TCDC focal points is proving to be a practical and
effective mechanism for combining efforts.

CONCLUSION

International technical cooperation is being challenged by a complex world
undergoing accelerated transformation.  Smaller adjustments will not suffice as
a response.  Replacement of the conceptual bases on which it is built is
required.


PRESENTFUTURE
Technical cooperation based on the principle of the supremacy of national
sovereignty.Technical cooperation based on the principle of the supremacy of
national sovereignty with the exceptions covenanted internationally.Technical
cooperation complacent with respect to inequities.Technical cooperation
committed to the eradication of human misery as the new frontier - the new
challenge for science, technology, and development.Technical cooperation
dominated by the influence of the industrialized countries as donors of official
assistance and through other means and instruments.Technical cooperation
centered on cooperation among developing countries carried out jointly with the
international donors and investment bankers.Technical cooperation based on
unilaterally determined financing (donations) with secondary multilateral
agreement.Technical cooperation based on internationally agreed-upon
financing - for both bilateral and multilateral technical cooperation.  Inclusion of
nontraditional sources, such as reduction of military expenditures.Segmented
technical cooperation with multiple public and private protagonists.Technical
cooperation associated with integrating dedication.   REFERENCES


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de la Salud.  1984.

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con América Latina y el Caribe.  1990.

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Latina y el Caribe.  1990.

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Secretaría Permanente del SELA.  1990.

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Relaciones entre América Latina y la Comunidad Europea.  1990.

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Latina y el Caribe.  1990.

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Globalization of Technology.  National Academy Press.  Washington, D. C. 
1988.

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Case of the American Hemisphere in Globalization of Technology. 
National Academy Press.  Washington, D. C.  1988.

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Growth in Globalization of Technology.  National Academy Press. 
Washington, D. C.  1988.

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Perspectives on Conflict and Cooperation.  Josser-Bass Publishers.  San
Francisco.  1990.

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Regulations, and Procedures of the Organizations of the United Nations
Development System.  May, 1991.

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Desarrollo Tecnológico en Salud.  1991.  OPS/OMS/SELA/PNUD.

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Andino sobre CTPD para el desarrollo Tecnológico en Salud.  1991. 
OPS/OMS/SELA/PNUD.
















PARTICIPATION OF COMMUNITY ORGANIZATIONS
IN THE CARE OF AIDS PATIENTS

















Maria Borges
Consultant
Pan American Health Organization






SUMMARY





Most of the community organizations in Latin
     America and the Caribbean were created during the
     last four years for the specific purpose of
     providing physical and psychosocial support to
     patients with AIDS.  These organizations are
     establishing home care as an alternative to
     hospitalization in order to provide assistance to
     an increasingly growing number of patients that do
     not have access to formal health services. 
     However, they do not have the personnel, the
     physical resources, or the techniques to carry out
     the activities of home care effectively on a
     continuous basis.  Home care requires not only
     trained personnel and minimum hygienic conditions
     in the home, but the support of the formal health
     services to provide continuity of care when the
     physical deterioration resulting from the disease
     requires it.  Home care as an alternative to
     hospitalization is an ambitious but feasible goal
     when it is coordinated closely with the formal
     health services.  The cooperation of community
     organizations is essential to meet the needs of the
     patients that those same health services cannot
     cover.  Accordingly, the Ministries of Health
     should intensify the dialogue with organizations in
     the community and provide them with the human,
     economic, and technical resources that they need to
     develop home care as an alternative to
     hospitalization for patients with acquired
     immunodeficiency syndrome.

INTRODUCTION


     The history of the health situation in the Americas
shows that the Region has experienced periods of
serious epidemics of diseases such as yellow fever,
smallpox, and meningitis.  During all those epidemics
social conflicts erupted over the rights of the
individual versus public health interventions, the
allocation of resources versus the administration of
the health services, and available technical knowledge
versus the lack of commitment to utilize it
effectively.

     AIDS is another epidemic that took the world by
surprise at a time when almost all of the countries of
the Region of the Americas faced economic crises,
social disorganization, social violence, and high crime
and delinquency.  Human immunodeficiency virus (HIV)
has made it evident that today, as yesterday, the
scientific knowledge and technology that are available
are not sufficient to provide the quality and the
quantity of health care and the support that the
affected population needs or to lessen the
discrimination, the stigma, and the persecution that
the AIDS patients suffer.

     AIDS was spread initially among the homosexual
population, which means that in principle the disease
was considered as belonging to that population group
exclusively.  This belief contributed to delays in
decision-making and in the implementation of control
measures and health care for these patients by the
health authorities.  The situation was aggravated when
it was confirmed that the second group affected by the
disease was bisexual, which strengthened the belief
that the disease was a homosexual plague caused by
moral decline.  These beliefs led to the thinking that
the disease did not represent a risk for the other
sectors of the population, and as a result, timely
preventive measures were not taken.  Moreover, the
absence of informative campaigns concerning the risk of
contagion of HIV helped the epidemic to spread among
other groups in society.

     For almost a decade the world has been facing the
pandemic of acquired immunodeficiency syndrome (AIDS),
a disease for which there is no cure at present and
against which there is no hope of achieving a vaccine
in the near future.  By 1 October 1991 the total number
of cases of AIDS officially reported to PAHO/WHO was
418,403, of which 237,436, or 56.7%, were reported by
the countries of the Americas.  In Latin America the
number of reported cases during the period 1988 to 1989
increased by between 50% and 200%.  Taking that report
as a basis, the World Health Organization estimates
that there are between 1.0 and 1.5 million people
infected in Latin America and the Caribbean and 2.5
million in the Region of the Americas (Quinn, Narain,
and Zacarías, 1990).

     The AIDS epidemic has aggravated the inadequacy of
the hospital and health services in the Latin America
countries.  This deficiency, together with the economic
crisis that the countries of the Region are enduring,
has obliged the health systems of those nations to
adopt new strategies and modalities of health care and
to develop services of prevention and control in order
to serve the increasingly growing number of patients
with AIDS and other associated diseases.

     In this respect, the national programs for control
of AIDS have emphasized the important function
performed by community-based organizations in the
outpatient and home care of those infected with HIV as
well as those that have already developed the disease
(Victor, 1990).

     The World Health Organization and the Pan American
Health Organization (PAHO/WHO), aware of the importance
of the functions performed by community organizations
in the prevention and control of AIDS, have sponsored
a study to evaluate and disseminate the activities of
these organizations, with the hope that it will serve
to orient the authorities responsible for making
decisions and executing policies for the prevention and
control of AIDS in the Region of the Americas.

     The study has as it principal objective the
evaluation of the activities that community
organizations develop to meet the needs of individuals
affected by HIV or AIDS - particularly the activities
involved in home care as an alternative to
hospitalization, in accordance with the strategies
formulated by PAHO/WHO to reach the goals of the AIDS
control programs.


PARTICIPATION OF COMMUNITY ORGANIZATIONS
  IN THE CARE OF INDIVIDUALS AFFECTED BY HIV OR AIDS

     Community organizations are national,
autochthonous, nongovernmental nonprofit institutions
that receive funds from the international and national
agencies and frequently enter into agreements with
governments.  These bodies usually respect the
recommendations of PAHO/WHO and the technical
guidelines of the Ministries of Health.

     The community organizations have as their principal
     objectives:

     To defend human rights,

     To fight for effective health policies directed
     especially toward persons affected by HIV or AIDS,

     To provide psychological support to patients with
     AIDS,

     To develop activities coordinated with the national
     and local health systems,

     To promote the training of health personnel,

     To counsel individuals affected by HIV or AIDS and
     their family members,

     To provide means of transport to the patients
     needing it to get to the health services,
     
     To provide legal assistance to the patients that
     require it, and
     
     To coordinate activities related to hospitalization
     and medical care with the local health services.

     For this purpose, the community organizations have
promoted the concept of shelter houses and ambulatory
care for patients with AIDS and have prepared
strategies for community participation based on primary
health care.

     The principal objectives of community organizations
include improvement of the quality of life of the
patient before death and the education of the members
of the community on the risks and effects of the
disease, utilizing group psychotherapy.  In addition,
these organizations are responsible for disseminating
up-to-date information on HIV and AIDS, promoting
social support to defend the human and civil rights of
AIDS patients, trying to reduce the patient's fear of
death, and fighting for effective health policies for
AIDS patients.

     However, the community organizations do not include
health care activities for AIDS patients since they
consider that these interventions are the exclusive
responsibility of the public health services.  However,
these bodies apply pressure on the governments using
all possible means so that the individuals affected by
the disease receive adequate health care and so that
preventive and educational activities are granted
priority.

     The community organizations orient their efforts
toward the training of the family and friends of the
patient so that they assume responsibility for their
care, for the foundation of shelter houses, for home
care, and for the distribution of food, clothing, and
drugs for the patients.  It should be pointed out that
many of these activities are carried out in
coordination with the health services.

     The results obtained through the community
organizations have awakened the interest of PAHO/WHO in
evaluating the actions of those entities in the control
and prevention of AIDS in the countries of the Region. 
With this purpose, PAHO/WHO has sponsored a study to
examine in detail the results obtained by certain
selected communities, with the hope that those positive
results orient the administrators, the planners, and
the health authorities responsible for making decisions
and preparing and executing the policies on control and
prevention of acquired immunodeficiency syndrome.


JUSTIFICATION OF THE STUDY

     The ever-increasing spread of AIDS in the countries
of America has emphasized the urgency with which the
health systems adopt nontraditional strategies and
methods to prevent and control the disease and offer
health care to the large number of individuals infected
with HIV.

     Despite the fact that the countries of Latin
America and the Caribbean have structures and services
of great significance, those services lack the
organization and the operations that are needed to
provide the coverage, quality, and quantity of health
care demanded by the severity of AIDS.  The economic
crisis that the countries of the Region are
experiencing has aggravated the chronic overload that
has troubled the hospital and health systems of the
countries for a long time and has obliged the
responsible officials to seek new means to meet the
demand for hospitalization.  In this regard, several
countries have assumed positions of leadership in the
mobilization of resources and in the execution of
alternatives to hospitalization, such as home care,
shelter houses, and day hospitals.  It is should be
emphasized in this context that the home care given by
public health nurses has emerged as a priority activity
in the health programs, mainly those for control of
communicable diseases.  This study was carried out with
the participation of four countries:  Brazil, Costa
Rica, Mexico, and Trinidad and Tobago which together
account for 65% of the AIDS cases reported by the
countries of Latin America and the Caribbean.  The
primary purpose of the study is to evaluate the
activities that the community organizations carry out
through outpatient care and home care, with a view to
determining the most effective way to strengthen that
type of care and incorporate it into local health
systems.

     The study has other principal objectives,
including:

1.   To evaluate the epidemiological situation of AIDS
     in the selected communities and to determine the
     resources of the community organizations to serve
     the AIDS patients.

2.   To examine the activities of those organizations
     within the context of the national policies and
     strategies for control of AIDS, the strategy of
     health for all, and the recommendations formulated
     by WHO.

3.   To analyze the benefits that AIDS patients have
     derived from the interventions of the community
     organizations.

4.   To study how families have participated in AIDS
     care and prevention activities and to learn their
     opinion on the activities of those organizations.

5.   To formulate recommendations to the countries, to
     the Pan American Health Organization, and to the
     community organizations to improve the health care
     provided to individuals affected by HIV or AIDS.

6.   To identify the principal needs of AIDS patients
     and to determine those that can be met in the home
     with the support of the family.

7.   To redefine the activities and responsibilities of
     those that provide home care.

8.   To define the participation of the local health
     services in the home care of AIDS patients.

9.   To emphasize the importance of community
     organizations for the national health systems of
     the countries and for PAHO.

     The community organizations participating in this
study, or the large majority of them, were created by
groups of homosexual men, probably because they
represented the population most affected by HIV.

     The AIDS epidemic made it necessary for the
community to demand the right to participate in the
prevention and control of the disease.  This community
mobilization represents an opportunity that should be
taken advantage of by the health systems in order to
form alliances with community organizations and expand
their capacity for action, especially in the countries
that are endeavoring to carry out activities to
decentralize the health services.

     The care that is provided by the community
organizations has an educational and orienting effect
consonant with the Latin American tradition:  the
patient prefers to die in his own house, surrounded by
family care and support.  In that sense it should be
remembered that in Latin America academic training in
health has always envisaged the promotion of community
care based on the nucleus of family care.  In Brazil,
for example, the first school of nursing was founded to
train nurses in the field of public health who carried
out epidemiological surveillance and home care
activities.  Public health nursing constitutes the
front in the fight against the preventable diseases and
the preacher of the gospel of health in the home. 
However, public health nursing lacks the appropriate
techniques to develop its potential for home care. 
That potential, strengthened by the formal health
system, can become an effective agent in the promotion
of preventive measures and in home treatment.

Epidemiological situation of AIDS in the countries
participating in this study

     The four participating countries reported 27,592
cases of AIDS, that is, 11.8% of the total number of
cases reported by the Region of the Americas.  Brazil
reported 19,361 cases; Costa Rica, 276; Mexico, 7,170;
and Trinidad and Tobago, 785.

     Although the first cases of AIDS reported occurred
in homosexual and bisexual men, that pattern of
transmission was modified beginning in 1987, when AIDS
cases were detected among the heterosexual population. 
Despite the fact that in Trinidad and Tobago
heterosexual transmission was considerably more
frequent than homosexual, in Brazil, Costa Rica, and
Mexico the first transmission pattern - that is,
homosexual transmission - still predominates.  In
Brazil transmission among homosexuals and bisexuals
accounts for approximately 60%; heterosexual, 10%; and
intravenous transmission, 14%, with a marked increase
observed in the cities of Rio de Janeiro and Sao Paulo. 
In Costa Rica, Mexico, and Trinidad and Tobago the
transmission among drug addicts still does not
constitute a problem of serious dimensions; however, it
should be noted that in Costa Rica, 71% of the reported
cases have occurred in homosexuals and bisexuals and
19% in those who have received blood and blood
derivatives.  The transmission through blood and blood
derivatives is a serious problem in the countries that
do not have the structure necessary for carrying out
the screening of transfused blood or effective control
measures.

     The World Health Organization estimates that there
are currently between 8 and 10 million people infected
in the world - that is, one infected person in every
400 adults.  Most of these persons will develop AIDS
within a period of 10 years, unless drugs that are
effective in combatting the disease are found (Merson,
1990).  The situation of women with respect to AIDS is
no less alarming; it is estimated that one of every 500
women is infected with HIV, with the registration of a
progressive increase whose effects are reflected mainly
in perinatal transmission (Merson, 1990).

     However, in comparison with other diseases, such as
cardiovascular diseases, diarrhea, malaria,
tuberculosis, and undernutrition, which exhibit high
rates of morbidity and mortality, acquired
immunodeficiency syndrome occupies a relatively lower
position.  Because of its mode transmission, its
characteristic as an incurable disease, at least at
present, and its high death rate, AIDS is the most
serious disease facing society today.

     The lack of studies on the prevalence of HIV
infection in the general population of the four
participating countries does not permit an exact
epidemiological analysis.  Despite the fact that Brazil
and Mexico show the highest absolute numbers of cases
in the Region, those countries present lower rates of
prevalence and of incidence that those of other
countries, such as Trinidad and Tobago.  In 1990, the
rate of accumulated incidence in Brazil reached 2.9 per
100,000 population, while in Trinidad and Tobago it was
13.5 per 100,000.  However, although the rate of
incidence in Brazil is several times less than that of
Trinidad and Tobago, the control of the disease in
Brazil is several times more complex, because of the
resources that are required to serve those cases.

     In those four countries a slight reduction was
observed in the number of cases among the homosexual
and bisexual male population and a proportional
increase in cases among the heterosexual population,
with greater significance in Trinidad and Tobago (PAHO,
1990).  In Brazil, the number of AIDS patients among
the population of intravenous drug addicts showed a
relative increase, while the male/female ratio varied
from 28/1 in 1986 to 9/1 in 1990.

     Similarly, in the participating countries HIV
transmission increased in the population under 15 years
of age.  In Rio de Janeiro, for example, the number of
cases increased from 10% in the period from 1986 to
1987 to 28% in the period from 1988 to 1989 (Ministry
of Health, Rio de Janeiro, 1990).

     More than 50% of the cases of AIDS occurred in the
capitals and large urban centers of those four
countries.  Sao Paulo and Rio de Janeiro account for
78% of the cases reported by Brazil.  In Mexico, the
Federal District and the city of Guadalajara contain
48% of the cases (Sepúlveda Amor, 1989), while in Costa
Rica and in Trinidad and Tobago most of the cases were
registered in the respective capitals.

Social effects of AIDS in the countries of the Region
of the Americas and their effect on the emergence of
community organizations.

     In the Region of the Americas the AIDS epidemic has
made it necessary for society to discuss openly
subjects that had been considered taboo for hundreds of
years, such as sexual practices, homosexuality, and the
use of condoms.

     In order to control the epidemic some agencies in
the government required serological examinations along
with the dismissal of the workers found to be HIV-
positive.  Insurance companies denied coverage to
homosexuals; undertakers refused to provide services
for individuals that had died of AIDS, and the
authorities searched houses and detained prostitutes
and homosexuals and required them to submit to tests
for detection of HIV as condition for their release
(Schifter, 1989; ABIA, 1989; Venciguerra, 1988; and
Galvan, 1990).  Some directors of departments of health
surveillance were sent to establish control measures in
the blood banks.

     In many countries the homosexual community was
organized for the purpose of denouncing deficiencies in
the health system, discrimination, and social rejection
and in order to fight for the rights of AIDS patients. 
Those manifestations of protest made the responsible
authorities recognize AIDS as a threat to all sectors
of the population.

Resources available for the control of AIDS

     In general, it can be said that all the countries
have the administrative, political, and technical
conditions to promote and carry out measures to control
the disease.  In all of them there exist:

1.   The political will of the Ministries of Health to
     establish programs for control of AIDS;

2.   The decision to create specialized agencies to
     prepare policies and standards and to develop and
     evaluate the activities of epidemiological
     surveillance;

3.   Plans for the preparation of legal instruments that
     control blood quality and require testing for HIV
     in all cases of transfusion;

4.   The commitment to establish medium-term national
     plans that encompass strategies and structural and
     organizational factors to control the disease, and

5.   A plan to create national reference centers and
     epidemiological surveillance.

     All these political, legal, administrative, and
technical instruments are essential for the health
programs.  However, any administrative reform and
planning will have little repercussion if it is not
accompanied by perceptible acts, hospital services,
drugs that are available, and enough services capable
of diagnosis and control of the blood and its
derivatives.

     In most of the countries a great scarcity of health
personal trained in direct care is noted.  The
countries do not have services for home care, shelter
houses, or day hospitals to care for ambulatory
patients; neither do they have referral systems; nor is
due consideration taken of the participation and
contributions of the community organizations in the
prevention and control of AIDS.

     In most of the countries of the Region sex
education at the primary and secondary school levels
has not been totally accepted, since it is feared that
teaching about the severity and the effects of AIDS can
promote "free sex."


COMMUNITY ORGANIZATIONS IN BRAZIL

     In Brazil there are approximately 50 community
organizations.  For the purposes of this study four
organizations were visited in the city of Rio de
Janeiro, five in Sao Paulo, and two in Salvador, Bahía.

Rio de Janeiro

     The state of Rio de Janeiro contains approximately
18% (1,593 cases) of the total number of cases of AIDS
reported by Brazil, and a rate of occurrence of 14.5
per 100,000 inhabitants.  Sixty percent of the patients
are in the group 20 to 40 years old.  According to
estimates of the Ministry of Health in Rio de Janeiro
the epidemic exhibits a rising curve; an estimated
1,000 cases were reported in 1990.

     The state of Rio de Janeiro has nine community
organizations devoted to providing assistance to AIDS
patients:  the Brazilian Interdisciplinary Association
for AIDS (ABIA); the Group for the Assessment,
Integration, and Dignity of AIDS Patients (VIDDA); the
Institute of Religious Studies (ISER); the Group for
Support and Prevention of AIDS (GAPA); Religious
Support in the Face of AIDS (PLOWS), the Group for the
Emancipation of Homosexuals (ATOBA), and Disque
AIDS/UNIMED.  The Institute of Religious Studies (ISER)
in turn supports three projects:  Religious Support
Against AIDS (ARCA), the Prostitution and Civil Rights
Program, and the Project Names.

     For the purpose of obtaining more detailed
information on the medical resources that the state of
Rio de Janeiro has for the care of AIDS patients,
visits were made to the community organizations ARCA,
ABIA, VIDDA, and GAPA, located in the city of Rio de
Janeiro, as well as to San Francisco de Asís Hospital
and the AIDS Referral Center at Clementino Fraga
University Hospital.


Religious Support Against AIDS (ARCA)

     ARCA is an autonomous nonprofit entity that carries
out cultural activities within an ecumenical spirit
(Galvao, 1989) and maintains relations with the
principal universities, churches, official agencies,
and political parties.  This organization provides
counseling services and is engaged in publication,
dissemination, and research oriented toward policies
that emphasize the importance of religion in the
processes of social transformation.

     ARCA obtains its funds from international
nongovernmental organizations, such as CAFOD, Caritas
Suiza, the Church of Sweden Mission, the World Council
of Churches, and others.  The organization is directed
by a directing council elected every two years which
has the authority to designate the executive
secretariat and the program coordinators; its national
members reside in different states of the country. 
ARCA receives technical and financial support from the
Institute of Religious Studies (ISER) which subsidizes
the group "Prostitution and Civil Rights" in a similar
manner; the latter also provides assistance to the
persons affected by AIDS (Galvao, 1989).

ARCA objectives and activities

     The general purpose of the ARCA group is to
facilitate a dialogue among religious groups with a
view to sharing knowledge and experiences on the
social, psychic, and religious effects of AIDS (Galvao,
1989).  It has as its fundamental goal the
incorporation of the spiritual dimension and the
participation of the church in the campaign against
AIDS.

     The organization develops activities over the
entire country, especially in the promotion of
international activities.  In 1988 ARCA promoted the
Latin American Church Consultation on AIDS, which
confirmed the importance of the participation of the
church in the effort to disseminate information on
AIDS.  The organization has created support groups
within the churches which carry out educational
activities, exchange experiences and make visits to
hospitals and ambulatory services, with emphasis on
spiritual support for terminal AIDS patients.

     In 1989 ARCA sponsored the Brazilian Encounter of
Pastoral Action in the Face of AIDS, which brought
together religious and secular groups to promote
collaboration with the Afro-Brazilian cult and with the
leaders of Christian youth.  Recently, it organized the
Brazilian Solidarity Chain (Galvao, 1989).

     For the period from 1990 to 1991, the ARCA
workgroup envisages analyzing the needs created by
AIDS, especially the urgent need for services of direct
care; studying the health policies of the government;
and strengthening the interinstitutional commitment of
the nongovernmental organizations and the official
agencies.

     The activities of ARCA for the biennium 1990-
     1991 include:

-    Training personnel from the religious communities,

-    The preparation of informative material for the
     communities,

-    Activities for the defense of the rights of the
     individual, especially those affected by HIV or
     AIDS,

-    The improvement of the interventions of the health
     sector, and

-    The preparation of educational material for the
     priests of Condomblé, an Afro-Brazilian religion.

     It should be pointed out that all those activities
are carried out with the advice of the Brazilian Black
Program and of the Ministry of Health in Rio de
Janeiro.

     Although ARCA does not carry out home care
directly, it welcomed this idea with interest and
presented a project for consideration by the Pan
American Health Organization and the World Health
Organization.

     Currently, ARCA acts in the areas of counseling,
education, information, and research.

     Through its advisory services:

     -     It provides psychological and spiritual support
to persons affected by HIV or AIDS and to
family members and friends.

     -     It provides services through DISQUE SIDA, a
direct telephone line that provides information
on the disease for eight hours each day.

     -     It offers group psychotherapy with the
collaboration of the VIDDA group.

     -     It promotes weekly meetings with persons who
test positive for HIV (Galvao, 1989).

     In the field of education, ARCA promotes:

     -     Dialogue with Afro-Brazilians religious.

     -     The distribution of literature on AIDS,
especially subjects related to citizens' rights
and the concepts of body, sin, and guilt.

     -     The preparation of courses for religious that
then act as multiplier agents and seminars for
religious leaders, priests, and persons
affected by HIV.

     In the area of information it carries out:

     -     The distribution of videotapes, pamphlets, and
bulletins among the religious and the general
population.

     -     The maintenance of a telephone hot line for
direct information.
     
     In research:

     -     It carries out studies on heterosexual
relations.

Group for Support and Prevention of AIDS (GAPA). 
Background

     The Group for Support and Prevention of AIDS (GAPA)
is a private, autonomous, nonprofit civil entity
without political, partisan, or religious linkage.  It
was created in 1987 in Tijuca, a rather populous
district of Rio de Janeiro for the primary purpose of
disseminating information on AIDS and improving the
situation of the patients (Gurgel, 1988).
     
     It is directed by a physician who acts as chairman,
two psychologists, and four persons that perform
administrative tasks.  The GAPA network encompasses
several states but the groups are independent and have
different objectives.  Its objectives encompass:

1)   The fight for effective health policies that
     include AIDS, particularly in the state of Rio de
     Janeiro.


2)   The campaign against discrimination and behavior
     that infringes on the rights of AIDS patients and
     those at risk of contracting the disease.

3)   The improvement of the living conditions of AIDS
     patients and those at risk of contracting the
     disease.

4)   The public denunciation of the hospitals, clinics,
     and health professionals that refuse to serve AIDS
     patients.

5)   The promotion of and participation in conferences,
     meetings, discussions, and other events that
     contribute to the achievement of the objectives of
     the Group.

6)   The collection of funds to finance the achievement
     of the goals of the organization through campaigns
     and social events.

7)   The coordination of activities and signing of
     agreements with public and private entities so that
     the Group might achieve its goals.

8)   The search for funds to offer patients health care
     at no cost to them in accordance with the plans
     approved for combatting AIDS (Gurgel, 1988).

     In addition, it distributes drugs to patients,
provides psychological counseling services, and offers
orientation through a direct telephone hot line;
however, it does not make home visits. 
     GAPA receives donations from the Ford Foundation
and the community contributes with drugs, food, and
other materials.  The funds are utilized to pay the
salaries of the professionals that comprise the working
team.  The Group maintains good relations with the
state government, which donated the shelter house for
AIDS patients.
     
     GAPA carries out activities in four principal
areas:

-    In prevention, by means of the distribution of
     educational material and the promotion of courses
     in the prisons, schools, and community
     associations.

-    In psychotherapy, especially for infected persons.

-    In counseling services, particularly for AIDS
     patients and their family members.

-    In the social area, through visits to the patients
     and to the family members to distribute condoms and
     medicines and to give them emotional support and
     orientation.

Brazilian Interdisciplinary Association for AIDS
(ABIA).  Background

     ABIA was founded in 1987 for the purpose of
fighting for the human rights of those affected by AIDS
and for the establishment of health policies that
include AIDS as a health priority.

     ABIA performs an important function in the
community as an agent for information, dissemination,
and education, through the publication of a widely
disseminated monthly bulletin.  This organization
aspires to create a responsible participatory
collective conscience to analyze in detail the
activities of the government agencies concerning AIDS
and to fight for the establishment in the country of
measures to control the quality of the blood in the
blood banks.

     ABIA is directed by young professionals,
psychologists, scientists, sociologists, journalists,
and others who occupy positions of leadership in the
intellectual media in Rio de Janeiro and frequently
participate in seminars and television debates in order
to influence public opinion.

VIDDA Group (For the Valuation, Integration, and
Dignity of AIDS Patients).  Background

     This organization was established in 1989 out of
the need for individuals affected by HIV to speak about
death.  It initiated its activities as a part of the
ABIA group and continues to share physical
installations with that group and take part in its
activities.  VIDDA does not have political, partisan,
medical or religious connections.  Its principal
objectives include:

-    To bring together the carriers of HIV, their
     friends, and family members,

-    To fight for the full rights of asymptomatic
     carriers of HIV and of AIDS patients,

-    To provide psychological and moral support, and
     informative material related to the disease
     (project of the VIDDA Group Foundation),

-    To fight against discrimination,

-    To help individuals to gain self-confidence.

-    To motivate patients so that make their own
     decisions,

-    To inspire affected individuals so that they
     participate and collaborate in community
     activities.

     VIDDA, like all other community organizations,
considers that it is the province of the government to
promote the creation of groups capable of carrying out
innovative health care activities.  The goals of the
VIDDA group are similar to those of ABIA; it also
receives funds of the Ford Foundation and exerts
considerable influence on other community organizations
of the country.

San Francisco de Asís Hospital Family Interaction and
Assistance Project.  Background

     This project was initiated in 1988 by the Ana Neri
School of Nursing of the Federal University of Rio de
Janeiro in San Francisco de Asís Hospital, a community
hospital for primary care.  The professors and students
of the school participate in the activities of this
organization.

     Among the goals of this group the following are
emphasized:

-    The participation of the family in the care of the
     hospitalized patient and the identification of the
     factors that interfere with family participation in
     the care of the patient.

-    The preparation of effective strategies for the
     participation of the family in patient care.

-    The formation of advisory groups and groups to
     visit homes.  

-    The study of a proposed analysis through the home
     care (Souza, 1989).

     The project activities are oriented toward health
education, with emphasis on self-care, the
participation of the family in the care, and the
training of the family to continue to provide care to
the patient when he leaves the hospital.  In the
future, the project envisages obtaining the funds
necessary for adapting the physical environment of the
hospital to serve AIDS patients.

National AIDS Referral Center of the Federal University
of Rio de Janeiro.  Background

     The Center operates in University Hospital located
on the Island of Fundáo, 30 kilometers from Rio de
Janeiro.  It has 10 beds and an ambulatory emergency
service for AIDS patients which operates 24 hours a
day.  This ambulatory service provides clinical and
therapeutic care and selects cases for referral for
hospitalization.  The Center is the only emergency
service for AIDS in the city of Rio de Janeiro and its
hospital and ambulatory capacities are very limited,
considering the large number of patients to be served,
which emphasizes the urgency of opening a day hospital,
a shelter house, and home care services in the city.

     In order to improve the capacity of this Center it
is necessary:

     To increase the size of the staff that provides
     educational services to family members while the
     patient is hospitalized.

     To increase the number of beds, since it has only
     10.

     To have a greater number of social workers in order
     to promote the educational and counseling
     activities for those that utilize the ambulatory
     services.       

     The city of Rio de Janeiro has 100 beds to serve
AIDS patients, distributed in 10 hospitals.  However,
because of administrative problems, only 45 beds,
distributed in four university hospitals, are actually
available for an increasingly numerous population of
AIDS patients.

State of Sao Paulo

     The state of Sao Paulo has a population of 15
million inhabitants, of which approximately 11 million
live in the capital, in "greater Sao Paulo."  In June
1990 the state had reported 7,716 cases of AIDS -
 that is, 69.7% of the total number of cases in the
entire country.  Of these, 4,524 cases, or 65.9%, were
infected through sexual transmission:  43% through
homosexual transmission, 16.4% through bisexual
transmission, and 6.4% through heterosexual
transmission.  Of the rest, 24.8%, or 1,699 cases, were
infected by blood:  20.3% by contaminated syringes;
2,8% by blood transfusion and infected blood
derivatives; 1.7% by transfusion to hemophiliacs; and
8.2% by unidentified means (Munhoz, 1990).  Most of
these cases occurred in the cities of Santos and Sao
Paulo, although a significant number of cases occurred
in other cities, such as Taubaté, Ribeirao Preto, Sao
José do Río Preto, and Sao José dos Campos.  The state
of Sao Paulo was the first state to establish two
reference centers for AIDS:  Emilio Ribas Hospital and
the AIDS Referral and Training Center.

     The AIDS Referral and Training Center was created
in 1988 by the Ministry of Health of the state for the
purpose of establishing standards and preparing plans
for the control of AIDS.  This Center consists of an
epidemiological surveillance unit, a department of
education and training, an outpatient service, and a
day hospital that occupies two floors with 14 rooms.

     The Center established control standards,
decentralized the activities, prepared criteria for
the utilization of hospital beds, and created a system
for the control of the available or vacant beds in the
state hospitals.  The day hospital offers specific
treatment and hospitalization during the time necessary
for providing the patient with therapy and the
necessary orientation so that he receives care in the
home.  The medical personnel at the Center consists of
15 physicians, four nurses, six nursing auxiliaries, 15
aides, three social workers, two psychologists, one
nutritionist, and three secretaries that work from 7:00
a. m. to 9:00 p. m.

     During the period from January 1989 to February
1990, the outpatient services served 25,128 patients,
a monthly average of 1,794 patients; the day hospital
served 8,510 patients; and 3,149 new cases were
evaluated, with a monthly average of 224 patients being
seen for the first time (Munhoz et al., 1990).

     In this way, this alternative of hospitalization,
which was implemented as an emergency measure, was
consolidated in an alternative care project which has
produced very positive results, has improved the
prospects for a hospital specializing in AIDS, and has
provided the basis for creating the first day hospital
in Brazil.
     
     Among the diagnostic and treatment activities
carried out in the Referral and Training Center are the
following:

Diagnostic activities:

     Skin biopsies, lumbar puncture, laboratory
examinations, endoscopy, and proctological examination;
treatment with oncovir, amphotericin, and other drugs;
transfusion of blood and blood derivatives; periodic
control of patients; and referral and back-referral.

Educational activities:

     Counseling services and education of patients and
family members on home care integrated into the care
provided by the day hospital; training of the health
personnel that work in AIDS; promotion of scientific
activities to evaluate the epidemic; creation of new
alternatives for care, preparation of treatment
standards, and epidemiological surveillance in the
state.

Coordinating activities:

     Promotion of coordination with the activities of
the national and international nongovernmental
organizations related to AIDS; maintenance of technical
cooperation agreements with other community
organizations, with the local health services, and with
the hospitals; coordination of activities with the
health services of private companies and industries in
order to promote the training of their workers in the
prevention of AIDS through the Prevention of AIDS
Project in the workplace.
     
In research:

     Promotion and participation in research projects on
the utilization of new drugs and in the studies on HIV
infection being carried out by the state of Sao Paulo.

     Epidemiological surveillance through the
collection, processing, analysis, and dissemination of
information on AIDS in the epidemiological bulletin.

     As a result of the excellent operation of the
Referral and Training Center and the day hospital, the
Ministry of Health of the state of Sao Paulo has
programmed the installation of other day hospitals in
the neighborhoods of the city that exhibit high rates
of prevalence of AIDS for the purpose of reducing the
demand for hospital beds even more.  In Sao Paulo, the
shelter houses and the day hospital have reduced the
average hospital stay from 60 to 17 days (Munhoz et
al., 1990).

Community organizations in Sao Paulo

     In the state of Sao Paulo there are 20 community
organizations, 12 of them in the city of Sao Paulo. 
For the purposes of this study five were visited:

     Project Hope, in Sao Paulo,

     The Alliance for Life (ALIVE), in Sao Paulo,

     The Movement for Free Sexual Orientation, (LAMBDA)

     The House of Brenda Lee, in Sao Paulo,

     The Support and Prevention Group (GAPA), in Santos.

     During our visits a great desire for cooperation
from the Referral and Training Center and the community
organizations was observed.

Project Hope.  Background

     This Project was created in 1988 under the auspices
of the Catholic Assistance Fund for Development (CAFOD)
in order to provide home care to HIV or AIDS patients
in collaboration with family members, friends,
previously trained volunteers, and personnel contracted
by the Project.

     The Project functions in the San Miguel district,
one of the poorer neighborhoods of the city of Sao
Paulo, and is administered by two nurses, a social
service auxiliary, and 14 volunteers.

     The nursing staff works from 8:00 a. m. to 10:00 p.
m. and coordinates the activities, provides home
nursing services, and trains and supervises the
personnel connected with the project.

     The Project Hope assistance plan includes:

     Diagnosis of the family situation and
     identification of its needs;

     Training of the family in home care activities;

     Supervision of the care provided by the family;

     Distribution of drugs, basic foods, clothes,
     disinfectant and other essential items in the home;

     Supplying the patient with transportation to the
     health services;

     Rental of special furniture, such as hospital beds
     and wheelchairs for home use;

     Teaching handcrafts, such as weaving and flower-
     making, to awaken a positive attitude in the
     patients,

     Weekly visits to seriously ill patients to help
     them to solve their problems;

     Training the family to carry out the following
     tasks: sponge-bathing; cure and prevention of
     eschars; diet preparation; elimination of
     contaminated material; application of intramuscular
     injections; massages; care in cases of diarrhea,
     vomiting, and oral candidiasis; temperature-
     taking; care in order to prevent hyperthermia;
     disinfection of the environment; and the disposal
     of refuse.
     
     The family is trained to assume responsibility for
the care of the patient even during the terminal stage,
since the family can usually give more relief, care,
and moral and spiritual support to the patient in the
home.  However, there are some difficulties to be faced
in home care - for example, not being able to leave the
patient alone, the physical and emotional fatigue of
the person providing the care, and attempting to keep
the disease a secret.  Continuous care of the terminal
patient is stress-inducing for both the family members
and the volunteer personnel, since the disease is
highly debilitating and the patient needs constant
emotional support.  In those situations an effort is
made to change the volunteers' shifts more frequently.
     
     The health services in the area of San Miguel do
not include activities for control of AIDS.  As a
result, it is necessary to transport the patients to
the Referral and Training Center or to Emilio Ribas
Hospital, which are located on the other side of the
city.

     Project Hope receives $25,000 annually from CAFOD
and the community contributes sporadically with food,
clothing, and drugs.  The Project also sponsors social
activities to obtain funds and to supplement its
budget.

     The good coordination between Project Hope, the
Referral and Training Center, and the hospitals has
made it possible to provide medical coverage and even
hospitalization to all of the patients.

Alliance for Life (ALIVI).  Background

     The Alliance for Life is a nonprofit civil
association, created in 1989 by the Archdiocese of Sao
Paulo, Episcopal Region of Santa Ana, at the initiative
of Bishop Don Joel Ivo Catapan.  This organization
works in the Parish of Santa Ana.

     The basis of the Alliance is theological and its
principal orientation is the Gospel and the Theology of
Freedom which postulates the freedom of man.  The
objectives of the institution include:

     To welcome and to treat the poor patients affected
     by AIDS that do not have housing and face other
     social problems.

     To maintain shelter houses for AIDS patients that
     do not have economic resources, with the goal of
     providing them with an opportunity to live with
     dignity within the community.

     To provide care to patients in the home, when this
     is possible.

     To provide social welfare to persons without regard
     for race, religion, political creed, and social
     condition.

     This Association is administered by a general
assembly, a deliberative council, a general
secretariat, and a financial council.  The executive
secretary is a nun from the Congregation of San
Francisco.

     The organization has 52 volunteers who participate
in various activities to meet the needs of the
families; in addition, the religious participate by
providing care in the home and in the shelter house. 
The general secretariat is responsible for the
coordination and execution of those activities.  The
Association receives funds from its members, from the
Archdiocese of Sao Paulo, and from international
nongovernmental organizations and MISERIOR, Action for
Assistance from the Bishops of Germany.

     The house that functions as a shelter is located in
Imirim district and was ceded by the community at no
cost to the organization.  Currently, the Association
is constructing a group of ten houses in a rural area
of Sao Paulo, where the Promised Land Support Center
will operate; it will have capacity for 100 patients. 
Every building will house a specific group of patients,
which will facilitate the administrative work and
relations among patients.

     Both ALIVI and Project Hope provide home care to
patients and their family members.  This has
contributed to the improvement of medical coverage,
since these institutions are located in neighborhoods
at considerable distance from each other.

     The institution receives donations from the markets
and storerooms of the community in the form of food,
which is distributed weekly to the shelter house, needy
families, and other community organizations that need
this type of resource.

     The internal administration of the shelter house
and nursing care are provided by a nursing auxiliary. 
Although the death rate in the house is relatively high
since the patients arrive very debilitated due to the
disease, most of the patients indicated that they were
satisfied with the care that they received in the
shelter house, although they would prefer to be in
their own homes if they had the necessary economic
resources and were accepted by their families.

     The organization faces difficulties due to the
limited number of personnel available for home care
activities and because shelter houses are not well
accepted by neighbors who fear the risk of contagion
and resent the behavior of drug addicts.  The
experiences of community organizations in Brazil
indicate that drug addicts affected by AIDS cause
problems that make peaceful coexistence in the
community difficult.  They frequently start fights,
exhibit aggressive behavior toward the other patients,
maintain relations with drug dealers, and instigate
thefts and surprise attacks to obtain money to purchase
drugs.  For that reason, ALIVI has established
standards that do not permit the reentry of patients
who are drug addicts into the institution.  Other
problems include the lack of drugs for the patients of
the shelter house and for those receiving home care and
the growing number of orphans of patients that die of
AIDS.  In this respect, ALIVI and Project Hope carry
out educational activities with the participation of
the churches, aimed at interesting families in the
adoption of orphaned children.  However, the process of
adoption is long and requires legal advice, since
families that desire to adopt children must meet the
requirements set by the law.  In this respect, the
Franciscan fathers have contracted the services of a
group of lawyers to provide legal advice.  The problem
of those children urgently requires solution since the
orphans of AIDS go on to swell the population of
abandoned children that populate the streets of Brazil.

Movement for Free Sexual Orientation.  LAMBDA

     This community organization was created in 1984 by
a group of homosexuals for the specific purpose of
providing home care and advice to AIDS patients and
their family members, promoting meetings of persons
affected by HIV, and providing educational talks with
emphasis on sexual relations and preventive measures. 
The activities of this organization are similar to
those carried out by ALIVI and Project Hope.

     The Movement coordinates its activities with the
Referral and Training Center and with Emilio Ribas
Hospital.  It is financed by the homosexual community
and, in addition, it receives contributions from the
community, especially from members of the families of
AIDS patients.

Brenda Lee House of Support.  Background

     This institution was created in 1983 by the
transvestite "Brenda Lee" as pension for other
transvestites.  Because of the AIDS pandemic, Brenda
Lee decided to accept in the pension sick persons who
were without economic resources; thus what was
initiated as a pension was rapidly transformed into a
hospital.  In order to defray the expenditures of the
House, Brenda Lee sold all his possessions and then
requested the assistance of the Ministry of Health of
Sao Paulo, which recognized the importance of the
shelter and agreed in 1987 to provide financial support
and medical services to the patients of the House of
Support.  The House has 35 beds and continues to be
administered by Brenda Lee.  Most of the maintenance
activities and the care of the patients is performed by
the residents themselves, who are for the most part HIV
positive.  The House provides the basic services to
meet the needs of the patients, a television room, and
a workshop for arts and crafts activities.

     The Referral and Training Center has been charged
with training the residents of the House of Support in
basic nursing skills.  The team of social workers and
nurses supervises the activities and provides social
and educational services, with emphasis on preventive
measures.  The Brenda Lee House of Support is an
example of what can be achieved through good
coordination.

Support Group for the Prevention of AIDS (GAPA) of the
city of Santos, Sao Paulo.  Background

     By June 1990 the city of Santos had reported 461
cases of AIDS and a rate of incidence of 404 per
million inhabitants, the highest rate in the entire
country.

     Although the acronym GAPA is utilized by various
nongovernmental organizations, these entities are
independent with respect to their administration, in
their activities, and in their financing.  The GAPA
group of the city of Santos was created in March 1988,
with the presentation of the "Henfil Review" in the
Student Research Center.  This organization arose from
the idea of a group of artists of collecting funds
through the presentation of a musical review in order
to pay for the treatment of Henfil, a hemophilic
caricaturist infected by a transfusion of blood
derivatives.  However, Henfil died before the
presentation of the musical review and the artists who
organized it decided to allocate the funds to found an
organization to support patients of AIDS without jobs
and family, similar to those that operate in Rio de
Janeiro and Sao Paulo.

     The death of Henrique de Souza Filho, Henfil,
political caricaturist, who was very well known and
admired in the country, provoked protests by the press
and obliged the responsible authorities to establish
standards to control the quality of the blood.

     The objectives of this support group are similar to
those of the GAPA groups in Sao Paulo and other states. 
However, some of its strategies utilize the theater and
other arts media as educational tools.  Its activities
encompass:

     Campaigns to warn the population through the
     Student Research Theater.  Preventive campaigns in
     the streets, presenting puppet plays.  Talks on the
     subject of AIDS at social events, such as style
     shows and bazaars, for the purpose of collecting
     funds.  Emotional support for the carriers of HIV
     by means of group therapy with the participation of
     family and friends and occupational therapy
     oriented toward the plastic arts.  Visits to the
     families to give them emotional support. 
     Preparation and distribution of material on
     prevention.  Educational activities in the prisons
     with the participation of the prisoners and the
     prison directors.

     Distribution of condoms among behavorial groups at
     risk:  drug addicts, transvestites, prostitutes and
     adolescents in poor neighborhoods, and prisoners. 
     Assistance to persons without resources, in such
     forms as drugs, clothing, and transportation. 
     Legal assistance to defend patients' civil rights.

     The group develops its activities in coordination
with the Ministries of Health of the municipality of
Santos and of the state, and maintains agreements with
the unique health services of the municipality.  Its
funds come from the incomes derived from the Henfil
Review and from donations made by the community.  In
1990 the Ford Foundation donated $35,000 which was
designated for social welfare activities and the
purchase of equipment and educational material.

     At present the group faces serious difficulties
because of lack of transportation services, the reduced
staff that it has available, and the ever-increasing
number of patients that request help.  However, the
group has entered into collaboration with the Order of
Lawyers of Brazil and the Ministry of Health to
evaluate the AIDS situation in two prisons in the city
of Santos.  The GAPA group requested the recourse of
habeas corpus for the benefit of prisoners that have
developed the disease of AIDS in order to be able to
provide them with adequate care.

     In 1989 the group also succeded in having a support
house established that is maintained by the Ministry of
Hygiene and Health of the city of Santos (A Tribuna, a
Santos newspaper, 1988).

Salvador, Bahía

     By 1989 the Ministry of Health of the state of
Bahía had received reports of 175 cases of AIDS in the
Northeastern Region of Brazil.  Bahía is the second
state of that region with the greatest number of
reported cases of AIDS.  For the purposes of this study
two community organizations were visited in the city of
Salvador, capital of the state of Bahía:  the Gay Group
of Bahía and the Group for Support and Prevention of
AIDS of Bahía.

Bahía Gay Group

     The Bahía Gay Group was established in 1980, for
the purpose of defending the civil rights of the
homosexual population and fighting discrimination and
bias.  It should be pointed out that the group
integrated the campaign against AIDS into its
activities among the homosexual community.  The Gay
Group carries out specific preventive activities
directed toward the adolescents that are concentrated
on the streets of the city of Salvador, using
continuing educational programs which include talks,
discussions, and conferences, during which they
distribute condoms and emphasize the importance of
their use.

Bahía GAPA Group

     The Bahía GAPA was created in 1988 by a group of
volunteers for the purpose of defending human rights
and fighting for effective health policies that
acknowledged AIDS as a health problem.  Its principal
strategies are oriented toward education and the
prevention of AIDS in the Bahía community through the
distribution of educational material.


  ACTIVITIES OF THE COMMUNITY ORGANIZATIONS IN MEXICO

     In 1988 the population of Mexico was estimated at
82,734,464 inhabitants, of which approximately 15
million live in the Federal District.

     The first cases of AIDS reported by Mexico occurred
in 1983.  In 1989 the country reported 4,416 cases. 
The rate of incidence during the period from 1983 to
1989 increased from 0.2 to 15.9 per million
inhabitants.  The Federal District reported 954 cases -
 that is, 32.5% - and a rate of incidence of 96.0 per
million inhabitants.  Of the rest of the cases, 67.5%
have occurred in the provinces, where a more
accelerated increase is observed than in the Federal
District.  Among the states with the highest incidence
the state of Jalisco stands out; 415 cases have
occurred there, with a rate of incidence of 83.4 per
million inhabitants (Secretaría de Salud, Programa de
Mediano Plazo, México, 1990, PMP).

     While sexual transmission has been stabilized
proportionally among homosexual men, it has increased
among bisexual and heterosexual men and among women. 
Transmission through blood and blood derivatives
continues to increase; in 1987 it represented 6% of all
cases; in 1988, 11%; and in 1989, 12%.

     Mexico has a National Program for the Control of
AIDS, coordinated and evaluated by the National Council
for the Prevention and Control of AIDS (CONASIDA). 
This Council is composed of a chairman, a general
coordinator, technical committees, academic committees,
an executive board, and state committees for prevention
of AIDS (COESIDAS).  This organization is supported by
the infrastructure of the national health system to
carry out its medium-term program.

     The national health system is composed of a
Ministry - a dependency of the Federal Executive, the
local health services (local health systems) in the 32
federal entities responsible for public health
activities, and the national institutes of health which
provide specialized medical care to the general
population.  In the Federal District there are two
services for diagnosis, for treatment, and for clinical
research.  However, in Mexico, as in other countries,
AIDS is not incorporated as a nosological entity in the
health service network.

     In the country there are 90 community
organizations, most of which are located in the Federal
District.  Five organizations were visited:  Companions
in Voluntary Educational Assistance (AVE), the Social
Research Group on AIDS (GIS-SIDA); Mexicans Against
AIDS (Confederation of Nongovernmental Agencies); the
Mexican Foundation Against AIDS, and the People's Union
of Nueva Tenochitlan Sur.  The offices of the Ford
Foundation and CONASIDA were also visited.

     On the day of our visit there was no community
organization that provided home care services in the
Federal District.  However, it is known that in 1989 a
group was formed that was composed of professionals
that carried out home visits.  This group was disbanded
because of the demands made by the hospitals and family
members of the persons affected by the disease.  In
addition, in Guadalajara, capital of the state of
Jalisco, there is a functioning group of volunteers,
composed mainly of mothers of AIDS patients, which
provides home care.


Companions of Voluntary Educational Assistance, AVE,
Civil Action Group in the Campaign Against AIDS. 
Background

     This group was created in 1988 by a group of
professionals from different disciplines.  It is
directed by a physician specializing in AIDS and in the
management of community organizations.  The principal
purpose of this institution is to provide information
on sexual relations and on preventive measures and to
train personnel to assume responsibility for developing
those activities in public and private institutions. 
For this purpose it collaborates with CONASIDA in the
promotion of workshops for AIDS patients.  In two years
the organization has trained 20,000 persons.

     The group's work plan for 1990 encompasses the
following:

Offering courses on sexuality to university
students.

Providing counseling services through a direct
telephone hot line.

Making contact with the health services in
order to refer patients.

Offering counseling services on serological
examination.

Presenting courses on sexuality that are
directed toward adolescents.

Providing counseling services to companions on
the care of patients in the home.


     The members that form the group have permanent jobs
in other institutions and thus the organization's
activities begin at 7:00 p. m. so that they do not
interfere with the work obligations of the volunteer
staffs.  The group was formed initially by infected
homosexuals but today mothers and teachers also
participate.    

     The AVE group has designed a five-year work plan
that it began to follow in 1988; it includes
educational and informational activities for the
populations in the following locations:

     Mexico City, Guadalajara, Monterrey, and Mérida 

     International tourist centers

     Border areas

     Industrial and factory centers

     One of AVE's priorities is home care.  However, in
order to develop this type of service it should have
the decided support of the government, since it
requires contract personnel in addition to the
volunteer staffs.

Social Research Group on AIDS (GIS-SIDA).  Background

     This community organization was founded in 1987
with the basic purpose of providing advisory services
and information on human rights to seropositive
individuals and to those affected by AIDS and in order
to engage in public relations activities and act
legally on behalf of the patients in all areas related
to their human rights (GIS-SIDA, El Nacional, 1990).

     The GIS-SIDA plan of activities for 1990 includes
the following:

     Organizing a legal assistance network in the
     Federal District for the defense of affected
     individuals.

     Informing AIDS patients and society in general of
     their civil rights.

     Promoting legal action, when appropriate, carrying
     out all types of administrative and judicial
     activities and presenting the case before the
     Public Ministry, among other activities.

     Acting as consultant to other community
     organizations and individuals.  Disseminating
     information on AIDS through the mass media. 
     Publishing the monthly bulletin "Human Rights and
     AIDS" in the newspaper La Nacíon. 

     Providing legal, accounting, and administrative
     advisory services to other community organizations.

     The organization is self-financed; however, it has
difficulty in obtaining the total amount of the budget
that it requires to cover all of its activities.  For
this reason, the Board of Trustees, which is the
financial organ of the Association, promotes social
events in order to collect funds.

     Due to its interventions in defense of human
rights, the group is highly respected by country
officials and by the other community organizations.

Mexicans against AIDS:  a confederation of
nongovernmental agencies.  Background

     The Mexican Confederation Against AIDS was founded
in 1985 on the initiative of a sector interested in
grouping all the community organizations under a single
structure.  Currently, it includes 15 organizations, 10
of which are located in Mexico City, Federal District. 
These 10 organizations only develop activities related
to AIDS.  The general objectives of the Confederation
are the following:

     To combat AIDS, uniting efforts to promote
     preventive measures and create a sense of
     solidarity with the persons affected by AIDS.

     To consolidate the development and growth of the
     Confederation and of its member groups in the
     metropolitan area and in the interior of the
     country.

     To promote activities for coordination with the
     national and international nongovernmental
     agencies.

     To strengthen the presence of the Confederation in
     all matters related to the campaign against HIV.

     In addition to the activities for education,
prevention, and defense of civil rights, the
Confederation provides advisory services and
orientation to groups that wish to be organized but
that do not have the necessary support.  To this end
seminars are held to inform individuals, especially
those that come from the interior of the country, on
the steps that they should take to organize, to meet
the needs of patients, and to try to solve their
problems.

Mexican Foundation Against AIDS.  Background

     This organization was founded in 1987.  It has its
own headquarters which it utilizes in the provision of
free services to AIDS patients.

     The Foundation is directed by a multidisciplinary
group, consisting of physicians, psychologists,
educators, and others who are permanently employed in
other institutes and work as volunteers in the
Foundation.  In addition, it has a team of four persons
under contract who work full time.

     The goals of the Foundation encompass:

     Keeping the public informed on the AIDS situation
     in the country.

     Carrying out diagnoses of HIV and providing
     orientation and advice to individuals that test
     positive.

     Providing psychological support to patients and to
     their family members and friends through group
     psychotherapy and self-help groups.

     Training volunteer staffs so that they promote
     educational activities in groups and provide
     individual orientation to AIDS patients.

     Sponsoring scientific events, seminars, courses,
     and other educational activities.

     Providing advisory services to other community
     organizations that request it.

     The Foundation, in collaboration with CONASIDA,
engages in research on sexually transmitted diseases,
including AIDS.  In addition, it meets with those
submitting to diagnostic tests to inform them of the
results and to recommend methods of relaxation and
meditation to them; it also provides orientation
through a direct telephone hot line and organizes
groups to address the patients' problems that require
legal action.

     In the future, the Foundation plans to carry out a
project on sex education and prevention of AIDS aimed
at adolescents especially.

     The funds of this organization come from donations
by private national companies.  These funds are
sufficient to cover wages and other operating expenses. 
The organization also has funds that it receives for
diagnostic examinations, for which it collects a
minimum fee to cover the cost of reagents.


Nueva Tenochitlán People's Union

     This group was formed initially with a view to
constructing dwellings for the victims of the
earthquake of 1985.  It is made up of women who carry
out social work directed especially toward children and
mothers.  In 1990 the People's Union included in its
plan of action activities related to AIDS.  In order to
carry out this type of activity the Union organizes
talks in the residential neighborhoods between 4:00 and
5:00 p. m. to provide the neighbors information on
preventive measures, to distribute condoms, and to
demonstrate and recommend their utilization.

     The efforts of the members of this organization are
worthwhile.  However, because of the inadequate
educational methodology used and the lack of specific
technical support for this type of activity, the
results that they obtain do not compensate for the
effort.  They do not generate a large attendance of the
neighbors at the meetings; the activities within the
neighborhood are seen as hampered by neighbors return
from work but do not go to hear the talks, by the
children who play in the same place where the talk is
being presented, and by the neighbors' general lack of
interest.


COSTA RICA

     Costa Rica has a population of 2,865,813
inhabitants.  The first case of AIDS reported by the
country occurred in a hemophilic in 1980.  By 30 March
1990 the total number of cases had increased to 151. 
Of 80,000 donations of blood examined during the period
between October 1985 and October 1987, 24 seropositive
donations were detected, 23 from homosexual or bisexual
men and one from an individual infected through blood
transfusion.  The Department of AIDS Control of the
Ministry of Health estimates that 15% of the homosexual
population of the country is infected with HIV.  The
Department of Control has records of 125 hemophiliacs,
of whom 80, or 64%, are infected with HIV, while the
results of the examinations carried out in 1987 among
2,000 prostitutes indicated a rate of infection of
0.1%.  Of the 115 cases recorded by 1989, 82, or 71%,
occurred in homosexuals, 21 cases or 18% in
hemophiliacs, four cases or 3% in heterosexual women,
and two cases or 1.7% in drug addicts.

Resources of the Government of Costa Rica for control
of AIDS

     In 1985 the National Commission on AIDS (CONASIDA)
was created as an advisory body of the Ministry of
Health to prepare standards for the control of HIV
infection.

     The country has two hospitals for AIDS patients;
however, only one of them has physicians and nurses
trained in AIDS.

Community organizations in Costa Rica

     In the country there are two community
organizations devoted to the care of AIDS patients: 
the Association for the Fight Against AIDS and the VIDA
Foundation.

Association for the Fight Against AIDS (ALCS). 
Background

     This organization has been working since 1980 to
defend the civil rights of the homosexual community. 
In 1987, the group decided to cease being anonymous and
protested in an open letter to the press against
repression, police raids on bars, imprisonment, and the
implementation of obligatory serological examinations
to detect HIV among public employees and homosexuals.               

     The principal activities of the Association
encompass education on the methods of preventing AIDS,
counseling services through a direct telephone hot
line, and home care.  The Association relies on three
volunteer nurses that train the families and friends of
the patients and even the health personnel in the
hospitals.  The organization faces difficulties in
carrying out activities in home care since it does not
have the support of the health sector.  However, it has
the backing of physicians, bacteriologists,
psychologists, and university professors who consider
the contribution of this Association as a strategy in
the control of the disease (Frajman, 1990).  In this
specific case the Pan American Health Organization
could act as a catalyst by coordinating the activities
of this Association with CONASIDA.

VIDA Foundation

     This organization was created in 1989 with a view
to forming self-support groups of individuals infected
with HIV.  Recently, the organization brought together
the first group of individuals; however, these people
still feel insecure and fearful and do not attend the
meetings of the self-support group since they are
afraid to admit their disease and suffer persecution. 
However, the Foundation continues to emphasize the
importance of group discussion.


TRINIDAD AND TOBAGO

     The population of Trinidad and Tobago is estimated
at 1,326,000 inhabitants.  AIDS is one of the greatest
concerns of the Ministry of Health.  The first cases of
AIDS were detected in 1983 among homosexual and
bisexual men.  However, at present most of the AIDS
cases occur among heterosexual individuals, with a
rising curve being observed in this population group. 
By December 1989 367 cases of AIDS had been reported
along with 563 deaths and a mortality rate of 65.2%
(Ministry of Health, 1990).  Of the reported cases, 43
- that is, 77% - were infected through sexual contact,
75% of these cases in the age group 20 to 49 years old. 
The index of seropositive individuals in the clinics
for sexually transmitted diseases fluctuates between
10% and 18%.

     Trinidad and Tobago have a primary care network
consisting of 102 health centers, two general
hospitals, two specialized hospitals, and four rural
hospitals, with a total of 4,607 beds.

     The AIDS Control Program was established in 1987,
when the National Committee on AIDS was created under
the Ministry of Health to prepare control standards,
supervise the activities of the subcommittees, and
evaluate the actions of the Program.

     In 1990 the National Committee on AIDS stated that
in order to achieve the objectives of the Program it
was necessary to have the participation of
representatives of the religious organizations, of the
Union of the Association of Employees, of the
nongovernmental organizations, and of the self-help
groups (Ministry of Health, Report on the AIDS
Situation, 1990).  With this in mind three
subcommittees were created:  the Ethical and Legal
Committee, the Committee for Care and Support, and the
Committee for Coordination with Nongovernmental
Organizations.

     The Program is developing a medium-term plan (1988-
1990) for the control of AIDS which includes the
following activities:

     Surveillance and research;

     Training of the health personnel;

     Special educational programs in the schools;

     Activities at the national level for the control of
     blood transfusions and blood derivatives;

     Control of sexually transmitted diseases;

     Care, support, and counseling;

     Direct telephone hot line;

     Among the activities for direct care and support of
patients the following are programmed:

     Hospitalization in four hospitals, three in Port-
     of-Spain and one in San Fernando.

     Orientation services provided by physicians,
     nurses, and social workers, residents of the
     Queen's Park Counseling Center, before and after
     serological examinations.

     Direct telephone counseling services through a hot
     line which functions from 8:00 a. m. to 8:00 p. m. 
     Those activities are directed by the volunteer
     personnel of the Queen's Park Counseling Center.

     Supply of drugs against opportunistic infections. 
     However, the drug AZT should be acquired for the
     patients in accordance with their economic
     resources.

     Training of nursing paramedic personnel; this is
     carried out in the Queen's Park Counseling Center
     (Ibid., 1990).

     Distribution of condoms at the Queen's Park
     Counseling Center.

     In 1989 the control of 19 laboratories that carry
out blood transfusions was initiated with the support
of the Caribbean Epidemiology Center of PAHO (CAREC). 
Those laboratories are equipped to carry out the ELISA
test on all donors of blood.  CAREC trains the
personnel of the network of laboratories in the
Caribbean (CAREC, Progress Report, 1989-1990).

Participation of community agencies in the control of
AIDS

     In 1988 the Pan American Health Organization
sponsored a study of the nongovernmental organizations
that work in health care in Trinidad and Tobago.  The
results of that study indicate that there are 116
nongovernmental organizations that carry out various
activities.  Two of them - Living Water and the
Association of Professional Nurses - develop specific
activities for the control of AIDS.

     In order to implement the program of the Ministry
of Health and at the request of the PAHO
Representation, visits were made, in the company of the
coordinator of the AIDS Control Program, to the
following organizations:  Living Water, the Salvation
Army, and CARITAS.

Center of the Living Water Community

     This center is a Catholic organization started in
1975; it has the following objectives:

     To help the poor, the patients, and those who are
     abandoned, to counsel them, evangelize them, and
     offer them spiritual guidance in order to promote
     the Christian faith.

     To meet the social needs of those individuals.

     To offer medical care and to relieve the poverty of
     the handicapped.

     The patient shelter was visited.  Most of the
patients hospitalized in this institution had terminal
cancer and others were found in an advanced state of
senility.  However, no AIDS patients were observed.

     The Living Water center is engaged in the following
activities:

     It maintains a center to care for beggars; it
     provides daily food, clothing, and health care to
     almost 600 persons.

     It operates Miriam House, a center for homeless
     unemployed young people; it has capacity for 40
     young people who receive education and training for
     employment.

     It provides counseling to drug-addicts and their
     family members.

     It operates a house for women in crisis.

     It promotes, through the Fount of Hope, the
     rehabilitation of the homeless, ex-prisoners, and
     drug-addicts.

     It trains young people in certain trades, so that
     they can to be reintegrated into society (PAHO/WHO
     Report on a Survey of Nongovernmental Organizations
     Involved in Health and Health-related Services in
     Trinidad and Tobago, 1988).

CARITAS

     This organization was founded in 1987 as a member
of CARITAS INTERNATIONALIS for the purpose of extending
charity and social justice in the world (Guilly, 1988).

     The institution has as its goals:

     Development of community services to help
     individuals to control their lives and their
     destinies and;

     Provision of assistance in cases of emergency;

     For this purpose it advances programs for
rehabilitation, social development, and agricultural
development by means of the following projects:

     Emergency Aid, Social Rehabilitation Program,
     Social Development Program, Agricultural
     Development Program, and the Seminar on AIDS.

     However, CARITAS does not provide home care; its
activities are oriented toward religious education and
spiritual support for patients.

The Salvation Army

     The goal of this organization is to provide social
assistance to the poor and those who are abandoned  amd
shelter to those without resources and without work. 
However, the organization establishes certain
conditions for those whom it accepts: they should not
smoke amd they should not drink alcohol or take drugs. 
The organization does not engage in activities related
to AIDS; however, it is studying the possibility of
providing shelter in the future to those affected by
the disease.

     In addition to the organizations mentioned, visits
were made to the following official institutions that
engage in activities related to the control of AIDS: 
the coordination of the national program, the Queen's
Park Counseling Center, and San Fernando General
Hospital.  In addition, we visited the nurse Angela
Daniel-Rocke who is responsible for the control of
sexually transmitted diseases in San Fernando Hospital.

     The coordination of the national program for the
control of AIDS maintains close ties to community
organizations, trains the district nurses, and trains
members of patients' families so that they can provide
home care.  To develop those activities it counts on
the primary health care network which has professional
nurses.


CONCLUSIONS AND RECOMMENDATIONS

     This study covered 21 community organizations, 15
of which were created at the initiative of groups of
homosexuals affected by AIDS, with the specific purpose
of defending their rights, providing psychological
support, taking preventive measures, meeting their
needs, and fighting for effective health policies to
combat the disease.  Three organizations were
established by religious institutions, and three
existed long before the AIDS epidemic appeared.  It
should be pointed out that most of those organizations
were founded less than four years ago.

     Of the participating community organizations only
four include in their programs home care activities
with the family as the nucleus of care.  Some of the
organizations consider that home care is the
responsibility of the public health services and
accordingly demand that their respective governments
supply adequate hospital care for all AIDS patients.

     However, the community organizations recognize the
complexity of home care.  It is a task that demands
full-time nursing personnel, in addition to the broad
participation of volunteer staffs.  It requires the
support of the formal health systems, referral and
back-referral services, transportation, a supply of
medicines, and a body of technical and administrative
knowledge so that those resources can be utilized
effectively and at minimum cost.

     It is the responsibility of the health authorities
to establish dialogues with the community organizations
and to seek viable alternatives.  In addition, the
leaders of the community organizations should analyze
the health situation in Latin America and the
Caribbean, taking into account the magnitude of the
public health problems and the high rates of morbidity
and mortality produced by both AIDS and other diseases
as well as the precarious economic conditions that the
countries are experiencing.

     The study indicates that individuals affected by
AIDS have a series of needs that the public health
services cannot fully satisfy.  The rest of those needs
can be met by community organizations through home
care.  However, the patient must have food, clothing,
and sanitary conditions for home care to be possible. 
In addition, he needs to rely on family members,
friends, or individuals who voluntarily assume
responsibility for his care while he is ill.

     Home care carried out by the family members and
friends of the patient is an alternative that is
culturally accepted in the countries of Latin America
and the Caribbean.  This alternative to hospitalization
will be useful whenever the activities of the community
organizations are coordinated with the formal health
systems and common objectives are laid out.

     Home care should be initiated with preventive
measures taken by the individuals infected by HIV who
have still not developed the disease and who live a
normal life.  However, one should always take into
account the changes that are presented in the health of
the infected individuals in order to provide them with
continuity in health care through a network of formal
services that ensure timely care.

     Community organizations are essential to the care
and control of AIDS.  However, it is necessary to
evaluate their operation in detail, to reformulate
their objectives, and to reorient their activities.  In
this regard, it is observed that some countries have
recognized the importance of coordinating the
activities of the community organizations with those of
the official institutions.

     It is recommended that the Ministries of Health
strengthen the activities of the community
organizations, especially those activities that are not
included in the programs of the health systems:  for
example, home care as an alternative to hospital care
and self-help and counseling groups.

     It is recommended that the Pan American Health
Organization act as a catalyst to strengthen the
coordination between the community organizations and
the Ministries of Health, to harmonize relations
between the community organizations and the different
government agencies, and to sponsor joint actions for
the benefit of patients with AIDS.  In this respect, it
is recommended that PAHO cooperate with the Ministries
of Health in the planning of joint programming with
common objectives and strategies and that it promote
the financial support of the community organizations
that are well-structured and have the capacity to
provide effective assistance to patients with AIDS.

     It is recommended that the Pan American Health
Organization promote workshops on home care with the
participation of the leaders of the community
organizations and the officials of the AIDS control
programs.  Such workshops can help the those in
responsible positions to formulate guidelines for the
implementation of home care and motivate the
governments to standardize and supervise the home care
carried out by the community organizations and train
those involved.

     It is recommended that in AIDS control programs
priority be assigned to activities for family education
to create citizen awareness of the importance of moral
support for the patients and of the need to train the
family so that it assumes responsibility for the care
of the patient in the home.

     Home care as an isolated activity loses
effectiveness.  For this reason, it is recommended that
the Pan American Health Organization reinstate home
care as a basic primary care activity in order to
reintroduce it into the local health services and
develop coordinated joint actions that encompass the
three principal areas of health care:  continuous
ambulatory and hospital medical care, community
support, and home care.

     The Member States of the Pan American Health
Organization accepted the world strategy of health for
all by the year 2000, which envisages community
participation as a fundamental policy.  However, the
participation of the community organizations in the
activities for the control of AIDS has generated tense
situations in some countries, which must be relieved if
really effective cooperation is to be achieved.

     Finally, the recommendation is made to the
countries to adopt specific policies and mechanisms to
provide decisive backing, through technical advisory
services and support in the form of resources, to the
participation of community organizations in the
planning and in the execution of activities against
AIDS.


DATE:  23
April 1991


PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION

























HEALTH AND DEVELOPMENT OF INDIGENOUS WOMEN
IN CENTRAL AMERICA AND PANAMA


SUBREGIONAL PROJECT














PROGRAM ON WOMEN, HEALTH AND DEVELOPMENT

Guatemala, October 1991





1. BACKGROUND

     Beginning in the 1980s, with the arrival of civil governments
in the Central American area, the population of the region began
to develop expectations that they would be able to actively
participate in the various development projects that each country
was planning and implementing.

     To a greater or lesser degree these expectations failed to be
realized either because the political intent of government
interventions inhibited popular participation or because the will
of the government was constrained by the behavior and customs that
prevailed in the sociopolitical life of these countries.  In the
case of the indigenous communities, cultural violence, for example,
is and has been a major obstacle to people's active participation
in strengthening their own capacities.  In most cases, it is
attempted to impose the goals of "development" on these people,
using Western society as the model and overlooking the fact that
within the populations themselves lies the power to generate an
alternative process which is rooted in their culture and led by
women as the principal transmitters of that culture.

     Recent United Nations evaluations show a serious decline in
the living conditions of the greater part of the population, and
with good reason we speak today of a lost decade, aggravated by the
human rights questions that arise as well. 

     In light of the difficulties occurring at the government level
as efforts are made to achieve sustained development, populations
are looking for opportunities to be the planners and subjects of
their own development.  Thus, a diversity of organizations has
sprung up at the community, rural, and ethnic level in every
Central American country.  The I International Seminar on Indian
Peoples, which was held recently in Guatemala, was attended by more
than 200 representatives who took a united stand in favor of
Culturally Rooted Development.  At the rural level, community
structures are seeking to become promoters of self-development
which is based on having the subject serve as the planner and
author of improvements in his own living conditions.

     Undeniably, the development philosophy that prevailed during
the 1970s and 80s, which focused solely on production factors, lost
sight of the importance of human factors and of the human
preference for alternative development strategies.  This has been
and still is forcing us to revise strategies so that we can
readdress the notion of subjects from the perspective of gender as
a key factor in the development process.

     Thus, in indigenous groups, women are the central axis around
which revolve the entire group culture and the transmission of
values.  Conducting in-depth research to learn about the problems
of these women, strengthening their training as a multiplier
factor, and examining the prospects for providing medical and
health support to them through alternative models of care are the
challenges that we face in trying to reverse the population's
negative trends in the area of health. 
 
1.1  PROJECT BEGINNINGS

     The subregional program on Women, Health, and Development that
is promoted by PAHO opened the doors to the possibility of
presenting a project aimed at improving the health of indigenous
women in the subregion, involving women in the search for solutions
to the health problems they face, and promoting self-evaluation,
self-care, and development, in response to one of the
recommendations made on this subject in Nicaragua between 28 August
and 1 September 1989.

     An evaluation prepared by Garro Valverde (1991) under the
subregional program shows that indigenous people are in a
precarious health situation whose corollaries are high infant
mortality, a high incidence of infectious and parasitic diseases,
and serious difficulties with gaining real access to health
services.

     Added to this is the vast experience obtained in the field
under the program on Women in Health and Development which, in
addition to confirming the merit of certain traditional medical
practices, such as delivery in a squatting position, has
highlighted the low impact that the official health apparatus is
having on the indigenous population.  This poor impact results from
the contrast between the centralized sanitary apparatus, which
operates through vertical hierarchical relationships and uses
European-North American philosophies, and a target population which
to a greater or lesser degree uses various cultural patterns as its
point of reference.  In addition, the program's progress today
reveals the need to gain a more in-depth knowledge of the
situational problems of indigenous women through experiences in the
field which will make it possible to understand their specific
world view, so that the activities that the project can promote are
practical and concrete responses to the concerns and needs
expressed by these women, according to a perspective that is in
harmony with their way of thinking and philosophy of life.  The
project is based on an approach which makes women the core of the
analysis, based on a reconsideration of the human factor in
development and the human preference for alternative strategies. 
The role of the family in general and of women in particular will
take on special importance in the measure that we are successful
in committing a large number of women to becoming participants in
health projects in particular, and in development in general, areas
of marginal involvement for them until now. 

1.2  CHARACTERIZATION OF THE PROBLEMS OF THE HEALTH SERVICES IN THE
     INDIGENOUS COMMUNITIES, AND OF INDIGENOUS WOMEN IN PARTICULAR

     The public entities that operate in the health sector in the
subregion have encountered serious problems when they have
penetrated or attempted to penetrate indigenous areas.  Culture
shock, a lack of mutual knowledge, and the existence of different
models and practices are influential factors when the impact and
coverage of these services is evaluated.

     The difficulty experienced by public health entities when they
try to penetrate and gain credibility in the indigenous areas is
a consequence of the relative inflexibility of the public model,
which obeys a logic different from that which governs the
communities in question.  Traditional medical practices, idea
systems regarding disease, internalized notions of the human body
and its workings are subjects that have been already studied by
anthropology; however, Western medicine and the health programs
have underutilized this information and have failed to develop a
frame of reference that makes it possible to identify the
nosological symptoms and framework of modern medicine that would
correspond to the symptoms and pathological signs of traditional
medicine.

     The existing medical models implemented by the governments
have felt the impact of the structural adjustment programs; this
impact is reflected also in the high cost of medicine today.  A
population's economic capacity to access a service is a significant
factor when considering what types of services can be purchased or
paid for.  Where it is possible to have access to imported drugs,
difficulties arise with regulating the doses, above all because it
is left up to the pharmacy owner to request information about drugs
that might be useful in combating a given set of pathological signs
and symptoms, although in most cases, these pharmaceutical
personnel do not have the knowledge or basic training they need to
respond to consultations.  Donations do not constitute a solution
either, and all the cooperation programs have confirmed that when
work proceeds according to this philosophy, there is a decrease in
the value of the activities and the impact of the projects.
 
     The lack of reliable data on the health situation of the
population in these groups is an important factor when it comes to
determining and establishing social policy, especially health
policy.  In Guatemala, data is available on the health status of
the population at the municipal level; in Honduras, the data that
has already been prepared and published uses the departmental level
as its point of reference; in Costa Rica, there is an even more
detailed breakdown, with information available all the way through
the district level.  All this information is scattered, and there
aren't any tables that permit subregional comparisons.

     Health policies directed toward women are not established
based on an analysis of health status by gender.  Health workers
are unfamiliar with the social and health conditions of the women
belonging to various ethnic groups.  There is no information on the
diseases and problems of women according to age group, and as a
result, the public programs directed toward this population do not
reflect what is really going on within the female population. 
According to the roles prescribed within ethnic communities, women
are traditionally responsible for providing the family's basic
needs, and unquestionably the way that social policies are planned
to meet basic needs has a considerable impact on women.

     The ideology and culture of these subregional ethnic groups
embody an idea system that differs from the Western one.  At the
level of health, their idea system in relation to disease is
closely related to their specific religious beliefs.  The divine
mandate involved in exercising a cure must not be underestimated,
since religion and propitiatory rites are important to that cure,
especially when the disease is considered to have supernatural
causes, or when the suffering has been imposed as a divine
punishment because the sufferer has failed to respect the moral
code of the group.  The official health services have not been and
are not able to meet the cultural needs of these groups, and the
lack of a language for communication makes it even more difficult
and expensive for the programs to have any impact.

     Research carried out by MUDAR (Women for Alternative
Development) shows that women and ethnic and racial groups are
particularly hard hit during periods of crisis.  A lack of access
to land in the case of Guatemala and El Salvador, a shrinking of
rural investments in the case of Honduras, the ongoing conflicts
in Nicaragua and El Salvador, and the lack of opportunities for
well-paid work in the case of Costa Rica are all factors that have
a decisive influence on women.  Women are migrating from the
country at a rate that is increasing all the time.  This
transformation is laying the groundwork for a series of changes
within rural families, and although there has certainly already
been discussion of the effect that the increase in work-for-
pay among women has had on gender roles within the family, we have
yet to take a closer look at the impact of these changes on their
health conditions, and at their repercussions for the nuclear
family.

     The prevailing patterns with regard to fertility, age at
marriage, and beliefs and customs surrounding pregnancy need to be
studied in depth, because this will produce basic information that
will allow us to learn in greater detail what types of services can
be provided, as well as to identify gender-specific health
problems.  Breastfeeding is an example of a cultural practice that
continues to be present in the most traditional societies.  In the
sixties, inadequate information on the part of health workers and
other factors fostered the abandonment of this beneficial practice;
today, efforts are being made to reverse this trend, but at the
same time much remains to be done in order to improve the paired
elements of maternal lactation and maternal nutrition which have
such an impact on the health of women and their families.

1.3. PREVIOUS WORK CARRIED OUT

     International agencies such as UNIFEM-UNICEF, WHO, PAHO, and
the private development organizations, as well as some
universities, have dedicated themselves in recent years to studying
women's current situation from the perspective of gender.  Most of
their work has taken into account urban problems, level of
industrialization, and the crisis and its effects on society in
general and on women in particular.  There are almost no gender-
based studies of the health problems of women in rural areas, and
of ethnic groups in particular, or of their relationship to a
greater or lesser degree of development in the community, despite
the fact that today these are considered to be a useful tool for
programs and projects whose priority it is to exercise a multiplier
effect on development.

     Some work done mainly in Guatemala brings out the importance
of integrating traditional medicine and the primary health care
system.  Since the 1950s, a study has been available which analyzes
the medical beliefs and practices of an indigenous people in
Guatemala (Adams, 1952), along with a working document which
classifies the indigenous population in terms of the acculturation
process (Adams, 1960) and makes it possible to distinguish
traditional groups, groups that have modified their traditional
culture, and acculturated groups, which bear a closer resemblance
to the mestizo population. 

     In the seventies, attention was turned to the problem of the
acculturation process and its relationship to ethnocentric
attitudes and underdevelopment.  One field study (Ghidinelli, 1976)
showed the situation of the family in particular, as well as the
situation among married couples in three ethnic groups (Ladino,
Caribe, and Kekchie) of Guatemala.  In 1977, the results of a study
on Maya-Quiché food appeared (Henne, 1977), and this information
was rounded out by a project that presented some ideas about the
hot-cold/wet-dry syndrome among the Quiché (Nevenswander and
Saunder, 1977).

     During the 1980s, in addition to several analyses on the
acculturation process among the Mayan and the Caribe population,
there was renewed interest in learning about indigenous ideas
regarding the structure, workings, and diseases of the human body. 
This work brought out the importance of gaining as thorough a
knowledge as possible of these ideas about the human body as a
preliminary step toward more extensive research on how a healer or
parchero within an ethnic group can cure certain diseases, and how
the idea system is related to the acculturation process (Ghidinelli
1981, 1986).

     At the end of 1989 in Guatemala, a private development
organization began a research project whose fundamental objective
was to take a more in-depth look at traditional Maya-Quiché
medicine, with a view toward facilitating integration with the
primary health care sector.  This body and its grass-roots
organization made a general assessment of priority health needs,
and held a workshop attended by personnel from the regional
hospital and traditional physicians whose principal objective was
to exchange information on the health activities being carried out
by the two groups.

     In Honduras, the IICA formulated a technical cooperation
project aimed at strengthening the institutional capacity of the
public sector to direct and coordinate rural development, and
presenting policy guidelines for development among autochthonous
ethnic groups.  An integral part of this project was the priority
execution of special health training programs which would take
advantage of the knowledge of natural medicine that is found among
ethnic peoples.  A joint project by the University of Costa Rica
and the Costa Rican Ministry of Health on the health of the
Amerindian populations brought out the difference between the
country's indigenous and non-indigenous communities, as well as the
need to be able to formulate alternative health policies that
collect information on cultural background and these communities'
views on health problems.

     It is important to mention some more recent work, such as the
research on mortality in women of reproductive age, with emphasis
on maternal mortality in the area of the Honduran Moskitia (Coello,
Maldonado, and Romero, 1990).  This project indicated that for
every 100,000 live births, 781 women were dying from causes related
to pregnancy, delivery, or the puerperium, a rate 15 times higher
than that reported by the Ministry of Public Health.  The death
rate for women of reproductive age was 2.29 per 1000 per year.  The
principal cause was maternal death, which represented 48% of total
deaths.  93% of the maternal deaths occurred outside of the
hospital setting.  The risk of dying for a pregnant women of
reproductive age was 1 in 148.  These maternal health indicators
are the most serious in Latin America, and are exceeded only by
those in some regions of Africa.

     To conclude, it can be said that this project today is an
attempt, above all, to reshape the capacity that ethnic groups, and
women in particular, have to strengthen alternative forms of
support for the health sector.  The work done at both the
theoretical and practical level will provide a basis for more
extensive research and detailed work that will allow health workers
to involve the population as the subjects of their own development,
using women as the key element of the process, and focusing on the
American subregion which is most affected by starvation, drought,
a crisis in food, energy, and water, and the external debt.

1.4. WOMEN IN A TIME OF CRISIS.

     The Kissinger report, the Sandford Commission, and studies by
ECLA, the World Bank, IDB, FAO, SIECA, UNDP, PAHO, WHO, and UNICEF
confirm that even in countries that are experiencing economic
growth, the benefits are distributed unequally, and there is a
prevalence of high rates of unemployment, underemployment, poverty,
indigence, illiteracy, and rural marginality, among other
indicators of socioeconomic problems.  In Central America, periods
of war and upheaval have led to diminished respect for the human
condition, a loss of sources of work and income, and a reduction
in state services, which has aggravated conditions in social
sectors in which the poor are usually more disadvantaged as well
as more numerous.  It is, therefore, imperative to try to
strengthen those aspects which, because of their originality and
fresh approach, provide alternatives for reversing the downward
trend in the living conditions of the population.

     As has been clearly shown in some studies of gender,
development affects men and women differently, and with few
exceptions, it can be said that the crisis in the region has
increased women's workload while at the same time it has decreased
their levels of health, nutrition, and education.  Central American
women, especially indigenous women, have never had high rates of
access to the benefits of a formal education, and so there is a
need for training outside the classroom in place of school-based
education.

     The incorporation of women into the labor market is an 
irreversible trend, and it is leading to culture shock and identity
problems in all women, whether or not they belong to more or less
traditional groups:  emotionally, women continue to be the central
axis for the economy of the home, health, education, socialization,
etc.  Topics such as subsistence and the maintenance of the home
come up in economic discussions, and the problem of the informal
economy is brought out for discussion as well, sparking sharp
polemic among specialists.

     Education and its impact on women has been analyzed, and the
conclusion is that it is essential for women to be given greater
educational opportunities, but ones that are based on
methodological alternatives that are compatible with the changes
that are being brought about, and the cultures of the indigenous
people (AID, 1989).

     The link between crisis and the organization of women has
facilitated the emergence of numerous women's groups throughout the
subregion who are seeking to play a more important role in
development on an equitable basis.  In June 1991, more than 40
representatives of women's organizations in Central America met in
Guatemala to find a common platform so that the voice of the
subregion can be heard at the next world conference on women.  This
group included women from both urban and rural areas, including
women belonging to various Central American ethnic groups.  One of
the working forums centered on an analysis of public policies and
their relationship to the situation of women; this analysis showed
that in all the countries, public policies in support of women are
currently in a gestation process, and that without decisive
intervention and popular pressure, it will be difficult for them
to go from being mere pieces of paper to become a reality (Messén,
1991).

     This meeting grew out of the fact that the women in these five
countries felt that they had no voice in the Region. 
Paradoxically, the Central American indigenous women said the same
thing on this occasion with regard to the representativity and
validity of the generalizations that affect gender relationships
among indigenous and mestiza women (Messén, 1991).

     Undoubtedly at this time an entire strategy for communication
between women is being created which can strengthen the
dissemination of information and programs that are useful and
functional.  Women in general are referring to the search for
alternative strategies that can reduce poverty and allow them to
participate in the decision-making process.

     With the experience gained through the Program on Women,
Health, and Development and other programs that support women, and
based on the information and interest demonstrated by each of the
countries in the subregion with regard to strengthening and
reshaping the role that ethnic groups play in socioeconomic
development, the need arises as well to center each series of
activities around an axis that will revitalize society.  In this
sense, indigenous woman as the guardians of their cultures and the
conveyers of standards and values can become a key element of
development, in the measure that they are allowed to participate
actively and on an equal basis in shaping a more just future for
their society.

     The project being presented today is the first attempt at the
Regional level to preserve the role of indigenous women and to
strengthen them as protagonists for positive change toward a better
future.  The project has been drawn up with a comprehensive
perspective, based on the view that health is not an isolated
event, but rather the result or product of the interaction of the
various economic, social, and political conditions in a society. 
And while all these obviously cannot be modified by a single
project, such a project provides guidelines for reversing the
strategies employed in the past decades, utilizing health as an
input for development and establishing new models for relationships
within the health system so that there can be harmony and
acceptance among the various tasks that can be undertaken at the
national level, not only in this field but in all areas of human
endeavor. 

     The specific characteristics of this project require it to be
coordinated by the PAHO Offices in each country; PAHO's
counterparts would be each of the Ministries in the subregion, and
nongovernmental organizations and/or groups of organized indigenous
women, with strong backing provided by the universities that show
an interest in taking part.  Each national project is free to take
on those counterparts that are considered most appropriate to its
phase of execution.


2.   JUSTIFICATION OF THE PROJECT

2.1. CURRENT SITUATION OF THE HEALTH SECTOR IN THE SUBREGION FROM
     AN ETHNIC AND GENDER-RELATED PERSPECTIVE 

     Something common to the subregion is an almost total lack of
statistical, demographic, and health information referring to the
situation of the ethnic groups.  The breakdown of variables by sex
is limited, in the case of women, to their reproductive stage
alone: as a result, it is impossible today to specify how the
variable of gender is influencing women's health conditions or
leading to other, as yet unreported, problems. 

     Guatemala is the only country that distinguishes the
indigenous population from the nonindigenous one.  Costa Rica has
the best reporting system in the subregion, but by constitutional
mandate does make any racial or cultural distinctions in its
information.  Statistical underreporting, which is common to all
the countries, makes it impossible to get any accurate picture of
the number of people in each ethnic group or of the health
conditions that affect this population.  Therefore, the various
national projects need to devote themselves to the preliminary work
of collecting and making use of the data available from the
censuses, the Ministries of Health, public and private agencies,
and national organizations.

     Summing up the data presented by each country, the indigenous
population of the subregion can be estimated at some 6,308,060. 
There are differences between these inhabitants with regard to
language, culture, and traditions, but they all have the common
denominators of illiteracy, low levels of health, oppression, and
poverty which weigh them down during the development process.

     In the rural area of Central America, although infant
mortality, general fertility, and the birth rate have declined,
they are still the highest in Latin America, with the most alarming
indexes occurring among the indigenous populations.  With the
exception of Costa Rica, the fertility rate is reported to be from
6 to 8 children per woman, and is clearly linked to the maternal
death rates; the factors usually referred to are unequal
distribution of food in the home, too-short intervals between
pregnancies, premature deliveries, spontaneous abortions, and
adolescent pregnancy. 

     Honduras has identified early pregnancy among adolescents as
an important problem in the health sector, and one of the principal
causes of maternal and child morbidity and mortality.  Guatemala
has identified the loss of adolescence as a serious health problem
among indigenous women who almost immediately go from being girls
to being mothers.

     Delivery in very young women is known to cause irreparable
health damage, as well as limited development, while, in addition,
maternal death rates among the young significantly exceed those of
adult women.  Guatemala reports 50% higher mortality in the
indigenous population than in the nonindigenous one, while Costa
Rica reports differences in morbidity between the indigenous as
opposed to the rest of the population, with a prevalence of
infectious and parasitic diseases found in the indigenous groups
(Garro, 1991:6).  Specific studies carried out among indigenous
peoples in this country have shown that the health status of the
indigenous populations is very precarious, and that they show
behaviors that the rest of the population gave up two decades ago.

     Central American women exhibit greater longevity than men in
all age strata, but they suffer from greater morbidity during all
periods of their lives.  Life expectancy at birth ranges from a
maximum of 70 years for Costa Rican women, to a minimum of 55 years
in Honduras, Nicaragua, and Guatemala (Inter-American Commission
on Women, 1985).

     Sepsis, hemorrhage at delivery, and toxemia of pregnancy are
the second and third causes of death among women from the ages of
15 to 44 years.  Cervical cancer is the leading cause of death for
those between the ages of 45 and 64 years (WHO/PAHO, 1988), with
the most critical situation occurring in the indigenous areas.

     Because of environmental conditions such as an absence of
piped-in water, poor disposal of excreta and wastes, a limited food
supply and poor food distribution in the home, indigenous women
tend to present higher rates of undernutrition, anemia, and
mortality from infectious diseases than the rest of Central
American women.

     Undernutrition, which affects the majority of indigenous
women, becomes more critical during pregnancy and lactation, and
in Guatemala, for example, the assessment of women's health which
was prepared by the National Office on Women with the support of
UNICEF reported that approximately 30% of pregnant women suffer
some degree of nutritional anemia caused by iron deficiency.
 
     The statistical reports on morbidity in women are closely
linked to the reproductive process and don't ever take ethnic
characteristics into account.  The official health systems view
women only in terms of their role as mothers, and not as subjects
with any right to special treatment as persons.

     Within ethnic groups, the system of popular conceptions of
disease provides psychological, social, and technical control; it
provides security in the face of uncertainty.  It is troubling to
be faced with an indefinite future.  Consequently, we humans
attempt to influence events, to anticipate them, to predict them
in ways that are specific to our culture.  In this way, popular
beliefs provide a group with security, while at the same time
establishing controls that discourage any deviation from the norm;
in other words, these beliefs get people to behave in a certain way
(Ghidinelli, GI, 1981:2).

     The scientific literature available on work and medical
knowledge in the pre-Columbian indigenous population has
demonstrated the complex patterns involved, and this is also shown
in the diversity of medical specializations.  When one considers
that these medical practices have been consolidated over some
thousands of years of civilization, it is possible to believe a
priori that they are effective, or at least partially so.  However,
there is no scarcity of literature blaming traditional medical
practices, totally or in part, for the high morbidity and mortality
in the indigenous areas.  These practices constitute
"superstitions," and the fact that they include magical rites seems
to many sufficient cause for denying that they have any scientific
validity.

     However, there has not been enough consideration of the
problems created by the acculturation process, through which
aspects of the most traditional practices are forgotten or only
partially recalled; these leftover bits of knowledge in the medical
field are the source of various dysfunctions, and result from the
fact that the traditional practices are not always transmitted
meticulously, with the entire rational scheme appropriate to the
case.

     Not only is there an impoverishment of the traditional
patterns, but the new patterns are not always understood and
assimilated correctly.

     The acculturation process has acted in such a way as to cause
the techniques and meaning of some therapeutic practices to be
forgotten; as a result, intervention ceases to be curative, and can
even be harmful to the patient's health.  One example of the loss
of ancestral health knowledge has to do with diarrhea:  the custom
of rehydrating children has been given up in favor of seeking above
all to make the diarrhea disappear, which means that the people are
using antibiotics and other drugs indicated by nonmedical
personnel.

     The Ministries of Health, with the support of UNICEF, have
been making extensive efforts to reestablish the practice of oral
rehydration, although they have not used an approach which permits
adequate communication between Western languages and the
traditional indigenous ones.  This language gap is one factor that
creates the high indexes of mortality that are striking these
populations.  At the level of public administration, the entire
state apparatus is not only insufficient, but not accepted by the
population due to the culture shock produced in different cultures. 
In addition, women receive care only in relation to the mother-
child relationship.  There are some private indigenous development
organizations which are working in some areas of the subregion and
these, if they receive support in the form of some organizational
and technical training, could be more operational, taking advantage
of the local initiatives and above all refraining from offending
against the most essential aspects of the traditional cultures. 
There is no lack of programs that work against the cultures of the
indigenous population and seek to impose so-called "development"
plans which do not respond to the needs of these people, which have
not been presented for consultation or approval by them, which are
prepared exclusively according to the whim of the authors, and
which view these people only as objects, because they are seen as
creatures who are impotent, ignorant, and savage. 

     In the subregion there are cultures that can be differentiated
by their social structure, attitudes, practices, and beliefs which
should be considered in the national projects.  Here we are only
presenting two systems of indigenous civilization among the ethnic
groups selected for the project:  the Mesoamerican and the
Macrochibcha.  In the subregion, the Mesoamerican system includes
the Maya of Guatemala, Belize and Honduras, and the Lenca in the
latter country.  They are characterized by the fact that corn is
the axis of their traditional culture and the fact that they are
patrilocal.  The Macrochibcha system of civilization is
characterized by its focus on the cultivation of tubers and its
matrilocal system; it includes the Miskito, the Guaymí, and the
Brunca.

     Guatemala's project will begin among two of the large majority
groups:  the Maya-Quiché and the Maya-Cakchiquel.  The Totonicapán
area, where the Quiché ethnic group predominates and serious
socioeconomic indexes have been noted, will be the principal axis
for the initial work, using the new health care models that were
envisaged in the national project.

     These details have implications above all for the traditional
gender relationships whose structure is the end product of
thousands of years of civilization, although these relationships
currently are in a state of serious imbalance due to the negative
effects of the acculturation process.

     In the traditional indigenous communities the economic
activities of the domestic unit can be divided into three
categories:  a) biological reproduction, i.e. all activities
directed toward producing and maintaining descendants; b) daily
reproduction, or activities aimed at maintaining the work force: 
feeding, water transport, household management, personal care,
clothing, and health.  An important part of this is the
transmission of culture to children from the time they are a few
months old; c) economic activities in the domestic sphere, such as
traditionally female handicrafts and, in some cultures, selling in
the market as well.  Men's work goes on outside the domestic
setting, lasts for a few hours, and is very demanding or dangerous. 
The spheres of male and female work are complementary although they
are totally different.  In the traditional societies, the nuclear
families that are integrated into the ecosystem appear stable.

     To the extent that the environment is degraded and economic
conditions are changed by an expansion in Western-style production,
a change is produced in the reproductive process of the family
group.  Traditional values and family stability become vulnerable. 
Men cease to have total responsibility for supporting their family
members and the women, who performed complementary economic tasks,
assume an active economic role and take on more responsibilities
than before.  Not much is known about the types of adaptations that
the indigenous family has made or is making in the process of
absorbing these changes in the material sphere, or about how women
are taking on and exercising their new role, or about how this is
affecting health.  It is clear, however, that all members of the
family are being groomed for participation in the labor market, and
this includes girls who, from the time they are small, are guided
toward supporting their mothers through caring for the younger
children and the house.

     Women's attitude toward life with regard to their income-
producing activities, the domestic arrangements they must make
within the family in order to maximize the limited resources
available, the ways they organize space and time in order to meet
family needs, and the arrangements they make for the socialization
process at the family and community level in support of daily
activities calls for grinding effort which, if it is not offset at
the physical and emotional level, creates serious health
imbalances.  The high levels of alcoholism found among male Miskito
and Guaymí, with a smaller incidence among the Mayan groups,
aggravates the health picture for women, increasing still more the
workload and responsibilities that women must assume in order to
sustain their families both spiritually and materially.  Such
pressure opens women up to physical and mental deterioration, but
in the field of mental health there is a complete lack of
information about the current situation of women; cases of
psychological abuse are not reported until they are irreversible.

     Contact between indigenous men and mestizo society--which
preserves the patriarchal characteristics of its colonial origins,
in which "machismo"  is an essential component and results in
paternal irresponsibility--affects the stability and conjugal
relations of indigenous homes.  Machismo is a characteristic
feature of the mestizo male culture.  The male is a "true" man who
can be identified with the bull, a mythic animal which is the
source of life and wealth in a society of livestock owners.  The
genuinely macho man should have the attributes of a bull:  a large
penis, the psychological and physical capacity to sleep with a lot
of women in a short time, fertility for procreation, combativeness,
and fearlessness in the face of danger.  Almost all women are
fertile territory for these males to prove themselves.  The vast
majority of men with sufficient economic means have several women,
and various out-of-wedlock children with them, and this is
something they boast about, although there are no official figures
to illustrate this phenomenon.  Women are forced to adapt to all
this because their role in society is a dependent one (Ghidinelli,
1976: 169).


3. THE PROJECT

     The project on "Health and Development of Indigenous Women,"
whose planning and rationale is summarized in the previous
sections, seeks to strengthen the role of indigenous women in the
Region as multiplier agents for change who make it possible to
develop, within the official health systems, alternative models for
health services and health care which are aimed at the female
population of their own cultural groups.

     In this sense, the target population of the project is
represented in the first instance by all the women who belong to
the Maya-Quiché, Maya-Cakchiquel, Miskito, and Guaymí ethnic
groups, as the principal users, promoters, and providers of health
care.  Collaterally, indigenous families will be the indirect
beneficiaries of the project as they receive the health and
educational practices that the women transmit in the area of
health, as multipliers who are responsible for implementing
measures for disease prevention, hygiene, nutrition, and care of
children.

     The project is based on the idea that ethnic groups encompass
a cultural base and a system of ideas about health and disease that
need to be made clear and preserved as a means of democratizing and
cutting down on costs in the health services in the subregion, from
a perspective based on respect and communication when the different
cultures interact. 

     In separating out gender, an attempt is being made to see that
the project components effectively address women's problems, at the
same time fostering a process of gender-based individuation that
opens the doors to a clarification and redefinition of women's
identity which is based on their cultural roots.  This is to be
done in such a way that the project becomes an innovative element
that can be imitated by other programs and projects that identify
women only according to the perspective of their relational
identity, referring to the status they derive from their kinship
ties, principally with the male members of their primary group.

     The institutional personnel of the Ministries of Health,
especially those working in the project areas, will have a major
responsibility for becoming involved in the project through an
intensive training phase that will allow them to adapt to all the
demands of implementing the services envisioned in the new health
care models. 

     The ethnic groups mentioned were selected based on
demographic, health, and geographic considerations.  From a
demographic perspective, the groups chosen had the largest
concentrations of people.  Of an approximate figure of 6,308,060
for the indigenous population of the subregion, the project would
encompass four ethnic groups, or 24% of the total. Based on a
hypothetical ratio between men and women, the total number of women
selected would be as follows:

Mayan Groups:
Quiché           462,500
Cakchiquel       202,500
Miskito           67,500
Guaymí            32,913
-----------
Grand total      765,413

     From the perspective of health, using the four largest groups
facilitates the design and application of innovative strategies
that impact on a greater number of persons.

     Geographically, the physical-territorial location of these
ethnic groups ties together the entire subregion.  The Miskito are
found in Honduras and Nicaragua; the Guaymí in Costa Rica and
Panama; and the Maya in Guatemala, Belize, and Honduras.  For this
reason the project is presented with a regional perspective,
according to which the activities of the Ministry of Health in each
country with regard to the chosen population groups should be
closely linked to the PAHO national offices, with flexible
coordination at the subregional level from a headquarters in
Guatemala, since that country features a population which is 50%
indigenous. 

3.1. GENERAL OBJECTIVES

     Taking into consideration that the authorized Western-style
health system is neither in harmony with nor meets the needs of the
local indigenous community systems, and that this phenomenon has
its worst effect on women, whether because of their decided
monolingualism, their level of illiteracy, or sex discrimination,
this project seeks to establish the bases for transforming this
situation by adapting the health systems so that they reflect the
ethnic, socioeconomic, and gender-related features and diversity
of the population.

     The project's general objectives are:

*    To increase both qualitatively and quantitatively the
     participation of the indigenous population, particularly
     women, in official and non-official health programs, and
     especially to remove the socioeconomic, ethnic, and gender-
     related barriers that prevent women from actively
     participating in the projects and programs.

*    To facilitate a multiplier effect in the project, so that it
     can be technically and easily adapted by other ethnic
     communities in the subregion.

3.2. SPECIFIC OBJECTIVES

     1.   To initiate the activities aimed at establishing the
bases for the project to enter its execution phase with
an adequate and efficient organizational proposal.

     2.   To learn about the gender relationships within the ethnic
groups and, based on these, to be able to individualize
the women's role and the activities that need to be
carried out so that their integration into the project
meets their own personal needs and those of the group.

     3.   To support the Central American indigenous women who are
seeking to improve the health and living conditions of
their communities based on their own cultures.

     4.   To gain a precise and clear knowledge of the factors that
facilitate or inhibit satisfactory relationships between
the official and the traditional health systems.

     5.   To formulate alternative models of care that are accepted
by the population and to present them to the official
health systems or to alternative organizations for use
in the project areas. 

     6.   To sensitize and train the official health personnel and
to implement alternative health care models that are
suitable for, desired by, and functional for the
population in question.

     7.   To train a specific number of indigenous women so that
they can become strengthening agents for the project
objectives. 

     8.   To facilitate a large-scale experiment in the collective
organization of women around this health project, so that
such organizations can become appropriate channels for
the planning and execution of activities for production,
assessment, and self-esteem. 

3.3  PROJECT COMPONENTS 

     The project consists of three components:

     a) Research
     b) Training and organization
     c) Health care models 

     3.3.1 Research.

     As a fundamental part of the project, the research component
     is considered basic to achieving the proposed objectives.  It
     is felt that in this subcomponent, various techniques can be
     utilized, depending on the desired scope and degree of
     complexity.  In all possible cases, it will be attempted to
     use participatory research as part of a strategy whose aim is
     to involve the community in learning about and solving their
     own problems.  Unquestionably, the variants of this
     methodology--action-oriented research, self-study, and self-
     assessment--will be used to fuse together the participation
     of the technicians and the population during the different
     phases of the research process.

     The research component will seek to provide the basic tools
     for:

     a)   Learning about the gender relationships that occur in the
traditional ethnic groups and during the acculturation
process, as a means of individually breaking down the
problems that arise from these relationships.

     b)   Learning about the types of ethnomedical specializations
that are found in these communities, and about how the
men or women who are specialists (traditional health
workers, or THWs) obtain their knowledge.

     c)   Learning about the idea system employed by the THWs with
respect to the workings of the female body, the diseases
specific to women, and the types of ethnotherapy used. 

     d)   Learning about the networks that are derived from such
knowledge, especially in the woman-world and woman-man
binomials.

     e)   Learning about the types of popular ethnotherapeutic
practices and common procedures that are used in
diagnosis and therapy for the diseases that afflict women
as subjects and in their referential relationships.

     f)   Learning about the popular therapeutic practices in the
area of maternal and child health, including the popular
dietary practices of mothers whose children present
diarrhea symptoms and the common procedures for
diagnosing disease.

     g)   Learning about the therapeutic practices utilized by the
THWs, including the specific steps of a cure as well as
the medicines used, and showing how Western medicine
would cure the patient and how the two therapeutic
methods could be combined. 

     h)   Identifying the positive and negative factors that
influence the work carried out by the THWs from the
perspective of gender.

     i)   Showing which traditional practices are useful and which
are not, for the purpose of assessing endogenous
therapeutic resources. 

     j)   Showing the relationships that exist between the
acculturation process and the problems of gender and
mental health.

     k)   Analyzing the medical practices utilized by hospitals and
health posts to be able to enter into concrete-
operational areas as a means of understanding how Western
medicine is used.

     l)   Learning about and describing health systems that are
found to be able to use the natural resources in a
locality as the raw material for the therapeutic process,
and using this information as a basis for facilitating
policies aimed at reducing the high costs of importing
drugs.

     3.3.2 Training and Organization.

     The training component is designed to give a satisfactory
     response to the needs of the women and the communities
     selected.  This component envisages three types of training
     or training services:  training for research; training for
     health; and training for development and organization.

A. Training for research.

As a methodological proposal, this area will try to
involve indigenous women in learning about and solving
their own problems, preparing them to participate
actively in the decision-making process and in the
execution of some or all phases of the research to be
carried out under the project.

The principal objective of this type of training is to
train a certain number of indigenous women to serve as
bilingual aides in the research process.  Women with
training in this area can intervene constructively in the
detailed planning of the research process and the
collection, preparation, and interpretation of data.  The
training that being planned combines both theory and
practice, and the latter will be strengthened throughout
the research process.  The proposed methodology has
already been used in a project carried out in Guatemala,
where it has proved to be technically viable.

The ideal profile would include an adequate number of
bilingual indigenous women who have completed their
education to at least the secondary level.

The major outlines of this subcomponent are:

a)   To train the selected women to write their mother
tongue. 

b)   To train the selected women in the anthropology of
interethnic relations so that they are able to
revitalize their own identity in the acculturation
process by recognizing their own cultural patterns,
as well as to develop the capacity to interact with
people from different cultures with attitudes of
solidarity, responsibility, and cooperation with
others.

c)   To train the selected women about the topic of
gender, which will be utilized as a basic tool
throughout the research process, so that it will be
possible to clearly, objectively, and precisely
identify the historical reality of women and their
own communities, as well as the contextual
variations that occur.

d)   To train the groups of participating women in
research planning, data collection, and practices
for adjusting the research instruments. 

e)   To train the women to use some computer programs
that are useful in the research process. 

B. Training for health.

Training for health seeks to train medical and
paramedical personnel at the local health posts,
hospitals, and health centers in the project area, as
well as local ethnotherapists so that they can produce
the knowledge needed to define appropriate activities
that make it possible to implement the lines of change
and transformation in health and development and in the
alternative health care models which are the project's
fundamental objectives.  This training will seek to do
the following:

a) To provide updated knowledge to medical and
paramedical personnel at all the levels of the health
sector on topics related to the health of indigenous
women and its conceptualization from the perspective of
gender (e.g. indigenous practices for women's health
care, family planning, indigenous techniques for
preparation at delivery, and integration of these into
the current practice of academic medicine).

b) To strengthen the training of traditional midwives and
other THWs, outlining strategies with them that will
provide better logistical support and continuous
educational supervision, in order to improve their work.

c) To promote a change of attitude among non-indigenous
health personnel toward a transcultural and more humane
and dignified treatment of the indigenous population,
especially women.


C. Training for Development and Organization

Health is not an isolated event; it unfolds and is
located in time, and as such is closely related to the
economic, political, social, and cultural reality of a
community.  As a chain of events, the process of project
execution will generate local initiatives and facilitate
expectations regarding the development of new working
approaches which ensure greater coherence with the needs
and expectations of the population.  Anticipating the
above, the subcomponent on training for development seeks
to facilitate the formation of a group of female
technicians who are trained in development and given
practical, simple, and useful tools that they can use to
formulate small-scale alternative socioeconomic projects.

In order for the project to have a real multiplier
effect, there needs to be a stable group of indigenous
women who are trained in research and project
formulation, so that when the project has been completed,
these indigenous groups will contain people who are
capable of continuing to plan development activities from
their own cultural perspective.

This subcomponent also seeks to train these women in the
management of gender-related problems as a means of
strengthening a kind of development at the individual
level which will in turn heighten the women's capacity
to shape their own future. 

Training for development will seek to do the following:

a) To motivate and promote the organization of women's
groups around projects of common interest.

b) To inform these women's groups about specific aspects
of the process of organizing and formalizing a group and
to explain the possible alternatives.

c) To convey to these women's groups, basic and simple
information on project formulation, socioeconomic
assessments aimed at identifying their priority problems,
and participatory research projects so that these can be
utilized at the grass-roots level as a tool for creating
specific projects.

d) To train groups at the grass-roots level about popular
medicine and herbalism in an effort to encourage them to
set up family medicinal gardens.

e) As an ongoing activity, to have every participating
community offer courses, seminars or meetings,
symposiums, and workshops that facilitate the
preservation and strengthening of local culture and
language, as well as self-esteem. 

3.4  HEALTH CARE MODELS.

     All the tasks carried out under the research and training
components will provide the basis for designing and organizing
alternative health care models directed toward women which are more
in harmony with the culture, needs, and expectations of these
groups. 

     In order to implement these health care models, there needs
to be a minimum investment in equipment and supplies, as well as
in retraining for the official health care services.  These
services can be provided either at the official level or through
NGOs, women's groups, or other institutions that demonstrate an
interest in and capacity for collaborating with the project.

     The implementation of the alternative health care models that
come into being should follow an ordering of priorities
which is based on the health problems that are identified in the
earlier phases of the project.  The alternative models will
include:

     a) The design of health care methodologies, including 

Mental health
Physical health

     b) A delineation of methodological profiles for the production
     of educational materials destined for health care workers in
     the public sector, THWs, and women in the community.

     The methodological profiles should be oriented toward:

      -   Facilitating the production of educational material based
on a clear understanding of the traditional system of the
ethnic groups.

      -   Looking at the positive aspects of the traditional
systems and promoting their reevaluation as a means of
preventing any imbalances resulting from the
acculturation process. 

     -    Setting anthropological guidelines that make it possible
to prepare radio scripts for production on local programs
which are in the languages of the ethnic groups and
provide information on health matters for women.
      

4.   PROJECT ORGANIZATION 

     Because of the specific characteristics of the project's
target population, the proposed organization is based on an ethno-
geographical approach that marks a break with the schemes
traditionally used in other subregional projects by various
institutions.

     Three geographical areas have been identified which make up
the habitat where the following ethnic groups interact:

     Maya-Quiché and Maya-Cakchiquel         Guatemala
     
     Miskito                                 Honduran and
Nicaraguan Moskitia

     Guaymí                                  Costa Rica and Panama



     The proposed organization includes:

A subregional coordination

An operational coordination for every ethnic group

A national counterpart
At the government level
At the community level

An operational level
To conduct the planned studies
and research

To implement the health care
models 

     The subregional coordination will be in charge of coordinating
the technical activities that are carried out in the project areas. 
It will have its headquarters in Guatemala, and at the same time
will act as area coordinator for the Mayan area.  At the
institutional level, PAHO will be responsible for performing these
duties and will designate a person for this position.

     The operational coordination will come under PAHO's
responsibility in the countries where the project is carried out,
and a coordinator will be named for that purpose to work with the
national Miskito project, as well as a coordinator to work with the
Guaymí project.  The operational coordinators will act as project
liaisons, operating between the coordinating agency and the local
counterpart (Ministries of Health, institutional health personnel,
NGOs, women's committee).  The operational coordination will be
responsible for running the project in the area of activity and
will be free to do any necessary hiring envisioned in the project. 
It will also be able to negotiate with the counterpart regarding
the feasibility of the services to be implemented in order to make
the health care model component effective. 

     The local counterpart.  The local counterpart is conceived of
as two units:  A governmental unit represented by the Ministries
of Health through their programs on Women, Health, and Development
which would operate in each of the countries in the area, and a
community level unit made up of representatives from indigenous
NGOs, women's organizations, or representative offices with
individual title in the areas of intervention.  The Ministries of
Health will provide technical support to the project coordination,
along with all the facilities needed to fulfill the project
objectives. 

     The indigenous NGOs and women's groups will serve as advisory
councils for the project, and as such will have a voice and a say
in any negotiations that precede implementation of the health care
services and modalities that grow out of the project; they will
also be able to take part in the negotiations carried out with the
official health services as a means of safeguarding their community
interests, as well as to be the ones who implement certain health
care models if they so desire.

     The operational level.  All project studies and research
planned for each of the three components will be carried out using
short-term contracts.  The studies, research, and field work can
be carried at both the individual and the institutional level.  At
the institutional level, the idea is to involve nongovernmental
organizations or private development organizations that have a
capacity for and an interest in working in the project areas.  In
the case of the health care models, the project, in addition to
negotiating with the Ministries of Health regarding the services
to be implemented, has considered the possibility of working
directly with women's groups or local NGOs who are interested in
developing some of these models.  For this purpose, the PAHO
offices in Guatemala are negotiating to procure financing that
could be utilized to support the implementation of these models by
organizations other than the government services.  The system of
shared costs could be utilized in the work of implementing the
models.

     Administrative support will be the subject of negotiation
between the project coordination and the local counterpart.  It
will be sought at all times to receive a commitment not only from
the health agents who work in the area, but also from the
community.  Taking advantage of the experience of the program on
Women, Health, and Development in Guatemala, an attempt will be
made to find the most appropriate mechanisms for directly and
safely channelling the necessary funds into the project so that the
project executives can work with some degree of financial autonomy
in the project areas.  This proposal is reinforced by the processes
of regionalization, decentralization, and strengthening of local
health systems that are underway throughout the subregion.


5.   OPERATIONAL MECHANICS OF THE PROJECT.

     When it is time to begin the project operations, the local
coordinators should prepare a detailed plan of work and timetable
which are broken down into the tasks to be carried out under each
project component.  This plan of work should be an annual one and
will serve as input for the evaluation phase.

     Along general lines, the project sequence envisioned for the
first year entails a continuous organizational effort, both at the
level of the project, as well as at the level of the official
health counterpart and contacts with grass-roots organizations.

     At this stage of organization, it will be attempted to contact
indigenous women and to strengthen their organization so that they
can serve as the local counterpart for the project and defend their
own interests.

     This contact with the grass-roots organizations will make it
possible to get precise data on the human potential that could be
harnessed to support the different phases of the project.
 
     At the same time that these human resources are contacted, an
intensive training phase will begin which will make it possible to
train the personnel needed to initiate the field work phase.

     This phase of personnel selection will also include the
personnel working in the official health system as physicians and
nurses.  The committees of indigenous women who act as counterparts
at the local level will be actively involved in selecting these
personnel.  The proposed intervention by these committees will be
viable only in the measure that it is the women themselves who
benefit from the project.

     The components identified are closely interrelated and they
are creating a network that will allow the first results to appear
in a short time.  In order to avoid administrative problems and
delays, and in anticipation of the fact that the project itself
cannot have a large permanent staff, a stated policy for each
component is the contracting of technical services.  For this
reason, the section on the project components clearly states the
expected results.  Hiring can be done at the individual or the
institutional level; for example, through private development
organizations. 

     It is expected that the local coordinators will be in constant
contact with the liaisons established at the Ministry level, as
well as with the community counterparts.  As a result, the local
coordinators will be travelling constantly to the places where the
project is being carried out.

     In order to facilitate autonomy at the local level, the
necessary paperwork will be prepared to allow discretionary use of
certain funds to meet pressing commitments.

     The local coordinators will have the continuous support of the
subregional coordination during the first year.  At least two
quarterly visits are planned for the Miskito and Guaymí area.  At
the end of the first year, the first evaluation is to be prepared. 
The evaluation described in the next section will include the
participation of women from the community, and will serve as the
basis for any necessary project reorientation. 

     The health care models will be created as the research
progresses.  The women in the community will be the ones who verify
the relevance of the models that are presented and determine which
ones should be implemented on a priority basis.  For the operation
of the models and the participation of the official health
services, it will be attempted to have the option of contracting
with NGOs to provide these services.  If this option proves to be
a valid one, it can be replicated in other ethnic groups.

     It should be noted that for the Quiché area, the health care
models will go into operation almost immediately, since there are
already inputs available to carry out this pilot study which will
serve as a control for the entire project.

     5.1  STRATEGIES FOR THE COMPONENTS

     5.1.1 In the area of training.

     The training methodology will be structured according to an
     operational orientation.  The idea is to work with practical
     and simple examples, and to do practical exercises at the end
     of each day in a working group session.  At the end of each
     working day, the groups will present their conclusions on the
     subjects covered and the difficulties they encountered as
     feedback for the work on the following day.

     The training component can be carried out with the
     collaboration of personnel and organizations who have
     experience in this area. 

     5.1.2 In the area of research

     The project has a strong research component.  The details and
     comprehensive planning of each research project will be
     handled by the consultant who is hired for each task.
     Independently of this, there will be monitoring to ensure that
     in most cases methodologies and techniques are utilized which
     are participatory in approach and involve the personnel to be
     trained by the project. 

     5.1.3 In the area of health care models. 

     The component on health care models.  The health care models
     that are structured and formulated should undergo evaluation
     at the community level as the first step toward
     implementation.  The priority given to the implementation of
     each component will be left up to the communities.  The
     project coordination will need to carry out negotiations with
     the Ministries of Health in order to be able to start up
     alternative services.  The women's organizations will be given
     the role of evaluating the services provided to see if they
     produce the expected results.  As a viable alternative, it
     will be attempted to contract with interested private
     organizations so that they too can provide some health care
     services that use the techniques produced by the project, and
     to confirm the potential for long-term stability of these
     alternative services and the degree of reliability with regard
     to the user population. 


6.   EVALUATION OF THE SUBREGIONAL PROJECT

     The Pan American Health Organization, through its Subregional
Program on Women, Health, and Development, will evaluate the
subregional project on Health and Development of Indigenous Women
in Central America and Panama.

     Schedule of evaluations:  The project has a duration of four
years.  The first evaluation will be made at the end of the first
year.  This evaluation should take into account not only the
fulfillment of the objectives set by the project, but also the
institutional capacity at the local level, the will of the
counterpart, and the level of acceptance by the population.  The
following is a list of some other project elements that need to be
systematically evaluated:
 
a.   The organization, communication, and working style
of the field team. 
  
b.   Community organization, participation, and response.

c.   The system of dissemination and entry into the
community; any necessary redesigning should be
carried out. 

     The second evaluation is planned for the end of the second
year, and in addition to examining the matters already described
in the previous paragraph, it should show whether or not the
recommendations from the previous evaluation were taken into
account and how much importance was given to them, as well as the
results obtained.

     A third and final evaluation is planned for the end of the
project.

     Evaluation committee.  It is proposed that a committee be set
up to conduct the evaluations, made up of:  

A PAHO representative who does not take part in the
execution of the project.

An external consultant with knowledge of the subject.

A representative from the communities.

A representative of the Ministries of Health.

Reports.  It is felt that each annual evaluation should not last
more than 30 days, leaving 15 days for the preparation and
presentation of the evaluation report.  The evaluation report
should be left in the hands of PAHO, which will be the institution
in charge of disseminating it to any interested parties.
7. PLAN OF WORK.

     The project has been set up to be carried out in four years. 
The operational timetable shows the major activities and the
expected results.  The plan of work goes into more detail regarding
the major activities that are presented in the timetable.

     The planned consultantships will take the form of short
contracts.  These consultantships can be carried out at the
individual or the institutional level.  The research projects are
participatory in approach and have a strong emphasis on practical
application. 

     During the first year, the training component will be oriented
toward training the women's group that will support the project at
the level of research as much as at the level of organization and
development.  At the same time, this component will train
technicians who can continue to work for the health and development
of indigenous women when the project's four years are up. 

     The organization of grass-roots level women's groups and the
training will also begin during the first year.  The women who have
been trained in project formulation can support the women's groups,
and the project will pay them for this work, in addition to
providing paper goods, equipment, and materials for the training.

     During the first year, an experimental pilot project is to be
launched in Totonicapán, taking advantage of the fact that
arrangements are being made to obtain the results of a research
project on traditional medical practices that has been carried out
by an NGO.  This pilot project will serve as a control for the
remaining models to be implemented during the subsequent years of
the project.  Two options for the implementation of health care
models have been selected.  One option is through the health
centers (the official health system) and the other option is
through the community NGOs.  A third option could be joint work
between the official health system and the indigenous NGOs.

     The research component is strong during this first year.  The
research aides, informants, and THWs assume a very important role. 
The project includes payment for the aides, informants and THWs. 
During the first year, the entire phase of data collection will be
completed, along with the phase of preparation for the area of
ethnomedicine.  Gender-related research for this first phase would
be reaching the point of information collection. 

     The annual evaluation would be planned for the end of the
year, and throughout the year there would be constant supervision,
both by the consultants hired to direct the work as well as by the
national project coordination and, in the case of Guatemala, by the
subregional coordination.

     During the second year, the project technicians (PTs) will
work intensively at the community level, organizing groups of women
for the preparation of small productive projects.  The project will
facilitate all the support necessary for this task.  The work will
include information and training in organization, advisory services
for the groups regarding the preparation of small projects,
workshops, and seminars on self-esteem. 

     Workshops on gender are planned at three levels:  the family
level, the community level, and the level of relationships outside
the immediate ethnic group or community.  The workshops will be led
by actual women from the community, with the support of the project
and the PTs.

     As a corollary to the process of doing research on
ethnomedicine, beginning in the ninth month of the second year
consultants will be hired for the operational studies who will
present concrete proposals of new health care models for the
community.  The studies should present specific proposals for
implementing the short-term models.

     The pilot models of health care in Totonicapán will be subject
to continuous evaluation by community groups and consultants, as
well as by the coordination.

     During the third year, the component on organization and
training will need to be able to show some very concrete results. 
During this year, the grass-roots organizations should be in a
consolidation phase, supported by financing around projects.  The
exact number of groups with projects will be ascertainable
beginning in the second year, but the plan is to have at least six
groups of women for each ethnic group who would already be
developing some project.  In the case of Guatemala, there would be
twelve projects, and in Guaymí there would be at least three.

     The operational research on the reporting system will set the
guidelines for beginning the work using the new models, with the
support of a proposal for clearly and precisely recording all data
on the health of the women in the area who use the health services,
and those who will be served under the health care models. 

     The new health care models will be launched in the fourth
month, supported by training material which the consultants hired
for this purpose would be finalizing beginning in the sixth month.

     An important task will be the first women's meeting.  This
meeting will mark the first encounter between Mayan, Guaymí, and
Miskita women to discuss common problems and to seek solutions. 

     
     With the project reorientations that result from its execution
and evaluations, at the beginning of the fourth year, a detailed
timetable of activities as well as a plan of work will be being
prepared.  Along general lines, during this year the emphasis will
be on intensive training for health personnel, THWs, and women,
both in the area of health and in the operation of the health care
models.  The process of taking root through action and
methodological strengthening will ensure that adequate service is
being provided to the population.

     Field supervision will become an ongoing and important
activity during this year.  The models will need to undergo
testing, follow-up, and reorientation wherever they show
weaknesses.  The coordination will have the important role of
negotiating with the Ministries of Health for approval and official
sanctioning of the implementation of the models in the project
area. 

     Support for the grass-roots organizations will continue,
especially through advisory services on project formulation and
financing.  The groups that are consolidated will already be able
to serve as multipliers through the strengthening of their leaders
so that they can provide support to other groups.
COMPARISON OF THREE PATTERNS
OF FETAL GROWTH ASSESSMENT

      To predict the risk of neonatal death, a comparison was made of the diagnostic reliability and
predictive power--measured in terms of sensitivity/specificity and positive/negative predictive value--of three
patterns of fetal growth assessment that have been developed for populations in Denver (United States of
America), Santiago (Chile), and Aberdeen (Scotland).  The study used data on births and deaths of
newborns reported in Chile during 1986, grouped into three categories according to gestational age at the
time of delivery:  38-42, 32-37, and 26-31 weeks.  Analysis of the receptor operating characteristic curve
showed that these patterns do not predict with any greater probability than chance whether newborns who
are large for gestational age (LGA) will die or survive, whereas they are capable of such prediction in
newborns who are small for gestational age (SGA).  The area above the indifference level was relatively
small in all cases.  Except with the group 26 to 31 weeks, the positive predictive values were generally very
low and the negative predictive values were high.  Thus it is concluded that the limits that define the risk for
neonatal death are not closely correlated with the percentiles that determine a diagnosis of SGA or LGA in
the distribution patterns studied.  In order to improve the diagnostic reliability and predictive power of fetal
growth assessment patterns, it is proposed that new patterns be developed that take into account the
effects on neonatal mortality of both birthweight and gestational age at the time of delivery. 
 


KNOWLEDGE ABOUT AIDS
IN THE ADULT POPULATION OF MANAGUA

      Nicaragua has the lowest prevalence of AIDS in Central America.  In other countries where AIDS is
more prevalent, the first epidemic of asymptomatic infections with human immunodeficiency virus (HIV) and
the second of clinical cases of AIDS have been followed by a third epidemic of fear and discrimination.  In
December 1989 a study was conducted to investigate knowledge and attitudes about AIDS in a sample of
287 persons from the adult population in Managua.  Most of the interviewees had heard of the disease from
newspapers and television, and more than 90% understood the principal means of HIV transmission. 
However, between one-third and half the interviewees believed that HIV can be transmitted by casual
contact, such as kissing (53%) or mosquito bites (49%).  In addition, the majority considered that isolation of
HIV-infected persons and control of immigration into the country would be effective measures for preventing
the spread of the disease.  These results are similar to findings from other studies carried out in countries of
Latin America where the HIV and AIDS epidemics had started much earlier.  This would suggest that the
so-called "third epidemic" of discrimination and fear is affecting Nicaragua in advance of the other two.


     


INTRODUCTION

The progressive increase in respect for human resources implies the promotion of
workers' health, an objective that today's management must incorporate and increase as
an indispensable condition for the achievement of health for all, as well as social and
economic development.  This points up the necessity of formulating and implementing
policies for manpower development that will lead to quantitative and qualitative increases
in the number of professionals and technicians who are engaged in the various facets of
occupational health.

At present the countries are paying more attention than ever to occupational health
because they have recognized the effect it can have on productive capacity and the quality
of life.  Studies have been undertaken to determine the impact that the promotion and
maintenance of good health in the workforce can have on economic progress and social
development.  And the benefits of health promotion in the workplace have been measured
by the degree of efficiency and integration of the workforce and by the increased length
of workers' economically active lives.

The dissemination of information contributes to the development of a new
preventive spirit and helps to increase every person's sense of motivation and
responsibility with regard to maintenance of his or her own health.  Since in the area of
occupational health the interests of employers, workers, and governments are the same,
in this area it is relatively easy to obtain widespread, active participation by all sectors. 
This participation can be more successful still when there is coordination and cooperation
at the state level and in the workplace, because this creates a favorable climate, facilitates
the necessary supervision, and improves the use of resources.

In recognizing the importance of human resources, the new structures of
management and organization have also acknowledged the importance of rapidly
increasing human resources in the area of occupational health, of training professionals
and technicians to ensure better health and greater satisfaction in the workplace. 
Management is trying innovative strategies aimed at humanizing the work environment. 
It recognizes that it is essential to adapt work to the characteristics of human beings and
promote their aware participation in the planning, execution, and evaluation of their jobs,
with a view to bringing about a change in old styles of organization and management in
today's modern societies and in those that are in the process of modernization, as well as
promoting studies and new attitudes that will result in well-being and active participation
by workers.  This new type of management is certain that prevention and health in the
workplace, as effected by occupational health experts, will facilitate dialogue, increase
productivity and earnings, and help to improve morale among workers, and it therefore
seeks a rapid increase in the number of professionals and technicians, who are essential
for optimizing management capacity.

The spiraling costs of curative care and rehabilitation, as well as compensation for
disabilities resulting from work-related accidents and diseases, are an added incentive in
the search for effective and economic solutions aimed at controlling and eliminating risk
factors in the workplace.  The assignment of priority to prevention helps to reduce the
numbers of serious and incapacitating accidents and diseases, which results not only in
increased social well-being but also in greater productivity and overall quality.

The close relationship between deteriorating health, low productivity, and low
socioeconomic status has been one of the primary factors that has demonstrated the
necessity of stepping up joint promotion of activities by governments, private enterprise,
and workers, or the institutions represent them.  It has been demonstrated that in the
developing countries the negative results of bad health and working conditions are more
traumatic and are more sharply felt than in the developed countries.  The vicious circle
of poverty causes undernutrition and disease, diminishes individual capacity and
productivity, increases the need for curative health care, and exacerbates situations. 
Often, simple and low cost measures can contribute to the reduction of the most serious
and prevalent injuries.
It is of the utmost importance to find new strategies for promoting the extension
of coverage, for delivering health care to the largest possible number of workers who are
currently without access to services, and for ensuring that the benefits thereof are
concentrated on prevention and on health promotion.  In addition, it is necessary to
intensify studies that will facilitate:  elimination, reduction, and control of the most
serious occupational risks; identification and prevention of the entire gamut of
work-related pathology; prevention of problems resulting from the adoption of new
technologies; reinforcement of a preventive spirit; improvement of the physical and
psycho-social environment; organization of the workplace and the dynamics of operation;
and support for new practices of occupational hygiene, safety, and health.

The achievement of health for all in the area of occupational health involves
creating and implementing the programs and structures that are needed in order to meet
the health needs of the working-age population (which represents more than 50 percent
of the total population) and, especially, the active population (which represents more than
one-third of the total population).  This calls, in turn, for a review of existing national
workers health plans, or for the preparation thereof in those countries that do not yet have
such an instrument.  It is necessary for the national plan for workers health to be
implemented in articulation with the national health plan and the national development
plan.

The national workers health plan should set targets that will be progressively more
specific as more knowledge becomes available about the existing situation.  It should
always include well qualified and quantified targets that are aimed at the reduction of the
risk factors, at the improvement of the health situation of workers, and at the structure of
programs and services.  In order to achieve these objectives it will be necessary not only
to conduct research, promote surveillance, and improve benefits and services but also, on
an urgent basis, to prepare specialists, professionals, and technicians to assume a
leadership role, provide the health services that workers need, and contribute to the
broader dissemination of their knowledge and to the formation of new experts in the
various disciplines in the area of occupational health.

Among all the priorities for workers health, the utmost importance is accorded to
the preparation of human resources in sufficient numbers and to an adequate level of
quality.  This is the line of program action that will permit development of the required
infrastructure and which is the is focus of the present workshop.















    TOWARD OVERCOMING THE EXISTING DEFICIENCIES

       IN HEALTH AND ENVIRONMENTAL SANITATION

IN LATIN AMERICA AND THE CARIBBEAN

DURING THE 1990S








Pan American Health Organization/
World Health Organization

November 1991







Presidential Summit of the Expanded Rio Group
Cartagena, Colombia,
2 and 3 December 1991







        TOWARD OVERCOMING THE EXISTING DEFICIENCIES IN
HEALTH AND ENVIRONMENTAL SANITATION
IN LATIN AMERICA AND THE CARIBBEAN
DURING THE 1990s



Contents


I. CHALLENGES IN HEALTH FOR LATIN AMERICA AND THE CARIBBEAN

   1.  Principal Characteristics of the Health Situation

   2.  Challenges for Health and for the Transformation of the Sector in the 1990s


II.HEALTH IN DEVELOPMENT:  A NECESSARY RESPONSE TO THE
   CHALLENGES THAT CONFRONT THE REGION

   1.  Strengthening the Social Responsibility of the State for Health
   
   2.  The Need for Reorganization of the Health Sector

   3.  Qualitative Changes in Health Services Delivery

   4.  Environmental Protection and Reduction of the Effects of the Environment on
       Health

   5.  Promotion of Social Participation for Health Purposes

   6.  Management of Knowledge in Health

   7.  Mobilization of Resources for Health

   


III.THE CHOLERA EPIDEMIC AS AN EXPRESSION OF THE EXISTING
   DEFICIENCES IN HEALTH, ENVIRONMENTAL SANITATION, AND SOCIAL
   DEVELOPMENT

   1.  Implications of the Recent Epidemic

   2.  Emergency Plan for the Prevention and Control of Cholera


IV.THE INVESTMENT PLAN FOR THE REHABILITATION OF THE HEALTH
   SERVICES AND THE DEVELOPMENT OF THE WATER AND
   ENVIRONMENTAL SANITATION INFRASTRUCTURE IN LATIN AMERICA
   AND THE CARIBBEAN


I.CHALLENGES IN HEALTH FOR LATIN AMERICA AND THE CARIBBEAN


   1.  Principal Characteristics of the Health Situation

   The social consequences of the crisis that most of the countries of Latin America and the
Caribbean are experiencing have meant increases in inequality and in poverty which have
been magnified both by the disruptions originating in mass urbanization and by the growth
of the population.  In turn, the reduction in the expenditures on the social sectors has
intensified the historic deficiencies in basic infrastructure and public services, including the
lack of adequate response to the essential needs of large sectors of the population and the
perpetuation of a social debt of vast proportions.

   The countries of the Region are experiencing accelerated changes which will intensify
during the 1990s and which are impacting all areas of social and productive life and have
broad repercussions on the demographic and health situations as well as on the nature,
structure, and distribution of the health services.

   The concentration of the population in dense urban masses exerts increasing pressure on
the infrastructure and social services of the cities.  The housing shortage has led to urban
overcrowding and segregation which have resulted in the proliferation, in many of the large
cities, of marginal urban communities with limited access to services for health and well-
being.

   In regard to the health situation in the Region, it should be pointed out that in the last 40
years there has been a considerable reduction in mortality in the countries of Latin America
and the Caribbean and hence a significant increase in average life expectancy.  But despite
the advances achieved, extraordinary efforts are required, since the basic problem that most
of the countries face is the persistence of large proportions of avoidable mortality and
morbidity that imply a reducible human cost, concentrated particularly in the first years of
life.  It is estimated that every year at least 500,000 deaths, particularly of mothers and
children, could be avoided.

   To this is added the fact that the differences in mortality between population groups in
a single country are often much greater than those between countries.  In addition, there
continue to be marked geographical differences in all of the countries, including in the most
developed, in mortality, morbidity, and accessibility to basic health services.

   The capacity to respond to the health problems of Latin America and the Caribbean have
been immensely affected in recent years by the deep economic crisis that the Region has been
experiencing.
   
   The economic stagnation of the 1980s meant, for Latin America and the Caribbean, not
only the elimination of any possibility of growth and a reduction in the average per capita
income, but also, very significantly, a reduction in the expenditures on the social sectors.

   While in the 1960s and 1970s operating and capital expenditures for social services, both
public and private, had grown at an average annual rate of 5%, during the 1980s they
remained fixed, while the population continued to increase at a rate of 2.2% per year.

   Gross public and private internal investment suffered severe reductions during the 1980s
in Latin America and the Caribbean, going from annual growth rates of 7.4% in the last two
decades to a negative rate - an annual decrease of 3.2% on the average.

   As a result of the stabilization and structural adjustment measures taken, total public
sector expenditures trended downward during the 1980s as did the gross domestic product in
the countries of Latin America and the Caribbean.  More marked still was the decrease,
during that period, of public investment, which tended to be in proportion to the total
expenditures of the public sector, particularly in the social areas; this involved an effective
reduction in the investment in human capital in the Region during the last decade, which has
limited the capacity to respond in the areas of health and environmental sanitation.

   This has been manifested by the limitations on investments in basic sanitation and in the
replacement, maintenance, and conservation of equipment and physical plant.  In addition,
it has been translated into an inability to maintain an adequate level of current expenditures,
which has impeded the normal operation of programs that address prevalent problems and
restricted administrative development and the training of personnel in the sector.

   The task of contending with these problems becomes more complex if consideration is
given to the fact that the structure and distribution of the health services have not been
developed with adequate attention to the criteria of equity, efficiency, and effectiveness. 
Inadequate use of technology, inefficient distribution of resources, poor utilization or scarcity
of trained personnel, excessively centralized bureaucratic structures, and lack of sectoral
coordination restrict both the coverage and the quality of the services.  This has been
aggravated by the failure to focus activity on the groups at highest risk and to emphasize the
promotion of health and the prevention of disease.

   The resources for health and the infrastructure for drinking water and environmental
sanitation tend to be concentrated in the large urban areas and are available to those who have
the ability to pay and who enjoy access.  This leaves large proportions of the rural and urban
marginal population without coverage.  The use of high-cost technologies creates greater
inequalities in distribution and access to the services.  To the above is added the inefficient
use of the existing resources, generating a situation in which, in most of the countries of the
Region, the health services are not responding adequately to the problems and their actions
are deficient in terms of quantity, quality, and coverage.

   2.  Challenges for Health and for the Transformation of the Sector in the 1990s

   In the field of health, although new problems have been added and it is necessary to
apply additional solutions, the risks and injuries to health, accumulated over the years, persist
unchanged, along with a large number of deficiencies in the sector.  This results in a
continuation of the unabated need for a profound transformation of the national health
systems in most of the countries of Latin America and the Caribbean so that a response can
be made to the existing sanitary debt.  But following that route requires completely
overcoming a series of problems which constitute true challenges for health and for the
transformation of the sector.

   The principal challenges that present themselves at the beginning of the 1990s can be
described in the following way:

   a)  It is necessary to grant health greater relative importance within the formulation and
       execution of social policies and greater attention as the basic ingredient of sustained
       human development.  In this, the importance of the agreement of the different
       public and private protagonists that can play a role in the improvement of health
       care must be acknowledged.

   b)  It is necessary to improve the capacity to analyze the situation and identify the
       population groups suffering the most sanitary deficiencies and the highest risks in
       order to respond better to their health care needs.  This requires the development
       of the capacity of the sector to understand the state of health of the population
       better, so that the priority health problems at the local level are defined, not only
       in terms of injuries but also with respect to risk factors.  This involves improving
       the capacity to define and identify the high-risk groups with the greatest needs for
       health care, on whom interventions of the sector should be focused.

   c)  There can be no delay in formulating and implementing policies and programs that
       pursue equity in health - that is, that lead to a reduction in the disparities in the state
       of health among the various social groups and guarantee all citizens access to
       attention to their basic health needs.  Specifically, it is necessary to reduce the
       growing deficiencies in the coverage of health services.  It is estimated that of the
       440 million inhabitants of Latin America and the Caribbean, at least a third -
        140 million - do not have regular access to health care.  It is expected, on the other
       hand, that by the year 2000, the population of Latin America and the Caribbean will
       increase by 90 million.  Currently, the health services reach 300 million people and
       in order to fulfill the commitment to provide universal access to the entire
       population of the Americas by the year 2000, it will be necessary to expend an
       effort of such magnitude that the health services will be expanded so that they are
       extended to an additional 230 million people - the 140 million not now covered and
       the 90 million inhabitants that will be added to the population in the next decade. 
       This is a colossal task, but one that is essential.

   d)  It is necessary to overcome the existing deficiencies in installed capacity, coverage,
       quality, and efficient organization of public health services aimed at strengthening
       the actions of the population, among which are the environmental health services. 
       Among the principal environmental problems that have an impact on human health
       and that require intensified action and investment are those involving guarantees
       of quality and availability of drinking water, the disposal of wastewater and excreta,
       housing quality and sanitation, the disposal of solid wastes, and chemical, physical,
       and biological contamination.

   e)  It is imperative to concentrate the programming actions of the sector on effective
       interventions that lead to the elimination of risks and the prevention and control of
       injuries that constitute public health problems.  This implies making adjustments
       in the models and practices of health care, adapting them to the needs of the
       population, as well as making changes in the expenditures on health that lead to the
       reassignment of resources to those actions that are most effective.

   f)  The need to increase the efficiency of the sector is pressing, particularly in relation
       to the limited resources that the sector has available.  This implies quantitative and
       qualitative changes in the patterns of the production of services that lead to an
       increase in productivity - to maximization of the care provided per unit of resource
       expended - and to an improvement in managerial capacity, whose final objective
       is the achievement of greater effectiveness of the actions carried out.

   g)  It will be necessary to redefine the ways that the sector is organized, manages its
       activities, and finances its operations in order to address the great problems of lack
       of access to the services, duplication of installed capacity, and lack of institutional
       coordination.

   h)  It is necessary to overcome the imbalances between the work force and the needs
       of the services, including the poor composition of the teams and the inconsistencies
       in professional training, the health situation, and the provision of services.

   Providing an articulated response to the challenges that are presented in the above
paragraphs will involve advancing with a firm step on the paths to the modernization and
recovery of the health sector and hence to an improvement in the health of the people of Latin
America and the Caribbean.


II.HEALTH IN DEVELOPMENT:  A NECESSARY RESPONSE TO THE
   CHALLENGES THAT CONFRONT THE REGION

   The countries of Latin America and the Caribbean face the growing need to give priority
attention to the human capital that their people represent.  In this, health plays a prominent
role to the extent that it involves, in the final analysis, the attainment of the full well-
being of all persons, an essential condition for the full expression of their creative and
productive potentialities.

   1.  The option of alternative development, which has been increasingly mentioned, is
       that of growth with equity.  This idea has been gaining consensus in recent years,
       both at the national level and in regional institutions and agencies.  The results of
       the crisis and the evidence of the exhaustion of the development model have
       facilitated a general trend toward the preparation of programs and the design and
       application of strategies oriented toward modifying the bases of economic
       development in order to combine equity with growth.

   2.  The proposed development implies a social process by which the population
       continues to cover its essential needs by means of sufficient availability of goods
       and services, adequate income, and equitable distribution of the surplus and the
       means for producing it in a context of political freedom and democratic
       participation in decision-making.  A new development involves permanent
       incorporation of technical knowledge to ensure the continuance of the satisfaction
       of needs in a relationship with nature that guarantees protection to the environment. 
       It requires a system that allows peaceful solution of conflicts and that demands
       respect for the autonomy and cultural expressions of the people and social groups.

       However, the marked reduction of public spending on what are called "non-
       productive activities," such as health and education, because of the adoption of
       policies of adjustment or of reactivation has led to a reduction in or absence of an
       increase in the amount of resources available for the development and operation of
       the health services.  This has been manifested in the limitations in investments
       allocated to basic sanitation and to the replacement, maintenance, and conservation
       of equipment and physical plant.  In addition, it has been translated into an inability
       to maintain an adequate level of current expenditures, which has impeded the
       normal operation of programs that address the prevailing problems and restricted
       administrative development and the training of the sector personnel. 
   
   As one can easily conclude from the above considerations, the Latin American countries
are facing the dilemma of making profound changes in their national health systems and
overcoming the existing deficiencies in health and the environmental infrastructure or
perpetuating a situation in which the unmet needs of vast sectors of the population continue
to accumulate.

   Among the principal courses that should be followed in the process of transforming the
national health systems in Latin America in the 1990s to achieve an effective improvement
of the health conditions of the population, it should be noted, are the strategy lines, mentioned
below, which form the fundamental policies that have been set by the Pan American Health
Organization for the coming years.

1.Strengthening the Social Responsibility of the State for Health

   In the first place, there is the need for strengthening the social responsibility of the state
with respect to health, which implies that the countries of the Region give priority to efforts
aimed at achieving a greater degree of equity in the living conditions and health of the
inhabitants of the continent and guaranteeing the population access to basic health services. 
This should lead to the incorporation of elements for improvement of health in the objectives
of the economic and social development policies of the countries, including actions to fight
poverty and the social solidarity programs to reduce the inequalities in the state of health and
in access to the services by social groups in the interiors of the countries.  In addition, it
should lead to an improvement in the relative position of health on political agendas and in
decision-making for the allocation of resources in all of the countries of the Region.
   
   A second dimension of this strategic line resides in the need to strengthen the role of the
state as guide, promoter, regulator, mobilizer, and coordinator of collective efforts directed
toward achieving greater social development, among which, significantly, are the formulation
of policies, execution of programs, and coordination of the provision of health services,
including actions related to the environment.


2. The Need for Reorganization of the Health Sector

   In the second place, it is fitting to point out the need to reorganize the health sector, to
transform the national health systems so that they can serve large sectors of the population
that continue to lack real access to the health services.  This reorganization involves a more
efficient utilization of the available resources, effective improvement of the organizational
and managerial capacity of the national health systems, and intense mobilization of internal
and external resources to meet the growing needs of the population in an appropriate way.

   Within this strategic line of action some specific intervention formulas that should
receive special attention during the coming years stand out, namely:  a stimulus for
decentralization accompanied by the strengthening and development of local health systems;
incorporation of the potential of social security through extension of its programs and
expansion of its coverage; and orientation of external financing toward the reorganization of
the sector, not only through investment plans, but also through sectoral adjustment credits
aimed at slowing the accumulation of the unmet needs of the unprotected population groups.

3. Qualitative Changes in Health Services Delivery

   In the third place, there is an urgent need to make qualitative changes in the delivery of
health services, since the sector models of health care have to go beyond just a passive
response to the demand for services once the injuries have occurred.  For this purpose it is
essential to continue the process of incorporating specific contents for the prevention and
control of diseases within the regular activities developed by the services.  On placing greater
emphasis on focusing actions on high-risk groups, concentrating resources on effective
interventions that are directed toward eliminating or reducing social, environmental, and
occupational risk factors and those linked to individual and group behavior with a high
prevalence, and reducing, controlling, or eliminating injuries to health that constitute public
health problems, greater effective coverage will be achieved, reducing the dispersion of the
actions of the sector, and thus reducing the inequities in the health situation and in access to
the services.

4. Environmental Protection and Reduction of the Effects of the Environment on Health

   In the fourth place, one finds the strengthening of the actions related to environmental
protection and the reduction of the harmful effects of the environment on health as
inseparable requirements of a sustained effective process of economic and social
development.  In this regard it is important to improve the knowledge of the impact of the
environment on health and to increase the implementation of actions aimed at blocking or
reversing the harmful effects of the environment on human health.  The latter has implications
for the organization of the services in the health sector, but goes beyond the area of health
actions and involves other organized sectors of the society that are to some degree related to
the environment, to its transformation, and to the ordering of the transforming process.

5. Promotion of Social Participation for Health Purposes

   In the fifth place, it is fitting to note the strategic line consisting of the promotion of
social participation for health purposes.  Included are activities for the promotion of health
aimed at transforming environmental conditions, collective forms of living, and patterns of
individual behavior injurious to health; the participation of the population in priority sector
programs and in the development of responsibility that is shared with the health services; and
the intensification of informative and educational efforts in health.

6. Management of Knowledge in Health

   In the sixth place, note should be taken of the need to improve the management of
knowledge in health - that is, to activate forms of production, dissemination, and
incorporation of both knowledge and new technologies that succeed in having the greatest
possible impact on the transformation of the national health systems.

   For this purpose it will be necessary to promote new institutional development in the
sector that makes it possible to link the production of services with the scientific and
technological innovations that are relevant and aimed at the improvement of health care.  The
strengthening of health research, the redefinition of the processes for training and updating
the human resources in the sector in a context of accelerated scientific and technological
change, and the development of scientific and technical information are essential ingredients
in this process.

7.Mobilization of Resources for Health

   Finally, in the seventh place, it will be necessary to implement an intense mobilization
of resources for health that encompasses a deepening of cooperation among countries for
purposes of health.  The transformation of the health systems requires all of the will, efforts,
and resources of all those social actors that can make an effective contribution to the
improvement of the health of the people of Latin America.  It will be necessary to mobilize
political will, public and private institutional resources, capacities of multiple sectors for
productive and social activity, internal and external financial resources, and joint actions of
the countries in order to resolve the existing health problems. 

   Only if, in the coming years, the countries of Latin America follow the paths indicated
above, will there be any effective progress in the contribution of health to building the
development processes that favor meeting basic human needs, have a humanistic values, and
seek to combine economic growth with a reduction in the social inequalities that our people
suffer today.


III.THE CHOLERA EPIDEMIC AS AN EXPRESSION OF THE EXISTING
   DEFICIENCIES IN HEALTH, ENVIRONMENTAL SANITATION, AND
   SOCIAL DEVELOPMENT

   1.  Implications of the Recent Epidemic

   The growing deterioration of socioeconomic conditions in the Ibero-American countries
and the deficiencies and cutbacks in social investment and basic infrastructure have resulted
in increased marginalization of the population and greater poverty.  These in turn have created
high-risk conditions conducive to violent outbreaks of epidemics, such as the cholera
epidemic whose magnitude has created a state of emergency in several countries.

   Between January and October 1991, some 320,000 cases of cholera have been confirmed
in Peru, Ecuador, Colombia, Brazil, Chile, Mexico, Guatemala, El Salvador, Bolivia,
Paraguay, and Honduras, of which approximately 140,000 have been hospitalized.  About
3,300 deaths have been attributed to this disease in the affected countries.  The prognosis is
reserved concerning the course of the epidemic in the affected countries and even in the other
countries of America, given the high risk of transmission of cholera from one country to
another and the marginality and unhealthful conditions prevalent in most of the Ibero-
American countries.

   The high rates of morbidity and mortality caused by diarrheal diseases, exacerbated as
a result of the cholera epidemic, reveal the high degree of fecal contamination of the water
and deficiencies in food hygiene in most of the Ibero-American countries.  These factors
affect the spread of the cholera epidemic in a crucial way and constitute the basic targets of
disease prevention activities.

   In order to address the health disaster that the cholera epidemic represents, there has
been a need, in the short term and on an emergency basis, for a series of actions in the areas
of medical care, public information, epidemiological surveillance, the strengthening of the
diagnostic and referral laboratories, food safety, disinfection of drinking water supplies,
wastewater treatment, and appropriate disposal of excreta in order to reduce the effects of the
disease in the affected countries and prevent its establishment in the countries unaffected thus
far.

   2.  Emergency Plan for the Prevention and Control of Cholera

   Such a proposal has been promoted by the Pan American Health Organization in
coordination with the national health institutions, especially the national committees for the
campaign against cholera, with the establishment of a series of preparatory works for the
development, in the short term, of Emergency Plans for the Prevention and Control of
Cholera.

   The emergency situation created by the cholera epidemic demands an immediate
mobilization of technical and financial resources, both internal and external, within the
framework for action of the Emergency Plan.  In addition, this should be supplemented with
a plan for medium- and long-term investments that facilitates the channeling of a broad
stream of resources toward investments in the field of drinking water and basic sanitation in
the coming decade.

   The Emergency Plans for the Prevention and Control of Cholera in the countries of Latin
America and the Caribbean, consolidated during the final four-month period of 1991,
envisage activities that should be developed in the next three years.

   In addition, work has been done on schemes for regional and subregional intervention
which include the actions that are listed below:

   a)  provision of basic inputs necessary for dealing with cholera;

   b)  strengthening of the systems for epidemiological surveillance of the disease;

   c)  strengthening of the clinical laboratories for diagnosis and referral, particularly at
       the level of the local health systems;

   d)  intensification of food safety measures;

   e)  development of actions in the areas of public information and health education;

   f)  strengthening of measures to guarantee drinking water quality;

   g)  intensification of the measures for the treatment of wastewater and disposal of
       excreta; and

   h)  institutional development for the preparation of plans for investment in the areas
       of drinking water and basic sanitation.

   During the second week of December 1991 in Washington, D. C., the International
Conference on "The Cholera Crisis" will be held under the auspices of the Pan American
Health Organization.  The emergency measures that have been taken in the different countries
in confronting the epidemic will be discussed; the national, subregional, and regional
emergency plans for the campaign against cholera will be presented to the international
community; and the requirements for international cooperation proposed in the emergency
plans of the countries of Latin America and the Caribbean will be presented to the
international organs and to the official development assistance agencies of donor countries
in order to promote the mobilization of resources for that purpose.


IV.THE INVESTMENT PLAN FOR THE REHABILITATION OF THE HEALTH
   SERVICES AND THE DEVELOPMENT OF THE WATER AND
   ENVIRONMENTAL SANITATION INFRASTRUCTURE FOR LATIN
   AMERICA AND THE CARIBBEAN

   In order to begin to reduce the enormous deficits existing in the infrastructure for the
health services, in the drinking water supply and quality assurance for the water provided, and
in basic sanitation, the Pan American Health Organization and international agencies have
initiated efforts aimed at identifying those needs in the countries of Latin America and the
Caribbean.

   The aim is to develop the Investment Plan for the Rehabilitation of the Health Services
and the Development of the Water and Environmental Sanitation Infrastructure for Latin
America and the Caribbean.  It will include the investment necessary to overcome the
deficiencies accumulated for decades in this field; these can be estimated at approximately
$200,000 million - an indication of the magnitude of the problem and the degree of effort that
must be sustained in the next decade.

   This huge spectrum of unmet needs, whose resolution would have considerable impact
not only on the prevention and control of cholera but also on the reduction of mortality and
morbidity due to diarrheal diseases and on the improvement of the quality of life of broad
sectors of the population, requires a firm political will to provide sustained support through
channeling financial resources to capital investments and operating expenses for drinking
water, basic sanitation, and health.

   A plan of such nature will have to include actions involving investment and
consolidation of operations and installed capacity over a period of 10 years and mobilization
of resources amounting to approximately $US200,000 million, with approximately 40%
coming from external resources and 60% from internal resources of the countries.

   Thus it will be necessary during the next decade to seek funding in at least four major
ways, namely:

   a)  The orientation of national capital resources at a rate equivalent to 1.5% of the
       gross domestic product annually toward investment in health, drinking water, basic
       sanitation, and other environmental actions.

   b)  The reorientation of the flow of official external financing, both bilateral and
       multilateral, in order to ensure that at least 20% of the available resources are
       allocated to investments in health, drinking water, basic sanitation, and other
       environmental actions.

   c)  The promotion of operations involving the exchange of foreign debt for investments
       in health, drinking water, and sanitation; and

   d)  The channeling of voluntary contributions from the international community,
       particularly the resources from official developmental assistance.

   The Pan American Health Organization is taking steps to support the efforts leading to
the formulation of the plan mentioned above and will seek to present it for consideration by
the chief executives in the Ibero-American Conference that will be held in Madrid in July
1992.

   Therefore, the backing that the Cartagena Presidential Summit of the Expanded Rio
Group can supply for this purpose will be of primary importance.



















EPIDEMIOLOGICAL STRATIFICATION OF MALARIA
IN THE REGION OF THE AMERICAS



       Carlos Castillo-Salgado, M. D., M. P. H., Dr. P. H.
Regional Consultant in Epidemiology
Communicable Diseases Program (HPT)


November 1991



EPIDEMIOLOGICAL STRATIFICATION OF MALARIA
IN THE REGION OF THE AMERICAS

       Carlos Castillo-Salgado, M. D., M. P. H., Dr. P. H.
Communicable Diseases Program (HPT)


1.   Malaria Situation during the 1980s.

     Malaria in Latin America and the Caribbean in the 1980s
presented a marked rising trend that has been sustained throughout
the decade (Figure 1).  Malaria emerged again during this period
as a serious public health problem.

     The rising trend in malaria is of particular importance since
it appeared in parallel with the socioeconomic deterioration
occurring during this decade in the countries of the Region.

     Beginning in 1987, more than a million new cases of malaria
were reported annually.  In 1990 the figure reached 1.04 million. 
These figures reflect the intensification of the transmission of
malaria in this period.


Figure 1

    This resurgence of malaria at a time of critical socioeconomic
conditions has made it necessary to review and adjust the
strategies used for prevention and control.  The purpose of this
article is to present briefly some of the more notable components
of epidemiological methodology that have been incorporated in the
strategy of epidemiological stratification of malaria.  In
addition, the progress of that process of stratification in the
Region is documented.


2.   Epidemiological Risk Approach and the Stratification of
     Malaria in the Region of the Americas

      In Latin America the stratification of malaria emerged as a
strategic approach in 1979 (1).  In 1985 it was recognized as a
strategy for performing an objective epidemiological analysis to
be used as the basis for planning malaria prevention and control
activities.

     The epidemiological risk approach was recently incorporated
into the stratification scheme; it serves as the basis for the
situational analysis and also to support the decisions on the
intervention strategies.  Some of the most important concepts in
this approach are described below.


3.   Basic Concepts of Epidemiological Stratification

     Definition of Stratification

     In the Region of the Americas, epidemiological stratification
in the malaria control programs has been defined as a continuous
dynamic process of research, diagnosis, analysis, and
interpretation of information that serves as a basis for the
methodological, comprehensive categorization of the geoecological
areas and population groups in accordance with the risk factors for
malaria (2).

     The principal characteristic of this new strategy is the
epidemiological study, in individuals and defined social groups,
of the risk factors that are responsible for the incidence of
malaria at the local level.  Knowledge of the profile of the risk
factors at that level is very useful in the selection of the
interventions for prevention and control of malaria.


4.   Scheme for the Epidemiological Stratification of Risk

     Stratification is an integrated process of analysis,
intervention, and evaluation that optimizes decision-making; it can
be summarized as follows:

     A.   Study of the annual parasite incidence (API) and its
secular trends in recent years, for the identification
of the priority areas.

     B.   Identification and measurement of the risk factors for
malaria in the priority areas or localities, utilizing
the methodology of epidemiological risk research.

     C.   Formation of epidemiological risk strata in accordance
with the ranking of the risk factors by importance.

     D.   Selection of the interventions to reduce or eliminate the
most important risk factors in each stratum.

     E.   Adaptation of the health services for the execution of
the actions based on the epidemiological risk
stratification.

     F.   Identification of the indicators of structure, process,
and impact in order to evaluate the effect of each
intervention.

     G.   Execution of the specific interventions in order to
reduce or eliminate each risk factor.

     H.   a.   Measurement of:

-    The reduction in the risk of becoming ill or
dying of malaria.  The indicators are the
specific rates of incidence and mortality.

-    The changes undergone by the risk factors
measured through the relative risk and
percentage of attributable population risk.

b.   Evaluation of each intervention through the
indicators of structure, process, and impact.

c.   Monitoring and adjustment of the process in all of
its phases.


5.   Identification of Priority Areas for Malaria Prevention and
     Control

     Through the study of the annual parasite incidence (API) and
its secular trends in recent years, one can identify those areas
where antimalarial interventions have not been successful.

     On the basis of a study of the API and its secular trend, the
priority areas are defined as those where the incidence has
increased and/or is very high.  Most of the countries of the Region
with active transmission of malaria maintain a record of the API
and have identified areas of risk on the basis of this indicator.


6.   Socioepidemiological Study of the Risk Factors for Malaria

     In the epidemiological approach, the risk factor for malaria
is defined as any variable or set of variables directly related to
the incidence of the disease.  More broadly, it can be defined as
any characteristic, attribute, condition, or circumstance that
increases the probability of the appearance of malaria or mortality
due to the disease at a specific moment.

     The risk of becoming ill from malaria implies an increase in
the probability of becoming ill through the presence of one or more
risk factors.

     The risk factors for malaria can be classified in different
ways.  However, every classification should include the ecological,
geographical, and entomological as well as the social, economic,
and demographic factors and those related to the organization of
the health services.


7.   Stratification in the Countries of the Region

     Recent experiences with the stratification of malaria in the
countries of the Region of the Americas indicate that its
development has not been continuous or homogeneous.  The initial
methods followed in the stratification depended to a great extent
on the diverse criteria used by the various countries and the type
of information in existence in each.

     However, by the end of the 1980s most of the countries in
which malaria was being transmitted had completed initial schemes
of stratification, utilizing the behavior and trend followed by the
annual parasite incidence (API).  This characterization of the
epidemiology of malaria in those countries has permitted the
subdivision of their malarious areas into "strata", or "priority
areas," using as the basic criterion the rates of incidence or
prevalence of malaria observed.  This integration of priority areas
has represented a first level of analysis and synthesis of the
malariometric information available.  In continuing the process of
reducing the complexity of the malaria problem, the stratification
should incorporate the epidemiological view of the analysis of the
determinants and the local characteristics recognized as risk
factors that explain the increase observed in the morbidity rates
of the disease.

     The criteria used to stratify the local malaria situation
epidemiologically should begin with the analysis and recognition
of the risk factors that determine the frequency and distribution
of the disease.

     Below there is a description of the current state of this
process in the various countries of the Region, covering the
information available during 1990.


8.   General Characteristics of the Stratification

     In general, the stratification of malaria in the different
countries of the Region has had the following characteristics:

     A.   The epidemiological stratification of malaria in the
countries of Latin America and the Caribbean has made it
possible to initiate the study of the different risks of
disease and death from malaria to which their populations
are exposed because of the presence of specific
attributes or characteristics in the individuals and
social groups, in the environment, and in the
organization of the health services.

     B.   The trend of the annual parasite incidence (API) in 21
countries of the Region shows an increase in the API from
1.7 in 1980 to 2.53 in 1990.  This average increase in
the API does not reflect the true intensification of the
transmission that has occurred in the malarious areas of
the countries.  On analyzing this indicator for the
interiors of the countries without including areas and
populations having no transmission or risk of becoming
ill, a more realistic picture of the malaria problem can
be obtained.  To illustrate this, we call attention to
the fact that in 1990 the API reported in some high-risk
areas in the various countries was 250 times greater than
the figure for the Region.  Thus, for example, the API
reached levels of up to 694 per 1,000 and 553 per 1,000
in some municipalities in Brazil, 659 per 1,000 in
localities in French Guiana, and 415 per 1,000 in Guyana.

     C.   Malaria is a disease that is expressed locally.  As a
result, the study of its distribution and of the various
mechanisms to be selected for its control should
basically include the local epidemiological profile of
its determinants.  The concepts of general and global
control strategies are not successful.  Although in
particular situations they facilitate a temporary
reduction in transmission, the continued existence of the
unaltered determining risk factors is the reason that
local transmission continues, reappears, or undergoes a
rapid increase.

     D.   The epidemiological mapping of the high-risk areas of
transmission of malaria has helped the countries to
recognize those priority human groups and geographical
and ecological areas in which the epidemiological
stratification of malaria makes it possible to recognize
the principal factors that determine malaria morbidity
and mortality and whose removal will be object of the
malaria prevention and control programs.

     Below there is a brief summary, for some countries of the
Region of the Americas, of the current state of stratification and
its relation to the malaria situation up to December 1990.

     The description is not exhaustive and not all of the countries
with malaria transmission are included.  However, it exemplifies
the role of epidemiological methodology in the stratification of
malaria.


BRAZIL

     The emerging process of the epidemiological stratification of
malaria in Brazil has made the differences that exists in the
distribution and frequency of malaria in this country more visible. 
Moreover, it has made it possible to appreciate the importance to
the control programs of the recognition of the specific risk
factors that determine the intensity and severity of malaria in the
different human groups and areas of the country.

     The trend of the malariometric indexes in Brazil from 1960 to
1990 is presented in Figure 2.  As is evident in that figure,
beginning in 1975 the API trend in Brazil was upward and
continuous.  Beginning in 1983 the upward trend in this indicator
intensified although the annual blood examination rate (ABER)
remained the same.  The house spraying rate (HSR) showed a decline
during the 1980s.


Figure 2




    In 1990 Brazil, with 560,396 cases of malaria and a total
population of 154 million inhabitants reported an API of 3.73. 
This API value does not reflect the increase in the number of cases
malaria in the areas of transmission.  There are large variations
among the regions and municipalities of the country.  For example,
for 1989 the Southeastern Region with 4,152 cases and an API of
0.21 contrasts with the Northern and Midwestern Regions, which had
455,632 cases (API, 46.1) and 66,302 cases (API, 13.2),
respectively.

     If this indicator is disaggregated further, it can be seen
that of the 27 states in the country, eight reported APIs higher
than 7 per 1,000.  The APIs of these states were as follows: 
Roraima, 146.5; Rondonia, 128.3; Amapá, 43.2; Acre, 38.5; Mato
Grosso, 28.8; Pará, 22.6; Amazonas, 16.9; and Maranhao, 7.2.

     The highest rates of transmission of malaria are found
basically in the states of the Amazon Region, where in 1990 97% of
the cases of the country were reported.  In that Region, three
states were responsible for most of the cases:  Rondonia with 45%
of the total, Pará with 21%, and Mato Grosso with 11%.

     On studying the intensity of the transmission at the local
level, one finds large differences among the national or regional
averages.  For example, in 1990 the state of Amazonas had
municipalities with APIs of 120; in Acre there were municipalities
with APIs of 198.9; in Amapá, with 125; in Rondonia, with 550; in
Pará, with 583.8; and in the state of Mato Grosso, there were
municipalities with APIs of 3,924.

     In the geographical areas where most of the cases of malaria
are found, particularly in the Amazon Region, two major social
processes are reported that are determinants of the risk of
contracting malaria.

     The first corresponds to an intense and disordered migratory
flow toward mining areas that are difficult to access, whose living
and working conditions are very precarious, and where the levels
of transmission are high.

     The second process, also of a social nature, corresponds to
the intensification of the population movements toward areas of
subsistence farming with the resulting creation of settlements
whose problems of inaccessibility, inadequate living conditions,
and limited health protection have provided the basic foundation
for the continuation and increase in malaria in those areas.

     Recognition of the forces and factors that are involved in
transmission and of the actions that can affect them, which would
be the basis of the control programs, constitutes the next stage
of this process of epidemiological stratification.


COLOMBIA

     In recent years the basic effort in the stratification of
malaria in Colombia has consisted of the identification and
grouping of critical malarious areas with the basic selection
criterion being the level of the API reached in those areas.

     Hence in Colombia the areas of malaria transmission have been
divided into three levels of risk, in accordance with the API.

     The classification of the corresponding risk utilizes as the
basic unit the municipality.  Thus, the municipalities that present
an API less than 0.5 are considered to be at low risk.  Most of the
municipalities in the consolidation phase are found at this level. 
The municipalities with an API between 0.5 and 10.0 are considered
to be at moderate risk.  Finally, those municipalities with an API
of more than 10.0 are classified as high-risk areas.

     The 100,286 cases of malaria that occurred in Colombia in 1989
were in 2,103 of the 37,841 localities in malarious areas of the
country.  In addition, there were 72,650 cases, representing 72%
of all of the cases registered in 1989, that were concentrated in
six regions.  These 72,650 cases were detected in 91
municipalities.  Of these 91 municipalities, 32 accounted for
57,414 cases, which represented 79% of the cases reported in these
regions and 57.4% of all of the cases in the country.

     The most important universal risk factors reported by the
Colombian authorities are included in Table 1 below.

     Because of the complexity of the social risk factors that are
involved in the transmission of malaria, in control programs
consideration should be given to facilitating intersectoral actions
with the economic sectors and other social sectors and to requiring
significant adjustments in their control measures.
  Table 1.   Global risk factors determining the persistence
of malaria transmission, by area.
Colombia, 1989.


===============================================================

CASES OF                 
AREA           MALARIA                  RISK FACTORS
----------------------------------------------------------------

Uraba          18,072         Factors associated with social
Baja Cauca                    conflicts.
Lack of resources.
----------------------------------------------------------------

Amazonia       17,903         Factors associated with social 
conflicts.
Lack of resources.
----------------------------------------------------------------

Pacific        16,074         Technical problems.
Coast                         Lack of resources.
----------------------------------------------------------------

Sarare          4,608         Low coverage with spraying.
Problems with the behavior of the
vector.
----------------------------------------------------------------

Magdalena       2,821         Low coverage with spraying.
Medio                         Changes in law and order.
Problems with the behavior
of the vector and of the parasite.
----------------------------------------------------------------

Catatumbo         694         Social problems.
Precarious housing.
Regions of colonization.
Low coverage with spraying.
Problems with the behavior
of the vector.
=================================================================VENEZUELA

     In Venezuela in 1989 there were 43,369 cases of malaria
reported.  The API of the country was 2.25, very close to the API
of 2.44 for 1988.  Venezuela has an epidemiological risk map on
which three geographical areas with high levels of transmission of
malaria can be seen.

     These areas correspond to the Southern Region, represented
basically by the state of Bolívar; the Western Region, which
includes the states of Zulia, Táchira, Apure, and the Federal
Territory of Amazonas; and the Eastern Region that surrounds the
state of Sucre.

     Analyzing the malariometric indicators in accordance with the
epidemiological approach of stratification, we can observe that the
distribution of morbidity due to malaria is concentrated in the
state of Bolívar; 61% of the malaria in the country is in this
state.

     As in the rest of the countries of the Region of the Americas,
malaria in Venezuela has a local distribution.


HAITI

     In recent years the epidemiological information on malaria in
Haiti has been limited.  By 1989, 23,231 cases of malaria had been
registered, all of them of Plasmodium falciparum.

     Of the four health regions into which the country is divided,
the Transverse Sanitary Region was responsible for 10,139 cases
which represented 44% of the cases registered in 1989.  In the
Western Region 6,458 cases were registered, while in the Northern
Region there were 3,737 cases and in the Southern Region, 2,897. 
These figures do not reflect the true morbidity due to malaria
since the source of epidemiological information on the cases of
malaria is very limited.

     In 1980 a primary scheme for the stratification of malaria was
carried out to define the most important areas at risk of malaria
in the country.  As in other countries, the basic criterion for the
selection of those areas was the behavior of the API.

     The areas considered to be at high risk were those localities
with APIs of 10 and more.  Areas with moderate risk were those
whose APIs were between 5 and 9.  Low-risk areas were those with
APIs of 0.1 to 4.  Localities whose APIs were outside these three
ranges were considered negative with respect to malaria.  On the
basis of this characterization, 66% of the localities (24,470) with
the 39.5% of the total population of the country were declared
negative with respect to malaria.

     There were 3,401 localities, 13.9% of the total number, that
had APIs higher than 10; they had 21.6% of the population and
constituted the areas at greatest risk of malaria in this country.

     At moderate risk were 6.3% of the localities (1,535) with
10.7% of the population, while 13.7% of the localities (3,345) with
28.2% of the population were designated as being at low risk of
malaria.

     Among the most important risk factors in the dynamics of
malaria transmission were the constant internal migrations and the
socioeconomic deterioration of the population.

     With respect to factors related to the organization of the
health services, it should be pointed out that in 1968 the control
measures began to be cut.  Beginning in March 1988, at the time of
a major financial crisis, the government closed the National System
for Eradication of Malaria, discharging all the field workers and
the administrative personnel.  Financial difficulties and political
instability have systematically impeded the reestablishment of
control measures.


BOLIVIA

     In Bolivia in 1989 there were 25,367 cases of malaria and the
national API was 3.57.  However, the API in malarious areas was
found to be 9.89.

     On studying this malariometric indicator by department, it can
be seen that the API in the department of Tarija was 21.  The API
in the department of Pando was 19.8; in the department of
Chuquisaca it was 11.8; and in Beni, 10.5.

     Among the risk factors that can explain the mechanisms of
malaria transmission are the migrations toward mining and rice-
producing areas whose great mobility and precarious living
conditions oblige the population to submit to high risks of
contracting malaria.  In addition, there is drug-resistance among
the parasites in the malarious areas of the departments of Beni and
Pando.  The low coverage of the services and operational problems
in the control programs are also important factors in the
transmission of malaria in the country.


ECUADOR

     In Ecuador in 1989, 23,274 cases were reported and the API was
2.22; the API had been 2.4 higher in 1988.  This phenomenon does
not necessarily reflect a real reduction in malaria since in 1989,
because of labor problems, the malaria control program was
paralyzed for several months, resulting in an annual coverage lower
than 40%.

     Taking the foregoing into consideration, one can state that
the API in 1989 underestimates to a great extent the true morbidity
due to malaria in the country.  On breaking the API down by
province, it can be seen that in the province of Sucumbíos the API
reached 45.46; in the province of Los Ríos, 16.95; in the province
of Napo, 11.84; in the province of Esmeraldas, 11.84; in the
province of Manabí, 4.16; and in that of Guayas, 1.38.

     Among the principal risk factors in transmission, those
related to the economic crisis in the country stand out as do those
linked to the problems in the administration of the malaria program
and the low operative capacity of the health services.


PERU

     In Peru, the total number of cases of malaria notified in 1989
was 32,114.  The overall API for the country was 4.46.  In the
interior there were APIs that were up to 12 times the national
figure.

     Thus, for example, the department of Junín, with 7,321 cases,
had an API of 53.88.  The department of Ayacucho had an API of
26.90; the department of Madre de Dios, 18.73; the department of
St. Martín, 15.43; and the department of Pasco, 14.83.

     Among the principal risk factors referred to as determinants
of malarial transmission, those related to the critical
sociopolitical situation being experienced by the country and the
great economic deterioration of a great part of the population were
mentioned.

     Moreover, the social factors related to violence and drug
trafficking have played an important role as have those caused by
population displacement and internal labor migration which involve
very precarious living conditions.


9.   Involvement of Social Factors in Malaria Transmission in
     Countries of the Region of the Americas

     The economic deterioration and the social adjustments that
have occurred in the 1980s in most of the countries of the Region
of the Americas have had a significant impact on the
epidemiological profile of health and on the malaria situation.

     The necessary diversification of the control measures requires
a comprehensive epidemiological approach that combines the
contributions of the social sciences and research on the health
services with the advances achieved in basic research, immunology,
entomology, and the clinic.

     The stratification of malaria provides the rational bases for
planning the control activities.  The epidemiological information
and the socioeconomic profile of the areas at risk are considered
basic elements for the selection of the control measures, which are
directed not only toward the temporary reduction of the
transmission of malaria, but basically toward the elimination of
the risk factors that sustain the disease.REFERENCES


     Organización Panamericana de la Salud.  Malaria en las
Américas, Informe Final.  III Reunión de Directores de los
Servicios Nacionales de Erradicación de la Malaria en las Américas. 
Oaxtepec, México.  Publicación Científica 405.  Washington, D. C.,
1981.

     Castillo-Salgado, C., and M. Bayona-Celis.  Uso de la
Investigación Epidemiológica en la Conformación de Estratos
Epidemiológicos de Riesgo y de la Selección de Intervenciones de
Control.  Materiales sobre Estratificación de la Malaria.  Programa
de Enfermedades Transmisibles.  Washington, D. C., Organización
Panamericana de la Salud, 1989.

     Orlov, V. S., and I. N. Semashko.  Malaria Stratification as
a Tool in Developing the Strategy and Tactics for Modern Long-term
Malaria Control Programs.  WHO/MAL/86.1029, 1986.

     Kouznetsov, R. L., L. Molineau., and P. F. Beales. 
Stratification of Malaria Situations in Tropical Africa for the
Development of Malaria Control within the Primary Health Care
Strategy.  WHO/MAL/86.1028, 1985.

Figure 1.  Malariometric Indexes.
Brazil, 1960 - 1990

ABER per 100 inhab.   HSR per 1,000 inhab.   API per 1,000 inhab. 

HSR

API

ABER

Malariometric indexes

API       ABER      HSR       








Figure 2.  Malariometric Rates of 21 Countries
Region of the Americas

API/ABER


Years

     API per 1,000 inhab.          ABER per 1,000 inhab.


PREFACE




      Urban rabies in the Americas is being brought under control as a result of
concerted efforts on the part of national governments, communities, institutions involved
in public health, and the Pan American Sanitary Bureau.

     The extension of health service coverage to control urban rabies in small cities and
towns is the target that has been set for the end of the decade.  However, over the last few
years there has been an increase in the number of cases of the disease among wild
animals, especially vampire bats, which have caused epidemic outbreaks in humans. 

     Population growth and the search for alternative livelihoods have led people to
settle unexplored areas and colonize new territories, thereby progressively pushing back
the agricultural frontier.  This expansion has brought about changes in the ecological
balance of the jungle, which is producing a cycle of rabies transmission that is different
from the original one.  In this new cycle, man and livestock are competing for space with
several wild animal species that occupy a place in the epidemiological chain of the
disease.

     In the past there were sporadic outbreaks of rabies transmitted by vampire bats,
which affected few people and usually followed the same ecological pattern.  This
generally occurred among rural inhabitants who settled lands freshly wrested from the
jungle, where the introduction of livestock favored growth in the vampire bat population
because of the greater availability of food. 

     Recently there have been outbreaks that have affected several dozen people,
including one in Choque, Madre de Dios Department in Peru, where 33 persons died; one
in Amazonas Department in Peru, where 22 people were affected; and an outbreak in
ApiaÛas, Mato Grosso State, in Brazil, in which there were seven deaths.  In these places
the ecological and epidemiological pattern that has been observed differs from the
classical pattern, and the ensuing social repercussions have affected all levels of the
community.

     In light of this emerging public health problem and the persistent questions and
rather unconvincing answers available so far regarding the natural behavior of the rabies
virus in its jungle cycle--especially in such a singular reservoir as frugivorous,
insectivorous, and vampire bats--and the status of existing knowledge on the control of
bovine rabies transmitted by vampire bats and the lack of experience in preventing the
disease in human populations in jungle areas, it was decided to hold the Expert
Consultation on the Attention of Persons Exposed to Rabies Transmitted by Vampire
Bats.

     This meeting brought together national and international experts for the purpose
of exchanging information and studying scientific tests, hypotheses, and empirical
observations, and reaching a consensus on the measures that should be implemented by
the national rabies control services in order to prevent epidemic outbreaks such as those
described above.

     I wish to express my appreciation to the experts who contributed the necessary
scientific basis for the discussions.  In addition, I am grateful to the French institutions
Rhîne Mérieux and Pasteur-Mérieux Sérums & Vaccins, whose international experience
helped to ensure the success of the Meeting and publication of the present report.




Dr. Carlyle Guerra de Macedo
Director
Pan American Sanitary Bureau


PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION



























SYNOPSIS OF THE EXPERIENCE OF THE PROGRAM ON   

MATERNAL AND CHILD HEALTH IN THE EVALUATION OF  

SERVICES IN COUNTRIES OF LATIN AMERICA     


























DR. NESTOR SUAREZ
OJEDA
1991     
   



CONTENTS

PAGE


        SYNOPSIS OF THE EXPERIENCE OF THE PROGRAM ON
  MATERNAL AND CHILD HEALTH IN THE EVALUATION OF SERVICES


I.        INTRODUCTION                                       1

II.       THEORETICAL FRAMEWORK AND METHOD                   1

III.      SUMMARY OF RESULTS                                 4

IV.       OUTLOOK AND RECOMMENDATIONS                        6
       SYNOPSIS OF THE EXPERIENCE OF THE PROGRAM ON
  MATERNAL AND CHILD HEALTH IN THE EVALUATION OF SERVICES



I.   INTRODUCTION

     The evaluation of health services that provide care
for women and children is one of the principal areas of
cooperation for the Program on Maternal and Child Health
(PMCH) of PAHO.  The enhancement and application of various
methods for the evaluation of services is a priority
activity for the strengthening of local health systems, as
well as for the reformulation and adaptation of program
procedures and standards.

     In 1985 PMCH initiated the development and application
of methodologies for service evaluation.  The initiative
was well received in the countries of the Region and to
date these methodologies have been used in 18 countries. 
Others are expected to implement them in the near future.

     The present document presents the results of
application of the instrument known as the "Efficiency
Evaluation Procedure" over a period from 1985 to 1990 and
includes the findings of evaluations conducted in 1,611
health services of different types.  In all cases the
evaluations were carried out by MCH units in the countries,
with support from the Regional Program.  Experts from other
countries also contributed their experience and were then
able to carry on the process back in their own countries.


II.  THEORETICAL FRAMEWORK AND METHOD

     If a positive change is to be made in the way a
service operates, one of the first steps to be taken should
be an evaluation, which means comparing an actual situation
with a standardized one and then interpreting the
differences found.

     Fully aware of the complexity and difficulties of the
task in its overall sense and recognizing the limitations
of restricting the procedure to an evaluation of only a few
elements, the Program undertook--as a first step--the
comprehensive application of the method known as
"Evaluation of Efficiency in Maternal and Child Health
Services."  This instrument makes it possible to examine
the structure of health care resources and assess their
capacity to ensure that the services operate effectively. 
The methodology has some limitations, but it is
nevertheless quite useful in identifying the structural and
procedural elements that either favor or hinder service
development.  Systematic application of the instrument can
contribute to the process of reorganization and
strengthening of maternal and child health services.

     This methodology for evaluating efficiency, which
originated during the 1960s, has been utilized in a number
of countries throughout the Region, with modifications to
tailor it to the epidemiology and operational modalities of
their services.

     In early 1985, the PAHO Programs on Maternal and Child
Health and Health Services Development brought together
several groups of experts to revise the guidelines for
evaluation, standardize the elements observed, and
introduce updated criteria and approaches in maternal and
child health care.

     A consensus model was thus developed, and application
thereof was promoted in all the countries of the Region. 
An attempt was made to keep the questions and scoring
uniform with a view to collecting data that would permit
some type of Regional analysis, although it was recognized
that the greatest value of this instrument lies in its
capacity to promote changes at the local health system
level.

     The model developed was disseminated in several
publications that were prepared for this purpose.  It was
soon accepted by the countries of the Region, which
undertook to apply it.  To date, 18 countries have utilized
this methodology based on the PAHO model to evaluate a
sampling of their services.  In one case (Córdoba,
Argentina), a study was conducted of all the services in
the public sector and the data have been cross referenced
with indicators of hospital productivity and performance.

     In several countries successive evaluations have been
carried out at one- or two-year intervals, which has made
it possible to follow the evolution of care conditions and
also to note whether or not the evaluations have had any
effect on the services.


TABLE 1

EVALUATION OF EFFICIENCY
FREQUENCY DISTRIBUTION OF THE SERVICES BY TYPE
AND OVERALL SCORE OBTAINED *

COUNTRIES OF LATIN AMERICA

------------------------------------------------------------------------
----------
TOTAL          CRITICAL       UNSATISFACTORY      
SATISFACTORY
       TYPE           SERVICES       SITUATION      SERVICES            
SERVICES
EVALUATED
No.  %           No.  %              No. 
%
------------------------------------------------------------------------
----------
HEALTH POST            4        71   15        369  80             22    5
------------------------------------------------------------------------
----------
HEALTH CENTER              427       35    8        367  86             25 6
------------------------------------------------------------------------
----------
OUTPATIENT OBSTETRICAL     173       12    7        142  82             1911
------------------------------------------------------------------------
----------
OUTPATIENT PEDIATRIC  174       27   16        140  80             7     4
------------------------------------------------------------------------
----------
NEONATOLOGY            74       14   19        52   70             8    11
------------------------------------------------------------------------
----------
INPATIENT
OBSTETRICAL                147       32   22        109  74             6 4
------------------------------------------------------------------------
----------
INPATIENT
PEDIATRIC                  154       36   23        106  69             128
------------------------------------------------------------------------
----------
TOTAL                1611      227   14       1285  80             99   6
------------------------------------------------------------------------
----------
* PAHO/WHO Program on Maternal and Child Health
TABLE 2

EVALUATION OF EFFICIENCY
FREQUENCY DISTRIBUTION BY AREA AND SCORE OBTAINED
COUNTRIES OF LATIN AMERICA


------------------------------------------------------------------------
-------
CRITICAL SIT.       UNSATISFACTORY      SATISFACTORY
  AREA                   (0-39)              (40-79)            (80-100)
No.       %         No.       %         No.       %
------------------------------------------------------------------------
-------
Physical Plant             238       20        686       58        263  22

Physical resources         133       11        761       64        293  25

Human resources       507       43        613       52         67        6

Standards and procedures   312       26        709       60        166  14

Programming           559       47        548       46         80        7
Administration

Supplies                   107        9        619       52        461  39

Health education      250       21        568       48        369       31

Community participation    583       61        348       27         17   2
_________________________________________________________________________
_____

* Program on Maternal and Child Health 


III. SUMMARY OF RESULTS

     The instrument utilized makes it possible to express
numerically the degree of efficiency in every service.  An
optimum score would be 100% of the assignable points.  The
lists of questions are grouped into the following subject
areas:  physical plant, human resources, standards and
procedures,  programming and administration, supplies,
health education, and community participation.

     The different types of service that provide care for
the maternal and child population are grouped as follows: 
health posts, health centers or outlying physician's
offices, outpatient obstetrics and gynecology, outpatient
pediatrics, inpatient neonatology, inpatient pediatrics,
and inpatient obstetrics and gynecology.

    
     Thus, when the resulting figures are tabulated it is
possible to analyze the data by type of service (health
post, health center, etc.) or by area in general or within
each type of service (physical plant, programming and
administration, etc.).
     
     This summary presents only the results by type of
service (Table 1) and overall results by area in all the
services evaluated (Table 2).  Since there is a wide range
of scores, the following frequency distribution criteria
were adopted based on the scores obtained: 

     Scores under 40% - Critical situation
     Scores between 40% and 79%  - Unsatisfactory
     Scores of 80% or over - Satisfactory

     Table 1 shows the results of frequency distribution by
type of service and overall scores obtained for the 1,611
services that were included in this study.

     An initial observation is that 80% of all types of
service fall under the heading of unsatisfactory (i.e.,
scores between 40% and 79%) and 14% are in critical
condition, whereas only 6% achieve a rating of
satisfactory.

     An examination of the "critical situation" column in
Table 1 reveals that a low percentage of health posts,
health centers, and outpatient centers are in such poor
condition.  However, the figures for inpatient services in
the areas of neonatology, obstetrics, and pediatrics are
close to and sometimes above 20%.  This shows the weakness
of hospital referral levels and points up the need to
strengthen this area.

     Table 2 presents a similar classification of the
scores obtained in different areas within the various types
of services.

     It is clear that the area of "community participation"
is the weakest component, given that the situation is
critical in 61% of the services that should include such
participation, while it is satisfactory in only 2%.  The
Region has only recently begun the process of democratizing
health care, and even in services at the primary care level
authoritarianism and exclusion of the community from
decision-making processes are common.

     Next in terms of seriousness are programming and
administration, with 47% in the "critical situation"
category and just 7% at satisfactory levels.  These figures
reflect the frequently noted fact that the health care
services, especially hospitals, do not program their
activities or have data on the population that they are
responsible for serving.

     At the other extreme is the area of "supplies," with
just 9% in the "critical situation" column and 39% under
"satisfactory."  This is probably due to the tremendous
effort that has been put forth by different components of
the Program to ensure that essential supplies for maternal
and child health care are provided on a timely basis. 

     These are only a few examples extracted from the
totality of the data available.  Specific studies with
cross-referencing are being carried out with statistical
data on hospitals, which will yield information that will
be particularly useful for the improvement of health
programs and services and for the rechanneling of technical
cooperation.


IV.  OUTLOOK AND RECOMMENDATIONS

     Analysis of the information available shows the
tremendous weaknesses in the services that provide maternal
and child health care.  Nevertheless, it is encouraging to
note that less than 15% of all the services are in critical
condition.  In other words, 85% are in unsatisfactory or
satisfactory condition, and it should be possible to
improve this situation in the medium term without huge
outlays through efforts aimed at enhancing programming and
management in the services.

     This methodology should therefore continue to be used. 
It should be adopted by new countries and carried on by
those that have already applied it as a means of monitoring
the advances made in the implementation of local health
systems.  In fact, four countries have already undertaken
successive evaluations and as a result have been able to
identify changes in the condition of their services.

     The relationship between the process of
decentralization and the development of local health
systems led PAHO to establish an Interprogram Group, which
is formulating more comprehensive methodologies on the
basis of this experience with a view to developing
mechanisms for evaluating the general operating capacity of
the services and measuring their impact on community
health.   At the same time, the Program on Maternal and
Child Health is working to develop a methodology for the
evaluation of community participation.

     It is evident that the evaluation of efficiency and
progressive application of the methodology in the countries
is a positive contribution toward the development of local
health systems, the strengthening of coordination between
programs and services, and more rational utilization of the
sector's resources. 

SPECIAL REPORT

AIDS AMONG WOMEN
IN LATIN AMERICA AND THE CARIBBEAN

   In Latin America and the Caribbean the AIDS epidemic is increasingly affecting women and children. 
The proportion of accumulated cases reported among women in the Caribbean as of 1989 (49.7 per million)
was higher than the proportion in North America (28.6 per million).  Serological data confirm that the
prevalence of human immunodeficiency virus (HIV) infection in prostitutes and women with infected male
partners is particularly high in the Caribbean, sometimes as high as 70% according to several studies. 
Morbidity reports received by the Pan American Health Organization show that the incidence of AIDS cases
in women increased by 185% in the Caribbean and 4548% in Central America between 1986 and 1989. 
Other areas of the Region, although they have not been as heavily affected, have also shown an increase in
the number of AIDS cases in women.  There is an urgent need to step up and coordinate serological
surveillance in order to enable better quantification of HIV infection among women in Latin America and the
Caribbean.  National AIDS programs should promote intensive education campaigns to protect women from
HIV.  In order to prevent infection, it is essential to ensure that no HIV-contaminated blood is used in
transfusions required for emergency treatment in connection with abortions or other obstetrical
complications.
INTERNATIONAL MEETING FOR THE ERADICATION OF
BOVINE TUBERCULOSIS IN THE AMERICAS

Saltillo, Coahuila, Mexico, 18-20 November 1991

FINAL REPORT

     Dr. Carlyle Guerra de Macedo, Director of the Pan American
Health Organization, in response to a request made by the
Ministers of Health during the VII Inter-American Meeting, at the
Ministerial Level, on Animal Health (RIMSA VII), held in
Washington, D.C., from 30 April to 2 May 1991, to prepare a
proposal for a plan of action for the eradication of bovine
tuberculosis in the Americas, convened the present meeting to
prepare and discuss the plan jointly with the national
authorities. 

     Thanks to the collaboration of the Office of the
Undersecretary of Agriculture and Water Resources (SARH) and the
hospitality of the State Government of Coahuila, the city of
Saltillo was offered as the venue for the meeting.

     The meeting, which was convened from 18 to 20 November 1991,
brought together 46 professionals from 20 countries in the
Americas:  Argentina, Belize, Canada, Chile, Colombia, Costa
Rica, Cuba, Dominican Republic, El Salvador, Ecuador, Guyana,
Honduras, Jamaica, Mexico, Nicaragua, Paraguay, Panama, United
States of America, Uruguay, and Venezuela.  The meeting was also
intended by four international organizations, IDB, IICA, OAD, and
IOE, and Mexican livestock associations. 

     The meeting was inaugurated on 18 November by the Governor
of the State of Coahuila, Eliseo Mendoza Berrueto.  Also on the
presidium were Dr. Gustavo Reta Petterson, Undersecretary for
Livestock in the Secretariat of Agriculture and Water Resources
of Mexico (SARH), Dr. Héctor Campos López, Director General of
Animal Health of SARH, Dr. Jorge Galo Medina Torres, Secretary of
Rural Development of the State of Coahuila, Dr. Raymundo Verduzco
Rossan, Secretary of Health of the State of Coahuila, Reginaldo
de Luna Villarreal, Delegate of SARH to the State of Coahuila,
and Francisco García Castell, representing the National
Livestock Federation.  During the ceremony, Dr. Juan Manual
Sotelo, PAHO/WHO Country Representative in Mexico, spoke on
behalf of Dr. Carlyle Guerra de Macedo, recalling the request of
the Member Governments to prepare a plan of action for the
eradication of bovine tuberculosis and the urgent need to
undertake actions in all the countries for this purpose in order
to reduce the financial and business losses brought on by this
disease.  He also referred to the importance of bovine
tuberculosis to public health at a time when almost 8,000 human
cases were reported in the Americas from this infection.

     Dr. Sotelo also mentioned the importance of ensuring that
the countries and areas, which had a total bovine population of
approximately 215 million head, were kept free from this disease. 
Finally, he urged the countries to pool their efforts in
formulating strategies to combat the disease jointly and offered
the support of the technical cooperation of the Pan American
Health Organization in reaching the targets set by the countries.

     Dr. Gustavo Reta Petterson, Undersecretary for Livestock of
SARH, after thanking PAHO/WHO for the honor of choosing Mexico as
the venue for such an important event, recalled that during the
1970s several countries took actions to combat bovine
tuberculosis with the result that at the present time there were
three categories of country situations:  1) Countries that have
achieved eradication or are very close to doing so; 2) Countries
that have succeeded in reducing prevalence to levels that will
make it possible to achieve eradication within a reasonable
amount of time; and 3) Countries that still have high prevalence
of the disease or do not have complete information available on
their situation.  Under present-day political, economic, and
social circumstances the plan of action represented a step
forward for the Latin American and Caribbean countries in the
elimination of bovine tuberculosis.  Dr. Reta noted that
diagnostic methods and epidemiological surveillance systems still
had to be improved; however, it was necessary to begin on a sound
basis by focusing on mass communication as a means of achieving
participation of the producers, even in the costs of the program. 
Lastly, Dr. Reta noted that the present time was a historic one
and therefore appealed to the participants to work hard and to
make appropriate recommendations for their countries. 

     Eliseo Mendoza Berrueto, Governor of the State of Coahuila,
viewed the meeting as a privileged opportunity to recognize the
ongoing work of the livestock producers of Coahuila in behalf of
public health in preserving the health of dairy cattle in the
region.  He also expressed concern for the bovine tuberculosis
situation in some countries, and in particular in Mexico as an
exporter of cattle on the hoof, noting that if the problem was
not dealt with properly it could bring about very serious
consequences.  The Governor then offered his decided support to
SARH and to all the organizations involved in undertaking the
venture and requested that all international organizations
provide collaboration in all stages of the programs.  He then
invited the cattlemen, as the principal actors involved, to
participate actively in carrying out the campaign.  Governor
Eliseo Mendoza Berrueto then concluded his remarks by welcoming
the participants and extending a warm greeting on behalf of the
people of Coahuila.

     The officers of the meeting were then elected, as follows: 
as Chairman, Dr. Douglas Hernández, Delegate of Venezuela; as
Vice Chairman, Dr. Silverio Tamayo, Delegate of Cuba; and as
Rapporteur, Dr. José Naranjo, Delegate of Chile.  PAHO/WHO acted
as General Secretariat for the meeting.


     The Program of Work (Annex 2) was developed in three plenary
sessions and in working groups in which the bases for structuring
the plan of action were discussed.

     The working group meetings were preceded by introductory
remarks by PAHO/WHO and SARH officials.

     During the plenary sessions the participants heard
presentations on:  "The Current Situation of Bovine Tuberculosis
in the Americas," by Dr. Elmer Escobar, Director of the Pan
American Zoonoses Center; "Bases for a Plan of Action for the
Eradication of Bovine Tuberculosis in the Americas," by Dr.
Eduardo Alvarez, Chief of Field Work of the Pan American Zoonoses
Center; and "Diagnostic Methods for Bovine Tuberculosis," by Dr.
Isabel Kantor, also of the Pan American Zoonoses Center.

     The participants were divided into four working groups on
the basis of the similarity of the epidemiological situation of
bovine tuberculosis and the geographical situation in their
countries of origin.  Officials from PAHO/WHO and other
international organizations, together with observers, were
distributed among the groups to provide support for and to act as
facilitators for the discussions (Annex 3).

     Dr. Albino Belotto of PAHO presented the methodology for the
working groups and explained how they were to be distributed,
noting further that all discussions would be accompanied by
guides prepared for this purpose (Annex 4).

     Four working sessions were held in which a topic was
discussed selected from the meeting's Program of Work.  At the
beginning of each working group session the topic was introduced,
as follows:

     -    "Definition of Areas on the Basis of their
Epidemiological Situation."
Dr. José Germán Rodríguez Torres - PAHO/WHO 

     -    "Bases for Epidemiological Surveillance of Bovine
Tuberculosis."
Dr. Salvador Solís - DGSA, SARH, Mexico

     -    "Strategies for the Control and Eradication of Bovine
Tuberculosis."
Dr. Alfonso Ruíz - PAHO/WHO 

     -    "Financing, Economics, and Mobilization of Resources
for the Eradicaton of Bovine Tuberculosis."
Dr. Salvador Solí, on behalf of Dr. Gustavo Reta
Petterson, Undersecretary for Livestock, SARH.

     A plenary session was held at the conclusion of each working
group session in which the conclusions reached by the groups were
presented by the group rapporteurs, followed by discussion.  The
principal conclusions of the working groups, according to the
topics of discussion, were as follows:

1.   Definition of Areas on the Basis of their Epidemiological
     Situation

All the groups referred to the difficulty of defining
     the areas because of the diverse situations existing between
     and within the countries and the particular concerns of
     each.

Nevertheless, it was agreed that both free and affected
     areas existed.  The latter areas were affected in different
     degrees, in epidemiological terms, some with programs under
     way and others not.  The basic unit for a free area was the
     free herd, which, of course, had to be considered in the
     definitions.  It was noted that the definitions of herd and
     free areas were already contained in the International
     Zoo-Sanitary Code of the IOE, and that the countries should
     consequently consider adopting these definitions instead of
     making new ones.  It was decided that the suggestions of the
     working groups in this respect would be incorporated into
     the plan of action.

2.   Bases for Epidemiological Surveillance of Bovine
     Tuberculosis

All the groups agreed on the need to institute
     epidemiological surveillance of bovine tuberculosis on the
     basis of the situation observed in the different areas.  For
     this purpose, certain preliminary conditions were required,
     such as geographic delimitation of the areas; survey and
     area registry of herds; a mobilization control system to
     provide information on herd movements within areas and
     countries; and areas of concentration of animals and
     slaughterhouses.  Another element identified as being of
     great importance for implementing surveillance systems was
     the need to train professionals in official and private
     organizations.

Great emphasis was placed on the strategy of exercising
     surveillance based on sanitary inspection of slaughterhouses
     and follow-up of places of origin of cattle for the purposes
     of epidemiological evaluation.  This strategy would oblige
     the countries to seek better coordination between the health
     and agricultural sectors, particularly in cases where
     sanitary inspection of slaughterhouses was conducted by the
     health service.  A recommendation was made to provide
     training programs to improve the inspection.

3.   Strategies for the Control and Eradication of Bovine
     Tuberculosis

The working groups used various approaches in
     discussing this topic, such as analysis of the
     epidemiological situation and the selection of strategies
     based on limitations of a political, economic, social, or
     technical order.  Nevertheless, full agreement was reached
     on the need to identify global strategies based on political
     choice and financing of the programs and specific strategies
     related to the diverse epidemiological situation of bovine
     tuberculosis in free areas, in both affected areas and in
     areas where the situation was unknown, including among the
     former those in the process of eradication or already under
     control.  Strategies and requirements were suggested for
     each of the situations mentioned that would be included in
     the plan of action.

4.   Financing, Economics, and Mobilization of Resources for the
     Eradication of Bovine Tuberculosis

It was agreed that these elements were the most
     important obstacles to implementing and developing programs
     for the eradication of bovine tuberculosis.  Given the
     recent status of the regional plan of action for the
     eradication of bovine tuberculosis, in addition to the fact
     that the countries did not have well defined plans in this
     respect, it was too early to be able to forecast regional
     budgetary needs.  Consequently, the working groups proposed
     forming an experienced working team that would be provided
     with political support and the resources required to make a
     feasibility study and obtain the information needed for
     analyzing the problem, proposing solutions and strategies,
     and conducting cost/benefit studies on possible strategies
     in the context of animal production and productivity,
     marketing, and public health.

Another working group was suggested to determine the
     budgetary needs for personnel, materials, and operation of
     the regional program within the framework established in the
     plan of action and also to identify national and
     international sources of financing. 

The working groups also indicated certain important 
     elements to be taken into consideration in establishing the
     costs of the programs and proposed alternatives for
     operational financing.  These recommendations will be taken
     into account by the working groups suggested above. 

The proposal for a plan of action based on the
     recommendations made by PAHO/WHO (Annex 5) was presented on
     20 November at 5:00 p.m.

The hemispheric plan of action for the eradication of
     bovine tuberculosis was based on the various situations
     existing with regard to the distribution and frequency of
     the disease within and between the countries in the Region
     and the existence of plans or programs under way in each.

The plan was formulated on the basis of the sum total
     of the national plans for control and/or eradication that
     all the countries were expected to have formulated or
     ratified before the end of the first year of the project,
     whose first phase will be of 10 year's duration.

At the end of this period, all countries with a
     prevalence lower than 0.1% will be considered to have
     eradicated the disease; those with prevalences of between
     0.1% and 1% will have reduced it in frequency and
     circumscribed it within an area in such a manner that in a
     second phase they will also be capable of eradicating bovine
     tuberculosis.

Countries with prevalences of more than 1% or those in
     which sufficient knowledge is not available regarding the
     extent of the disease will have formulated national programs
     and have carried out actions to ensure that there are
     disease-free areas within their territories. 

Lastly, free countries and areas will have been able to
     maintain this status. 

GENERAL RECOMMENDATIONS

1)   All the countries should update feasibility studies to
     include a cost/benefit analysis.  These studies will provide
     information for the preparation of national plans of action.

2)   All the countries should prepare their own plans of action
     and include in them strategies based on the situation of the
     various existing epidemiological areas.  It is suggested
     that the CEPANZO guides be used for this purpose.  Insofar
     as possible, these plans of action should involve a
     commitment on the part of the livestock producers and
     industry.

3)   All the countries should make a critical evaluation of their
     sanitary inspection systems in slaughterhouses to bring them
     into line with effective surveillance of the programs for
     eradication of bovine tuberculosis.  This evaluation should
     take into account the necessary relations between the
     veterinary inspectors and the institutions responsible for
     the eradication programs. 


4)   Standardization should be required of diagnostic methods in
     the Region, particularly as regards the use of tuberculin,
     interpretations, models, laboratory methods, and eradication
     methods.

RECOMMENDATIONS CONCERNING TECHNICAL COOPERATION

1)   The Pan American Health Organization (PAHO/WHO) was
     requested to set up a Committee for the Eradication of
     Bovine Tuberculosis, similar to the Committee for the
     Eradication of Foot-and-Mouth Disease, to advise,
     coordinate, and support the member countries in the
     planning, organization, obtaining of resources, monitoring,
     follow-up, and evaluation of the individual programs of each
     country. 

2)   The needs or requirements of the countries for specific
     technical cooperation during any phase of the eradication
     program should be channeled through PAHO/WHO.

3)   PAHO should encourage the various sectors involved in the
     plan of action for the eradication of bovine tuberculosis to
     participate in the stages of planning, execution, and
     evaluation pursuant to the RIMSA VII resolution of 30 April
     1991.

4)   PAHO should design, submit for consideration by the member
     countries, and implement a hemispheric Epidemiological
     Surveillance System to keep the countries informed with
     regard to the epidemiological situation of bovine
     tuberculosis and the advances and achievements of the
     program for eradication of the disease.

5)   PAHO should provide assistance to the countries in the
     formulation, follow-up, and evaluation of projects
     containing epidemiological bases and economic cost/benefit
     analyses.

6)   PAHO should promote intercountry cooperation in making
     situation and epidemiological assessments and evaluating the
     achievements of the corresponding programs. 

7)   PAHO, as Secretary of the next meeting of the Inter-American
     Group on Cooperation in Animal Health (IGCAH), should inform
     other technical cooperation organizations of the regional
     plan of action as a means of optimizing international
     resources.

     Officiating at the closing session, which took place on 20
November at 5:00 p.m., were:  Chairman, Dr. Douglas Hernández,
Director of Livestock Development of Venezuela; Rapporteur, Dr.
José Naranjo Yáñez, Delegate of Chile; Dr. Primo Arámbulo III,
Coordinator of the Veterinary Public Health Program; Reginaldo de
Luna Villarreal, State Delegate of SARH; and, as representative
of the Government of the State of Coahuila, Jorge Galo Medina
Torres, Secretary of Rural Development.

     During the ceremony, Dr. José Naranjo presented the Final
Report of the meeting, which was approved unanimously by the
participants.  Dr. Primo Arámbulo III, PAHO/WHO, then expressed
his satisfaction with the work carried out in the working groups
and with the recommendations that had been made, which he
believed would make a positive contribution to the proposed plan
of action.  Dr. Arámbulo also expressed his profound gratitude
to the Government of the State of Coahuila and the state
authorities of SARH for their hospitality and their expressions
of friendship.  The Chairman of the meeting, Dr. Douglas
Hernández, said that he was pleased to have participated in such
an important meeting, particularly in view of the agreements
reached, which would doubtless facilitate the work of the
countries in achieving their difficult goal.  On behalf of all
the participants he thanked PAHO/WHO for the initiative and for
the excellent organization of the event.

     Finally, Reginaldo de Luna Villarreal, representing the
Secretary of Agriculture and Water Resources, Carlos Hank
González, expressed his gratitude for Saltillo having been
chosen as the venue for the important meeting and stressed the
need for inter-American collaboration in using resources to
achieve the goals proposed.  In conclusion, Reginaldo de Luna
Villareal again stressed the ties of friendship between Mexico
and the countries of the Americas and formally closed the meeting
at 5:50 p.m. on 20 November 1991. 
THE BENEFITS OF PHYSICAL EXERCISE FOR CARDIOVASCULAR HEALTH

by Elkin Martínez López, MD, MSc, MPH

In human beings, the heart is the first organ to form and the last to die.  As early as eight weeks after
conception, long before a child is ready to come into the world, it is possible to distinguish the first beats of what will
become its heart.  At the other end of the spectrum, life ends when the heart stops beating. 

The muscles of our bodies are extremely responsive to stimulation.  They can be strengthened and developed
with proper exercise or, conversely, they can be allowed to weaken and atrophy through lack of exercise.  The heart
is a muscle and, as such, it is subject to the same physical laws that govern all muscles.

The heart is an extraordinary organ, capable of working tirelessly throughout a lifetime.  But to do so, it must
have an ample supply of oxygen, as well as constant and proper nutrition.   It is essential that we take good care of our
hearts--especially since each of us has only one--if we want them to continue to work efficiently over many years.

Physical exercise, active recreation, and sports are ideal ways to strengthen our hearts and improve circulation.

Unfortunately, in the modern age, with its mind-boggling technological development, we have tended to view
progress as anything designed to make human activity easier and spare us from even minimal physical exertion. 
Remote control, elevators, automatic washing machines, escalators, and modern automobiles are all marvelous modern
inventions that keep us from having to perform even the simplest physical activities in our daily lives.

The price that we are paying for this mass physical inactivity can be seen in the enormous rise in chronic
degenerative diseases, including cardiovascular diseases, which today constitute the leading cause of death and are also
a significant factor in the loss of productive years for many people.

During exercise, the heart beats more rapidly, blood pressure increases, and the blood vessels dilate in all the
active muscles as well as the heart muscle itself.  Oxygen consumption increases in order to meet the body's energy
needs, and the blood flows faster, propelled by each contraction of the heart.  Sugar and fat reserves, which provide
the fuel for physical activity, are mobilized and actively processed in the muscle fibers in order to supply energy.

After exercise, the body returns to a state of rest--but the beneficial effects of stimulation continue.  During
the next few hours, with rest and balanced food intake, the body will replace its reserves and strengthen all the
structures related to body movement and the chemical process of energy production.  It will also form mitochondria,
small energy-producing components inside the cells.

When the stimulation of exercise is repeated on a regular basis, one of the main beneficiaries is the
cardiovascular system.  The heart gets larger and stronger, the blood vessels open up and expand, blood flows more
easily, and blood pressure gradually drops.  The entire system works more smoothly and efficiently.  There are also
positive changes in levels of blood fats and cholesterol which help to prevent or halt the slow and dangerous narrowing
of the blood vessels known as arteriosclerosis.

Recent epidemiological research has confirmed that physical exercise will prevent cardiovascular disease and
prolong our lives.  But, perhaps even more important, exercise will increase our bodies' circulatory, respiratory, and
metabolic reserves, which in turn will increase our ability to live and cope effectively with the many demands of daily
life.

Ultimately, what is important is not just to add a few extra years to our lives, but to have the strength to lead
a healthy, active life and live every day to the fullest! 















[Note to DPI:  We recommend taking out the footnote, since the term "mitochondria" has been explained in the text.]






PLAN OF ACTION

1992 -  1995




REGIONAL PROGRAM FOR

MATERNAL AND CHILD HEALTH

COMPREHENSIVE HEALTH CARE FOR ADOLESCENTS









PAN AMERICAN HEALTH ORGANIZATION


WORLD HEALTH ORGANIZATION








I.   BACKGROUND



     The health of young people should be viewed as an essential element for
social and economic development in the countries of the world, as was emphasized
by the representatives of all the countries at the Technical Discussions held on this
subject during the Forty-second World Health Assembly in May 1989 in Geneva,
Switzerland.

     To date, for reasons that are not entirely clear, the 10-24 age group
(comprising adolescents and young adults) has been largely left out of processes that
address biopsychosocial health/disease, well-being, and development, and the active
participation of young people in these processes has not been sought.  This group
has been overlooked by even traditional health care services, and it has been given
only minimal consideration in the countries' efforts to implement the primary health
care strategy.

     This is the situation in the countries of Latin America and the Caribbean,
where young people constitute a large segment of the population and where they are
subject to economic, political and social conditions that make it absolutely essential
to give priority attention to this group, in view of the weighty social responsibilities
and commitments that they are called on to fulfill.

     Under the Regional project sponsored by the W.K. Kellogg Foundation, after
two extensions, a very important process was initiated to raise awareness, gather
information, and establish terms of reference relating to the health and well-
being of adolescents and youth, with special emphasis on the psychosocial
components.  It is important that interest in this matter continue to be promoted at
the political, institutional, and community levels, taking into account
recommendations and resolutions of the governing bodies of the various
international organizations and experiences and programs at the local, intermediate,
and national levels in the countries.  In this way it will be possible to lay a solid
foundation for national, subregional, and Regional initiatives.  This is the basic
purpose underlying the present proposal. 

     The plan of work approved by the Kellogg Foundation during the last
extension period is essentially aimed at strengthening the lines initiated in previous
stages in the area of adolescent health, which in turn will give continuity to the
process that the present proposed plan of work is intended to consolidate.


II. DIAGNOSIS OF THE SITUATION OF ADOLESCENTS IN THE REGION

     In Latin America and the Caribbean, young people (persons aged 10-24)
comprise around 25% of the total population.  It is estimated that by the year 2000
there will be some 230 million adolescents and young adults living in the Region.  In
recent decades there has been an increasing concentration of young people in urban
areas.  The phenomenon has been more marked for this age group than for the
population as a whole.  Currently more than 65% of all young people reside in
urban areas and estimates indicate that by the year 2000 the figure will be
approaching 80%.

     Urban growth in the Region has occurred chiefly in marginal sectors under
the precarious economic conditions that are found in all the cities of Latin America
and the Caribbean.  Moreover, the ranks of those migrating to the cities have been
swelled by persons fleeing from brutal political and social conflicts, such as the ones
that have occurred in Central America and in some of the South American
countries.

     In the late 1970s, the Economic Commission for Latin America estimated that
40% of the Latin American population was living in poverty and 19% were indigent. 
The problem has grown steadily worse, owing in large part to service of the
countries' external debt, which between 1983 and 1989 amounted to $US 184
billion.  For adolescents who live and grow up in urban fringe areas, the situation is
even more serious, since such places present high risks for the development of
disease and negative behavior patterns.

     The use of free time, for example, in these marginal areas is limited by the
lack of appropriate places to engage in healthy recreation, such as sports and
cultural and artistic activities.  For example, there are many more bars and other
attractions for vice than green areas or sports facilities.  In these areas there tends to
be a rapid proliferation of juvenile gangs, which band together for both positive and
negative reasons. 

     Several studies have shown that in 1980 unemployment among young people
was triple that of the total population.  Underemployment is also high among young
people in the Region, and both unemployment and underemployment are increasing
as a result of the economic crisis.

     In regard to formal education, in most of the Latin American countries only
half of all students complete six years of elementary school, while 30% finish
secondary school.  Only 5% to 7% of them go on to the university level. 
Proportionally more males than females are enrolled in schools.

     Although some laws and policies have contributed to the improved
development of young people, there have rarely been consistent policies designed to
address the specific needs of this group.

     The effectiveness of health, education, employment, and recreation services
depends largely on national priorities as expressed in a country's laws and policies. 
In all the countries there are laws that apply to young people, such as those that
establish the legal age for voting, marriage, driving a motor vehicle, drinking
alcohol, or military service.  However, these laws do very little in terms of meeting
their needs and, on the contrary, often become a source of conflict between young
people and the authorities.

     A clear example in most of the countries is the absence of laws that treat
adolescent health and development in a comprehensive and balanced way. 

     This is a result of the fact that adolescents, in comparison with other age
groups, are generally considered to be healthy, and only recently has there been an
increase in attention to the psychosocial problems that affect a large segment of this
population.

     Adolescents as a group are creative and have abundant energy and idealism. 
They are concerned about the quality of their lives and are ready to use their
abilities to full advantage if they are given the proper opportunity and respect.

     In view of the foregoing, the countries need to create and strengthen
preventive programs that will promote participation by young people in health and
development.  However, it should be pointed out that total coverage would require
the health sector to program services for an additional 270 million people, which is
highly unfeasible given the existing resources and service models.

     Present models rarely take into account the needs of adolescents.  Health
services for adolescents must have specific characteristics in order to meet the
specific needs of this group.  These features include: comprehensive care, a
multidisciplinary preventive approach, short waiting periods, confidentiality, etc. 
Naturally, it is also essential that service providers demonstrate a positive attitude
toward the different needs of adolescents, which are often more psychosocial than
biological. 

     It is recognized that the health of young people is influenced by the
circumstances in which they grow up and will influence in turn the quality of their
life in adulthood and the health of their children in the future. 

     In all the subregions of the Americas, accidents are the leading cause of death
for both males and females.  The second leading cause of death is often homicides
or suicides in males (although there is known to be a problem of underreporting in
this area), while in females it is usually heart disease or complications of pregnancy,
delivery, and the puerperium.

     The causes of morbidity among adolescents fall into the following categories: 
accidents (traffic and violence), diseases associated with the reproductive process,
sexual behavior, and psychosocial disorders.  This last category includes the use and
abuse of drugs, alcohol, and tobacco; certain eating disorders such as anorexia and
bulimia; and antisocial behaviors.

     Despite the lack of policies on adolescent health, in recent years there has
been some progress in the development of health services for adolescents, but this
has occurred chiefly at the secondary and tertiary levels of care, through isolated
efforts on the part of individuals or groups.  Such groups have endeavored to use an
interdisciplinary approach, and they offer great potential for referral and education,
but coverage has been fairly limited since adolescents have only sought care in the
event of illness.

     Although there are institutions with vertical programs that address a single
aspect of health, such as drug use or teenage pregnancy, not all of them employ a
comprehensive approach, and most of them lack experience in other aspects.

     The first level of care, which is so important for prevention and health
promotion, has been insufficient in terms of the structure and operating capacity of
the services to meet the needs of healthy adolescents.

     In addition, first level-services are fragmented and lack an integrated
approach that takes into account the family and the community.  They do not
encourage active participation by healthy young people in self-care and in efforts to
achieve health for all.  A further problem is that the health workers in these services
are not trained to recognize and respond to the specific needs of young people, and
at times they may even tend to drive them away, especially when dealing with such
matters as sexuality and contraception.  They are not accustomed to working in
teams, and the services often lack multidisciplinary personnel.  Moreover, the
curricula used in the training of health care workers focus mainly on the biological
aspects of health, overlooking the psychosocial issues that are so important during
adolescence.

     The experiences that have been accumulated over the last few decades
constitute an important resource for the countries and will form the basis of support
systems for the implementation of national initiatives in adolescent health, which the
present Plan of Action is intended to strengthen and utilize as a vehicle for the
gradual development of other initiatives.


III. OBJECTIVES

1.   The project described below constitutes the central axis of international
     cooperation with the countries.

Principal Objective:

To contribute to the development of national and Regional initiatives aimed at
ensuring comprehensive health care for adolescents in the countries of the Region.

     General Objectives:

     1) To develop ways of equipping the health services to provide
        comprehensive health care for adolescents.

     2) To design and carry out a plan for human resources development in
        order to facilitate the teaching and delivery of comprehensive health care
        for adolescents. 

     3) To develop support mechanisms with a view to optimizing the
        participation and performance of the national, subregional, and Regional
        networks of comprehensive health care programs for adolescents and to
        implementing alternative methodologies of participation, especially by
        adolescents, in order to promote and strengthen comprehensive health
        care at the local level.


VI.  PLAN OF WORK

A.   STRATEGIES

     The proposed project itself is a strategic mechanism for strengthening,
accelerating, and ordering the gradual process of adolescent health development in
the Region.  It will be carried out within the following strategic framework.

     1. From a process standpoint:
     
        a) The project will be based on the fundamental principles of the master
strategy of primary health care (PHC).

        b) Emphasis will be on basic primary prevention for the prevention and
control of risk factors and the reduction of morbidity and mortality.

        c) The following integrative approaches will be applied:

-   Risk approach,
-   Community-based planning and promotion of social
participation,
-   Family approach to prevention and restorative intervention,
and
-   Interdisciplinary and intersectoral teamwork.

        d) Emphasis will be placed on participation by youth organizations and
adolescents/young people in the different stages of programming.

        e) A contextual approach will be used to interpret the origin and
relative importance of the determining factors, lifestyles/health
behavior, levels of health, and development of adolescents:

-   The political and economic context (macro)
-   The changing cultural context (intermediate)
-   The local context (micro)

.   Family
.   School
.   Workplace
.   Recreation area
.   Street
.   Other


     2. From the operational standpoint, there will be four main strategies:

        a) Utilization of local, national, and Regional resources, including
scientific associations; technical-scientific institutions; subregional
agreements; groups; leaders in maternal, child, and adolescent
health; and local programs and projects such as the Kellogg or
UNFPA projects to disseminate scientific materials and provide
training and methodological evaluation and demonstration. 
Technical, technological, and logistical resources from both the
Regional (PAHO) and global (WHO) levels will be utilized.

        b) Strengthening and activation of networks of leaders for community-
based projects, programs, and institutions within and between
selected countries.

        c) A subregionally based geographical approach for the selection of
countries for certain activities, taking into account their geographical
proximity and relative similarity in terms of needs, resources, culture,
etc.  This strategy is intended to optimize resources and promote a
possible exchange of cooperation and experience.  Activities at the
subregional level may spill over to the national and local levels
through the formation of multipliers (waterfall effect).


        d) The countries will be given priority based on the following criteria:

-   Political will and commitment at the central and regional levels.

-   Unmet needs.

-   Feasibility of developing an effective and assessable plan of
work.

-   Operating capacity.

-   Ability to maintain ongoing action during and after the project.

-   Existence of leadership or potential for development thereof.

        e) Initially a network of six (6) countries have been selected as focal
points for development actions.  These will be supported by centers
constituting a second network made up of five (5) other countries in
the Region.  The first network of focal countries will include
Argentina, Bolivia, the Dominican Republic, Guatemala, Paraguay,
and Saint Vincent.  The second network will comprise centers in
Barbados, Brazil, Chile, Colombia, and Costa Rica.

As can be seen, the two networks correspond to countries located in
several subregions of Latin America and the Caribbean (see table). 
This is important because development activities such as training,
dissemination of information, observation visits, and other activities
may eventually extend to neighboring countries, provided there are
no deterrents and that funds can be obtained from other sources.

Distribution of Countries Directly Involved

SubregionFocal networkSupport networkEnglish-speaking Caribbean
Barbados
Central America
Spanish-speaking Caribbean
Andean 
Southern ConeSaint Vincent
Guatemala
Dominican Republic
Bolivia
Argentina
ParaguayCosta Rica
Colombia
Chile
Brazil

        In all the countries included above there is special interest at the central,
        regional, and local level in launching activities to provide comprehensive
        health care for adolescents.  There are also resources at the local,
        regional (in the case of Brazil), and even national (in Costa Rica) levels
        with valuable experience that can serve as examples to other areas within
        their own countries, as well as to other countries.  It should also be
        emphasized that interaction is expected within each of the networks and
        between them.  At the least, the following types of activities can be carried
        out:

-   Activities in every focal country with support from the reference
centers.

-   Activities that involve the entire focal network and the network
of support or reference centers (see Figure 1).

        f) The central point of action in the focal countries might be a center
for the care of adolescents that occupies a leadership position in the
national context, preferably a university that has ties with the health
services and communities, or some other prestigious national,
regional, or local entity, such as the adolescent health commission or
committee of a pediatrics society.  In each of the focal countries the
plan of action should lay the foundation for a gradually expanding
network of centers and programs which will eventually become an
important resource for national initiatives or programs that provide
comprehensive health care for adolescents.
Figure 1 

SELECTED COUNTRIES AND NETWORKS 


NETWORK OF REFERENCE CENTERS 

COL
CHI                 COR
BRA                                   BAR






TECH-ADM
COMMITTEE





W.K.K.    PLAN PAHO
OF
WORK


     ARG                                               SAV

BOL                                   PAR

DOR       GUT


NETWORK OF FOCAL COUNTRIES


OTHER COUNTRIES            · LEADING
CENTERS

LEADING
COUNTRIES
As Figure 1 shows, an attempt has been made to represent the various
subregions:  Central America and the Caribbean, the Andean countries, Brazil, and
the Southern Cone.  This approach will facilitate concomitant and successive
expansion of the results within and between countries, as well as the implementation
of activities at the subregional and Regional levels as part of the regular functions of
international cooperation of the Pan American Health Organization.  At the same
time, it is hoped that the efforts made at the level of selected countries will help to
strengthen the impact of the local projects for adolescent health and development
being sponsored by the Kellogg Foundation in Latin America and the Caribbean.


B.   PLAN OF ACTIVITIES

     In order to implement the Plan of Work, the following four components are
considered essential:

     1.  Development of ways to equip the health services to provide
comprehensive health care for adolescents.

     2.  Design and execution of a human resources development plan to
facilitate the teaching and delivery of comprehensive health care for
adolescents.

     3.  Strengthening of the Regional networks of institutions committed to
working with adolescents.

     4.  Support to develop operating capacity for execution of the Project.

     The first three components coincide with the three General Objectives
described above.  The last is aimed at strengthening PAHO's structural and
functional capabilities for the execution of the Project.  It should be emphasized that
the four components cannot be considered separately since they are complementary
parts of a whole.

     Listed below are the activities to be carried out under each of the foregoing
components:

Component 1:

     Development of ways to equip the health services to provide comprehensive
health care for adolescents.
      
Activities:

1.1. Development of instruments for the evaluation of services at the primary,
     secondary, and tertiary levels of care.

1.2. Development of normative guidelines for programming.

1.3. Support for national processes aimed at the standardization of
     comprehensive health care for adolescents.

1.4  Development of a clinical history model for adolescents that includes the
     instrument, the instructions, computerized management of the data, and the
     analysis thereof.

1.5. Development of an instrument for the identification of dysfunctional
     families.


Component 2:

     Design and execution of a human resources development plan to facilitate
the teaching and delivery of comprehensive health care for adolescents.

Activities:

2.1  Training of trainers for teachers and service personnel (seven three-week
     courses).

2.2  Promotion of intersectoral action in the provision of comprehensive health
     care for adolescents in the countries (seven seminars for professionals from
     various fields).

2.3  Development of participatory techniques for working with adolescents.

2.4  Development of a training module on adolescent health care aimed at
     workers at the primary level.


Component 3:

      Strengthening of the two networks of countries involved in the project.

Activities:

3.1  Promotion and dissemination of publications, standards, and programs
     related to comprehensive health care for adolescents.

3.2  Strengthening and support of three information centers at the country level.

3.3  Organization of three traveling seminars for leaders of local and national
     projects.



Component 4:

      The aim of this component is to promote coordination between local projects
in the countries that comprise each network and between the two networks, as well
as coordination between the local projects in every country and at the Regional and
central levels in order to strengthen the impact of initiatives at the local and
intermediate levels so that they will support national adolescent health initiatives.

Activities:

4.1  An initial planning meeting with the focal points in every country.

4.2  Four meetings of the Scientific Technical Advisory Committee.

4.3  Two trips by a PAHO official to provide supervision and support for the
     country networks.

     Other HPM Program activities related to comprehensive health care for
adolescents.



OTHER ACTIVITIES


     In addition to the activities under the project described above, the Regional
Maternal and Child Health Program, through the Adolescent Health Unit and the
Units for Women and Children, will continue to carry out basic technical
cooperation activities with the countries of the Region in already existing areas.

a)   Mobilization of resources both within PAHO and with other agencies,
     particularly UNFPA, UNICEF, WHO, and NGOs (Carnegie Corporation,
     Pew Charitable Trust, IYF, and others).  Mobilization of scientific
     associations in the countries, subregions, and Region as strategic
     instruments or mechanisms for the implementation of new initiatives and for
     the strengthening of programs at the national, subregional, and Regional
     level.

b)   The distribution of scientific and educational material to institutions in the
     countries will also be a priority. 

c)   Direct technical assistance to the countries--especially in the development of
     plans and programs through PAHO/WHO resources and short-term
     consultants--will continue to be provided to the extent possible.  Technical
     resources in the countries will continue to be mobilized to support other
     countries.

d)   Support for health services research, including operational, epidemiological,
     and evaluative aspects, will also be continued. 

e)   The inclusion of topics relating to adolescence will be gradually
     incorporated into courses sponsored by the Program in the areas of maternal
     and child health and management at both the international and national
     levels.



COUNTERPARTS   



      At the international level, technical-financial participation will be sought
from the Kellogg Foundation, UNFPA, AID, the International Youth Federation,
the Carnegie Corporation, and the Pew Charitable Trust, among others.

     The Global Program on Adolescent Health (WHO) will continue to support
activities aimed at methodological development, research, and technical support. 

     There will be continued collaboration with ECLAC as the coordinating body
for activities relating to adolescents and youth carried out in the Region by
UNESCO, ILO, CELAJU, CELADE, and UNICEF.

     At the institutional level (PAHO), the Program will be enhanced by the
contributions of technical personnel responsible for accident prevention, prevention
of substance abuse, and mental health.  Activities will be closely coordinated with
the Programs for Health Promotion and Nutrition.

     Within the Program for Maternal and Child Health, there will be continuous
coordination in the areas of human reproduction, growth, and development. 

     At the country level, the consultants in maternal and child health or in
health services will act as focal points for activities relating to adolescent health
carried out in and through the Country Representations.

     An attempt will be made in conjunction with those responsible for programs
on maternal and child health in the countries to determine whether or not the
different countries have the financial, physical, and human resources needed in
order to carry out the activities and achieve the desired results.


BUDGET AND PERSONNEL TIMETABLE 


A. OPERATING EXPENSES (Excluding salaries)

   1992/1993   1994/95    FUNDS

   $  63,700$  70,000Regular
   $  25,000$  30,000MCH, P3
   $ 100,000$ 125,000UNFPA *
   $ 100,000$ 500,000KELLOGG * *



B. PROFESSIONAL PERSONNEL - TIME

Estimated Cost

Medical Officer, full time,   1 year  $ 112,400
Dr. Carlos V. Serrano
25% additional Medical Officer,4 years$ 119,450
Dr. José A. Solís
5%  Program Administration Officer4 years$  20,900
Mr. King Morgan
15% Field Medical Officer     4 years $  62,650
Dr. Norberto Martinez
10% Program Coordinator       4 years $  47,800
Dr. JoØo Yunes
15% Nurse/Matron,             4 years $  62,500
Ms. Nelly Farfán
50% Voluntary Medical Officer 4 years     --
Dr. Mabel Munitz
20% Medical Officer, Brazil,4 years$  95,560
Dr. Solum Donas


T O T A L

 * To be negotiated
** Carried out through PAHEF
** National personnel cost
***Does not include secretarial support





Proposal for the Development Public Health Theory and Practice in the
Countries of the Americas


      In late 1989 the Pan American Health Organization entered into an
agreement with the American Association of Schools of Public Health (ASPH)
and the Latin American and Caribbean Association of Public Health Education
(ALAESP) to conduct a joint preliminary assessment of the Region's situation
and trends in the area of public health.  This undertaking was ultimately to
form the basis for a broader proposal for cooperation.  The present project
serves as a corollary to lines of action implemented by a group of technical
programs of PAHO and other institutions during the period 1987-1990 which
made it increasingly apparent that there is need to implement a more
comprehensive approach in the field of health.

      This new initiative of the Organization is an outgrowth of increasing
world awareness that public health is currently in a state of crisis.  In the
face of changing circumstances, most societies are no longer able to promote
and protect their own health.  This initiative draws its justification from
the insufficient progress that has been made by the countries toward the goal
of Health for All by the Year 2000 and at the same time from the new demands
being posed by the socioeconomic situation in the Region, which have made the
aforementioned crisis all the more patent and have underscored the need to
look for fresh alternatives.

      Originally the problem was thought to lie in the schools or in the
public health education process--as was the case, for example, during the
1970s.  However, evidence now places the issue in a far more complex
dimension that also includes the pattern of customary practices and a broad
range of health indicators.

      The fact is that a major portion of the Latin American population--
mostly the socioeconomic groups with the lowest standards of living--is at
excessive risk of illness and death.  This is true for all age groups and for
most health problems, particularly those that should already have been
overcome.  In all the countries, including the most highly developed ones,
there continue to be significant geographical differences in terms of
mortality, morbidity, and access to basic health services, which are even
more marked between the different social groups.

      It has been estimated that more than 130 million people lack regular
access to basic health services.  Moreover, with the growth in population
projected for 1990-2000, this figure is expected to increase by another 100
million.  Thus the health services will have to gear up to meet the needs of
230 million more people in addition to those already being covered while at
the same time improving the quality of the medical care currently provided
and giving increased emphasis to health promotion and protection.

      It is now important to raise political and scientific awareness of the
critical problems and deficiencies in public health and to focus on the
motives and practices that have characterized the situation in the Americas
in order to encourage the formulation of guidelines that will shape the
decisions needed in the medium and long term.  In keeping with processescurrently under way at the global level, the project conceives of public
health not just as a field of professional specialization but, more
importantly, as a duty of the state and, above all, as a commitment of
society to its health ideals.

      The objectives are:  on the one hand, to describe and account for the
situation of public health and its major trends in the Americas within the
context of the new challenges posed by the social situation in general and by
health in particular and, on the other hand, to identify ways of revitalizing
or reorienting the conceptual, methodological, and operational practice of
public health in the countries of the Region, especially through the
promotion of sectoral leadership, research, and advanced training in public
health.


Conceptual and Referential Framework

      Public health is regarded as the means, whether organized or not, by
which society translates into action its commitment to seek the attainment of
its health ideals.  It is recognized that the development of society's fund
of knowledge, attitudes, traditions, beliefs, and practices with regard to
health is causally related to changes in the economic, political, and social
context.  At present, this context in the Region of the Americas is
characterized by profound economic crisis, a growing trend toward
democratization, and increasingly active social participation.

      Even though the health situation differs markedly between subregions,
countries, areas within a single country, and population groups, on the whole
it is characterized by a decline in communicable diseases and a rise in
noncommunicable diseases and damages or risks to the environment as a result
of growing industrialization and urbanization, coupled with an aging
population.  In the health services, the perennial problems remain:  the
programs are largely vertical and fail to provide the infrastructure needed
in order to serve the population and the environment on a comprehensive
basis; coverage is low; emphasis is placed on the curative approach; the
quality of care remains poor; and the services have become progressively less
accessible.  The recent trend toward the privatization of health care is
raising a number of questions and will undoubtedly undermine public services
even further.  Public health education has failed to keep pace with the
social, economic, and political changes that are taking place, which
necessitate a shift to new, more complex theories and practice.  And finally,
in most of the countries there is a sizable gap between theory and practice.

      Against this backdrop, a promising sign has been the attempt to
reorient national health systems by developing and strengthening local health
systems--a Regional political commitment that corresponds to an operational
tactic within the primary health care strategy.  Also encouraging is the
trend toward strategies that include people-oriented intervention, active
health promotion, tapping into multisectoral potential and the potential of
popular wisdom, recognition of the role of the family, and espousal of thevalues inherent in such concepts as health, participation, citizenship,
social control, and others.


Principal Characteristics of the Present Line of Action

      The central focus of analysis, promotion, and development efforts under
the project will be public health theory and practice as expressed through
service, education, and research.  The basic approach will move,
scientifically, from the specific to the general and, geographically, from
the national to the Regional level.

      The analysis component will not only view a cross-section of reality
but will go on to take a longitudinal look, both retrospective and
prospective, at the challenges, processes, and most important actors in the
field of health.  One facet of this analysis will involve a study of the
political, scientific, technical, and operational changes that have taken
place, while another will look at the repercussions these transformations
have had on the social processes of service, education, and research.  In
this way it should be possible to examine--or anticipate--the interaction
over time between specific problems or ideals, on the one hand, and, on the
other, specific actions or programs.

      Information will be gathered from a number of sources (individuals,
institutions, studies, publications) at the national, subregional, and
Regional level.  The counterparts for the different components of the present
project may be either national (Ministries of Health, Social Security
institutions, universities, research institutions) or international (for
example, Economic Commission for Latin America, World Bank, Inter-American
Development Bank, Kellogg Foundation, U.S. Centers for Disease Control,
etc.).  The focal points may be persons, groups, or institutions.


Expected Outcomes and Actions

      As already indicated, the description and assessment of the situation
and trends in public health theory and practice that will emerge from the
present proposal are expected to serve as a basis for the promotion and,
hopefully, the generation of a movement aimed at the formulation and adoption
of policy guidelines or directives for social action in this area in the
Region of the Americas.

      The following outcomes and actions are expected in the medium term:

      1.  Initial reflection (individual and collective contributions). 
      Implementation of the present proposal will lead to the consolidation
      of previous PAHO work in this area and also to requests for
      contributions from selected experts.  These contributions, taken as a
      whole, should represent the various views of public health theory and
      practice in the Region.  On this basis, an attempt will be made to puttogether a collective picture.  All the contributions will be widely
      disseminated in the hope of generating extensive discussion on public
      health theory and practice in the Region.

      2.  Fostering of critical awareness (national and subregional
      meetings).  As an essential part of the process, group discussion and
      reflection will be promoted in selected countries or subregions in
      order to encourage the development of specific areas.  The areas
      identified for action will constitute important reference points for
      the channeling of PAHO technical cooperation.

      3.  As a line of research, partial description and analysis of the
      development of public health.  Based on a document or proposed plan
      outlining the corresponding objectives, categories of analysis,
      variables, areas of study, and methods, national or subregional studies
      will be promoted to ascertain the size and sociocultural
      characteristics of the populations as well as the availability of
      critical information.

      4.  Dissemination of conceptual, methodological, and operational
      materials (publications).  These will include reports written by
      experts on experiences to date, institutional accounts, and summaries
      of meetings and studies planned or carried out in the course of the
      project.

      5.  Regional guidelines for the reorientation of public health
      (Region-wide scientific meeting).  Presentations requested from
      institutions, groups, or invited experts will be discussed and analyzed
      in a major scientific conference.  The basic documents, conclusions,
      and recommendations from this meeting will be widely distributed with a
      view to stimulating concrete action at the country level.

      6.  Creation of political momentum (caucus).  A group of leaders in
      education and service from the northern and southern parts of the
      Hemisphere will analyze a document on the public health situation and
      formulate a series of conclusions and recommendations for future
      development.  The recommendations will take the form of a declaration
      or manifesto that will be widely disseminated.

      7.  Theoretical, methodological, and operational development
      (development networks).  An effort will be made to set up development
      nuclei in institutions or consortiums of institutions wherever
      political, technical, and operational conditions are such that they
      will permit selective progress in the review of difficulties
      encountered or progress made toward filling the gaps identified during
      the process.  Formation of an informal network will be encouraged in
      order to facilitate the exchange of theoretical, methodological, and
      instrumental information and to help ensure that the knowledge or
      technologies generated are applied to the specific institutional and
      social reality in each country.


Tentative Timetable

      The proposal is intended to be implemented at three levels:  conceptual
and referential, with emphasis on understanding the problem; methodological,
with emphasis on development; and operational, with emphasis on application
and development.  These levels comprise the various activities either under
way or planned, as described below.

      During the last quarter of 1990, a series of reference documents were
prepared offering different perspectives on the basic values and determinants
of public health theory and practice in the Region.  These documents* were
distributed to selected experts for review, and their comments or reactions
were consolidated and presented at a meeting held in New Orleans, Louisiana,
on 21-24 October 1991.  This event was sponsored by the Latin American and
Caribbean Association for Public Health Education and the American
Association of Schools of Public Health with the support of PAHO and
participation by the authors of the respective documents.

      The participants concluded that public health is currently in a state
of profound crisis and that it is suffering from the following deficiencies:

      - Inability to meet the needs of society.  Fundamentally, the crisis
      lies in the discrepancy between theory and practice--in other words,
      the inability to use the knowledge that is produced in ways that will
      influence the social situation.  But the crisis is more far-reaching
      than this:  there is also a need to rethink theory and practice from
      the ground up.

      - Inadequacy of current explanatory models.  Public health is focused
      on the concept of disease.  To get beyond this point will involve
      redefining its basic concepts, redefining the field of knowledge, and
      rethinking the theory in terms of disciplines that provide explanatory
      models drawn from the social sciences.

      - Limitation of public health practice to patient care, with little
      concern for the prevention of disease.  This reduces the health sector
      to a network of medical and public health services and the management
      of these services.  Public health is not in a position to take
      advantage of the opportunity for reconstruction that civilian society
      is currently offering through organizations that are looking for new
      ways to cope with disease, especially in the face of government
      cutbacks in the provision of basic services.  The rethinking of public
      health practice will involve redefining such basic concepts as society,
      state, sector, and population, as well as mounting actions aimed at
      building widespread consciousness based on social control in response
      to the privatization of health care and advocating a form of government
      that will foster the democratization of power, participation by the
      people, and due regard for social movements.

     The participants also looked closely at trends in public health theory
and practice with a view to suggesting modifications and proposing new
strategies.

      The group discussed the continuity of this initiative, pointing out,
with respect to analysis, the importance of multicenter projects that will
allow greater in-depth study of the determinants of the public health crisis
and, in regard to promotion, the need to influence the grass-roots level and
to expand debate in technical, scientific, and political circles as well as
within the entities or institutions involved.

      The foregoing individual and collective contributions will add a great
deal to subregional and national discussion, which in turn will serve as a
basis for determining the work that needs to be done in the areas of service,
research, and education and for preparing a proposal (development plan) for
the corresponding studies.  These activities will receive technical and
financial support from PAHO.  The meetings and research that are planned for
1992-1993 will require the mobilization of special funds.  It is expected
that in 1992 a workshop for the promotion of research projects will generate
proposals for consideration by the PAHO/WHO Research Grants Program.

      One of the medium-term goals is to hold a Region-wide conference on the
subject, tentatively scheduled for late 1994, which will include progress
reports on the foregoing activities as well as the national and subregional
studies.  The political caucus is expected to be held in 1995.  The financing
of these activities will require considerable external resources in addition
to special PAHO funds.

      Further activities relating to theoretical and practical development,
aimed at achieving the fundamental objective of the project, will be
programmed later on, as theoretical, methodological, and operational gaps are
detected and potential development centers are identified.







FOREWORD


      For the second time in the recent history of the Pan American Health
Organization, the Member Governments have established lines for institutional
action over a four-year period and laid down the axes that should lead to the
transformation of national health systems.

      This collective exercise in strategic planning takes on particular
significance in light of the far-reaching and overwhelming changes that are
taking place in the world, which give a new dimension to the regional
scenarios in which the work of the sector is carried out.

      The two documents in this volume, the first presenting the Strategic
Orientations and Program Priorities for the Pan American Health Organization
during the Quadrennium 1991-1994 and the second setting forth the criteria
for their implementation, were approved by the Organization's Governing
Bodies in September 1990 and in June 1991, respectively.

      Together, these documents provide the doctrinal framework and the
instrumental approaches that the Member Governments have agreed upon as the
fundamental outline for the task of the sector in the present quadrennium.

      In publishing these basic orientations for the quadrennium, the
Organization is giving broad dissemination to the mandate of its Governing
Bodies and hopes to contribute to the efficiency, effectiveness, and progress
of national programs and to the consolidation of health as the fundamental
pillar of social development in the Hemisphere.




Carlyle Guerra de Macedo
Director













REGIONAL SEMINAR ON STRATEGIC PLANNING
IN LOCAL HEALTH SYSTEMS



CONTENTS


OBJECTIVES


CONCEPTUAL ASPECTS OF LOCAL STRATEGIC ADMINISTRATION (LSA)


PRESENTATION OF METHODOLOGIES AND INSTRUMENTS: DRAFT REPORT


REPORTS OF THE GROUPS

Group A: Social Participation and Local Strategic Administration

Group B: Health, Development, and the Intersectoral Approach

Group C: Management and Information Systems

Group D: Programs and the Identification of Health Problems
















REGIONAL SEMINAR ON STRATEGIC PLANNING
IN LOCAL HEALTH SYSTEMS


OBJECTIVES

      The objectives of the meeting were:

      -  To discuss, within the framework of strategic planning, the
conceptual and methodological bases of local strategic
administration as it contributes to the development and
strengthening of instruments to be used in the management of
local health systems.

      -  To exchange information about experience gained in the use of
methods and instruments for the implementation of local health
systems in the Region.

      -  To explore lines of intercountry cooperation, with the
collaboration of the Pan American Health Organization, for the
strengthening of local health systems.

























FINAL REPORT

        Conceptual Aspects of Local Strategic Administration (LSA)



Chairman:   Dr. Hugo Salinas
Rapporteur: Dr. Douglas Soza


        The Regional Seminar on Strategic Planning in Local Health Systems
was held in Santiago, Chile, on 7-11 October 1991.  The meeting was opened
by the acting Minister of Health, Dr. Patricio Silva, and Dr. Gustavo Mora,
PAHO/WHO Representative in Chile, speaking for the director of the Pan
American Organization and in the name of the World Health Organization. 
The inaugural addresses were followed by a roundtable discussion on
strategic planning which provided background for the subsequent debate.  In
the afternoon, the preliminary version of the basic LSA document was
presented, following which the meeting broke into groups to discuss aspects
of LSA.  On the morning of 10 October a plenary session was held in order
to discuss reports on the following topics:

a) Social Participation and Local Strategic Administration (LSA)

b) Health, Development, and the Intersectoral Approach

c) Management and Information Systems

d) Programs and the Identification of Health Problems

        Social participation in health calls for the establishment and
institutionalization of channels of participation, coupled with mechanisms
that will ensure that decisions taken at the local or regional level will
have an impact on political decision-making at the central level.  Also, it
is of the utmost importance to examine the role of health workers as social
actors.  Our Ministries of Health have bureaucratic and excessively
hierarchical structures and operating procedures and are not very open to
accepting and adopting political decisions that are generated at the local
level.  Their structure needs to be recast in a democratic framework.  At
the same time, social movements are gaining momentum and new actors are
emerging, including the nongovernmental organizations (NGOs).  Social
participation and local health systems should be seen as mechanisms that
will lead to the strengthening of health systems.

        This situation, however, should not lead us to the mistaken
position of opting for a civilian society that is is pitted against the
State, since in the current Latin American context the State is probably
the only real mechanism available to protect the poor.  Hence the State has
the obligation to facilitate coordination between agents and institutions
that defend the unprotected, to guarantee equity and access, to promote the
practice of democracy.

        At the theoretical level, the intersectoral approach is recognized
in all areas of the health sector, but everyday practice is at odds with
theory.  The intersectoral approach offers extraordinary potential at the
local level, the context in which it is best facilitated, since the
health-development equation finds its concrete expression in actors who are
known to all and where the relationship between the intersectoral approach
and social participation is not constrained by exacting limitations.  In
any case, it should be made clear that reaffirmation of the concept does
not preclude intersectoral articulation at the other levels but in fact
reinforces the need there as well.  With regard to the characteristics that
are essential for intersectoral articulation at the local level, the
following should be pointed out:

      a) The local political authority should be the axis and the local
conductor of the intersectoral approach.

      b) For this to happen, it is essential that there be a truly
effective process of decentralization.


      c) The fundamental mechanism of intersectoral articulation should be
consensus.

      d) There is need to formulate a policy on mass communication for the
promotion of local health system development.

      e) Decentralization and the intersectoral approach should be
developed as mechanisms to facilitate assigning priorities to
problems and taking decisions that will have an impact.

      Programs, as a rational ordering of knowledge, resources,
activities, and dates, make it possible for local health systems to adhere
to the principles of efficiency, effectiveness, quality, and equity. 
Knowledge expressed in the form of skills and technologies is an important
element in identifying problems.  The democratization of knowledge is an
indispensable requirement.

      The strategy of health promotion, which was emphasized by the XXIII
Pan American Sanitary Conference (1990), strengthens and facilitates the
processes of social participation, intersectoral initiative, and assumption
of responsibility by each and every member of society for the true
development of health as a valuable resource for all.  The local health
system managers should focus on implementing mechanisms that will lead to
concrete action in the area of health promotion.

      In the identification and study of problems, the unit of analysis is
the social group.  Programs should start from the needs of the entire
population and act according to the criterion of equity, thus gaining
legitimacy in the context of participation.

      Knowledge of reality is not enough to enable the health sector to
identify problems and formulate responses; the concept of local health
system implies an intersectoral view of the phenomenon--one that is
comprehensive and quite distinct from the process of planning and
programming.

      Standards and programs will continue to exist and will be developed
at every level.  They should be sufficiently flexible to avoid conflicts
and duplication and at the same time be able to meet the needs.



      Effective and efficient operation of the services, within a process
of local integration that not only responds to the demand for care but also
includes prevention and health promotion, continues to be very important.

      In order to create a setting in which management is based on the
perception of health as a social value, it will be necessary to recast the
sector and redefine its leadership, since health is not now its heritage.

      The complex, pluralistic, and uncertain environment in which LSA
takes place calls for systems, instruments, and personal capacity that will
make it possible to negotiate a consensus among a variety of autonomous
actors and interests.  It is fundamental that the managerial function
inhere in a setting that has the capacity to assume leadership, forge
consensus, and negotiate in areas such as decision-making and the
mobilization of intra and resources intersectoral and that is able to give
direction to the process.

      In order for management to be able to take a strategic approach and
have the necessary autonomy to operate, it is essential to develop
DECENTRALIZATION.  This, in turn, requires:  a political commitment to the
principle, the necessary legal instruments, and instruments provided by the
central level to make it operational and effective.  Decentralization
should be compatible with the regulatory role that corresponds to the
central level, which guarantees coordination with national policies and
makes it possible to maintain a systemic approach throughout the health
sector.

      Strategic administration requires knowledge of the epidemiological
reality, development of local diagnoses that make it possible to measure
the degree to which services are meeting the needs of the population, and
tools that are sufficiently sensitive to identify expectations and needs.

      The legal framework that supports the local health system must be
flexible enough to allow for decision-making and action that will
facilitate strategic administration, especially in the discretional areas
of resource management.

     The managerial approach should be aimed at replacing supervision/
control with a more advisory-type supervision at both the local and the
central level.

      Training, in addition to being a strategy, is also an area which in
itself needs to be transformed so that it is seen as an overall context and
as an ongoing process rather than an end in itself, with special emphasis
on in-service training.

      Analysis of the current status of information systems indicates that
for the most part the systems are producing information that is out of
date, insufficient, unreliable, and non-participatory, because they are
organized vertically and directed from the central level, failing to
reflect the needs of those directly involved in the process.  Average
national indicators conceal local differences and are of little use at the
grass-roots level.

      An information system for local strategic administration should be
generated and analyzed by the protagonists at the local level while at the
same time providing the information needed at the central level.  It should
also provide useful and timely information for local management in terms of
indicators that are fully sensitive to the problems of the particular
community and also serve as an instrument that enables corrective measures
to be adopted.

      The information produced should be expressed into simple terms that
can be easily understood by the community, which should be kept regularly
informed about important aspects of the health situation and about
resources being used via whatever media my be available, starting with
those forms that require simpler, more easily resolvable data in smaller
amounts.

      After the reports were read, the group as a whole proceeded to
discuss them, making the contributions and modifications that are
summarized below.

      It was pointed out that health, independently of how it is
perceived, it is a political fact that must be taken into consideration in
the implementation and development of local health systems.  Consequently,
it is important that political and religious organizations participate as
intermediaries between civilian society and the State, facilitating the
necessary processes of negotiation and consensus.

      Another aspect that was considered in the discussion was financing,
it being pointed out that even when local health systems already have funds
allocated to them locally, it is desirable for the participating
institutions to press for a reorganization of existing resources in their
specific territory and population.

      Several ways of approaching this problem were mentioned:

1.   Financing should not be regarded merely as the acquisition of more
      resources; instead, the concept should be expanded to include the
      best utilization of installed capacity.

2.    Consideration should be given not just to traditional resources but
      also to other types that may help to solve the problems identified.

3.    The allocation of budgetary and financial resources should take into
      account the territory, the population, the basic needs that are not
      being met, the level of poverty, and other considerations.

      Another aspect discussed was programs and the identification of
health problems.  The former, it was pointed out, are mainly being framed
in terms of damages to health and age groups.  With respect to the latter,
the necessary epidemiological and social analysis has yet to be carried
out.  One way of overcoming these deficiencies would be through integration
into the local setting, changing the traditional disease-oriented approach
to a view in which health is seen as the object of its own action.

      Finally, attention was called to the way in which the document
"Local Strategic Administration," presented at the meeting, creates a false
dichotomy between normative and strategic approaches to planning, which the
meeting felt were necessarily complementary.
PRESENTATION OF METHODOLOGIES AND INSTRUMENTS


Chairman Dr. Hugo Salinas
Rapporteur:  Dr. Elva Fleitas de Franco


        The purpose of these working sessions was to present and review
case reports reflecting national experiences in the development and
application of methodologies and instruments used in local administration
and programming.  It was felt that the dissemination and exchange of these
experiences would help to consolidate the development and strengthening of
local health systems.

        A total of 39 reports were presented in the course of the meeting,
reflecting experiences in 18 countries of the Region:


COUNTRYNo. CASES

Argentina                    2
Bolivia     1
Brazil                       1
Chile                       14
Colombia                     3
Costa Rica                   1
Dominican Republic           1
Ecuador     2
El Salvador                  1
Guatemala                    1
Honduras                     1
Mexico      1
Nicaragua                    1
Panama                       1
Paraguay                     1
Peru                         1
Uruguay     1
Venezuela                    1
PAHO                         3

TOTAL                       39

        The presentations were given on the afternoons of Tuesday, 
Wednesday, and Thursday, 8-10 October, in four simultaneous breakout
sessions.  For the group that met in Room A the moderator was Dr. Jorge
Mandl and the rapporteur, Dr. Fernando Sacoto.  Dr. María Emilia M. de León
and Dr. Carlos Matamala had the respective tasks of moderator and rapporter
for Group B, Drs. Carlos Morales and Horacio Pracilio for Group C, and Drs.
Fernando Muñoz and José M. Cárdenas, respectively, for Group D.

        One of the countries presented 14 cases, another country presented
three, three of the countries presented two, and the rest of countries
presented one each.  PAHO presented three cases.

        The reports highlighted aspects relating to the development of
local health systems such as the application of strategic approaches to the
methodological development of local administration and programming;
management information systems; social participation; legal and
administrative instruments for decentralization and municipalization;
curricula and strategies for the training of health teams; methodological
approaches to the execution of specific programs; experiences in the
strengthening of programs on women, health, and development; methods and
instruments for the management of epidemics at the local level (e.g.
cholera); and natural disasters.


I.  Aspects Relating to the Service Infrastructure

        This section covers those presentations that focused on the
strengthening of health systems through application of the local health
system strategy.

A.  Application of Strategic Approaches to Local Administration and
Programming

        With regard to the application of strategic approaches to local
administration and programming, some of the presentations emphasized the
need to make provision for achieving equity, effectiveness, and efficiency
in the delivery of health services to the population.  The reports on the
different experiences brought out the importance of reorienting policies so
that they will encourage the application of strategic approaches.  One of
the reports traced the development of guidelines for the implementation of
a national health plan that called for local programming as its operational
instrument.



        The instruments presented were aimed at developing new primary
care models and recasting health systems to give more emphasis to local
systems, and their basic elements included the application of new
epidemiological approaches, the development of the managerial capacity,
decentralization, and social participation.  Another instrument consisted
of a simulation model to aid the health system administrator and facilitate
the programming of activities for specific time periods.

        One of the presentations reported on the preparation and execution
of an overall strategic plan for health services development which
incorporated political, economic, social, demographic, and health aspects
with a view to upgrading and modernizing the management of these services.

        Another report described the operational organization of a local
health system at the municipal level, in which a management model was
established for the development of comprehensive health care, along with
mechanisms for seeing that health plans are incorporated into comprehensive
plans for municipal development and that local, regional, and national
resources are enlisted.

        Finally, there was a presentation on the theoretical and
instrumental aspects of transferring, incorporating, and utilizing health
technology to streamline the delivery of services.

        The cases presented emphasized the need for instruments to enhance
the effective integration of programs by ensuring that they are articulated
with other sectors.

B.      Management Information Systems

        In the area of management information, the countries presented
cases showing how the application of strategic instruments of this kind had
helped to systematize the information used for decision-making.

        This approach is especially useful at the central level, since it
enables local health systems to employ a more comprehensive approach in
dealing with problem situations, thus ensuring that the population's needs
are being linked to existing socioeconomic conditions and to the given
problem-solving capacity of the services.

        One of the presentations reported on a management information
system that has made it possible to focus efforts more precisely by
providing data that compare living and health conditions, identify risks
and resources available, and follow the performance and impact of
activities through the evaluation of micro-trends in sentinel populations.

        Another report described the developent of a district health
system in an urban area.  In this case, social participation played a
fundamental role in consolidating the system.

        Several of the presentations included proposed evaluation schemes
based on the development of groups of indicators.


C.      Legal and Administrative Instruments for Decentralization and
        Municipalization

        On the subject of legal and administrative instruments for
decentralization and municipalization, experiences were presented on
legislation aimed at facilitating the process and providing the legal
framework for the decentralization processes and the organizational and
functional structuring of municipal agencies.

       In addition, there were specific experiences in the strengthening
of municipal governments in order for them to play a major role in all
actions aimed at achieving comprehensive development of the people's
well-being.  These processes promote social participation in all aspects of
public management and, in addition, encourage the processes of
democratization.  This, in turn, enhances the capacity for negotiation and
consensus between the social actors.

        These initiatives and the efforts being undertaken by the
municipal governments are serving as a framework for the development of
local health systems.


D.      Curricula and Strategies for the Training of Health Teams

        Models were presented for developing, as an integral part of the
health team, a continuing education process based on analysis of the local
context, the identification of health problems, the need for training, the
introduction of unconventional methodologies, and the parallel development
of systems to follow up and monitor training initiatives in support of
health services management.


II.     Local Health System Development and the Solution of Problems

        This section summarizes the presentations that focused on local
development and the application of strategic approaches to the
administration of services for the resolution of specific health problems.

A.      Methodological Approaches to the Execution of Specific Programs

        One of the approaches called for the creation of a network of
establishments for comprehensive mental health services for children,
adolescents and their families, with focus on community action.

B.      Strengthening of Programs on Women, Health, and Development

        A report was given on experience in the organization and execution
of programs for women, health, and development in nongovernmental
organizations, with focus on coordination with other NGOs and state
agencies, coupled with active participation by the population, especially
women, in the program's development.

        In addition, a training methodology was proposed for including, on
an operational basis, key aspects of the program on women, health, and
development.

C.      Management of Epidemics and Disasters

        Finally, the cholera problem in the Region gave rise to
experiences in the development of programs for managing and combating the
epidemic.  These experiences took place at the local level and were
strengthened by active participation of the population and by links with
other sectors involved.

        A report was presented on the creation of a civil protection
system for the management of emergencies and disasters.  Responsibilities
were defined for the different levels of health care and also for the
corresponding services.
GROUP A
SOCIAL PARTICIPATION
AND LOCAL STRATEGIC ADMINISTRATION

Rapporteur:  Dr. Osvaldo Lazo


A)      Concepts and Characteristics of Social Participation

        The group outlined some of the precepts that underlie the notion
of social participation:

1.      Community participation is political by nature:  it involves a
        redistribution of power, expressed through the capacity of social
        actors to generate leadership and concerted management of the
        social dynamic at the local level.

2.      It stresses the involvement of all social actors, without
        exception, in the participatory process.

3.      It is not the same as community participation; while it embraces
        this concept, it goes beyond it.

4.      While social participation is political in nature, it is not so in
        the sense of partisan politics, since the parties involved are
        different in each case.  The two levels of participation should
        interact; they are complementary and do not compete or conflict
        with one another.

5.      It is necessary and important to differentiate the two levels of
        social participation in health:  participation in health services
        management, and participation in health development.  Local health
        systems should focus on promoting this second area of
        participation.

        The emphasis on participation in health development does not
        negate the importance of participation in health services
        management; on the contrary, it is often the case that the
        Ministries of Health, which are the actors in this process, are
        obliged to participate at this first level in order to regain
        their credibility.

        Participation in services management should be regarded as a
        precondition for taking steps to participate in health
        development, which is more complex, involves greater demands, and
        requires broad social endorsement of the participating actors.

6.      Since the social dynamic in our countries is quite complex and
        still not well understood, most of the assumptions and categories
        that are currently used to characterize social participation
        correspond more from the modern world and its rational way of
        thinking than to traditional cultures.  It is necessary explore
        this area in greater depth and to decode and analyze the values
        inherent in the heterogeneity, fragmentation, and conflictiveness
        that typically characterize the Latin American social processes.

7.      Social participation is the central element in the
        health-development relationship.


B)      Social Participation and Its Relationship to the State

1.      Social participation may be thought of as a strategy for social
        democratization--a means of reversing the growing historical
        opposition of the State versus civilian society, which is a
        situation that most of our countries face.

2.      Social participation in health involves the creation and
        institutionalization of channels of participation and mechanisms
        for guaranteeing that decisions adopted at the local or regional
        level will affect political decisions at the central level.

        Our Ministries of Health have bureaucratic and excessively
        hierarchical structures and operating procedures and are not very
        open to accepting and adopting political decisions that are
        generated at the local level.

        The inability to make progress in health through social
        participation, stemming largely from social difficulties and
        shortcomings, has undermined confidence in this process.

3.      The institutionalization--even legalization--of opportunities,
        channels, or mechanisms that seek to guarantee respect for and
        compliance with decisions taken at the local level should not
        undercut the autonomy and independence of the participating social
        actors, since there is the risk that social participation could
        become a means by which the State could gain political control of
        society.

4.      Social participation in local health systems should be regarded as
        a strategy for the strengthening of health systems.  The
        Ministries of Health must be democratized, structurally
        transformed, and their role redefined.

5.      This universally conflictive situation should not lead us to the
        mistaken position of opting for a civilian society that is pitted
        against the State, since in the current Latin American context the
        State is probably the only real mechanism available to protect the
        poor.  In this sense, it has such important obligations as:

        -  Guaranteeing equity and solidarity as basic underlying
principles of life in society.

        -  Facilitating contact and coordination between the various
actors in society, both popularly based and institutional.

        -  Promoting and strengthening the practice of democracy.

6.      In the area of health, the fulfillment of these obligations means
        that the Ministries of Health must recover their regulatory role,
        which has become seriously eroded.

        This role of the State should be expressed through its ability to
        formulate, through common agreement, orientations for the
        development of health and the formulation of its basic policies. 
        It should take charge of the health process, building on
        consensus, while at the same time regulating and controlling it
        with sufficient firmness to ensure that the health system achieves
        equity for all.


C)      Social Participation in the Latin American and International
        Contexts

        An analysis of the constraints and difficulties that frequently
stand in the way of social participation in our countries confirms the
following:

1.      Our countries have a lumbering, outdated heritage of social
        structures tend to be vertical, authoritarian, and basically
        antiparticipatory.

2.      In addition, there has been a prolonged presence of dictatorial or
        populist regimes which, in their need to gain legitimacy, have
        developed charity-oriented policies that have led to passiveness
        and dependency on the part of our peoples.

3.      The Latin American social scene has undergone major changes in
        recent years, including the process of democratization, the debt
        crisis, and, finally, the application of economic liberalization
        programs, all of which have fostered individualism and loss of
        social solidarity.  In some countries there has been a conscious
        effort to impose a "culture of non-participation" which will be
        difficult to reverse.

4.      At the same time, the depth and duration of the crisis in several
        of the countries, and the consequent imposition of harsh
        adjustment policies, has led broad sectors of the population to
        come up with their own creative responses, giving rise to
        so-called "survival strategies" which have taken the form of
        widespread resistance in the people's effort to protect
        themselves.

        These expressions of participation, important as they may be, are
        usually focused on physical survival, consuming much popular
        energy and effort for the purpose.  To rechannel at least some of
        this participation for survival into social participation for
        development is a challenge which in practice poses great
        difficulties.

5.      At the international level, on the other hand, there is a trend
        toward centralizing economic decisions as part of the process of
        economic internationalization.  It is necessary to be aware that
        strengthening at the local level goes counter to this trend,
        especially in the absence of policy orientations and development
        strategies.  As a result, it is necessary to make a political and
        strategic assessment of the real potential available at the local
        level.




D)      Mechanisms for Promoting Participation

        A list of mechanisms were proposed which, in the experience of the
group's participants, would serve to promote social participation.

1.      Mechanisms aimed at the democratization of health institutions

        -  Encourage institutional transparency, since most of the
population, including the users of services provided by these
institutions, are unaware of the services offered and the
processes and mechanisms that dictate how they are used.

        -  Disseminate information about the rights and obligations of
service users (patients' bill of rights), as well as the
mechanisms available for enforcing them.  There have been a
number of experiences with the use of posters and elementary
promotional material which are displayed or distributed in the
health services.

        -  Ensure that the people know about and participate in setting
the health and social goals being proposed by the services, and
that they are kept informed of the results achieved.

        -  Establish evaluation teams in the health institutions with the
participation of workers in the various areas as well as
representatives of the social actors and their health agents.

        -  Gain greater in-depth knowledge of the sociopolitical and
cultural factors that enter into the population's perception of
the health services (the opinion they have of them, what they expect of them, how much legitimacy they should have);
diagnosis of the aspects that are invisible.

        -  Seek common areas of interest and expectations that are shared
by health workers and the population.

2.      Mechanisms aimed at strengthening the popular participatory
        processes.

        -  Support the formulation of popular proposals; provide technical
support for these initiatives and development of the
corresponding managerial capacity.

        -  Promote popular management through technical, logistic, and
financial support mobilized by the social organizations
themeselves for miniprojects in the area of social development.

        -  Schedule grassroots planning events, fairs, floral feasts,
etc., that capture the people's festive spirit and other
elements of the popular culture.

3.      Mechanisms aimed at strengthening areas of social consensus.

        -  Create areas and situations in which consensus can be reached
while at the same time preserving the autonomy of the
participating social actors.  Several experiences were offered
as examples:   local councils, neighborhood committees, local
management committees, etc.

E)      Recommendations

1.      With regard to the document under discussion:

        -  Change the sequence of the chapter on social participation so
that it starts out with the general and conceptual aspects of
participation and then presents the analysis of the social
actors.

        -  The analysis of the social actors is cursory and somewhat
one-sided, with considerable emphasis on the nature of the
participation, which may lead to excessive highlighting of the
feminist movement relative to other social movements.  There is
need for further analysis of the diversity and complexity of
social movements and the emergence of new actors, including the
NGOs.

        -  It is important to regard health workers as social actors while
at the same time also defining their role as specialists.

        -  There is need to review the sense in which some of the
terminology is used, since there are terms, such as
"negotiation" and "consensus" [concertación], which are used
with different meanings in the various chapters of the
document.

2.      With regard to development of local strategic administration

        -  The process should put into practice internally the same
conceptual changes that it proposes.  Mechanisms should be
established at the local, national, and regional level to
ensure consultation and participation of the social actors in
these changes.

        -  The implementation of local health systems and local strategic
administration require qualitatively different human resources,
the formation of which depends not only on training systems but
also, and more importantly, on adopting new approaches and ways
of looking at reality.


GROUP B
HEALTH, DEVELOPMENT, AND THE INTERSECTORAL APPROACH


Rapporteur:  Dr. Guillermo Williams

        The intersectoral concept as it is defined in the document, is
limited.  It should be taken in a broader sense to refer to the general as
well as the local level.

        -  In practice, the prevailing perceptions of health do not take
the intersectoral approach into account.  At the theoretical
level there is no area that fails to emphasize its importance
and point to the need for its implementation, but everyday
practice is at odds with theory.

        -  This discrepancy impacts on the countries' development, because
the prevailing health models are closely tied to development,
as well as to health sector involvement in the formulation and
execution of the structural adjustment policies that our
countries have to deal with--an involvement that so far has
lacked the necessary vitality.

        -  The intersectoral approach offers extraordinary potential at
the local level, the context in which it is best facilitated,
since the health-development equation finds its concrete
expression in actors who are known to all and where the
relationship between the intersectoral approach and social
participation is not constrained by exacting limitations.

        -  In any case, it should be made clear that reaffirmation of the
concept does not preclude intersectoral articulation at other
levels but in fact reinforces the need there as well.

        -  With regard to the characteristics that are essential for
intersectoral articulation at the local level, the following
should be pointed out:

        a) The local political authority should be the axis and conductor
of the intersectoral approach.

        b) For this to happen, it is essential that there be a truly
effective process of decentralization.

        c) The fundamental mechanism of intersectoral articulation should
be consensus.

        d) There is need to formulate a policy on mass communication for
the promotion of local health system development.

        e) To facilitate the intersectoral approach, a mechanism needs to
be established to regulate decentralization.

        f) In order for decision-making based on the intersectoral
approach to have full impact, it is necessary to draw up a list
of problems according to their relative priority.

        g) The intersectoral approach should be reaffirmed as a means of
developing and implementing overall development plans in
addition to plans for the health sector.

        With regard to Topic 3 in the Discussion Guide, the following
should be pointed out:

        a) The shortage of tools available for mass communication

        b) Furthermore, the shortage of health education materials.

        c) The need to devote more effort to human resources development.

        d) In the area of financing, basic instrumental weaknesses.

        Finally, the following points were made with regard to conceptual
considerations:

        a) The document does not make a clear distinction between general
and sector-based definitions, and as a result some of the
concepts may be interpreted in more than one sense.

        b) Health and development are inextricably linked.  Although our
proposal is predicated on the risks inherent in the health
sector, we cannot lose sight of the overall development
picture--and it is at the local level where this perspective is
clearest and where a systemic approach can lead to concrete and
effective solutions.




GROUP C
MANAGEMENT AND INFORMATION SYSTEMS


Rapporteur:  Dr. María Luisa Daigree


        This working group focused on a review of the topics suggested in
the Discussion Guide.

1.      What strategies should be promoted in order to support the new
        profile being proposed for decentralized management?

        Based on the new conditions imposed by local health
        systems--namely decentralization, the intersectoral approach, the
        need for consensus and negotiation between the various social
        actors involved in the process--it is important to develop
        managerial capacity at several different levels.

        One of the more fundamental aspects is the need for the management
        function to be vested in a "Managerial Team" and not in a single
        individual as in traditional administration--in other words, to
        replace the notion of one-man vertical authority with consensual
        leadership toward a given goal based on teamwork and shared
        responsibilities.

        Management should be capable of leading and giving direction to
        the process, of arranging and negotiating in areas such as
        decision-making, and of mobilizing intra- and intersectoral
        resources.

        The concept of leadership as a basic dimension in local strategic
        administration, and not just another aspect thereof, poses new
        challenges for management.  The concept of local health systems
        and the complex and uncertain pluralistic setting in which LSA
        must act calls for systems, tools, and negotiation skills in order
        to bring about a consensus between multiple autonomous actors with
        various interests at stake, as opposed to giving orders to
        subordinates within an single institution.  Among the tools
        required for this purpose, for example, will be an analysis of the
        positions, potential contributions, and roles of the social actors
        involved in the solution of specific problems.

        It has now become necessary to reconsider the so-called
        instantiations of LSA in the sense of recasting leadership and
        management as interactive and complementary facets of the LSA
        process--both to allow for a systematic process of information,
        decision-making, and execution which provides ongoing feedback. 
        It is proposed that these be regarded as instantiations of LSA.

        A revised scheme such as the one proposed, in addition to giving
        greater importance to leadership, would serve to fully incorporate
        the subject of information, which has been somewhat scanted in the
        document.  It should be kept in mind that the information required
        for leadership is different in content and characteristics from
        the information required for management.

        One of the strategies identified for supporting the new profile of
        decentralized management is Training of the Management Team, this
        being understood as an ongoing process that includes formal and
        nontraditional types of personnel development and incorporates the
        exchange of experience in terms of both knowledge and
        experimentation in different ways of organizing local health
        systems, depending on the actual situation.  This would provide
        elements for developing a frame of reference that would be suited
        to the particular needs of each area.  The training should take
        into account other social science disciplines in addition to
        health.

        The development of DECENTRALIZATION is a basic prerequisite in
        order for management to act with a strategic approach and have the
        necessary autonomy for efficient operation.  This requires the
        existence of several elements in combination.  In the first place,
        it is essential to have political will in order to achieve
        effective decentralization backed by the necessary legal
        instruments, including instruments at the central level that will
        ensure that the decentralization is operational and effective.  It
        also requires that local management have the capacity to decide on
        the organization and allocation of human, physical, and financial
        resources based on local needs and realities.

        With regard to the intersectoral dimension of local health
        systems, it is considered essential that all the sectors involved
        in the LSA process advance simultaneously toward decentralization. 
        This will ensure that the local area has adequate decision-making
        authority over the utilization of resources to deal with the
        problems affecting it.

        In order to support and strengthen the decentralization of local
        health systems, it will be necessary to identify the key
        instruments that define the concept in each country--standards,
        regulations, directives, etc.--and then to immediately make known
        and exchange these key instruments.

        Decentralization should be synchronized with the regulatory role
        corresponding to the central level, which provides for coordinated
        liaison with national policies and ensures that the health sector
        maintains a consistent focus.

        The INTERSECTORAL APPROACH is another strategy for promoting
        management capacity in local health systems.  This presupposes the
        existence of coordinated local efforts and resources, whether
        institutional, community-based, or provided by NGOs, in order to
        identify the problems involved in each situation, prioritize them,
        bring about a consensus on the mechanisms for solving them, and
        carrying out the required actions on a coordinated basis.  In this
        regard, special concern was expressed regarding the leadship role
        that would need to be assumed by the health sector in improving
        the quality of life at the local level, and the mechanisms that
        would have to be in place in order to gather sufficient resources
        and avoid competition between the sectors.

        SOCIAL PARTICIPATION is recognized to be a strategy that
        contributes effectively to achievement of objectives and at the
        same time enables the many social actors involved in the LSA
        process to make a commitment to community development.

        The search for EQUITY in services delivery has highlighted the
        characteristics of EFFICIENCY and EFFECTIVENESS that underlie it. 
        Mechanisms and instruments are being defined that will make it
        possible to optimize the use of the available resources.  Given
        the political and economic situation in most of the countries, it
        is unlikely that additional resources will be acquired by
        accretion or as a product of the structural adjustment policies. 
        This means that steps need to be taken to maximize the
        productivity of existing resources by recovering idle capacity,
        which will redound in real increases in the budgets without the
        need for nominal increases.

        In addition, redefinition of the health problem and of the
        strategies for attacking it through combined optimum utilization
        of the decision-making potential of multiple social actors opens
        up a perspective on the resources concept that goes beyond
        traditional budget headings and involves other factors in health
        promotion which do not necessarily require direct spending in
        order to be mobilized.  This poses a new challenge to the
        creativity of those in the LSA leadership role.

2.      Where should efforts be focused in order to bring about the shift
        in traditional health services administration, which is
        acknowledged to be necessary but not sufficient, so that it is in
        alignment with the strategic approach being advocated?

        Strategic administration calls for changes in several areas.

        On the one hand, knowledge should reflect the epidemiological
        reality as closely as possible--in other words, diagnosis should
        be developed at the local level.  This involves instruments that
        will make it possible to measure the degree to which services are
        meeting the needs of the population, and tools that are
        sufficiently sensitive to identify the community's expectations
        and needs.

        Local health systems should make local diagnoses that incorporate
        the risk approach and focus on channeling resources toward actions
        that will have the greatest impact.

        In addition, attention should be given to the development of
        indicators at will serve as management tools and facilitate
        monitoring at the local level--which should be selective,
        pertinent, and timely.

        The information systems that support the leadership process should
        also meet the criteria outlined above.

        The legal framework that supports the local health system must be
        flexible enough to allow for decision-making and action that will
        facilitate strategic administration, especially in the
        discretional areas of resource management.



        The managerial attitude in local strategic administration needs to
        undergo significant change.  It is necessary to replace the
        supervisory/control function with a more advisory-type supervision
        or training at both the local level and the central level.  It is
        suggested that the Ministries of Health assume a supporting role
        in this regard rather than a normative or leadership role.

        In view of the foregoing, training, in addition to being a
        strategy, is also an area which itself needs to be transformed so
        that it is seen as an overall context and not merely as an end in
        itself.  This should be an ongoing process, special importance
        being given to in-service training.

        The financial area also needs to undergo changes, while at the
        same time upholding the obligations imposed by traditional
        administration.  One of the changes proposed is that budgets
        should be prepared in terms of goals, and they should have
        financial systems that make it possible to have a prospective view
        of available resources.

        Traditional administration, which is normative and regulatory,
        should continue to exist in those areas of the process that are
        required in order to maintain supervision over the system.  This
        is necessary but insufficient, because it lacks the element of
        leadership.

        In this way, local strategic administration can be expected to
        emerge as a synthesis and complementation of the two approaches. 
        As a strategy for change, it does not need to replace the old but
        only to supplement it.

3.      The viability of the process of change is ensured through
        administrative restructuring in terms of changes in strategies and
        areas, as has been indicated, with strong emphasis on supervision
        and strategic monitoring of the process.

4.      INFORMATION SYSTEMS IN LOCAL STRATEGIC ADMINISTRATION

        Analysis of the current status of information systems indicates
        that for the most part the systems are producing information that
        is out of date, insufficient, unreliable, and non-participatory,
        because they are organized vertically and directed from the
        central level, failing to reflect the needs of those who are
        directly involved--in other words, the protagonists--in the
        process.  In addition, feedback is rarely provided for the local
        level where the information is produced.

        An information system for local strategic administration should be
        generated and analyzed by the protagonists at the local level
        while at the same time providing the information needed at the
        central level.

        In addition, the system should provide useful and timely
        information for local management in terms of indicators that are
        fully sensitive to the problems of the particular community and
        also serve as an instrument that enables corrective measures to be
        adopted.

        The information system should bring together networks from
        different areas, whether within a single operational unit or from
        different units in the same sector.

        Given the intersectoral thrust of LSA, the managerial levels need
        to have intersectoral information.  In this regard, an effort
        should be made to identify specific areas and look at how they can
        be made operational.

        The information produced should be expressed in simple terms that
        can be easily understood by the community, which should be kept
        regularly informed about important aspects of the health situation
        and about resources being used via whatever media may be
        available.

        Given the limited resources available, the design of an
        information system should be judged in terms of its
        cost-effectiveness.

5.      USEFULNESS OF THE DOCUMENT

        Working Group C has agreed on option (b).  The modifications that
        are felt to be necessary have been indicated through the analysis
        in the present report. 

GROUP D
PROGRAMS AND THE IDENTIFICATION OF HEALTH PROBLEMS


Rapporteur:  Dr. Liliana Guzmán G.


        Programs, as a rational ordering of knowledge, resources,
activities, and dates, make it possible to meet the objectives of local
health systems in terms of the principles of efficiency, effectiveness,
quality, and equity.

        The determination of objectives, the rational organization of
resources, and the setting of targets should be the outcome of a rational
process of assessing how the social group as a whole can reach the proposed
objectives.

        Hence the programs are not in themselves the instrument for
building policy; it is the knowledge they contain which helps give policies
their necessary rationale and becomes a substantial asset in the building
of local health systems.

        Knowledge expressed in the form of skills and technologies is an
important tool for identifying problems, and in this context the
democratization of knowledge is an indispensable requirement.  It needs to
be recognized, moreover, that in the process of identifying and assigning
priorities to problems the transfer of information technologies, as well as
technologies for the analysis of information, are of fundamental
importance.

        The recognition in local health systems of the principles of
territoriality and demographic, political, and administrative "spaces"
corresponding to the respective actors involves a new perception, a fresh
approach, and innovative technology for identifying problems at the local
level and developing the responses.  An important part of this process is
political negotiation, in which health is one of the prime actors.  In this
sense, strategic planning takes on special importance.

        In the identification and study of problems, the unit of analysis
is the social group in which they are produced.  What needs to be changed
is the focus of the programs, because even though an analysis of what is
available should be taken into account, programs should start from the
needs of the entire population; actions should be global, based on criteria
of equity for the group as a whole and not merely targeted toward groups at
risk.

        Accordingly, the problem is a political reality in the
communities, and it is through extensive negotiation that the true problem
emerges, enabling the community to take control of it without its being
altered by other levels of authority and decision.  The programs gain
legitimacy in the context of participation.

        The health sector's knowledge of reality is inadequate for
identifying problems and formulating responses, and consequently a local
health system is much more than a local system of health services.  It is
essential to recognize that it is an intersectoral phenomenon, which
entails a comprehensive and a quite different view of the planning and
programming process.

        It is important to recognize the need for the political
construction of contexts that allow for demands and negotiation both within
local health systems and between the local and other levels.

        The local level should have the capacity to manage resources in
order to carry out what has been planned.  This means that there must be
flexibility with regard to resources at higher levels and also within the
programs themselves so that they can be optimized as a whole at the local
level.

        Room should be allowed for participation within the institutions,
which will serve to orient new approaches, concepts, and activities
undertaken by the personnel.

        Standards and programs will continue to exist and will be drafted
and developed at all levels as appropriate, but there should also be
sufficient flexibility to avoid conflicts and duplication and enable
strategic planning to lead to true responses to needs.

        People should be helped to underestand that it is no longer a
question of hospital "coverage" but rather of people living in a given
political or administrative area.

        The sectoral "technicians" should not be seen as taking charge of
the problem because of their knowledge or expertise but rather because of
their ability to negotiate, taking into account needs that are felt and
articulated at the local level, and harmonize these needs with a holistic
national programming process.  The specialist knows how to do this, and he
or she should intervene at the proper time.

        It should be a democratic, pluralistic, and participatory process
that leads to the development of solutions and to the execution,
administration, and evaluation of programs through true management and
social monitoring that takes the fundamental postulates and principles into
account within the framework of equity, efficiency, and effectiveness.

        Still, the foregoing notwithstanding, the effective and efficient
operation of the health services system continues to be very important. 
Thus, the local integration of programs, projects, non-program operations,
and services is also an important reality, since the people continue to
require services while at the same time they are beginning to appreciate
the importance of prevention and health promotion.

       In this picture it becomes vitally important to strengthen and
make changes at the central level, not only in order to ensure national
unity with regard to the overriding objectives but also to consolidate and
produce new knowledge, to administer it, and to transfer it, thus
preventing regional imbalances that will undermine equity.

        The building of a leadership system based on the broad view of
health as a desirable and attainable social value may demand of the
"classical" health sector a fundamental shift that will diminish its
leadership role, for HEALTH IS NOT THE PROPERTY OF THE SECTOR.

        Within the planning process there is stage of social
identification which generates a set of responses that lead to a
comprehensive solution.

        There is also an adaptation phase in which the level local is
integrated with the other levels, obliging the latter in turn to redefine
their roles.

        The programs should now offer the local areas the possibility of
giving comprehensive responses, bearing in mind, however, that the
responses also depend on policies established in different places,
resulting in different political responses.

        The instruments that are developed should be consistent with the
purposes, methods, and objectives, and they should have sufficient
flexibility to allow for adaptation and construction at all local or
regional levels.

        It is necessary to have an information system that is useful,
simple, acceptable, and valid.

        The very concept of the local health system rules out the single
instrument as a means of solving problems; instrumental logic is more
important than the instrument itself.

        Instruments are not politically neutral and cannot be taken only
for their technical value, inasmuch as the management of these instruments
is necessarily intersectoral.

        Hence the existing instruments should be validated, and their
results, in view of the logic of the current situation, should be widely
disseminated and analyzed so that they can be adapted to the needs of the
current historical moment in our countries' lives.




WOMAN, WORK, AND OCCUPATIONAL HEALTH


      A new attitude toward workers' health is emerging, prompted by
awareness of its relationship to economic progress and the social impact to
be gained from the prevention of occupational accidents, occupational
diseases, and other work-related pathology.

      Analysis of the situation, taking into account the growing size of
the working population, the constant emergence of new techniques in the
workplace that entail new risks, and the scarcity of resources available
for promoting and maintaining the health of the active population, resulted
in approval of mandates aimed at finding solutions with the collaboration
of all the health programs of the Organization.

      The Organization's strategic orientation calling for the integration
of women in health and development provides the foundation for joint action
to improve the health and quality of life of working women.

      The employment structure varies over time and from country to
country, but the fact remains that women continue to be concentrated in
industries and professions for which the qualifications and pay are lower
than they are for men.  However, legislation that focuses on the protection
of women as a weak and unorganized group of workers is no longer necessary
in many of the countries.

      Like men, women are leaving the agricultural sector and moving on to
the industrial and tertiary sectors.

      In both agriculture and industry, as in all workplaces, it is
possible to identify work-related risk factors that are characteristic of
the various tasks being carried out.  Since workplaces, as well as
machinery and tools, are devised by man, it is possible to eliminate or
control the risk factors when the design stage takes into account the
well-being of workers and when the health services in or near the workplace
are concerned primarily with prevention and with the promotion of healthier
labor practices and lifestyles.

      The principal objective of occupational health is to eliminate
and/or control work-related risk factors:  to ensure that working
conditions and techniques in all industries and occupations are acceptable,
and that exposure to noxious agents in the workplace does not exceed
acceptable levels so that working women, as well as working men, can do
their jobs in a hazard-free environment.


FRAMES OF REFERENCE AND MANDATES ON THE SUBJECT OF WORKERS' HEALTH

      Despite the fact that 43% of the working population is without
access to health services, and that only 9% have the benefit of a full
range of coverage that includes prevention and promotion as well as
treatment (as provided for in ILO Convention 161 and Recommendation 171),
many different instruments already exist to guide the structuring and
operation of health care for workers, including the following:

Analysis of the Health Situation of Workers

      Document CSP23/4, which was presented and approved in the Pan
American Sanitary Conference, deals with occupational health services for
the working population and specifies that coverage should include:

      -  Both men and women;
      -  All trades and occupations;
      -  Salaried, independent, domestic, temporary, and migrant workers;
      -  Both remunerated and unremunerated work;
      -  Both rural and urban population;
      -  Any form of contractual relationship;
      -  Family-run, small, medium, and large establishments;
      -  Workers of all ages (children, adolescents, adults, and the
elderly);
      -  Sick and disabled workers.

      The document provides the following facts about the sex distribution
of the economically active population in 21 countries of Latin America and
the Caribbean in or around 1985:

      Women corresponded to 30% of the economically active population
(EAP), and a comparison with percentages in previous years shows that there
has been, and continues to be, a steadily progressive increase in the
female work force.

      In view of the concerns to which workers' health care is committed,
it can be said that the potential target population is not just the current
EAP but rather the entire population of working age, which in Latin America
and the Caribbean represents more than 60% of the total population.

      There are large numbers who are underemployed, unemployed, seeking
employment, or disabled, and in these groups, which together amount to more
than 20% of the total population, women predominate.  On the other hand, in
the retired population there is a predominance of men.  This means that the
problem of extending health services coverage to workers, or to the
working-age population, is more pressing, and will require more effort, in
the case of working women.


Workers' Health as a Priority Program Area and Resolution XIV

      The XXIII Pan American Sanitary Conference emphasized to the member
countries and the Pan American Health Organization the urgent need to
develop workers' health and, upon endorsing a series of conceptual
considerations and acknowledging the importance of occupational health,
decided, by its approval of Resolution XIII, that workers' health should be
a priority program area during the quadrennium 1991-1994.

      On 27 September 1990 the XXIII Pan American Sanitary Conference also
approved Resolution XIV on workers' health, in which it endorsed the
program lines and cooperation in occupational health envisaged in the
foregoing document and agreed on a series of operative approaches, which
included:

      -  Calling on the Member Governments to give priority to the
formulation of specific policies and to coordination; to emphasize
the development and implementation of laws and standards,
including measures aimed at reducing risks and preventing injury
and disease; to promote increased coverage through institutional
development, education, and health promotion; to facilitate the
participation of workers and employees; to develop and train the
necessary human resources; to establish information and
epidemiological surveillance systems; and to encourage the
development of legal instruments on working conditions and the
working environment.

      -  Requesting the Director of the Organization to give greater
priority to workers' health; to promote and encourage the
mobilization of resources and increased capacity for cooperation;
to encourage support, in particular, for people employed in the
agricultural sector, small businesses, and the informal sector;
and to assist in the strengthening of institutions concerned with
occupational health.

      -  Designating 1992 the Year of Workers' Health, with a view to
encouraging and promoting the mobilization of resources.


Initiative "1992: Year of Workers' Health"

      The goal of this Initiative, approved by the XXIII Pan American
Sanitary Conference in its Resolution XIV on workers' health, is to raise
awareness of the importance of workers' health without diminishing efforts
that are already under way to develp projects and activities at the
national, subregional, or regional level, and to promote their articulation
and strengthening through a comprehensive program and a broader political
spectrum.  With the high visibility given to the area of workers' health in
1992, it should be possible to obtain a commitment from leaders, promote
the exchange of information between the employers and workers regarding the
problems and causes of work-related accidents and diseases, and foster the
development of a preventive consciousness.  This, in turn, should result in
increased resources for occupational health programs and the plans of
action that have been or are being developed.  It should also to contribute
to widespread recognition of the social and economic importance of such
programs.  Finally, it should help to bring about the needed changes of
attitude so that, even after the campaigns carried out during this
Initiative have come to an end, the activities in progress will continue
and there will be increased attention to the health of workers, with
special emphasis on promotion, maintenance, and prevention activities aimed
at enhancing their health and ability to work.

      The targets of this Initiative are:  for all the countries to
approve a National Plan for the Development of Workers' Health, and for at
least 10 countries to institute the necessary mechanisms and shape the
implementation of their National Plans.


National Plans for the Development of Workers' Health

      The Plan of Action, updated and approved in February 1992, presents
the two targets of Initiative "1992: Year of the Workers' Health" in the
following terms:

      1) By the end of the Initiative, all the countries of the Region
will have approved a National Plan for the Development of Workers' Health.

      The National Plans seek to contribute to the progressive extension
      of workers' health coverage until it becomes a universal right for
      all workers regardless of their particular activities or companies
      in which they perform their functions.  The overall approach of such
      coverage not only encompasses curative treatment, rehabilitation,
      and material compensation when an incapacitating condition is
      diagnosed but also assigns priority to the promotion and maintenance
      of health and to prevention in the workplace.

      2) By the end of the Initiative, at least 10 countries in the Region
will have set up mechanisms for intersectoral articulation, coordination,
and cooperation through multidisciplinary working groups and the
organization of National Committees on Occupational Health, and they will
also have initiated implementation of their National Plans for the
Development of Workers' Health.

      In order to consider that implementation of a National Plan has been
      initiated, it is required that at least the following conditions
      have been:

      a)  The political decision to promote workers' health has been
clearly expressed and confirmed, with due consideration of its
relationship to the well-being of most of the population and as a
basic condition for achieving social and economic development and
reducing poverty;

      b)  Existing legislation has been revised to take the current
situation into account and to guarantee the rights and
obligations that will facilitate the application of a body of
doctrine, knowledge, and techniques that will benefit workers
directly and, by so doing, indirectly increase their capacity for
work and production and thus be of help for business enterprises
and have a positive effect on the socioeconomic equilibrium;

      c)  The structure of a public technical information system is in
place which will provide data on the dramatic social and economic
costs of work-related pathology and the disability it can
produce; the social value of aware and active cooperation on the
part of employers, workers, and the State; the significance of
various work-related risk factors; and the common characteristic
they share in that they are all capable of being eliminated
and/or controlled;

      d)  Training in occupational health for workers, employers, and
decision-makers has been stepped up, together with manpower
training, based on planned numbers and training needs;

      e)  Technical leaders have been identified who are capable of
bringing about a change in attitude and who can broadly motivate
understanding and acceptance of the concepts and their
application; and

      f)  The minimum material and institutional resources necessary for
the development of occupational health have been mobilized with
the participation of the institutions and the social groups
concerned.


Declaration on Workers' Health

      The Declaration on Workers' Health promulgated in Washington, D.C.,
on 26 February 1992 calls attention to the situation and asserts that the
current situation of workers' health in the countries of the Region could
benefit substantially from strengthening and better articulation of the
services structure, from benefits that are geared more directly toward
health promotion and the prevention of accident and diseases, and from the
extension of coverage to those workers who are most exposed, most
vulnerable, and least served--namely, children, women, indigenous groups,
and the handicapped.


WOMAN, WORK, AND OCCUPATIONAL HEALTH

      The rationale for the Integration of Women in Health and Development
contained in the strategic orientations approved by the Organization for
the quadrennium 1991-1994 is based on a change in attitude toward workers'
health.

      The historical convergence of three major milestones--the decision
of the Pan American Sanitary Conference to approve its resolution on
workers' health, the designation of workers' health as a priority program
area for the quadrennium 1991-1994, and the Initiative "1992: Year of
Workers' Health"-- corresponds to a situation without precedent in the
Region.

      This background imposes a great responsibility to promote health,
achieve benefits, and secure effective and appropriate services for working
women, whose incorporation into working society is occurring at a rapid
pace and contributing to development.

INTERNATIONAL INSTRUMENTS

      In addition to the mandates of the World Health Organization and the
Pan American Health Organization regarding primary health care, and in
particular workers' health and women, health, and development, the health
of working women has been the subject of various international agreements,
including a number of conventions and recommendations of the International
Labor Organization (ILO):

      ILO Convention 3 (1919) deals with maternity protection, and
Convention 103 (1952) is a revision thereof.

      ILO Recommendation 12 (1921), on maternity protection in
agriculture, is supplemented by Recommendation 95 (1952) which refers to
all working women.

      Recommendation 123 (1965) refers the women with family
responsibilities and calls for appropriate measures to ensure their job
security.  According to Recommendation 119 (1963), on termination of
employment, in the event that a woman's employment is terminated after
maternity, she should be considered for reemployment.

      Convention 45 (1935) prohibits women to work underground.

      Convention 13 (1921), on white lead poisoning, prohibits the
employment of women in painting.  White lead poisoning is also covered in
Recommendation 4 (1919).

      Recommendation 114 (1960), on radiation protection, stipulates that
all possible measures should be taken to prevent women of reproductive age
from high exposure to radiation.

      Convention 136 (1971), on poisoning from benzene derivatives,
establishes that pregnant women and lactating mothers should not be
employed in work that exposes them to these substances.  These same
principles are set forth in Recommendation 144.

      Recommendation 102 (1956), on food services and facilities for rest,
recreation, and transportation, contains specific standards with respect to
women.

      Recommendation 112 (1959), on occupational health services (revised
in Recommendation 171), covers special medical checkups at the beginning,
during, and at the end of employment in order to monitor the health of
workers, particularly certain groups of workers, including women.

      Convention 127 (1967) and Recommendation 128, both of them on the
subject of maximum weight to be transported manually, does not establish a
maximum weight for women but suggests that it be substantially lower than
the limit allowed for adult male workers.  Moreover, in principle it
prohibits women to carry heavy weights during pregnancy and the 10 weeks
after delivery.

      Convention 161 and Recommendation 171 (1985), on occupational health
services, outlines an ideal framework of services that should be provided
by employers.  Unfortunately, in the Region of the Americas services of
this kind are available to less than 9% of the active population.


LEGISLATIVE INSTRUMENTS AT THE NATIONAL LEVEL

      In the countries, legislation and regulations on the subject of
working women most often refer to maternity protection, but some
legislation also focuses on minor female workers, night work, working
hours, work in mines, heavy labor, and hazardous and insalubrious working
conditions.

      Almost all the countries provide for maternity leave before and
after delivery amounting to a total of at least four months.

      Maternity benefits usually include subsidies during maternity leave
plus medical benefits.  In addition to medical care for the mother and the
newborn, there is often provision for assistance related to breast-feeding.

      Legislation relating to job security includes prohibition against
discharging a woman during the period when she has the right to maternity
leave, and in many countries this protection is extended for a longer
period.

      Breaks and appropriate facilities for breast-feeding are granted for
six, 12, or 15 months after delivery.  In some countries the installation
of day-care centers is compulsory.

      Health protection during pregnancy and after delivery may cover the
entire pregnancy or the final months, and it often includes prohibition
again night work, overtime, heavy labor or hazardous tasks, as well as
transfer to assignments that are lighter and less dangerous.

      Finally, there are provisions prohibiting the employment of women in
tasks or occupations that are considered to be hazardous or insalubrious
for women.


PROPOSAL FOR FUTURE ACTION

      In view of the lack of adequate dissemination and promotion, as well
as the need to know more about problems associated with the health of
working women, especially since knowledge about the current situation with
regard to the health of working women is indispensable for the planning of
programs that will contribute to improvement of their well-being,
elimination of the occupational risks to which they are exposed, and the
creation of appropriate structures for maintaining their health and
improving their quality of life, the Program on Workers' Health hereby
advances a proposal which, with the collaboration of the Program on Women,
Health, and Development and the present Subcommittee, will serve as the
basis for a line of action to address the key issues of concern in this
area.

      The main characteristics of the proposal are outlined below, and we
expect that these headings will be analyzed and developed in greater detail
in the near future.


Terms of Reference Envisaged

      -   Lines of action to which occupational health programs in general
should give priority;

      -   Lines of action to which the occupational health services should
give priority in or around the workplace;

      -   Objectives of a plan or program for workers' health (with
emphasis on the specific situation of working women);

      -   Study and adjustment of health policy instruments related to
working women with a view to preparing a National Plan, to
achieving the integration of women into the economically active
population, and to finding effective solutions;

      -   Use of selective placement, or in other words a methodology which
in the case of working women will take biological characteristics
into account as well as the relationship between production and
reproduction;

      -   Attention to the causes behind the high incidence of fatigue in
working women;

      -   The effects of occupational health education on working women,
their families, and the community;

      -   Data that should be taken into account in the preparation of a
National Plan:  sex distribution of mortality and morbidity; sex
differences in anthropometric measurements and musculoskeletal
development; institutional and human capacity;

      -   Suggestions, objectives, ideas for the mobilization of resources,
branches of activity to be studied, and scenarios to be
considered in the development of a full proposal and a set of
working hypotheses.

Steps to be Carried Out

      Prepare and approve a proposal that will serve as a basis for
consciousness-raising and mobilization of the resources needed in order to
carry out the program.

      Prepare and disseminate a basic document that will stimulate
interest at the level of the countries in the Region, together with a
survey that will facilitate the collection of data of greatest relevance
for the health of working women and to the tailoring of benefits for
working women in the regular and specialized occupational health services.

      Promote meetings of discussion groups to participate in the
collection of data with a view to exchanging experiences, enriching
knowledge, identifying models of action, and putting into practice adequate
mechanisms for the promotion of women's health in the workplace.

      Disseminate the results of studies on the health of working women
and report on advances in research, training, and practice with regard to
the protection of working women.

      The plan of action will include a timetable with mechanisms for
carrying out a network of events and publishing material for discussion and
dissemination.  It will be based on the situation in the Region, and it
will be especially geared to serving the countries of the Hemisphere.




Revision
February 1992
MOD1524I















Note:
Draft Version
  Please do not reproduce or quote without the authorization of
the Pan American Health Organization





   MEASUREMENT OF THE RISK OF BECOMING ILL OR DYING OF MALARIA



1. Introduction


     The present materials are aimed at providing the
methodological bases to support the process of Epidemiological
Stratification of Malaria in the countries of Latin America and the
Caribbean.  Application of the epidemiological method to the
analysis of situations, events, and factors related to the
transmission of malaria and with regard to measures of intervention
and for controlling the disease constitutes a major portion of the
epidemiological content of these materials.

     Among the most important criteria in epidemiological research
related to the transmission of malaria presented here are: 
(a) absolute risk or incidence; (b) relative risk; and 
(c) attributable risk.  These criteria are fundamental, since they
make it possible to quantify the degree of risk incurred by both
individuals and social groups of becoming ill or dying prematurely
of malaria as a result of their living conditions and their
exposure to one or more specific risk factors.

2.     Measurement of the Risk of Becoming Ill and Dying

       2.1 Concept of Risk Factor

       As mentioned in the introduction, in the field of
epidemiological research, measurement of the risk of becoming ill
or dying as the result of a health impairment such as that caused
by malaria requires resort to the epidemiological concept of risk
factor.  Risk factor refers to any characteristic or circumstance
of a person or group that is associated with an increase in the
probability of suffering or developing a particular disease. 

       According to contemporary works on epidemiology and the
definition presented in A Dictionary of Epidemiology, edited by
John Last (1), the term risk factor is used to express the
following: 




      1)   An attribute or exposure that is associated with an
increased probability of a specified outcome, such as
the occurrence of a disease.  Not necessarily a causal
factor;

      2)   An attribute or exposure that increases the probability
of occurrence of a disease or other specified outcome;

      3)   A determinant that can be modified by intervention,
thereby reducing the probability of occurrence of
disease or other specified outcomes.  To avoid
confusion, it may be referred to as a modifiable risk
factor.



       Knowledge about the natural history of a great number of
diseases, advances in epidemiological research on infectious and
noninfectious chronic diseases, and recognition of the multicausal
nature of diseases have led to a recognition of the multiple forces
that intervene in the health-disease process.  These forces are
called risk factors.  It is important to note that one of the most
important characteristics of risk factors is that they are
attributes that are observable or identifiable before the morbid
phenomenon they foreshadow takes place.  Consequently, they allow
for maximum use of strategies based on prevention and on health
promotion. 

       Risk factors may affect individuals, the family, the social
group, the community, or the environment.  The presence or
combination of one or more risk factors in the same individuals or
social groups increases the probability of causing a health
impairment.

       Health impairmentis understood to mean any possible
negative change in the state of health as a result of living
conditions and vulnerability and exposure to determining risk
factors.  The health impairments most studied are disease and
death.  However, injuries, accidents, and disabilities also
constitute major health impairments.


       It is important to point out that in different situations
a characteristic may be identified as both an impairment and a risk
factor.  For example, undernutrition may be recognized as a
specific health impairment and may also be viewed as a risk factor
for other, subsequent health impairments.  A precise definition of
the impairments and risk factors to be investigated is of great
importance in the conduct of epidemiological research.

       Risk factors may be specific for a particular impairment. 
For example, the presence of breeding sites of vector mosquitoes
near dwellings may be a specific risk factor for the development
of malaria.  It may also happen that a single risk factor increases
the probability of producing several different health impairments. 
Examples of this are poverty, illiteracy, and contaminated water,
the presence of which is associated with various illnesses such as
malaria, gastroenteritis, and undernutrition.

       The epidemiological importance of a particular risk factor
depends essentially on three considerations:

       (a) Degree of association and determination of the risk
factor vis-Õ-vis the health impairment being
investigated;
       (b) The frequency of this factor in the community; and
       (c) The possibility of preventing or controlling it. 

       During the 1980s, various countries in Latin America
experienced a steady and marked increase of the incidence of
malaria.  The need was therefore recognized to step up the number
of epidemiological and social studies on the dynamics of malaria
transmission by use of a methodology whereby measurement and
evaluation of the distribution of the various risk factors for
becoming ill or dying of malaria in different social groups can
serve as a basis for the intervention programs for prevention and
control undertaken by the health services.  Hence, it is essential
to give special attention to a socioepidemiological definition of
the risk factors and damages being studied. 

       Risk factors may be classified, inter alia, as:
       (1) biological (for example, certain age groups);
       (2) environmental (for example, lack of adequate systems of
excreta disposal, deficient supply of drinking water);
       (3) economic (for example, low income, unemployment);
       (4) sociocultural (for example, certain ethnic groups, low
levels of education, displaced human groups);
       (5) those related to health care services (for example, 
insufficient coverage, low quality of care); and
       (6) behavioral (for example, smoking and drug addiction).

       Generally speaking, it is considered that the risk factors
causally associated with a given health impairment make it possible
to carry out a variety of health actions, including those concerned
with primary prevention.  Noncausally associated risk factors may
be considered for secondary prevention activities, and they are
particularly useful in identifying groups at high risk for the
particular health impairment under study. 

       In order to be able to distinguish or recognize the
individuals or groups at high risk of becoming ill or dying
prematurely from the health impairment under study, various
epidemiological risk criteria are employed.  These criteria are: 
(a) absolute risk; (b) relative risk; and (c) attributable risk. 
A review and assessment of these criteria are provided in the
section that follows. 

       2.2 Absolute Risk, Relative Risk, and Attributable Risk

       Knowledge about the present characteristics of the
individuals and groups who are experiencing the health impairment
under study is used to undertake a methodological search with the
primary objective of calculating the probability that individuals
with certain characteristics will experience a health impairment
in the future and thus being able to take the necessary preventive
measures.  This search is based on the notion of distribution of
the risk of becoming ill or dying in specified populations.

       The concept of incidence refers to the number of new cases
of a disease that occur during a given period of time in a
specified population.  It is a measure of the risk a given
population has of becoming ill, and it marks the progression from
being healthy to being sick.  Incidence is therefore a synonym of
absolute risk.  This factor of absolute risk, or incidence, is the
basic measurement for calculating relative risk and attributable
risk.

       Relative risk is a measure of the probability of individuals
and groups experiencing an impairment of health as the result of
a specific risk factor compared with those who do not run that
particular risk. 

       Relative risk is a ratio of absolute risks--that is, it is
a ratio in which the numerator expresses the incidence of the group
exposed to a risk factor and the denominator expresses the
incidence of the group not exposed to this factor.  This
measurement indicates how much greater the risk is of becoming ill
among those who have the characteristic or the risk factor compared
with those who do not have it (2).  Thus, for example, if the
relative risk associated with the presence of a risk factor is
3.25, this means that the probability of developing or contracting
the disease is 3.25 times greater among those who have the risk
factor than among those who do not (see Table 1.1).

       An important characteristic of relative risk is that it
measures the STRENGTH OF ASSOCIATION between a risk factor and a
specific health impairment.  This measurement is widely used in
seeking out the causality or determining factor of diseases and
their etiology.

       Relative risk and attributable risk are measures of
association of the excess risk from exposure to or presence of a
specific risk factor.

       Attributable risk measures the excess risk (incidence) that
may be attributed to exposure to a particular factor (for example,
substandard housing, undernutrition, smoking).  It is calculated
as the difference between two rates of incidence:  in other words,
the incidence for the group not exposed to the risk factor is
subtracted from the incidence for the group that was exposed to the
factor.  The excess observed in the rates is the excess risk due
to the factor in question.  Usually, in order to facilitate
interpretation of the attributable risk, this measurement is
calculated as a percentage.  Thus, for example, in the calculation
shown in Table 1.1, it may be assumed that 69.25% is the excess
risk for malaria in the group exposed to dwellings near breeding
sites.  This is known as the attributable risk in the exposed
population.  A concept of great importance in public health is the
concept known as population attributable risk.   This measure takes
into account the prevalence of the risk factor in the entire
population, and its interpretation is in terms of the potential
benefit that can be expected in the community--not only in the
exposed group--of reducing the risk if exposure to the risk factor
is reduced in that population, given that the factor is causal in
nature.

       Population attributable risk is a measure of association
influenced by the prevalence of the factor in the total population. 
Population attributable risk measures the percentage decline in the
number of cases or deaths that could be prevented if the causal
factor were totally eliminated or neutralized. 


       The formulas and calculations for estimating the relative
and attributable risk are shown below.

RR =      IE        
INE

RELATIVE RISK = Incidence in the population exposed to the factor
Incidence in the population not exposed to the
factor

ATTRIBUTABLE RISK =     Incidence in the population exposed 
IN THE POPULATION     - Incidence in the population not exposed
EXPOSED                 ARE = IE - INE

PERCENTAGE OF           Incidence in the population exposed 
ATTRIBUTABLE RISK =   - Incidence in the population not exposed
x 100
IN THE POPULATION       Incidence in the population exposed
EXPOSED                 % ARE =      IE - INE     x 100
IE

PERCENTAGE OF           Incidence in the total population 
ATTRIBUTABLE RISK =   - Incidence in the population not exposed
x 100
IN THE POPULATION       Incidence in the total population
% ARP = Itp - INE  x 100
Ipt


The following is an alternate formula: 

     
     POPULATION ATTRIBUTABLE RISK =   P (RR-1)   x 100
1 + P (RR-1)

where P signifies the proportion of the risk factor in the
population and RR signifies relative risk.


On the basis of the information provided by Table 1.1,
calculations are presented of the risk measures referred to above.



Table 1
        Correlation between Malaria and Proximity to Breeding Sites
of Vector Mosquitoes in Locality X, 1988.

Malaria 

Characteristic                      YES            NO       Total
--------------------------------------------------------------------------
-
Dwellings < 500 m from 
breeding sites                      202           2016       2218
- -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  -
  Dwellings > 500 m from 
breeding sites                       81           2811       2892
- -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  - -  -
 
Total                          283           4827       5110

    Incidence in the exposed population:    202/2218 = 91.07 per 1,000
    Incidence in the unexposed population:  81/2892 = 28.00 per 1,000

      RELATIVE RISK = 91.07 = 3.25
28.00

      ATTRIBUTABLE RISK = 91.07 - 28.00 = 63.07
(in the population exposed)

% ATTRIBUTABLE RISK = 91.07 - 28.00 x 100 = 69.25%
(in the population            91.07
exposed)

POPULATION ATTRIBUTABLE RISK  =     O.434 (3.25-1)   x 100 =
49.4%
1 + 0,434 (3.25-1)
where P = 2218/5110, and RR = 3.25


       Based on the results obtained in the foregoing example, for
this population during the time period studied the risk of becoming
ill with malaria was 3.25 times greater for individuals who lived
less than 500 meters from the breeding sites of vectors than for
those who live at a greater distance from such breeding sites.  For
those exposed (those who live near the breeding sites), as much as
69.25% of their malaria problem could be explained by this risk
factor, and up to 49.4% of the malaria problem in this population
could be resolved if this risk factor is causal and were to be
eliminated.

       It is important to point out that there are other possible
explanations for these results, and the presence of other
concomitant factors could interfere with the influence of a
particular risk factor on the occurrence of malaria.  In order to
correctly determine the results, such concomitant factors should
be recognized and taken into account in the analysis.


REFERENCES

       Last, J.M. (ed.) A Dictionary of Epidemiology.  Second
Edition.  New York, Oxford University. 1988



 
PREFACE



   When cholera broke out in Peru in January 1991 there had been no
epidemics of the diseases in Latin America or the Caribbean for almost a
century.  In a few months the disease spread to other countries and cases
occurred in places as far away from the initial focus as Mexico, Guatemala,
Brazil, Chile, and Argentina.  As of 3 April 1992, the Pan American
Sanitary Bureau had received reports of 493,162 cases, 213,042
hospitalizations, and 4,572 deaths.

   The cholera epidemic has had a strong impact on the economies of some of
the countries.  Although there is still very little information available,
there have been sizable losses for tourism, agriculture, and fishing, and
also in terms of exports.  The social cost is even more difficult to
estimate because as yet no way has been found to assign a specific economic
value to the loss of lives.

   The presence of cholera in Latin America and the Caribbean has called
attention to the consequences and implications of a long-standing
structural and economic crisis, in addition to the severe breakdown of
infrastructure and the deteriored quality of drinking water, basic
sanitation services, and direct health care for individuals.

   After two decades of economic growth that did little to redress poverty,
this trend reversed and the economies of Latin America and the Caribbean
declined considerably in the last decade.  The gap relative to the
industrialized countries of the world has become wider, and vast sectors of
the population have joined the ranks of those living in poverty and misery. 
Per capita gross domestic product and regional consumption fell by 8.0% and
12.8%, respectively, between 1980 and 1990.  According to the Economic
Commission for Latin America and the Caribbean, the Region probably has no
fewer than 189 million people living in poverty and, of these, no fewer
than 89 million are indigent.

   Cholera develops, spreads, becomes epidemic, and finally becomes endemic
when people live in substandard environmental conditions and health
services are not equipped to respond adequately to the needs of the
population at risk.  In Latin America and the Caribbean, 110 million people
are without drinking water, 280 million discharge their wastes into
untreated bodies of water, 230 million are unable to eliminate their refuse
in a sanitarily acceptable manner, and at least 160 million do not have
access to permanent direct health care services.  As budgetary restrictions
become more acute, the quality of the services and of their
outputs--drinking water, for example-- gradually declines, infrastructures
break down for lack of maintenance, and deficiencies in the administrative
management of the available resources become more acute.


   Unless political decisions and commitments are made to reverse these
situations, high rates of morbidity and mortality will continue due to
diarrhea and other water-borne infectious diseases, cholera will become
endemic, and other typical pathologies of poverty will emerge.

   The countries of the Region have made considerable efforts to control
the spread of the disease and to prevent epidemics.  And indeed, despite
the severe constraints imposed by the economic crisis and the resulting
adjustment measures, it has been possible to achieve satisfactory results. 
However, what has been done is not enough.

   In the face of this challenge, the countries of Latin America and the
Caribbean, through the Pan American Health Organization, have proposed a
two-phase strategy.  In the short term, they have mounted an Emergency
Plan, currently being implemented, whose overall objectives are to combat
cholera and reduce the risk of its spread and its social and economic
impact.  At the same time, they have developed a far-reaching Regional Plan
for Investment in Environment and Health which is aimed at recouping the
deteriorated infrastructures of the environment and direct health care,
extending them, and above all, improving their efficiency and
effectiveness.

   This document presents the basic proposal for the Regional Plan for
Investment, which should be understood as a Hemisphere-wide strategy to
promote and facilitate major reforms in the environment and the health
systems.  These reforms are urgently needed and cannot be postponed.




CHAPTER I
HEALTH IN DEVELOPMENT AND INVESTMENT

1. The severe economic crisis that is currently affecting the countries of
Latin America and the Caribbean is not a circumstantial phenomenon.  It is
in fact the outgrowth of a long process of structural deterioration that
has become increasingly evident during the second half of the present
century.  In the context of progressive globalization of the world economy,
the development models that were adopted in the Region were inadequate, and
the countries failed to respond in time by introducing the essential
changes needed in order to adapt to the new international realities.

2. This situation became more acute in the 1970s, although it was masked by
a heavy flow of capital and a consequent growth in external indebtedness,
and in the last 10 years it came to a crisis in the true sense of the word. 
National economies became stagnant, poverty and misery increased, social
expenditures were deeply cut, and underfunded social services deteriorated
and became increasingly inefficient.
The countries were obliged to take drastic economic adjustment measures,
which were not always accompanied by the means for cushioning their
negative social effects.  It should not be forgotten that great
inequalities already existed in Latin America and the Caribbean before the
crisis.

3. Hence the economic and social problems and the concept of development
should be seen from the perspective of a region in which socially and
politically dangerous deficits have been accumulating for some time.  While
it is urgent and essential to emerge from the economic crisis as soon as
possible and to initiate a process of sustained growth, this alone is not
enough.  Economic growth is not development unless the benefits of this
growth are distributed equitably.  The increase in poverty and the
accentuation of inequalities may pose a major threat to continued growth
and, even more, to the legitimacy, stability, and viability of the social
systems and the political structures that are currently being defended and
strengthened throughout the world.

4. In order for economic growth to be stable and sustained, it must be
accompanied by processes that will reduce poverty, inequalities, and social
injustice.  This will require firm political commitments on the part of
governments, coupled with the solid, consistent political support of
national societies as a whole.  The fundamental requirements for stability
and continued economic growth are effective pluralistic, decentralized, and
participatory democracy and respect for the freedoms that make it truly
possible to function.  Thus, proposals are needed that will lead to greater
equity in the distribution of the benefits of growth.

5. In today's world, drinking water, basic sanitation, and health services
have become minimum basic needs.  They are the key components of
well-being, and, inasmuch as they protect human capital, they make a major
contribution to development.  When these needs are met for only certain
social groups, an injustice is perpetrated or consolidated, and it cannot
be ignored or postponed indefinitely.

6. The promotion and maintenance of a society's health depends on a broad
range of economic, social, and political actions.  However, health care is
most directly linked to the protection and control of man's immediate
physical and biological environment and to the provision of direct health
care for the population.  People, either individually or through their
primary social units--the family, the workplace, the grassroots social
organization--have a tremendous potential capacity, not yet completely
discovered, for protecting and controlling their environment and providing
direct health care.

7. Under the countries' conventional approach to sectoralization, i.e.
functional division and distribution of administrative responsibilities,
the services that are responsible for drinking water, sanitation, and
environmental protection and control have come under the umbrella of
various different governmental sectors, such as housing, public works,
interior affairs, natural resources, human environment, or health. 
Normally, rural affairs has come under health, but generally speaking there
has been no effective coordination of intersectoral actions.

The so-called health sector has tended to be limited to medical and
curative actions carried out by a number of isolated institutions.
At present both these systems are going through a very critical period. 
The physical infrastructure has deteriorated through lack of maintenance
and replacement, operating budgets have been cut and purchasing power
curtailed, services are deficient, and the quality of their work has
declined.  As a result, their coverage has become progressively inadequate
and is increasingly concentrated in residential areas in the capital cities
and large urban metropolises at the expense of rural areas, small towns,
and marginal urban areas.  It is therefore urgent to introduce major
reforms into these systems.

8. Any reform process should begin with functional and effective
supplementation of water and sanitation systems and services, protection
and control of the environment, and direct health care, and it should
introduce changes that will make them efficient and effective and at the
same time socially equitable.
The two basic thrusts of these reforms are decentralization and social
participation.

9. Decentralization should be seen as the effective and final transfer of
political power, which includes full decision-making capacity in regard to
the use of economic, human, technological and material resources, together
with full responsibility for the results and consequences of any decisions
that are taken.  This process of transfer must extend beyond the formal
limits of institutions and reach the population itself, because only in
this way is it possible to achieve genuine social participation.
Decentralization is a far-reaching political process, not merely an
isolated administrative measure.  It requires--without this being a
contradiction--a strengthening of the central and intermediate levels in
order to ensure unified national direction and to promote and facilitate
effective decentralization.  In practice, it is a difficult process because
it should not be directed against the cultural tradition of centralism and
authoritarian government in all spheres of social life.  The current crisis
can be viewed as an opportunity to bring about changes which under normal
conditions would appear to be impossible.

10.Social participation is another broad political process which is fully
expressed when genuine and effective decentralization takes place.  The
population should have full capacity to identify and make decisions about
their needs, demands, priorities, and approaches to the solution of
problems, thereby assuming the primary responsibility for health care
without interference.  The natural meeting point of the two processes is
found at the grass-roots level of society and at the most peripheral local
level, toward which the decentralization process is directed and from which
participation originates.  It is at this level where environmental
protection and control and direct health care are integrated and where the
values of universality, solidarity, and equity can be given full
expression.

11.The population should therefore assume the role of principal
protagonist.  The people, in their families, workplaces, and grass-roots
social organizations, cease to be passive subjects without responsibility
and become responsible, active protagonists.  This is reflected in
"self-care," which entails a restructuring at the other level of the
systems and redefinition of the roles of the other social actors.

In order for this to take place, there must be an effective transfer of
information, knowledge, skills, and responsibilities through carefully
designed actions and mechanisms.  Some of the areas in which information
and continuing education should be provided are:  lifestyles and hygiene
habits; selection, care, and utilization of food; quality control,
disinfection, and conservation of water; reduction of non-sanitary
elimination of excreta and solid wastes from households and the workplace;
vector control; follow-up of child growth and development; prevention and
diagnosis of prevalent diseases and intervention with simple and safe
treatment; timely referral to formal care services; and water and
sanitation infrastructure.
The transfer of responsibility means that the minimum basic elements for
diagnosis and treatment must be available, which in the present Regional
Plan for Investment corresponds to the "self-care module."  This is a unit
that can be installed in a church, school, or home which contains
equipment, instruments, materials, drugs, reagents, etc., in very compact
form.

12.The grass-roots social organizations and the local institutions of
civilian society share responsibility with the local government, which
should be decentralized in order to bridge the gap which in many cases
separates it from the population.  Much of the legislation on local
government recognizes this situation and provides for concrete formulas
such as "municipial delegates" or "municipal agencies."
The nongovernmental organizations should play a major role and assume a
large share of the responsibility in this undertaking because they are in
an especially advantageous position to promote creative and different ways
of transforming these ideas into reality.

13.The State should redefine its role in the systems and services for
environmental protection and control and for the delivery of direct health
care.  The environment and health are social resources that society has a
overall responsibility to protect.  There is a general consensus in Latin
America and the Caribbean that the State should be less bureaucratic, more
decentralized, more efficient, and less involved as the direct operator or
provider of services.  Only in this way can it become a strong State that
is capable of guiding, conducting, and facilitating the processes of
change; of formulating national policies; and of promoting decentralized,
participatory, and regulatory systems.  The State should not cease to
provide technical advisory services or participate actively in the
development of human resources, nor should it relinquish its capacity to
regulate the actions of all the social actors, but this should be done
through mechanisms of agreement and consensus.

14.A more preponderant role should be assigned to the private sector.  To
the extent that private participation is encouraged through well-defined
and stable policies that give it the role of financer, owner and/or total
or partial operator of services and/or activities, it will then be possible
for groups with greater purchasing power and those that have social
security coverage to cease being users of public sector services, in the
case of health care, and for services that are well-operated and
well-maintained to achieve greater coverage in the area of the drinking
water supply, sanitation, and environmental protection.  Financial
incentives, tax credits, and other economic and fiscal policy measures
applied within regulatory frameworks that clearly identify rights and
obligations can ensure very positive social behavior on the part of the
private sector.  The proposals for cost recovery contained in the present
Regional Plan for Investment can also contribute to this end.

15.All the reforms are aimed at introducing maximum relevance, efficiency,
and effectiveness into the systems and services through the best possible
use of the limited institutional, economic, physical, human, and
technological resources that our societies are able to assign to health
care in a time of crisis.

16.The implementation of reforms is a political process.  Although the
reforms themselves are based on studies and interpretations of the reality
in which they are to be applied, the decisions regarding their selection,
definition, form and sequence of execution, follow-up, evaluation, etc.,
are basically political.
Hence a reform process entails strategic and political management.  One of
the essential elements in the conduct of a political process is the
continuity of the support that backs up the decisions, both when they are
taken and during their execution, especially with regard to the
consequences and implications they give rise to.  It is then necessary to
achieve a consensus that expresses a commitment by the majority of national
society.  Building this consensus is an important aspect of political
leadership.

17.At the present moment there is an urgent need in Latin America and the
Caribbean to overhaul the deficient service infrastructure and expand it in
accordance with national possibilities and in keeping with the principles
of universality, solidarity, and equity.
If the current deficits in health care coverage are projected on the basis
of the expected increase in population by the year 2004, the unserved
population would be almost equal to that which is theoretically covered at
the present time (Table 1 and Tables 2 and 3 of Chapter III).

18.Investments, when they are considered to be merely projects that are
technically well prepared, can serve to entrench situations that have been
regarded as unsatisfactory and negative, as well as to reinforce obstacles
and resistance to needed change.  It is very different, however, when
investments respond to a process of justified reforms.  In this context, in
addition to whatever technical merits they may have, they become strategic
actions that provide leverage--in the form of transmitters or
multipliers--for the effective achievement of such reforms.



TABLE 1
        POPULATION OF LATIN AMERICA AND THE CARIBBEAN (IN MILLIONS);
TOTAL, URBAN, AND RURAL, 1990-1993, 2000, AND 2004;
AND INCREASES, 1991-2004


YEARS
1990
1993
2000
2004INCREASES
1990-2004
(%)
   TOTAL

   URBAN

   RURAL
444.5

317.8

126.7
470.2

343.6

126.6
534.5

408.2

126.3
569.9

443.9

126.0
28.21

39.68

<0.06>
Sources: World Population Prospects, 1990, Population Studies 120, New
York, 1991.
United Nations; World Demographic Estimates and Projections,
1950-2025.
World Urbanization Prospects, United Nations, 1990.







CHAPTER II
FUNDAMENTAL GUIDELINES FOR PREPARATION OF THE
INVESTMENT PLAN

1. The Regional Plan for Investment is a strategy and a frame of reference. 
In addition to including a series of investment proposals, it sets out the
broad guidelines for reform of the systems and services for the protection
and control of man's immediate biophysical environment and for direct
health care.  Guided by selective criteria, the priority areas for
investment have been spelled out, the criteria of efficiency and
effectiveness have been taken into account, and, in general, certain
fundamental elements have been proposed so that the countries, in
accordance with their realities, their potential, and their limitations,
will be able to draw up their National Investment Plans and, in developing
them, formulate concrete projects.

2. The Plan is also a frame of reference for cooperation organizations and
agencies, whether international or national, multilateral or bilateral,
public or private.  To the extent that they participate in its ultimate
development and enhancement, the Plan will provide orientation both for
technical advisory services and project approval and for the granting,
channeling, or facilitation of the required external financing.

3. It is important to point out that the Regional Plan for Investment is
not a proposal limited to the responsibility of governments or States.  It
should be understood at all times as the expression of a plan for society
as a whole.  Individuals, social organizations, the private sector, the
different powers and levels of the State, and local, regional and national
governments should all be responsible for the development and execution of
this proposal.  Hence the Plan includes components that respond to the need
to create and/or strengthen the broadest political and consensual support
on the part of all the countries of Latin America and the Caribbean.

4. As a feasible approach to the attainment of universalized coverage and
access to services, preference has been given to self-care and to effective
decision-making capacity in the peripheral ambulatory services.  With
regard to environmental protection and control, design and cost criteria
have been established that the countries can support with different levels
of services of equal quality and safety.  Health posts and health centers
would cease to be poorly equipped establishments passively waiting for
indiscriminate demand which in the end is not being adequately served in
either quantitative or qualitative terms.  Priority has been given to the
rehabilitation and re-equipment of existing infrastructure.  At the same
time the countries need to allow for necessary increases in recurring
costs, especially those involved in maintenance and operational efficiency.


5. In order to ensure access to levels of greater complexity, the capacity
of hospitals, as an essential component of the services system, has been
strengthened.  At the same time, however, questions have been raised about
certain standards which are impracticable and which, through indiscriminate
efforts to comply with them, have led to patent inefficiency.  The economic
breakdown of the systems of medical and curative services is due largely to
the existence of small hospitals with deficient installations, inadequate
equipment, and limited operating budgets.  This has led to inefficiencies
at enormous economic cost.  As a result, priority has been given to the
rehabilitation and re-equipment of hospitals upwards of a certain size with
a view to increasing their capacity and level of care to the greatest
degree possible as the last point of referral in a system as a whole which
will be capable of resolving most of the problems through promotional,
preventive, and distributive measures from the lowest levels based on
direct involvement of the population.

6. Both self-care and the role of supervision and training that is added to
the responsibilities of the health posts and health centers help to
strengthen and consolidate social unity at the local level and, by
projection, at the national level.  Through greater effective access to the
systems and services and through decentralized participatory operations at
the peripheral levels, an attempt is made to infuse more equity into the
uses and benefits derived from the resources assigned to health care. 
Equity entails the assignment of priorities in order to meet minimum social
needs.  The Regional Plan for Investment is selective in that it favors
from among the investment areas under consideration those that will
correspond to the need for drinking water, excreta and waste disposal,
control of water pollution, peripheral services, and, especially,
self-care.

7. The content of the Plan reflects not only the urgent need to overhaul
the deteriorated and deficient infrastructure but also the importance of
facilitating the processes of decentralization and participation while at
the same time introducing factors of efficiency and effectiveness.  It
gives serious consideration to elements that had previously been neglected,
forgotten, or regarded as attempts against supposed social principles.  For
example, for a long time it was considered that the provision of free
services was a social paradigm and that any system which attempted to
recover costs was antisocial.  However, experience has shown, on the
contrary, that free services do not necessarily serve the poorest nor those
who for cultural or educational reasons do not use them to the same extent
as the wealthiest and most educated sectors do.  The absence of cost
recovery systems has contributed to progressive deterioration, lack of
maintenance, and failure to replace physical facilities, as well as to
inefficiencies which today do the greatest damage precisely to the poorest
in the population.  As far as financing is concerned, the Regional Plan for
Investment supports the principle that services should be paid for.  At the
same time, of course, it is important to develop systems that have
differential payment structures and provide for partial recovery.  In the
particular case of drinking water and sanitation, the service companies
should operate on the basis of financial self-sufficiency.  The
governments, through transparent policies providing for specifically
targeted subsidies, ensure access to these services by well-defined
population groups whose household economies would not otherwise enable them
to receive minimum levels of service.

8. In the same way, emphasis has been placed on the need for maintenance,
and express consideration has been given to what this should represent as
part of operation costs.  It is important to protect investments and
prevent them from being eroded within a short time, as so often happens. 
The cost of inadequate maintenance, or no maintenance at all, is too high: 
it leads to the breakdown of infrastructure or, at the very least,
inefficiencies in terms of quality and continuity in the production of
services.  In the end, the result is even worse for the groups at greatest
risk and the poorest segments of the population.  The quality of water
delivered for consumption is the most critical example of this situation.

9. High priority has been given to institutional development, the formation
and consolidation of human capital, and, in general, to national capacity
for the management of reform processes, management of the systems, and for
the formulation of investment plans and proposals.  The preparation of the
Regional Plan brought to light the true magnitude of the information
needed--as well as the absence and insufficiency thereof--in order to
determine the real situation of the countries and reduce the margins of
error.  Thus, one of the first elements to be considered in institutional
development and in any pre-investment program is the establishment of
information systems that will provide for smooth and easy registration,
referral, processing, and utilization of the pertinent information.  In
order to save effort, it has been proposed that there be mechanisms that
will allow for regular updating of the information, since otherwise the
process of formulating plans and projects will be more difficult, less
reliable, and antieconomic.

10. The disproportion that exists between the immense need and the possible
resources available makes it necessary to act at all times with a rigorous
sense of selectivity and to define priorities in terms of varying criteria: 
geographical location, type, size, functions, etc.  The population groups
to be benefited should be prioritized according to social criteria, and the
costs of investment and comparative recurring costs should be given special
weight in the setting of priorities.  In the end, priority is given to the
rural population, to those at greatest risk, and to those who are most in
need.  The reforms to be promoted envisage health promotion and protection,
which is possible through the emphasis given to self-care.  This naturally
includes actions to protect and control the environment and to provide
direct health care.  It is also important to provide for a series of prior
investments to ensure that the countries will comply with the Plan.  Thus
pre-investment and institutional development have high priority and should
be attended to first.  Water supply and sewerage services are already
working in this vein.  Priority is also being given to actions aimed at
facilitating the control of certain diseases that are prevalent in Latin
America and the Caribbean.  

Investments in technological development and the application of various
technologies will make it possible to reduce operating costs, provide
continuity, make the services more reliable, and, as a result, attain the
coverage envisaged.  Finally, clear priority has been given to
reorientation, adaptation, and rehabilitation (including re-equipment) of
the existing physical infrastructure.  This will lead to  substantially
improved operating capacity and to greater efficiency and effectiveness of
existing systems and services.  The extension of infrastructure, even
though it means large investment costs and even larger recurring costs, is
complementary in nature and will respond to the priority that has been
assigned to rural populations, those at greatest risk, and those in
greatest need in marginal urban areas and poverty-stricken urban slums, and
it will also help to deal with the expected growth in population during the
period in question.



GOVERNING BODIES

109th Meeting 
Washington, D. C.
June 1992


Provisional Agenda Item 4.4                                                                                                                   CE109/11 (Eng.)
28 April 1992
ORIGINAL:  SPANISH


PLAN OF ACTION FOR THE ELIMINATION OF LEPROSY IN THE AMERICAS



        A frame of reference is presented which includes a review of
the leprosy situation and its trends vis-Õ-vis programs under
way in the Region of the Americas, the use of multi-drug therapy
(MDT) to control it, and the results obtained.  The current
prevalence of leprosy in the Region and the feasibility of
reaching the targets proposed by the Forty-fourth World Health
Assembly (1991) and ratified by the XXXV Meeting of the
Directing Council of the Pan American Health Organization (1991)
are analyzed.  Pursuant to Resolution XIV of the latter meeting,
a Plan of Action for the Elimination of Leprosy of the Americas
is presented at this time.

        The Plan of Action responds to the Organization's collective
mandate in terms of both the responsibility of the member
countries to implement it and the technical cooperation
activities of the Pan American Sanitary Bureau.

        The objectives envisage reduction of the prevalence of leprosy
to such levels that it no longer constitutes a public health
problem--that is, to less than 1 case per 10,000 population. 
The immediate, short-term, and medium-term targets (for 1992,
1994, and 2000, respectively) emphasize intensive case-finding,
epidemiological surveillance, care of disabilities, and
treatment using MDT therapy, depending on epidemiological
conditions in different groups of countries and the feasibility
of carrying out the operations.  The plan defines the indicators
of elimination and the procedure for certifying its achievement.

        The strategies and technical components to be applied by
official institutions and nongovernmental organizations, working
in concert, include:  (a) improvement of the diagnosis of
initial and advanced cases (improved coverage, specificity, and
sensitivity), strengthening of the public health laboratory
network for routine bacteriological diagnosis and referral, and
development of the epidemiological surveillance system; (b)
timely and regular administration of MDT in all suspected and
confirmed cases accordance with the scheme proposed by the WHO
Expert Committee; (c) training of technical and administrative
personnel in the development of decentralized programs that are
buttressed locally and integrated into other programs for health
promotion; (d) elements for direction, programming,
surveillance, evaluation, and certification of the results
obtained; and (e) operations research.
        It is requested that the Executive Committee examine the Plan
of Action with a view to encouraging the Member Governments of
the Organization to support its implementation through pertinent
political decisions at the national and local level and through
allocation of the necessary human resources so that the programs
will operate on a sustained basis with the efficiency,
effectiveness, and equity that the Plan requires.


CE109/11 (Eng.)





CONTENTS




        I.               FRAME OF REFERENCE

        II.              ANALYSIS OF THE LEPROSY SITUATION

        III.             CONTROL OR ELIMINATION OF LEPROSY

        IV.              STRATEGIES AND TECHNICAL COMPONENTS

        V.               TACTICS

        VI.              ORGANIZATION AND ADMINISTRATION

        VII.             ANNEXES

1.                  BASES FOR THE DEVELOPMENT OF PROGRAMS FOR THE
ELIMINATION OF LEPROSY IN THE COUNTRIES OF
THE REGION OF THE AMERICAS

2.                  MAP 1.  DISTRIUTION OF LEPROSY BY PREVALENCE
IN THE COUNTRIES OF THE REGION OF THE
AMERICAS AND STATUS OF ELIMINATION

3.                  REFERENCES








     

CE109/11 (Eng.)


PLAN OF ACTION FOR THE ELIMINATION
OF LEPROSY IN THE AMERICAS


I.         FRAME OF REFERENCE

The XXIII Pan American Sanitary Conference (1990) requested
the Member Governments and PAHO/WHO to study the feasibility of
eliminating leprosy as a public health problem in the Americas. 
The XXXV Meeting of the Directing Council of PAHO (CD35)
concluded that its elimination in the Region is feasible and
instructed the Secretariat to formulate a Plan of Action based on
a mandate given by the Forty-fourth World Health Assembly (1991)
to eliminate leprosy worldwide by the year 2000 through timely
diagnosis and multi-drug therapy (MDT).  Resolution CD35.14 lists
leprosy among the communicable diseases whose elimination is
feasible in the Region.  In October 1991 the conclusions and
recommendations of the Conference for the Control of Leprosy in
the Americas, which included the participation of most of the
Region's countries in which the disease is endemic, identified
technical lines and strategies for its control and elimination
and agreed to include these recommendations in the present Plan
of Action for the Region.

In addition, PAHO considers that, in terms of the Strategic
Orientations and Program Priorities for the Quadrennium 1991-
1994, the elimination of endemic diseases such as leprosy will
enhance the credibility of the health services.  In addition,
there is interest on the part of numerous nongovernmental
organizations (NGOs) in continuing to support activities for the
care of leprosy patients.  These organizations have now decided
to lend their support to basic activities for the elimination of
leprosy, as agreed in the conclusions of the Conference for the
Control of Leprosy in the Americas (Mexico, 1991).  Not only is
this undertaking feasible in the technical sense, it has become
financially feasible because in most instances the Governments'
allocations are being supplemented by contributions from the
private sector.

The Plan of Action responds to the Organization's collective
mandate in terms of both the responsibility of the member
countries to implement it and the technical cooperation
activities of the Pan American Sanitary Bureau.


II.  ANALYSIS OF THE LEPROSY SITUATION

Leprosy continues to be a serious public health problem in
many of the developing countries.  Its potential for producing
disability and the ensuing social stigma make it a greater public
health problem than the figures on its prevalence would indicate.

Approximately 80% of the population in the countries of Latin
America live in areas where the prevalence exceeds 1 case per
10,000 population--that is, they are at risk of contracting the
disease.  The epidemiological problem posed by leprosy in the
Region of the Americas may be regarded as intermediate in
severity by comparison with other regions of the world. 
According to information available for 1991, the Region had
301,704 cases on its registers, or 8% of the world total; the
number of new cases detected during the year came to 30,543, or
5% of the those detected throughout the world; prevalence came to
4.20 per 10,000 population; and the detection rate was 0.42 per
10,000 population.  For an idea of the importance of leprosy on
the Hemisphere, Brazil ranks second among the countries of the
world in absolute number of cases (266,578) and there are four
countries in the Region (Brazil, Colombia, Mexico, and Venezuela)
with more than 10,000 cases on their registers.  In 21 of the 35
countries of the Region leprosy can still be considered a public
health problem, since its prevalence is greater than 1 per 10,000
population.

Endemic leprosy is not uniformly distributed in the Region: 
there are countries such as Chile where the disease is not
endemic at all, while it is hyperendemic in some areas of the
Amazon subregion.  There are also wide variations in endemicity
within a single country, as well as variations in terms of
absolute numbers of cases registered and detected, values of the
respective rates of prevalence and detection, MDT coverage, and
degree of dispersion of the endemic disease.  There is the case
of Brazil, which had 87% of all the registered cases in the
Hemisphere in 1990 and approximately 95% of the new cases
detected (28,000 cases), while in nearby Ecuador the prevalence
is less than one per 10,000 population, and most of the countries
fall between these two extremes.

Of the Caribbean countries and territories--Anguilla, Antigua
and Barbuda, the Bahamas, Barbados, Belize, Bermuda, the Cayman
Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St.
Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines,
Suriname, Trinidad and Tobago, Turks and Caicos Islands, and the
Virgin Islands--seven have not detected any new cases since 1985
and MDT coverage in the subregion is high.  However, leprosy is
still considered a problem in Guyana, Saint Lucia, Suriname, and
Trinidad and Tobago.

In the countries of Central America, Panama, and Uruguay, the
conditions are somewhat similar to those in the Caribbean, with
low levels of prevalence.  In addition, even in those countries
where MDT coverage is inadequate, the conditions for improving it
exist.

Another group of countries is characterized by moderate
endemicity, variable MDT coverage, and/or concentration of the
endemic disease in certain geographical areas.  This is true of
Argentina, Cuba, the Dominican Republic, Mexico, Paraguay, and
Venezuela, where the prevalences are 4.8, 5.4, 1.5, 2.1, 5.8, and
6.0 per 10,000 population, respectively.  In Argentina the
highest rates are found in the northeastern provinces.  In Cuba
the highest rates are in provinces on the eastern part of the
island.  A similar phenomenon is also observed in Mexico, where
87% of the patients are concentrated in 10 states that have 28%
of the national population.  Although Bolivia, Colombia, Haiti,
and Peru might also be included in this group, there are gaps in
the available epidemiological information that make it impossible
to have a clear picture of the current status of the endemic
disease.

The national leprosy control programs in the Region vary in
terms of their organization, development strategies, financing,
cooperation with nongovernmental organizations, arrangements with
related programs, degrees of integration into the general health
services network, and integration into the health system. 
However, they share in common a number of operational problems,
such as the difficulty of "cleaning up" and standardizing
centralized files so that they can be keyed to the working
definition of a leprosy case and the criteria for patient
discharge.  Several of the national programs are vertical, which
underscores the risk that, with integration and competition from
other health problems that are more severe or more urgent,
leprosy control activities could lose priority and fail to
receive the resources they need.

The only effective leprosy control measure that was applied
in the 1980s was multi-drug therapy (MDT).  Its implementation
results in a significant decrease in prevalence, sometimes to
levels compatible with elimination of the disease.

The rationale for the use of MDT lies in the fact that from
the outset the medication acts on a mixed population of
Mycobacterium leprae.  It is estimated that there are 1010 to 1011
viable bacilli present in a case of multibacillary leprosy. 
These bacilli are usually sensitive to rifampicin, dapsone, and
clofazimine, except for three small populations of approximately
104 bacilli each that are resistant to all three of these drugs. 
With the WHO/MDT regimen for multibacillary cases, rifampicin
will quickly kill the great majority of bacilli, including those
resistant to dapsone and clofazimine.  The remaining viable
bacilli, which will be sensitive to the three drugs or resistant
to rifampicin, will then be killed gradually, at a slower rate,
by the bactericidal activity of the dapsone and the clofazimine.

Paucibacillary patients appear to start out with a much lower
population of viable bacilli (106).  The existence of resistant
bacilli is unlikely in such cases except for possible primary
resistance to dapsone.  Although monotherapy with rifampicin
should be sufficient for paucibacillary patients, in the chance
that there might have been an error in diagnosis or
classification, two drugs are recommended.  Thus the combination
of three drugs for multibacillary patients and two drugs for
paucibacillary patients should be sufficient to kill all the live
organisms that the patient may be harboring.

Of course, MDT regimens are more expensive than monotherapy
with dapsone.  However, it should be taken into account that the
treatment is completed in a much shorter time.  For
paucibacillary cases, the cost of dapsone and rifampicin for six
months is estimated at $US3.00, whereas with the multibacillary
cases the cost of the treatment with dapsone, rifampicin, and
clofazimine for two years is $US50.00, and each additional year
costs $US25.00 more.  Although the total expenditure for MDT
includes other components that increase the total cost of
treating a case to $US100.00, 50% of this amount corresponds to
the cost of the drugs and the rest to the cost of services,
including training and treatment.

The logistics of distributing the drugs is a critical factor
in the execution of MDT.  To avoid operational difficulties, some
countries elsewhere in the world have adopted the practice of
using dose-dated packets designed specifically for the program. 
The objective is to safeguard against administration of the wrong
drugs or incorrect dosages, prevent rifampicin from being used
for other purposes, facilitate inventory control, protect the
drugs, and improve treatment compliance on the part of the
patient.

With the implementation of MDT at the global level there has
been a worldwide reduction in prevalence of approximately 31% in
the last five years (from 5.4 million cases in 1985 to 3.7
million in 1990).  Currently, global MDT coverage is 55.7%.

In the Region of the Americas, the expansion of MDT coverage
has been slow, especially in Brazil.  Today coverage in the
Region as a whole reaches barely 23.7% of all known cases. 
However, official data show that thanks to MDT Ecuador has
succeeded in attaining a level of prevalence compatible with the
elimination of leprosy as a public health problem.

Uruguay, Panama, and the countries of Central America and the
English-speaking Caribbean are subregions in which the incidence
of leprosy is decreasing, which means that elimination of the
endemic is feasible in the short term.

The elimination of leprosy as a public health problem at the
Regional level (by reducing prevalence to less than 1 case per
10,000 population) is feasible if there is early case detection
and effective treatment (MDT).  The sustained application of
these measures provides the basis for the elimination of leprosy
as a public health problem in some of the countries in the Region
by the year 2000.  However, attainment of this target will depend
on the capacity of control programs to improve their coverage and
become integrated into the general health services system.


III.  CONTROL OR ELIMINATION OF LEPROSY

Purpose

To eliminate leprosy or attain a level of control such that
it no longer constitutes a public health problem on the basis
of a four-stage process:  immediate, short-term, medium-
term, and certification.

Objectives:

-               To reduce prevalence.

-               To prevent disabilities.

-               To achieve a gradual and sustained reduction in incidence.

Targets:

-               Immediate (1992):  epidemiological surveillance completely
organized for the intensive detection of new cases,
recurrences, and disabilities, and skills maintained.

-               Short-term (1994):  MDT completed for more than 80% of all
cases and more than 80% of the new cases detected without
disabilities.

-               Medium-term (2000):  MDT completed for more than 95% of all
cases and all new cases detected without disabilities.


IV.  STRATEGIES AND TECHNICAL COMPONENTS

Implementation of the primary health care strategy offers
useful alternatives for the improvement of case-finding,
subsequent diagnosis, and timely treatment, and at the same time
it opens up possibilities for increasing the program's coverage
through decentralization and the strengthening of local health
systems.

The strategies and technical components include:

(a)      Improvement in the diagnosis of initial and advanced cases
(improved coverage, specificity, and sensitivity),
strengthening of the public health laboratory network for
routine bacteriological diagnosis and referral, and
development of the epidemiological surveillance system;

(b)      Timely and regular administration of MDT in all suspected and
confirmed cases in accordance with the scheme proposed by the
WHO Expert Committee.

The only effective resource available for achieving the
elimination of leprosy is the administration of MDT to the
largest possible number of patients.  The objective of the
other strategies and components of the Plan is to obtain
complete, regular, efficient coverage with MDT.  Local
health systems will be responsible for the programming and
execution as well as the management and monitoring of the
program.

(c)      Training of technical and administrative personnel in the
development of decentralized programs that are buttressed by
local health systems and integrated into other programs;

(d)      Elements for financing, direction, programming, management,
surveillance, evaluation, and certification of the results
obtained; and

(e)      Operations research.


V.  TACTICS

1.       Expansion of MDT coverage

For this purpose the PAHO/WHO operational definition of a case
will be applied.

2.       Improvement of case-finding and follow-up and adoption of
treatment, to be accomplished through:

(a)      Dissemination of basic knowledge about the signs and symptoms
of leprosy, as well as procedures for reporting suspected
cases, among auxiliary health personnel and in the
communities, with a view to increasing the coverage of case-
finding and reporting, especially in rural areas and locales
that are difficult to reach.

(b)      Adequate promotion among health services personnel and in the
community aimed at encouraging spontaneous consultation,
timely identification of carriers with signs suggestive of
leprosy, timely utilization of diagnostic resources, and
regular compliance with supervised treatment, especially in
urban areas, for all cases on the register.

(c)      Formation of groups and networks of volunteers to support
follow-up of regular treatment for patients living in locales
that are difficult for the health personnel to reach.

(d)      Inclusion of case-finding activities as part of integrated
referral and back-referral procedures in the local health
systems.

3.       Definition of suspected, early, and advanced leprosy

A suspected case of leprosy is one in which the patient
presents only one of the cardinal (or equivalent) signs
mentioned above.

Early leprosy is present whenever two cardinal (or equivalent)
signs are found and reflected in a limited number of lesions,
with no disability.

An advanced case of leprosy is one in which the lesions are
extensive and/or there are disabilities.

4.       Improvement of technical and managerial capacity

The elimination of leprosy as a public health problem and the
maintenance of indications that it has been eliminated call
for the strengthening of capacity at the local level to offer
and administer the corresponding services.  Emphasis should
be placed on the training of managers at the local and/or
regional levels through modular programs, based on a
standardized pedagogical methodology, directed toward the
development of capacity to manage the program at the level of
local health systems.

5.       Strengthening of the network for bacteriological diagnosis

High-quality bacteriological diagnosis of leprosy based on
cutaneous smears is essential for the confirmation and
classification of multibacillary forms.  Also, for purposes
of case-finding, it is equivalent to presence of the cardinal
clinical signs.  In order to improve diagnostic reliability,
bacilloscopic diagnosis will be incorporated into the
laboratory activities of the existing general laboratory
network as well as the tuberculosis services that perform
bacilloscopic examinations, which will help to strengthen
them, exercise quality control, and provide training for
personnel at the applied level and those responsible for
referral.

6.       Epidemiological surveillance

In order to increase MDT coverage and get it to patients
earlier, as well as to evaluate the impact of this fundamental
strategy for elimination of the disease, it is essential to
have an epidemiological surveillance system that will lead to
early case-finding and provide adequate and timely information
for stratification of the risk to human groups and specific
areas.

7.       Stages of elimination

The principal achievements proposed for each stage of the
elimination process are:

Immediate (1992)

(a)       Surveillance for new cases (intensive case-finding)

(b)       Surveillance for recurrences

(c)       Care being provided for disabilities

(d)       Maintenance of skills

Short-term (1992-1994)

(a)       MDT completed for more than 80% of all cases

(b)       More than 80% of the new cases detected without
disabilities

Medium-term (1995-2000)

(a)       MDT completed for more than 95% of all cases

(b)       100% of the new cases detected without disabilities.

8.       Research development

Special impetus will be given to operations research applied
to health systems, including the epidemiological/social
aspect, with a view to achieving results of a practical
nature, whenever possible, that can be applied in the short
term.  Some examples from the research areas identified are:

1.        Search for alternatives leading to broad and timely
case-finding and follow-up of cases undergoing
treatment with MDT.

2.        Study of factors that hinder regular compliance with
MDT schemes.

3.        Identification of economic, social, and cultural risk
factors that are conducive to the transmission of
leprosy or the failure of MTD.

4.        Assessment of the reliability of the diagnosis.

5.        Study of new treatment schemes or prevention
alternatives.

9.       Surveillance and evaluation

As progress is made toward elimination, the programming of
activities will basically emphasize surveillance and the
evaluation of programs, and it should include clinical and
laboratory aspects that have unwittingly been overlooked in
the activities of the existing referral centers, such as those
related to the prevalence of resistance to the drugs being
used for treatment.

Surveillance and evaluation will be carried out on the basis
of the epidemiological indicators generated by the system or
by surveys when they are appropriate.  This mechanism will be
supported by frequent Regional advisory services to the
countries plus annual evaluation meetings of national
officials responsible for the programs at which they will
present results and exchange information.

10.      Articulation with other programs

In addition to articulation between the services at the
different levels of complexity in the national health systems,
intersectoral articulation (between education, science and
technology, and the communications media) will be a national-
level objective.  PAHO cooperation, on the other hand, will
involve the promotion of articulation with other programs (TB,
AIDS, EPI), especially in such activities as personnel
training and logistics for the provision of drugs, etc.  In
conjunction with the Health Situation and Trend Assessment
(HST) program, a project is proposed for the structuring and
implementation of an Integrated Information and
Epidemiological Surveillance System for Leprosy, and with the
Health Services Development (HSD) program, a joint promotion
of operations research.  The objective is to achieve rapid and
effective integration of the leprosy control activities in the
general health services systems.


VI.  ORGANIZATION AND ADMINISTRATION

1.       National organization and administration.  It is essential for
the countries to strengthen their administrative structures
and officially prioritize and support the elimination of
leprosy as a public health problem.  Accordingly, they should
all carry out the following initial actions which constitute
the required commitments:

-         Express manifestation of the will to eliminate leprosy as
a public health problem by the year 2000.

-         Designation of a full-time technical unit for the
management of leprosy control activities if such does not
already exist.  This unit will be assigned the following
functions:

-        Definition of the elimination plan

-        Financing

-        Provision of drugs and other basic supplies

-        Training of personnel

-        Mass educational activities (radio and TV, for example)

-        Collection and analysis of statistical data
(surveillance) and data for research protocols.

-        Preparation of research proposals

-        Supervision and evaluation.

Organization of a national committee to support the
elimination of leprosy:

(a)       To adapt the structure of the national control programs to
the goals of elimination through the incorporation of
diagnostic activities, MDT treatment, and comprehensive
care for patients with disabilities within the local health
systems, in accordance with local epidemiological and
operating characteristics.

(b)       To strengthen technical, operating, and managerial capacity
for the application of appropriate technology to the
elimination of leprosy.

2.       PAHO/WHO technical cooperation

The PAHO/WHO Communicable Diseases Program (HPT) will
participate in the development of an information system that
will combine national, state, and local data into a database
that will allow for stratification of the vulnerable social
groups in the countries in which the disease is endemic so
that the most effective interventions can be channeled toward
the leprosy elimination program.  It will also promote the
development of subregional, national, state, and
jurisdictional data bases so that use of the epidemiological
stratification method will reach the countries' interior.

PAHO/WHO will participate in the review and evaluation of
research proposals and will collaborate in the identification
of sources of funding through national and international
agencies that promote science and technology.  The governments
will be encouraged to give priority to research on leprosy in
their national institutions.  PAHO/WHO will participate in the
transfer of technology when research results generate other
effective alternatives that can readily be incorporated into
the elimination program.

Strategic guidelines:  These guidelines, which are consistent
with the functional approaches normally used by PAHO (resource
mobilization, information dissemination, policy development,
training, research, and direct technical cooperation), may be
summarized as follows:

-         Promotion of the political decision to implement the
Conclusions and Recommendations of the Conference for the
Control of Leprosy in the Americas.

-         Support for the integration of national programs into the
general health services system.

-         Support for the formulation, implementation, and evaluation
of national and subregional plans for elimination.

-         Support for the development of information systems and
epidemiological surveillance.

-         Promotion of the strengthening of operational capacity in
the local health services.

-         Support for operations research and training.

-         Coordination of cooperation with NGOs and among countries
or subregions.

-         Search for financial resources to supplement those from the
countries and the donor agencies.

Expected outcomes:

(a)       National control programs, based on the primary health
care strategy with activities incorporated into the local
health systems and through the mass implementation of MDT,
will have either achieved higher levels of control or else
eliminated leprosy as a public health problem;

(b)       Technical, operational, and managerial capacity in the
countries will have reached a sufficiently high level to
keep the endemic disease under increasing levels of control
and/or under post-elimination epidemiological surveillance
with a view to preventing its reappearance.

Surveillance systems:  This technical cooperation plan will
undergo annual administrative and budgetary programming in
accordance with PAHO standards and procedures.  The Four-
Month Plans of Work spell out the annual program at the level
of activities and tasks.  Surveillance of their execution is
the responsibility of PAHO/WHO technical personnel, and
evaluation of the fulfillment of technical cooperation
activities is done each year as part of the evaluation of the
Communicable Diseases Program.









PREFACE



When cholera broke out in Peru in
January 1991 there had been no epidemics of
the disease in Latin America or the
Caribbean for almost a century.  Within a
few months it spread to other countries and
cases occurred in places as far away from the
initial focus as Argentina, Brazil, Chile,
Guatemala, and Mexico.  As of 8 June 1992,
the Pan American Sanitary Bureau had
received reports of 586,306 cases, 266,034
hospitalizations, and 5,129 deaths.

The cholera epidemic has had a
strong impact on the economies of a number
of the countries.  Sizable losses have been
registered in the tourism, agriculture, and
fishing sectors, as well as terms of exports. 
The high social cost is difficult to estimate
because no way has been found to assign a
specific economic value to the loss of human
life.

The presence of cholera has called
attention to the consequences of a
long-standing structural and economic crisis
and to the enormous inequalities that exist in
the Region.  The epidemic is also a product
of deterioration in the infrastructure and
quality of drinking water supply, basic
sanitation services, and health care. 

After two decades of economic
growth that did little to redress poverty, the
economies of Latin America and the
Caribbean suffered a considerable decline
during the last decade.  The gap relative to
the industrialized countries of the world has
become wider, and vast sectors of the
population have joined the ranks of those
already living in poverty and misery.  Per
capita gross domestic product and Regional
consumption fell by 8.7% and 12.6%,
respectively, between 1980 and 1990. 
According to the Economic Commission for
Latin America and the Caribbean, the Region
probably has no fewer than 192 million
people living in poverty and, of these, no
fewer than 91 million are indigent.

Cholera develops, spreads, becomes
epidemic, and finally becomes endemic
when people live in substandard
environmental conditions with no access to
potable water and basic sanitation services
and when health services are not equipped to
respond adequately to the needs of the
population at risk.  

Today, in Latin America and the
Caribbean, more than 130 million people do
not have access to a safe water supply; 145
million lack sanitary sewerage and waste
disposal systems; 300 million are
contaminating waterways through the
disposal of untreated wastes; 100 million,
90% of whom live in urban fringe areas,
have no access to a refuse collection system;
240 million dispose of their refuse in
conditions that are hazardous to their health
and to the environment; and 160 million lack
access to permanent direct health care
services.  

Firm political decisions and
commitments must be made at the national
and Regional levels to reverse these
situations as soon as possible.  Until this
occurs, there will be no reduction in the high
rates of morbidity and mortality from
diarrhea and other infectious diseases. 
Millions of people, mainly children and the
poorest segments of the population, will
continue to become ill and die from
preventable risks and diseases.  Cholera will
become endemic, and other pathologies
typical of poverty will emerge.

The countries of the Region have
mounted a vigorous effort to control the
spread of cholera and to prevent epidemics. 
Despite the severe constraints imposed by
the economic crisis and the resulting
adjustment measures, it has been possible to
achieve satisfactory results.  However, what
has been done up to now is not enough.

In the face of this challenge, the
countries of Latin America and the
Caribbean, through the Pan American Health
Organization, have proposed a strategy of
action with two major components.  In the
short term, they have mounted an Emergency
Plan, the general objectives of which are to
combat cholera, reduce the risk of its spread,
and limit its social and economic impact.  

At the same time, they have proposed
the formulation of a Regional Plan for
Investment in Health and the Environment
during the period 1993-2004.  The Plan
constitutes a Regional strategy, as well as a
frame of reference for the countries and for
international cooperation.  It provides a
common orientation for bringing about major
reforms in the systems that are connected
with comprehensive health care.  The
purpose of all this is to rebuild and extend
the infrastructure and services that are linked
to the protection and control of man's
immediate physical and biological
environment and to direct health care for the
population.  In this way it will be possible to
cover both the deficits and demands that
exist now and those that will emerge as the
population grows over the next twelve years.

The Regional Plan for Investment
should be the result of direct action by the
countries.  Its final formulation will emanate
from the set of National Plans that the
countries prepare.  These should not be a
limited and exclusive responsibility of the
Governments or the countries.  They should,
at all times, be a responsibility that is shared
on an ongoing basis by all sectors of the
society and by all participants in the national
political processes.

This first version of the Plan lays the
basic foundations for initiating a process of
dialogue and consensus between the
countries of Latin America and the
Caribbean.  Ambitious but essential targets
are proposed.  Estimates are included for
amounts of financing that might, at first
glance, appear extremely high but ultimately
are not beyond reach.

The present proposal is being
formulated in the midst of crisis.  The
countries of Latin America and the
Caribbean are undergoing a series of
different crises which have multiplied and
intensified the problems that are affecting
them.  However, there are hopeful signs that
the Region is on the verge of an economic
recovery.  In these circumstances there is a
moral duty to respond with proposals that
correspond to the magnitude of the problems. 
The crises affecting the countries provide the
opportunity to set in motion changes and
reforms that are urgently needed and must no
longer be put off.

This proposal is consonant with the
principles contained in the Declaration of
Alma Ata and those of the International
Decade of Drinking Water and Sanitation,
approved by all the countries of the world in
1978 and 1980, respectively.  Moreover, it
will contribute the to attainment of the goals
established by the World Summit for
Children.



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


HEALTH PROGRAMS DEVELOPMENT 
VETERINARY PUBLIC HEALTH PROGRAM









PROMOTION AND DEVELOPMENT OF 
VETERINARY PUBLIC HEALTH
       IN THE SCHOOLS OF VETERINARY MEDICINE
IN LATIN AMERICA
















Blacksburg, Virginia
27 - 31 January 1992



PROMOTION AND DEVELOPMENT OF VETERINARY PUBLIC HEALTH
IN THE SCHOOLS OF VETERINARY MEDICINE IN LATIN AMERICA


BACKGROUND


     The XXIII Pan American Sanitary Conference, held in 1990,
approved the document Strategic Orientations and Program
Priorities for the Pan American Health Organization during
the Quadrennium 1991-1994, and requested the Director to
apply it in formulating programs and biennial budgets.  The
principal strategic orientation was that of Health in
Development, in which the need for the Organization to expand
the scope of its activities with respect to health was
recognized.

     The relevant document (CSP23/14) examined the general
question of development in the Americas and pointed out the
need for activating the structures and forms of production
that meet the basic material needs of the population.  This
implies a process of coordinating and integrating the
activities of the different sectors involved so that
development can continue.

     The Conference agreed that human development is the most
important and accepted the hypothesis that health has a
function to perform in the formation of human capital,
necessary for economic growth in the countries of the
Americas.

     The Health in Development approach meant reducing the
inequalities in health to a minimum, reducing the effects of
the crisis among the most indigent, establishing
comprehensive programs for social well-being, and improving
the living conditions and the health of the most
dispossessed, in particular.

     The Strategic Orientations thus expressed have
implications that go beyond the health sector, with
consideration of how to have a social function, in the sense
of undertaking activities that could relieve poverty.  As a
result, the health sector should relate to the other sectors
and propose the view that the health of individuals is not
only an indicator of human development but can also be a
resource that will activate growth and economic development. 
It is not only the health of the people that constitutes a
resource; the health of their environment will also
contribute to economic growth.

     Within this context of collaboration and intersectoral
promotion of the concept that the health sector is a
development sector, the Veterinary Public Health programs
with their multiple interactions play a predominant role in
the implementation of this strategic orientation through the
control of zoonoses, food protection, the improvement of
animal production, the protection of the environment, and the
development of biomedical models for research.

     In the VII Inter-American Meeting, at the Ministerial
Level, on Animal Health (RIMSA VII), held in Washington from
30 April to 2 May 1991, through Resolution VIII the valuable
contribution of the multidisciplinary multisectoral approach
that the Veterinary Public Health Program develops through
its activities of technical cooperation to the countries was
recognized and the Governments of the Member Countries were
asked to institutionalize the concept of veterinary public
health.

CONCEPTUAL FRAMEWORK OF VETERINARY PUBLIC HEALTH

     In accordance with the WHO definition, veterinary public
health is utilized as a generic term to provide a conceptual
framework and programming structure to the activities in
public health that involve the application, skill, and
resources of veterinary medicine for the protection and
improvement of public health.  This serves as a bridge
between agriculture and public health.  The field and
functions of veterinary public health are dynamic and subject
to the changing policies and priorities of the various
sectors - in particular, the economic, industrial, trade,
health, and agricultural sectors.

     Veterinary public health is conceived as the catalytic
axis of the veterinary sciences, contributing to the
development and well-being of man by supplying proteins of
animal origin in sufficient quantities and under conditions
of optimum quality and safety, avoiding the harmful effects
of the animal diseases that can be transmitted to man,
preserving the environment, and contributing to the solution
of health problems through the development of animal models
that facilitate biomedical research.

     This veterinary public health concept has been the result
of a process and of responses to the multiple health needs
and the socioeconomic development exhibited by the countries. 
Veterinary public health combines the many functions of the
veterinary medical sciences to articulate them and translate
them into actions that lead to improved health and
formulation of a policy for the social and economic
development of the countries.  Veterinary public health is a
broad field.  It operates basically in five areas of action,
as follows:

a)   The promotion of animal health with a view to increasing
     production and productivity in order to make adequate
     quantities of animal protein available for human
     nutrition and for the socioeconomic development of the
     producing countries with export potential.

b)   Protection of food for human consumption, guaranteeing
     its safety and nourishing quality and preventing the
     transmission of disease-causing agents.

c)   Surveillance, prevention, and control of zoonoses and
     communicable diseases common to man and the animals -
      causes of morbidity, incapacitation, and mortality in
     vulnerable human groups.

d)   Promotion of protection of the environment against the
     potential risks to public health generated by possession
     of productive animals and pets, the prevalence of harmful
     fauna and synanthropic animals in cities,
     industrialization of animal production, and export of
     nontraditional species.

e)   Development of biomedical models, promoting the
     conservation and reproduction of animal species and their
     rational use in the development of the biomedical
     sciences.

     One of the significant phenomena in the context of
socioeconomics is the growing, rapid, unplanned
disproportionate urbanization, involving the movement of
rural population groups toward large cities with obvious
deterioration of living conditions, particularly in suburban
areas.  As a result of this, there are larger conglomerations
of human groups in extreme poverty, with greater
unemployment, a deficiency of basic services, decreased
availability of food, and greater population density with its
consequences of social insecurity.  It is known that this
displacement of persons and animals signifies risks to the
health and well-being of man.  Taking this context as a
reference, health is conceived as an integral part of the
whole socioeconomic and political development of a people.

     The declaration of Alma Ata in 1978, ratified by the
World Health Assembly in 1979, establishes the world goal of
health for all by the year 2000 (HFA/2000).  The key to
reaching this target is the strategy of primary health care,
based on four  operational principles that include
intersectoral collaboration, community participation, the
utilization of appropriate technology, and cooperation among
countries.  Standardization of primary health care implies
that the health sector cannot by itself attain the goal of
health for all.  This will require the participation and the
coordinated effort of all the sectors and factors related to
national and community development, especially in
agriculture, livestock raising, and education.  Basic to the
achievement of the health and well-being of man is the effort
of various sectors and professions that work together. 
Veterinary public health through its fields of action plays
an important role in the achievement of this development in
the countries of Latin America.

     Veterinary medicine has a predominant social role, not
only as a profession, but also through the commitment of the
practice of every professional so that he mobilizes his own
efforts and those of others to reach the goal of HFA/2000. 
It is essential that the veterinarian possess a comprehensive
orientation and that he have the capacity to analyze a
problem, seek the relevant information, and apply it in
achieving a solution.  In addition to acting as an
administrator of information and analyst of problems, he
should have the ability to communicate and to make rational
decisions.

     In addition, he should be prepared to deal with the
programs for improvement of animal production in quantity and
quality, for prevention and eradication of diseases, for
protection of the environment, and for development of the
biomedical models that will be increasingly necessary and
requested.  Veterinary medicine should also take into
consideration all those factors that modify the political
social and economic picture.

     The schools of veterinary medicine, for their part,
should produce professionals with analytical capacity in
epidemiology so that they can identify the risk factors in
diseases for man and his animals and are also able to plan
and administer immediate actions for control and measures for
prevention or eventual eradication.  For this purpose their
training should be multidisciplinary.  In addition, it should
be possible to evaluate the social, economic, and even the
political implications to justify the adoption of plans and
strategies for action, in order to mobilize resources in an
appropriate form for the purpose of contributing to the
multidisciplinary and multisectoral efforts toward
development.

     Within the educational process - the teaching and the
learning that forms the basis of the above-mentioned
training, a methodology is required that emphasizes the
development of critical analysis, of self-management, and of
social participation, the utilization of information, and the
integration of knowledge with the daily practice of the
profession in its various branches.  In addition, structural
flexibility is required so that the student continues in the
direction of his specialty as he advances in his program of
studies.

     It is essential that during his training period the
professional acquire a commitment, so that at the end of his
career, he can consider his participation in the overall
technical, scientific, and ethical development of the
profession as basic.

     To this productive purpose of the school is added that of
research and technological transfer in the various areas in
order to improve the services and hence the development of
man's health and well-being.  That research should be
consonant with the needs of the country - for example, the
development of appropriate viable technologies that can be
applied - and there should be real commitment on the part of
the university to active participation in its implementation.

     In order to reach these goals and objectives, the school
should have professors that bring together merits, abilities,
and aptitudes and a philosophical and technical framework,
agreed upon among the faculty, technicians, and assistants,
to serve as a guide for institutional development.

     To respond to these challenges the Veterinary Public
Health Program of the Pan American Health Organization is
providing its activities of technical cooperation to the
countries through its strategic approaches.

     Control and elimination of priority zoonoses

     -    Elimination of urban rabies.
     -    Eradication of bovine tuberculosis.
     -    Control of taeniasis and cysticercosis.
     -    Control of hydatidosis.

     Hemispheric eradication of foot-and-mouth disease

     Food protection

     -    Development of integrated programs of food
protection.
     -    Strengthening of analytical and inspection services.
     -    Development of epidemiological surveillance systems
for food-borne diseases.
     -    Protection of the consumer through community
participation.

     Surveillance of the environment and emerging zoonoses

     -    Control of harmful fauna.
     -    Surveillance of equine encephalitides.
     -    Surveillance and control of the use of pesticides.
     -    Management of the possession of domestic animals and
livestock.

     Development of biomedical models

     -    Conservation and reproduction of nonhuman primates.
     -    Strengthening of animal reproduction centers.
     -    Development of in vitro models.

     Strengthening of veterinary public health services.

     -    Strengthening of veterinary public health education
in the schools of veterinary medicine.
     -    Strengthening of laboratories for diagnosis and
production and quality control of biologicals.
     -    Administration of programs for veterinary public
health and animal health.

Training the veterinarian

     The constant economic, social, and political changes in
the countries demand comprehensive planning of their
development in which the university must be involved since it
is a source of the human resources essential for achievement. 
The schools of veterinary medicine should contribute and take
an active part in the formulation of the development plans,
particularly in the health and agriculture sectors, adapting
their curricula to the political and economic decisions of
the individual countries.

     This is indeed one of the challenges that the schools
have to address in order to achieve that participation. 
However, it is not independent; it must be integrated with
other challenges and various stages must be transcended so
that the school gains a leading role in society and
contributes to the health and well-being of man and
consequently to the development of the countries.

     The development of biotechnology constitutes a greater
challenge for the academic centers, which must continually
update knowledge and analyze the new scientific bases in
order to adapt them to national problems.

     The subregional initiatives for economic integration
require the schools of veterinary medicine to be close to the
official and private sectors in order to maintain an exchange
of information on the normative aspects related to animal
health and veterinary public health and to contribute to the
planning and management of the livestock subsector to meet
the goals for international trade.

     Another factor of importance is the proliferation of
schools of veterinary medicine, which increased in number
from 53 in 1970 to 126 today; many of these operate with
insufficient funds and, of course, produce professionals
based entirely on theoretical orientations.  This situation
demands reorganization of the planning of manpower training
in accordance with the real needs of the countries, as well
as better coordination of the maintenance of the technical
quality of the graduate through programs for continuing
education.

     It is evident, as a result, that the moment has arrived
for reflection on the area of training, its involvement in
social and economic changes, and the strategies for the
preparation of new professionals.

     Because of the importance that is allotted to manpower
development in veterinary public health, PAHO/WHO proposes to
support the strengthening of education at the university
level, promoting institutional development and a tighter
linkage of the schools of veterinary medicine with the health
and development processes as a means of encouraging programs
along priority lines.

PURPOSE

     To promote a process of reflection and analysis in the
schools of veterinary medicine in Latin America that makes it
possible to determine the current situation of veterinary
public health education, examine different future prospects,
and define the institutional development programs.  This, in
turn, will permit the development of programs that take into
account the continuous political, social, and economic
changes in the countries as well as the policies and
priorities of the Ministries of Health and Agriculture,
aiming at the achievement of a proper vision of the role of
the school of veterinary public health as an institution that
contributes to health and human development.

OBJECTIVES

1.   To carry out a situational analysis of the faculty in
     relation to a future image that incorporates the
     principles of veterinary public health and the contextual
     development of the surroundings.

2.   To develop a vision of the desired future based on that
     analysis, individualized for the particular school, its
     environment, and its possibilities for mobilizing
     resources to achieve these changes.

3.   To crystallize plans and strategies to achieve this
     vision of institutional development, contributing in turn
     to the human and sociopolitical development of the
     country and the region.

4.   To establish mechanisms of coordination between the
     centers of professional training and the official and
     private sectors that use the human resources.


METHODOLOGY OF A PROSPECTIVE STUDY

Prospective Analysis

     Prospective analysis is a methodology for examining a
given situation and determining, through that analysis,
proposed changes for the future.  Its employment is of
recognized usefulness since it consists of an effort to
discover, explore, and examine systematically different
aspects of a possible future reality.  It attempts, in
addition, to distinguish clearly between ends and means and
is concentrated more on the qualitative aspects than on the
quantitative.

     As its name indicates, there are two key elements to
prospective analysis.  The first is the perspective that is
taken with respect to a situation under study.  The second is
the way that the analysis of that situation is carried out.

     The perspective of this methodology is different from the
one usually utilized because it is aimed at the immediate
future and therefore at examining what is necessary for
achieving it.  In a certain sense, it can be seen as a
retrospective vision from the future that works toward
actions that lead to the desired change.  A fundamental part
of prospective analysis is the conceptualization of a given
situation or element, examined using a comprehensive approach
- considering health, for example, as a phenomenon and a
component of politicosocioeconomic development and not as a
separate element.  The second key element is the form in
which the analysis is carried out.  Beginning with the
future, several alternatives for achieving the desired future
are examined and contrasted, not only from the point of view
of their effectiveness, but also with consideration of the
social consequences that result from the different strategies
chosen for that achievement.  The possibility of examining
the probable social consequences of an action before being
committed to it is a benefit of that methodology.

     Utilization of the methodology of prospective analysis is
understood as an exploratory process, after which a proposal
is generated for developing a model of change, followed by an
implementation phase with the development of strategies.  It
does not end there, but while the strategies are being
applied and the contextual situation is being changed, it
will be necessary to carry out a new process in order to
maintain the prospective point of view.

     The richness of the methodology is derived from several
aspects.  Perhaps the most important is that the school
adopts as its own a methodology that permits it to be an
agent of change with respect to its reality.  In addition,
the dynamics produced when prospective analysis is utilized
correctly is mobilizing.  The creative abilities of the
participants are promoted and a dialogue is provoked among
the several existing divisions in the institution where new
knowledge can appear, with rich discussions whose purpose is
arriving at a consensus.  Through this process the divergent
points of view within the institution can be identified and
the discussions for unifying criteria can be facilitated. 
Prospective analysis provides the institutions with a
methodology that leads them understand their role within the
social, political, and economic contexts and allows them to
plan strategies to achieve the desired objective. 
Prospective analysis is positive since it is concentrated on
what the institution can achieve, thus avoiding the
disagreeable process of evaluation, in which the school
judges what it has been doing.

     An additional important aspect related to this
methodology is the immediate feedback of information on the
real position of the school with respect to a desired future. 
The immediate availability of information avoids loss of the
group's momentum, which can occur with some methodologies in
which there is an interval between the realization of the
exercise and an understanding of the situation on the part of
those interested.  Note should also be taken of the value of
prospective analysis in enabling the school to construct its
own model for change instead of having to accept imposed or
imported criteria.  In addition, the fact that the school has
designed its own future encourages it to commit itself to
work to achieve what was planned.  It shows also that this
methodology provides more marked support to the qualitative
aspects, an important factor in any transformation.

THE APPLICATION OF THE FORM

     In the application of the form in the schools of
veterinary medicine several phases can be identified:

First Phase:  Preparatory

     During this stage the school identifies the participants
in the process and provides them with the document and an
orientation to the methodology of prospective analysis.

     It is essential in this phase that there be thorough
discussion of the concepts involved in the scenarios with
their political and historical implications, so that the full
benefit can be gained from the exercise.  It is also
important for the group to reconfirm or develop its own
conceptual framework and arrange it within the conceptual
framework of the form, which might need certain adaptations
if there is some incompatibility.

     The decision to carry out the exercise using this
methodology implies an agreement and a commitment by the
school to use the results in managing changes.  Any other
decision would mean a loss of time, energy, and money and
without doubt would cause frustration among the participants.

     To assist in guiding the process and in the naming of
facilitators that are charged with orienting and following a
work dynamic, it is suggested that this document and its
objectives be presented to the largest group of persons
possible in the school, and that, starting from there, a work
schedule for carrying out the prospective analysis be
prepared.  This schedule should anticipate the time necessary
for discussion, which should not be prolonged beyond
practical limits.  It is recommended that the entire process
of the prospective analysis, from the situational analysis
through the plan of action, not exceed three months.

Second Phase:  Situational analysis

     In this stage the school utilizes the prepared form as a
guide for discussion and analysis in order to identify the
current state of the institution with respect to the
scenarios included in it.

     First of all, a response to the form is requested from
individuals; afterwards the prospective analysis is carried
out through group work.  For this, it is suggested that
several groups be constituted (with not more than 12 to 15
persons in each).  The groups will produce better, more
animated discussion if they are composed of representatives
from several sectors of the school - namely, professors,
students, and administrators; individuals involved in the
livestock sector; and the community.  The purpose of the
group work is to obtain a CONSENSUS of the group on the
position that the institution currently takes on the future
scenarios on the form.  If there is more than one group,
there will be a need to arrive at a general consensus.  It is
important to emphasize the value that this stage could
generate if it is well carried out.  Arriving at a consensus
is always difficult and among groups with varied
representation, as is suggested for this methodology, perhaps
it is even more so, but the result is worth the effort. 
Using the mathematical average or the mean for this purpose
loses the richness of the methodology.  There are also such
techniques as "brainstorming" and "Delphi" that help in this
process if it is difficult to get a consensus of a group
through a simple majority or the agreement of the
participants is difficult to obtain.

     Although the form was designed to permit discrimination
of every scenario in order to promote discussion, it is not
necessary to prolong it to achieve a specific point, if there
is general agreement on the position of the school.  For
example, if after a long discussion, the participants can
agree that their institution is in Scenario B except for
Points 1 to 3, for the purposes of analysis and planning it
may be that the selection of B is sufficient.

Third Phase:  Analysis of results

     Before beginning the analytical stage it is important
that the group recognize that it did not carry out a simple
evaluation exercise but an exercise involving examination of
its position and the current trends with respect to the
future.  Therefore, in the analytical stage attention is
centered on this same aspect, that is, looking at future
institutional development.

     There are several useful forms that the school can use to
analyze the results obtained and descriptions of them follow

     One can perform an analysis by scenario in which the
general trends in the school are identified and tabulations
are made of the percentages and numbers of variables that
correspond to each one of the future scenarios:  the scenario
of limited changes (Scenario A); that of significant changes
(Scenario B); and that of transformation (Scenario C).  With
this activity, a view of the general trends of the
institution with respect to change is developed.

     Another way to analyze the results is through the
identification of the variables whose situations exemplify
trends in the scenario of transformation, that is, the
variables that were located in Scenario C.  It is logical to
suppose that if the school has reached a certain stage of
development with respect to some variables, it is due to a
certain investment of its efforts in this area.  This
information is very valuable for the development of the
following stage - the preparation of the strategic model,
since it allows the institution to address the elements that
had been prioritized and hence to make a decision on whether
to continue that policy.  It will be necessary to consider
this in light of the introduction of other elements - certain
changes needed to achieve more comprehensive institutional
development.

     An analysis by profile is carried out by making a graphic
representation of the consolidated results from the school
(see Figure 1).  The institution can analyze this profile
using different schemes in order to establish its meaning.

Example of a profile



















     Within the analysis by scenario or by profile, one can
examine the four categories:  context, structure, function,
and comprehensive nature as a whole, with regard to their
tendencies to change.

     At a more specific level one can look at each one of the
variables in a similar way.  Every variable can be subject to
individual examination with respect to the future scenarios. 
One method that some institutions have utilized to study the
meaning of the individual variables has been to establish a
critical point; this identifies, beforehand, the level of
development or trend toward change that the institution
considers the present acceptable minimum for every variable. 
The critical points are determined for the variables on the
basis of the conceptual framework and the values for that
school.  The establishment of a critical point for each
variable allows individualization of its analysis and gives
more weight to certain variables that have priority for the
institution, indicating critical points that are more
advanced within the trends of change or transformation.  At
the same time it recognizes that not all the elements
(variables) are at the same stage of development within a
school.  To do the analysis, the institution addresses its
situation identified in the situational analysis within which
it has marked a critical point for each variable.  If the
variable shows less tendency to change than the minimum
acceptable, this variable could be considered as having
priority in the future development of that institution.  For
example, the school sets the level of acceptable change for
the variable "research" in Scenario B3 and it is found to be
in Scenario A2, which implies that it will be necessary to
designate research as a possible priority activity when the
strategic model is prepared.

     Miniprofiles can also be drawn using only the variables
that correspond to the different elements of the conceptual
framework; for example, the integration of education and
service.  This way of analyzing the results of the diagnostic
stage is valuable since all the elements of a subject are
joined to give a comprehensive view with regard to certain
aspects of the development of the institution.  Very
interesting discussions arise when the participants identify
internal inconsistencies within the same subject.

     The result of the analytical stage is the identification
of critical areas and elements, essential for the development
of the institution and necessary for the fulfillment of the
commitment of the school to contribute toward the
transformation of the social and health situations.

Fourth Phase:  The strategic model

     The results of the analysis give rise to the next stage,
the creation of a strategic model.  Using the instrument with
the three scenarios described and the points identified as
priorities for the development of the institution in the
analytical phase, the school prepares a strategic model of
what it wants to achieve by a given date in the future (for
example, the year 2000).  The scenarios on the form allow the
group to compare several images, discuss their differences
and possible consequences, and even to have an idea of the
degree of change necessary based on the previously completed
analysis.  Using the critical points identified and knowledge
of its own particular reality, the institution determines a
possible attainable scenario for itself.  Creativity reigns
in this stage and the discussions are enriching.  As the
participants continue to establish what they believe can be
accomplished in the development of the institution and look
in turn at the consequences both for the school and its
social impact, its own individual model begins to appear.  It
will be necessary to take care so that the group does not
limit itself to some mathematical projections or cause-and-
effect situations but promotes the thinking toward new
knowledge, tactics, and possibilities.

     It is fitting to note again the need to seek a true
consensus in the definition of the model.  The use of a
mathematical average is not adequate for the situational
analysis, less still for the construction of the strategic
model, since if only the point representing the mathematical
average were sought, every member of the group would remain
in his original position and the model would become something
fictitious to which no one is committed.

     At the end of this process the school in question has
established it own image for its future.  The fact that the
institution created its own strategic model encourages the
participants to commit themselves to work to achieve its
purpose.

Fifth Phase:  The transformation

     This stage brings together the activities of
operationalization and transformation.  Through the
establishment of a plan of action the school consolidates its
commitment to the strategic model.  The individuality of
every situation is developed even more in the solidification
of activities that will direct it toward the desired changes.

     The plan of action should be quite precise but should
also propose some alternatives for the achievement of the
proposal, thus taking into account that change is part of the
process and making it possible for the plan to remain viable
although the situation may vary.

     For example, the school takes into account the worsening
of the economic crisis and proposes strategies for the search
for extrabudgetary financing.  One strategy could be the
development of interinstitutional agreements or projects at
the national and international levels that contribute to the
strengthening of the development of plans for the
institution.  But at the same time, the school, aware of this
economic limitation, searches for various ways to maximize
the utilization of its resources, in the short and
intermediate terms.

     There is a series of elements that should be considered
during this part of the work.  Whenever possible, it is
important to anticipate the limitations, the crisis
situations, and the problems that could block the process. 
The necessary resources and the possibilities of obtaining
them should enter as objects of the analysis, in terms of
their feasibility and viability, before any strategy is
configured.

     As in any process that implies change, it is necessary to
have the power to arrange for administrative and political
support for such ends.  In the application of strategic
planning, every institution will seek to individualize its
projects according to its priorities, possibilities, and
resources, often incorporating in the process other specific
techniques and/or methodologies that complement the
achievements of the prospective analysis.

     It will be necessary to guard against the tendency toward
a very limited view of this planning, exploring the very
short or very long term.  Taking into account only the
immediate future in the process of planning can restrict
creativity because of the clarity with which one can see the
current limitations; on the other hand, if there is a
concentration of effort only on gains to be obtained in the
long term, the planning can be much too general and not serve
as a guide in the establishment of concrete strategies.

     Finally, it should be emphasized that the response
obtained to the challenge of institutional development
through the application of prospective analysis is neither
static nor an absolute standard; it is a plan of work that
should have directionality and flexibility.  Since change is
an integral part of life, adjustments and even restatements
may be needed.  Prospective analysis as a methodology does
not end there but enters into a cycle that requires continual
looking toward the future.  In practice, preparatory phases
and situational analysis and the creation of a strategic
model for planning and implementation should be repeated as
many times as necessary - at least every two to three years -
 in order to maintain its prospective point of view and to
provide information on the effectiveness of the measures
adopted.
DEFINITIONS

Primary health care

     This is a strategy for addressing health problems in a
concrete reality that commits and affects the entire health
system and the population that it serves.  It forms part of
the nucleus of the world health system and of all the
economic and social development in the community.  It implies
that health care is related to the needs of the population,
community participation in the planning and implementation,
efficient and effective utilization of the available
resources, and the recognition of health as a social value
included in the economic and social development of the
community.

Social communication

     This is the systematic effort to influence the health
practices of extensive populations positively, utilizing
principles and methods of mass communication, instructional
design, social marketing, behavioral analysis, and medical
anthropology.

Context

     It is the total environment into which the school of
veterinary medicine is inserted.  It influences the
institutional role of the school and has observable effects
on the school's programs.

Institutional development

     This consists of the set of activities planned to adapt
the organizational and administrative structure, the
principles and elements of academic education, and the human
resources, oriented and integrated for the achievement of the
objectives of the institution as they are framed in the
social, political, and economic context of the country.

Scenario

     This is the set of hypotheses on selected variables,
prepared on the basis of common values and describing a
future situation with possibilities for realization.

Structure

     This includes the internal and external organization of
the school.  Internally, it refers to the curriculum and
administrative organization; externally, to its organization
in relation to its context or environment.

School of veterinary medicine

     This is understood to mean the institution that is
responsible for the training of professional veterinarians.

Function

     This refers to the school's own actions to achieve its
purpose.

Management

     Effective, efficient management of resources, such as
personnel, budget, supplies, and equipment.

Objective image

     This consists of the description of the panorama or
picture of the situation of veterinary medicine in the year
2000.

Indicators

     These are concrete elements used in evaluating a variable
qualitatively and quantitatively.

Integration of teaching and service

     A process of growing articulation among educational and
health service institutions to improve health care and to
orient the generation of knowledge and the training of
personnel, taking as a basis the epidemiological profile in a
specific population in a regionalized context; it permits
continuity in the educational process (the process of
continuing education) that arises from the work and is
capable of transforming it.

Comprehensive nature

     This is the interrelationship of the three components,
context, structure, and function, that permits the
institution to respond as a whole to society.  It is
visualized through the activities of the institution itself
and of those of its graduates.

Strategic model

     This is a scenario of goals prepared by the school that
describes its desired future attainable in a defined time
period.  The strategic model is different for each school
since it takes into account the school's own needs,
priorities, possibilities, and resources.

Variables

These are significant elements, chosen to represent the
characteristics of the situation under study and make it
explicit.

Veterinary public health

     The concept of health extended to the community.  In
accordance with the WHO definition, this is the component of
public health activities that is concerned with the
application of professional knowledge, ability, and resources
in veterinary medicine, with a view to protecting and
improving human health.  Its principal function is to serve
as a catalyst for the implementation of intersectoral
collaboration between agriculture and health, which is one of
the principal pillars of the Declaration of Alma Ata on
primary health care.

Figure 1.  The role of veterinary public health and its plans
of action.

1. Development
2. Health and well-being of man
3. Health and animal production
4. Protection of the environment
5. Biomedical models
6. Veterinary public health
7. Prevention and control of zoonoses
8. Food protection
9. Taken from:  Organización de los Servicios de Salud
Pública Veterinaria de América Latina y el Caribe
[Organization of the Veterinary Public Health Services of
Latin America and the Caribbean].  Drs. Alfonso Ruiz and
Jaime Estupiñán, Veterinary Public Health Program, PAHO/WHO. 
Special OIE publication.
BIBLIOGRAPHIC REFERENCES


*  Análisis Prospectivo de la Escuela de Salud Pública I
   ETAPA. Caracas, Venezuela.  Octubre, 1986.

*  Desarrollo Organizacional de la Escuela de Salud Pública,
   Facultad de Medicina, Universidad Central de Venezuela. 
   Modelo Operativo "Momento 88".  Plan.  Caracas, Venezuela,
   1988.

*  Análisis Prospectivo de la Educación de Enfermería. Doc.
   No. 6549 H. Marzo, 1989.

*  Situación Actual y Futura de la Medicina Veterinaria. 
   Dres. Primo Arambulo III y Alfonso Ruiz.  Conferencia
   presentada XII Congreso Panamericano de Ciencias
   Veterinarias 31 julio - 4 Agosto, 1990. La Habana, Cuba.

*  Facultades de Medicina Veterinaria de América Latina.
   Directorio.  OPS/OMS. Agosto, 1991.

*  Análisis Prospectivo de las Escuelas de Salud Publica.
   Borrador de trabajo Dr. Pedro Luis Castellanos para
   HSM/OPS. Enero, 1988.

*  Ciencias Veterinarias y Sociedad: Reflexiones sobre el
   Paradigma Profesional.  Dres. Félix J. Rosenberg y Raúl
   Casas Olascoaga.

*  PAHO Strategies for Strengthening and Developing Biomedical
   Research in Latin America.

*  Organización de los Servicio de Salud Pública Veterinaria
   en América Latina y el Caribe. Dres. Alfonso Ruiz y Jaime
   Estupiñán.  Programa de Salud Publica Veterinaria. OPS/OMS.

*  Salud Pública Veterinaria y Atención Primaria de Salud. E.
   Larrieu, C. Dapcich, María T. Costa, Susana Romero, A.
   Aquino, R. Bigatti, y A. Fernández. Rev de Med Vet Vol. 71,
   No. 5, 1990. Argentina.

*  Feeding the world in the 1990s and beyond: A role for
   veterinary medicine. William R. Pritchard. DVM, Ph. D.,
   LLB. JAVMA Vol. 198.1, 1 January, 1991.

*  Alma Ata 1978. Primary Health Care. Geneva, WHO.

*  Seminario Latinoamericano de Educación Veterinaria y
   Atención Primaria de la Salud. 4-7 Octubre.
   Asunción,Paraguay.

*  Evaluación de la Calidad de la Educación Médica. Dr. José
   Roberto Ferreira.  Conf. Asoc. Mexicana de Educación
   Médica. Guadalajara, México, Agosto, 1985.

*  Strategic Orientation and Program Priorities for the Pan
   American Health Organization during the Quadrennium 1991-
   1994.  PAHO/WHO Document CSP23/14.  Washington, D. C.,
   1990.

*  La Salud Pública Veterinaria y su Contribución a la Salud y
   Desarrollo.  Primo Arámbulo III y Jorge A. Escalante. 
   Conferencia presentada XXIV Congreso Mundial de
   Veterinaria, Brasil, Agosto, 1991.

*  Veterinary Public Health: Future Perspective. Dr. Primo
   Arámbulo III, Veterinary Public Health Program, PAHO/WHO. 
   1991.

INDIVIDUAL RESPONSE SHEET 


Student ________    Year __________    (Semester)
_________

Teacher ________    Area of responsibility _________

Full time _________

Part time _________


Administrative _______________

Other (specify) _______________

Other school _______________

Official sector_______________

Private sector_______________


Instructions:  Individual

  These descriptions represent some possible situations of
veterinary public health education in the schools of
veterinary medicine.

  Every participant, having been instructed in the process of
prospective analysis, will choose the description from
Columns O, A, B, or C that corresponds most closely to the
situation of the school at the current moment.

  Once the position of the variables relative to the
descriptions is identified in general terms, the reader is
requested to estimate the level of achievement that the
school has reached in relation to that indicator, in such a
way that the final response is made up of a letter and a
number - for example, C-1.

  This sheet will serve the student or educator as a reference
when he participates in group work since the final form of
the information that is the product of the exercise will be
based on consensuses (group study).
GROUP RESPONSE SHEET


Number of participants __________    School (name)
____________

Area representative __________________

Time necessary for achieving consensus
(hours)________________


Instructions:  (Consensus)

  The participants of the group will have to discuss their
points of view in order to justify their judgment of the
position of the school at that moment.

  For the enrichment of the discussion the appointment of a
facilitator is suggested.  The process followed is similar
that for the individual level, beginning with a choice of
Columns 0, A, B, or C, whichever is closest to the position
of the school, and followed by a judgment of the
corresponding degree, 1, 2, or 3.

QuestionNot
applicable                    ABC
01231231231.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.
21.22.
QuestionNot applicable        ABC
012312312323.24.25.26.27.28.29.30.31.32.33.34.35.36.37.38.39.
40.41.42.43.
QuestionNot
applicable                    ABC
012312312344.45.46.47.48.49.50.51.52.53.54.55.56.57.58.59.60.
61.62.63.64.       SCHEDULE OF ACTIVITIES

ActivityDateLocationContacts1.Preparation of the
preliminary form10-20 December, 1991Washington, D. C.HPV
Officers:  Dr. Alfonso Ruíz, Dr. M. Genovese
Director:  Carol Collado2.Evaluation and revision of the
form, Meeting of Group of Experts27-31 January,
1992Blacksburg, Va.Consultant Group:  HPV Officials
Director:  Carol Collado3.Preparation of methodology by
coordinatorsFirst two weeks in May, 1992CountriesGroup of
coordinators4.Application of the survey (average of one month
per school)June, July, August, 1992Latin AmericaFacilitators: 
HPV, countries
Group of Professors and students:  Proposed by each
school5.Analysis of data:
a. Preliminary report
b. Final reportSeptember, 1992Washington, D. C.HPV Officers
Director:  Carol Collado6.Preparation of final report and
publicationsOctober to November, 1992Washington, D. C.HPV
Officers, Editor













     HEALTH OF THE ELDERLY 



    ANALYSIS OF THE SITUATION

.    It is estimated that the
     population aged 60 and over in
     Latin America will increase
     from 23.3 million in 1980 to
     40.9 million by the year 2000
     and 93.3 million by the year
     2025, these figures
     representing 6.4%, 7.2%, and
     10.8% of the total population,
     respectively.

.    It is also estimated that life
     expectancy at birth will
     increase from 51.2 years during
     the period 1950-1955 to 71.8
     years during period 2020-2025.

.    These demographic changes point
     to an inevitable overburdening
     of the medical and social
     services for this population
     group. 

.    The majority of the elderly in
     Latin America are cared in
     family settings, while only
     relatively few reside in
     institutional care facilities. 
     In view of the reduction in
     family size and the effects of
     rapid urbanization and
     industrialization, it is
     essential that steps be taken
     to strengthen and expand family
     care, as well as provide more
     modalities of open care
     (groups, clubs, day-care
     centers, day-care hospitals,
     etc.)





PAHO PROGRAM ON HEALTH OF THE
ELDERLY 

The accelerated demographic trend
toward aging in most of the
countries of the Region, and the
relative lack of tradition in the
provision of appropriate services to
meet the specific needs of this
population segment, led the Pan
American Health Organization in 1982
to establish a specific program on
Health of the Elderly in order to
support the national programs in the
Member Countries.

The Program subscribes to the
concept of "active aging," which
advocates the maintenance of
autonomy by the elderly, the
adoption or strengthening of healthy
lifestyles, involvement of the
elderly in processes related to
their well-being, and participation
in their social milieu.



OBJECTIVES OF THE PROGRAM

The overall objective of the Program
is to ensure that all elderly
persons receive care that is
accessible, equitable, and of
optimum quality.  To this end, its
actions are geared mainly toward the
promotion of national plans,
policies, and programs for
comprehensive care of the elderly.

The primary emphasis of national
programs should be the maintenance
of elderly persons within their
family environment, enabling them to
preserve the utmost physical,
mental, and social independence.
STRATEGIES AND PRIORITIES

1.   To heighten awareness in the
     general public and in decision-
     making circles of the needs of
     the elderly and their right to
     non-discriminatory treatment
     and comprehensive care.

2.   To obtain and disseminate
     relevant information on the
     situation of the elderly in the
     Member Countries.

3.   To promote an examination of
     the medical and social programs
     and services for the elderly
     with a view to rationalizing
     their use within a framework of
     comprehensive coverage,
     efficiency, and effectiveness.

4.   To promote active involvement
     of the elderly in diverse
     pursuits that will enhance
     their bio-psycho-social
     capacities.









LINES OF ACTION


1.  Mobilization of resources

One of the Program's foremost lines
of action is to enlist the
participation of the various sectors
and agencies, both governmental and
private, in order to obtain greater
technical and financial support for
national activities.


2.  Dissemination of information

The dissemination of knowledge and
experiences in regard to programs
and services to help the elderly, as
well as support for the publication
of related information in the
countries, is an extremely important
facet of the Regional Program which
is backed by a technical information
service based at PAHO headquarters.


3.  Use of the mass media

The Program also promotes use of the
mass media as an instrument for
educating the public.  In this way
it attempts to combat the negative
myths that surround old age and
replace them with a positive
attitude toward the elderly and
their problems, while promoting the
adoption of appropriate policies. 


4.  Training 

Since 1986 the Program has sponsored
an Annual Regional Course on
Gerontology for health science
professionals involved in national,
provincial, or local care programs
for the elderly.  It also arranges
international workshops for the
exchange of experiences in the
provision of services for this age
group.

5.  Direct technical cooperation

Technical cooperation is provided to
the countries for the design,
execution and evaluation of
programs, the transformation of
services, and the adoption of
strategies for research and manpower
development.  The Regional Adviser,
supported by a panel of experts from
the Region, provides the services
required by the countries.


6.  Promotion of research

Within this priority area of the
Program, particular importance is
attached to epidemiological and
operations research.  Noteworthy
endeavors in this connection include
the Survey of the Needs of the
Elderly, carried out in 15
countries, and the studies of
morbidity, prevalence of dementia,
and patterns of drug use among the
elderly.

ACKNOWLEDGEMENT 


     This document, which is intended to articulate the outcomes of
three regional meetings sponsored by the Pan American Health
Organization (PAHO) has sponsored since 1987, is the result of the
collective efforts of several technicians working in the area of
urban sanitation.  PAHO wishes to express its appreciation for the
efforts made by the persons listed below and for the enthusiasm with
which they have contributed their valuable experience:


-  Martha Alegre             (Argentina, 1987)
-  Jorge Arroyo              (Peru, 1990)
-  Héctor Collazos           (Colombia, 1987)
-  Luiz E. Costa Leite       (Brazil, 1990)
-  Francisco Gálvez          (Chile, 1987)
-  Ricardo Giesecke          (Peru, 1990)
-  Camilo Gómez              (Colombia, 1990)
-  Rafael Gómez              (Peru, 1990)
-  René Herbas               (Bolivia, 1987)
-  Carlos Herz               (Peru, 1990)
-  José Labiosa              (USA, 1990)
-  José M. de Mesquita       (Brazil, 1988)
-  Julio C. Monreal          (Chile, 1988)
-  Jamil Reston              (Brazil, 1990)
-  Patricia Ríosvelasco      (Mexico, 1987)
-  Hernando Rodríguez        (Colombia, 1988)
-  Efraín  Rosales           (Mexico, 1988)
-  José P. Teixeira          (Brazil, 1987)
-  Geraldo Velardo           (Brazil, 1990)
-  Guido Acurio              (PAHO/WHO)
-  Guillermo H. Dávila       (PAHO/WHO)
-  Augusta Dianderas         (PAHO/WHO)
-  Alberto Flórez            (PAHO/WHO)
-  Horst Otterstetter        (PAHO/WHO) 
-  Rodolfo Sáenz             (PAHO/WHO) 
-  Homero Silva              (PAHO/WHO) 
-  Pilar Tello               (PAHO/WHO)
-  Carlos Vergara            (PAHO/WHO) 
-  Francisco Zepeda          (PAHO/WHO) 




PREFACE


     For 30 years the Pan American Health Organization and other
international organizations have been collaborating with the
countries of the Region of the Americas in the area of urban
sanitation, mainly through manpower training and direct technical
assistance.  This effort has been fruitful and has produced some
trained personnel in the Region, especially in the large cities. 
Technology has also been advanced and personnel have been trained in
the development of sanitary landfills, whose number has grown
substantially.  At the same time progress may be noted in the
institutional approaches that are being utilized for the management
of urban sanitation services.  Despite this progress, similar changes
have not been observed in the medium and small-size cities, and low
coverage persists there as it does in the marginal areas of the large
cities.

     Faced with this constantly changing situation, the Pan American
Health Organization is attempting in this document to establish
guidelines to improve urban sanitation.  The document provides an
analysis of the current situation with regard to the organizations
involved and the national institutions responsible for leadership in
the sector.  Targets, directives, and basic strategies are proposed
for the organizations operating in large cities, and also for medium
and small-size cities through proposal for a "National Urban
Sanitation System."  Finally, an analysis is made of the role that
should be played by the Pan American Health Organization and other
binational and international cooperation organizations in developing
the sector at the regional level.

     In this document the Pan American Health Organization seeks to
provide a guide to assist the countries in improving urban sanitation
at the national level and directives that will orient and coordinate
the participation of international cooperation in a more effective
manner.


Guillermo H. Dávila
Coordinator
Environmental Health Program


CONTENTS 
Page
     

1.   BACKGROUND

2.   THE PROBLEM AND FUTURE OUTLOOK

     2.1.  Demography and Urbanization                         2.2Com
pos
iti
on
and
Qua
nti
ty
of
Was
tes
     2.3   Socioeconomic and Political Outlook                

3.   CURRENT SITUATION

     3.1   Technical and Operational Considerations           
     3.2   Institutional Factors                              

4.   GUIDELINES FOR THE COUNTRIES

     4.1   General Objective                                  
     4.2   Guidelines for the Operating Agencies 
     4.3   Guidelines for the Programs at the National Level

5.   GUIDELINES FOR PAHO AND OTHER COOPERATION AGENCIES

     5.1   Objective                                          
     5.2   Targets                                            
     5.3   Strategies                                         






GUIDELINES FOR DEVELOPMENT OF THE 

      URBAN SANITATION SECTOR IN LATIN AMERICA AND THE CARIBBEAN

1.   BACKGROUND

     In 1960 PAHO adopted its first resolution on solid wastes, which
     urged the Ministries of Health to take steps to promote and
     improve adequate final disposal of wastes and called on the
     Organization to provide collaboration and technical assistance.

     Subsequently, in 1972, in the Ten-Year Health Plan for the
     Americas, formulated by the Ministers of Health in their III
     Special Meeting in Santiago, Chile, a target for the end of the
     decade was set for the first time:  "Establish adequate systems
     for the collection, transport, treatment, and disposal of solid
     wastes in at least 70% of the cities with 20,000 population or
     more."

     In 1978, prior to the meeting of the Inter-American Association
     of Sanitary and Environmental Engineering (AIDIS), held in the
     Dominican Republic, a Regional Symposium on Solid Wastes was
     held in which both technical and institutional problems were
     identified. Although some progress was recognized in the large
     metropolises, the need was pointed out for formulating national
     urban sanitation plans that would extend the benefits of
     national technical assistance and training programs to small and
     medium-size cities, since it was observed that if deficiencies
     were great in the capital cities, they were still greater in
     other cities in the countries. 

     In 1986 the First Latin American Encounter on Hazardous Wastes
     was held in Lima, Peru, which alerted the countries to the
     problems that were being detected and to the small amount of
     attention they were receiving from the organizations responsible
     for protecting health and the environment.  A certain percentage
     of these hazardous wastes are taken to waste dumps or sanitary
     landfills.

     In 1987 and 1988 two meetings of specialists on solid wastes
     were held in Washington, D.C., to analyze the regional problem,
     draw conclusions, and propose lines of action for the countries
     and for PAHO.  The first meeting focused on Administration and
     Organization of Urban Sanitation Services, and the second dealt
     with the best means of carrying out a program of national scope
     based on organization of a "National Urban Sanitation System." 
     The reports of both meetings and the outcome of a documentary
     review of the reports of the PAHO urban sanitation consultants
     were used to prepare the first version of this document, which
     was presented to an advisory meeting held in Lima, Peru, in
     August 1990, and formed the basis for the present publication. 

     The intent of this document is to provide a compendium of
     conclusions and recommendations of these meetings and
     encounters, to analyze them, and to make a proposal regarding
     the policies and strategies the countries should adopt to
     strengthen the urban sanitation subsector and the guidelines to
     be followed by the PAHO Environmental Health Program in
     supporting the efforts of the countries.

2.   THE PROBLEM AND FUTURE OUTLOOK 

     2.1   Demography and Urbanization

     According to United Nations statistics on Latin America, in
     1975, 198 million (62%) of the 320 million population in the
     Region lived in cities.  By 1990 these figures had risen to 323
     million (72%) and 448 million (72%), respectively--that is, in
     15 years the population requiring services for the collection
     and final disposal of its solid wastes has grown by 63%.  By the
     year 2000 the population of the Region will have swelled to 540
     million, of whom 416 million will be city dwellers.  By that
     time there will be a total of 57 cities of more than one million
     population, among which the two largest in the world, Mexico
     City and Sao Paulo.  The rural population will begin to decline
     slightly from 124 to 123 million, according to United Nations
     projections.

TABLE  2.1 

Projection of Distribution of the Urban Population 


City Population                                                       
   
(thousands)           1975              1990            2000
   
No.    Mill.      No.   Mill.     No.  Mill.       
Cities   Pop.      Cities   Pop.   Cities    
    Over 4,000         5     45       10   103         17   165   
    2,000-3,999        6     16       11    34          8    22   
    1,000-2,999       11     16       21    27         32    45   
    500-999           22     15       38    26         -      -
    250-499           41     14        -     -         -      -
    100-249           90     16        -     -         -      -
    Under 100                 76         -      -      -           -  
  Total Urban          -    198        -   323         -    416      
TOTAL                       320            448              539   

2.2  Composition and Quantity of Wastes

    The evolution of societies from agrarian or agrarian-industrial
    stages to industrial-agrarian stages also brought about an
    increase and diversification in the production of goods and
    services that placed a demand on natural resources and increased
    the generation of solid wastes.  Indeed, 30 years ago the per
    capita generation of wastes was some 200 to 500 gr/day, whereas
    today it is estimated at between 500 and 1,000 gr.  In the
    developed countries this figure is two to four times greater. 
    The problem, however, does not reside only in the quantity of
    waste but also in its quality or composition, which has evolved
    from dense and almost completely organic to voluminous, partially
    nonbiodegrable, and increasingly made up of toxic materials.

    The quantity of urban solid wastes generated daily in Latin
    America in 1990 was 250,000 tons.  A fleet of 25,000 collection
    trucks and 300,000 m3 daily of space are required to collect and
    disposes of these wastes sanitarily. 

    Each one of the 40 cities with more than one million population
    in the Region requires fleets of from 100 to 1,500 trucks for
    collection and from 500 to 10,000 street sweepers to clean the
    streets.  The logistical, administrative, organizational and
    financial problems associated with this situation can only be
    handled by well organized operating agencies.  Although to a
    lesser extent, the problems are similar in medium and small-
    size cities, with the further disadvantage that they are
    physically more distant from technological development, decision-
    making, and information centers.

    Finally, the population is not properly informed of the
    environmental and health problems caused by inadequate management
    of wastes and it is not organized nor is it organized for
    participation in the solutions.  The accumulation of wastes in
    urban areas without collection or with deficient collection
    services is associated with the reproduction of disease vectors,
    bad odors, and unsightly environments.  The disposal of waste in
    open dumps or unsanitary landfills also causes contamination of
    drinking water sources. 

    2.3               Socioeconomic and Political Prospects

    In the 1970s the Region was characterized by sustained growth
    with an increase in the per capita gross domestic product from
    US$1,508 to US$2,018.  A decline began in 1980 that reached a
    minimum of US$1,812 in 1983; a subsequent upward trend took
    place, but it has moved so slowly that it is not expected that
    1990 will attain the levels current at the beginning of the
    decade.  Forecasts by economists for the 1990s, if at least not
    pessimistic, do not augur sustained growth, which has obliged the
    countries to curtail public spending.  The financial resources
    for equipment and physical works are limited.  The sanitation
    services, which require medium but constant investment in
    equipment, have been severely affected and are struggling in
    their attempts to keep equipment in operation that in other
    circumstances would have been retired.  In almost every revenues
    from rates or fees cover only a small portion of the operating
    costs, and still less when financial costs and depreciation of
    investments taken into consideration. 

    Tables 2.2 and 2.3 present some economic indicators for the
    Region.

TABLE 2.2

Evolution of Regional GDP

        
Regional Per 
Year               Capita GDP
(in US$)                     


        
1970               1,508
1975               1,740
1980               2,018
1981               1,980
1982               1,909
1983               1,812
1984               1,834
1985               1,859
1986               1,885
1987               1,898
1988               1,869


        
Source: CEPAL - Anuario Estadístico de América
Latina y el Caribe, 1989.

TABLE 2.3

Grouping of Countries by GDP (1988)

        

       
    GDP  (US$/per cap.)               C O U N T R I E S               


        
    - less than 500        Haiti and Guyana

    - 500 to 999           Bolivia, Honduras, Nicaragua, El Salvador,
and
Guatemala


    - 1,000 to 1,499       Peru, Dominican Republic, Jamaica, Panama,
Paragua
y,
Ecuador
,
Colombi
a, and
Costa
Rica

    - 1,500 to 1,999       Brazil

    - 2,000 to 2,499       Uruguay, Chile, Mexico, and Argentina

    - 2,500 to 2,999       Venezuela

    - over 3,000           Trinidad and Tobago, Barbados

    - over 10,000          Canada and USA

        
    Source:  CEPAL - Anuario Estadístico de América
Latina y el Caribe, 1989.


    In the political sphere it is expected that a more accelerated
    transition toward democracy will take place, accompanied by
    greater participation by the people in the decision-making
    process, which was previously centralized to a greater or lesser
    degree.  This process brings with it a more active role for local
    governments in planning the work projects and services and direct
    involvement of the citizenry through the various levels of civil
    society--that is, neighborhood, professional, and union
    associations, political parties, and--of great importance for
    environmental health--ecologists and environmental protection
    organizations.

    The economic growth the countries might achieve in the 1990s is
    to a great extent geared to industry and services.  This means
    that the production of industrial wastes, especially hazardous
    wastes, will increase, and that the countries are not prepared
    for managing them without causing risks for health and the
    environment.

    The limiting factors described--that is, the demographic
    explosion, the ever-increasing quantity of wastes generated by
    society, the economic crisis that has made it necessary to reduce
    public spending and maintain low rates, institutional weaknesses,
    and the lack of health education and community participation,
    have led to the situation described below. 

3.  CURRENT SITUATION

    There is are no reliable statistical controls in the countries to
    provide precise information on the problem.  However, the data
    contributed by the specialists in various meetings, together with
    other information derived from reports by sanitation institutions
    and consultants, provide an approximate picture of the current
    situation.  Table 3.1 summarizes part of the information analyzed
    in this chapter.  It also contains information on 17 of the
    principal cities in the Region.

    3.1  Technical and Operational Considerations

    3.1.1Classification of Wastes

    The great quantity and types of sources that generate solid
    wastes, together with the characteristics of these wastes, which
    range from inert to extremely hazardous, oblige the countries to
    include clear definitions and classifications of wastes in their
    laws in order to delineate the responsibilities incumbent upon
    the sector's regulatory and operational institutions, the
    generators of waste, public users, and civil society
    organizations.

    One of the most general definitions is provided by the
    Environmental Protection Agency (EPA) of the United States
    (1989), which states that ...Solid wastes are understood as any
    refuse, wastes, sludge, and other solid wastes resulting  from
    industrial, commercial, and community activities.  It does not
    include solids or materials dissolved in household sewage waters
    or any other significant pollutant in the water resources such as
    sludge, solids suspended or dissolved in industrial wastewater
    effluents, materials dissolved in irrigation outlet channels, or
    other common contaminants in the water.  This definition provides
    an implicit classification of wastes according to their origin or
    source.  Brazilian legislation further classifies wastes as
    hazardous, inert, and non-inert--that is, it classifies them
    according to one or another of their characteristics.

    With regard to hazardous wastes, EPA states that...Hazardous
    wastes are understood to means any combination of wastes that
    represents an immediate or potential danger for human health or
    for other living organisms by virtue of the fact that they are
    not degradable or persist in nature, they can be increased
    biologically, they can be lethal, or for any other reason they
    can cause or tend to cause cumulative detrimental effects. 
    Brazilian legislation defines such wastes in a similar manner,
    while Mexico's makes no mention at all of the damages to human
    health and is limited to defining them by their toxic
    characteristics, such as corrosive, infectious, etc.  Colombian
    legislation covers only the latter without referring either to
    public health or the environment.

    3.1.2Generation and Composition of Wastes

    The generation of household waste in the Region ranges from 0.3
    to 0.6 kg/per cap./day.  When household wastes are compounded
    with other municipal wastes, such as those generated by
    businesses, hospitals, markets, and street sweeping, this
    quantity is possibly increased by 50%, which means that overall
    generation is from 0.5 to 1.0 kg. per capita, with a regional
    average of 0.7.  Table 3.2 shows the generation of waste in some
    countries and cities.  Waste composition may be interpreted, on
    the one hand, as an indicator of average family income and of the
    current extent of consumerism, and on the other, as an indication
    of the value of recovery of wastes for recycling.  Table 3.3
    shows the results of some analyses of composition percentages
    made under varying moisture conditions.

    Actually, for the purposes of comparison, all samples should be
    reduced to a single moisture percentage.  Table 3.3 shows a
    relationship between the Gross National Product (GNP) of the
    country and the "quality" of the waste, which may be interpreted
    by means of the percentage of paper it contains.

    Other important parameters that differentiate the waste of the
    countries of the Region from the waste of the developed countries
    are moisture, which ranges from 35% to 55%, and density, which
    ranges from 125 to 250 kg/m3 when it is weighed loose, from 375
    to 550 kg/m3 when it is in a compactor truck, and from 700 to
    1,000 kg/m3 when it is compacted in sanitary landfills.



TABLE 3.2

Per Capita Generation in Some Countries and Cities



        

  COUNTRIES                                     CITIES

        

Canada             1,900   k/p.c./d  Mexico City.      0.900  
k/p.c./d
    USA.           1,500     "       Rio de Janeiro    0.900     "
    Netherlands    1,300     "       Buenos Aires      0.800     "
    Switzerland    1,200     "       San José          0.740     "
    Japan          1,000     "       San Salvador      0.680     "
    Europe(others) 0.900     "       Tegucigalpa       0.520     "
    India          0.400     "       Lima              0.500     "

        



TABLE 3.3

Composition of Wastes (% in weight) in Various Countries 


Country      Sweden     USA  Japan   Europe   Mexico  El Salv. Peru   India
P.cap. GDP
(relative)*    54       51     39      40        9     3         5       1 
H20 (%)        -        25      -      30       45     -        50      50  
Cardboard
  and Paper         44.0    36.0  40.0   30.0   20.0  18.0   10.0     2.0
Metal                7.0     9.2   2.5    5.0    3.2   0.8    2.1     0.1
Glass                5.0     9.8   1.0    7.0    8.2   0.8    1.3     0.2
Textiles             -       2.1   -      3.0    4.2   4.2    1.4     3.0
Plastic             10.0     7.2   7.0    6.0    3.8   6.1    3.2     1.0
Organic              -      26.0   -     30.0   50.0  43.0   50.0    75.0
Other               34.0     9.7  49.5   19.0   10.6  27.1   32.0    18.7

* Per capita Gross National Product compared to that of India. 



3.1.3   Storage in the Home and Special Cases

        There are few cities where appropriate storage of waste is available in
        homes, businesses, hospitals, and other places where there is a great
        amount of waste generation.  As far as is known, standard use of
        containers or plastic bags has been only partially achieved in Havana,
        Rio de Janeiro, and Buenos Aires.  In other cities only the higher
        income have appropriate storage containers; in the lower income groups
        only health education is provided to encourage low-cost changes in the
        containers used. 

        Other special storage problems also represent a risk for health, such
        as waste management in hospitals.  At the country level it is known
        that Chile has good management of such wastes, as do certain other
        cities such as Rio de Janeiro and Sao Paulo.  For years incinerators
        have been installed in the hospitals to burn wastes; however, this
        operation is expensive and administrators prefer to take the waste to
        disposal sites in the city.  One way of lowering costs consists of
        installing incinerators that burn only the infectious components of the
        waste, which requires an internal management arrangement that separates
        them inside the hospital.  Other typical storage problems arise in
        markets, industries, and community disposal sites--either clandestine
        or tolerated--that are formed in peripheral areas where there is no
        service and the people are accustomed to placing their refuse in vacant
        lots or on the public thoroughfare, where it is picked up sporadically
        by trucks detailed for this kind of collection.

        3.1.4Street Sweeping and Public Sanitation 

        This kind of sanitation service is performed mainly on paved
        thoroughfares with heavy pedestrian traffic.  In the Latin American
        cities street sweepers cover from 1.0 to 2.5 km/day of street (or 2.0
        to 5.0 km of gutter) and collect from 30 to 90 kg of refuse per
        kilometer.  Between 0.4 and 0.8 street sweepers are required for every
        1,000 population, depending on the support of mechanical sweeping, the
        proportion of paved to unpaved streets, the degree of difficulty of
        sweeping, and the educational level and cooperation of the community. 
        Some cities are more difficult to sweep than others, such as Rio de
        Janeiro, which requires cleaning of its beaches.  The cost of sweeping
        per kilometer of street varies from US$.50 to US$1.50, according to
        labor costs and the degree of difficulty involved.  Mechanical sweeping
        costs less but causes job losses and the outflow of foreign exchange,
        since automated street sweeping equipment must be imported.  Table 3.4
        provides information on sweeping in some cities in the Region.

        3.1.5 Collection

        According to Table 3.1, the average coverage of this service is 82% in
        the large cities and much less in smaller size-cities.  Collection
        employs between 0.2 and 0.4 workers per 1,000 population depending on
        the amount of generation per inhabitant, the concentration of wastes,
        and the degree of difficulty of the route.  On average each worker
        collects between 2 and 5 tons per day.  The equipment most used is the
        compactor truck.  With a capacity of 10 to 15 m3, it makes two trips,
        collecting from 4 to 8 tons per shift.  In the case of trucks which
        because of labor conditions can make only one trip, the trucks have to
        work two shifts.  The high and medium-income areas are well served, but
        in marginal, low-income areas the services are only sporadic, precisely
        where overcrowding and precarious housing conditions demand more
        frequent collection.  Unfortunately, less attention is given to these
        areas because of the low payment capacity of their inhabitants. 

        In countries such as Bolivia, Brazil, Colombia, Guatemala, El Salvador,
        Honduras, Mexico, and Peru unconventional methods of collection with
        community participation have been tried.  These methods of primary
        collection tend to replace part of the conventional collection
        equipment with manually operated or semi-mechanized carts, which
        provides jobs to some of the population in the area served.  So far
        these experiences have been at the pilot level.  Other methods consist
        of providing containers that are loaded mechanically with compactor
        trucks provided with lifting devices.  The people in the surrounding
        areas take their waste to containers, thereby lowering the cost of the
        services.  In the Region the collection costs range from US$12 to US$25
        per ton, and in the United States from US$25 to US$75.  As a result of
        national actions the countries reporting the most progress are Cuba and
        Chile.  In the latter collection coverage in the urban populations has
        reached 98.2%.  In the rest of the countries the medium and small-
        size cities of the interior have much lower coverage, and they are
        always subject to critical equipment problems.  Table 3.5 presents
        information on collection in the Region.

        3.1.6Transfer

        Migration from rural areas to the cities, couple with the natural
        increase in the population, have resulted in annual growth rates on the
        order of 3% to 5% in the Region's cities.  This has brought about
        accelerated expansion of the urban population, which makes it
        increasingly difficult to find appropriate sites for final waste
        disposal by reason neighborhood opposition and the cost of the lands
        involved.  The great distances to new sanitary landfills have led to
        the growing use of transfer stations that enable waste to be
        transported in units of 40 m3 to 60 m3 with lower unit transportation
        costs.  Stations of this kind exist in countries such as Brazil,
        Argentina, Colombia, Mexico, Peru, and Venezuela, and others are being
        planned in Bolivia and Ecuador.  In cities such as Rio de Janeiro,
        Mexico City, Caracas, and Buenos Aires more than 50% of collected
        wastes pass through transfer stations, and it is expected that they
        will be used more and more frequently in the Region.

        The costs of these services range from US$1.50 to US$3.50 per ton,
        according to the transport distance involved.  Current costs in the
        United States range between US$8 and US$20.  Table 3.6 provides
        information on some transfer stations in the Region.

        3.1.7Sanitary Landfills

        In Table 3.1, which includes 17 large cities, it may be seen that 25%
        of collected waste is transferred to open dumps, 30% is taken to
        landfills under fair management conditions--or "controlled landfills"-
        -and almost 45% goes to good quality landfills or "sanitary landfills." 
        If these figures are compared with those of slightly more than a decade
        ago, it may be considered that good progress has been made.  However,
        it should be noted that this has taken place in only a small number of
        very large cities, a factor that has produced deviations in statistical
        parameters that may lead to exaggerated optimism.  Indeed, the
        situation in the medium and small-size cities is not very promising. 
        In Brazil, a survey conducted at the national level showed that 57% of
        the cities had open dumps, 14% had controlled landfills, and 29% had
        sanitary landfills or some other appropriate method for final disposal. 
        Chile is reported to have attained a coverage of 72.3% at the national
        level, and Mexico 30%.  No other country--such as Bolivia, Ecuador,
        Peru, and most of the countries of Central America, excluding the
        capital cities--has a sanitary landfill.

        The characteristics of the waste, such as its moisture and composition,
        have effects on the sanitary landfills in the Region that differ from
        those described in the technical literature of the developed countries. 
        The density of the compacted waste is greater and thus the periods of
        design or useful life of the landfills are longer than those planned
        initially.  Moisture and compaction accelerate the methane-producing
        stage of decomposition in such a way that the production of biogas
        takes place earlier on.  Biogas is used in natural-gas distribution
        networks and as a fuel for waste collection in countries such as Brazil
        and Chile, and, in the near future, Uruguay.  It should be noted that
        none of these countries is an oil exporter.
        As previously mentioned, if the 250,000 tons of urban waste produced in
        the Region daily were taken to sanitary landfills, 300,000 m3 per day
        of space would be required for their deposit.  This gives an idea of
        the needs for land and of the need to formulate strategies aimed at
        granting priority to operating organizations in competing for urban or
        suburban lands.

        The costs of operating sanitary landfills in the Region vary from
        US$1.00 to US$3.00 per ton, with some exceptional cases of up to
        US$6.00, according to the size and quality of the operation, the
        topography, and the hydrologic and hydrogeological conditions of the
        site selected.

        In the United States, where regulation is becoming increasingly strict,
        costs range from US$12 to US$50 per ton.  Table 3.7 provides
        information on the sanitary landfills of some cities in the Region.

        The problem of human refuse separators continues in almost all the
        cities, thereby hampering, in most cases, safe and sanitary operation
        of sanitary landfills.

        One of the greatest problems is the operation of sanitary landfills in
        small cities of less than 50,000 population, since the costs of capital
        and operation of a tractor for such small amounts of refuse do not
        permit economies of scale.  At this point it should be mentioned that
        the manual sanitary landfill program is being implemented in Colombia
        and may provide a solution to these kinds of problems.

        3.1.8  Treatment, Utilization, and Recycling

        In the developed countries the most common forms of use of waste or of
        its by-products are sanitary landfills that use biogas, incineration
        that utilizes the energy produced, biotransformation from composting,
        and the production of auxiliary fuel or refuse-derived fuel (RDF).  The
        great majority of these processes are based on prior selection of
        recyclable materials, which may be achieved through prior separation
        either where the refuse is generated or in the plant where the
        principal process is carried out.  In the developed countries the
        growing costs of sanitary landfills make the processes of incineration
        and composting competitive, even though advanced technology is
        employed.  In the developing countries, however, sophisticated
        treatment may cost as much as 20 times more than sanitary landfills. 
        For that reason incineration in the Region has been disappearing, so
        that now only small incinerators for special wastes remain, mainly in
        hospitals and in industry.  The production of compost through
        simplified processes such as are piling, rotary biodigesters, and more
        recently, vermiculture, are also been being abandoned because of their
        cost and because their promoters convinced the municipal authorities
        that they would obtain profits when it was proven that the use of
        ecologically more acceptable alternatives had an associated cost.  It
        is estimated that in the last 20 years no fewer than 30 compost plants
        have been purchased in the Region; however, instances are known of the
        machinery being purchased and abandoned even before it was installed,
        and at least 15 others which closed down after a few years because the
        municipalities refused to continue to subsidize them.  Table 3.8
        provides information on trends in treatment and final disposal in
        various parts of the world.



TABLE 3.8


Trends in Treatment and Final Disposal 
in Various Countries and Regions



Treatment or Final Disposal (%)        
Country or                Sanitary      Combustion  Compost             
Region                    Landfill                                 
(or dump)                                

    United States          80          19           1
    England                10          -            1
    Japan                  30          70           2
    Germany                70          30           3
    France                 55          40           9
    Switzerland            20          80           1
    Sweden                 40          55           5
    Spain                  80          15           5
    Latin America          98           1           1

       

    Little detailed information is available on compost plants
    in Latin America; however, the following is known:  


    Acapulco, MEX       A plant was purchased and never installed;
the machinery was abandoned. 

    Guadalajara, MEX    160 tons/shift functioned for 15 years
(closed).

    Monterrey, MEX      160 tons/shift functioned for 15 years
(closed).

    Oaxaca, MEX         80 tons/shift, in operation.

    San Salvador, ELS   Closed for more than 20 years.

    Venezuela           A plant was acquired but never became
operational. 

    Quito, ECU          5 tons/shift pilot plant with rotary
biodigester has functioned for more than 20
years.

    Cuenca, ECU         Pilot plant with rotary biodigester in
operation.

    Guayaquil, ECU      A plant was purchased but never installed,
which produced a political crisis.

    Brasilia, BRA       A plant was installed that encountered many
difficulties in the beginning of its
operations.

    Brazil              A certain number of small plants have been
installed whose operation has not been
evaluated over the medium-term.  Large plants
are in operation in Sao Paulo and Rio de
Janeiro.

    Table 3.9 provides more detailed information on other plants in
    operation.  They are all of the compost type, with the exception
    of the network of plants for food for pigs in all the provinces
    in Cuba, regarding which no further details are available. 

    Recycling, on the other hand, is widely and profitably practiced. 
    Because of the low content of recyclable materials produced by
    households in the Region as compared with that of the developed
    countries, one individual in the United States  generates from 20
    to 30 times more paper than a Peruvian, and the applicable
    recycling methods are also different.  The most important factor
    is the market for recovered materials, since if there are no
    factories for reprocessing, recycling will be confined merely to
    reuse. 

    The extent of recycling in the countries is not known, but it is
    believed to be high.  It is achieved in two ways:  the first is
    through separation in households and in other sources that
    generate recyclable materials (paper and cardboard, bottles,
    plastics, and ferrous materials) for sale to specialized private
    collectors or for delivery to "separated collection programs"
    managed by the municipios; the second consists of removing
    recyclables from the mixed refuse, either from the containers the
    public deposits in the street, from the collection truck by
    sanitation workers, or from recycling plants or sanitary
    landfills.

    In Japan recycling has already reached 50%, and in the United
    States 10%, with plans of attaining 25% in three years' time.  In
    the countries in the Region this figure should range between 10
    and 40%.  In Mexico City, for example, it is estimated that
    refuse separation in the trucks is 2.5%, and in landfills, 10%. 
    To this should be added a possibly greater quantity that is
    recycled at the source--namely, in homes, houses, offices,
    restaurants, and industries.  The Mexican glass industry, for
    example, reports national recovery of 60% of its production. 
    Twenty-five percent of the raw materials used by the Peruvian
    paper industry consists of recycled material. In Colombia
    recycling programs have been implemented in several cities based
    on a very interesting social approach that should be documented
    with a view to considering their application in other countries. 
    All recycling projects should give priority to social
    considerations and recognize that the human separators who make
    possible this recycling, which is so important for the economy
    and the ecology, live and work under unacceptable sanitary
    conditions.



C.   SUMMARY OF BILATERAL AGREEMENTS BY COUNTRIES

     1.   BOLIVIA

Bolivia negotiated preliminary agreements with:

COUNTRIESAGREEMENTSUBJECTCOLOMBIA0001BCG Vaccine

0002         Parenteral Fluids
Genetic Probes 
In Vitro Fertilization
Embryo Transfer

0003         Techniques of Autotransfusion
Reuse of Syringes and Probes
Laminar Flow 

    ECUADOR       0050         Radioactive Drugs
Goitrogenic Plants and Substances

0051         In Vitro Tissue Cultures 

0052         Diagnostic Kits 
Hormone Dosage

    PERU          0020         Tuberculosis and AIDS Networks 
Exchange of Information

0021         Training
Production of Biologicals
Rabies Vaccine
Diagnostic Kits 
Laboratory Supplies 
Exchange and Supply of Strains

0022         Medicinal plants
Extraction of Active Principles

0023         Quality Control of Drugs
Toxic Substances
Standardization
COUNTRIESAGREEMENTSUBJECTPeru (Cont.)0024Exchange of
Information
Chagas'
Leishmaniasis
Malaria
Anthropozoonoses 
Cysticercosis 
Distomatosis 
Hydatidosis
Tapeworms
Joint Research

0025         Training
Maintenance
Medical Equipment
Shared Expenses

    VENEZUELA     0038         BCG Vaccines
Effectiveness 

0039         Information
Quality Control
BCG Vaccine

0040         Production
Marketing
Biologicals
Vaccines
Commercial Agreement

0041         Exchanges of Experts
Manpower Training 
Child Rehabilitation

0042         Scientific Information
Synthesis of Active Principles
Medicinal Plants

0043         Industrial Complementarity

2. COLOMBIA

    Colombia negotiated preliminary agreements with:
COUNTRIESAGREEMENTSUBJECT
    BOLIVIA       0001         BCG Vaccine

0002         Parenteral Fluids
Genetic Probes 
In Vitro Fertilization 
Embryo Transfer

0003         Techniques of Autotransfusion
Reuse of Syringes and Probes
Laminar Flow 

    ECUADOR       0014         Vaccine Effectiveness 
Leishmaniasis
Cholera
Hepatitis-B
Delta Hepatitis
Malaria

0015         Laboratory Networks
Research
Training
Transfer of Technologies
Testing of Diagnostic Kits and  Vaccines
Exchange of Information

0016         Insulin
Albumin
Human Gamma Globulin

0017         Meeting
Production
Biologicals
Vaccines
Human Use
Animal Use
New Markets
Technical Potential 
Financial Potential 
COUNTRIESAGREEMENTSUBJECT
    Ecuador(cont.) 0018        Information Network
Medicinal Plants

0019         Meeting
Manufacturers
Medical-Hospital Equipment

    PERU          0033         Information
Production
Rabies Vaccine

0034         Information
Research
Cholera Vaccine 

0035         Malaria Vaccine 

0036         Consortium
Production
Medical-Hospital Equipment

0037         Information
Production
Drugs  
Essential Drugs

    VENEZUELA     0053         Missions
Biologicals
Vaccines

0054         Production
Quality Control
Vaccines
Biologicals
DPT
BCG
Human and Canine Rabies 
Antivenomous Sera 
Febrile Antigens
DPT Vaccines 
COUNTRIESAGREEMENTSUBJECT
   Venezuela (cont.)
0055         Information
Vaccine
Leishmaniasis

0056         Microcarrier Technique 
Production
In Vitro Cells

0057         Information
Drugs 
Production
Essential Drugs
3. ECUADOR

    Ecuador negotiated preliminary agreements with:
COUNTRIESAGREEMENTSUBJECT
    BOLIVIA       0050         Radioactive Drugs
Goitrogenic Plants and Substances

0051         In Vitro Tissue Culture 

0052         Diagnosis Kits
Hormone Dosage

    COLOMBIA      0014         Effectiveness Vaccine 
Leishmaniasis
Cholera
Hepatitis-B
Delta Hepatitis
Malaria

0015         Laboratory Networks
Research
Training
Transfer of Technologies
Testing of Diagnostic Kits and     Vaccines
Exchange of Information

0016         Insulin
Albumin
Human Gamma Globulin

0017         Meeting
Production
Biologicals
Vaccines
Human Use
Animal Use
New Markets
Technical Potential 
Financial Potential 

    
COUNTRIESAGREEMENTSUBJECTColombia
(cont.)
0018         Information Network
Medicinal Plants

0019         Meeting
Manufacturers
Medical-Hospital Equipment

    PERU          0044         Rabies Vaccine
Antivenomous Serum 

0045         Generic Drugs

0046         Medical Instruments and Equipment
Meeting

0047         Research Network 
Vaccines
Biologicals

0048         Medicinal Plants

0049         Biological Materials for Dentistry


    VENEZUELA     0026         Consortium
Production and Markets
DPT Vaccines 
Human Rabies Vaccine

0027         Exchange of Technology
Freeze-dried BCG Vaccine
Hyperimmune Sera
Vaccines for Animal Use 
Laboratory Animals
Quality Control

0028         Pilot Plant
Manufacture
Pharmaceutical Chemical Products
Active Principles
Importation
COUNTRIESAGREEMENTSUBJECT
    Venezuela (Cont..)
0029         Industrial Meeting 
Medical-Chemical Instruments
Hospital Equipment

0030         Maintenance
Physical Infrastructure
Medical Equipment and Materials

0031         Collaborative Network
Biotechnology
Data Base
Protocols for Collaboration
Critical Supplies
Media and Reagents

0032         Biological Materials
Dental Equipment and Work Spaces


4. PERU

    Peru negotiated preliminary agreements with:
COUNTRIESAGREEMENTSUBJECT
    BOLIVIA       0020         Tuberculosis and AIDS Networks 
Exchange of Information

0021         Training
Production of Biologicals
Rabies Vaccine
Diagnostic Kits 
Laboratory Supplies 
Exchange and Supply of Strains

0022         Medicinal plants
Extraction of Active Principles

0023         Quality Control of Drugs
Toxic Substances
Standardization

0024         Exchange of Information
Chagas'
Leishmaniasis
Malaria
Anthropozoonoses 
Cysticercosis 
Distomatosis 
Hydatidosis
Tapeworms
Joint Research

0025         Training
Maintenance
Medical Equipment
Shared Expenses

    COLOMBIA      0033         Information
Production
Rabies Vaccine


COUNTRIESAGREEMENTSUBJECTSColombia
(cont.)
0034         Information
Research
Cholera Vaccine 

0035         Malaria Vaccine 

0036         Consortium
Production
Medical-Hospital Equipment

0037         Information
Production
Drugs 
Essential Drugs

    ECUADOR       0044         Rabies Vaccine
Antivenomous Serum 

0045         Generic Drugs

0046         Medical Instruments and Equipment 
Meeting

0047         Research Network
Vaccines
Biologicals

0048         Medicinal Plants

0049         Biological Materials for Dentistry

    VENEZUELA     0004         Information
Diagnostic Laboratory
Communicable Diseases

0005         Lines of Research
Scientific Publications
Bank of Projects

0006         Cell Lines
COUNTRIESAGREEMENTSUBJECT
    Venezuela (cont.)
0007         Diagnosis Kits 
Hepatitis
Cytomegalovirus 
Herpes

0008         Production
Biologicals
DPT Vaccine

0009         Production
Generic Drugs
Therapeutic Plants

0010         Common Standards
Registration and Quality Control
Molecular Biology
Genetic Engineering

0011         Parasitic Diseases
Leishmaniasis
Chagas'
Malaria
Joint Research

0012         Training of Technicians
Equipment
Physical Infrastructure

0013         Quality Control
Cosmetics
In Vitro and In Vivo Experimental Techniques 

Internships




5. VENEZUELA

    Venezuela negotiated preliminary agreements with:
COUNTRIESAGREEMENTSUBJECT
    BOLIVIA       0038         BCG Vaccines
Effectiveness 

0039         Information
Quality Control
BCG Vaccine

0040         Production
Marketing
Biologicals
Vaccines
Commercial Agreement

0041         Exchanges of Experts
Training of Human Resources
Child Rehabilitation

0042         Scientific Information
Synthesis of Active Principles
Medicinal Plants

0043         Industrial Complementarity


    COLOMBIA      0053         Missions
Biologicals
Vaccines

0054         Production
Quality Control
Vaccines
Biologicals
DPT
BCG
Human and Canine Rabies
Antivenomous Sera 
Febrile Antigens
DPT Vaccines 
COUNTRIESAGREEMENTSUBJECT
    Colombia (cont.)
0055         Information
Vaccine
Leishmaniasis

0056         Microcarrier Technique
Production
In Vitro Cells 

0057         Information
Drugs 
Production
Essential Drugs


    ECUADOR       0026         Consortium
Production and Markets
DPT Vaccines 
Human Rabies Vaccine

0027         Exchange of Technology
Freeze-dried BCG Vaccine
Hyperimmune Sera
Vaccines for Animal Use 
Laboratory Animals
Quality Control

0028         Pilot Plant
Manufacture
Pharmaceutical Chemical Products
Active Principles
Importation

0029         Industrial Meeting 
Medical-Chemical Instruments
Hospital Equipment

0030         Maintenance
Physical Infrastructure
Medical Equipment and MaterialsCOUNTRIESAGREEMENTSUBJECT
    Ecuador (cont.)
0031         Collaborative Network
Biotechnology 
Data Base
Protocols for Collaboration
Critical Supplies
Media and Reagents

0032         Biological Materials
Dental Equipment and Work Spaces

    PERU          0004         Information
Diagnostic Laboratory
Communicable Diseases

0005         Lines of Research
Scientific Publications
Bank of Projects

0006         Cell Lines

0007         Diagnosis Kits 
Hepatitis
Cytomegalovirus 
Herpes

0008         Production
Biologicals
DPT Vaccines

0009         Production
Generic Drugs
Therapeutic Plants

0010         Common Standards
Registration and Quality Control
Molecular Biology
Genetic Engineering
COUNTRIESAGREEMENTSUBJECT
    Peru (cont.)
0011         Parasitic Diseases
Leishmaniasis
Chagas'
Malaria
Joint Research

0012         Training of Technicians
Equipment
Physical Infrastructure

0013         Quality Control
Cosmetics
In vitro and In Vivo Experimental Techniques 
Internships

D. SUMMARY OF BILATERAL AGREEMENTS BY AREA

    The following is a breakdown by technological area of the preliminary agreements
negotiated by the countries:  
AGREEMENTSUBJECTCOUNTRIES
1. VACCINES

    0001         Effectiveness                      BOL/COL
BCG Vaccine

    0008         DPT Vaccines                       PER/VEN

    0014         Vaccine Effectiveness              COL/ECU
Leishmaniasis
Cholera
Hepatitis B and Delta Hepatitis
Malaria

    0015         Vaccines                           COL/ECU

    0017         Vaccines for Human Use             COL/ECU
Vaccines for Animal Use 

    0021         Rabies Vaccine                     BOL/PER

    0026         Consortium                         ECU/VEN
Production
DPT Vaccines 
Human Rabies 
Markets

    0027         Technological Exchange             ECU/VEN
Freeze-dried BCG Vaccine

    0033         Information                        COL/PER
Production
Rabies Vaccine

    0034         Information                        COL/PER
Research
Vaccine
Cholera AGREEMENTSUBJECTCOUNTRIES0035Information
COL/PER
Vaccine
Malaria

    0038         Effectiveness                      BOL/VEN
BCG Vaccine

    0039         Information                        BOL/VEN
Quality Control
BCG Vaccine

    0040         Production                         BOL/VEN
Marketing 
Vaccines
Commercial Agreement

    0044         Rabies Vaccine                     ECU/PER

    0047         Research                           ECU/PER
Vaccines

    0053         Missions                           COL/VEN
Vaccines

    0054         Production                         COL/VEN
Quality Control
Vaccines
DPT
BCG
Human Rabies 
Canine Rabies 

    0055         Information                        COL/VEN
Vaccine for Leishmaniasis

2. BIOLOGICALS

    0006         Cell Lines                         PER/VEN

    0007         Diagnostic Kits:
Hepatitis, Cytomegalovirus,       PER/VEN
and HerpesAGREEMENTSUBJECTCOUNTRIES
    0008         Production of Biologicals         PER/VEN

    0010         Registration and Quality Control  PER/VEN
Common Standards
Molecular Biology
Genetic Engineering

    0015         Biologicals                        COL/ECU
Research
Training
Transfer of Technology
Testing of Diagnostic Kits
Information

    0016         Insulin                            COL/ECU
Albumin
Gamma globulin
Research

    0017         Meeting                            COL/ECU
National Institutes of Hygiene
Production of Biologicals
New Markets

    0021         Training                          BOL/PER
Production of Biologicals
Diagnostic Kits
Supply of Strains

    0027         Hyperimmune Sera                  ECU/VEN
Quality Control

    0040         Production                        BOL/VEN
Marketing
Biologicals
Commercial Agreement

    0044         Antivenomous Serum                ECU/PER

AGREEMENTSUBJECTCOUNTRIES
    0045         Research                          ECU/PER
Vaccines
Biologicals

    0052         Diagnostic Kits                   BOL/ECU
Hormone Dosage
    
    0053         Missions                          COL/VEN
Biologicals

    0054         Production                        COL/VEN
Quality Control
Antivenomous Sera 
Febrile Antigens

    0056         Microcomputers                    COL/VEN
In Vitro Production of Cells

3. DRUGS

    0002         Parenteral Fluids                 BOL/COL

    0009         Production of Generic Drugs       PER/VEN
Plants for Therapeutic Purposes 

    0013         Quality Control of Cosmetics      PER/VEN
Experimental Techniques
Courses
Internships

    0014         Information Network                COL/ECU
Medicinal Plants

    0022         Medicinal Plants                  BOL/PER
Active Principles

    0028         Pilot Plant                       ECU/ VEN
Manufacture
Pharmaceutical Chemical Products
Active Principles
Importation
AGREEMENTSUBJECTCOUNTRIES
    0037         Information                        COL/PER
Production
Drugs
Essential Drugs

    0042         Scientific Information            BOL/VEN
Synthesis of Active Principles
Medicinal Plants

    0043         Drugs                             BOL/VEN
Industrial Complementarity

    0045         Generic Drugs                     ECU/PER

    0048         Medicinal Plants                  ECU/PER

    0050         Radioactive Drugs                 BOL/ECU

    0057         Information                        COL/ VEN
Synthesis of Drugs 
Production
Essential Drugs

4. MEDICAL DEVICES

    0003         Reuse of Syringes and Probes      BOL/COL
Laminar Flow 

    0012         Training of Technicians           PER/VEN
Technical Services
Medical Equipment

    0019         Manufacturers                      COL/ECU
Production of Medical-Hospital Equipment 
Meeting

    0025         Training                          BOL/PER
Maintenance
Medical Equipment
Shared Expenses
AGREEMENTSUBJECTCOUNTRIES
    0029         Industrial Meeting                ECU/VEN
Medical-Surgical Instruments
Hospital Equipment

    0030         Maintenance                       ECU/ VEN
Physical Infrastructure

    0036         Consortium                        COL/PER
Production
Medical-Hospital Equipment

    0046         Meeting                           ECU/PER
Medical Instruments and Equipment

5. LABORATORIES

    0015         Laboratory Network                 COL/ECU

    0020         National Networks                  BOL/PER
Tuberculosis
AIDS
Exchange of Information

    0021         Laboratory Supplies               BOL/PER
Exchange
Supply of Strains

    0027         Laboratory Animals                ECU/VEN
Quality Control

    0031         Media and Reagents                ECU/VEN

6. RESEARCH AND DEVELOPMENT

    0005         Lines of Research                 PER/ VEN
Scientific Publications
Bank of Projects
AGREEMENTSUBJECTCOUNTRIES
    0011         Joint Research                    PER/VEN
Parasitic Diseases
Leishmaniasis
Chagas'
Malaria

    0024         Exchange Information              BOL/PER
Parasitic Diseases
Chagas'
Leishmaniasis
Malaria
Anthropozoonoses 
Cysticercosis 
Distomatosis 
Hydatidosis
Tapeworm
Joint Research

    0031         Collaborative Network             ECU/VEN
Biotechnology
Data Base
Protocols for Collaboration

    0047         Research
Vaccines
Biologicals

7. ORAL HEALTH  

    0032         Biological Materials for DentistryECU/ VEN
Work Spaces
Dental Equipment

    0049         Biological Materials for DentistryECU/PER

8. INFORMATION SYSTEMS
    
    0004         Information System                PER/VEN
Laboratory Network

AGREEMENTSUBJECTCOUNTRIES
    0018         Information Network                COL/ECU
Medicinal Plants

9. TRANSFUSION MEDICINE

    0003         Autotransfusion                   BOL/COL

10. HUMAN REPRODUCTION

    0002         In Vitro Fertilization            BOL/COL
Embryo Transfer
Genetic Probes 

11. FOOD/NUTRITION

    0051         Research                          BOL/ECU
Food Plants  
Goitrogenic Substances
In Vitro Tissue Cultures 

12. REHABILITATION

    0041         Information                       BOL/VEN
Exchange of Experts
Human Resource Training
Child Rehabilitation
E. STRATEGIC INTEGRATION PROJECTS PREPARED

    Project #001ANDEAN CONSORTIUM FOR THE SUPPLY OF BIOLOGICALS
AND VACCINES

        a) General Objective

To supply traditional vaccines and biologicals to the Andean Subregion.

        b) Specific Objectives

1. Evaluation of the installed capacity and potential for expansion.

2. Marketing studies in the subregion.

3. Feasibility of negotiated production levels and an economic and
financial study.

4. Study and agreement on a legal framework for the consortium
(taxation, health records). 

5. Promotion of the necessary political decisions.

6. Studies of marketing mechanisms (revolving fund).

        c) Sources of Financing

-  Andean Development Corporation (ADC).  

-  European Economic Community (EEC).

-  Ibero-American Cooperation Institute (ICI).

-  United Nations Development Program (UNDP) Cycle V.

-  UNICEF

        d) Executing Agencies

PAHO/WHO in coordination with LAES and UNDP.

       e) National Agencies in Charge

BOLIVIA      Ministry of Social Welfare and Public Health 
Dr. Fernando Ladadensa - Chief of Cabinet 

COLOMBIA     Ministry of Health 
Instituto Nacional de Salud (INS)
Dr. Antonio Iglesias - Director

Scientific and Technical Development
Dr. José Armando Porras - Director

ECUADOR      Ministry of Public Health 
Instituto de Investigaciones para el Desarrollo de la Salud
Dr. Fernando Sempértegui - Director

CONACYT
Eng. Oscar Aguirre - Executive Director 

Instituto Nacional de Higiene y Medicina Tropical
"Leopoldo Izquieta Pérez" 
Dr. Gualberto Avalos - National Director 

PERU         Ministry of Public Health 
Office of International Cooperation 
Dr. Eugenio Villar - Technical Director 

Instituto Nacional de Salud
Dr. Carlos Carrillo - Chief 

VENEZUELA    Ministry of Health and Social Assistance 
Dirección General Sector de Salud Pública Internacional
Dr. Teolinda Galicia de Núñez
General Sectoral Director

Instituto Nacional de Higiene "Rafael Rangel" 
Dr. María Carmona de Chacón - President

        f) Specific Activities

- PAHO/WHO will finalize the project proposal and submit it to the
countries for approval.

- The Government of Venezuela, through agencies designated by the
countries of the Subregion, will present and negotiate the project proposal
with ADC, carry out the corresponding follow-up, and inform the rest of
the countries as to the status of the negotiations.

- Each country will send ADC a letter expressing its support for
Venezuela's efforts.
   Project #002ANDEAN NETWORK FOR RESEARCH AND DEVELOPMENT
IN HEALTH BIOTECHNOLOGY

        a) General Objective

To promote and develop health biotechnology by complementing and
integrating scientific and technological capacities and resources in the
countries of the Andean Subregion.

        b) Specific Objective

To create an Andean Network of Centers for Research and Development
in Health Biotechnology.

        c) Activities

1. Situational analysis of the development of health biotechnology in
each country of the subregion.

2. Identification of the biotechnology needs in the countries of the
subregion, with emphasis on the specific needs of the research centers
in the countries. 

3. Establishment of the information network using as a reference the data
base of the Latin American and Caribbean Information Network on
Biological Sciences (RIBLAC) located at IVIC.

4. Organization of a meeting of the managers of the research centers in
order to establish the networks and define the protocols for
collaboration.

Possible elements to be included in the cooperation protocols:

- System of linkage between the network and the Andean Consortium
for the supply of biologicals and vaccines.  

- Mechanism for exchanging input.

- Transfer of technologies, institutionalization, etc.

- Mechanisms for exchanging scientific information and information
on available products (new strains, supplies, protocols, software
packages).

- Financial sources and mechanisms to make the network operational.

- Joint development of new vaccines, biologicals derived from blood,
reagents, and other materials. 

        d) Sources of financing for establishment of the network

-   UNESCO
-   "Pérez Guerrero" Trust Fund
-   ADC 

        e) Executing Institution

PAHO/WHO in coordination with UNDP and LAES

        f) Participating National Centers

BOLIVIA

*   Instituto Boliviano de Biología de Altura
Dr. Enrique Vargas - Director
 
*   Instituto Nacional de Laboratorios de Salud
Dr. Bolaños - Director

*   Centro Nacional de Enfermedades Tropicales
Dr. Rivera - Director

*   Instituto Nacional de Medicina Nuclear
Dr. Luis Barragán - Director

*   Instituto Nacional de Salud Ocupacional
Dr. Naciff Manuel - Director

*   Instituto Nacional de Alimentación y Nutrición
Dr. Cáceres - Director

*   Instituto de Genética Humana - Director

*   School of Biochemistry and Pharmacy - Dean 

*   Universidad Boliviana 

*   National Council for Science and Technology in Health 
Dr. Luis Barragán - Director

COLOMBIA

Institutions participating in the biotechnology network project:

Focal point: Ministry of Health 
Instituto Nacional de Salud (INS)

Universities:Universidad Nacional (Bogotá)
Instituto de Biotecnología

Universidad de Antioquia (Medellín)

Universidad del Valle (Cali)   

ECUADOR

Universidad Central del Ecuador:
- Immunology Center, School of Medical Sciences 
- Biochemistry Laboratory, School of Medical Sciences 

Instituto Nacional de Higiene "Leopoldo Izquieta Pérez" 

Ecuadorian Social Security Institute (IESS)
- Immunology Laboratory

PERU

- Instituto Nacional de Salud
- Universities
- Private institutions, both national and regional

VENEZUELA

Instituto Nacional de Higiene "Rafael Rangel" 
Dr. María Carmona de Chacón - President

Instituto Venezolano de Investigaciones Científicas
Dr. Horacio Venegas - Director

Instituto de Biomedicina
Dr. Jacinto Couvitt - President

Universidad Central de Venezuela
- Instituto de Medicina Tropical
- Instituto de Biología Celular

Universidad Simón Bolívar

Universidad Centro Occidental "Lizandro Alvarado"



   Project #003ANDEAN ASSOCIATION FOR RESEARCH ON MEDICINAL
PLANTS - IDENTIFICATION AND SYNTHESIS OF ACTIVE
PRINCIPLES

        a) General Objective

To create an Andean Association for the development, extraction, and use
of active principles from medicinal plants.

        b) Activities

1.  Identification of the institutions, centers, and groups that study
medicinal plants in the countries of the subregion.

2.  Analysis of the status of research and production of active principles
from medicinal plants in the countries of the subregion.

3.  Establishment and articulation of national data bases. 

4.  Inventory and registration of the National Laboratories capable of
identifying, extracting, purifying, and synthesizing active principles.

5.  Identification of subregional reference facilities.

6.  Definition of a legal instrument establishing an Andean Association
for the development, extraction, and use of active principles from
medicinal plants.

        c) Specific Activities

1.  The national science and technology agencies will be responsible for
identification of the centers and groups that study medicinal plants
and will facilitate establishment of the national data bases.

2.  The national science and technology agencies will define the
mechanisms for articulating the data bases.

3.  The national science and technology agencies will inventory the
national laboratories.

4.  PAHO/WHO will conduct an evaluation of the laboratories'
capabilities.

5.  The countries will seek advisory services from the Board of the
Cartagena Agreement in order to draw up the legal instrument
establishing the Association.

6.  The countries will be called on to approve the legal instrument
(PAHO/WHO in coordination with LAES and UNDP).

        d) Sources of Financing

ADC 
ICI (V Centennial Program)

        e) Executing Agencies

National science and technology agencies 
PAHO/WHO in coordination with LAES and UNDP

        f) Strategy

1.  PAHO/WHO will finalize the project proposal and submit it to the
countries for approval.

2.  The Government of Venezuela will be responsible for presenting and
negotiating the project with ADC and informing the rest of the
countries as to the status of the negotiations. 

3.  The Governments of the countries agree to send letters to ADC in
support of Venezuela's efforts.
   Project #004ANDEAN ASSOCIATION FOR THE TECHNOLOGICAL AND
INDUSTRIAL DEVELOPMENT OF HEALTH SUPPLIES AND
EQUIPMENT    

        a) General Objective

To promote the establishment of an Andean Association for the
development, production, and marketing of health supplies and equipment.


        b) Specific Objectives

1.  To facilitate exchange, cooperation, and association between
manufacturers in the Subregion for the production and marketing of
supplies and equipment.

2.  To sponsor the creation of Subregional Research Networks for the
development of new equipment, instruments, and appropriate
technologies in the industrial sphere.

3.  To undertake coordinated activities to ensure maintenance and quality
control in equipment use.

        c) Activities

1.  Call on manufacturers, research and development centers, and
marketing companies in the Andean countries to promote the
establishment of National Associations.

2.  Call on the National Associations to create the Subregional
Association.

3.  Request technical and legal support (training, advisory services) to
support the establishment and initial development of the Association. 

4.  Recommend lines of technological development that will strengthen
the relationship between manufacturers and research centers in the
framework of the Subregional Association.

        d) Specific Activities

1.  The national focal points for TCDC and the national science and
technology agencies will enter into contact with manufacturers'
associations to enlist their support.

2.  In each country a directory will be established of the manufacturers
and research centers that are engaged in the development and
production of medical and dental equipment and implements. 

3.  PAHO/WHO will provide information on similar entities, data bases
containing the names of manufacturers and products, regulations,
international events, product nomenclature standards, publications,
legislation, and management. 

4.  Once the National Associations have been established, a subregional
meeting will be held in the city of Quito, Ecuador, to form the Andean
Association.

        e) Sources of Financing

ADC
European countries
CIDA-CANADA

        f) National Agencies in Charge

- National focal points for TCDC
- National science and technology agencies
- Fondo Nacional Hospitalario of Colombia


F.  STRATEGIC INTEGRATION PROJECTS FORMULATED

    Project #0005ANDEAN COOPERATION IN URBAN SANITATION

    The area of basic sanitation (drinking water, excreta and refuse disposal) is
    considered a high priority in the Subregion owing to the current low levels of
    service coverage, the dubious quality of the services that are provided, and the
    implications of this situation for health maintenance.

    There are two subregional agencies that offer institutional support:  the Andean
    Association of Drinking Water and Sewerage Corporations (ANDESAPA) and the
    Association of Urban Sanitation Services of the Andean Area (ASEAS-Andean).

    It was recommended that the area of basic sanitation (drinking water, excreta and
    refuse disposal) be included under the Project for Technical Cooperation between
    Countries for Health Technology Development.

    It was also recommended that the country delegates work with the respective
    national authorities responsible for drinking water supply and sanitation, as well as
    the chapters of ANDESAPA and ASEAS-Andean, with a view to ensuring the
    incorporation of subregional or intercountry projects.  The same should be done
    with the national occupational health institutes or similar agencies.

    It was also agreed that the country delegates should promote research, development,
    standardization, production, and marketing of sanitation technologies.

    Project #0006ANDEAN COOPERATION IN TECHNOLOGY FOR
WORKERS' HEALTH 


    "Technical Cooperation between Countries and Technological Development in
    Areas of Occupational Health"

        While it is true that ergonomic adaptation and the improvement of health
    conditions, hygiene, and safety in the workplace have not received sufficient
    attention, it is also true that products and equipment that could well be produced
    in the countries of the Region are often imported. 

        If this situation were rectified, it would be possible not only to economize on
    foreign exchange but also to improve working conditions, thereby increasing
    productivity, reducing losses as a result of occupational accidents, and boosting
    production levels.

        It should be possible to produce a variety of materials and equipment for
    occupational health in the Region, including: 

    1.  Material used for prevention in the workplace 

        -  design and manufacture of prevention systems 
        -  adaptation of machinery, tools, signals, and commands to the
anthropometric characteristics and biomechanics of the population in the
various countries
        -  guards and barriers

    2.  Information and training materials

        -  data bank on risk factors, effects, and the prevention thereof
        -  list of hazardous processes and products and corresponding prevention
measures
        -  posters
        -  audiovisual materials
        -  manuals on environmental and biological prevention programs 

    3.  Workshops for the maintenance and calibration of gauging equipment and
        materials 

        -  laboratory equipment and instruments
        -  occupational health
        -  safety
        -  occupational medicine
4. Equipment and materials for occupational medicine

        -  for consultation and general checkups
        -  audiometers
        -  equipment for vision testing
        -  equipment for measuring respiratory capacity
        -  equipment for toxicology diagnosis 
        -  telemetry
        -  equipment for the evaluation of behavioral changes resulting from
exposure to toxic substances
        -  vaccines and antidotes
        -  non-allergenic personal hygiene products

    5.  Occupational health equipment 

        a) Equipment for direct measurement in the field:

-   equipment for measurement of noise
-   equipment for direct measurement of chemical products, such as CO,
CO2, etc.
-   equipment for measurement of thermal load 
-   tubes and filters for collection of samples

        b) Laboratory equipment:

-   colorimeters 
-   equipment for identifying and quantifying physical and chemical risk
factors in samples of biological products and in samples of air, water,
etc.

        c) Equipment for sample collection:

-   Petri dishes
-   devices for collection of air samples
-   tubes of activated carbon, and other materials

    6.  Equipment for collective protection

        -  insulating material
        -  sound-absorbent material for noise protection 
        -  materials for heat protection
        -  protection from machinery
        -  ergonomic adaptations
        -  alarm systems 
        -  showers and other sanitary and safety equipment for the workplace
        -  equipment and elements for fire protection 
        -  ventilation and air conditioning systems 

    7.  Equipment for individual protection

        -  helmets
        -  earplugs and other hearing protection materials 
        -  work clothes for heat protection, etc.
        -  gloves and aprons
        -  safety footwear and gaiters 
        -  protective respiratory masks 
        -  filters
        -  visors and safety glasses 
        -  protective creams

    
   Project #0007ANDEAN COOPERATION IN WATER TREATMENT
TECHNOLOGY 

    Ecuador presented information on simplified equipment for water quality control
    and treatment for use in rural communities.  It was suggested that this crucially
    important technology be adapted, produced, and marketed by institutions in the
    Andean countries.

    It was recommended that this technological area be included as a priority for later
    development and for discussion at the Regional Meeting in Chile.
   Project #0008ANDEAN COOPERATION FOR THE PRODUCTION AND
MARKETING OF ESSENTIAL DRUGS

    Various countries expressed interest in establishing cooperation activities in the
    area of essential drugs;  however, because there were insufficient bases for the
    preparation of project proposals, it was agreed that this matter should be included
    as a priority for future development.

    It was recommended that proposals be formulated for discussion and negotiation
    at the Regional Meeting in Chile.
   Project #0009ANDEAN COOPERATION IN DENTAL TECHNOLOGY

    Ecuador introduced the following proposal for the development of project profiles
    in the area of oral health: 

    INTRODUCTION

    Oral diseases are among the most prevalent of health problems. They affect
    approximately 99% of peope at some time in their lives.  However, large sectors
    of the population continue to lack access to health services.

    The expansion of coverage to the most underserved sectors of the population, the
    rationalization of resource use, and the achievement of health for all will require
    a series of modifications, adaptations, and research in accordance with the priorities
    that are set for each country, taking into account their internal capacities.  These
    priorities must also be included in overall national and Regional development
    strategies.  

    These modifications and adaptations should be aimed at ensuring the
    implementation of primary care strategy, strengthening of local health systems, and
    solving health problems, as well as bringing about a more equitable distribution of
    resources.  Actions should be directed toward socioeconomically disadvanted
    persons, who are at the greatest risk of becoming ill.

    The countries of the Region are currently experiencing a grave economic crisis, one
    of the manifestations of which is enormous external debt.  This has led, in many
    cases, to a contraction of the social sector, which includes the health sector and oral
    health.

    As a result of this situation, the oral health services are incapable of meeting the
    needs of all sectors of the population.  Moreover, no improvement can be expected
    in the future unless there is a move away from traditional practices based on
    individual care that is geared to treating disease through methods that often involve
    some kind of mutilation. 

    The attainment of health for all by the year 2000 will require not only an expansion
    of service and program coverage to those who are currently unserved, but will also
    necessitate the use by decision-makers in the health sector of all the mechanisms
    available to them.

    In new plans for oral health policies there is a strong tendency to promote dental
    practices that incorporate technologies that are either developed in the countries
    themselves or are developed in countries outside the Region and then modified or
    adapted.

    Technological development that is aimed at improving the health of the people will
    contribute to the expansion of coverage and help to enhance the quality of the
    services provided to the community.  It will also supply the instruments needed to
    meet the demand for health services based on the population's needs and on
    scientific principles and specific economic, social, and epidemiological conditions.

    Technological development that is linked to a political commitment at the national,
    subregional, or Regional level will make it possible to coordinate efforts, thereby
    preventing the misuse of resources and increasing the quality of life.

    Oral health programs should generally include eight components:  oral health
    education, health promotion, prevention of oral diseases, health services, manpower
    training, research, technology, and communication.

    The Pan American Health Organization (PAHO) plays an important role by
    promoting the reorganization of oral health services, with a view to adapting them
    to Latin American culture and prevailing socioeconomic and political
    circumstances.  The PAHO programs in the areas of oral health and health
    technology and health policy development have, together, worked out a set of
    projects. 

    These technological projects envisage new ways of solving oral health problems. 
    The projects contemplated here incorporate the eight components mentioned above
    and are aimed at expanding coverage, promoting equity in the distribution of
    services and programs, and adapting these services and programs to the economic
    reality in the Region through the use of existing technologies or the development
    of new ones.   

    Project #0010ANDEAN COOPERATION IN THE TECHNOLOGY OF
ORTHOSES AND PROSTHESES

    Bolivia presented a proposal for cooperation in the area of child rehabilitation, with
    particular emphasis on the technology of orthoses and prostheses.

    It was agreed that this proposal would be included for development and discussion
    at the Regional Meeting in Chile.

    Project #0011ANDEAN COOPERATION IN TECHNOLOGY TO REDUCE
MATERNAL MORTALITY

    The Mineral Metabolism Unit, a section of the Nutrition and Metabolism Research
    Laboratory of the School of Medicine at the Universidad Central del Ecuador
    presented a proposal entitled "Reduction of the Incidence of Preeclampsia in
    Andean Primigravidae by Supplementation with Calcium Salts."

    Background

    Pregnancy-induced hypertension (PIH), or preeclampsia, is the leading cause of
    maternal death in Ecuador.  Isolated studies have indicated that this condition
    occurs in 15% to 30% of pregnant women.

    Over the last ten years the Mineral Metabolism Unit of the School of Medicine at
    the Universidad Central del Ecuador has been working to develop preventive
    measures and to explain the pathogenesis of this serious condition.

    The results obtained show that supplementation of the diet of a group of pregnant
    women with calcium salts reduced the incidence of PIH from 27% to 4%, and from
    70% to 13% in patients at risk of developing the condition, with a positive roll-
    over test.

    These results suggest that calcium supplementation is an easy and inexpensive
    nutritional intervention measure that produces no side effects and effectively
    diminishes the incidence of PIH, thereby improving pregnancy outcome and
    birthweight.  It is recommended for application in countries with characteristics
    similar to Ecuador's.

    However, the clinical tests conducted involved only a small number of patients and
    will therefore need to be corroborated by a Region-wide multicenter
    epidemiological study.

    In addition, in view of the fact that PIH is a public health problem in Ecuador and
    that the Andean countries have characteristics similar to Ecuador's, cooperative
    research projects in this field will be necessary.

    Work Plan

    In this project it is proposed that a multicenter study be carried out, including the
    following components:

    1.  Training of personnel to carry out the roll-over test and oversee calcium
        supplementation. 

    2.  Identification of patients based on the following criteria:  under 25 years of
        age; primigravida; in the 20th week of gestation; resident of an Andean area
        with an altitude of more than 2,000 m.; positive roll-over test positive; no
        history of endocrine, metabolic, renal, or cardiovascular disease. 

    3.  A random, controlled, double-blind clinical study will be carried out.

    4.  The pregnant women will be monitored from the 20th week of gestation
        through the end of pregnancy.  The birthweight of their babies will also be
        recorded.

    Through the implementation of this project, an attempt will be made to demonstrate
    how this simple intervention measure can reduce the incidence of PIH in the
    pregnant women included in the study, prolong pregnancy, and result in newborns
    with birthweights over 3,000 g.

    Given the importance of this proposal, it was recommended that it be included as
    an Andean collaborative project for negotiation at the Regional Meeting in Chile.

       FOURTH:  OBSERVATIONS AND RECOMMENDATIONS


    The participants made the following observations and recommendations:

-   The development of joint cooperation activities among countries in the Andean
    Area will help to improve the efficiency of the countries' respective health
    programs.

-   Bilateral agreements adopted through direct contact will make it possible to
    establish a real basis for exchange and collective commitment in the effort to solve
    the health problems of the Subregion.

-   Project Convergence, under the sponsorship of PAHO/WHO, LAES, and UNDP,
    will make a valuable contribution toward the development of health technology in
    the Andean Subregion.

-   In the project proposals there is a lack of strategic programming in the health care
    delivery systems.

-   The participating countries are to be commended for including in their project
    proposals initiatives relating to research, production, and marketing in the health
    sector. 

-   The participating countries gratefully acknowledged the contribution made to the
    Meeting by the representatives of the international organizations--PAHO/WHO,
    LAES, and PNUD. 

-   The delegations from Bolivia, Colombia, Peru, and Venezuela expressed their
    gratitude to the Ecuadorian delegation for Ecuador's efficient organization and
    coordination of the Meeting.

-   The focal points for technological development and technical cooperation between
    countries should be strengthened at the national and health-sector levels and
    encouraged to exercise the leadership needed to support this development.

-   The TCDC process should be stepped up as an essential instrument for the
    development of health programs.

-   Real national mechanisms of coordination should be promoted to foster
    technological development.

-   Projects should be incorporated in the areas of sanitation, occupational health,
    maternal and child health, nutrition, and dentistry.




ANNEX 1




KEY WORDS

- commercial agreements
- albumin
- laboratory animals
- anthropozoonoses  
- associations
- harmonization of standards
- autotransfusion
- project banks 
- data base
- biologicals
- molecular biology
- biotechnology
- biological materials
- training
- cysticercosis 
- cytomegalovirus 
- industrial cooperation
- marketing
- industrial complementarity
- consortia
- quality control
- quality control of cosmetics
- courses and internships
- Chagas' disease
- medical devices
- distomatosis 
- hormone dosage
- DPT
- medical equipment
- hospital equipment
- dental equipment
- parasitic diseases
- training
- feasibility studies
- testing of effectiveness
- manufacturing
- in vitro fertilization 
- laminar flow 
- training of technicians
- human gamma globulin
- management 
- herpes
- hydatidosis
- importation
- scientific information
- instruments
- insulin
- laboratory supplies 
- exchange of information
- exchange of strains
- exchange of experts
- exchange of technologies
- joint research
- diagnostic kits for hepatitis
- leishmaniasis
- cell lines
- lines of research
- lines of production
- malaria
- maintenance
- drugs 
- generic drugs
- media and reagents
- markets
- exchange missions 
- technical standards
- dentistry
- medicinal plants
- plants for therapeutic purposes 
- pilot plant
- active principles
- production
- pharmaceutical chemical products 
- production of biologicals
- prototypes
- effectiveness tests 
- scientific publications
- radioactive drugs  
- information network
- laboratory network
- registration and quality control
- child rehabilitation
- reuse of syringes and probes
- AIDS
- synthesis of active principles
- alimentary fluids
- parenteral fluids
- genetic probes 
- antivenomous serum 
- hyperimmune sera
- goitrogenic substances
- toxic substances
- in vitro and in vivo experimental techniques 
- microcarrier techniques 
- tapeworms
- embryo transfer
- transfer of technology
- tuberculosis
- vaccines
- vaccines for human use
- vaccines for animal use
- rabies vaccine
- human rabies vaccine
- freeze-dried BCG vaccine
- cholera vaccine 
- leishmaniasis vaccine 
- hepatitis B vaccine 
- Delta hepatitis vaccine
- malaria vaccine 
- testing of diagnostic kits 
- testing of vaccines
    
    






STRATEGIC ADMINISTRATION IN LOCAL HEALTH SYSTEMS


       The strategic orientations and program priorities of the
quadrennium reiterate the Organization's commitment to collaborate with the
countries of the Region on the transformation of national health systems
through the development and strengthening of local health systems as an
operational tactic within the primary care strategy.

       The evaluations that have been carried out make it possible to
appreciate the important steps that have been taken toward the
implementation and consolidation of local health systems, especially in
terms of their conceptualization and experiences in their application. 
Attention is now beginning to be focused on the need for instruments to
guarantee their operation.

       Important progress has been made in decentralization, local
programming, social participation, financing, application of the risk
approach, and revision of the health care models.

       At the same time, the exercise has also shed light on the need to
develop an integrated approach that will make it possible to fully and
coherently implement strategies for local health system development so that
the countries will have a frame of reference for drafting procedures and
developing methods and techniques to support the transformation of their
systems.

       In the local health system context, strategic administration is
understood to be a way of connecting the health problems and needs of a
social group living in a particular geographical area with the knowledge
and resources that are available.  In this way it becomes possible to set
priorities, consider different alternatives for action, allocate and
organize resources, and conduct the process up to the point of resolving or
gaining control over the problems in question.





       The topics addressed in this proposal are:

       1)   The Local Health System Context

- Health and its Determinants
- Health and Health Promotion
- Health in Development
- Health and the Transformation of Health Systems
- Health and Financing

       2)   Development of Infrastructure

- Strategic Administration in Local Health Systems
- Leadership
- Programming
- Management
- Instruments, Techniques, and Procedures for LSA


       On this basis, the following lines of analysis are proposed:

       1)   LSA and the Integration of Programs:  Models of Care

       2)   LSA and Sectoral Development:  Role of the Central Level and
Financing











WOMEN, WORK, AND OCCUPATIONAL HEALTH

Terms of Reference of the
Proposal for Joint Action by 
the Programs on 
Workers' Health and Women, Health, and Development

























INITIATIVE "1992:  Year of the Workers' Health"

WOMEN, WORK AND OCCUPATIONAL HEALTH


Lines of action to which occupational health programs in general should give
priority:


DISSEMINATION OF INFORMATION (SCIENTIFIC, TECHNICAL, AND
PUBLIC)

TRAINING AT ALL LEVELS (INCLUDING WORKERS)

RESEARCH (INCLUDING SEX-BASED DIFFERENCES)

INSTITUTIONS AND COORDINATED ARTICULATION THEREOF

ACTIVE PARTICIPATION BY WORKERS AND EMPLOYERS

COMPREHENSIVE HEALTH CARE IN OR NEAR THE WORKPLACE 

STRATEGIES FOR ACHIEVING UNIVERSAL COVERAGE



Expected outcomes


REVIEW OF POLICIES

NATIONAL PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH

EXTENSION OF COVERAGE (FROM BOTH A QUANTITATIVE AND A
QUALITATIVE STANDPOINT)


WOMEN, WORK, AND OCCUPATIONAL HEALTH

Lines of action to which occupational health services should give priority in or
around the workplace:


DEVELOPMENT OF A PREVENTIVE CONSCIOUSNESS


HEALTH EDUCATION


PROMOTION OF SELF-CARE AND HEALTHY LIFESTYLES


HEALTH PROTECTION AND MAINTENANCE


IDENTIFICATION AND CONTROL OF OCCUPATIONAL RISK
FACTORS


MEDICAL AND TECHNICAL PREVENTION 


CURATIVE MEDICAL CARE


REHABILITATION


COMPENSATION IN CASES OF TEMPORARY OR PERMANENT
DISABILITY


EXPECTED OUTCOMES

Review of policies:

NATIONAL PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH

EXTENSION OF COVERAGE (CURRENTLY NEAR 9 PERCENT)

WOMEN, WORK, AND OCCUPATIONAL HEALTH




In order to achieve its proposed objectives, a health plan or program for workers'
health needs to include:


MEASURES THAT ADDRESS THE NEEDS OF THE ENTIRE WORKING
POPULATION, TAKING INTO ACCOUNT GENDER DIFFERENCES 


ADAPTATION OF WORK TO VULNERABLE GROUPS


SPECIFIC SITUATION OF WORKING WOMEN IN TERMS OF:


FERTILITY, PREGNANCY, AND MATERNITY

FEEDING OF NEWBORNS

HYPERSENSITIVITY AND VULNERABILITY OF FETUSES AND
PREGNANT WOMEN













WOMEN, WORK, AND OCCUPATIONAL HEALTH


In order to prepare a NATIONAL PLAN FOR THE DEVELOPMENT OF
WORKERS' HEALTH it is necessary to study and adjust existing health policies
that concern working women who are also mothers:



IMPORTANCE OF LEGISLATION TO PROTECT WORKING MOTHERS


OUTCOME OF REGULATIONS AND ACTIONS AIMED AT
FACILITATING BREAST-FEEDING OF NEWBORNS


DAY-CARE CENTERS


OTHER LEGISLATION, REGULATIONS, AND STANDARDS


DEGREE OF EFFECTIVENESS/APPLICABILITY



Expected outcome:


ACHIEVEMENT of the integration of women into the labor market









WOMEN, WORK, AND OCCUPATIONAL HEALTH




In order to find effective solutions, the plans, programs, and services for
occupational health need to take into account the differences between the sexes
(identified by situational analysis) and achieve the adaptation of work to both male
and female workers.



This implies the study of:


PHYSIOLOGICAL AND PSYCHOLOGICAL CHARACTERISTICS


DEGREES OF RESISTANCE


LEVELS OF VULNERABILITY


CONSEQUENCES OF EXPOSURE TO PHYSICAL, PSYCHOLOGICAL,
SOCIAL, AND ERGONOMIC RISK FACTORS 













WOMEN, WORK, AND OCCUPATIONAL HEALTH



In order to achieve optimum integration of the work force and facilitate selective
placement, it is indispensable to study and make adjustments for:



INDIVIDUAL CHARACTERISTICS AND ABILITIES IN THE
PHYSICAL, PSYCHOLOGICAL, AND SOCIAL SENSE


PHYSICAL, PSYCHOLOGICAL, AND SOCIAL OCCUPATIONAL
REQUIREMENTS, AND EXPOSURE TO PHYSICAL, CHEMICAL,
BIOLOGICAL, ERGONOMIC, AND PSYCHOSOCIAL RISK FACTORS


EVALUATION OF SUITABILITY AND SUGGESTIONS FOR THE
ADAPTATION OF WORK





IN THE CASE OF WOMEN, IT IS IMPORTANT TO TAKE INTO ACCOUNT
BIOLOGICAL CHARACTERISTICS, GENDER DIFFERENCES, AND THE
RELATIONSHIP BETWEEN PRODUCTION AND REPRODUCTION, IN
ORDER TO ENSURE THAT THEY ENJOY WELL-BEING THROUGHOUT
THEIR LIFE CYCLE.











WOMEN, WORK, AND OCCUPATIONAL HEALTH





Causes behind the high incidence of fatigue and difficulties in securing time for
rest and recovery:




INTEGRATION OF WOMEN INTO THE LABOR MARKET



RELATIONSHIP BETWEEN EMPLOYMENT OF WOMEN AND
FAMILY AND SOCIAL ROLES



WOMEN'S TRADITIONAL RESPONSIBILITY FOR DOMESTIC
TASKS AND CHILD CARE 

















WOMEN, WORK, AND OCCUPATIONAL HEALTH


Health education for workers and prevention in the workplace have a positive
impact on:



-          WORKERS



-          FAMILIES



-          EMPLOYERS AND SOCIETY



IT IS IMPORTANT TO NOTE THAT A WORKER WHO RECEIVES
HEALTH EDUCATION CAN BE MOTIVATED TO PROMOTE A
PREVENTIVE CONSCIOUSNESS AND CONCERN FOR HEALTH
MAINTENANCE WITHIN HIS/HER FAMILY AND SOCIAL CIRCLES.



IT IS ACCEPTED THAT THIS EFFECT CAN BE EVEN MORE
PRONOUNCED IN THE CASE OF WORKING WOMEN, WITHOUT THIS
REPRESENTING AN ADDITIONAL BURDEN ON WOMEN IN TERMS OF
THEIR ACTIVITIES IN THE HOME, WORKPLACE, OR
FAMILY/COMMUNITY.








WOMEN, WORK, AND OCCUPATIONAL HEALTH

Data that should be taken into account in preparing a
       NATIONAL PLAN FOR THE DEVELOPMENT WORKERS' HEALTH 



SEX DISTRIBUTION OF MORTALITY AND MORBIDITY 



LIFE EXPECTANCY


AVERAGE WORKING LIFE 


OCCUPATIONAL RISK FACTORS BY OCCUPATION AND POSITION



PRINCIPAL HEALTH PROBLEMS


EXISTENCE OF SPECIFIC AND DIFFERENTIAL RISK FACTORS
FOR THE TWO SEXES












WOMEN, WORK, AND OCCUPATIONAL HEALTH

Data that should be taken into account in preparing a
   NATIONAL PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH 




SEX DIFFERENCES IN ANTHROPOMETRIC MEASUREMENTS AND
MUSCULOSKELETAL DEVELOPMENT:



PHYSICAL AND MENTAL DIFFICULTY OF THE TASKS



PROGRESSIVE ELIMINATION OF THE MOST PHYSICALLY
DEMANDING TASKS



ERGONOMIC ADAPTATION OF WORK (TAKING INTO ACCOUNT
THE CHARACTERISTICS OF GROUPS, THE SEVERITY OF RISK
FACTORS, AND THE LEVELS OF CAPACITY)














WOMEN, WORK, AND OCCUPATIONAL HEALTH

Data that should be taken into account in preparing a
   NATIONAL PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH 



EXISTING AND POTENTIAL OPERATING CAPACITY


INSTITUTIONAL CAPACITY


INTERSECTORAL COOPERATION


AVAILABILITY OF HUMAN RESOURCES


MOTIVATION


RATE OF TRAINING OF PROFESSIONALS AND TECHNICIANS IN
OCCUPATIONAL HEALTH











WOMEN, WORK, AND OCCUPATIONAL HEALTH

Data that should be taken into account in preparing a
   NATIONAL PLAN FOR THE DEVELOPMENT OF WORKERS' HEALTH 



MULTICENTER ACTIVITY TO BE DEVELOPED IN VARIOUS
COUNTRIES, AND SUGGESTIONS:

Argentina
Brazil
Colombia
Cuba
Guatemala
Guyana
Mexico



OBJECTIVES:

Understand the legal framework and determine its conformity with
international instruments

Determine the degree of enforcement of legislation, regulations, and
standards

Gain an appreciation of the real situation



MOBILIZATION OF RESOURCES AND SUPPORT:

Focal points for woman, health, and development

Focal points for workers' health

Human and material resources to be identified


WOMEN, WORK, AND OCCUPATIONAL HEALTH



Key areas of activity to be studied:* 


NURSES


TEACHERS AND EDUCATORS


OFFICE WORKERS


TEXTILE INDUSTRY


CHEMICAL AND PHARMACEUTICAL INDUSTRY


FINE WELDING


ASSEMBLY PLANTS


FARM WORKERS (PESTICIDES)


DOMESTIC OCCUPATIONS





*          Because they employ large numbers of women and involve activities with high
levels of risk and low levels of protection and prevention.
WOMEN, WORK, AND OCCUPATIONAL HEALTH
Hypotheses for future scenarios:

RAPID INTEGRATION OF WOMEN INTO ALL OCCUPATIONS--
FACILITATED BY POLICIES FOR THE DEVELOPMENT OF
OCCUPATIONAL HEALTH AND HUMAN RESOURCES--UNTIL THEY
REPRESENT APPROXIMATELY 50% OF THE WORK FORCE


This presupposes:                

A better division of labor
A reduction of the risk factors to which women are exposed
Adaptation of work to women's capabilities


This represents:

A basic frame of reference for equality and defense against
discrimination


This facilitates:

Equality of obligations, responsibilities, self-esteem, and responsible
competitiveness


SLOW INCREASE IN THE INTEGRATION OF WOMEN INTO MALE-
DOMINATED OCCUPATIONS 

This presupposes:

Maintenance of the current division of labor, with women remaining in
the most demanding, lowest-paying positions in which there is the least
opportunity for advancement 


This represents:

Continuation of the situation of inequality

Review
February 1992
MOD1525I












Note:
Draft Version
    Please do not reproduce or quote without the authorization of
the Pan American Health Organization


CONTENTS






1.     Introduction                                                


2.     Epidemiological Research

       2.1   Concept                                               
       2.2   Epidemiological Reasoning                             
       2.3   Stages of Epidemiological                             
Research

3.     Types of Epidemiological Study Designs  

       3.1   Introduction                                          
       3.2   Design of Experimental Studies                        
       3.3   Design of Observational Studies                       
       3.4   Types of Observational Studies                        

3.4.1  Cross-sectional study
3.4.2  Retrospective (case-control) study              
3.4.3  Prospective study


4.     Epidemiological Research on Malaria

       4.1  Introduction                                           
       4.2  Definition of Purposes and Objectives                  
       4.3  Formulation of the Research Hypothesis                 
       4.4  Selection of the Research Design                       
       4.5  Analysis of correlation between Malaria                
and the Probable Risk Factors to be studied

4.5.1  Introduction  
4.5.2  Chi-Square Test                                 
4.5.3  Calculation of the Chi-Square Test              

       4.6  Calculation of Relative Risk and Attributable Risk     
       4.7  Preparation of the Final Report on the Research        



       Bibliography                                                



      LIST OF TABLES

      Table 1                                                   
      Table 2                                                   
      Table 3                                                   
      Table 4                                                   
      Table 5                                                   
      Table 6                                                   
      Table 6-A                  
      Table 7                                                   
      Table 8                                                   
      Table 9                                                   



      EXERCISES

      Exercise 1                 
      Exercise 2                 
      Exercise 3                 



EPIDEMIOLOGICAL RESEARCH ON MALARIA


1.    Introduction


      The purpose of Workbook II is to present the basic elements of
epidemiological research used in the epidemiological stratification
of malarious areas in countries of Latin America and the Caribbean. 
The workbooks offer a general introduction to the epidemiological
concepts and tools that facilitate recognition of the correlations
that exist between malaria and the various risk factors that are
involved in and determine the transmission of malaria by the vector
mosquito in various human groups.

      It should be emphasized that knowledge of epidemiological
principles and methods is not the exclusive preserve of technicians
or professionals engaged in epidemiological research.  This knowledge
is basic for all members of the health team.  An epidemiological study
permits recognition of the determinants of the differential
distribution of the risks of becoming ill or dying in the various
social groups that comprise a population or specific community. 
Moreover, it provides a basis for the existing options and intervention
alternatives being used by the health services and facilitates choosing
from among them.  The results of epidemiological research contribute
significant elements to the development of infrastructures capable of
supporting local health systems in the prevention and control of
malaria as part of the primary health care strategy.


2.    Epidemiological Research

      2.1 Concept

      Epidemiological research involves the study of the frequency
and distribution of the determinants of the health-disease process in
human population groups.  Since health impairments are not distributed
at random in the entire population, the search for the characteristics,
events, or factors that influence and determine their distribution is
a basic part of epidemiological research.

      The epidemiological information pertaining to the population
group with a higher frequency of a disease or with a greater risk of
contracting it is useful to the health services, since it points out
which segments of the population should be the focus of their
activities, as well as the types of intervention that should be carried
out.




      2.2   Epidemiological Reasoning

      Epidemiology is considered to be a series of ordered steps of
reasoning related to the observation of a health impairment that occurs
in specific groups of the population, the objective of which is to be
able to elucidate and determine the causal factors of that health
impairment.

      The epidemiological method is primarily comparative.  The study
of health impairments is carried out by comparing different times,
places, or population groups.  In the study of a health impairment, the
presence of certain characteristics or the exposure of a population
group (having the impairment) to determining factors is compared with
the exposure to or presence of those factors in another population
group (without the impairment).

      The determination of the linkages, relationships, and
associations between the factors and the health impairments, along
with the formulation of inferences based on that determination, is a
central part of the epidemiological reasoning process. 

      It should be mentioned that, although the measurement of the
epidemiological events constitutes a basic part of the research, it
is not sufficient for the formulation of the epidemiological inferences
concerning the population.  The American epidemiologist W. Frost (1936)
asserted the foregoing when he said that epidemiology, in any period
in time, is more than the sum of its established actions.  It
encompasses the ordered grouping of these actions into chains of
inference that exceed the limits of direct observation to a greater or
lesser degree.  Such chains, when they are well ordered, guide the
research toward future actions; those that are poorly ordered will only
hold up progress.


      2.3   Stages of Epidemiological Research

      One of the fundamental considerations of epidemiological
research is the definition of the theoretical or conceptual framework
that makes it possible to give direction and sense to each of the
stages of research that are mentioned below.  Thus, for example, the
epidemiological risk approach has as its central frame of reference the
elimination of inequalities in the distribution of the risks of disease
and death among different human groups.  The concept and use of the
notion of risk factor articulates with the concept of equity.  The
differential risks of becoming ill or dying
are conceptualized as structures that are shaped by the living
conditions of the different socioeconomic groups.  Outstanding among
these conditions are the health problems and the risk factors that
shape them, as well as the access of the different groups to health
services.  Thus the concept of equity and the elimination of
inequalities in the risk of becoming ill or dying constitute an
important substrate for the frame of reference of epidemiological
research on risk.

      In order to effectively establish the determining relationships
between the health impairment selected and its risk factors, various
steps or stages should be provided for in the epidemiological research
process, the most important being:


      BASIC STAGES OF EPIDEMIOLOGICAL RESEARCH:

      (a)   Statement of the problem;

      (b)   Formulation of the specific research objectives and
hypotheses for the epidemiological study;

      (c)   Selection of a study design that is appropriate to
demonstrate the research hypotheses formulated;

      (d)   Definition and selection of the study population and an
adequate sampling method;

      (e)   In the case of a sampling study, calculation of the
required sample size;

      (f)   Preparation of the list of data and information  collected,
as well as the contingency tables to be used in the
analysis of the information;

      (g)   Analysis of the relationships between the health
impairments and the risk factors being studied through
tests of statistical significance and the calculation of
relative risk, attributable risk, and other relevant
measures;

      (h)   Preparation of risk profiles that characterize the high-
risk groups as well as the distribution of risk in the
community; and

      (i)   Preparation and dissemination of the final report of the
research results in such a way that they can be utilized
for the design of intervention strategies by the health
service.



      Each of these stages will be described briefly in Section 4, in
the context of epidemiological research on malaria.

      The epidemiological research designs that are most commonly used
in the study of diseases and their determinants are reviewed  below.


3.    Types of Epidemiological Study Designs 

      3.1   Introduction

      In epidemiology in general, the studies can be divided into two
broad groups:  experimental studies, and observational studies.  One
of the differences between these two types of study is that in the
experimental study the research team can specify and control the
conditions under which the study is to be conducted, while in the
observational study those conditions are not controlled.


      3.2   Design of Experimental Studies

      In epidemiology, the experimental study is called a controlled
clinical test.


      CONTROLLED CLINICAL TEST:

     This has been described as a study in which the conditions are under
     the direct control of the investigator.  The population is selected
     for the controlled study of an intervention or regimen in which the
     effects are measured by comparing the result of the intervention in
     the experimental group with the result of another intervention in a
     control group.  With a view to avoiding biases, the members of both
     the experimental group and the control group should be comparable
     except in the regimen offered to them.  In a controlled random
     clinical test, the allocation of the individuals to the experimental
     group and to the control group is through randomization or chance. 
     (Last:35).


      Controlled clinical tests are for studying the effectiveness
and safety of therapeutic or preventive interventions.  The
effectiveness of drugs, vaccines, and surgical procedures and the
impact of interventions--for example, the fluoridation of water to
prevent dental caries and the application of insecticides and the
elimination of breeding sites of anophelines to control malaria-
- are the kind of topics investigated in this type of study.  In
studies of human populations, because of ethical considerations, it
is not always feasible to carry out experimental studies, which means
that research will have to be carried out through observational
studies.

      3.3 Design of Observational Studies

      As indicated above, in observational studies the research team
does not create the conditions or manipulate the variables involved;
the results are observed under "natural" conditions or situations or
without manipulation.

      OBSERVATIONAL STUDY:

      This has been defined as study that is carried out in situations
      in which the changes or differences in one characteristic are
      studied in connection with changes or differences in another
      characteristic, without the intervention of the investigator. 
      (Last:72).


      In observational studies, the research team carries out the
study under conditions as they are presented.  The results will depend
on the different degrees of exposure to the factor or factors studied
as these were manifested "naturally."  The individuals or social groups
have their own attributes or characteristics or are exposed to a
factor; the exposure to a factor is not given or created by the
investigator.  Examples of this would be the effects of advanced age,
habitation in unenclosed spaces, poverty, occupation, and the linkage
of all these to the development of a disease or other health
impairment.

      One source of bias that can be a problem in observational
studies is the fact that the observed groups may vary in terms of
characteristics other than the specific factor being studied.  If
these characteristics are relevant in the chain of causality and if
there is no adjustment or control of the characteristics, confusion
can result and the conclusions can be affected.

      The data collected in a observational study can be classified
in a contingency table.  This table is usually four-celled, as shown
in Table 1.


Table 1

Classification of the Data Collected in
Epidemiological Observational Studies

Health Impairment

PresentAbsentTOTAL
Exposure to the factor
YES


NOA


CB


DA + B


C + DTOTALA + CB + D  A + B +     C + D
      3.4 Types of Observational Studies

      The two relevant events that serve to distinguish and classify
the type of epidemiological study that is being designed are:

      1.    Health impairment--for example, disease, disability,
lesions, or death.

      2.    Exposure to one or several risk factors.

      The way that these two events occur over time and the way that
they are observed methodologically makes it possible to characterize
the type of epidemiological study design involved.

      Hence the analytical observational studies can be divided into
three types:  (1) cross-sectional studies; (2) retrospective studies,
and (3) prospective studies.  In cross-sectional and retrospective
studies, the selection of the individuals is based on the presence or
absence of the disease or other health impairment, while in prospective
studies, the selection of the individuals is done on the basis of
exposure to a factor, agent, or condition.  A cross-sectional study is
differentiated from a retrospective one by the fact that in the cross-
sectional study the presence of the impairment and the exposure to the
factor are observed  simultaneously; that is to say, it is not possible
to distinguish which of the two events occurred first in time.  To put
it another way, it cannot be shown whether the exposure occurred prior
to the impairment or not.  In the retrospective study, the exposure or
characteristic existed in the past, prior to the presence of the
impairment (Lilienfeld:174).

      3.4.1 Cross-sectional Study

      A cross-sectional study, also called a prevalence study, is one
in which the data on the presence of the risk factors and the  health
impairments are observed simultaneously, which usually prevents knowing
the time relationship between one possible causal association and
another.  This design does not allow determination of whether the risk
factor was present prior to, after, or simultaneously with the
occurrence of the impairment observed.  It does, however, make it
possible to establish whether there is a statistical association
between them.

      CROSS-SECTIONAL STUDY:

      THIS IS A STUDY THAT EXAMINES THE RELATIONSHIP BETWEEN DISEASE
      AND OTHER VARIABLES OF INTEREST, SUCH AS EXIST IN A GIVEN
      POPULATION AND AT A SPECIFIC MOMENT.  THIS RELATIONSHIP IS
      EXPRESSED IN TERMS OF THE PREVALENCE OF THE DISEASE IN THE
      SUBGROUPS WITH OR WITHOUT THE VARIABLES OF INTEREST.  THE TIME
      SEQUENCE OF CAUSE AND EFFECT CANNOT NECESSARILY BE DETERMINED. 
      (Last:24).

      This type of design is simple and is generally utilized to
determine the profile of a population and the prevalence of risk
factors or of a health impairment in that population.

      Cross-sectional studies in general involve a sample taken from
the entire population; they are carried out over a single, brief,
well-delimited period; and they are used to describe the attributes
of those that have experienced a health impairment and those that have
not.


      3.4.2 Retrospective (case-control) study

      In a retrospective study, also called a case-control study, the
investigator begins with selection of the cases and the controls. 
Following Table 2, (A + C) cases are selected, which are going to be
compared with (B + D) controls.  In this 2 x 2 table, (A + C) and (B
+ D) represent the column totals for the cases and the controls,
respectively.  Subsequently, both the cases and the controls are
assigned to the cells in the rows according to whether or not they had
been exposed to the risk factor being studied.

      RETROSPECTIVE STUDY:

      THIS IS A STUDY THAT IS INITIATED WITH THE IDENTIFICATION OF
      INDIVIDUALS WITH THE DISEASE OF INTEREST ALONG WITH AN
      APPROPRIATE GROUP OF INDIVIDUALS WITHOUT THE DISEASE.  THE
      RELATIONSHIP BETWEEN A FACTOR OR ATTRIBUTE AND THE DISEASE IS
      EXAMINED BY COMPARING THE FREQUENCY OF THE PRESENCE OF THE
      ATTRIBUTE IN THE CASES AND IN THE CONTROLS.  (Last:15).



Table 2

DESIGN OF THE RETROSPECTIVE (CASE-CONTROL) STUDY.

HEALTH IMPAIRMENT


Present         Absent

CASES      CONTROLS        TOTAL


Exposure         YES         A                 B
to the factor        

NO          C                 D


TOTAL         A + C           B + D      A + B + C + D


      1.    THE STUDY IS INITIATED WITH THE SELECTION OF THE CASES AND
THE CONTROLS.

     2.     THE ANALYSIS IS CARRIED OUT BY MEASURING PRIOR EXPOSURE
TO RISK FACTORS FOR THE CASES AND THE CONTROLS.

      3.    THE OBJECTIVE IS TO COMPARE THE PROPORTION OF THE CASES
EXPOSED TO A RISK FACTOR WITH THE PROPORTION OF THE 
CONTROLS EXPOSED TO THE SAME RISK FACTOR.


      The analysis of the retrospective study is carried out by
comparing the rates of exposure to the risk factor of the cases with
the rates of exposure of the controls.  If through tests of statistical
significance it is found that the frequency of individuals with the
risk factor is higher in the cases than in the controls and that the
difference is statistically significant, it can be taken that there is
a statistical association between the disease and the factor being
studied.

      In order to measure the degree or strength of the association
in the retrospective studies, various statistical methods have been
devised.  One of the most important measures is called the ODDS RATIO,
also known as the cross-product ratio.  This measure is a ratio in
which the numerator contains the odds of the cases having been exposed
to the risk factor and the denominator, the odds of the controls having
been exposed to the same risk factor.

      It should be noted that the odds ratio can be an estimator of
the relative risk if two assumptions hold: (a) the frequency of the
disease in the population is very low (rare diseases); (b) the cases
and the controls being studied are representative, respectively, of the
cases and of the "non-cases" that exist in the population
(Lilienfeld:188).

      In accordance with Table 2, the formulas for the measurements
used in the retrospective design are the following:



      Rate of exposure of the cases        = A/(A + C)

      Rate of exposure of the controls     = B/(B + D)

      ODDS RATIO                 = (A/C) / (B/D)     

where (A/C) is the odds of the cases exposed to the factor and (B/D)
is the odds of the controls exposed to the factor.

      The odds ratio is also known as the cross-product ratio because
it is equivalent to:

(A * D) / (B * C)


      3.4.3 Prospective study

      A prospective study is also known as a cohort study, a
longitudinal study, or study of incidence.  The design of this study
permits the calculation of incidence and relative risk.

     PROSPECTIVE STUDY:

      THIS IS A STUDY IN WHICH SUBGROUPS OF A POPULATION ARE
      IDENTIFIED, DEPENDING ON WHETHER THEY HAVE OR HAVE NOT BEEN
      EXPOSED TO A FACTOR, WHICH HYPOTHETICALLY INFLUENCES THE
      PROBABILITY THAT A DISEASE OR OTHER INJURY TO HEALTH OCCURS. 
      IT INVOLVES THE OBSERVATION OF A SUFFICIENT NUMBER OF PERSON-
      YEARS, TO ALLOW THE GENERATION OF RELIABLE RATES OF INCIDENCE
      IN THE SUBGROUPS OF POPULATION.  (Last:20).


      In the prospective study, already at the outset, there has
usually already been exposure to the risk factor, but the disease has
still not occurred.  Both the group of exposed individuals and the
group with no exposure are disease-free.  The investigator initiates
the study by selecting the individuals that have been exposed to the
risk factor and those that have not, with the respective numbers of
individuals corresponding to the total numbers of exposed (A + B) and
unexposed (C + D) found in Table 3.  Both groups are followed over a
specified period of time.  At the end of this period, the number of
exposed individuals that developed the disease is observed, along with
the number of those who had not been not exposed but that became ill.

Table 3
DESIGN OF A PROSPECTIVE (COHORT) STUDY.

      1.    THE STUDY IS INITIATED WITH THE SELECTION OF INDIVIDUALS
EXPOSED TO AND NOT EXPOSED TO THE RISK FACTOR.

     2.     THE ANALYSIS IS CARRIED OUT BY MEASURING THE PRESENCE OF
THE HEALTH IMPAIRMENT IN THOSE EXPOSED AND IN THOSE NOT
EXPOSED TO THE RISK FACTOR BEING STUDIED.

      3.    THE OBJECTIVE IS TO COMPARE THE INCIDENCE OF THE HEALTH
IMPAIRMENT AMONG THOSE EXPOSED TO A RISK FACTOR WITH THE
INCIDENCE AMONG THOSE NOT EXPOSED TO THE SAME FACTOR.


HEALTH IMPAIRMENT

Present      Absent           TOTAL

EXPOSED TO THE RISK FACTOR            A              B           A + B


NOT EXPOSED TO THE FACTOR             C              D           C + D


TOTAL                            A + B + C + D


      In the analysis, the incidence in the exposed group is compared
with the rate incidence in the unexposed group.  Since this design
allows estimation of the incidence of the health impairment in the
exposed and unexposed groups, the relative risk can be calculated
directly.  In addition, because this design allows direct measurement
of the absolute and relative risks of developing the particular health
impairment in a population, it is very powerful for testing hypotheses
about the relationship between risk factors and health impairments.

      Presented below are the most commonly used formulas in this type
of an epidemiological study:

      Rate of incidence in the exposed     = A/(A + B)

      Rate of incidence in the unexposed   = C/(C + D)

      RELATIVE RISK        =         A/(A + B)
C/(C + D)


The advantages and disadvantages of each of the three
observational designs are outlined in Table 4.
Table 4

     COMPARISON OF THE ADVANTAGES AND DISADVANTAGES OF THE PRINCIPAL
TYPES OF DESIGN FOR EPIDEMIOLOGICAL RESEARCH

TYPE OF DESIGNADVANTAGESDISADVANTAGESCROSS-SECTIONAL1.Simple and
inexpensive.
2.    Allows determination of the prevalence of a disease or a risk factor.
3.    Permits a description of the population.1.    Does not allow
inferences with respect
to causality.
2.    Neither the incidence nor the relative risk can be determined.RETROSPECTIVE1.I

n

e

x

p

e

n

s

i

v

e.
2.    Short period of study.
3.    Fewer individuals.
4.    Adequate for rare diseases.
5.    The cases are easily identified.1.   Possibility of bias.
2.    Incidence cannot be determined.
3.    The relative risk is approximate.
4.    It is difficult to select the controls.
5.    Not suitable for rare risk factors.PROSPECTIVE (Cohort)1. Less
possibility
of bias.
2.    Allows determination of relative risk.
3.    Allows determination of incidence.
4.    The study of various injuries can be combined.1.     Requires a
prolonged study.
2.    Frequently costly.
3.    Not adequate for rare diseases.
4.    Requires a greater number of subject.
5.    Suffers from the problem of the loss of subjects during follow-up.
Source:     Adapted from PAHO/WHO.  Manual sobre el enfoque de riesgo en la
atención maternoinfantil [Manual on the Risk Approach in
Maternal and Child Care].  Paltex No. 7, Washington, D. C.,
1986.  pp. 55-56.



CHAPTER III
THE PLAN FOR INVESTMENT

General Considerations

1.The preparation of this initial proposal involved the
conceptualization of certain terms whose common definitions
appear to be somewhat restrictive in light the realities in
Latin America and the Caribbean, the magnitude of their economic
and social problems, and the possible practical means available
to the countries for emerging from the crisis and redirecting
their social development.
Knowledge about the realities of a sector is considered to be
indispensable to any decisions about the investments that have
to be made.  This knowledge, as with any diagnosis of a reality,
is determined by the perspective from which it is viewed, the
values through which it is interpreted, and the willingness to
face it, to maintain it, or to modify it.  In other words, an
investment should not be an isolated action out of context but
rather a commitment based on clear guidelines and adequate
knowledge of the reality on which it is to make an impact.  An
action need not be repeated merely because it was done that way
in the past.  It is generally recognized that current systems
for protection and control of the environment and health care
are in crisis and that they need to undergo substantial reforms.

2.It is also recognized that there is a lack of complete up-
to-date knowledge about sectoral realities and that the
countries need to have operating capacity for the management
this knowledge, especially for efficient management of the
actions considered to be appropriate responses to the problems.
In the specific area of water supply and sewerage services this
need has been recognized in the past, and several countries of
the Region have set up information systems of the kind.
Actions are taken in the context of reality through political
processes that are fluid and difficult.
Accordingly, resources need to be enlisted for these purposes
as a prior and concurrent condition to the formulation of
investment plans and the preparation of corresponding projects. 
The validity and relevance of the investment and the allocation
of economic resources are dependent on these prior and
concurrent actions.  Consequently, in the components of the
Regional Plan, sectoral analyses have been regarded as
pre-investments, along with the development of national
guidelines for reforming the systems and country-level capacity
for the preparation of national investment plans and the
corresponding concrete projects.

3.Technical and financing agencies already look upon
institutional development as part of investments in concrete
projects because they want to ensure that there is capacity to
implement the investment and, more important, to manage it
afterwards with maximum efficiency and effectiveness.  In the
case of drinking water supply, it is even a prerequisite for
investment.  Otherwise the investment does not produce the
results it was intended to and fails to make the expected
impact, and the situation soon leads to deterioration and loss. 
The establishment of information systems, the creation and/or
strengthening of facilities for efficient management, especially
when it is to be decentralized, and the improvement and
development of human capital at all levels are the essential
components of institutional development that guarantee the
implementation of physical investments.
The usual definition of infrastructure is narrow and unrealistic
when it is limited to buildings, installations, and equipment.

Structure and Content

4.The Regional Plan for Investment contains six major
components.  Each of these major components, in turn, is broken
down into selectively identified subcomponents corresponding to
priority areas for action.
The Plan covers a 12-year period, from 1993 through 2004, and
varying levels of physical and monetary investment have been
scheduled throughout this period.  Thus, for example, pre-
investments are concentrated during the first four years and
those in institutional development during the first six years,
while investments in new peripheral services and hospitals start
in the third year, and so on.  Self-care modules may begin to
function as of the first year, and water supply and sewerage
projects have been carried over from the International Drinking
Water Supply dand Sanitation Decade in the 1980s.

Estimates Required

5.In both physical and monetary terms, the Plan is expressed in
average figures for Latin America and the Caribbean.  However,
in order to calculate the figures for the Plan it was necessary
to break down the information available.  For each country--33
countries and several territories--the urban areas were
differentiated from rural areas and the former were subdivided
into residential areas, marginal areas, capital cities, and
large urban metropolises of more than a million inhabitants. 
The proposed diagnostic criteria, standards, and other elements
had to be applied to each of the breakdowns because national
averages conceal heterogeneities and sometimes profound
differences, thus distorting the interpretation of reality.
Average values for the Region are taken as midpoints with 5
percent variation on either side.  The ranges, in turn,
represent the "median area" of the different values arranged in
ranked order.  A broad variety of factual information from the
countries was used in an effort to eliminate the extremes and
prevent the distortion that would be masked by merely averaging
all the values available.
An effort was made to obtain the most recent and reliable
information, and only when information for the period 1989-
1990 was not available was earlier information resorted to. 
Preference was given to information from international agencies,
especially those of the United Nations family.  Accordingly,
sometimes these sources were used in preference to other more
recent information that may have been just as reliable.  In the
population projections, preference was given to the United
Nations low-growth hypothesis in each case.

6.Estimates of coverage, which are an important factor in
formulations of this kind, were problematic in the case of
direct health care because of the lack of reliable information. 
It is difficult to expect accurate figures when there are so
many different institutions and systems whose actions often
overlap within the same population groups, when theoretical and
legal coverage tend to be confused with effective satisfaction
of demand, when the services cover varying areas of influence,
when access to health establishments may be impeded for cultural
or economic reasons, lack of transportation, or other factors,
and when information about place of residence is not even
recorded let alone processed.  On the basis of the little
information available in this regard and the estimates that have
been made by various international organizations, it has been
assumed for the purposes of this first approximation that
coverage will vary depending on whether it involves capitals
cities, large urban metropolises, rural areas, institutional
systems, etc.  The estimates contained in the Plan have taken
these differences into account (Table 2).

       TABLE 2 : COVERAGE OF DIRECT HEALTH CARE SERVICES, 
LATIN AMERICA AND THE CARIBBEAN, 1990-2004



CATEGORIES1  9  9  02 0 0 41 9 9 1 - 2 0 0 4P O P U L A T I O NC O V E R A G EP O P U L A T I O N
INCREASE
(in millions)TO BE COVERED IN THE 
    PERIOD2                                                           IN
MILLIONS
%PRESUMABLY
COVERED1   PRESUMABLY
NOT COVEREDIN MILLIONS
%TOTAL

URBAN

URB. RESID.

URB. MARG.

RURAL

IN CAPITALS

IN L.U.M. > 1'**

OTHER URBAN AREAS                                                    444.5

317.8

206.5

111.3

126.7

70.5

70.6


176.7100.00

71.50

46.46

25.04

28.50

15.86

15.88


39.75286.6

242.3

175.5

66.8

44.3

59.9

56.5


125.9157.9

75.5

31.0

44.5

82.4

10.6

14.1


50.8569.9

443.9

267.4

176.5

126.0

96.7

97.3


249.9100.00

77.89

46.92

30.97

22.11

16.97

17.07


43.85125.4

126.1

60.9

65.2

(0.7)

26.2

26.7


73.2284.0*

201.6 

91.9

109.7 

82.4*

36.8

40.8


124.0 
1          It has been assumed, conservatively, that coverage reaches 85% of the residential urban population, 60% of the marginal urban population, and 35% of the rural population, for
an average of 64.5% of the total population, which means that between 35% and 40% of the population is not covered.
2          Total population presumably not covered plus the expected population increase between 1991 and 2004.
*          Rows do not add up.    **  Large urban metropolises of more than 1 million population.

Sources: World Urbanization Prospects, United Nations, 1990; various estimates by UNDP, IBRD, IDB,
ECLAC, PAHO.




7.With regard to the environment, coverage was estimated using
information from the regional evaluation of the International
Drinking Water Supply and Sanitation Decade, 1981-1990, and
September 1990 projections by the Pan American Health
Organization for the year 2000, based on information submitted
by the countries following a standard model for presentation of
the data.  The figures on coverage are for 1988, and individual
adjustments were made to take into account activities carried
out by the countries in recent years.  Although the adjustment
factor varied by activity and area, it was usually less than 1.
In the solid waste subsector the most up-to-date and
comprehensive source of information on coverage, types of
services, and unit costs was that provided by the Pan American
Health Organization.  Regional experts were also consulted
(Table 3).

       TABLE 3: COVERAGE OF DRINKING WATER AND SANTITATION SERVICES, 
LATIN AMERICA AND THE CARIBBEAN, 1993-2004

· POPULATION IN MILLIONS  

S E R V I C E S1 9 9 32 0 0 4 1 9 9 4  -  2 0 0 4COB.
%POPULATIONTOTAL
    POPUL.                                                           COV.
%POPULATIONTOTALSERVEDINCREASETO BE COVERED IN  THE
PERIOD
URBAN DRINKING WATER      SUPPLY
85
343.6
292.1
443.9
98
98.3
143.0URBAN SEWERAGE
SERVICES 
78
343.6
268.0
443.9
93
93.3
144.9
RURAL DRINKING WATER      SUPPLY 
53
126.6
67.1
126.0
75
<.6>
24.8RURAL SEWERAGE
SERVICES
30
126.6
38.0
126.0
75
<.6>
53.9
URBAN WASTEWATER TREATMENT 

10

343.6

34.4

443.9

50

50.2

187.6
SOLID WASTES 
   A. COLLECTION
   B. FINAL DISPOSAL 

70
30
343.6

240.5
103.1
443.9

90
90

90.3
90.3

159.0
296.5
SOURCES:   Pan American Health Organization: Evaluation of the 
International Drinking Water Supply and Sanitation 
Decade, 1981-1990; Sept. 1990.
Other sources:  IBRD, IDB, ECLAC, PAHO.
Note: Not included in this table is the population 
affected by water pollution of industrial origin 
measured in terms of the organic polluting
content, as             estimated for the corresponding
investment.



8.The estimates presented in real or physical terms were
prepared on the basis of existing information after the
appropriate breakdowns were made, and they were prepared
independently for each component or subcomponent.  Thus, for
example, the deficits in physical infrastructure have been
calculated separately for the rehabilitation of buildings,
installations, and equipment; for re-equipment; and for the
construction and equipment of new facilities.
The "concealed" deficits under the heading of rehabilitation and
re-quipment have been calculated using criteria to estimate
inadequate conditions, deterioration, and obsolescence.

9.The estimates in monetary terms have been prepared by
converting all the values into 1990 US dollars and applying the
conversion factors used by the World Bank.
Unit reference costs have been estimated on the basis of
information from concrete investment projects either already
completed, under way, or approved.  As explained previously, the
values for each element were arranged in ranked order, a "median
area" was established, and the average and range were
calculated.  These values must not be taken as standards being
proposed as part of the Plan.  In practice, each concrete
project will use different values depending on the country's
particular situation and circumstances.
Some of the reference standards, such as ratios, rates, and
other parameters used for comparison, have also drawn on
information from concrete projects which has served as a basis
for reaching a consensus among technicians from various
organizations.


COMPONENTS OF THE PLAN

10.Although the present proposal is only a broad first
approximation, each component and subcomponent has been
formulated based on the criteria of uniqueness and
complementarity.  This has given coherence to the various parts
of the whole.  It has also meant that some investments might
also have been justifiably included elsewhere in the proposal. 
The analysis of financial costs is presented at the end of the
chapter.


1. Investment in Man's Immediate Physical and Biological Environment

11.In view of the impact on health and the magnitude of existing
deficits and future requirements in terms of both quality and
coverage of services, priority is being given to investments in
areas related to drinking water supply and sewerage services, urban
sanitation (solid wastes), and control of the water pollution from
municipal and industrial effluent.
Attainment of the percentages of coverage envisaged in terms of size
of the population, regular reliable service, and quality will
require, in addition the investment of available or potential
financial resources, optimization of operating capacity in the
companies and institutions of the subsector.  Thus it is important
to develop them institutionally and to enlist more active
participation by the population in the solution of these problems. 
It will not be enough to merely set standards for drinking water
quality during 1993-2004; there must be routine verification by
quality control laboratories staffed with qualified personnel and
equipped with adequate instruments and means of transportation.
The protection of water supplies for human consumption, the
processing of water to make it potable, and the sanitary
distribution thereof down to the ultimate consumers are major tasks
for the institutions and companies of the sector, and their relative
success will determine the health or disease of the population. 
These are also basic elements for the attainment of equity.  It is
sad to note that one of the many factors contributing to the cholera
epidemic was the high percentage of drinking water disinfection
facilities either out of service or experiencing operational
problems (lack of qualified personnel and lack of chemicals for
disinfection, among others).
This proposal for regional prioritization also takes into account
the potentially critical repercussions at the national or local
level of hazards that can result from other environmental risks--for
example, air pollution in Mexico City or Santiago.  For each area of
investment, the requirements for new projects and for the
rehabilitation of existing infrastructure are identified.

12.The proposed investment of US$113.9 billion represents 54.86% of
the total investments under the Plan.  Of this amount, US$97.67
billion is for new projects and US$16.230 billion for the
rehabilitation of existing infrastructure, representing 85.75% and
14.25%, respectively, of the total investments in environmental
infrastructure (Table 4).

TABLE 4 : REGIONAL PLAN FOR INVESTMENT,
        INVESTMENT IN PHYSICAL INFRASTRUCTURE, 1993-2004
(in millions of 1990 US$) 

INVESTMENT IN PHYSICAL INFRASTRUCTURE TYPE OF INFRASTRUCTUREREHABILITATIONEXPANSIONTOTAL
GENERAL TOTAL 

SUBTOTAL FOR ENVIRONMENT

DRINKING WATER AND SEWERAGE 
WATER POLLUTION 
SOLID WASTES 

SUBTOTAL FOR HEALTH CARE 

SELF-CARE MODULES 
HEALTH POSTS AND CENTERS 
HOSPITAL BEDS 
33,230

16,230

14,140
1,530
560

17,000


750
16,250
143,890

97,670

61,860
28,750
7,060

46,220

4,850
2,620
38,750
177,120

113,900

76,000
30,280
7,620

63,220

4,850
3,370
55,000
13.    With regard to urban drinking water, the estimated current
coverage of 85% (household connections and easy access) is to be
increased to 98%, which will provide service to 143 million people. 
Of this total, 35% corresponds to marginal urban population.  This
reality was taken into account in the characterization of
consumption, the technologies to be utilized, the types of
connections, the types of services to be provided, per capita unit
costs for construction in 1990 US dollars, and the feasibility of
the total investment planned.
Urban drinking water accounts for a proposed investment of US$36.32
billion, or 31.9% of the total investment in the environment.
The amounts of US$27.52 billion for new projects and US$8.8 billion
for rehabilitation represent 76% and 24%, respectively, of the total
investment in urban drinking water supply.

14.   With regard to sewerage systems for urban areas, the current
coverage of 78% (conventional and latrines) is to be increased to
93%, which will provide service to 145 million people.
Considerations similar to those for water supply are applied here to
the marginal urban population and quantification of the
corresponding investments.  Adjustments have been made for types of
services and design criteria, and social participation has been
emphasized in the construction and operational phases. 
Consideration was given to such options as simplified
reduced-diameter sewerage systems and hydraulically sealed latrines.
For urban sewerage services, the investment proposed is US$32.71
billion, or 28.72% of the total investment in the environment.
The amounts of US$28.090 billion for new projects and US$4.62
billion for rehabilitation represent 85.9% and 14.1%, respectively,
of the total investment in urban sewerage services.

15.    With regard to the rural population, the intention is to
increase the coverage of drinking water supply and rural sanitation
services, now at 53% and 30%, respectively, to 75% in both cases by
the end of the period.  This means that an additional 24.8 million
people will have access to drinking water and that sanitary excreta
disposal services will be extended to 53.9 million inhabitants in
rural areas.
The proposed amounts of US$3.73 billion and US$3.24 billion
represent 3.27% and 2.,85%, respectively, of the total investment in
the environment.
The population to be served was divided into different groups and
geographic locations in order to determine the type of service to be
provided and the kind of technology to be used and to estimate the
investments required.
The amount required for rehabilitation was calculated for each area.

16.    The analysis under the heading of solid wastes included the
cost of public cleanup, the collection and final disposal of
household wastes, and recycling stations.
Trash collection coverage, which now reaches 70% of the urban
population, will be increased to 90%, and final disposal, using the
sanitary landfill method, will be increased from the current level
of 30% to 90%.  This means providing these services to 159 million
and 296.5 million people, respectively.
The use of sanitary landfills as a method of waste disposal, if they
are properly designed, operated, and maintained, considerably
reduces the investment cost.
The amount of US$7.62 billion represents 6.7% of the total
investment in the environment.  This includes US$7.06 billion for
equipment, collection trucks, bulldozers, power shovels, other new
infrastructure, recycling stations, workshops, and garages, plus
US$560 million for the rehabilitation of installations, vehicles,
and workshops.

17.    The heading of water pollution includes the treatment of
municipal and industrial wastewater prior to discharge into
watercourses.
Although financing has been available in the past for the treatment
of domestic/municipal sewage, water and sewerage companies, as a
subsector, have not assigned priority to or been successful in
orienting management in this area.  Less than 10% of the municipios
and industries in the Region adequately treat their wastewater
before releasing it into natural watercourses.
The joint analysis and presentation in the Regional Plan for
Investment seeks to point out that above and beyond the
responsibility and/or capacity of the individual companies
responsible for operating the installations, the countries of the
Region should make a commitment to address this critical situation.
This environmental problem impacts negatively on the health of the
population, increases the costs of treating water for human
consumption, and impinges on the quality and availability of water,
a natural resource that is in limited supply and has multiple and
conflicting uses.  A control program, in order to be successful,
calls for simultaneous action against the sources of pollution and a
commitment on the part of all social sectors to provide the support
and time necessary in order to restore the watercourses that have
become contaminated.
Although local responsibility and operation are emphasized, the
problem of water pollution requires regulation that goes beyond
local jurisdictions.  As an intrinsic aspect of the Plan, there
needs to be legislation that regulates the use, conservation, and
preservation of water resources at reasonable cost and also provides
for control agencies that are independent of any linkage with a
particular sector of users.

18.    Currently wastewater treatment, i.e. treatment prior to
discharge into watercourses, covers 10% of the urban population.  It
is intended to increase this figure to 50%, which represents of the
sewage produced by a total population of 187.6 million.
The amount of US$15.6 billion set aside under this heading
represents 13.7% of the total being allocated to the environment. 
It includes US$14.07 billion in new projects and US$1.53 billion for
the rehabilitation of existing plants and installations.
Two technological options (conventional treatment and stabilization
ponds) were analyzed in order to quantify the investment.

19.    Although the risks and dangers posed by chemical substances
and heavy metals contained in industrial wastewater (toxins,
carcinogens, mutagens, etc.) must not be ignored, the organic
content is the polluting factor taken into account in determining
the equivalent population (BOD) that would require wastewater
treatment.  It is assumed that if programs for the control of water
pollution are developed at the national and local level in
watersheds or hydrographic regions, such undertakings as evaluation
of the degree of pollution and the possibility of recovery, regular
monitoring of polluted watercourses, and control of runoff will take
into account parameters that cover all contaminants and not just
organic components.
In any case, the Region must be committed to mounting a major effort
in this area to tackle the health problems that still exist today as
a result of these avoidable risks.
The amount proposed is US$14.68 billion, which represents 12.9% of
the investment in the environment.  No information was available for
the evaluation of rehabilitation.
The total investment in the environment represents an annual average
of approximately US$9.5 billion.

2.    Physical Infrastructure for Direct Health Care

20.  The calculation of investments in this area seeks to respond to
the impact they can be expected to have on the application of
general guidelines for reforms to direct health care systems and for
environmental control (Table 4).
Self-care is the essential element, even though the magnitude of the
investment cost and recurring costs is not commensurate with its
importance.  The useful life of the modules is estimated at only 10
years, and the maintenance and replacement of materials will require
a fixed allocation for this purpose which is specific, guaranteed,
and irrevocable in the operating budgets.  This is feasible because
the formal structure of the corresponding budgets does not take into
account the monetary expenditure for human resources.
Self-care modules can begin to function during the first year of the
Plan, the sole limitation being the effective capacity of current
health posts and health centers to provide the necessary
information, training, and advisory services.  It is important, from
the strategic standpoint, for them to begin to function as soon as
possible so that they will exert political pressure to bring about
an early reorientation of the role of health posts and health
centers.
The amount for this component of the Plan is US$4.85 billion, which
represents 7.7% of the component and 2.3% of the total,
respectively.  It is important to point out that the feasibility and
effectiveness of this subcomponent will depend a great deal on the
investments made in institutional development, an area through which
training is financed, plus the elements that will ensure a
continuous flow of information, the updating of knowledge and
skills, supervision, advisory services, and evaluation.

21.    The rehabilitation and re-equipment of health posts and
health centers also important.  In order for self-care to work,
these establishments should be able to play a new role of support
and supervision.  At the same time, their decision-making capacity
should be increased with regard to the main pathologies that cannot
be resolved by self-care.
Preference has been given to the re-equipment of health posts and
health centers in rural and marginal urban areas, and as a result
the unit investment costs are higher than they would be in the case
of establishments located in an urban residential setting.

Only for the purposes of this first regional approximation and as an
average to be used as a reference, it is considered that a health
post can supervise up to 20 self-care modules and provide coverage
to a population of approximately 10,000.  A health center, in turn,
can supervise up to three health posts and provide coverage to a
population of approximately 30,000.
The estimated investment for health posts and health centers comes
to approximately US$3.37 billion, which represents 5.3% of the
component and 1.6% of the total for the Plan, respectively.
The rehabilitation and re-equipment of existing infrastructure
amounts to 22.3% of the investment in health posts and health
centers.

22.   It should be pointed out that the foregoing calculations and
estimates have been prepared on the basis of very little
information.  Problems exist with regard to terminology and
definitions, which vary from one country to another and even within
countries.  Information is lacking, for example, about budgets,
resources, production, and beneficiaries, and consequently no valid
indicators are available for estimating efficiency, effectiveness,
impact, or relevance.  The information available in some of the
countries is different, for understandable reasons, and for the
Region as a whole it is not very reliable.  Little is known about
the number and the quality of services of the health posts and
health centers that come under the private sector or public
institutions other than to the Ministries of Health and the Social
Security institutions.  Thus estimates of visible and "concealed"
deficits had to be made on the basis of references gleaned from
monographs, studies, and research reports, coupled with the
consensus of technicians with experience at these levels.

23.    With regard to hospital beds, priority has also been given to
the rehabilitation and re-equipment of existing hospitals, as long
as they have more than 150 beds when they are located in capital
cities or large urban metropolises, and more than 100 beds in other
locations.  On the basis of the most reliable information--concrete
investment proposals for rehabilitation and re-equipment--it has
been estimated, for purposes of this preliminary regional
approximation, that 70% of the hospital beds located in capital
cities and urban metropolises are found in hospitals with more than
150 beds and that the percentage for other locations is 50%.
It has been very difficult to uptain up-to-date and reliable
information on the number of beds and their geographical and
population coverage in the countries.  Information has had to be
requested directly from the national authorities through the PAHO
Representations, but there are still gaps in the data obtained, as
well as lack of uniformity.
In Latin America and the Caribbean together there are slightly more
than 1 million hospital beds not counting those allocated for mental
patients and others with chronic pathologies.  Thus, for a
population of 444.5 million there are 2.48 beds per 1,000
inhabitants.  In the capital cities the bed ratio is 2.52, with
variations that range (considering only countries with populations
of more than 1 million) from 9.26 to 1.11.  In the large urban areas
with more than 1 million inhabitants the bed ratio is 3.3 per 1,000,
with variations that range from 5.07 to 1.52.  In other areas the
bed ratio is 2.28, with variations ranging from 6.69 to 0.56.

24.   The breakdown of this information has made it possible to
verify the distorting effect of national averages.  Countries whose
national average would indicate that they do not have any bed
shortages regardless of the reason, rate, or ratio used,
nevertheless show geographical areas and population groups in which
deficits do exist when the information is broken down.  This
situation can be attributed to the historical trend of migration
from rural to urban areas and of scattered populations in rural
areas, as well as the Region's inherent long-standing tradition of
centralism.

25.    Another important point that warrants further study in much
greater depth is the impact of medical and/or curative services on
the health of the population.  In the particular case of hospitals,
especially in their current state of deterioration and lack of
financing, the "beds per 1,000 population" ratio has little meaning. 
Countries with bed ratios of less than 1.0 have better health
indicators than countries with ratios of 3.0, 4.0, or more.
For a long time the accepted standard has been a ratio of 5 beds per
1,000 population.  More recently, however, concrete investment
projects have suggested that the ratio is closer to 3 beds per 1,000
population.  Since the regional average for Latin America and the
Caribbean is 2.48 at the present time, a standard of 2.5 has also
been proposed.  If this ratio is accepted and it is intended to
cover the current visible and "concealed" deficits and prepare for
the expected increase in population by the year 2004, this would
require 3.6 times more financing than the estimate contained in the
present Regional Plan for Investment, or a total of $180 billion. 
Even in the hypothetical case that financing of this magnitude would
be available for hospital beds alone, the extremely high recurring
costs would make such a proposal totally unfeasible.

26.    The amount proposed for the rehabilitation and re-equipment
and for the construction and equipment of hospital beds is on the
order of US$55 billion, which represents 87.0% of the component and
26.5% of the total for the Plan, respectively.  The component
corresponding to the rehabilitation and re-equipment of existing
infrastructure accounts for 29.5% of the investment in hospital
beds.

3.    Pre-investment

27.    In order for the Regional Plan for Investment to be
translated into national plans for investment and eventually
transformed into specific projects and to prevent it from being
reduced to merely a list of physical infrastructure projects without
any regard for local needs, priorities, or operating capacity,
components corresponding to pre-investment, institutional
development, and science and technology have been included as
investment areas.  Their importance and relevance to the proposed
Plan for Investment exceed their quantification in monetary terms.
28.    The pre-investment component, amounting to US$750 million,
represents 0.36% of the total investment proposed (Table 5).
This heading includes, as its point of departure, the preparation of
an entire plan and the conduct of sectoral analyses at the country
level which will reveal information, inter alia, about:  deficits,
the structural organization of the sector's institutions, the legal
framework, operating capacity, and the financial and human resources
available in terms of numbers and quality.
This framework is adaptable to the realities in each country, and it
is proposed to prepare models for carrying out the studies and
establishing systems and mechanisms for their permanent updating and
for the transfer of information.

29.    It is also intended to cultivate a base of support in society
and its various political, professional, and social elements. 
Meetings, encounters, workshops, seminars, and discussions are
considered to be the most appropriate means for achieving this
objective, coupled with extensive use of the mass media.

30.    With a view to uniformity in the information collected and
processed, as well as to an exchange of experiences at the country
level within the Region, it is planned to develop appropriate
orientation methodologies that will be adaptable to the type of
investment, to local realities, and to the prospects for financing. 
In order to provide for a true transfer of knowledge and to expand
the capacity of the countries, it is planned to enlist the
participation of universities and the entire formal education system
in the expansion and maintenance of this training.

31.    The channeling of sectoral projects to the various financing
agencies will be facilitated if the projects are well defined and
well structured and if they have clear-cut guidelines with regard to
policies, strategies, priorities, operating capacity, financing
systems, and cost recovery.  This will also help to reduce the
excessively long time that it currently takes to get projects
approved.


ANNEX 1

BASES FOR THE DEVELOPMENT OF THE PROGRAMS FOR THE ELIMINATION OF
 LEPROSY
IN THE COUNTRIES OF THE REGION OF THE AMERICAS


The table below shows the capacities that need to be
developed at the different levels.


LEVELCAPACITY(a) CommunityIdentification
of suspected cases (probable cases according to clinical
manifestations).  Collaboration to ensure regular compliance
with treatment.  Support for disabled patients.(b)  Primary
(basic health unit)Passive case detection.
Active case-finding among contacts within and outside the
household.
Provision of MDT.
Application of simple techniques for prevention and management
of disabilities.
Operational participation in research protocols.(c)  Secondary
(Outpatient or inpatient)Intensive search for probable cases in
open communities in areas targeted for elimination.
Bacteriology.
Confirmation of doubtful cases.
Management of adverse reactions and effects of treatment.
Application of techniques of greater complexity in the
prevention and management of disabilities.
Participation in the training of primary level personnel.
Collection of statistical data for surveillance and for research
protocols.
1.              Improvement of Diagnosis

Improvement of detection activities with a view to
increasing sensitivity and specificity in the diagnostic
confirmation of a clinically suspicious case.  This will be
accomplished through:

a.              Training and motivation of general health services
personnel as well as development of local referral
resources for diagnostic confirmation and the management of
complications;

b.              Utilization of the general laboratory network that supports
the regular medical services.  In these multipurpose
laboratories, with a clear definition of public health,
have there is already equipment and personal geared to
case-finding and control for tuberculosis based on
bacilloscopic examinations using smears treated with acid-
fast stain and alcohol.  This installed capacity should be
enlisted for the confirmation of leprosy diagnoses by
training the nursing and laboratory personnel to take
samples of suspicious lesions and examine them
microscopically.

2.              Mechanisms for the Development of Decision-making Capacity

a.              Maximum utilization of the resources available at each
level of care (and in the referral and back-referral
systems) in the local health systems.

b.              Development of intra- and extrasectoral articulation and
community participation at the local and regional levels.

c.              Incorporation of leprosy control activities with the
activities of other teams responsible for the control of
endemic diseases related to public health dermatology,
tuberculosis, and AIDS.

d.              Training of health personnel through a program that
includes preparation and publication of information on the
strategic and tactical aspects of the Plan for the
Elimination of Leprosy in the Americas in an annual
bulletin that will cover the technical standards and
procedures to be followed regularly in the country-level
programs for the clinical, epidemiological, and
administrative management of leprosy.

3.              Epidemiological Surveillance System

The epidemiological surveillance system to be implemented
will emphasize the following aspects:

a.              Mechanisms for case detection:  (a) application of the
definition of a suspected case by auxiliary and community
personnel who have been trained, integrated into the
referral system, and work under continuous supervision; (b)
active case-finding among contacts within and outside the
home and in open communities in those countries that are in
the final stage of leprosy elimination.

b.              Notification (registration of cases):  (a) the auxiliary
and community personnel will immediately refer an
individual with a suspected case to the health service for
diagnostic confirmation by a physician; (b) the health
service will report confirmed cases to the next higher
level each month.  The central epidemiology offices in the
countries will also submit this information to PAHO/WHO on
a monthly basis.

c.              Confirmation of cases using the following procedures:  (a)
clinical and the laboratory confirmation (bacilloscopic 
examination) in multibacillary cases; (b) clinical
verification by a physician in paucibacillary cases.

d.              Processing of the information:  the information will be
consolidated and processed for determination of the values
of the indicators at the municipal and provincial (or
departmental) levels and at the central level.

e.              Feedback.  The epidemiology department at the central level
will issue a bulletin at least once a year, to be sent to
the local levels and to PAHO/WHO, which will, in turn,
issue an annual bulletin on the status of leprosy
elimination in the Americas.

4.              Evaluation of the Effectiveness of Surveillance

Indicators will be developed that reflect achievements in
the areas noted, and these will be subject to periodic
evaluation.

5.              Implementation of Stratification

Stratification is a fundamental process for setting
priorities for intervention based on diagnosis, research,
analysis, and interpretation of the information to be used as
the basis for methodological categorization of the geoecological
areas and the social groups in terms of the risk of contracting
leprosy.  For this purpose it is essential to have
epidemiological and operational information that will make it
possible to establish the pertinent strata.

Based in the data available to date, the following
tentative grouping of the endemic countries of America is
proposed for the Region taking into account existing
epidemiological and operational conditions and the outlook for
the future (Annex II, Map), with specification of the aspects
to be developed differently in each group.  In the context of
the goal of global elimination by the year 2000, the country
groups will progressively attain the goals in terms of, inter
alia, organization, effectiveness of services, allocation of
resources, reduction of the epidemiological problem, and
elimination of leprosy before that year.

GROUP I:                        Countries which, through the use of MTD, have attained
operational and epidemiological indicators that are compatible
with elimination.  Only Ecuador is in this situation.

Such countries are on the verge of immediate elimination,
are in a position to certify the results, and are able to
maintain post-elimination surveillance; their principal
activities in the coming years will be:

-               Intensified epidemiological surveillance (intensive
detection of new cases, including active case-finding in
open communities in areas targeted for elimination);

-               Post-treatment surveillance (timely detection of
recurrences);

-               Support of the timely supply of drugs in adequate
quanitities;

-               Maintenance of skills, especially for diagnosis;

-               Care for the disabled.

GROUP II:  Countries or subregions with operational and
epidemiological indicators showing that elimination in the
short term (by 1994) is feasible.

This category includes the English-speaking countries of
the Caribbean, the Central American countries, Panama, and
Uruguay.  These countries could eliminate leprosy in the short
term, which means that their principal activity in the coming
years will be the formulation and implementation of the Plan of
Action for Elimination.

GROUP III:  Countries with epidemiological indicators
showing moderate endemicity but with acceptable operational
indicators (proportion of patients receiving MDT), or with
endemic disease that is restricted to specific areas: 
Argentina, Cuba, the Dominican Republic, Mexico, and
Venezuela.

These countries will be able to achieve indicators showing
elimination in the medium term (between 1995 and 2000) and their
principal activity in the coming years will be the development
of epidemiological stratification.

This group might also include other countries such as
Bolivia, Colombia, Haiti, Paraguay, and Peru.

In the first four countries there is a shortage of
essential information.  The lack of information from these
countries reflects certain shortcomings in the organizational
and operational aspects of their control programs, although the
epidemiological reality may not be serious.  The immediate
activities required will be:

-               Improvement of the program's organization through
definition of the line of technical command, assignment of
responsibilities, institutional coordination, and
standardization of technical criteria.

-               Implementation of the epidemiological surveillance system.

Paraguay has an organized program and sufficient
information, but the MDT scheme recommended by the WHO Expert
Committee is not being used, which makes it impossible to
include this country in the forecasts for elimination, which are
based on the use of a therapeutic scheme of verified
effectiveness which does not have significant harmful effects.

GROUP IV:  Brazil's epidemiological indicators point to
high endemicity and are coupled with unfavorable
operational indicators (low MDT coverage).  This country
will achieve indicators of elimination in the long term (by
the year 2000) and its principal activity in the coming
years will be the development of intersectoral projects, on
the basis of regional planning, that will involve social
security, the university system, the science and technology
system, and the mass media.

6.              Certification of Elimination:

a.              Indicators of elimination.  The indicator of the
elimination of leprosy as a public health problem that has
been adopted is a prevalence rate of less than 1 case per
10,000 population.

Associated indicators are in the process of being
identified and the following are tentatively suggested: 
(a) maintenance of a prevalence rate of less than 1 case
per 10,000 population, at least during the last five years;
(b) MDT coverage of over 95% of the cases; and (a)
detection of all of new cases without disabilities in the
last two years.

In addition, it is suggested to compare the status of
leprosy elimination with an indicator of health system
effectiveness normally used in the evaluation of integrated
programs, namely coverage of over 80% with the complete DPT
vaccination scheme in children under 1 year of age in the
previous two years.

b.              Formal procedure for certification.  The following is also
tentatively suggested:  the information generated by the
epidemiological surveillance system will be evaluated vis-
Õ-vis the indicators of elimination by a National
Certification Commission, which will be responsible for
certifying elimination in a given country or one of its
jurisdictions.  In the Americas there will be a Regional
Commission that will confirm the certification awarded by
the National Commission.

7.              PAHO/WHO Technical Cooperation

In order to guarantee implementation of the Plan of Action
for the Elimination of Leprosy as a Public Health Problem,
PAHO/WHO will carry out the following activities:

a.              An annual evaluation meeting will be held with 10 countries
from Groups III and IV together with a group of five
experts from these countries and the principal NGOs
involved in these countries.

b.              A biennial evaluation meeting will be held with five
countries (or subregions) from Groups I and II together
with a group of three experts from these countries and the
principal NGOs involved.

c.              A Committee for the Certification of Elimination, to be
made up of individuals at the technical, administrative,
and political levels who are not directly involved in the
Plan for the Elimination, will meet when as required in
order to confirm the countries' indicators vis-Õ-vis
established epidemiological and operational criteria and to
certify the elimination officially.

d.              Direct advisory services will be provided by the Regional
Adviser (or Temporary Advisers):  two visits a year to
Argentina, Brazil, Colombia, and Venezuela; and one visit
a year to the other countries of Group III and countries
(or subregions) from Groups I and II.

e.              Subregional and national advisory services.  In order to
give viability to the technical support for the countries,
PAHO/WHO might determine when this is considered necessary
for a limited time and provide national and subregional
advisory services in the case of one or several of these
countries.

Human Resources:  The personnel roster of the Communicable
Diseases Program (HPT), including regional and country
advisers, constitutes the human resource to be used for
technical cooperation in the control and/or elimination of
leprosy.

Financial Resources:  The resources of the LEP project come
under the HPT program and are from regular PAHO/WHO funds
as well as from extrabudgetary sources donated by
nongovernmental organizations in the sector and channeled
through PAHO/WHO.

References

Borges, M. V., P. L. Tauil, and R. Albornoz.  Situación de los
Programas de Control de la Lepra en las Américas.  Organización
Panamericana de la Salud, PNSP/88-14, Washington, D. C., 1988.

Bryceson, A. E., and R. E. Pfaltzgraff.  Leprosy (3rd edition). 
Churchill Livingstone, 1990.

Hastings, R. C.  Leprosy.  Churchill Livingstone, 1985.

Mc Dougall, C. Implementing Multidrug Therapy for Leprosy (4th
edition).  Oxfam Practical Health.  Guide No. 3, U.K., 1988.

OPS.  Desarrollo y Fortalecimiento de los Sistemas Locales de
Salud - La Administración Estratégica.  HSD/SILOS, 2,
Washington, D. C., 1992.

OPS/OMS.  Informe de la Conferencia para el Control de la Lepra
en las Américas, Ciudad de México, Octubre 1991.  (In press.) 

PAHO.  Strategic Orientations and Program Priorities, 1991-
1994.  Washington, D. C., 1991.

Progress in Leprosy Control Through Multidrug Therapy.  World
Health Statistics Quarterly 44(1), 1991.

WHO.  International Meeting on Epidemiology of Leprosy in
Relation to Control (Jakarta, Indonesia, 17-21 June, 1991): 
Major Conclusions and Recommendations.  (Unpublished).

WHO.  Report of the Informal Consultations on Predictions and
Estimations in Leprosy (Geneva, 27-28 Feb., 1991). 
WHO/CTD/LEP/91.2.

WHO.  Report of the First Meeting of the WHO Working Group on
Leprosy Control (Geneva, 1-3 July, 1991).  WHO/CTD/LEP/91.4.

WHO.  Report of a Consultation on the Early Diagnosis of Leprosy
(Geneva, 23-25 May, 1990).  WHO/CTD/LEP/90.2.

WHO.  A Guide to Leprosy Control.  2d ed.  Geneva, 1988.

WHO.  WHO Expert Committee on Leprosy: Sixth Report.  Geneva,
1988.  Technical Report Series No. 768.

WHO.  Epidemiology of Leprosy in Relation to Control.  Geneva,
1982.  Technical Report Series No. 716.

ANNEX 2


MAP 1.  DISTRIBUTION OF LEPROSY BY PREVALENCE IN THE COUNTRIES
OF THE REGION OF THE AMERICAS AND STATUS OF ELIMINATION



SITUATION

NOT END. AND NOT CLASSIF.
IMMEDIATE ELIMINATION
ELIMINATION 1994
ELIMINATION 1995-2000
PROGRESS IN 1995-2000
ELIMINATION BY 2000




SITUATION OF VETERINARY PUBLIC HEALTH

C O N T E X T

Scenario A - Stable situationScenario B - Moderate changesScenario C - Imaginative, obtainable through
transformationsSocioeconomic situation

1. The school recognizes the influence of socioeconomic factors on public health conditions, incorporating them through support or supplements
in separate subjects with little emphasis on the content of veterinary medicine.

The school recognizes the influence of socioeconomic factors on the conditions in veterinary public health and relevant information is included
in the content of the subjects taught.

The influence of socioeconomic factors in veterinary public health is an integrating focus of the curriculum; this is evidenced in the entire practical
and theoretical development.Characteristics of the human and animal population

2. The school treats information on the human and animal populations without relating it to the profession of veterinary medicine.


The school recognizes the importance of information on human and animal populations in biostatistics and considers it an influential factor in
planning in veterinary public health.


The school takes into account information on the projections and trends of the human and animal populations in orienting the entire contents
of the curriculum.Animal health situation

3. The school takes into account the situation of the country and the region to identify some aspects related to animal production and health in
the curriculum.

The school takes into account the situation of animal production and health of the country and the region and the curriculum demonstrates this.

The school takes into account the situation of animal production and health, establishing lines of work that demonstrate a close relationship with
present and anticipated problems.Policies of the agricultural and livestock sector

4. The school includes agricultural and livestock goals and/or policies in the theoretical subjects, without a corresponding emphasis in the
practice.


The school recognizes the importance of agricultural and livestock policy and pays close attention to it in the distribution and orientation of the
curriculum.


The school, through the development of the curriculum, provides opportunities to analyze, discuss, or develop strategies for the achievement
of the goals included in the agricultural and livestock policy.Organization of the animal health sector

5. The school prepares the veterinarian on the basis of the traditional models of organization of the practice of animal health.

The school takes into account several models of the organization of the field of animal health and analyzes the role of the veterinarian in terms
of contributing to its efficiency.

The school considers several alternative models for the organization of the sector and through the curriculum promotes critical analysis of the
role of the veterinarian in its transformation.Human health situation

6. The school takes into account the situation of human health in the country and the region to identify some aspects related to morbidity and
mortality to be included in the curriculum.

The school recognizes the importance of the health policies and relates them to the distribution and orientation of the curriculum contents.


The school takes into account the health situation of the country, establishing lines of work that demonstrate a close connection to current and
anticipated public health problems.Health policy

7. The school includes in the curriculum themes related to the national human health goals and/or policies, although these are presented
superficially.

The school recognizes the importance of the health policies and relates them to the distribution and orientation of the content.

The school, through the development of the curriculum, provides opportunities to analyze and discuss the strategies for the achievement of the
goals included in the public health policies.Organization of the health system

8. The school prepares the veterinarian on the basis of the predominant models of the practice in the health services, accepting his participation
in them.

The school includes several models of veterinary practice, emphasizing its contribution to the efficiency of the work in the health services.

The school considers or generates several alternative models of the practice and through the orientation of the curriculum promotes critical
analysis of the role of the veterinarian in the transformation of the health services.Health and development

9. Primary care is mentioned as a strategy of health care for the achievement of the health and development goals.  In some cases, certain
activities in specific projects can be observed.

The school lends visibility to primary health care as a strategy for the management of the goals of health and development through curriculum
development and makes an effort to see that the students have some practice in its application.

The school gives priority to the development of learning experiences in those areas that apply primary care as a strategy for achieving the health
and development goals, recognizing health as a component of the economic and social development of the population.10. Food production and
marketing are mentioned as goals of animal production.Food production and marketing are treated as a philosophic basis for socioeconomic
development and are therefore included in some subjects.The production, industrialization, and marketing of food are integrated into the
curriculum as a strategy for achieving health and development in the country and the school guides the students to make it viable through
practices with the official and private sectors.11. The student is exposed to the cultural environment through courses in such subjects as history
and anthropology but there is little integration into the content of the professional courses.Recognizing the importance of sociocultural factors
in the profession, practical work in aspects related to rural sociology, health education, or social communication has been initiated.The school
demonstrates the importance of and interest in sociocultural aspects through curriculum development, supplementing that with extension and
research activities and specific projects involving the participation of students, instructors, professionals, and the community.Manpower
development policy

12. Only estimates of the number of veterinarians in existence are available.  There is a need to define the profile of the professional in keeping
with the strategy of veterinary public health.

There is information on the number of professionals available, and the school utilizes it to establish curricula, mainly following a profile derived
from traditional practice.

The school, on the basis of a study of the needs of veterinarians, coordinates with the various sectors of the labor market, providing the quantity
and quality of professionals needed to contribute to the development and well-being of man.13. The policy of personnel training in veterinary
medicine is determined by the rare or very relative participation of the veterinarians who teach and those in professional practice.Manpower
training policy in veterinary medicine is defined by groups composed of veterinarians and other professionals through formal and/or informal
mechanisms.  However, its relationship to a general policy of manpower development is weak.Manpower training policy in veterinary medicine
integrates the general policy of manpower development in health and agriculture and is defined through formal mechanisms with the participation
of veterinarians from the different areas.14. The school receives the decisions on the number of entrants per year from the university; there is
little participation in the decision-making.The faculty participates in planning the number of entrants per year on the basis of projections of the
needs of the population, national policies, and possibilities of employment.The school plans the number admitted per year according to the needs,
health and labor policies, and the demand for veterinarians.  It participates actively in the search for mechanisms and resources to adapt the
demand to the needs.Social basis of veterinary practice

15. The conditions in veterinary practice that facilitate and guarantee the full exercise of the profession are considered as matters that concern
the employing institutions and the individuals, outside the purview of the school.

The curriculum envisages working conditions that facilitate and guarantee full exercise of the profession, with joint activities with professional
associations.

Throughout its curriculum development, the school, taking into account the utilization of the veterinarian under the various working conditions,
promotes the full exercise of the profession and takes an active role in this process.Entrance requirements

16. The previous education of the student is taken into account, in requesting as an entrance requirement the years of previous schooling and/or
the level of academic performance of the student.

The school considers prior preparation in biological and social sciences and certain abilities, such as reading, drafting, and communicating,
important and includes them in the criteria for admission.

In admitting new students to the university, the faculty compares their previous preparation in basic, exact, social, and natural sciences in relation
to a set of criteria that include an analysis of skills in addition to academic performance.  I have designed mechanisms to facilitate the
development of these attributes in the applicants that do not possess them.
S T R U C T U R E

Organization of the school -  Management of knowledge

17. The institutional structure promotes independent development of the various health professions.  Integration is sporadic and informal.


The institutional structure provides mechanisms through which the students develop joint activities with other health professions through specific
coordinated works.


As an integral part of its institutional structure the school includes educational activities in veterinary public health in multidisciplinary teams, both
theoretical and practical.18. The school is organized on the basis of isolated disciplines that are the responsibility of independent
departments.The school is organized into departments that unite various disciplines or subjects.The school organizational structure facilitates
the representation of various areas in the different units.19. The organization of the curriculum reflects a lack of integration, rote learning, and
repetition of subject matter.The curriculum follows an organizational model that permits horizontal and vertical articulation but that depends on
the desire of the various chiefs of departments or units to participate.The structure of the curriculum is directed toward the processes of health
and development.  This requires the integration of various areas of knowledge in addition to their logical, continuous presentation.20.  In the
structure of the curriculum, the school emphasizes the clinical and therapeutic aspects.In the structure of the curriculum, the study unit is oriented
toward the sick animal and incorporates elements of livestock production, risks to man's health, and planning.In the structure of the curriculum,
the unit of study includes clinical, epidemiological, and managerial aspects, enabling veterinary public health to contribute to health and
development.21. Program activities are based on objectives that do not include definition of the minimum competence of the graduates.Program
activities are guided by objectives that include specific competencies of the graduates in veterinary medicine, which are derived from profiles
developed individually for each subject.Program activities are based on objectives that specify an occupational profile of skills for the graduates,
emphasizing the contribution of veterinary medicine to the solution of problems in order to achieve the goals of health and development.Relation
to the organization of the services

22. The structure of the school bears little relation to the organization of the services; there is some development through certain programs for
control of specific diseases of animals.  Existence of agreements for student practice in the area of food protection.

The organization of the school corresponds to the services of zoonoses, production, and animal health, reflecting limited connections with the
new fields in veterinary public health.

The structure of the school provides several mechanisms (for example, agreements) that ensure a close relationship with the organization of
the veterinary public health services in such areas as food protection, biotechnology, control and eradication of zoonoses, development of
biomedical models, and protection of the environment.23. In the constitution of a practical base, the school has access to and/or utilizes a
limited number of services, which restricts the development of their programs.For the development of the practical base, the school utilizes a
variety of services, thus ensuring adaptation of its programs.The school utilizes for its programs a variety of different services that in their
entirety constitute broad populational and organizational bases and represent the elements of a comprehensive veterinary public health
system.Structural flexibility

24. There are committees in the school to examine necessary changes.  They tend to be limited to curricular aspects and there are long delays
in making adjustments.

Through institutional and structural integration, the school has mechanisms that permit adjustments without a long process.  Within every subject
the changes are relatively easily accomplished.

The school has dynamic mechanisms that facilitate and generate processes of transformation according to need.  There is continuous updating
of the curriculum; the absence of this represents instability.Research

25. The organization of the school indicates a low priority for research.  When it is included, it is isolated.

The organization of the school indicates a recognition of the need for research.  It provides means for its development but there is very little
linkage with the services and teaching.

In the organization of the school, research is considered of fundamental importance to the country in the educational and service processes;
it is incorporated into the theoretical and practical aspects of the curriculum.Social communication and extension

26. In the structure of the school, extension activities are located in such a way that their importance is minimized.

The structure of the school permits the realization of activities of social communication, without much substantive development.

The place occupied by social communication and extension in the organization of the school demonstrates the relevance of these activities to
the mission of the university in the national context.Administrative support

27. The structure of the school only encourages coordination between administrative and educational activities in limited instances, each being
developed independently.

The overall structure of the school facilitates the coordination of the administrative and teaching activities, but two separate structures are
maintained for them.

The school utilizes an administrative structure that prioritizes the management of education, extension, and research.28. In the preparation and
administration of the budget, the school has little access to the decision-making process.The school prepares the budget and administers it, but
enjoys limited participation in the decision-making related to its approval.The school prepares its budget, participates in the related decision-
making, and administers it.Access to bibliographic information

29. The school has a limited library and does not have a budget devoted to its maintenance.  The information is concentrated in books and there
are few journals and offprints.  The available journals are often not appropriate for the curriculum content or because of their language.

The school has a library of books and nontraditional materials, adequate in quantity and quality.  There are Latin American and other journals
available with relevant information for the development of the programs of the school and there is a reference system that allows access to
bibliographic information outside the school.

The school has introduced automated systems for access to information that are connected with other schools and international reference
libraries.Availability of audiovisual aids

30. The school has limited audiovisual aids, acquired through commercial catalogs, to illustrate the teaching presentations.

The school has an adequate quantity of audiovisual aids to illustrate the lectures but the possibilities of their being updated are limited.

The school has and updates its audiovisual aids for illustration of the lectures.  In addition, it cultivates and maintains an active exchange with
other teaching and research centers.Structure of the faculty

31. The school, in establishing criteria for selecting faculty members, pays little attention to specialization and/or professional experience in the
specific area.

The school has determined criteria for selection of the members of its teaching staff that include scientific and technical preparation and/or
experience in their specialization.

The criteria for selection of instructors include scientific and technical preparation and experience in their area of the work, in addition to  the
abilities needed to conduct research.32. The faculty consists of a group of instructors that participate very little in the practice of the profession
after they are named.With the support of the school, the teaching staff is composed of personnel that engages in the practice of veterinary
medicine without regulation.The faculty is fully incorporated in the practice of veterinary medicine through varied mechanisms; this facilitates
its continuous updating.
F U N C T I O N

Relationship of theory to practice

33. The theory is taught in accordance with a preestablished program.  The practical experiences bear little relation to the theoretical.

Because the theory and practice are planned separately, they are related through coordinating mechanisms.

The interrelationship of the theoretical and practical elements of the curriculum is comprehensive, stemming from a single program basis.34.
The teaching and learning processes are carried out mainly in the lecture hall.  The practical experiences lack planning and the teaching in this
regard is occasional.The teaching and learning processes are carried out both in the classroom and in practice although sometimes the emphasis
is different in the two aspects.The processes of teaching and learning are carried out in varied situations with integrated emphasis and content.35.
The school selects some practices for the students to learn, with priority on technological development.The school takes the analysis of
technological development into account in its curriculum.  In the selection of experiences for students, it takes into account the appropriate
utilization of technology, but this is given a low priority.The school takes into account and participates in the critical analysis of technological
developments in the practice, assessing to what degree it utilizes and produces technologies that respond to its needs.  Students are given
experience in the rational utilization of technology.36. Participation of the nonteaching personnel in the public and private sectors is minimal or
tangential to the development of the curriculum.Nonteaching personnel in the private and public sectors participate with the instructors in the
identification of health problems and the areas to be emphasized in curriculum development.  Some participate in classroom
teaching.Nonteaching professionals in the private and official sectors participate fully in the different aspects of curriculum
development.Methodology

37. Professors utilize existing methods and means of transmission of knowledge that correspond to previously established behavior, which leads
to rote learning.

In some courses methodologies are utilized that promote the development of critical and analytical abilities in the students.

The faculty incorporates educational methods and means in the program so that the student develops critical and analytical abilities with regard
to the program contents and to their professional actions.38. The school utilizes a variety of educational materials in the more highly developed
media that are not adapted to the reality.There are departments that analyze and adapt educational materials produced for different media. 
Production in the school is minimal.The school identifies the needs for educational material; it searches for what exists, prepares it, or coordinates
its production.Evaluation

39. Curriculum evaluation is developed only to fulfill an administrative requirement and the results are not utilized for curriculum changes.

There are departments that carry out evaluations in an attempt to improve subjects and areas but the curriculum itself is not affected.

The school periodically develops an evaluation of its curriculum that is based on the political, economic, and social changes in the country and
an assessment of the performances of the graduates.40. Evaluation of the students is individual and measures almost exclusively the capacity
to repeat theoretical material with little or no emphasis being placed on the practice.Evaluation of the students provides a balanced measure
of the development of aptitudes and knowledge, the degree of conceptualization, and analytical capacity, as well as practical abilities.The school
favors self-evaluation by the student and by the professor, emphasizing the capacity for analysis and the solution of problems.41. Evaluation
of the teaching and learning processes is utilized informally and sporadically through evaluation of the faculty.Evaluation of the teaching and
learning processes is continuous through evaluation of the faculty.Evaluation of the teaching and learning processes is a mechanism integrated
into the curriculum for analysis of the performance of the school, along with the educational methodologies and the performance of the
graduate.Updating (training)

42. The activities to update the instructors constitute particular actions to meet the individual interests of the professors.  The school supports
the activities with blocks of time or salary but does not initiate or encourage them.

The activities of updating involve continuing education through courses with clear objectives and defined programming, to improve technical
knowledge in fields specifically related to the teaching and learning processes.

The subjects to be updated are chosen on the basis of needs identified by the school, by professional groups, and by the services.  They are
framed within a concept of continuing education.43. The school has few professors with pedagogical training, which is acquired as a result of
personal interest on the part of the instructor and not as a requirement of the school.The school encourages pedagogical preparation and
establishes opportunities and programs for continuous training in order to develop the teaching skills of all the instructors.The school has a
program of continuing education for its personnel, thus facilitating the application by the school of the pedagogical principles and techniques that
the institution has selected.44. The activities of continuing education are scarce and directed only toward the professionals in veterinary
medicine.The school has developed a formal program of continuing education for the professional veterinarian in which participation in some
events is open to other professionals.The school has a permanent program of continuing technical and scientific education that leads to the
development of knowledge and the transformation of the reality.  It is incorporated in multidisciplinary groups for certain programs.Production
of scientific knowledge

45. Research is generated by the particular interests of the investigators with no priorities established by the school.

Some units of the school have defined lines of research based on their area of work or on the possibilities of budgetary support.

The school defines lines of research in accordance with the needs of the profession, the educational process, and the population.46. Research,
when it is carried out, is done sporadically, and is not formally incorporated into the programs.Research is a formal activity in the curriculum; it
is carried out at several levels with emphasis on biological and pathological aspects.Research forms the basis of the programming.  Emphasis
is placed on the social and epidemiological aspects, although some space is made for other kinds of research.47. The faculty publishes few
works, usually in the form of monographs to disseminate the results of its teaching, service, and research work.The faculty occasionally publishes
in the areas of its teaching, service, and research work.The faculty periodically publishes material on its teaching, service, and research work
in an established professional journal.Budgetary availability

48. The school budget allows it to fulfill only its teaching function and even this is limited.

The budget of the school allows it to fulfill its functions, with priority for education and care, or in some cases for the interests of certain
departments.

The budget of the school, for research and as well as for teaching, service, and extension, reflects its commitment to programs that respond to
the health needs of the population.49. The school makes few attempts to find sources of extrabudgetary financing for several reasons, among
which are lack of access and lack of information.The school occasionally seeks extrabudgetary sources of financing, usually at the national level
and through the initiative of some individual on the teaching staff.The school has the capacity and mechanisms to generate its own resources
(through advisory services and projects, for example), which has significance for the budget.
I N T E G R A T I O N

Conceptual framework (guidelines for the development of the institution)

50. The instructors are guided by their own systems of values, although the school might have unified the philosophy of veterinary medicine to
apply to curriculum development.  Therefore, their impact on the actions of the institution is rarely noted.


The instructors have determined the philosophic framework of the school.  The need to include representatives of the students, graduates, and
personnel of the services in its preparation is still not well-recognized and its review is sporadic.  However, it provides general guidelines for
the development of the teaching aspects.


The teaching personnel of the school, jointly with members of student groups, graduates, and service personnel, determines the philosophical
framework of all the institution's activities.  That framework is redefined periodically, as the situation demands.51. The school has a conceptual
framework of veterinary medicine in accordance with the health and development situation in the country, but its influence on curriculum
programming is limited.The school has a conceptual framework in accordance with the social, health, and development situation in the country;
this is more evident in the theoretical aspects than in the overall programming.In all its activities the school reflects a valid current conceptual
framework in accordance with the social, health, and development situation.Role of the school in the society

52. The school prepares human resources on the assumption that they participate in the process of the development of the country.

The school identifies its action in regard to manpower training with the process of development in the country.  With respect to extension and
research its response is more limited.

The school, through its functions of education, service, and research assumes a dominant role in promoting transformation of the health and
development situation, participating in the process of decentralization and in other forms of social change.53. The school participates with the
various social actors in the planning and/or evaluation of veterinary public health only when it is requested to do so.The school is represented
in coordinating committees for the planning and/or evaluation of veterinary public health activities.The school is actively involved with the
various social actors (health, agriculture, associations, veterinary school, private sector) in planning and evaluation related to public health.54.
The school participates in health services delivery only through the practice of the students.  It has little contact with its graduates for purposes
of improving veterinary care.The school, through its instructors and students, contributes to changes of orientation in practice.  There are
mechanisms for follow-up and the graduates are incorporated into this process.The school utilizes mechanisms to integrate instructors and
students, and also graduates, whom it involves in educational and research activities and in contributing to the veterinary practice of the
students.55. The school carries out its functions with a predominantly curative approach without prioritizing the activities of management and
preventive medicine.
In the development of the functions of the school the role of the veterinarian in health promotion and disease prevention is emphasized.  Material
on administration and the rural economy are incorporated.The school in the fulfillment of all its functions emphasizes the fields of action of
veterinary public health and management as axes of the professional activities of the veterinarian in the search for social transformation for health
and development.56. The school prepares the veterinarian to occupy a position on the health or agricultural team.  It discusses his role within
a multidisciplinary context in a limited way.The school of veterinary medicine considers the veterinarian as an independent professional member
of a multidisciplinary team.  This concept is made viable through its theoretical and practical content.The school considers multidisciplinary
teamwork and the capacity to make decisions with professional independence as basic; it participates actively in searching, planning, and
implementation that demonstrate these qualities and elements.57. In its teaching the school utilizes the results of research carried out by various
health professionals, but the actual research activities are minimal.The instructors, students, and graduates question the models of animal health
care, carrying out research on related problems.The instructors, students, and graduates of the school, forming interdisciplinary teams, participate
through the results of their research in the prevention and solution of the priority problems in veterinary public health.58. The school, through
its instructors, students, and graduates, participates in discussions (for example, scientific days) that tend to define the functions and bases of
the profession.The school, through its instructors, students, and graduates, organizes activities to discuss the nature of the profession,
using the existing theories as a basis.  The professional profile responds partially to the needs of the country.The school, through its instructors,
students, and graduates and with the help of the various social actors, assumes a significant role in research and other activities that tend to
define the profile of the veterinarian to include contributing to the resolution of problems related to health, food protection, the environment,
animal production and health, and the development of biomedical models.59. The school treats the subjects related to working conditions in the
profession very lightly, both in the theory and in the practice.The responsibility for improving working conditions in the profession is assumed
by the school as a line of action in the institutions where the students practice; the latter participate in a limited way in the discussion of the
curriculum.The school assumes a significant role in the improvement of working conditions in the profession.  It prepares the veterinarians to
take an active part in the search for the strategies and mechanisms that are conducive to good professional performance.The graduate of the
school in the society

60. The graduates of the school have knowledge, abilities, and skills in their field of work.  In the labor market they demonstrate their limitations
in analysis and research.

The graduates of the school demonstrate knowledge and abilities in the practice while at the same time conducting applied research to improve
the services.  Their critical attitudes are limited to their participation in review and improvement committees in their places of work.

The graduates of the school demonstrate knowledge, abilities, and professional aptitudes and perform efficiently.  They develop critical and
analytical aptitudes in their occupation in order to identify, through applied research and other activities, new ways to promote health and
development.61. The graduates accept the ethical values of the institution where they work.The graduates consciously apply professional values
in considering the environment.The graduates of the school have an ethical social conscience which they apply to social transformation.62. The
graduates of the school enter the labor market where they follow the existing lines of authority and standards.  They demonstrate a personal
interest but participate only in the application of some specific regional and local health programs.When they enter the labor market, the
graduates of the school demonstrate qualities of leadership, striving for the improvement of veterinary care and veterinary personnel.The
graduates of the school demonstrate capacities of leadership and management that are conducive to the transformation of health and
development.63. The graduates of the school see veterinary medicine as a dependent profession and a source of relatively secure
employment.The graduates of the school are identified with their profession and become leaders in its promotion.The graduates of the school
are fully identified with the profession, promoting its development in all areas.

     TOBACCO OR HEALTH


















ANALYSIS OF THE SITUATION

.    At least 90% of the deaths from
     lung cancer, 75% of those
     caused by chronic bronchitis,
     and 25% resulting from ischemic
     heart disease can be traced to
     smoking.

.    It is estimated that in the
     Americas smoking is associated
     with more than half a million
     avoidable premature deaths
     every year. 

.    In Canada and the United States
     of America, which have had
     prevention and control programs
     for more than two decades, a
     sustained decline in tobacco
     use has been observed, owing in
     large measure to the fact that
     many adults have given up the
     habit. 

.    In Latin America and the
     Caribbean, where only a few
     countries have national
     programs for prevention and
     control, it is estimated that
     tobacco use is increasing in
     some population groups,
     especially among adolescents
     and young women with stable
     incomes who live in urban
     areas.

PAHO PROGRAM ON TOBACCO OR HEALTH

The Governing Bodies of PAHO/WHO
have adopted a number of resolutions
urging the Governments and the
nongovernmental agencies to assume
a more active role in the fight
against the use of tobacco.

Activities in this regard have
included the convening of panels of
experts, the organization of
workshops, and the promotion of
policies, plans, and programs for
the prevention and control of
smoking in the countries.

The Organization cooperates in the
analysis of existing legislation and
in the promotion of legal measures
aimed at reducing the use of tobacco
and protecting the population
against its harmful effects.

As the culmination of this process,
PAHO/WHO has established a program
on "Tobacco or Health," the plan of
action for which is based on
Resolution XII of the XXXIV meeting
of the Directing Council (1989) and
is supported by the Ministers of
Health of the Region.

PAHO, in addition to promoting
awareness of the risks of smoking
and encouraging the implementation
of control measures in the
countries, provides technical
advisory services, identifies
critical areas and deficiencies,
collaborates with the countries in
the development of programs, and
cooperates in training and research.
OBJECTIVES OF THE PROGRAM

1. To promote public health measures
at  the Regional, subregional, and
national levels in order to reduce
the incidence and prevalence of
smoking and protect the health of
non-smokers, working to see that
their rights are upheld.

2. To ensure that future societies
and generations will remain "smoke-
free."




STRATEGIES AND PRIORITIES

The attainment of the ultimate
objectives of the program will be
facilitated by the adoption of
strategies for implementation of the
Regional Plan of Action for the
Prevention and Control of Smoking. 
This plan recommends concrete
control measures, including:

*    Promoting the development of
     policies, plans, and programs
     for the prevention and control
     of smoking.

*    Facilitating the mobilization
     of public opinion, the
     encouragement of appropriate
     political action, and the
     utilization of resources for
     prevention and control of the
     habit.

*    Facilitating the production,
     collection, and distribution of
     pertinent technical
     information.











LINES OF ACTION


1.  Development of policies, plans,
and programs

Promotion of policies, plans, and
programs on smoking.  Efforts in
this regard are aimed at raising
awareness of the health risks posed
by tobacco in the general public,
opinion groups, and decision-making
circles in order to promote the
adoption of clear-cut policies on
the problem.

2.  Mobilization of resources

Identification and mobilization of
all possible resources that could
contribute to execution of the
program:  mobilization of public
opinion, identification of
preeminent experts and centers,
determination of sources of
financing, utilization of social
networks, cooperation with involved
community groups.


3.  Dissemination of information

Collection, production,
dissemination, and exchange of
educational/informative material on
smoking.  Use of the mass media as
an instrument for prevention.


4.  Training

The Program supports short-term
training activities for personnel in
charge of formulating and
implementing programs for the
prevention and control of smoking.


5.  Research

The Program encourages and supports
research on the causes and
prevalence of smoking, as well as on
the effectiveness and impact of
prevention and control activities.


6.  Direct technical cooperation

Technical advisory services are
provided to the countries that
request them for the development of
national programs that are
compatible with the Program's lines
of action.  The Program arranges for
the services of experts and
cooperates in working group meetings
and activities of planning and
evaluation.
4.    Epidemiological Research on Malaria

      4.1   Introduction

      The need for epidemiological research on malaria can vary
greatly not just between countries but also from one locality to the
next.  The incidence of malaria as well as mortality from the disease
vary both geographically and with the social composition of
populations.  For example, in 1986, although just 3.8% of the
population of the Region of the Americas was living in the subregion
comprising Central America, Panama, and Belize, this area accounted for
123,000 cases of malaria, or 20% of the total number of cases in the
Region.  Within this subregion, Costa Rica and Panama had only 2% of
the cases, while 98% were concentrated in the five remaining countries
(PAHO, 1988:5).  Within these countries, it is possible to identify the
localities and population groups which account for the majority of
malaria cases and in which the probability of occurrence of the illness
is greater than in others places or groups.  It is therefore of vital
importance to identify the set of characteristics or factors in such
localities and groups that explain the increased probability of
becoming ill or dying of malaria.

      Recognition of the risk factors for malaria, and of the relative
importance of each of them, in each of the localities and population
groups during a specific period can be accomplished through
epidemiological research studies.  Epidemiological research seeks to
collect and organize information on the risk factors associated with
a higher risk of becoming ill with a disease, thereby contributing to
more complete knowledge of the epidemiological situation of that
disease.  In addition, it facilitates the establishment of a
population's risk profile and the selection of interventions aimed
specifically at modifying or eliminating this profile in high-
risk localities and groups. 

      The three basic assumptions that provide the rationale for
malaria research based on the epidemiological risk approach can be
stated as follows: 
      (1)   Within the malarious areas selected, it is possible to
identify, through indicators based on risk factors, certain
subgroups of the population in which the probability of
contracting malaria is greater than in the rest of the
population.

      (2)   Such subgroups account for a substantial proportion of the
morbidity from malaria that occurs in the total population.

      (3)   It is possible to increase the effectiveness and efficiency
of the general health services in the management of malaria
prevention and control interventions by rechanneling
activities and resources toward:
a.   the causal risk factors identified; and
b.   the individuals and groups that are at greatest risk
of contracting malaria.


      These three premises facilitate the formulation of research
objectives and hypotheses that will establish the correlation between
malaria and the various risk factors under study.

      4.2   Definition of Purposes and Objectives

      In all situations in which an epidemiological study of malaria
risk is to be carried out, it is fundamental that the purposes and
objectives of the research be rationally defined.

      One of the general objectives of epidemiological research on
malaria is to identify those individuals and social groups in malarious
areas who, by reason of their social, economic, or environmental living
conditions, are at very high risk of becoming ill or dying of malaria.

      4.3   Formulation of the Research Hypothesis

      Epidemiological research is conducted with a view to answering
certain specific questions, or hypotheses, relating to the frequency,
distribution, and determinants of malaria in various social groups.

      Thus, an initial step in epidemiological research is the
formulation of relevant questions that can be the subject of research. 
Such questions are presented in the form of one or more hypotheses. 
These hypotheses express the probable correlation that exists in the
study population between exposure to one or more risk factors and the
occurrence of an impairment to health, in this case malaria.

      RESEARCH HYPOTHESIS:

      An assumption or conjecture that is advanced to account
      for certain facts or events and is used as a basis for
      research which seeks to prove or disprove the hypothesis.
      (OMS/OPS, 1986:47)


      Well-formulated hypotheses lead to better-structured research. 
An example of a hypothesis for epidemiological research on malaria
might be the following:

      The individuals in locality "x" who lack regular access to
      medical care will have greater morbidity from malaria than those
      who have regular access to health services.


      The number of hypotheses will depend on the objectives and scope
of the research as well as on the number of risk factors under study. 
Most research hypotheses are stated in negative terms.  This way of
stating a hypothesis is known as a null hypothesis.

      NULL HYPOTHESIS:

      The statistical hypothesis that one variable has no
      association with another variable or set of variables...
      In simplest terms, the null hypothesis states that the
      results observed in a study, experiment, or test are no
      different from what might have occurred as a result of
      the operation of chance alone (Last:90).
      

      The basic reason for formulating a research hypothesis as a null
hypothesis is that the tests of statistical significance utilized in
the analysis of the hypothesis can only reject (or not reject) it when
they measure the probability that the results obtained in a study might
have occurred by chance.

      The null hypothesis corresponding to the research hypothesis
proposed above is as follows:

      There is no difference in terms of morbidity from malaria
      between the individuals of locality "x" who do not have regular
      access to medical care and those who do have regular access to
      health services.


       The formulation of research hypotheses facilitates selection
of the research design, the methodology to be used, the variables that
will be included, and the way in which the data will be analyzed. 
Moreover, it avoids confusion, loss of time, and unnecessary data
collection.
EXERCISE 1


      Malaria has been defined as a priority problem in Malarialand,*
and a group of investigators from the general health services of that
country have therefore decided to carry out a series of epidemiological
studies on the risk of malaria in the malarious areas of the country. 
Annex I presents general information about the country and its four
malarious areas. Using the information that you have at your disposal,
start your research with the following activities:


STEP  1:  Of the four malarious areas in Malarialand, select the one
that can be defined as having the highest priority.  Also identify,
within this area, the locality or localities in which research will
be initiated, specifying the criteria you applied or the reasoning
behind your selection of the particular region and locality or
localities.

STEP  2:  Formulate the general objectives of the epidemiological
research on the risk of malaria.

STEP  3:  State six hypotheses that the research will seek to prove
or disprove with a view to studying the role of six probable risk
factors that might account for the increased incidence of malaria in
the localities selected.

STEP  4:  Formulate a null hypothesis corresponding to each of the
six research hypotheses.

STEP  5:  Prepare a preliminary list of the information that you will
need to collect in order to prove the research hypotheses.








     4.4 Selection of the Research Design

      Like all scientific research, the epidemiological study of
malaria should be carried out on the basis of a structure, plan, or
design.  The research design makes it possible to structure the
theoretical frame of reference in accordance with the research
hypotheses.  Moreover, it facilitates selection of the number and type
of characteristics or factors to be studied and of the methods for
organizing, analyzing, and interpreting the data. 

      RESEARCH DESIGN

      The procedures and methods, predetermined by an
      investigator, to be adhered to in conducting a research
      project (Last:114).


      The selection and planning of the research design implies
identification of the variables or characteristics to be investigated
and definition of the procedures for selecting the groups that will be
studied, as well as the plan for randomization, if the design is
experimental.  As was pointed out in the Chapter 3, the most frequently
used epidemiological research designs are: 
(a) cross-sectional; (b) retrospective (case-control);
(c) prospective (cohort); and (d) controlled clinical trial.

      The research hypotheses and objectives must be taken into
account in selecting the research design.  In addition, it is necessary
to bear in mind existing limitations on information and resources. 
Finally, consideration should be given to whether or not a particular
research design will provide the structure needed in order to
adequately analyze the basic questions to be studied.

      4.5   Analysis of the Correlation between Malaria and the
Probable Risk Factors to be Studied

      4.5.1 Introduction

      After the research design has been selected, the next step is
to actually carry out the study.  Once all the epidemiological
information has been collected and sorted, it is broken down into the
corresponding contingency tables.  This is followed by calculation of
the basic measures for study and application of the statistical test
that has been selected for analysis of the study hypotheses. 

      The analysis and interpretation of epidemiological studies is
based on the results obtained in the tests of statistical significance. 
One of the most frequently used tests in epidemiology, and one that
exemplifies the use of contingency tables, is the chi-square test.

      4.5.2 Chi-Square Test

      In epidemiological research, one of the analytical strategies
for interpreting data is the use of a statistical test that makes it
possible to determine if there is a statistical association between the
presence of a disease--malaria, in this case--and the set of risk
factors postulated.

      The statistical association indicates the degree of probability
that an observed value, or a series of values, or the differences
between two values could have occurred by chance.

      STATISTICAL SIGNIFICANCE:

      Statistical methods allow an estimate to be made of the
      probability of the observed or greater degree of
      association between independent and dependent variables
      under the null hypothesis.  From this estimate, in a
      sample of given size, the statistical "significance" of
      a result can be stated.  Usually the level of statistical
      significance is stated by the P value (Last:124).
      
      Although there are many tests of statistical significance, the
selection of the one to be applied will depend to a large extent on
the type of research hypothesis formulated and the statistical
measurement that is desired.  In Section 4.3 it was pointed out that
all tests of statistical significance include null hypotheses.  The
development of null hypotheses is an indispensable requirement, since
statistical tests can be applied only with this type of hypothesis. 
As was mentioned previously, these hypotheses posit that there are no
differences in the population parameters (average, proportions, etc.)
between the two or more groups compared.  Statistical tests measure the
probability that the results obtained in a study could have occurred
by chance (see definition of P or probability value).  If it turns out
that there is very little probability that this could have happened,
the hypothesis of "no difference," or null hypothesis, can then be
rejected and the alternative hypothesis--i.e., the proposed research
hypothesis--accepted.


      Since the primary focus of the epidemiological research
discussed in these materials is malaria, and one of the research
hypotheses is that living in a dwelling that is not completely enclosed
is one of the probable social risk factors that increase the risk of
developing malaria, we must first establish the existence of a
statistical association between malaria and exposure to this risk
factor.  A frequently used test for determining this statistical
association is the chi-square test.

      CHI-SQUARE TEST
      Any statistical test based on comparison of a test
      statistic to a chi-square distribution.  The oldest and
      most common chi-square tests are for detecting whether
      two or more population distributions differ from one
      another; these tests usually involve counts of data, and
      may involve comparison of samples from the distributions
      under study, or the comparison of a sample to a
      theoretically expected distribution (Last:18).


      This test makes it possible to reject or not reject the null
hypothesis.  In other words, it makes it possible to establish the
association or lack of association between malaria and each of the
risk factors postulated.  It indicates the probability that the results
obtained could have occurred by chance.  This probability is stated as
the P or probability value.  This value expresses the probability that
the difference observed could have occurred purely by chance.  The P
value that is universally accepted as statistically significant is P
< 0.05.  However, this is an arbitrarily selected value and should be
considered merely a guide for interpreting the results.

      P VALUE:

      The letter P, followed by the abbreviation n.s (not significant)
      or the symbol < (less than) and a decimal notation such as 0.01,
      0.05, is a statement of the probability that the difference
      observed could have occurred by chance, if the groups are really
      alike (Last:94).


      Table 5 shows four cells, indicated by the letters a, b, c, and
d, which represent the number of individuals who possess both
characteristics at the same time.  Thus, for example, cell a expresses
the number of individuals who have the risk factor in question and who
also developed malaria (the health impairment that is being studied). 
Cells b, c, and d also express other important relationships.  The
formula for the chi-square test is as follows:

Sum of the
four cells  = (observed value -  expected value )2
expected value

Table 5
      Correlation between Malaria and Community Participation in the
Malaria Campaign among Inhabitants of Locality X, 
Malarialand, 1988

Health Impairment

Risk                                            MALARIA     
Factor                              Present       Absent     Total

   --------------------------------------------------------------------
  Nonparticipation in                      a               b       a + b
  malaria campaign
   - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- 
  Participation in
  malaria campaign                              c               d   c + d

   - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
   Total                                        a + c         b + d      n

Calculation of the expected value for each cell:

EXPECTED VALUE = (column total) x ( row total)
total number of cases (n)

      For cell a, the expected value is calculated as follows:

EXPECTED VALUE OF a = (a+c) x (a+b)
n

FORMULA FOR CHI-SQUARE = Sum of  (Observed - Expected)2
Expected for each cell



Table 6
      Correlation between Malaria and Community Participation in the
Malaria Campaign among Inhabitants of Locality X, 
Malarialand, 1988

MALARIA

   Characteristic          YES           NO       Total
   -------------------------------------------------------
   Nonparticipation in     152          1313       1465
   malaria campaign
   - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Participation in        502          7911       8413
   malaria campaign
   - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Total                   654          9224       9878
      4.5.3 Calculation of the Chi-Square Test

      An example of the way in which this test is calculated is
presented below.  The data from Table 6 are used to calculate the
expected values for each cell assuming that the null hypothesis is
correct.  The corresponding formula was used to obtain the following
expected values:

EXPECTED VALUES:
Cell a:  654 X 1465/9878 = 97    Cell c:  654 X 8413/9878 = 557
Cell b:  9224 X 1465/9878 = 1368      Cell d:  9224 X 8413/9878 =7856


Table 6-A
     Results of the Calculation of Expected Values from Table 6
to be Used for the Chi-Square Test


Health Impairment

Risk                                       MALARIA     
Factor                     Present       Absent     Total
   
---------------------------------------------------------------
Nonparticipation in               97            1368        1465
malaria campaign

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Participation in
malaria campaign           557             7856        8413

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   
Total                      654             9224       9878

      Once the expected values have been obtained for each cell, it
is necessary to calculate the difference between the observed and the
expected value.  This difference is then squared and divided by the
expected value.  The same calculation is made for all four cells and
the results are then totalled.  In our example, the result obtained
from the chi-square test was 39.21.  This value is compared with the
values found in Table 7 to determine the level of significance (P
value).  Thus, the probability of finding a chi-square value with a
degree of freedom of 2.71 or more is 10% and that of finding a value
of 3.84 or more is 5%.  In our example, since the chi-square value was
39.21, the level of statistical significance was less than 0.001.  This
means that it is unlikely that the association between the risk factor
and malaria could have occurred by chance (less than 0.001), or, in
other words, the possibility of incorrectly rejecting the null
hypothesis is less than 1 in 1000.


Steps Followed to Obtain the Value of the Chi-Square Test:

X2 = (O - E)2 for each of the cells, which are then added together
E

X2 = (152-97)2 + (1313-1368)2  + (502-557)2  + (7911-7856)2 
97      1368            557            7856

X2 = 31.18 + 2.21 + 5.43 + 0.385

X2 = 39.21

P < 0,001 n.s.


Table 7

Level of Statistical Significance for
the Chi-Square Test with One Degree of Freedom *

Value of the                   Level of Significance
Chi-Square Test                (P value)

1.64                           0.20
2.71                           0.10
3.84                           0.05
6.63                           0.01
10.83                           0.001
-----------------------------------------------------------
* The fourfold table always contains data with one degree
of freedom.
Source:  Snedecor G, and W. Cochran.  Métodos Estadísticos, 
Mexico, Compañia Editorial Continental, 1980. p. 47.



      Obviously, the simple fact that a statistical association is
found is not sufficient to demonstrate the degree of determination or
causality between the risk factors studied and malaria.  It is
necessary to determine whether or not the statistical association
found was the result of an error or bias--in other words, whether or
not it involved an artificial or spurious association.  Moreover, for
the determination of causality, in addition to the criterion of degree
of association, it is necessary to take into account other non-
statistical criteria such as specificity, temporality, and consistency
of the association, as well as biological credibility.
EXERCISE 2

The epidemiological study of risk for malaria was carried out using a
prospective study design.  Table 8 shows the number of individuals with
each of the first six risk factors studied, as well as the number in whom
the presence of malaria was observed or not observed.


Table 8
Number of Individuals with Malaria and with 
the First Six Risk Factors Studied, Malarialand, 1988

      Risk Factor                     Number of       M a l a r i a
Individuals           Yes       No
      

1. Rural occupation                        433              52        381

2. Family income
   at the poverty line                654              70  584

3. Habitation of not completely 
   enclosed dwelling                  598             121  477

4. Less than 6 years of schooling          302              33        269

5. Habitation of dwelling without 
   indoor bathroom                         505              59        446

6. Presence of breeding sites
   within 500 m                       714             190  524
      
   Total number of individuals
   in the sample          9878                  633      9245

STEP 1:
      Using the information from Table 8, complete the contingency
tables for each of the six risk factors.

STEP 2:
Calculate the chi-square value for each of the six tables completed.

STEP 3:
Discuss the results obtained in the preceding exercise, pointing out
the risk factors that are most statistically significant.      4.6 Calculation of Relative Risk and Attributable Risk

      Once the tests of statistical significance have been completed,
the research team is left with a list of factors that are statistically
associated with malaria.  The next step is to quantify the degree or
strength of each of the associations found.  The importance of a
particular risk factor depends on the degree of association and
determination that it has with malaria, the frequency with which that
risk factor occurs in the community, and the possibility of preventing
or controlling it.

      The next task is to calculate the relative risk for each of the
risk factors that were found to be statistically significant.  As has
already been explained, the relative risk in this study is the ratio
of the risk of contracting malaria in those individuals who are exposed
to any of the risk factors studied to the risk in those who are not
exposed. 

      This ratio indicates how much greater the risk of contracting
malaria is in those who have the characteristic or risk factor than
it is in those who do not have it.

      Relative risk measures the degree of association between malaria
and each of the postulated risk factors.

      Both relative risk and attributable risk are measures of
association of the excess risk from exposure to or presence of a
specific risk factor.

      Attributable risk measures the excess risk of malaria that can
be attributed to exposure to a certain factor, for example, exposure
to housing that is not completely enclosed.

      Population attributable risk is a measure of association
influenced by the prevalence of the factor in the total population. 
Population attributable risk measures the percentage decline in the
number of cases of malaria that would occur if the causal factor were
totally eliminated or neutralized. 

      The formulas and calculations necessary for estimating relative risk
and attributable risk are the following:

RELATIVE RISK   =  Incidence in the population exposed to the factor  
Incidence in the population not exposed to the factor


ATTRIBUTABLE RISK IN  =     Incidence in the population exposed
THE POPULATION EXPOSED   -Incidence in the population not exposed     



PERCENTAGE OF               Incidence in the population exposed
ATTRIBUTABLE RISK IN  =   - Incidence in the population not exposed x 100
THE POPULATION EXPOSED      Incidence in the population exposed


PERCENTAGE OF             Incidence in the total population
ATTRIBUTABLE RISK     =  -Incidence in the population not exposed x 100
IN THE POPULATION         Incidence in the total population

    The following is an alternate formula:

     POPULATION ATTRIBUTABLE RISK =     P (RR-1)  x 100
1 + P (RR-1)

     where P signifies the proportion of the risk factor in the population
and RR signifies relative risk.
     


     Table 9 presents the data on another of the risk factors studied in
community X of Malarialand:  nonparticipation by the inhabitants in the
malaria campaign.  The relative risk and the attributable risk are
calculated on the basis of these data.



Table 9

      Correlation between Malaria and Community Participation in the
Malaria Campaign among Inhabitants of Locality X, 
Malarialand, 1988


M  A  L  A  R  I  A
   Characteristic               YES           NO       Total
   -------------------------------------------------------------------
   Nonparticipation in the      152          1313       1465
   malaria campaign
   - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
   Participation in the              502          7911       8413
   malaria campaign
   - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
   Total                             654          9224       9878

    Incidence in the population exposed  152/1465 = 103.75 per 1,000
    Incidence in the population not exposed    502/8413 = 59.67 per 1,000


      RELATIVE RISK  =     103.75   =  1.74
59.67

      ATTRIBUTABLE RISK = 103.75 - 59.67  = 44.08
      (in the population exposed)

    % ATTRIBUTABLE RISK IN = 103.75 - 59.67  x 100  = 42.49 %
      THE POPULATION EXPOSED     103.75

    POPULATION ATTRIBUTABLE RISK =   O.148 (1.74-1)   x 100 = 9.89%
1 + 0.148 (1.74-1)


     Based on the results obtained in the foregoing example, for this
population during the period studied the risk of becoming ill with
malaria was 1.74 times greater in those individuals who refused to
participate in the malaria campaign than it was in those who did
participate in the campaign.  For those exposed (who were unwilling to
participate in the campaign), 42.49% of their malaria problem could be
explained by this risk factor.  Moreover, 9.89% of the malaria problem
in the entire community would be resolved if this risk factor were
eliminated.  It is important to point out that there are other possible
explanations for these results, and the presence of other concomitant
factors could interfere with the influence of a particular risk factor
on the occurrence of malaria.  In order to correctly determine the
results, such concomitant factors should be recognized and taken into
account in the analysis.

     In summary, relative risk and attributable risk are measures that
make it possible to identify and recognize the extent to which each of
the risk factors studied influences the risk of developing malaria. 
Moreover, they offer information concerning the degree to which malaria
could be reduced if each of the causal risk factors were eliminated
from the community.  These measures allow the health team to calculate
the expected level of malaria control that could be achieved if the
health program were oriented specifically toward modification of the
causal risk factors studied.  The team responsible for implementing
actions would expect the reduction of malaria levels to be proportional
to the excess risk eliminated.  Moreover, as a result of the
acquisition of epidemiological knowledge and information at the local
level, it will be possible to develop new strategies for malaria
control and formulate better operational objectives aimed at
eliminating the risk factors that determine the local distribution of
malaria.
EXERCISE 3

STEP 1:
Calculate the relative risk for the risk factors from the research
hypotheses previously decided on.


STEP 2:    

On the basis of the relative risk, rank the risk factors by degree of
importance and correlation with malaria.

STEP 3:

Calculate the attributable risk for each of the risk factors listed
in the foregoing questions.

STEP 4:

Develop a new list of risk factors, ranking them by population
attributable risk. 

STEP 5:

Discuss the differences found between the two lists of risk factors. 
Indicate the magnitude of the relative risk and the attributable risk
for any individual in particular and for the community as a whole.

STEP 6:

Indicate which of the risk factors can be modified:
     a)  in the health sector,
     b)  intersectorally.

STEP 7:

Discuss the importance of epidemiological research and the calculation
of these two measures of risk for the programming of malaria control
interventions.


    4.7   Preparation of the Final Report on the Research

    The research team should prepare a series of reports and documents
incorporating the conclusions of the research project for publication and
dissemination to health programs, social and community organizations, and
the scientific community.

    These technical reports should clearly articulate the research
hypotheses, the research design, the methods used for sampling and data
collection, and the techniques for analysis and interpretation of the
results.  They should also indicate how the results might affect the
formulation of intervention strategies for malaria control.

B I B L I O G R A P H Y 



Mauser, J., and A. Bahn.  Epidemiología.  Mexico, Editorial
Interamericana, 1977.

Lilienfeld, A., and D. Lilienfeld.  Fundamentos de Epidemiología.
Mexico, Fondo Educativo Interamericano, 1983.

Last, J.M. (ed.).  A Dictionary of Epidemiology.  New York, Oxford
University Press/I.E.A. 1988.

Kahn, H.A.  An Introduction to Epidemiologic Methods.  New York, Oxford
University Press, 1983.

OMS/OPS.  Manual sobre el enfoque de riesgo en la atención
maternoinfantil.  Serie Paltex No. 7. Washington, D.C., Pan American
Health Organization, 1986.

Schlesselman, J.J.  Case-Control Studies: Design, Conduct, Analysis.
New York, Oxford University Press, 1982.

Fleiss, J.L.  Statistical Methods for Rates and Proportions (Second
Edition).  New York, Wiley, 1981.

Kleinbaum, D.G., L.L. Kupper, and H. Morgenstern.  Epidemiologic
Research.  Belmont, Calif., Lifetime Learning Publications, 1982.  
Camel, F.  Estadistica Médica y de Salud Publica.  Mérida, Venezuela,
Universidad de los Andes, 1979.

Fox, J.P., C.E. Hall, and L.R. Elveback.  Epidemiology: Principles
and Methods.  Boston, Little, Brown & Co. 1970.

4. Institutional Development

32.The investment under this heading has been estimated at US$4.66 billion,
which represents 2.25% of the total investment proposed.  It is considered
to be an important component of the Plan, since the physical investments
for infrastructure are not enough alone to ensure a steady and reliable
supply of services and/or benefits for the target population (Table 5).

The responsible sectoral and subsectoral institutions and companies should
be strengthened, consolidated, and geared to assimilate and deal with the
administrative, operational, and financial changes that are generated by
the Plan for Investment as well as the principles that underlie the
reformulation of the health care system.
In this vein, for example, maintenance should not be seen as an isolated
activity but rather as part of the operational management of efficient
institutions and companies.

33.The Information System component envisages optimization of the
companies' management capacity through the development, strengthening,
adaptation, or updating of on-line systems for purposes of decision-making,
planning, administration, operation, and maintenance; for the registration
of users and installations, costs, rates, and financial management; for the
control of technical and administrative management; and for assessments
based on indicators of efficiency.  This heading also includes the
installation of equipment for processing the information and the physical
facilities and elements required in order to obtain the basic information
to be processed.  In the area of drinking water supply, it includes the
installation of macro- and micromeasures and pitometry equipment.

34.These information systems for modern and efficient management of the
companies are even more important in the case of decentralized management,
since the information will make it possible for decentralized management to
take initiatives as well as immediate necessary corrective measures or
actions.  At the same time, the information should flow in an upward
direction.

35.With its systematic perspective, institutional development includes and
integrates the training and development of human resources at all levels in
order to ensure the full implementation of investments.  The Regional Plan
recognizes that human resources are an essential and intrinsic component of
the institutions and of the self-care system.

36.The formation and development of this human capital includes training
and continuing education in the institutions, training at the managerial
level (agents of change) and the reorientation of existing human resources
to adapt them to the proposed self-care system, as well as members of the
grass-roots organizations (agents of change), and articulation between the
more peripheral local systems, social organizations, families, and
individuals.  This component also includes mobility and monitoring as an
area of investment in order to provide advisory services and supervision at
the national, regional, and local levels of the governmental sector.

TABLE 5: REGIONAL PLAN FOR INVESTMENT,
OTHERS INVESTMENTS, 1993-2004
(in millions of 1990 US dollars)

C O M P O N E N T SAMTC O M P O N E N T SAMT3. PRE-INVESTMENT

1. Sectoral analyses
2. Orientation of health       care system reforms 
3. Development of national     capacity 
4. Formulation of projects           750

160

60

   280
2505. SCIENCE AND TECHNOLOGY

1. Adaptation and              application
   of scientific and           technological               development 
2. Basic research

6. SPECIAL AREAS                    1,620





1,420
200

3,6504. INSTITUTIONAL
DEVELOPMENT 

1. Information systems
2. Facilities for              operation 
   of decentralized            management 
3. Development of human        resources
4. Strengthening of            supervision
   and advisory services           4,660


2,260



    225

    830


  1,3451. Promotion and               development of basic
   social organizations 
2. Women in health care 
3. Indian peoples and          health
4. Critical poverty in         urban and rural
   areas
5. Workers' health 
6. Control of specific         diseases 
7. Water purification

250
170

    230


    150
150

2,550
    150  

5. Science and Technology

37.It is recognized that scientific and technical development is a
fundamental supporting element in the reformulation of the health care
systems with a view to obtaining equity and greater social effectiveness
and efficiency.  The proposed amount of US$1.62 billion represents 0.78% of
the total investment for the Plan (Table 5).

38.A total of US$200 million is proposed for basic research, with the
particular aim of encouraging its development and improving the conditions
under which it is carried out.  It is planned to intensify links between
science and the national and/or regional production sectors so that
scientific output will be geared more directly to real demands.

39.The sum of US$1.42 billion has been allocated for the adaptation and
application of scientific and technical development.  This activity is of
particular importance for the attainment of objectives relating to coverage
and quality of the services and for actions in the environmental sector
within the proposed investment.
The Plan envisages the application of technology appropriate to local
conditions based on standards, processes, and materials designed to cut
construction costs, facilitate operation and maintenance, and, wherever
possible, make use of local labor and materials.

40.In this area the Region has considerable know-how, and some of the
countries have made notable progress in research and application of
appropriate technology.
A long list of approaches have been studied, developed, and applied: 
design criteria, simplified reduced-diameter sewerage systems, water
purification systems, water treatment processes, methods of analysis, and
equipment and installations that range from handpumps for the extraction of
groundwater to hydraulically sealed latrines and low-water-use toilets. 
Despite this progress, a great deal remains to be accomplished.
The Plan recognizes the importance of facilitating the dissemination of
available information on technologies and real experiences--both successes
and failures--as well as providing support to national and regional centers
for technological research with a view to stepping up research and
development.

41.The priority that the Regional Plan assigns to the problem of
controlling solid waste and water pollution opens up areas for the
intensification and initiation of research on appropriate technology and
community participation, such as:  the collection, recycling, and reduction
of wastes; the utilization of biogas; water conservation technologies; the
substitution of inputs or products used in industrial production; recovery
of by-products; anaerobic treatment processes; etc.

42.In addition, the priority given to marginal urban and rural populations
calls for unconventional solutions for water supply services, sewerage
systems, and excreta disposal.
The additional effort to be made during the period in terms of sewerage
infrastructure and disposal and treatment of urban wastes points to the
need for appropriate technology, since the high cost and complexity of
conventional solutions has been standing in the way of progress in this
area.

6. Special Areas

43.Although the investments in the foregoing components are designed to
benefit the entire population of Latin America and the Caribbean through
the delivery of comprehensive health care, there are certain critical areas
that need to be strengthened and prioritized (Table 5).
Some of these areas involve elements that are essential for implementation
of the Regional Plan for Investment and, in particular, for reform of the
systems.  Notable among these are grass-roots organizations and women's
groups, for which the amounts of US$250 million and US$170 million,
respectively, have been proposed.

44.In the case of Indian populations, there are specific population groups
which for historical, cultural, ethnic, and economic reasons constitute
pockets of poverty and discrimination.  These groups offer positive
potential, since they have survived thanks to having preserved their values
of solidarity and equity.  The Inter-American Indian Institute has made
considerable progress in creating the conditions for effective and positive
utilization of these investment resources and has prepared proposals and
concrete projects for comprehensive health care based on the same
principles and lines of orientation that underlie the present Regional Plan
for Investment.  The amount proposed comes to US$230 million.
There is also an urgent need to improve living and health conditions in the
pockets of extreme poverty of the large urban metropolises and in socially
depressed rural areas.  The amount proposed is US$150 million.

45.Workers' health is a relatively neglected area in terms of the
investments that are essential in order to improve conditions in the
workplace.  Since the present Regional Plan for Investment is a proposal
that should be the responsibility of the society as a whole, it is felt
that the private commercial sector could finance or facilitate the
financing of an investment in the proposed amount of US$150 million.

46.The provision of water that meets minimum standards of bacteriological
quality requires--in addition to the efforts being carried out by the
countries to rehabilitate, construct, and operate their purification
faciltities correctly--the establishment of a three-year, short-term
purification program in problematic urban and rural areas, assisted by
community participation and control laboratories.  The amount of the
investment envisaged is US$150 million.

47.Investments for the control of certain prevalent diseases deserve
special consideration.  This subcomponent includes diseases that are
largely conditioned by social factors such as poverty; those whose
epidemiological characteristics do not provide sufficient economic
incentive to investigate, develop, and produce the diagnostic and
therapeutic means for their control; those that can be eradicated or
controlled by vaccines that are still under development or capable of being
developed; and others for which technologies for diagnosis and treatment
already exist but require considerable initial investment through regional
revolving funds.  Most important of all, however, is the reorientation of
control measures for the major endemic diseases, where initial investment
is required in order to make it possible for control to be carried out on
an ongoing basis.  Investments in this area is a practical expression of
the priority that presumably should be assigned to preventive actions.  In
view of the importance of these diseases, an amount of US$2.550 million has
been proposed.

48.The total proposed investment, including the cost of financing and
unforeseen contingencies, comes to US$ 207.6 billion, which corresponds to
the estimate of possible financing (Table 6).

TABLE 6: REGIONAL PLAN FOR INVESTMENT,
TOTAL INVESTMENT, 1993-2004
(in millions of 1990 US dollars)

INVESTMENT COMPONENTS             AMOUNT%TOTAL
INVESTMENT                         207,6001001.
ENVIRONMENT 
   REHABILITATION
   EXTENSION                       113,900
16,230
97,670 54.862. DIRECT
HEALTH CARE 
   REHABILITATION
   EXTENSION                        63,220
17,000
46,220 30.453. PRE-INVESTMENT    750  0.364. INSTITUTIONAL DEVELOPMENT   4,660  2.255. SCIENCE
AND TECHNOLOGY                        1,620  0.786. SPECIAL
AREAS                                 3,650  1.76FINANCING   9,420 4.54UNFORESEEN
CONTINGENCIES                        10,380 5.00
Physical infrastructure for the environment and for health care represents 85.31% of the investment;
pre-investment, institutional development, and science and technology account for 3.39%.

FINANCING

49.In the analysis of the financial feasibility of the Regional Plan for Investment, three sources were considered
and studied independently:  internal financing, including the private sector and possible schemes for self-financing
and cost recovery; external, multilateral, bilateral, public, and private financing; and, external debt conversion
(Table 7).


TABLE 7 : PROJECTED FINANCING, 1993-2004
(in millions of 1990 US dollars)

S O U R C EAMOUNT% GDPTOTAL

NATIONAL

  Public sector
  Social Security
  Private sector
  Self-financing

EXTERNAL
 
  Multilateral
  Bilateral                         207,600

143,500

70,000
26,250
29,750
17,500

63,000

31,500
31,5001.186

0.820

0.400
0.150
0.170
0.100

0.820

0.180
0.180DEBT CONVERSION  1,1000.006
An attempt was made to obtain information from all the Latin American and Caribbean countries, from the
industrialized countries, and from multilateral financing agencies.  Various macroeconomic variables were tested,
but only the most significant were used.  Others had to be ruled out because they did not match up with the ones
previously used, as in the case of gross domestic savings and gross domestic investment.

1.  Internal Financing

50.For internal financing, the criteria used were gross domestic product (GDP), size of the government as a
whole and the central government, public spending, public sector expenditures on health, Ministries of Health,
Social Security institutions, and private and public investment in water supply and sewerage services.  The
principal sources of information were the World Bank, the International Monetary Fund, the United Nations,
ECLAC, and PAHO.  In all cases, preference has been given to information from the World Bank.
It has been necessary to work with certain assumptions, especially with regard to projections for 1991 and 1992
and 1993-2004.  Thus, for example, it has been assumed that the size of the public sector and the government as a
whole, public spending on water and sewerage infrastructure and on health services, the relative size of the social
security and public and private health care subsectors, and expenditures on social security, all expressed as
percentages of GDP, would be remain constant during the period 1993-2004.  Available information for the
periods 1971-1978, 1973-1980, and 1977-1980 were taken as the bases.

51.The figures for internal financing were derived on the basis of the following steps:

a) Calculation of the percentage of gross domestic product represented by total public spending of the countries
   of Latin America and the Caribbean, which yielded an average of 27.77% per year.


b) Calculation of the percentage of total public spending represented by public spending on health services,
   which yielded an average of 5.64% per year.

c) Calculation of the percentage of public spending on health services represented by public sector investment in
   health services infrastructure, which came to an average of 8.10% per year.

d) Estimation of total public investment in health services infrastructure on the basis of the foregoing figures,
   which yielded an average 0.1268% of GDP per year.

e) Calculation of the percentage of gross domestic product represented by public sector investment in water
   supply and sewerage services, which gave a figure of 0.584%

f) Calculation of the percentage of national investment relative to total investment.  The result was 743%, which
   means that the percentage as a portion of the GDP came to only 0.400%

g) Calculation of the ratio of private sector and social security expenditures to public sector expenditures. 
   Correlation of this result with investments.  It was assumed, conservatively, that the pattern of investment in
   social security would be proportionally similar to that of the Ministries of Health, and that of the private
   sector would represent only 50%.  Accordingly, investments in social security and the private sector would
   represent 0.1481% and 0.0840%, respectively, of the GDP.

h) To the foregoing must be added the estimated prospects for self-financing based on the assumption that
   payments for health services represent only 7% of the current expenditure on public sector health services
   (not including central and regional administration expenditures).  If, from this amount, 25% were to be used
   for recurring expenditures at the local level and 55% for small local investments and institutional
   development, the remaining 20%, used as a source for a national investment fund (compensatory, in order to
   guarantee the principles of solidarity and equity), would represent an average of 0.0428% of the GDP per
   year.

   Finally, it would have to be assumed that the countries are already committed to pre-investment and
   institutional development, although specific figures do not appear in the national and sectoral accounting.  A
   preliminary estimate, based on partial information, gives a figure of 0.0183% of GDP, which would be
   distributed proportionally among national sources.

   Self-financing in the area of environment would come principally from the drinking water sector and would
   be used partly for new investment.  This area is estimated to represent 10% of total financing, or 0.056% of
   the GDP.

i) The total of the foregoing estimates from internal sources is based on the assumption that total investment in
   the environment and health in the 1970s averaged 0.82% of annual GDP.

52.On the basis of World Bank projections, it was assumed that the GDP of Latin America and the Caribbean
would show an annual increase of 4.2% during the period 1993-2004.  This growth would justify the expectation
that investment capacity can return to the levels of the 1970s.

53.Consequently, the aggregate GDP for Latin America and the Caribbean for the period 1993-2004 would be
on the order of 17.5 trillion (1990 US dollars).  If thesame percentage of 0.82% is applied to this figure, internal
financing for the present Regional Plan for Investment would be on the order of 143.5 billion 1990 dollars.

2. External Financing

54.For the calculation of external financing, information has been used from the OECD and the World Bank. 
The calculations have taken into account the contributions made by the industrialized countries, multilaterally and
bilaterally, to investments in drinking water supply and sewerage services and health services in Latin America
and the Caribbean during the period 1973-1980.  This information covers disbursements made through "Official
Assistance to Development" (OAD) (concessional) and through what is known as "Other Disbursements"
(nonconcessional).  As in the case of internal financing, these disbursements have been figured as a proportion of
the aggregate GDP of the industrialized countries.

55.The assumptions behind the calculations were as follows:

a) The target is to return to the percentages allocated for water supply and sanitation and for health services
   during 1973-1980;

b) Allocations by the industrialized countries to multilateral international financing would be increased from
   8.5% to 10.0% in order to make it possible for the World Bank to carry out its new policy of devoting 25% of
   its investment resources to the social sectors.

c) The aggregate GDP of the industrialized countries is expected to increase by 1.7% in 1991 and 1992 and by
   3.0% thereafter.  

Accordingly, it has been estimated that the available financing from these external sources for the period
1993-2004 would come to a total of approximately US$63 billion (1990 US dollars).

56.It must be noted that the industrialized countries have failed to comply with the commitment they made some
decades ago to contribute at least 0.7% of their GDP to cooperation with the developing countries.  At the present
time only the Nordic countries, France, and the Netherlands have met or exceeded that target.  Cooperation from
the industrialized countries as a whole would be doubled if these levels of allocation were maintained for Latin
America and the Caribbean for the purpose of water supply, sanitation, and health services.

57.It has been virtually impossible to make a serious estimate of the contributions that could be expected from
nongovernmental organizations (NGOs) as sources of external financing.  It is known that the industrialized
countries--both the governments and the private sector--help to finance the NGOs, but it is not known how much
of this contribution is already included in the calculations above.  Furthermore, no information is available on the
expenditure of the NGOs on water supply, sanitation, and health services.

3. Conversion of External Debt

58.With regard to conversion of external debt, only one country (Ecuador) has opted to swap their external debt
for investments in health, drinking water supply, and sanitation services, for totals of US$12 million and US$14
million (1990 US dollars) during the period 1989-1991--that is, an average of US$4 million and US$4.5 million
per year, respectively.  This represents only 0.085% of its external long-term debt.  The only estimate possible
based on current practices for these projects and on the percentage of debt conversion possible for health and
environment for Latin America and the Caribbean is a total of US$360 million (1990 US dollars) for the period
1993-2004.
The financing of investments through external debt conversion requires, as is often the case with estimates of
financing of all kinds, political decisions and agreements between the governments of the countries and the
creditors, which would have to be accompanied by amendments to existing legislation and changes in
international procedures.  If only 0.25% of the external debt of Latin America and the Caribbean--three times the
percentage for Ecuador--could become investments in health, this would amount to US$1.100 billion (1990 US
dollars).
The following sources have been referred to in the analysis and the development of assumptions:
International Monetary Fund (IMF), "Government Finance Yearbook Statistics, 1973-1980"; ECLA, "Gasto
Público Social en América del Sur en los Años Ochenta," Publication LC/R 961, and "Gasto Público Corriente y
Gasto Público de Capital", Publication CI/R 962, 1990.
World Bank:  "Latin America and the Caribbean Region, Water Supply and Sewage Sector: Proposed Strategy,"
1988; "Financiamiento de la Atención a la Salud en América Latina y el Caribe, con Focalización en el Seguro
Social," Mesa-Lago, Carmelo, 1989; "Social Spending in Latin America", Grosh, Margaret, 1990, "The Financing
of the Health Services in the Developing Countries", 1987.  "World Bank Selected Economic Data," 1991, and
World Development Report, 1990.
OECD, "Geographical Distribution of Financial Flows to Developing Countries," 1975; 1980; 1985; 1990. 
PAHO/WHO "International Decade of Drinking Water Supply and Sanitation: Report on Progress in the Region,
1987."  Troya, Solórzano, Vallejo, "Conversión de Deuda Externa para Proyectos de Desarrollo en Salud: Estudio
del caso de Ecuador," 1991.

4. Total Financing

59.A study of all sources of financing leads to the conclusion that for the period 1993-2004 an aggregate amount
on the order of US$207.6 billion (in 1990 US dollars) would be feasible.  The proposal contained in the Regional
Plan for Investment has been adjusted to this amount.

5.  Financing Costs

60.The financing costs included in the summary of the Regional Plan for Investment (Table 4) need to be
considered.
Since internal financing is based on funds that would be classified as being available, the financing cost for these
would be close to 0.%, and hence it has not been estimated at this time.  External financing has different and
variable interest rates.  An analysis of this picture, by sources and types of funding, could start with an estimate
that the weighted average is around 8%, which, after allowance for inflation, would be 4% in real terms.  The
amounts shown in the table are weighted averages for the most common loans--for example, 25 years with a
five-year grace period.

6. Recurring Costs

61.Recurring costs during and after the period of the Plan have been regarded as a very important factor
throughout the preparation of this proposal.  Reform of the systems, selectivity in the types and forms of
investment, and other technical considerations are significantly affected by recurring costs.  In addition, repeated
annotations have been made regarding the importance of preventive maintenance and timely replacement in order
protect the value of investments and keep the services from lapsing back into inefficient and ineffective operation. 
Table 8 shows capital costs (amortization and interest) and operating costs (for operations as such plus
maintenance and depreciation).

62.In order to obtain this financing, a number of measures will have to be taken by the countries of Latin
America and the Caribbean.  This will require a special strategy that envisages, inter alia, financing plans, specific
legislation in some of the countries, and special measures regarding fiscal policy, taxation, and the like.  In
addition, incentives will have to be considered for the private sector.


TABLE 8 : REGIONAL PLAN FOR INVESTMENT,
CAPITAL AND OPERATING COSTS, 1993-2004
(in millions of 1990 US dollars)



CAPITAL COSTSOPERATING COSTSTYPE OF INFRASTRUCTURE

AMORTIZATION

INTEREST

TOTALOPERAT.    AND     MAINT. 
COSTS 


DEPRECIATION

TOTAL
GENERAL TOTAL

SUBTOTAL FOR
ENVIRONMENT

DRINKING WATER SUPPLY AND SEWERAGE SERVICES 
WATER POLLUTION
SOLID WASTES 

SUBTOTAL FOR HEALTH CARE

SELF-CARE MODULE 
HEALTH POSTS AND CENTERS 
HOSPITAL BEDS
3,860


2,800

1,870
740
190

1,060

80
60
920
5,110


3,660

2,440
970
250

1,450

110
80
1,260
8,970


6,460

4,310
1,710
440

2,510

190
140
2,180
108,150


24,840

10,850
6,560
7,430

83,310

5,180
10,390
67,740
34,930


21,430

13,350
6,030
2,050

13,500

4,680
1,070
7,750
143,080


46,270

24,200
12,590
9,480

96,810

9,860
11,460
75,490

CHAPTER IV
STRATEGY FOR ACTION

1. The Regional Plan for Investment should be the expression of a firm political commitment
by the countries of Latin America and the Caribbean.  This commitment cannot be limited to
the governments alone.  The magnitude of the proposal and the effort that is required in order
for it to become a reality make it necessary to seek all possible means with which to build a
solid and stable base of political support.  It is necessary to enlist the active participation of all
members of national society and to promote, facilitate, and strengthen this participation through
joint action by the countries.  The Pan American Health Organization and the other agencies,
institutions, and international agencies in some way linked to protection and control of the
environment and to direct health care should now contribute effectively to the formation of this
base of political support.

2. The present version of the Regional Plan for Investment is only a first approximation.  It
needs to be more fully developed with the direct participation of the countries and other
international cooperation agencies.  In other words, the present document can serve as the basis
for an initial political commitment and, once this is obtained, for the design and execution of a
series of immediate actions, some of the which are indicated below.

3. It is urgent to set up a regional pre-investment fund so that sufficient financing can be
immediately obtained in order to initiate execution of the pre-investment component.  This is
indispensable for the preparation of a second version of the Regional Plan for Investment, for
the implementation of actions to build political consensus in the countries in support of the Plan
and its subsequent developments, and for the first steps toward the formulation of national
investment plans.

4. The second phase in this process should be the establishment of national, multisectoral, and
representative commissions and technical working teams.  An attempt would be made, inter
alia, to complete, correct, and/or refine the information that served as a basis for this first
version; to carry out studies; to test the validity of certain assumptions, criteria, and standards
of reference; and to analyze the feasibility of the regional estimates of internal financing,
especially with regard to participation of the private sector and the recovery of costs.

5. It is essential to start work on actions leading to the formation of an alliance of agencies
and other international cooperation institutions in order to provide the countries with the
technical assistance they need in order to best carry out the actions outlined above and at the
same time to provide, channel, and/or facilitate financing for pre-investments, institutional
development, and projects relating to some of the components or subcomponents of the
Regional Plan for Investment.
The magnitude and implications of the Plan, coupled with the requirement for an initial
political commitment and for the formation of an alliance, make it essential to draw up new
strategies for supporting the countries and to redefine the roles that international cooperation
should assume in order to support the substantial reforms that are needed in systems for
protection and control of the environment and direct health care as one of the strategic elements
within the context of the Regional Plan for Investment.

6. This also means that each country needs to design strategies to ensure the political viability
of national investment plans as well as continuity and strengthening of the necessary political
support.

7. In summary, in the face of the various crises being experienced by the countries of Latin
America and the Caribbean, there is a moral duty to respond with proposals that are
commensurate with the overwhelming magnitude of the problems and to seize the opportunity
to promote and facilitate changes and reforms that are urgently needed and cannot be
postponed.
Governments and all elements of society in the countries of the Region, international
organizations, and industrialized countries should join together and share the responsibility of
solving the social problems that are currently affecting many millions of people in this part of
the world.  At stake is not only the situation of the Region's peoples but also the protection of
values on which it is hoped to build a universal society that lives in peace and is founded on
solidarity and justice.

Chapter I

HEALTH IN DEVELOPMENT AND INVESTMENT


The Economic Crisis


1.              The economic crisis that is
currently affecting the countries of Latin
America and the Caribbean is not a
circumstantial phenomenon.  It is an
outgrowth of a long process of structural
deterioration that has become
increasingly evident during the second
half of the present century.  
In the context of progressive
globalization of the world economy, the
development models that had been
adopted in the Region have proved
inadequate to reduce the tremendous
social inequalities.  The countries have
been incapable of responding in time and
have failed to introduce the essential
changes needed in order to adapt to
social, economic, and demographic
processes at the national level as well as
new realities at the international level.

2.              This situation became more acute
during the 1970s, although it was masked
by a heavy flow of capital and a
consequent growth in external
indebtedness.  In the last 10 years it has
reached crisis proportions, in the true
sense of the term.  National economies
have become stagnant and poverty and
misery have increased.  Between 1970
and 1990 the ranks of the poor and
indigent swelled by 77 million and 39
million, respectively.  In addition, a
process of progressive impoverishment
has occurred in urban areas, where 60%
of the poor now live in urban fringe
areas.  Social expenditures have been
deeply cut, and underfunded social
services have deteriorated and become
increasingly inefficient.
The countries have been obliged to
implement drastic economic adjustment
measures, which have not always been
accompanied by the means needed in
order to cushion their negative social
effects.  

Social Development and
Economic Growth

3.                                                                                           The economic and social issues
and the concept of development should
therefore be seen in the context of a
region in which socially and politically
dangerous problems have been
accumulating for some time. While it is
urgent and essential to overcome the
economic crisis as soon as possible and
to initiate a process of sustained growth,
this alone will not be enough. 
Economic growth cannot be
considered development unless the
benefits that accrue from this growth are
distributed equitably.  The increase in
poverty and the accentuation of
inequalities may pose a major threat to
continued growth and, worse still, may
jeopardize the legitimacy, stability, and
viability of the social systems and
political structures that people the world
over are currently endeavoring to defend
and strengthen. 

4.              In order for economic growth to be
stable and sustained, it must be
accompanied by processes that will
reduce poverty, inequalities, and social
injustice.  This will require firm political
commitments on the part of governments,
coupled with solid and ongoing political
support from national societies.  The
fundamental requirements for stability
and continued economic growth are the
existence of an effective pluralistic,
decentralized, and participatory
democracy, together with respect for the
freedoms that make it possible for
democracy to truly work.  
In this spirit, there is a need to
formulate proposals that will lead to
greater equity in the distribution of the
benefits derived from growth.

Health in Development

5.              In today's world, drinking water,
sanitation, and health services have
become basic needs.  They are the key
components of well-being, and, inasmuch
as they protect human capital, they make
a major contribution to development. 
When these needs are met for only
certain social groups, a situation of
injustice is created or perpetuated which
cannot be overlooked or disregarded
indefinitely.

6.                                                                                           The promotion and maintenance
of a society's health depends on a broad
range of economic, social, and political
actions.  However, health care is most
directly linked to the protection and
control of man's immediate physical and
biological environment--including water
supply, sewerage, refuse disposal,
treatment of municipal and industrial
waste, etc.--and to the provision of direct
health care for the population--
promotional, preventive, and curative
activities carried out through
establishments and services at various
levels of complexity within the formal
institutional system, whether public or
private.  Moreover, people, either
individually or through their primary
social units--the family, the workplace,
or grass-roots social organization--have a
tremendous potential capacity, which has
not yet been fully tapped, for protecting
and controlling their environment and
caring directly for their own health. 

Protection and Control of the
Environment

7.                                                                                           Under the conventional 
sectoraliza-tion, functional division, and
distribution of administrative
responsibilities, the services that provide
drinking water, sanitation, and
environmental protection and control
have come under the umbrella of various
institutional sectors and systems, such as
housing, public works, interior affairs,
natural resources, human environment, or
health.  In general, services for rural
areas have come under the health sector. 
However, in practice there has
been no effective coordination or
complementarity of intersectoral and
interinstitutional action.  A good example
of this is the lack of supervision and
control over drinking water supply
sources and over water quality between
the source and the end consumers. 

Health Care

8.              The so-called health sector--i.e.,
the health services--has gradually
abandoned promotional and preventive
actions in favor of medical and curative
measures.  Resources, principally
financial, have been channeled into large
hospitals located in major cities. 
Coverage by the various institutions--
public, semi-public, and private--has
been circumscribed to certain population
groups and these institutions have failed
to achieve any coordination between
themselves, each one functioning as in
isolation from the rest.

Systems in Crisis

9.                                                                                           Both systems are currently in very
critical condition.  The physical
infrastructure has deteriorated through
lack of maintenance and replacement,
operating budgets have been cut, which
has reduced operating capacity.  The
inefficiencies in the management of
available resources has been accentuated. 
As a result, the services operate
ineffectively and yield products of poor
quality. 

Reforms and Orientation

10.                                                                                          In the face of this situation, it is
urgent that major reforms be introduced
in these systems, beginning with
functional and effective supplementation
of the systems and services that supply
water and sanitation and direct health
care for the population.  
This process should be guided by
three basic lines:  decentralization, social
participation, and operational efficiency. 
With these lines it will be possible to
optimize the use of available resources
and achieve, in a practical and
progressive way, universal access to
services, as well as social solidarity and
equity.

Decentralization

11.             Decentralization is a sweeping
political process, not an isolated
administrative measure.  It should be
understood as an effective transfer of
political power, which includes full
decision-making capacity in regard to the
use of economic, human, technological,
and material resources, together with full
responsibility for the results and
consequences of any decisions that are
taken.  
This process of transfer must
extend beyond the outer limits of formal
institutions and reach the population
itself, because only in this way will it be
possible to achieve genuine social
participation.
Such a process requires--without
this being a contradiction--a
strengthening of the central and
intermediate levels in order to ensure
unified national direction. 

Social Participation

12.             Social participation is another
broad political process which is fully
expressed when genuine and effective
decentralization takes place.  
The population should have full
capacity to make decisions about needs,
demands, priorities, and ways of dealing
with problems and results, and should
therefore have primary responsibility for
health care.  

The Local Level

13.                                                                                          The natural meeting point of these
two processes is found at the grass-roots
level of society and at the most
peripheral local level, toward which the
decentralization process is directed and
from which participation originates.  It is
at this level that environmental protection
and control and direct health care become
naturally integrated, and it is here that the
values of universality, solidarity, and
equity can be given full expression.

Operational Efficiency

14.                                                                                          The disproportion between
multiple, growing, and concurrent needs
and problems and scarce and limited
available resources has been a constant in
all human societies.  As a result, it is
necessary to prioritize needs and
problems with a view to consolidating
and making better use of existing
resources.
Nevertheless, in practice, this
situation is either ignored or is not given
sufficient importance.  This is what
occurs in many health systems and
services.  There has been a lack of an
economic mentality and awareness
among the leaders, managers, and
operators.  Factors external to the
systems and services, including the
interpretation of certain values and
principles, have significantly influenced
this behavior.

15.             The economic and structural crisis
that is affecting the countries of Latin
America and the Caribbean, the
adjustment measures aimed at
overcoming it, the consequent cuts and
loss of purchasing power in the budgets
for social services, the deterioration of
service infrastructure, and scientific and
technological development are some of
the factors that make it imperative to
introduce policies, systems, mechanisms,
and measures to improve operational
efficiency in the institutions and services. 
The progressive improvement of
operational efficiency is a process that
must be carried out strategically through
a series of actions that extend far beyond
the traditional mechanisms of
administrative streamlining.

Articulation of the Two Systems

16.             Functional articulation of
environmental protection and control
systems with direct health care systems
will lead to better joint use of resources
at the same time that it minimizes
duplications and gaps.  To the extent that
each system functions as an efficiently
interconnected network, the mechanisms
of referral and back-referral between the
systems will lead to greater coverage at
lower operating costs. 
This articulation should not be
limited to the formal institutional
systems.  Direct participation by the
population is a form of double
articulation--between the two systems,
and between the people and their grass-
roots organizations and the most
peripheral levels of the formal
institutional systems. 

Maintenance and Control

17.                                                                                          In the area of institutions and
services there are operational standards
that have been neglected, disregarded, or
forgotten despite their importance. 
Ongoing maintenance, the control of
physical and economic losses, and
control over the use of services are
factors that should always be taken into
account in investment plans and
proposals.
Efficiency in Demand

18.                                                                                          The measures aimed at achieving
operational efficiency have generally
been limited to the delivery of services,
little attention having been paid to the
wide range of action possible in relation
to demand.  The centralist and non-
participatory tradition of the systems has
helped to condition negligent and
indifferent behavior on the part of the
population.  Decentralization and social
participation provide suitable channels
and means for the population to make an
active contribution to the rational use of
services.  This, in turn, enhances
operational efficiency and effective cost
containment.

Recover of Costs

19.             Practical mechanisms of cost
recovery, conceived not only on the basis
of economic criteria, sliding rate scales,
and efficient collection systems permit
more rational use of existing resources
and the expansion of services, in
accordance with the principles of
universality, solidarity, and equity.

Reforms Originating at Peripheral
Levels

20.             The three broad guidelines for
reform will lead to systems different
from those that have traditionally existed.
Reforms should originate at the most
basic local levels of systems and then
extend from the peripheral to the central
level.
The "peripheral level," as it is used
here, refers to the functional and organic
articulation of the most peripheral levels
of the State--and of public and/or private
institutions--with grass-roots
organizations.  Based on this conception,
the population assumes the role of
principal protagonist.  The formal
institutional system must, therefore,
reformulate its roles and responsibilities.

The Population and Self-care

21.             People--within their families,
workplaces, and grass-roots
organizations--cease to be passive objects
without any responsibility for their own
health care.  They become active and
responsible participants, both in terms of
carrying out certain direct actions that
affect them and their immediate
environmental surroundings and in terms
of their involvement in the management
and operation of the peripheral services
of formal institutional systems.

22.                                                                                          In order for people to become
active and responsible participants it is
necessary to reverse a historical process. 
The truth is that the formal institutional
systems have progressively stripped the
population they were intended to serve of
all direct responsibility.  In fact, many
experiences involving so-called
"community participation" have merely
been a means of obtaining unpaid labor
to carry out actions that were decided on
unilaterally by institutional techno-
bureaucracies.
If this process of alienation is to be
reversed it will be necessary to establish
an effective process by which to transfer
pertinent and understandable
information, solid and useful knowledge,
adequate and assimilable skills,
appropriate and adaptable instruments
and means, and full and irrevocable
responsibility.  This process of transfer
should be carried out through innovative,
but carefully designed, actions and
mechanisms.  Ongoing practical training,
supervision--in the educational rather
than the control sense--, and continuous
technical support are effective tools for
this purpose.

23.             The content of the transfer process
includes:  lifestyles and hygiene habits;
selection, care, and utilization of food;
quality control and disinfection of water
and reduced consumption thereof;
minimization of the non-sanitary
elimination of excreta and solid wastes
from the places in which people live and
work; vector control; monitoring of the
growth and development of children;
prevention and early diagnosis of
prevalent diseases and initiation of
simple, effective, and safe treatments;
timely referral to formal health care and
water and sanitation services, etc.

24.             It is proposed that term "self-care"
be used to refer to the development and
application of the foregoing concepts. 
There are always difficulties and
dangers inherent in the use of terms,
especially when these have been used
previously to refer to different or
apparently similar concepts and forms. 
In addition, if the concept is already well-
known and a certain body of experience
has grown up around it, the assignment
of a new sense is liable to invite
controversy and criticism.  Nevertheless,
this term has been chosen because it is
the one that best expresses everything
explained above.

Shared Local Responsibility

25.             In an effective process of
decentralization the most peripheral
layers of the State and the formal
institutional systems--both public and
private--are articulated, at the local level,
with the various expressions of civil
society, mainly grass-roots organizations. 
Any decentralist and participatory model
obliges a substantial redefinition of the
roles of the various social participants.

Decentralized and Participatory Local
Government


26.             Local or municipal governments
should be reformed as part of the
indispensable modernization of the State. 
It is a fact that in many countries there
continues to be a gap separating the
population from the government at the
local level.  Governments at this level
reflect and reproduce many of the defects
and behaviors of central governments
and the State in general in the sense that
they tend to be centralized, authoritarian,
bureaucratic, and non-participatory. 
Some of the reforms that will facilitate
smoother operation and greater
effectiveness of both environmental
protection and control systems and direct
health care systems need to take place at
the level of local governments. 
Examples of such reform might include
greater decentralization of local
governments that cover very large
geographical areas and/or populations,
legislation concerning local governments
that acknowledges this situation and
proposes specific formulas, such as"municipal delegates" or "municipal
agencies," etc.
Local governments, thus
decentralized, need to expand their
decision-making components and
advisory structures in order to
incorporate representatives from the
various traditional institutions of civil
society and the grass-roots organizations,
as well as from the technical levels of the
formal institutional systems at the local,
regional, or national level.

Integrated Local Health Systems

27.             Integrated local health systems
should be established as the basic units
within national health care systems. 
They should not be considered simply a
level of care but rather the minimum
political-administrative structure capable
of responding to the health needs and
demands of a population group, based on
the levels that are deemed equitable and
just in a given society.  Local health
systems incorporate a whole range of
resources, from the least complex (lay
midwives, health auxiliaries, etc.) to the
most complex (hospitals of all types),
without overlooking the health resources
that social groups can offer.  They are,
then, articulated networks of services and
resources, both institutional and from the
community.

28.             The most peripheral formal
institutional elements of local health
systems are the health posts and centers. 
These components are responsible for
creating and maintaining the conditions
that make self-care possible.  The transfer
of information, knowledge, skills,
instruments, means, and responsibilities,
as well as supervision and technical
assistance--both concerning the
protection and control of the environment
and environmental hazards and direct
health care for the population--becomes
the principal function of health posts and
centers.
Water supply and sanitation
services and hospitals--the latter as a
component of the integrated local health
system--provide support at more complex
levels.

The New Role of the State

29.                                                                                          In order for the principles of
universality, solidarity, and equity to be
upheld, especially in societies that are
characterized by poverty, indigence, and
tremendous inequalities, the active
presence of the State is indispensable.
It is an irrefutable fact that the
State in Latin America and the Caribbean
has undergone a serious and dangerous
process of deterioration.  Growing
centralization and bureaucratization,
alienation and indifference to the needs
and demands of the population,
indiscriminate intervention in the
ownership, management, and operation
of systems and services, etc. have
contributed to the inefficiency of the
State and, to a certain extent, to a loss of
legitimacy.  As a result, the State needs
to be reorganized and modernized and its
role redefined at each of the levels at
which it acts.
Such a redefinition is particularly
essential in the area of responsibility for
the systems that protect and control the
environment and provide direct health
care for the population.

30.             Decentralization, social
participation, and operational efficiency
require a strong State:  one that is capable
of fulfilling its role in terms of guidance
and leadership, facilitation of economic
recovery processes, and promotion of
social development in the countries.
The State also has its own specific
responsibilities, which include
standardization, supervision and, in some
cases, regulation and control of the
actions of social participants in the
processes of development.  This onerous
responsibility should be carried out
mainly through mechanisms of
negotiation and consensus. 

Ineluctable Responsibilities of the
State

31.             Health care for poor and indigent
groups, as well as health care in areas for
which other social groups are unwilling
take responsibility, must ultimately be
the ineluctable responsibility of the State.
In societies such as those in Latin
America and the Caribbean, the State
must play a very important role in the
acquisition and channeling of financial
resources if the principles of universality,
solidarity, and equity are to be upheld.

Promotion of the Private Sector

32.                                                                                          The private sector can play a more
prominent and responsible role in health
care.  This is a complex sector that
comprises a number of distinct systems. 
There is a nonprofit private sector, which
includes lay and religious volunteer
organizations, cooperatives, and entities
that are linked to revenue-earning
enterprises.  There is also a for-profit
sector, which is commercial, cooperative
and includes the private practice of health
professionals.  All of these are
interrelated, in different ways and to
different degrees, with the systems of the
public sector and social security, which
sometimes makes it difficult to know
what approach to take in dealing with
them.  Some of them also have
operational inefficiencies that need to be
corrected.

33.                                                                                          As private-sector involvement is
promoted, through well-defined and
stable policies, the population groups that
have the greatest purchasing power or
those that are covered by social security
can cease to be users of public-sector
services.  As far as drinking water and
sanitation services are concerned, private
enterprise can help to improve levels of
coverage and quality of services, by
virtue of its administrative flexibility,
greater availability of credit, and
institutional stability.  Through different
mechanisms, the private sector can
intervene as a financial agent, owner,
and/or total or partial operator of services
and/or activities.
Financial incentives, tax credits,
and other fiscal and economic measures,
applied within regulatory frameworks in
which rights and obligations have been
clearly defined, can induce very positive
social behavior by the private sector.

Nongovernmental Organizations

34.             Nongovernmental organizations
(NGOs) and other voluntary forms of
participation by civil society, should have
a very important role and responsibility
in the promotion and application of
reforms in health care systems.  In
practice, they have demonstrated a great
capacity and potential for promoting
different and innovative solutions that
can help to make the principles and lines
of orientation proposed herein a reality.

Reform as a Political Process

35.             The implementation of reforms is
a political process.  Although the reforms
themselves are based on studies and
interpretations of the reality in which
they are to be applied, the decisions
regarding their selection, definition, form
and sequence of execution, follow-up,
evaluation, etc., are basically political.
Hence a reform process entails strategic
and political management.  
One of the essential elements in
the conduct of a political process is the
continuity of the support that backs up
the decisions, at the time they are taken,
as they are being executed, and, above
all, in the face of the consequences they
produce.  It is thus necessary to achieve
a consensus that expresses a commitment
by the majority of national society. 
Building this consensus is an important
aspect of political leadership.

36.            At present there is an urgent need
in Latin America and the Caribbean to
overhaul the deficient service
infrastructure and expand it in
accordance with national possibilities and
in keeping with the principles of
universality, solidarity, and equity.

37.             Investments, when it is simply
channeled into a series of projects, even
if these are technically well designed, can
serve to entrench situations that are
considered unsatisfactory and negative. 
It can also reinforce obstacles and
resistance to needed change.  Something
very different happens, however, when
investment is part of a process of
justified reforms.  In this context
investments become strategic actions that
help to bring about reform, as well as
vital strategic elements of social policy in
a context of economic crisis. 




Review
February 1992
MOD1526I










Note:
Draft Version
  Please do not reproduce or quote without the authorization of
the Pan American Health Organization




USE OF EPIDEMIOLOGICAL RESEARCH IN THE
STRUCTURING OF EPIDEMIOLOGICAL RISK STRATA
AND THE SELECTION OF CONTROL INTERVENTIONS


INTRODUCTION


     Malaria has experienced a resurgence in Latin America in
recent years, making it necessary to review the strategies for
its prevention and control.  Eradication and control programs
have had a permanent impact only in certain areas such as
southern Europe, the United States, Latin America, and the
Caribbean, where living and health conditions were already
satisfactory or where continuous interventions, such as the
reduction and elimination of breeding sites and improvement of
dwellings, were practiced.

     Previous materials have already proposed an approach for
epidemiological diagnosis of the malaria situation through
quantification of the problem and epidemiological investigation
of the risks.  This section will review the different uses of
epidemiological information in the planning and implementation of
interventions to prevent and control the disease based on the
risk approach.  The purpose of this approach is to assign an
epidemiological rank to specific measures or interventions with a
view to reducing or eliminating the risk factors for malaria.  In
this way, an attempt is made to avoid the generalized application
of interventions when the local epidemiological situation is
unknown.  Moreover, it permits recognition of social inequalities
in the distribution of risks of disease and death from malaria. 
In addition, it helps to reduce the indiscriminate expenditure of
resources, as happens when they are not used in interventions
that are specifically targeted at each of the causal risk
factors.  The purpose of these materials is to present the
various components of the epidemiological methodology that are
needed in order to select intervention measures according to each
of the determining risk factors for malaria and to evaluate the
impact of such measures on the incidence of the disease.


EPIDEMIOLOGICAL STRATIFICATION OF RISK

Background

     Malaria stratification has emerged as a strategic approach
in Latin America since 1979 (Oaxtepec, Mexico).  In 1985 it was
recognized as a strategy for making an objective epidemiological
diagnosis on the basis of which prevention and control activities
could be planned (WHO, 1985).  Recently the epidemiological risk
approach has been included in the stratification scheme as a
basis for decision-making.  Moreover, it is included as a basic
part of the process of evaluating the impact of intervention
measures which makes it possible to utilize resources rationally
and more efficiently (PAHO, 1987; PAHO, 1988).

     Epidemiological stratification in malaria control programs
may be defined as a dynamic and ongoing process of research,
diagnosis, analysis, and interpretation of information which
serves to categorize geo-ecological areas or population groups
methodologically and homogeneously according to risk factors of
malaria.

     A risk stratum refers to the population of individuals or
social groups in their corresponding geographical areas who share
a similar ranking of principal risk factors.  Hence the measures
or interventions aimed at modifying them are similar within each
stratum (PAHO, 1987; PAHO, 1988).

     The principal characteristic of this new strategy is the
epidemiological study, in individuals and particular social
groups, of the risk factors which are responsible for the
incidence of malaria at the local level so as to define
prevention and control interventions aimed at diminishing or
eliminating such factors and, consequently, achieving control of
the disease.

     Scheme for the Epidemiological Stratification of Risk

     Stratification is an integrated process of diagnosis,
intervention, and evaluation which optimizes decision-making. 
The principal stages may be summarized as follows:

1.   Study of the annual parasite incidence (API) and its secular
     trends in recent years to identify priority areas.

2.   Identification and measurement of malaria risk factors in
     priority areas or localities utilizing the study of
     epidemiological risk.

3.   Formation of epidemiological risk strata based on a ranking
     of the most important risk factors.

4.   Selection of interventions to reduce or eliminate the most
     important risk factors in each stratum.

5.   Articulation of the interventions with the activities of the
     health services and adaptation of resources to carry out
     interventions based on the epidemiological stratification of
     risk.

6.   Identification of the indicators of structure, process, and
     impact to evaluate the effect of each intervention.

7.   Execution of specific interventions to reduce or eliminate
     each of the risk factors.



8. a.  Measurement of:

     -    Reduction of the risk of becoming ill or dying.  The
indicators are the specific rates of incidence and
mortality.

     -    Changes in risk factors as measured by relative risk
and percentage of population attributable risk.
     
  b. Evaluation of each intervention based on the indicators of
     structure, process, and impact.
     
  c. Monitoring and adjustment of the process in all its phases
     (see Table 3.1).


     The present workbooks present the basic elements in the
process of epidemiological risk stratification when it is used as
a strategy for the planning and execution of malaria prevention
and control activities.
TABLE 3.1

       SCHEMATIC SUMMARY OF EPIDEMIOLOGICAL STRATIFICATION
FOR THE CONTROL OF MALARIA


Identification of priority areas

Study of risk factors

Formation of strata

Selection of intervention(s)

     Articulation of interventions with the activities of the
health services and adaptation of resources

Identification of indicators for evaluation

Execution of interventions

Evaluation, monitoring, and adjustment
QUESTIONS


Exercise 1


Question 1:   Define epidemiological risk stratification in your
own words.

Question 2:   Briefly define an epidemiological risk stratum.

Question 3:   List the stages of epidemiological risk
stratification.
III.MALARIA PREVENTION AND CONTROL BASED ON EPIDEMIOLOGICAL RISK
     STRATIFICATION

A.   Identification of Priority Areas

 Through a study of annual parasite incidence (API) and its
secular trends in recent years it is possible to identify the
areas where antimalarial interventions have not been successful. 
Such a study should first determine the magnitude of current
incidence and, second, ascertain whether it has increased,
diminished, or plateaued in recent years.  At times data will not
be available for previous years and the single parameter of
selection will be the magnitude of the incidence at the time of
study.  Whenever possible, it is desirable to base decisions on
both sets of data, since by itself the current incidence does not
give a full picture of the impact of the control measures that
have been applied so far, and favorable responses to the
interventions being used may fail to be identified.  Thus there
is a risk of implementing unnecessary changes in the control
strategies.

 On the basis of the study of the API and its secular trend,
priority areas are defined as those in which there has been an
increase in the incidence and/or it is of great magnitude.


B.   Study of Risk Factors

1.   Risk Factors for Malaria

 A risk factor for malaria is any variable or set of variables
which has a direct relationship with the incidence of malaria.  
More broadly, it may be defined as any characteristic, attribute,
condition, or circumstance that increases the probability of the
appearance of malaria or mortality due to malaria at a specific
time.

 Malaria risk factors may be classified in different ways.  Table
3.2 shows an example of a classification adapted from the reports
of the Workshops on the Epidemiological Stratification of Malaria
held in Venezuela and Honduras (PAHO, 1987; PAHO, 1988).  These
risk factors were selected by professionals in the area of
malariology based on their own practical experience and on data
published in the literature (the information is not exhaustive
and is working material to be supplemented and improved during
the course of the workshop).
TABLE 3.2
      CLASSIFICATION OF POTENTIAL RISK FACTORS FOR MALARIA 

SOCIOLOGICAL AND ECONOMIC
GROUP I



UNIT OF              JUSTIFICATION/        
COMPONENTS/
  RISK FACTOR     OBSERVATION          IDENTIFICATION  
MEASUREMENT SCALE



 1. Age           Individual        Age in years        Age in years

 2. Sex           Individual        Different exposure  Male, female 

 3. Ethnic group  Individual        Different culture   No. de indi-
(language)          viduals in
each
ethic group or
religion

 4. Occupation    Individual        Job/exposure        Type of oc-
cupation
(mining,
agriculture)

 5. Migration     Individual        Penetration of      No. of
    migrants
malarious area (or
malaria carrier)    

 6. Religion      Individual        Religion            No. of indivi-
duals
belonging
each to ethnic
group or
religion

 7. Land tenure   Individual/family Type of tenure      Latifundio/   
of each individual    minifundio

 8. Incomplete    Individual/family Protected/unpro-    No. of indi-
    dwelling                        tected              viduals with
unprotected
housing

 9. Crowding      Individual/family Contribution to     No. of indi-
problem             viduals living
in dwelling
(crowding)

10. Relative lack Individual/family Contributes to pro- No. of years
    of education                    blem                of education

11. Financial     Individual/family Contributes to pro- Per capitainco
me
blem
or 
fami
ly
income

12. Poor communityIndividual        Contribution to     No. of indivi-
    participation                   problem             duals who par-
ticipate

      


TABLE 3.2
CLASSIFICATION OF POTENTIAL RISK FACTORS FOR MALARIA

GROUP II
PARASITOLOGICAL AND IMMUNOLOGICAL



RISK FACTOR
OBSERVATION
UNIT
DEFINITION/
JUSTIFICATIONCOMPONENTS/
MEASUREMENT
SCALE
1.   Parasite
     speciesIndividual
     parasiteVirulence
     Pathogenicity
     FatalityP. vivax
P. falciparum
Associated
forms
2.   Resis-
     tance to
     chloro-
     quineIndividual
Parasite
CommunityContributes
to
transmission
and fatalityGradation: 
S, RI, II,
and III
3.   Micro-
     scopic
     diagnosi
     s of
     poor
     qualityMicroscopist
     CommunityLack of
     treatment;
     fatality% of error in
     sensitivity,
     specificity,
     predictive
     values
4.   High
     parasite
     densityIndividualTransmission
     Pathogenicity
     FatalityNo. of
     parasites per
     field; no. of
     parasites x
     mm3 of blood
5.   Lack of 
     early
     
diagnosisIndividualPathogenicity
Fatality
TransmissionNo. of days
elapsed
between
sampling and
diagnosis
6.   Presence
     of
     asymp-
     tomatic
     carriersIndividual
     CommunityIdentificatio
     n or
     detection of
     carriers
     (contributes
     to
     transmission)Number and %
     of
     asymptomatics
7.   Low or
     inade-
     quate
     immunity
     to
     infectio
     nIndividual
     CommunityImmune status
     or responseTitration of
     specific
     antibodies; %
     of
     individuals
     with
     inadequate
     immunity
     level
8.   Endemi-
     cityCommunityCustomary
     presence of
     cases
     TransmissionPrevalence
     Incidence
9.
     Epidemi-
     cityCommunityInstability;
     extent of
     outbreak;
     magnitude of
     affected
     populationPrevalence;
     incidence;
     attack rate;
     number of
     epidemic
     outbreaks per
     unit of time
TABLE 3.2
CLASSIFICATION OF POTENTIAL RISK FACTORS FOR MALARIA

ENTOMOLOGICAL

GROUP III



     RISK
     FACTOR
OBSERVATION
UNIT
DEFINITION/
JUSTIFICATIONCOMPONENTS/
MEASUREMENT
SCALE

I.   Man-vector contact:

1.   Endophag
     eSpecific
     vector
     populationAnopheles
     biting within
     householdNo. of bites
     per man/hour
     within
     household
2.   Anthropo
     -philic
     density"No. of bites
     per person in
     and around
     householdBites per
     man/hour
3.   Parity
     rate"Proportion of
     multiparous
     Anopheles
     (w/dilations)No. of
     multiparous
     Anopheles;
     no. of
     dissected
     Anopheles
4.   In-
     fectivit
     y rate"Proportion of
     infected
     Anopheles
     (ELISA)No. of
     infected
     Anopheles;
     no. of
     dissected
     Anopheles
5.   Anthropo
     -philia"Proportion of
     Anopheles
     with human
     bloodNo. of
     Anopheles
     with human
     blood; no. of
     Anopheles
with blood
examined
6.   Endo-
     philia"Anopheles
resting in
householdNo. of live
and dead
Anopheles per
house/hour
7.   Ectophag
     e"Anophelines
     biting
     outside
     dwellingNo. of
     Anopheles
     biting per
     man-hour
     outside
     dwelling
TABLE 3.2
CLASSIFICATION OF POTENTIAL RISK FACTORS FOR MALARIA

CONTINUATION OF GROUP III


II.  Ecologic:

1.   Resis-
     tance to
     insecti-
     cidesAdult or
     immature
     vectorMortality in
     susceptibilit
     y testsNo. of dead
     Anopheles;
     no. of
     exposed
     Anopheles
2.   Inade-
     quate
     re-
     sidual 
     effect
     of
     insect-
     icideAdult vectorMortality in
     biological
     testsNo. of dead
     Anopheles;
     no. of
     exposed
     Anopheles
3.   Be-
     havioral
     change
     in
     resting
     habitsAdult vectorChange in
     behavior in
     intra-
     domiciliary
     restingNo. of
     jumps/hour in
     area unit
4.   Breeding
     sitesImmature
     vectorLarval
     productivityLarvae per
     scoop within
     3 km radius
5.   Repro-
     duction
     habits
6.   Resting
     habits
7.   Feeding
     habits
8.   Structur
     e of
     ano-
     pheline
     popu-
     lation
TABLE 3.2
CLASSIFICATION OF POTENTIAL RISK FACTORS FOR MALARIA

DIAGNOSTIC, CLINICAL, AND TREATMENT-RELATED 

GROUP IV


     
     RISK
     FACTOR
OBSERVATION
UNIT
DEFINITION/
JUSTIFICATIONCOMPONENTS/
MEASUREMENT
SCALE
1.   Lack of
     timely 
     diagnosi
     sIndividual;
     slides;
     micro-
     scopists; no.
     of slides
     with correct
     diagnosisLack of
     treatment;
     microscopists
     ; untrained
     personnelNo. of
     trained
     microscopists
     x 100; no. of
     microscopists
2.   Quality
     of diag-
     nosis Medical and
     paramedical
     personnel;
     microscopistIncorrect
     diagnosis;
     lack of
     treatment;
     fatality% of errors;
     % of trained
     personnel
3.   Under-
     nutritio
     nIndividualDegree of
     undernutritio
     nNo. of under-
     nourished per
     age group
4.   Pregnanc
     yGravida;
     hypo-
     glycemia;
     treatment
     limitationsAnemia; hypo-
     glycemia;
     treatment
     limitationsNo. of
     pregnant
     women
5.   Severity
     of
     clinical
     pictureIndividualIntensity by
     species% of severe
     cases
6.   Immunode
     -
     ficiencyIndividualAggravation
     of clinical
     picture;
     mortalityYes  No
7.   Ethnic
     groupsIndividualSusceptibilit
     yYes  No
8.   Resis-
     tance to
     anti-
     malarial
     drugsIndividualChloroquine;
     sulfa + pyri-
     methamine;
     quinine; me-
     floquineYes  No
9.   Side
     effectsIndividualNausea/vomiti
     ngdiplopia;
     blood
     dyscrasiaYes  No
10.  Re-
     luctanceIndividualSide effects;
     behavioral
     habits;
     religious
     background;
     pregnancy% of
     occurrence
11.  Quality
     of drugDrugQuality
     controlYes  No
12.  Inade-
     quate
     dosageIndividualTraining;
     supervisionYes  No
 It should be mentioned that any classification of risk factors
to be used for epidemiological risk stratification should be
supported by previous studies (epidemiological, social,
entomological, and parasitological) carried out in the geographical
area of implementation.  Ideally, this information should be
supplemented by preliminary field observations in each priority area
or locality.  This phase is very important, since malaria is a local
problem and its characteristics may differ from one place to another.

     The preliminary field observations should be made in a
systematic and organized way, with an effort to determine possible
risk factors that account for the increase and/or magnitude of the
malaria incidence.  The data are obtained through the experience of
the local health services or the malaria service, which usually carry
out epidemiological case studies in which the information presented
in Table 3.3 is commonly included.
Table 3.3
BASIC INFORMATION FROM MALARIA CASE STUDIES

Age, sex, and place of birth

Residence and occupation

Place and date of onset of fever

Places visited in the last two years

Date of blood sampling

Date of diagnosis

Parasitological diagnosis

Possible focus of infection

Classification of cases
(autochthonous, introduced, imported)
Type of housing
Data on spraying
Other control measures

Measures for the protection of personnel

    If this basic information is lacking, a pilot study should be
carried out at the community level.  Such a study should collect
information on recent cases of malaria to determine at least the age,
sex, occupation, date of diagnosis, possible focus of infection, and
place of residence during the last two years.  These data are
analyzed as a case study to determine the percentage distribution by
age, sex, occupation, etc.  This study is utilized to generate
hypotheses concerning possible risk factors (Hennekens, 1987).

     During the visit to the community, it is desirable to specify
whether there have been recent population movements, types of
housing, existence and type of breeding sites, and control measures
used by the population.  It is particularly important to find out
about the level of development of the services and their operating
capacity, as well as the degree of community participation in the
work of the malaria program and in the rest of the local health
services.  This preliminary information serves to determine the
resources needed in order to conduct a study of the risk factors.


2.   Assessment of Risk Factors

     In any epidemiological study, the search for risk factors
entails the possibility of erroneous identification.  The error may
be due to several causes, such as the selection of an inadequate
population or sample, biases inherent in the design of the study, the
type of data collected, the way in which the information was
gathered, or the influence of distracting variables, also known as
confusion variables.

     After an objective analysis has been made of the data derived
from the study and the limitations have been correctly interpreted,
conclusions can be drawn about the validity of a statistical
association between exposure to the factor and the occurrence of
malaria.  It is then necessary to consider whether the relationship
is causal, since a simple statistical association does not signify
causality.  The causality of a risk factor is determined only after
an evaluation of all the information available in the literature, and
it should be reevaluated in the light of each practical experience.

     a)  Application of relative risk

     Relative risk (RR) estimates the strength of association between
exposure to the factor analyzed and the disease by indicating the
risk of developing malaria in the group exposed to the factor
relative to the risk in the unexposed group.  In malaria, the RR is
defined as the ratio of malaria incidence (specific API) in the
exposed group divided by the API in the group unexposed to the risk
factor.

     Thus, the RR for the factor "living in unprotected housing"
(defined as housing not sprayed) would be calculated in the following
way:

RR of inhabitants     =  API of inhabitants of unprotected housing
of unprotected housing       API of inhabitants of protected housing 
    
        

     Thus, an RR of 1 would indicate that the incidence of malaria
among inhabitants of unprotected housing and protected housing is
equal, and thus there would be no association between exposure to
this risk factor and malaria.  If the RR is greater than 1, however,
it indicates a positive association between the factor (unprotected
housing) and malaria, or an increase in the risk of becoming ill
because of exposure to the factor.  When the RR is less than 1, it
denotes a negative association between the factor and the disease.


     For example, let us assume that the people of a community who
live in unprotected houses have an API of 18.6, while the API in
those who live in protected houses is 1.3.  The RR would be:

RR of the persons in      = 18.6/1.3 = 14.3
unprotected housing

     That is to say, the persons who live in unprotected houses face
a risk 14.3 times greater of developing malaria than those who live
in protected houses.

     Thus, the calculation of RR makes it possible to select the risk
factors for a given locality.

     Ideally, an exhaustive study of all possible risk factors should
make it possible to determine all the interventions required in order
to control malaria effectively in the situation and population being
studied.  However, since such a study would be huge and very
expensive, is acceptable to make a selection of those possible risk
factors which have been identified in the localities under study
based on the previous experience of local health personnel or the
malaria service, data obtained in preliminary field observations, or
information in the epidemiological literature.

     After the specific malaria incidence has been calculated for the
population exposed and not exposed to each factor on the basis the
information obtained in the surveys, a calculation is made of its
statistical significance (through a chi-square or other test of
statistical significance) and the RR is then calculated for each of
the risk factors found to have statistical significance.  In this
way, the most important risk factors in a locality can be determined.

     It is well to bear in mind that the RR may change or differ
between communities or within the same community at different times,
just as the transmission and incidence of malaria can vary depending
on such factors as changes in rainfall.  Changes or differences of
this kind in the RR depend on the period of observation during which
the cumulative incidence is calculated.  This change in relative risk
may also depend on other concomitant factors (confusion variables)
which alter the relationship between the factor under study and the
incidence.  This last problem can be overcome by controlling
concomitant factors during analysis of the data by the use of
statistical adjustment for multiple variables such as multiple linear
regression and multiple logistical regression.  Information on this
type of methodology can be found in textbooks on biostatistics or
epidemiological research methodology such as Kleinbaum (1982).

     An important aspect to be considered with regard to the RR is
that this measurement does not take into account the proportion of
population at risk of becoming ill with malaria.  If this proportion
is very small, elimination of that factor will have only a very
slight impact on the reduction of malaria incidence in the entire
population, even though the RR is very high.  This is because
elimination of this factor directly benefits the exposed population
only.  To go back to the previous example, if in light of a high
incidence of malaria it is found that only a small percentage of the
population in a locality lives in unprotected dwellings, it is very
possible that modification of that small percentage of dwellings will
not result in a sizable reduction in malaria incidence for the entire
locality, although an abatement of the incidence will probably be
observed in those persons who had been living in unprotected
dwellings.




     To resolve the problem noted in the previous paragraph and also
to determine the importance of each factor in the incidence of
malaria among the entire population, the measurement of population
attributable risk is used.


     b)  Application of the percentage of population attributable
risk

     It is of the utmost importance to be able to estimate the
population's percentage of risk of developing malaria as the result
of exposure to a particular risk factor.  This indicator of risk,
called population attributable risk (PAR%), expresses the proportion
of disease in the study population which is attributable to the
factor in question in such a way that this proportion of risk would
disappear if the factor were to be eliminated.

     It will be recalled that the PAR% is calculated as follows:

PAR% =   P (RR - 1)    x 100
P (RR - 1) + 1

where P is the proportion of the population at risk and RR is the
relative risk calculated for that risk factor, as indicated
previously.

     In the example, let us assume that 70% of the individuals in the
community live in unprotected houses.  Then the PAR% due to the lack
of protection of the dwellings would be calculated as follows:

PAR% =   0.7 (14.3 - 1)   x 100 = 90.3%
0.7 (14.3 - 1) + 1

     Thus, 90.3% of the malaria incidence in this community, assuming
that this is a causal factor, is due to housing conditions at the
time of the study.  As a result, elimination of the "unprotected
housing" factor may produce a reduction of up to 90.3% in the
incidence of malaria.

     In the example, both the RR and PAR% were very important because
of the strength of association between the factor and the disease (RR
= 14.3) and the large proportion (70%) of exposed individuals.  On
the other hand, if only a small percentage of the population live in
unprotected dwellings, let us say 1%, although the RR is as high as
14.3, the PAR% is only 11.7%, since it also depends on the percentage
of persons exposed:

PAR% =   .01(14.3 - 1)   x 100 = 11.7
.01(14.3 - 1) + 1   

     In other words, 11.7% of the malaria incidence in this community
is due to its housing conditions.  If the intervention to control
malaria is oriented toward improving the unprotected houses, the
reduction in incidence will at most be only 11.7%.
EXERCISE 2

     A study to evaluate the risk factors for malaria was carried out
in a mining community on the northern coast of Malarialand for more
than a year.  In this study it was determined that the API of the
miners was 110, while the rest of the males in the same age group in
that community had an API of 20.  The proportion of male miners in
this age group was 85%.  It was also found that the API of the non-
mining individuals of all ages and both sexes in the same community
was 11.  The proportion of miners relative to the total population in
the community was 19%.

QUESTION 1:  What is the risk factor for malaria being studied in
this community?

QUESTION 2:  Find the RR and PAR% for male miners in their age group
and compare these figures with the calculation of RR and
PAR% for the miners vis-Õ-vis the rest of the community.

QUESTION 3:  Interpret the results.
    c)  Formation of epidemiological risk strata

     After the risk factors have been studied in terms of relative
risk and population attributable risk and before the interventions
for each risk factor have been selected, the areas or populations
under study are divided up into strata.  As already indicated above,
a stratum is a group of individuals or geographical areas that share
a similar rank order in the distribution of principal risk factors,
which means that the measures or interventions applied in order to
modify them will be similar.  Thus, the presence and order of
importance of the principal risk factors make it possible to
establish the epidemiological risk strata.

     The RR and PAR% are the indicators of risk which we have used to
evaluate the importance of each risk factor.  They are also used to
form the strata and classify the communities within them.  Since
areas that are endemic for malaria are generally located in
developing countries where resources are limited, it is recommended
to rank the risk factors for each locality where the PAR% has been
used.  Thus, when it is not possible to take action against all the
possible risk factors, resources and interventions will be directed
toward the factors that are most prevalent and most strongly
associated with the incidence of malaria in the population so that
these activities will have maximum impact.

     As was already explained above, the RAP% takes into account the
importance of the factor from the point of view not only of the
strength of association but also the proportion of population at
risk.  Thus it tells us the percentage of risk due to each factor
studied in the population.  By extension, it allows us to determine
the impact on the incidence of malaria which we can expect to find
after eliminating that factor.  In contrast, the RR tells us the
strength of association between the factor and the disease.  It is
recommended to be used for the identification of factors that have an
especially strong (possibly causal) association so that they will be
included in the epidemiological profile and their PAR% calculated. 
Thus, from a list of the risk factors studied, their statistical
significance, and the corresponding RR (for those that are
statistically significant), for each community under study only those
are selected that are statistically significant and have the greatest
RR.

     Table 3.4 shows the RR of six risk factors and their statistical
significance in four communities in a malarious area.  In this
example, factors F1, F2, F3, F4, and F5 would be selected for the
four communities.  Factor F6 would not be selected because no
statistical significance was found between this factor and the
probability of malaria existing in any of the four communities
studied.                     Table 3.4
RELATIVE RISK AND STATISTICAL SIGNIFICANCE
IN FOUR COMMUNITIES OF A MALARIOUS AREA, 1989

RISK FACTORS


     
Com-mun-ityF1F2F3F4F5F6RRpRRpRRpRRpRRpRRpA2.20.031.50.053.80.021.60.044.50.021.00.90B6.70.021.20.052.10.047.70.011.60.051.10.10C3.30.041.20.047.50.011.50.013.30.021.20.10D9.10.011.30.053.00.039.30.021.40.051.10.15
     F1 - F6:  Risk factors
     p:  Statistical significance

     The next step would be to measure the PAR% for the factors
selected.  For example, Table 3.5 contains the RR and PAR% for the
five most important risk factors in the four communities studied.
Table 3.5
     RELATIVE RISK AND PERCENTAGE OF POPULATION ATTRIBUTABLE RISK
IN FOUR COMMUNITIES IN A MALARIOUS AREA

RISK FACTORS


   
Com-mun-
ityF1F2F3F4F5RRPAR%RRPAR%RRPAR%RRPAR%RRPAR%A2.239.31.520.43.862.71.616.24.555.5B6.769.21.212.02.132.17.775.91.616.0C3.344.11.216.17.571.01.59.13.359.1D9.158.21.310.83.038.29.366.61.412.9
F1 - F5:  Risk factors


     In order to show the relative ranking of the risk factors
according to their importance and then classify the communities into
risk strata, the rank order is indicated under each PAR%, as shown in
Table 3.6.
Table 3.6
      RELATIVE RISK, PERCENTAGE OF POPULATION ATTRIBUTABLE RISK,
AND ITS RANKED ORDER IN FOUR COMMUNITIES
IN A MALARIOUS AREA

RISK FACTORS


Com-mun-ityF1F2F3 F4F5RRPAR%RRPAR%RRPAR%RRPAR%RRPAR%A2.239.31.520.43.862.71.616.24.555.534152B6.769.21.212.02.132.17.775.91.616.025314C3.344.11.216.17.571.01.59.13.359.134152D9.158.21.310.83.038.29.366.61.412.925314

F1 - F5:  Risk factors
Bold:  Rank order of PAR%.

     For the same example, Table 3.7 shows the ranked order of PAR%.
Table 3.7

RANKED ORDER OF FACTORS
OF RISK ACCORDING TO 
POPULATION ATTRIBUTABLE RISK IN
FOUR COMMUNITIES IN A MALARIOUS AREA



COMMUNITY       RANKED ORDER

A      F3, F5, F1, F2, F4

B      F4, F1, F3, F5, F2

C      F3, F5, F1, F2, F4

D      F4, F1, F3, F5, F2



F1 - F5:  Risk factors


     As it can be see in Table 3.7.  Communities A and C have the
same sequence, which is different from that of Communities B and D,
which in turn share a common sequence.  Note that the RRs do not
necessarily follow this hierarchical order, since the proportion of
the exposed population may be different in each locality (Table 3.6).

     In this way, Communities A and C would belong to a single
epidemiological stratum which would be different from that of
Communities B and D.  Table 3.8 shows the formation of
epidemiological risk strata for these four communities.
Table 3.8
    FORMATION OF EPIDEMIOLOGICAL RISK STRATA FOR FOUR COMMUNITIES
IN A MALARIOUS AREA ACCORDING TO THE RANKED ORDER OF
RISK FACTORS BASED ON THEIR PERCENTAGE
OF RELATIVE POPULATION RISK



STRATUM     RANKED ORDER      COMMUNITIES


I     (F3, F5, F1, F2, F4)       A,C

II    (F4, F1, F3, F5, F2)       B,D



     If resources are limited and prevent the application of all
possible intervention measures, attention should be given to the
ranked order of the risks found and an effort made to influence those
risk factors that have the highest PAR%, as will be seen further on
in these materials.   
EXERCISE 3
     
     In the study of risk factors in six communities in the municipio
of San Miguel (northeastern region) of Malarialand and, the following
results were found:

COMMUNITY A
FACTORS                                    % EXPOSED RR   p *        
1. Low family income                       70        3.1  0.03
2. Rural occupation                        22        5.2  0.02
3. Unprotected housing                     60        1.7  0.04
4. Overcrowding                            55        1.8  0.12 N.S.
5. Breeding sites less than 100 meters away35        8.3  0.01
6. Does not use the local health service   10        3.4  0.03


COMMUNITY B

FACTORS                                    % EXPOSED RR   p *
1. Low family income                       58        3.8  0.02
2. Rural occupation                        19        5.9  0.01
3. Unprotected housing                     55        1.9  0.03
4. Overcrowding                            56        1.3  0.19 N.S.
5. Breeding sites less than 100 meters away63        7.9  0.01
6. Does not use the local health service   21        3.1  0.04


COMMUNITY C

FACTORS                                    % EXPOSED RR   p *
1. Low family income                       75        1.7  0.01
2. Rural occupation                        25        5.2  0.01
3. Unprotected housing                     80        4.8  0.03
4. Overcrowding                            77        1.4  0.05
5. Breeding sites less than 100 meters away15        3.6  0.02
6. Does not use the local health service   38        4.0  0.02


COMMUNITY D

FACTORS                                    % EXPOSED RR   p *
1. Low family income                       61        2.9  0.001
2. Rural occupation                        26        4.1  0.001
3. Unprotected housing                     23        3.6  0.001
4. Overcrowding                            38        1.6  0.001
5. Breeding sites less than 100 meters away28        3.9  0.001
6. Does not use the local health service   31        3.8  0.001
COMMUNITY E

FACTORS                                    % EXPOSED RR   p *
1. Low family income                       69        1.7  0.002
2. Rural occupation                        28        5.2  0.001
3. Unprotected housing                     74        5.6  0.001
4. Overcrowding                            27        1.9  0.001
5. Breeding sites less than 100 meters away23        2.8  0.001
6. Does not use the local health service   43        3.9  0.001

COMMUNITY F

FACTORS                                    % EXPOSED RR   p *
1. Low family income                       58        3.2  0.001
2. Rural occupation                        31        3.6  0.001
3. Unprotected housing                     18        3.9  0.001
4. Overcrowding                            27        1.1  0.35 N.S.
5. Breeding sites less than 100 meters away35        3.4  0.001
6. Does not use the local health service   29        4.4  0.001


*    Statistical Significance,
     Value of "p"
     N.S.  Not statistically significant

QUESTION 1:    Select the risk factors that should be evaluated
in each of community.

QUESTION 2:    Calculate the PAR% for each factor selected.

QUESTION 3:    Rank the risk factors and classify the communities
according to epidemiological risk strata. 
D.  Selection of the Intervention by Risk Factors

     Methodology

     Once the communities have been classified into
epidemiological strata (for which the risk factors were
identified, measured, and ranked), the next step is to select the
appropriate intervention for reducing or eliminating the risk
factors.

     Selection of the interventions is based on the order of the
risk factors, ranked according to their PAR%.  Since these
interventions are aimed at the reduction or elimination of the
risk factors, their impact is expected to be a reduction in the
incidence of malaria, which is the ultimate goal of this
prevention and control process.

     When a shortage of resources limits the capacity to
intervene with respect to all the factors that yielded a high
PAR% and there is more than one risk factor susceptible to
intervention that has a very similar PAR% or there is more than
one possible intervention, it is necessary to make a decision. 
The following criteria should be taken into account for this
purpose:

1.   The factor with the higher RR may be causally more
     important.

2.   There are interventions that can reduce or eliminate more
     than one risk factor at the same time.

3.   Some interventions are more feasible for implementation than
     others (cost, local resources available, etc).

     Table 3.9 is a schematic example of the relationship between
risk factors and different types of interventions.  (The
information is not exhaustive and is working material to be
supplemented and improved during the course of the workshop.)

Table 3.9

      DESIGN OF INTERVENTION MEASURES BASED ON RISK FACTORS
SOCIOLOGICAL AND ECONOMIC

GROUP I


INDICATORS

RISK FACTORINTERVENTION
MEASUREPROCESSIMPACT


1.Type of
oc-
cupation
favoring
trans-
missionPrevention
and
protection
measures
(specify
measures
according to
problem)% of
protection
coverageAPI
Mortality
Morbidity
2.MigrationEpidemiologic
al
surveillance
and screening
of immigrants% of
immigrants
screenedAPI
Mortality
Morbidity
3.Ethnic
groups
unwilling
to visit
health
servicesHealth
education% of
acceptanceAPI
Mortality
Morbidity
4.Incom-
plete
housingImprovement
of  housing% of houses
improvedAPI
Mortality
Morbidity
5.Ignorance
of
problemHealth
education% of persons
sensitizedAPI
Mortality
Morbidity
6.Low per
capita
financial
incomeImprovement
of economic
conditionsPer capita
financial
incomeAPI
Mortality
Morbidity
7.Deficient
or
reluctant
community
parti-
cipationHealth
education and
community
organization% of
communities
organized and
willingAPI
Mortality
Morbidity
TABLE 3.9
       RELATIONSHIP BETWEEN RISK FACTORS AND INTERVENTIONS
AIMED AT REDUCING OR ELIMINATING THEM

GROUP II
PARASITOLOGICAL AND IMMUNOLOGICAL



     RISK FACTORINTERVENTION MEASURES
1.   Parasite species- Individual or mass
     chemotherapy
- Epidemiological
investigation
- Vector control
2.   Resistance to chloroquine- Use of alternative drugs
- Control of self-medication
- Education
3.   Microscopic diagnosis
     (poor quality)- Training of technicians
4.   High parasite density- Chemotherapy
- Vector control
- Immunization
5.   Lack of eearly
     diagnosis- Decentralization
- Improved management
- Community participation
- Coordination
- Integration
6.   Presence of large numbers
     of asymptomatic carriers- Identification
- Chemotherapy
7.   Lack of immunity to
     infection- Vaccination
TABLE 3.9

       RELATIONSHIP BETWEEN RISK FACTORS AND INTERVENTIONS
AIMED AT REDUCING OR ELIMINATING THEM

GROUP III
ENTOMOLOGICAL



     RISK FACTORINTERVENTION MEASURES
1.   Endophage1.                         Chemical methods
2.   Anthropophilic density1.1           Residual household
spraying
3.   Ectophage1.2                        Spatial spraying
4.   Endophilia2.                        Physical methods
5.   Parity rate2.1                      Dwelling protection
6.   Infectivity rate2.2                 Use of mosquito nets
7.   Breeding places near
     dwellings or workplaces1.           Physical methods
1.1                                       Source reduction
through drainage,
landfilling, cleaning,
etc.
1.2                                       Biological and chemical
methods
8.   Vector resistance to
     insecticides                   Change in insecticides;
implementation of new
control measures
9.   Inadequate residual
     effect of insecticide 
a.   Due to poor application        Supervision and retraining
of sprayers
b.   Due to aggressiveness

     - of the population
     - of the area sprayed          Education for community
participation; area
improvement
TABLE 3.9
RELATIONSHIP OF RISK FACTORS AND INTERVENTIONS
TO REDUCE OR ELIMINATE THEM

GROUP IV
DIAGNOSTIC, CLINICAL, AND TREATMENT-RELATED



     RISK FACTORINTERVENTION MEASURES
1.   Lack of timely
     parasitological diagnosis- Decentralization of clinical
     and    parasitological
     diagnosis
- Training of health and
volunteer    staff
- Adequate provision of inputs
and    equipment
2.   Poor quality of diagnosis
     Errors in diagnosis- Staff training
- Timely control of quality
- Timely and adequate
equipment       and inputs of
good quality
3.   Nutritional deficit- Nutritional education
- Improvement in per capita
income
- Crop diversification
- Interinstitutional
coordination
4.   Uncontrolled gestation in
     malarious area- Adequate prenatal and
     puerperal     control
5.   - Clinical picture
     - Subclinical picture
     - Presence of
     asymptomatic     
     carriers- Timely/complete clinical     
examination
- Compliance with treatment    
      standards
- Education of physicians
6.   Immunodeficiency- Disease prevention
- Provision of dispensaries
7.   Ethnic groups- Health education to prevent  
malaria in such
     population          groups
8.   Resistance to drugs- Rational use of drugs
9.   Side effects of drugs- Health education for service 
personnel and the
     population
10.  Reluctance to be treated- Health education
11.  Poor quality of drugs- Quality control
12.  Incorrect dosage of
     treatment- Verification of compliance
     with     treatment regimens
13.  Availability of drugs
E.   Articulation of Interventions with Health Services
     Activities and Adaptation of Resources

1.   Background

     Given the current situation of the health services and their
future development aimed at meeting the goals of Health for All
by the Year 2000 and applying the strategies of primary health
care, it is felt that the general health services should be
responsible for malaria control activities such as the diagnosis
and treatment of cases, as well as the collection of information
and referral of cases.

     With regard to control, after the process of epidemiological
risk stratification has been accepted at the central level as the
strategy to be followed, it is necessary to conduct an overall
review of operations for the control of malaria and their
organization.  At the local level, there should be an assessment
of the extent to which the operations of the malaria program are
integrated into the other health programs at the level of the
local services and are in alignment with the strategies of
primary health care.  If integration has not taken place, the
articulation or integration of the activities should be planned
in order to determine the level of resources and make the
necessary adjustments, and this should be done first at the local
level so that an objective plan can be prepared for consideration
by regional and national authorities.  In later stages, a greater
degree of integration should be planned and gradually implemented
at all levels in order to meet local needs.

2.   Social Participation

     There is a difference between what has been called
"community participation," which simply means the community's
acceptance of antimalarial interventions, and the concept of
social participation as the decision-making process for
collaboration in the planning, operation, and control of
interventions and health services.  The latter concept refers to
the interaction of health workers and the community as active
participants in undertakings.

     In the case of malaria, the interaction focuses on how to
ensure that social participation will strengthen execution of the
activities of the health services within the communities and that
the general health services will expand that participation (WHO,
1984).  There are examples of social participation in diagnosis,
treatment, household spraying operations, reduction or
elimination of vector breeding sites, and acquisition of
epidemiological information.  In some of the cases the
participation has been obtained on the basis of financial
remuneration, and in others voluntarily.  It has been the
experience that without ongoing promotion by the health
authorities, social participation will falter unless it is tied
to material or economic benefits.

     WHO study groups (1984) have compiled specific
recommendations for evaluating the degree of social participation
needed and suggestions for promoting such participation in order
to guarantee the good operation of malaria control as part of
primary health care.

     Lack of social participation has been considered a major
obstacle to effective malaria control.  Consideration should
always be given to the study of cultural patterns and the
inclusion of respected individuals and local leaders in the
health committees.  Educational programs for schoolchildren
always have a positive impact on the entire community's
willingness to collaborate, which means they should always be
tried.

     The interventions that produce permanent changes which
reduce or eliminate risk factors are the most useful weapons in
malaria control.  Examples are the elimination of vector breeding
sites and the development of local capacity for diagnosis and
treatment.  However, unless these are implemented within the
primary health care system and with social participation, malaria
control cannot be effective and lasting and its cost may increase
so much that it becomes impracticable.

3.   Activities

     Once the rank order of risk factors for malaria has been
established, the resources needed in order to evaluate them
regularly have been identified, and the interventions aimed at
reducing or eliminating them have been decided on at the local
level, the local health systems must be geared up to implement
them so as to guarantee the continuity of stratification
activities within each of the risk strata.

     First a list is made of the resources needed in order to
carry out all the phases of the stratification process at the
local level.  Second, an inventory is taken of the resources
already available locally and those that should be produced
locally or be provided from other levels.  It should always be
borne in mind that resources should be sufficient throughout the
stratification process and throughout the period of intervention. 
For this reason, it is preferable to utilize existing local
resources or whenever possible promote their production through
social participation.

     In order to implement epidemiological risk stratification in
the local health services, it is essential to achieve the
following goals:

     1.   Autonomous local technical capacity for timely and
specific diagnosis and treatment.

     2.   An adequate system for the collection of information,
including data on malaria cases, risk factors, and
evaluation indicators, to be analyzed at the local,
regional, and central levels.

     3.   Decision-making authority and capacity to implement
interventions.

     4.   Guaranteed operation of a system of ongoing supervision
and execution of periodic epidemiological follow-
up evaluations for which the regional and central
levels are responsible.
EXERCISE 4

     The research team in Malarialand agreed with the Governing
Committee (composed of representatives of the Ministries of
Health and Planning, the health workers' federation, the miners'
and farmers' unions, and the women's organization) that a malaria
control strategy should be carried out on the basis of:

1.   The epidemiological stratification approach.

2.   Data provided by epidemiological studies of risk.

3.   The following statements in the National Health Plan (1988-
     1991):
     "The health care system in Malarialand will be based on the
     principles of primary health care.  Every citizen in
     Malarialand has the right to health care, since the
     Government of Malarialand has made a commitment to social
     equity and justice."


Question 1:    Prepare a list of the points which should be
included in the description of the new strategy of
malaria prevention and control.  Base your
response on selection of the priority areas (local
level) and recognition of the focal distribution
of malaria.

Question 2:    Based on the risk stratum that is to be a target
for intervention, select the risk factors that may
be faced by the services in the initial phase
using a risk-based strategy.

Question 3:    For each of the risk factors mentioned, outline
the different types of interventions that can be
implemented, and for each factor and intervention
selected, draft one objective and two operational
targets that should serve as the basis for
programming and evaluating the interventions.

Question 4:    Discuss possible limitations to carrying out the
malaria control program using the epidemiological
stratification approach.


REFERENCIAS


-    Bruce-Chwatt L. J. (1987).  Malaria and its control: Present
     situation and future prospects.  Annual Review of Public
     Health, 8, 75-110.

-    Bruce-Chwatt, L. J. (1980).  Essential malariology. London:
     William Heinemann Medical Books Ltd.

-    Carnevale, P., & Mouchet, J.  (1987).  Prospects for malaria
     control.  International Journal of Parasitology. 17,
     181-187.

-    Clyde, D. F. (1987).  Recent trends in the epidemiology and
     control of malaria.  Epidemiologic Reviews, 9, 219-243.

-    Graves, P.M. et al.  1987.  Reduction in incidence and
     prevalence of Plasmodium falciparum in under 5-year-old
     children by permethrin impregnation of mosquito nets. 
     Bulletin of the World Health Organization, 65 (6): 869-877.

-    Hennekens, C.H. and Buring, J.E.  Epidemiology in Medicine. 
     Little, Brown and Company, 1987.

-    Kitron, U.  (1987).  Malaria, agriculture, and development:
     Lessons from past campaigns.     International Journal of
     Health Services. 17, 295-326.

-    Kleinbaum, D.B., Kupper, L.L. and Morgenstern, M. 
     Epidemiologic Research.  Wadsworth, Inc., 1982.

-    Kliger, I. J.  (1928).  Further studies on the epidemiology
     of malaria in Palestine.  American Journal of Tropical
     Medicine and Hygiene. 8, 183-198.

-    Kligler, I. J. (1924).  Malaria control demonstrations in
     Palestine.  American Journal of Tropical Medicine and
     Hygiene. 4,139-174.

-    Molineaux, L. and Gramiccia, G. (1980).  The Garki Project. 
     Research on the epidemiology and control of Malaria in the
     Sudan Savanna of West Africa.  W.H.O., Geneva.

-    Pan American Health Organization/World Health Organization. 
     (1987b, November 16-19).  Taller sobre indicadores de salud
     para la estratificacion de la malaria.  Puerto
     Azul-Naiguata-Venezuela.

-    Pan American Health Organization/World Health Organization. 
     (1988).  Taller sobre estratificacion epidemiologica para el
     control de la malaria  La Ceiba, Honduras.

-    Pan American Health Organization/World Health Organization. 
     (1985).  Malaria en las Americas.  Análisis crítico cuaderno
     técnico No. 1.  Ginebra, Suiza. 1985.

-    Prasittisuk, C.  (1985).  Present status of malaria in
     Thailand.  The Southeast Asian Journal of Tropical Medicine
     and Public Health. 16, 141-145.

-    Rojas, W. et al (1987).  Reduction of malaria prevalence
     after introduction of Romanomermis culcivarax (Mermithidae: 
     Nematoda) in larval Anopheles habitats in Colombia. 
     Bulletin of the World Health Organization, 65 (3): 331-337.


-    Terminología del Paludismo y de la erradicación del
     paludismo.  Organización Mundial de la Salud, Geneva, 1964.

-    Watson, R.B. and Maher, H.C. (1940).  An evaluation of
     mosquito- proofing for malaria control based on one year's
     observations.  The American Journal of Hygiene.  34
     (Sec.C):86-94.

-    World Health Organization.  (1987a).  Vector control in
     primary health care (Tech. Rep. Series No.755). Geneva.

-    World Health Organization.  (1986c, May 2).  Weekly
     Epidemiological Record. Geneva.

-    World Health Organization.  (1986a).  WHO  expert committee
     on malaria eighteenth report (Tech. Rep. Series No. 735).
     Geneva.

-    World Health Organization.  (1984).  Malaria control as part
     of primary health care (Tech. Rep. Series No. 712). Geneva.

-    World Health Organization.  (1957).  Malaria sixth report of
     the expert committee  (Tech. Rep. Series No. 123).  Geneva.

-    Zahar, A. R.  (1984).  Vector control operations in the
     African context.  Bulletin of the World Health Organization,
     62 (Suppl):  89-100.







(MOD1526I.  February 1992)













     ACCIDENT PREVENTION




ANALYSIS OF THE SITUATION


.    The epidemiological profile of
     Latin America indicates that
     although communicable diseases
     are still quite common, chronic
     diseases are gaining in
     prevalence, and accidents and
     violent behaviors have become
     problems of growing importance.

.    Accidents in the Region affect
     certain groups
     disproportionately, especially
     young adults and the elderly. 
     They are a significant cause of
     death, disability, and disease,
     and they generate high demand
     for services from emergency
     rooms and hospitals, as well as
     centers and programs for
     rehabilitation.

.    Unintentional injuries account
     for the highest number of years
     of potential life lost in the
     Region.  In 1986 an estimated
     one-third of the total number
     of years of life lost from all
     causes of death in the 1-24 age
     group corresponded to deaths
     attributable to this type of
     injury.

.    Among accidental deaths, those
     resulting from traffic
     accidents have reached epidemic
     proportions in the Region.

.    Accidents are still often
     viewed in the Region as
     inevitable or chance
     occurrences, which
     unfortunately hinders
     establishment of the concept of
     accident prevention and
     perpetuates erroneous attitudes
     and beliefs.



THE PAHO PROGRAM ON ACCIDENT
PREVENTION 


The PAHO Program on Accident
Prevention provides support to the
Member Countries for the
establishment of accident prevention
programs and for the care of
accident victims.  It cooperates
with the countries in the
organization and rationalization of
care, placing due emphasis on the
delivery of services at the primary
care level within the local health
services and in emergency rooms.  It
supports epidemiological and
operations research.



OBJECTIVES OF THE PROGRAM


1.   To substantially reduce the
     frequency of accidents in the
     Member Countries, mitigating
     their individual and collective
     impact through the creation or
     strengthening of national
     prevention programs.

2.   To document the magnitude of
     the problem of accidents
     through the collection of
     epidemiological information.

3.   To disseminate information
     aimed at heightening awareness
     in the population and among the
     various sectors that need to
     participate in preventive
     action.












STRATEGIES AND PRIORITIES

1.   Surveillance and follow-up of
     the epidemiological situation
     of accidents in every country
     through collection and ongoing
     analysis of the information
     available on the subject.

2.   Promotion of policy- and
     law-making, as well as the
     adoption of technical measures
     of prevention that are of
     proven effectiveness,
     especially at the local level.



LINES OF ACTION


1. Mobilization of resources

The Program seeks to pool the
efforts and coordinate the actions
of governmental and nongovernmental
agencies in the area of accident
prevention.  It coordinates its
activities with those of civic
groups, programs for the prevention
of accidents in industrial settings,
transit authorities, insurance
firms, and agencies for social
action, with a view to obtaining and
utilizing technical and material
resources to aid the national
programs.


2.  Dissemination of information

Dissemination of technical
information on the epidemiological
situation, risk factors, safety
measures, environmental protection,
and other matters relevant to the
changes of behavior that are
necessary in order to prevent
accidents and deal with their
consequences.  

The periodic and special
publications of PAHO and the
scientific press in the Region
constitute a tool of unquestionable
value.

3.  Training 

Personnel training falls within the
sphere of the Regional Program,
which attaches importance to the
organization of workshops and
national and international seminars;
the collection, production, and
dissemination of educational
materials; and support for teaching
centers.


4.  Direct technical cooperation

The Program promotes the development
of national policies and programs of
a multisectoral nature.  It seeks to
facilitate the establishment of ties
between centers with recognized
expertise in the field of accident
prevention and national programs in
the early stages of development.


5.  Research

The Program encourages and
cooperates in the design and
execution of research on accidents
that can will be applicable to the
development of programs for
prevention and control.










Revision
February 1992
MOD1527I














Note:
Draft Version
    Please do not reproduce or quote without the authorization of
the Pan American Health Organization



EVALUATION OF MALARIA CONTROL INTERVENTIONS 
BASED ON THE EPIDEMIOLOGICAL RISK APPROACH


I.   Basic Concepts Regarding Evaluation Indicators

     The evaluation of malaria control interventions based on the
epidemiological risk approach is fundamental to assessing their impact
on the levels of malaria transmission among the population.

     Last's A Dictionary of Epidemiology defines evaluation as "A
process that attempts to determine as systematically and objectively
as possible the relevance, effectiveness, and impact of activities in
the light of their objectives"  (Last:44).

     The fundamental objective of evaluation is to determine to what
extent a strategy based on the epidemiological risk approach is a
better alternative than the strategy used in traditional interventions. 
The three possible outcomes of evaluation are:

     1.    That there is NO change in the levels of malaria
transmission in the community based on the indicators
selected for the evaluation.

     2.    That there is a negative change in the levels of malaria
transmission--that is, a deterioration of health conditions
has taken place as manifested by an increase in the
incidence of malaria.

     3.    That there is a favorable change in the levels of malaria
transmission in the community, which is reflected in turn 
in a decline in the incidence of malaria and an increase
in the levels of health of the population.

     A key feature of the evaluation of interventions based on the
epidemiological risk approach is the possibility of determining whether
the positive or negative impact--or lack of impact--is in fact a
consequence of the stratification strategy based on the risk approach
and not of other factors.  This methodological problem can be
controlled only through careful design of evaluation studies and
appropriate selection of evaluation indicators.

     Generally speaking, evaluation may be carried out using three
kinds of indicators:

     a) Indicators of structure
     b) Indicators of process
     c) Indicators of impact or outcome 

      The indicators of structure reflect quantitative information on
the infrastructure of the health services, their level of organization,
the kinds of services to which the population has access, and the
resources available.  The kind of evaluation that can be carried out
with these indicators presupposes that the quality of the health care
provided and the levels of health attained depend on the resources
available.

      The indicators of process include information on the manner in
which the services are adapted to the needs of the population, what
steps are taken in the diagnosis, the kind of treatment provided, the
conditions and means of access to the health care system, the standards
being used for referral, and the kinds of services provided at the
various levels of care.  In summary, the process has to do with
organization and articulation of the various components of the health
system in the delivery of health services and interventions.

      The indicators of impact or outcome are used to evaluate the
level of health attained as a consequence of the intervention.  They
seek to identify the variations and changes in the levels of disease,
disability, or death in the community that are brought about by the new
strategy based on the risk approach.  The evaluation of these kinds of
indicators occasionally takes a long time, since changes in mortality
or in morbidity rates are expressed more clearly in the medium term. 
These indicators are fundamental for evaluating the impact of
interventions in the transmission of malaria among the population.



2.    Importance of Baseline Information

      Baseline information is understood to be the basic set of data
collected as minimum information prior to the intervention.  It shows
the health conditions of the population in malarious areas prior to
implementation of the epidemiological stratification strategy, and it
makes it possible to measure the changes and effects produced by the
strategy based on the risk approach.

      The evaluation indicators should utilize baseline information
to confirm the changes that have taken place in the area under study. 
The selection of indicators is closely tied to the design of the
evaluation study.  In turn, the design of the study will reflect the
existence or nonexistence of control groups and the kind of basic
information to be used. 

3.    Design of the Evaluation Study

      The literature on methodologies for the evaluation of health
services mentions various possible designs for the evaluation of new
interventions.  Some of these research designs are presented below.

      a)    A single cross-sectional design.  In this design, all
      measurements are made subsequent to the intervention.

      b)    A before/after design, without area(s) of comparison. 
      This design is based on cross-sectional surveys, the first of
      which is carried out before, and the second, after the
      intervention.  In this design, the premise is that the
      differences observed in the indicators before and after are due
      to the effects of the intervention(s) that took place during
      this interval of time. 

      c)    A before/after design, with areas of comparison, in which
      the information may be taken from existing, routinely collected
      statistics.  This design measures the variables in two
      population groups, one in which the new intervention strategy is
      introduced and another in which traditional intervention is
      used.  It requires two measurements, one before the intervention
      and the other after the intervention has been introduced.  The
      comparison group should be as similar as possible to the group
      under study, differing only in the type of intervention carried
      out.

      d)    A before/after design in the area of intervention, with
      cross-sectional studies and the use of national data area of
      comparison.

      These designs of evaluation studies, like all observational
studies, may be subject to problems of validity and reliability. 
Consequently, generalization of the results will depend on the
magnitude and direction of the biases introduced or encountered.  In
addition, consideration should be given to the relevant ethical aspects
that come into play with regard to the population under study.  

      For the evaluation of a new intervention strategy, the ideal
situation would be to have one or more areas of comparison in which
changes are not made in the care and intervention system.  In both
the areas of study and the areas of comparison, the levels of malaria
transmission should be evaluated in high- and low-risk groups, and the
differences encountered should be documented. 

      If there are statistically significant differences between the
levels of malaria transmission in the high- and low-risk groups in
the areas of study and comparison, it may be concluded that the new
strategy has modified the malaria and health situation in the area of
study; if this change is positive, there is reason to believe that the
new intervention strategy is more effective than the strategy that was
being used before.




4.  Analysis of the Data and Conclusions

      On the basis of the foregoing points, it can be said that the
principal components of the evaluation process are the following: 

      a)    The object of study is an activity or intervention that
is introduced in a program or service;
      b)    It assumes that there are pre-established objectives;
      c)    It is a measurement process; and
      d)    It requires evidence to demonstrate whether the change
observed is the result of the activities or interventions
carried out.

      Accordingly, all evaluation studies should pose two central
questions.  The first should ask whether, during the implemention of
the new strategy, program, or service, significant changes took place
in the levels of health of the population covered by the actions under
study.  The second should ask whether such changes and/or the
achievement of the objectives proposed should be attributed to the
program or to the planned intervention.  Both questions should refer
to a specific period of time.  This means that the evaluation process
should cover a period of time that corresponds to the point at which
the possible change can be observed, measured, and analyzed.

      The changes observed in the study and control groups may be
measured by tests of statistical significance.  The most common are
the chi-square test, analysis of variance, multiple linear regression,
and logistic regression.  An extensive discussion of each of these may
be found in works on biostatistics and advanced epidemiology.

      The general idea in statistical analysis is to carefully
document all the differences and conclusions that may be derived from
the data.  Analysis of the data makes it possible to draw conclusions
regarding the impact achieved by the new risk strategy.  Great care
must be taken in the interpretion of the data.  What may appear at
first glance to be a simple judgment about the difference between two
sets of data is actually a complicated process.  The statistical
methods used in the analysis should be applied with the utmost care. 
Participation in the evaluation process should be broad-based and
include the study group, health and administrative personnel, personnel
with political decision-making power, and representatives of the
community.  Each of these groups has particular interests that
influence interpretation of the data.  When evaluation is carried out
as a group process, it is difficult to skew the results.  Broad-
based participation will help to facilitate application of the results. 
The study's scientific value should not be lost sight of, and the
interpretations of the study should be accepted as part of a
sociopolitical process aimed at controlling malaria and improving
levels of health.            EXERCISES

1.    Formulate a hypothesis of change that can be used to evaluate
      the risk strategy in the malarious area under study.

2.    Specify the design for an evaluation study that you would use
      in evaluating interventions based on the risk approach.  Justify
      your selection.  Discuss its advantages and disadvantages. 

3.    Mention three indicators used for the measurement of elements
      of structure, process, and impact as they relate to the strategy
      of epidemiological stratification of malaria.

4.    For the purpose of evaluating the new strategy of intervention
      in malaria, use your general knowledge of Malarialand and your
      responses to the exercises to describe the areas of study and
      comparison that you would select for this evaluation.

5.    Prepare the contingency tables for each of the indicators
      mentioned in Exercise 2. 

6.    For each of the tables prepared, suggest which kind of
      comparisons and statistical tests would be appropriate. 

7.    Discuss the other variables that might be associated with the
      results being observed.  Point out possible sources of error
      and discuss the probable limitations with respect to
      generalization of the results.




















CHRONIC NONCOMMUNICABLE DISEASES 







ANALYSIS OF THE SITUATION

During recent decades the
demographic and epidemiological
profiles of all the countries of the
Region have undergone significant
changes:  fertility rates, infant
mortality, and mortality from
infectious and nutritional diseases
have shown a sustained decline,
while life expectancy, urban
migration, and population size have
steadily increased.

These changes in the demographic
structure have been associated with
an aging of the population.  The
concomitant social transformations
have brought about changes in
lifestyle which, together with
environmental transformations, have
led to a substantial increase in
mortality from chronic
noncommunicable diseases (CND). 

At present, mortality, morbidity,
disabilities, and demand for health
services in the Region are
attributable primarily to
cardiovascular diseases, malignant
tumors, diabetes, and chronic kidney
and respiratory diseases.

The response of the services to
these problems has in general been
insufficient.  There are very few
programs for prevention and
promotion, and resources are used
mainly for the care of the advanced
stages and complications of these
diseases, which strains the capacity
of the services.

The use of high technology
contributes to the high cost of care
and to its inaccessibility by the
needy classes.



PAHO PROGRAM ON CND 

The PAHO Program on CND directs it
efforts mainly toward the promotion
of health through interventions
aimed at promoting lifestyles and
environmental modifications that
will mitigate or eliminate factors
that jeopardize health.

The Program's efforts are directed
toward the dissemination of evidence
on the causes and risk factors
associated with CND and the use of
mass media to promote public
awareness of the harmful influence
of certain behaviors and the
effectiveness of prevention. 


OBJECTIVES OF THE PROGRAM

1.   To promote the establishment
     and development of "integrated
     operational interventions" for
     the promotion of health and the
     prevention of CND through the
     control of the risk factors. 

2.   To cooperate in analysis and
     diagnosis of the status of CND
     in the Region and in the
     dissemination of pertinent
     information. 

3.   To collaborate in efforts to
     train health workers to carry
     out programs for the correct
     management of CND.

4.   To cooperate in the
     transformation of services for
     CND by providing support for
     epidemiological research and
     prevention and control efforts.

5.   To promote policies on the
     rational use of high technology
     for the diagnosis and treatment
     of CND.

STRATEGIES AND PRIORITIES

The growing problem of CND in the
Region calls for the adoption of
nontraditional public health
strategies, including community
interventions aimed at counteracting
the most common risk factors through
actions that are feasible and
acceptable to the community.

Such activities, grouped under the
rubric "integrated interventions,"
are carried out within the local
health systems through:

.    General measures for the
     promotion of health (risks to
     the population at large);

.    Prevention of the risk factors
     for CND (risks to individuals);

.    Improvement of the
     effectiveness and accessibility
     of health services; and

.    Appropriate utilization of the
     mass media. 

LINES OF ACTION


1.  Development of policies, plans,
and programs

Activities in this regard involve
gaining access to decision-making
authorities in order to supply them
with the proper information and make
them fully aware of the situation,
with a view to encouraging the
adoption of policies and strategies
aimed at health promotion and the
prevention of CND.


2.   Mobilization of resources

The identification and utilization
of qualified experts and prestigious
centers engaged in the field of CND,
the establishment of ties with
sources of financing, and the
mobilization of public opinion are
several of the approaches employed
by the Program.


3.   Dissemination of information

Abundant educational and informative
material is produced in the Region
on the subject of CND prevention and
control.  The Program contributes to
the collection and exchange of such
material between countries.  It also
supports the development of
innovative methods of mass
communication with a view to
promoting changes in collective
behavior that will be conducive to
healthy lifestyles.


4.   Training 

The Program supports short-term
training activities for managers and
directors of programs, emphasizing
instruction in the analysis of
problems related to CND and the
proper development, execution, and
evaluation of programs for the
promotion of health and the
prevention of CND.


5.   Promotion of research

Particular importance is attached to
epidemiological and operations
research in relation to services for
CND.  The Program also promotes
socio-anthropological studies for
the analysis of behaviors and risks.


6.   Direct technical advisory
services

Advisory services are provided to
the countries on specific matters
related to implementation of the
preceding lines of action through
visits by the Regional Advisers and
a panel of consultants from the
Region.



Chapter IV

STRATEGY OF ACTION


The Regional Plan for Investment is the initial proposal for promoting a process in the
countries of Latin America and the Caribbean.  Its aim is to facilitate the definition of common
purposes and concrete actions with a view to achieving, in the areas of protection and control
of the environment and direct health care for the population, the principles of universality,
solidarity, and equity.  It is a process that will be carried out at the national level and will be the
inalienable responsibility of the countries themselves.

A Political Commitment

1.         The Regional Plan for Investment,
as a strategy and frame of reference that
will guide the formulation of the National
Plans of Investment, should be the
expression of a firm political
commitment on the part of the countries
of Latin America and the Caribbean. 
This commitment cannot be limited to
the Governments.  The magnitude of the
proposal and the effort that it will require
will make it necessary to seek all
possible forms and means of building a
solid and stable base of political support. 

Building Political Support in the
Countries

2.         It is indispensable to achieve the
active participation of all those who
make up the national society in each
country, while at the same time
promoting, facilitating, and strengthening
such participation through joint action by
all the countries.
The Pan American Health
Organization and the international
development and lending agencies,
institutions, and organizations which
have some link to the areas of protection
and control of the environment and direct
health care for the population should
contribute effectively to the formation
and consolidation of this base of political
support.

Strategic Actions

3.                                                                                      The Regional Plan of Investments
must be developed with the direct
participation of the countries and other
international cooperation agencies.
This first version will serve as a
foundation for the initial political
commitment, on the basis of which a set
of strategic actions can be designed and
carried out.  Some of these actions are
discussed below.

The National Plans of Investment

4.         The National Plans of Investment
will be a concrete expression of the
countries' political commitment.  They
will  constitute a strategic action that will
further the process.  They will also
strengthen and contribute to achievement
of the objectives of the Regional Plan for
Investment.  The National Plans will
make it possible to adapt, where
necessary, existing investment proposals
or formulate new ones that respond to the
orientations and priorities.  It is essential
to begin developing national capacities in
the countries for the formulation of these
Plans and the subsequent development of
Yconcrete projects.

Institutional Development and 
Preinvestment

5.         Institutional development is an
area of action in which the countries can
get started immediately by rechanneling
and/or strengthening the resources that at
present are being utilized for training
activities, improvements in managerial
systems, etc.
The preinvestment component of
the Regional Plan also includes actions
aimed at guiding institutional
development.

Regional Preinvestment Fund

6.         In order for the countries to be in
a position to implement the Regional
Plan, they need to initiate, as soon as
possible, several processes at the national
level.  These include sectoral analysis,
training, the formulation of policies to
guide the reform of systems and
institutions, and the preparation of a
National Plan of Investment, the
development of concrete projects, etc.
It will then be necessary to
activate mechanisms that will ensure that
this first phase is indeed carried out.  An
indispensable and urgent instrument is
the creation of a Regional Preinvestment
Fund, made up of multiple contributions
from the countries in the Region and
donors outside the Region.  This
mechanism could be designed and
overseen by the Pan American Health
Organization.Orientations for Reform

7.         The countries can assume, as early
as possible, the responsibility for making
the Regional Plan for Investment viable
through actions aimed at achieving the
commitment and mobilization of the
most significant and important
participants in their national political
circles.  The objective is for the content
of the orientations to become a
consensual component of a National
Project in each country.  The orientations
for reform outlined in this proposal
should be debated at the national level by
all sectors of public opinion and,
especially, by the grass-roots
organizations.  Only in this way will they
have the political viability and
indispensable continuity that is required
by undertakings of such scope and
duration.

Creation of National Commissions

8.         Multisectoral and representative
National Commissions should be created,
as should technical teams.  Their
purpose, inter alia, would be to complete,
correct, and/or refine the information
utilized for the preparation of this first
version of the proposal; carry out various
studies; confirm the validity of certain
referential assumptions, criteria, and
standards; and analyze the feasibility of
the Regional estimates of internal
financing.  Regional and subregional
meetings for the purpose of exchanging
experiences and information and seeking
international support for national efforts
would facilitate and strengthen the work
of the National Commissions.


Building on Existing Activities 

9.         The countries are already carrying
out activities that are related to the
proposed Regional Plan.  These should
be taken advantage of, either by
reorienting them, when necessary, or by
intensifying and expanding them, if this
is strategically more expedient.  It is not
a question of starting from scratch or
waiting until the National Plans are
completely formulated.  The minimum
needs that must be met have already been
identified and it is urgent to respond
without delay.
A Support Alliance

10.                                                                                     To complement the actions at the
national level an alliance of international
cooperation agencies and institutions
should be formed.  In this way it will be
possible to provide the countries with the
technical assistance that will to enable
them to achieve the objectives outlined
above, while at the same time channeling
and/or facilitating the financing needed
immediately for preinvestment and the
development of the components or
subcomponents of the Regional Plan.
The magnitude and implications of
the Plan, the political commitment
required from the countries, and the
formation of this alliance are factors that
will make it necessary to formulate new
strategies of support for the countries and
redefine the roles that should be played
by international cooperation.


In the face of the different crises affecting the countries of Latin America and the
Caribbean, there is a moral duty to respond with proposals that correspond to the magnitude
of the problems.  These crises offer the opportunity to promote and facilitate changes and
reforms that are urgently needed and must no longer be put off. 
In these circumstances, the Governments and all segments of society in the countries
of the Region, the international agencies, and the industrialized countries should act together. 
A solution must be found to social problems that are currently affecting millions of people in
this part of the world--problems such as malnutrition, environmental conditions that make it
impossible for people to attain even a minimum standard of living, and lack of access or failure
to use the simple and low-cost technologies that are available.  A way must be found of
preventing people from dying unnecessarily and prematurely.
Nevertheless, it is not just the lives of these hundreds of millions of people that are at
stake but the values that will form the basis for the construction of a universal society in which
peace will prevail, the prerequisites for which are solidarity and justice.
POPULATION AND ACCESS TO DRINKING WATER SERVICES AND SANITATION
LATIN AMERICA AND THE CARIBBEAN, 1992 and 1993 -  2004
(population in millions)

1 9 9 22 0 0 41 9 9 3 -  2 0 0 4CATEGORIES
Total
Assumed to 
be Served
Assumed to be                                
Unserved1
Total
Population
Increase 
To be served
during the period                        Population
to be Served
under the PlanURBAN DRINKING WATER
     Urban 
     Urban Fringe                          333.3
216.6
116.7266.5
199.1
67.4 66.8
17.5
49.3427.8
278.1
149.794.5
61.4
33.1161.3
78.9
82.4145.4
71.2
74.2URBAN SEWERAGE
     Urban 
     Urban Fringe                          333.3
216.6
116.7246.7
197.4
49.3 86.6
19.2
67.4427.8
278.1
149.794.5
61.4
33.1181.1
80.6
100.5158.0
70.5
87.5RURAL DRINKING
WATER                                      126.2 66.9 59.3121.2(5.0)54.3 27.4SEWERAGE AND EXCRETA
DISPOSAL IN THE RURAL ENVIRONMENT

126.2

37.9

88.3

121.2

(5.0)

83.3

55.0WATER CONATMINATION
     Municipal Drains
     Industrial Wastewater
333.3
33.3
300.0
427.8
94.5
394.5
188.0
175.02SOLID WASTES
COLLECTION
     Urban 
     Urban Fringe
FINAL DISPOSAL                             333.3

216.6
116.7
333.3233.3

205.8
27.5
100.0100.0

10.8
89.2
233.3427.8

278.1
149.7
427.894.5

61.4
33.1
94.5194.5

72.2
122.3
327.8152.0

62.4
89.6
285.0
1    The term "Assumed to be Unserved" includes the population currently without service plus the population that is being served but suffers from interruptions and unreliability of service.
2    This table includes the population equivalent of the contamination of water of industrial origin
     measured in terms of biochemical oxygen demand utilized for the estimate of the corresponding investments.
SOURCES:  Evaluation of the International Decade of Drinking Water and Sanitation 1981-1990; Sept. 1990.  Pan American Health Organization.
     Other Sources:  IBRD, IDB, EPLAC, CELADE, PAHO, etc.POPULATION AND ACCESS TO DIRECT HEALTH CARE SERVICES,
LATIN AMERICA AND THE CARIBBEAN, 1992 and 1993 -  2004
(Population in Millions)



CATEGORIES
1 9 9 22 0 0 41 9 9 3 -  2 0 0 4

TotalCOVERAGE

Total
Population
IncreaseSupply
of Access
under 
the Plan2Assumed to 
have Access1Assumed not to
have AccessTOTAL

URBAN

    Urban
    Urban Fringe

    In Capital Cities
    In LUCs >  1M * *
    Other Urban Areas

RURAL                                      459.5

333.3

216.6
116.7

73.9
74.0
185.4

126.2298.3

254.1

184.1
70.0

62.8
59.3
132.0

44.2161.2

79.2

32.5
46.7

11.1
14.7
53.4

82.0549.0

427.8

257.7
170.1

93.2
93.8
240.8

121.289.5

94.5

41.1
53.4

19.3
19.8
55.4

(5.0)255.7 *

173.7

73.6
100.1

30.4
34.5
108.8

82.0 *
1    Assumptions:  85% of the urban population, 60% of the urban fringe population, and 35% of the rural population is assumed to have access.  This signifies an access of 64.9%
     for the total population, which is a conservative figure, since most of the estimates indicate that between 35% and 40% of the population lacks access to permanent health services.
     
2    Sum of the population assumed to be without access and the population increase expected for 1993-2004.
*    Does not add up horizontally.      ** Large Urban Conglomerations of more than one million inhabitants.

Sources:  World Urbanization Prospects U.N. 1990.
Various estimates from UNDP, IBRD, IDB, CEPALC, PAHO, etc..           INVESTMENTS IN PHYSICAL INFRASTRUCTURE OF THE ENVIRONMENT, 1993 - 2004
POPULATION TO BE SERVED AND INVESTMENT COSTS
(population in millions, in terms of 1990 dollars)



CATEGORIES

TOTAL
POTABLE
WATER
URBAN

SEWERAGE
URBAN
POTABLE    WATER
  RURAL

SEWERAGE
RURALWASTE
TREATMENT 

SOLID WASTES
MUNICIPAL
INDUSTRIALREFUSE
COLLECTIONREFUSE DISPOSAL
POPULATION TO BE SERVED
(in millions)
TOTAL

URBAN
     Urban 
     Urban Fringe
RURAL


145.4

145.4
71.2
74.2

158.0

158.0
70.5
87.5

27.4

27.4


27.4

55.0

55.0


55.0

188.0

188.0


188.0

175.0 *

175.0


--

152.0

152.0
62.4
89.6
--

285.0

285.0


285.0
INVESTMENT COSTS
(billions US$)
TOTAL

Rehabilitation and
re-equipping
New works to cover
current deficits
New works to
respond to 
population growth


114.83


16.23

65.945


32.655


35.58


8.8

11.09


15.69


33.06


4.62

13.735


14.705


3.72


.45

3.27


--


3.24


.27

2.97


--


16.57


1.53

15.04


--


15.04


**

15.04


--


7.62


.56

4.8


2.26

*    Population equivalent measured in terms of biochemical oxygen demand.
**   No information available.                     INVESTMENTS IN PHYSICAL INFRASTRUCTURE
OF DIRECT HEALTH CARE FOR THE POPULATION, 1993 -  2004
PHYSICAL WORKS (in thousands) AND INVESTMENT COSTS (in billions)


CATEGORIES
Total
Self-careHealthPosts 
Health
Centers
Hospitals *PHYSICAL WORKS
TOTAL

URBAN
  Urban 
  Urban fringe

  In capital cities
  In LUCs > 1M * *
  In the rest of the country

RURAL

Rehabilitation and re-equipping
New works to cover current deficits
New works to respond to population growth


592.6


340.2






252.4


485.8
106.8
47.6


19.7
15.7





12.2

22.0
16.2
9.4
14.6


5.7
5.0





3.9

6.0
5.4
3.2
804.7





118.5
133.7
552.5



417.2
307.3
80.2INVESTMENT COSTS
TOTAL

URBAN
  Urban 
  Urban Fringe
RURAL

Rehabilitation and Reequipping
New Works in Order to Cover Current Deficits
New Works in Order to Respond to the Population Growth
64.48


8.58
12.43
43.47

16.97
37.42
10.09
6.06



3.48
2.58


4.97
1.09
2.0


.63
.75
.62

.44
1.0
.560
1.42


.45
.54
.43

.28
.72
.42
55.0


7.5
7.66
39.84

16.25
30.73
8.02
* In hospital beds.
**Large Urban Conglomerations of more than one million inhabitants.
  FINANCING THE PLAN FOR INVESTMENT

I.  METHODOLOGY

1.In the analysis of financial feasibility of the
Regional Plan for Investment, three possible
sources of financing were independently
considered and studied:  a) internal financing,
including the private sector and possible schemes
of self-financing and cost recovery; b) external,
multilateral, bilateral, public, and private
financing; and c) external debt conversion.

2.An attempt was made to obtain information
from the countries and from Latin America and
the Caribbean as a whole, as well as from the
industrialized countries and multilateral lending
agencies. 
  Different macroeconomic variables were
tested, only the most significant of which were
utilized. Others had to to be ruled out because
they varied in relation to the preceding variables,
as in the case of Gross Domestic Savings and
Gross Domestic Investment.

A.  INTERNAL FINANCING

3.With regard to internal financing,
calculations have been based on the Gross
Domestic Product (GDP); size of the overall
government and the central government; public
spending; expenditure on investment in health by
the public sector (Ministries of Health, Social
Security) and the private sector; as well as public
investments in water and sewerage.
The principal sources of information have been
the World Bank, International Monetary Fund,
United Nations, ECLAC, IDB, and PAHO.  In
order to maintain a certain consistency in the
assumptions and calculations preference has been
given to the information from the World Bank.
It has been necessary to work with several
assumptions, especially with respect to
projections for 1991 and 1992 and for the period
1993-2004.
It is considered that the size of the public sector
and of overall government; public spending on
the infrastructure of water, sewerage, and health
services; the relative size of the public, social
security, and private subsectors; and spending on
Social Security--all expressed in percentages of
GDP--will remain constant during the period
1993- 2004.  According to available information,
the periods 1971-78, 1973-80, and 1977-80 have
been used as bases.

4.                                      The calculations for internal financing
were made in accordance with the following
reasoning:

a) The percentage represented by total public
spending, in relation to the Gross Domestic
Product of the countries of Latin America and the
Caribbean, is, on the average, 27,77% annually.

b) The percentage represented by public spending
on health services, in relation to total public
spending, is, on the average, 5.64% annually.

c) The percentage represented by investments by
the public sector in the infrastructure of health
services, in relation to public spending on health
services, is, on the average, 8,10% annually.

d) On the basis of the preceding values public
investment in the infrastructure of health services
represents, on the average, 0.1268% of the GDP
annually.

e) Spending on health by the private sector and
social security vis-Õ-vis the public sector is 1.33
and 1.18 to 1.00.   Assuming, conservatively,
that the investment behavior of social security is
proportionally similar to that of the Ministries of
Health, and that of the private sector is only 50%,
investments in health by social security and the
private sector represent, on the average, 0.1481%
and 0.0840% per year, respectively, of GDP.

f) To the foregoing it is necessary to add
prospective estimates of self-financing, on the
basis that payment for health services would
represent only 7% of current spending on health
services by the public sector (discounting central
and regional expenditures for administration).  If
25% of this figure is utilized at the local level in
recurring expenditures, 55% for small local
investments and institutional development, and
the remaining 20% as source for a National
Investment Fund (compensatory, in order to
guarantee the principles of solidarity and equity),
self-financing would represent an average
0.0428% annually of GDP.

g) The total of internal financing of the health
sector then is, on the average, 0.4017% annually
of the GDP of the countries of Latin America and
the Caribbean.

h) The percentage represented by investments by
the public sector in water and sewerage, in
relation to Gross Domestic Product, are, on the
average, 0.548% annually.

i) The preceding amount includes external
financing, which represents 25.7%. 
Consequently, national investment is reduced to
0.40% of GDP.  This last figure can, in turn, be
broken down into a proportion of 65% public
financing, 21% private, and 14% self-financing or
costs recovery, which represent, in relation to
GDP, 0.260%, 0.084%, and 0.056%, respectively.
  Self-financing in the environment would
come principally from the drinking water sector
and would be utilized in part for new
investments.

j) Finally it would be necessary to assume that
the countries are already investing in
preinvestments and institutional development,
although in national and sectoral accounting no
specific figures appear.  A preliminary estimate,
on the basis of partial information, yields
0.0183% of GDP, which is distributed
proportionally among the national sources.

k) Adding together the previous estimates of
internal sources gives a total average investment
in health and the environment, during the 1970s,
of 0.82% of GDP annually.

4.In accordance with projections of the World
Bank, it was assumed that the GDP of Latin
America and the Caribbean would undergo an
increase of 4.2% annually in the period 1993-
2004.  Based on this rate of growth, investment
capacity could return to 1970s levels. 

5.                                      As a result, the aggregate GDP of the
Latin Americas and Caribbean counries for the
period 1993-2004 would be on the order of the
US$ 17.5 trillion.  Applying to this amount the
same percentage of 0.82%, internal financing for
the present Regional Plan for Investment would
be on the order of US$ 143.5 billion.
Table A of this annex shows the
percentages of GDP and the corresponding
amounts.

B.                                      EXTERNAL FINANCING

6.                                      With regard to external financing,
information has been utilized from OECD and the
World Bank.
The calculations have been made
considering what the industrialized countries
have contributed, multilaterally and bilaterally, to
investments in drinking water and sewerage and
health services in Latin America and the
Caribbean during the period 1973-1980.  This
information covers the disbursements made
through "Official Development Assistance" -
 ODA (concessional) and the so-called "Other
Disbursements" (non-concessional).  Similar to
what what done with internal financing, these
disbursements have been related to the aggregate
GDP of the industrialized countries.  The
amounts obtained have been converted into
percentages of the GDP of the countries of Latin
America and the Caribbean.

7.                                      It is assumed that the percentages
allocated to water and sanitation and health
services for Latin America and the Caribbean will
be maintained in the future.  Adding to this the
new World Bank policy to invest at least 25% of
its resources in the social sectors, the allocation
of funds from the industrialized countries to
multilateral sources, and for health and sanitation,
would rise from 8.5% to 10%.  In addition, it is
assumed that the increase in GDP of the
industrialized countries in 1991 and 1992 will be
1.7% and it will be 3.0% from 1992 onward.  It
is thus possible to estimate that for the period
1993-2004 there would be an availability of
resources from these sources on the order of the
US$ 63.0 billion.  This corresponds to 0.360% of
the GDP of the countries of Latin America and
the Caribbean.

C.EXTERNAL DEBT CONVERSION

8.In regard to external debt conversion only
one country (Ecuador) has carried out
conversions of external debt for health, drinking
water, and sanitation, with an sum of US$ 12.0
million and US$ 14.0 million in 1990 dolars for
the period 1989-91, i.e. an average of US$ 4.0
and 4.5 million per year, respectively.  This
represents only 0.085% of the country's long-
term external debt.  The only estimate possible
based on current practices in transacting these
projects and the possible percentage of debt of
conversion for health and the environment, is a
total amount on the order of US$ 360 million for
the Latin American and Caribbean countryes
during the period 1993-2004.Investment
financing through external debt conversion would
require, like many of the estimates of financing
from all sources, political commitments and
agreements between the Governments of the
countries and creditors, along with the
modification of existing legislation and
international procedures.  If only 0.25% of the
external debt of the Latin American and
Caribbean countries--three times the percentage
in the case of Ecuador--could be converted to
investment in health, this would represent an
amount on the order of US$ 1.1 billion.

D.SENSITIVITY ANALYSIS

9.It is possible to calculate the financing that
would be available using other hypotheses:
If the level of recurring expenditure and capital
were that of the 1970s plus the difference
between this level and that of the 1980s, the
result would be an annual recurring expenditure
on health of:
  5.64% + 0.42= 6.06%
Thus, annual capital expenditure is:
  8.1% + 2.6%= 10.7%
These percentages replace those mentioned
above, (4.b and 4.c) and are utilized in the same
way.  It is assumed that contributions to the
environment from external sources and through
debt conversion remain the same, and thus
1.3391% of GDP of the Latin American and
Caribbean countries would be utilized for
investment, which represents $234.3 billion.

10.If the GDP of the Latin American and
Caribbean countries grows by 3% per year
instead of 4.2% during the period 1993-2004,
GDP would be on the order of $ 16.163 trillion. 
Doubling the percentage of the GDP shown in
Table A (1.1861%) yields total financing on the
order of the $ 191.7 billion.
 TABLE A:  FINANCING PLANNED FOR THE REGIONAL PLAN OF
 INVESTMENTS IN HEALTH AND THE ENVIRONMENT,  1993 - 2004
in billions US$, 1990 dollar values



SOURCEENVIRONMENTHEALTHTOTAL%
of 
GDPAMOUNT
billions
of 1990
dollars

%
of 
GDPAMOUNT
billions
of 1990 
dollars                        %
of 
GDPAMOUNT
billions
of 1990
dollarsNATIONAL

Public sector
Social Security
Private sector
Self-financing

  Sub-total

EXTERNAL

Multilateral
Bilateral


0.260

0.084
0.056

0.400



0.1332
0.0148


45.5

14.7
9.8

70.0



23.31
2.59


0.1268
0.1481
0.0840
0.0428

0.4017



0.0508
0.1612


22.2
25.9
14.7
7.5

70.3



8.89
28.22


0.4000
0.1500
0.1700
0.1000

0.8200



0.1840
0.1760


70.0
26.22
29.752
17.52

143.52



32.23
30.813

Concessional
Non-concessional
0.0222
0.1258
3.89
22.01
0.03125
0.18080
5.47
31.64
0.05345
0.30660
9.36
53.65
  Sub-total

DEBT CONVERSION

  TOTAL
0.148


0.0032

0.5512
25.9


.570

96.47
0.21205


0.00291

0.6167
37.11


.510

107,920
0.3600


0.00611

1.1861
63.01


1.083

207.59 3                    ANNEX V

II.  REFERENCES AND EXPLANATIONS OF METHODOLOGY

1.Government Finance Statistics Yearbook, International Monetary Fund (IMF) 1991, shows that during 1984-1988, central
  government spending represented 24.4% of GDP.  "Social Public Spending in South America in The Eighties", ECLAC,
  publication LC/R 961, p.21, shows that central government spending represents 88% of the overall government spending in 8
  countries of South America covering 88.4% of the total population of that subregion, during the period 1977-86; public spending
  represents 27.77% of GDP.

2.Government Finance Statistics Yearbook, IMF, 1991.

3."Gasto Público Corriente y Gasto Público de Capital, ECLAC Publication LC/R 962, 1990, pp. 48-53.

4."Financiamiento de la Atención a la Salud en América Latina y el Caribe, con focalización en el Seguro Social," MESA-
  LAGO (Carmelo), World Bank, 1989, p.33; "Social Spending in Latin America", GROSH (Margaret), World Bank, 1990, p.9,
  and World Bank, "El Financiamiento de los Servicios de Salud en los Países en Desarrollo," 1987, p.17.  According to these
  3 documents, the health public sector, social security, and the private sector spent, respectively, 28.5%, 33.5% and 38% of the
  total expenditure on health.

5.Total current expenditure by the public sector on health represented 1.1562% of GDP during the period 1973-80.  Of that, 81.9%
  represents current expenditure and 85% of this expenditure corresponds to establishments.  7% of this expenditure is recovered
  through the cost recovery systems and 75% of the recovered amount is channeled into investment and institutional development. 
  The 7% is based on estimates of Ch.  GRIFFIN, "User Charges for Health Care in Principle and Practice," World Bank, EDI
  Seminar Paper No. 37, 1988, p.21.  See also D. De FERRANTI, "Paying for Health Services in Developing Countries," World
  Bank, PHN Technical Note, 1984, p.11.

6."Latin America and the Caribbean Region, Water Supply and Sewerage Sector", Proposed Strategy, World Bank, 1988, p.23. 
  (The figures from this source cover the period 1971-1978 and were converted to 1990 values for purposes of the estimates).

7."Decenio Internacional del Abastecimiento de Agua Potable y Saneamiento:  Informe sobre la marcha de los trabajios en la
  Región," OPS, 1987, p.20.

8.By using the 1990 GDP of the Latin American and Caribbean countries given in World Bank Selected Economic Data, 1991,
  adjusted to 1990 values, and projecting to 1993 based on growth rates of 2.32% for 1991, 2.28% for 1992, and an average of
  4.2% annually from 1993 onwards, on the basis of World Bank, World Development Report, 1990, p. 16, the figure of $17.5
  trillion for the period 1993-2004 is obtained.

9.OECD, Geographical Distribution of Financial Flows to Developing Countries, 1975, 1980, 1985, and OECD, Development
  Cooperation, 1987 to 1991.

10.US$ 4.27 billion annually through ODA and US$ 28.06 billion annually from other disbursements, which represent 0.0348%
  and 0.2287%, respectively, of the GDP of the industrialized countries.  These percentages applied to the projected GDP of the
  industrialized countries during the period 1993-2004 represents US$ 6.67 billion annually in ODA and US$ 43.81 billion
  annually in other disbursements.

11.Official communiqué from the Vice President for Latin America and the Caribbean of the World Bank to PAHO, in which he
  mentions that the World Bank intends to increase its contribution to the social sectors to 25% of its total loans, which would
  signify a doubling of the financing to these sectors (see World Bank Anual Report 1991, p.181).  The percentage that the World
  Bank provides to the health sector of the Latin American and Caribbean countries would therefore increase from 6% to 12%,
  and the contribution of all multilateral sources to the health sector could rise from 8.5% to 10%.

12.OECD, Projections mentioned in a communiqué, 1992, and, World Development Report, World Bank, 1990, p. 16.

13."Conversión de deuda externa para proyectos de desarrollo en Salud," Case study from Ecuador, Troy, Solorzano, Vallejo, OPS,
  1991.

14.World Bank, World Debt Tables, 1991-92, Vol. 2, p. 118, show the long-term external debt of Ecuador in 1990.

15.Government Finance Statistics Yearbook, 1991, show that the central government spent 5.13% of its annual resources on health
  during the period 1981-88.  The difference between the amount spent in the 1970s vis-Õ-vis the 1980s is 5.64% -
    5.13% = 0.51%.  It is assumed that this difference is also valid for 1989 and 1990.  Thus, 0.51% x 10 years Ÿ 12 years = 0.42%
  per year.  The 0.42% is added to 5.64%, yielding 6.06%.

16.ECLAC, LC/R. 962, pp. 48-53, shows that investment in health was 8.1% during the 1970s and 5.0% during the 1980s.  The
  difference of 3.1% x 10 years Ÿ 12 years = 2.6%, which added to 8.1% gives 10.7%.


















MENTAL HEALTH








ANALYSIS OF THE SITUATION

.    Societies do not attach to
     mental health the importance
     that it deserves as one of
     characteristics that
     distinguish humankind.

.    There continues to be a great
     deal of unfounded skepticism
     with regard to the feasibility
     of controlling mental illness,
     despite the advances that have
     been made in research on the
     brain and in the treatment of
     such illness.

.    The budgets allocated for
     mental health activities are
     limited and are used largely
     for institutional psychiatric
     care.

.    Current mental health needs are
     enormous and will grow
     considerably by the year 2000,
     when it is estimated that 88.3
     million people in Latin America
     and the Caribbean will suffer
     some type of mental disorder.

.    Coverage by mental health
     services is insufficient, which
     leaves a widening gap between
     supply and demand.  This gap
     will continue to grow unless
     effective interventions with
     social participation are
     undertaken and community-based
     alternatives to institutional
     care are offered.

.    Training for human resources in
     mental health will need to
     stress the areas of knowledge
     involved in the new program
     content of national health
     plans, including mental health.






PAHO PROGRAM ON MENTAL HEALTH

PAHO provides technical assistance
to the countries of the Region in
carrying out actions aimed chiefly
at the promotion of mental health
and the provision of care and
rehabilitation based on the concepts
of equity and social participation.

The program responds to several
mandates from the Governing Bodies
of PAHO/WHO, which have adopted
resolutions that recommend the
incorporation of prevention
activities in health programs with
a view to reducing the risk of
mental, neurological, and
psychosocial disorders.


OBJECTIVES OF THE PROGRAM

.    Prevention of mental and
     neurological disorders.

.    Incorporation of a mental
     health component in health and
     social development plans.

.    Adoption of the psychosocial
     approach in health care.




STRATEGIES AND PRIORITIES

.    Promotion of Regional and
     subregional plans of action to
     address mental health
     priorities on an intersectoral
     basis. 

.    Support for the inclusion of
     national mental health programs
     in health and social
     development plans.

.    Strengthening of community-
     based psychiatric care,
     integrated with primary care
     and local health systems.



LINES OF ACTION


1.  Development of policies

Cooperation in the development of
national policies, plans, and
programs on mental health and in the
adoption of laws to protect patients
based on the guidelines suggested by
PAHO/WHO.


2.  Direct technical cooperation

Assistance, at the request of the
countries, in the development,
implementation, and evaluation of
mental health programs, with
emphasis on the restructuring of
psychiatric care using a community-
based approach.


3.  Dissemination of information

Promotion of the strengthening of
technical and scientific knowledge
in the area of mental health through
the preparation and dissemination of
materials and the support of
Regional centers that supply mental
health information.


4.  Mobilization of resources

Identification and utilization of
sources of material and technical
support, centers with recognized
expertise in the area, and relevant
programs that will be useful in the
strengthening of programs and in
technical cooperation among
countries.


5.  Training 

The Program promotes new programming
and strategic orientations through
the strengthening of academic
programs at the undergraduate and
graduate levels, continuing
education activities, and in-service
training.  It supports the
organization of seminars, courses,
and workshops and it provides
support for subregional training
centers.


6.  Promotion of research

The Program supports and provides
technical assistance for
epidemiological, operational, and
sociopsychiatric research in the
countries as a means of providing a
scientific foundation for the
programs, furthering their execution
and evaluation, and facilitating the
decision-making process.


      PREVENTION AND CONTROL
OF DRUG ABUSE

ANALYSIS OF THE SITUATION


The social and health problems
associated with the abuse of alcohol
and psychoactive substances are
becoming increasingly prevalent in
the Region.

Alcohol ranks first among abused
substances.  It has been estimated
that nearly 80% of the adult
population in the Region consumes
alcoholic beverages (5% are
considered true alcoholics and 10%,
heavy drinkers).

In 1990, marijuana was used by 0.9%
to 33% of the adolescent and adult
population in six countries of the
Region.

During the same period, cocaine use
in the same countries ranged from
0.2% to 8%, while inhalants were
used by 1% to 10% of the populations
studied.

The abuse of psychotropic substances
in some Latin American countries is
particularly significant among
adults and adolescents.  It is
estimated that it affects between 4%
and 9% of the population.

Substance abuse leads to disease,
injury, and death, most notably
mortality from cirrhosis of the
liver, which exceeds 20 deaths per
100,000 in the countries where
alcohol consumption is heaviest.

A high proportion of traffic and
work-related injuries and deaths are
also attributable to the use of
drugs and alcohol. 

In addition, numerous assaults,
homicides, and suicides are strongly
linked to the use of these
substances.

Consumption of drugs and alcohol
leads to huge losses in production
and results in tremendous
expenditure on health services.

The consequences for the family and
the community are enormous,
especially in terms of
disorganization and violence within
the family and impaired child
development.

Society is undermined by the crime
associated with the use and
trafficking of mind-altering
substances.  The Regional response
to the problem has centered around
the implementation of control
measures (fiscal, legal, and police)
and the delivery of care. 

However, for the most part the
measures have not been sufficiently 
implemented, and prevention is still
in an incipient phase.



RESPONSES BY PAHO

PAHO's Governing Bodies have
mandated the development of care and
prevention programs through
resolutions of the XXI Pan American
Sanitary Conference and the XXXIII
Meeting of the Directing Council.

The Regional Program has focused its
efforts on the prevention of
behaviors that lead to substance
abuse. 

Through the mobilization of experts
and the promotion of technical
cooperation among countries, the
Organization fosters the development
of appropriate national responses.

PAHO coordinates its efforts with
other international agencies,
including the United Nations, the
OAS, and the IDB in channeling
resources and technical assistance
to the countries.



OBJECTIVES OF THE PROGRAM

To promote the development of
policies, plans, and programs aimed
at reducing the use of psychoactive
substances and mitigating the
aftereffects of such use. 

To advise the countries on the
establishment of epidemiological
surveillance and the design and
development of research on substance
abuse and its consequences. 

To reduce the demand for drugs and
alcohol through programs to promote
healthy lifestyles.

To provide appropriate assistance to
persons affected by substance abuse.STRATEGIES AND PRIORITIES

To promote health sector leadership
in the definition of policies and
programs and in the search for
concerted solutions with other
sectors that are concerned with the
problem. 

Mobilization and coordination of
organized community groups in
efforts to heighten awareness, as
well as in the design of prevention
and control activities.

Analysis of the situation through
methodologies that are suitable,
practical, low-cost, and easily
applied.

Promotion of technical cooperation
among countries, multicenter
research, and the use of centers of
recognized expertise in the area.


LINES OF ACTION

Mobilization of Resources

The Program advocates the provision
of assistance to the countries using
both national and international
sources of technical and financial
support.

It identifies outstanding centers
and promotes technical cooperation
among countries.

Dissemination of Information

Collection, dissemination, and
distribution of technical
information.

Use of mass media to educate the
population and heighten public
awareness of the problem.

Development of participatory
methodology in programs for
preventive education.

Training 

Organization of courses, seminars,
and workshops on prevention and
care.

Production of teaching materials
tailored to national needs.

Adaptation of curricula on drug
addiction for use in centers that
provide instruction in the area of
health.

Direct technical cooperation

The program advises the countries on
the negotiation of external
assistance and promotes national
responses through coordination
between sectors.

It also provides advisory assistance
in the design, implementation, and
evaluation of programs.

Promotion of research

Advisory assistance in the design
and implementation of
epidemiological surveillance
systems. 

Development of projects to identify
risk factors and behaviors that are
associated with addiction. 

Support for operations research in
this area.