seases 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 da