Consolidating Achievements

The countries of the Americas have much to celebrate with respect to health advances during the first decade of the 2000s. The Region has achieved meaningful gains in life expectancy, social protection in health, reorganization of health systems, and the treatment, control, or elimination of many infectious diseases (see Chapter I)¹. Contributing to these advances was a less tangible but equally important accomplishment: the consolidation of health as a basic human right onthe political agendas of nearly every country, including incorporation of this right into many national legal frameworks. Even on the Region’s most historically intractable problem—inequity—there was progress during the decade, although this area is where the greatest challenges remain. This chapter discusses what is needed to consolidate and sustain these achievements, examines key health goals that have not been fully met, and points to some of the major emerging challenges the Region faces in the near term.

As noted in Chapter I, public health spending in the Americas grew during most of the first decade of the 2000s, although it did not reach the levels generally considered necessary to achieve universal health coverage. A major challenge will be to ensure the sustainability of expanded social protection in health by increasing health and social budgets sufficiently or developing innovative new financing mechanisms, or both. The process of defining new financing mechanisms should recognize that universal coverage cannot be achieved if all coverage is linked to formal employment, and that coverage for a segment of the population will need to be subsidized. It is also important that new mechanisms contribute to reducing the segmentation (and resulting inequities) of health systems, for example, by incorporating additional groups into existing systems of health care rather than relegating them to separate and often lower-quality care or reduced coverage packages. Countries that have achieved unified national health systems can offer valuable lessons in this regard.

Ongoing PAHO/WHO technical cooperation to support expanded health coverage focuses on policies and mechanisms for financing social protection and health systems as well as studies on the evolution of health system inequalities, including analyses of the progressivity of health financing and of impoverishment resulting from catastrophic out-of-pocket expenditures.

Continued progress in reforming and reorganizing health systems based on primary health care (PHC) is also critical to the sustainability of expanded health protection. Efforts in this area have advanced more in some countries than in others, but PHC strategies have proven their worth in making systems more efficient while improving the delivery of care.

A key component of the PHC strategy, essential to both sustainability and quality of health systems, is the implementation, strengthening, and expansion of integrated health services delivery networks (IHSDN). For countries that have begun implementing IHSDN, further progress will require the progressive integration of different providers as well as the collaborative participation of health authorities at the national, provincial, and local levels. In implementing IHSDN, it is important also to overcome what are often excessively hierarchical relations among different categories of health professionals, promoting instead collaborative teamwork and mutual respect.

Many countries still have shortages of health workers, and a number of Caribbean countries, in particular, continue to experience significant emigration of nurses. But many more countries have skewed distribution of health personnel of different skills sets and levels of specialization. Throughout the Region, urban areas continue to have higher rates of health personnel per population than rural and remote ones. Health systems based on PHC require adequate numbers and distribution of physicians, dentists, psychologists, nursing staff, and others. Appropriate training and educational opportunities, more rational distribution, effective incentive structures, and favorable working conditions—including measures to protect health workers from occupational hazards—are needed for health personnel at all levels to ensure that reorganized health systems meet the heterogeneous needs of different economic, social, cultural, and geographical groups. This also implies increased collaboration and coordination between the health, education, and labor sectors.

Sustaining gains in health systems also requires adequate professional capacity and retention in public health management and leadership positions. For this reason, ensuring the availability, attractiveness, and stability of a public health career track should be a key goal of human resources strategies. This includes providing avenues for professionals to acquire competencies in specific fields related to the PAHO/WHO-recommended essential public health functions² of national health authorities. In recent years, country-to-country cooperation and networking—for example, through the Pan American Network for Drug Regulatory Harmonization (PANDRH)—have been effective ways of supplementing training and education programs that are available within countries. It is also essential to have public health professionals who can advocate for the health sector and collaborate in the development of legislation, for example, to build legal frameworks to consolidate national health systems and strengthen national health authorities.

Other areas of health systems that require continued strengthening include blood and radiological safety, patient safety and patient-provider relations, evaluation and implementation of medical infrastructure and technologies, quality control and enhancement, oral and ocular health services, health information systems, health services accreditation systems, and hospitals safe in disasters.

As noted in Chapter I, the Region of the Americas has been a leader in the control and elimination of vaccine-preventable diseases. It was the first WHO region to eradicate smallpox and polio, has since eliminated endemic transmission of measles and rubella, and has reduced neonatal tetanus such that it is no longer a public health problem in any country except Haiti.

Maintaining these impressive achievements will require sustaining the Region’s high levels of immunization coverage as well as continued surveillance of vaccine-preventable diseases and monitoring of coverage rates. Countries must remain vigilant given the ongoing risk of imported measles cases and must bridge the coverage gaps that continue to exist in hard-to-reach and vulnerable communities. Vaccination Week in the Americas is an important initiative for addressing this latter problem. At the national level, countries must continue building public support and consolidating political commitment to ensure sustainable financing for their expanded immunization programs.

Though the Region as a whole has been a leader among developing regions in adopting new vaccines, a number of countries have not yet introduced important new vaccines such as pneumococcal and HPV. Taking advantage of the technical cooperation and joint procurement services of the PAHO/WHO Revolving Fund and the ProVac initiative can help countries make sound, evidence-based decisions about new vaccines as well as the wider use of underutilized vaccines, particularly for influenza. It is also important that countries with the capacity to produce vaccines engage in technology transfer to those with unrealized potential in this area.

Other challenges for consolidating immunization achievements include, for some countries, strengthening the cold chain, fully implementing nominal immunization registries, and certifying the elimination of measles and rubella. Surveillance for events supposedly attributable to vaccination or immunization (ESAVI) also needs to be strengthened.

Another area in which Latin America and the Caribbean have led the developing world is expanding access to antiretroviral treatment (ART) for people with HIV. As of 2010, 63 percent of those needing ART—521,000 people—were receiving it in the two subregions combined. Coupled with a decline in new infections, expanding ART coverage contributed to a declining number of HIV deaths in Latin America and the Caribbean between 2000 and 2010. Nevertheless, more than one in three people who need ART went without it, and in some countries the treatment gap remains much larger. This is despite policies in all the countries that support free access to ART as a basic human right.

Overcoming these treatment gaps will require improvements in early diagnosis, referrals, and monitoring of HIV patients, as well as more efficiency in the procurement and use of ART. PAHO’s 2012 report Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean recommends that countries reduce the number of ART regimens to only those with the highest effectiveness; phase out obsolete, and especially toxic, drugs; increase their use of international procurement mechanisms such as the PAHO Strategic Fund; adopt new service delivery models based on strategic information and patient-centered care; expand and ensure early diagnosis of HIV infection; and strengthen monitoring of patient viral loads and CD4, among other measures.

Other challenges for the response to HIV include mobilizing national resources to reduce dependency on external financing for ART, accelerating innovation-transfer programs, ensuring the appropriate use of rapid tests and simplified diagnostic algorithms, implementing adherence-support measures, and using web-based monitoring platforms for strategic commodities and drugs.

A larger challenge still facing many countries is to fully integrate HIV prevention into sexual and reproductive health strategies and primary health care, with special attention to the most vulnerable groups. This includes HIV testing of pregnant women, provision of ART to mothers and infants, and early diagnosis of exposed infants, in line with the Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis. Integrating HIV into primary health care and other programmatic areas can have the added benefit of reducing stigma and discrimination as well as addressing dependence on external funding for activities related to HIV. Better coordination of tuberculosis and HIV care is also needed to address the problem of HIV/TB coinfections.

Addressing the Unfinished Agenda

As noted in Chapter I, the Region’s impressive health gains over the past decade have not benefitted all countries or population groups equally. Significant disparities exist across and within countries on such basic indicators as life expectancy, maternal and child mortality, malnutrition, access to clean water and sanitation, and access to health services.³ Reducing these inequities has been and remains the Americas’ greatest public health challenge.

Nowhere are these disparities more apparent than in maternal mortality, one of the MDGs the Region is not currently on track to meet. Disparities in access to comprehensive, quality sexual and reproductive health services—including skilled care at birth and contraception—are major reasons for the Region’s failure to make sufficient progress toward MDG-5.⁴

At the regional level, efforts are under way to accelerate progress in reducing maternal and infant mortality. These include the Regional Task Force for the Reduction of Maternal Mortality (GTR), the Newborn Health Alliance for Latin America and the Caribbean, the Safe Motherhood Initiative, and PAHO regional strategies on maternal mortality and morbidity (CSP26.R13 [2002]) and neonatal health (CD48.R4 [2008]). These initiatives and PAHO/WHO’s technical cooperation in this area emphasize evidence-based interventions within a continuum of maternal, newborn, and child care and with special attention to vulnerable women such as indigenous women, adolescents, and women in poor communities.

At the country level, important areas that need to be reinforced include basic obstetric care and referral systems for women in remote areas, early detection and management of obstetric complications in hospitals, perinatal information systems, and maternal mortality surveillance based on case-finding of deaths among women of childbearing age.

Comprehensive sexual and reproductive health services must include prevention, treatment, care, and support services for HIV and other sexually transmitted infections as well as access to contraception and sex education—including family counseling services and parent education programs—to prevent adolescent and unwanted pregnancies that contribute to high fertility rates and put women at unnecessary risk. In many countries, contraception and sex education that could help protect the health and lives of adolescents of both sexes are opposed by vocal segments of society. Overcoming the barriers to full exercise of women’s sexual and reproductive rights (including the rights of pregnant and nursing women in the workplace) is a major item on the unfinished agenda and requires legal protections as well as individual empowerment and education, and awareness raising in families, communities, and the health sector itself.

A related challenge is the broader incorporation of gender, ethnicity, and human rights approaches into the health sector. A gender perspective is crucial not only for women’s health equality but also for men’s health and well-being. Men and women have different health needs and profiles that must be taken into account for health policies and interventions to be effective. A key area of gender and ethnicity mainstreaming is collecting disaggregated data to facilitate reporting and analysis of health outcomes and trends that are different for men and women and for members of ethnic groups.

In general, addressing these and other social determinants requires strengthening health information systems at both the national and subnational levels to produce quality, timely, and disaggregated data that can be analyzed, reported, and used to develop policies, strategies, and plans that contribute to reducing health inequities. PAHO/WHO is supporting capacity building in these areas while working to ensure these principles are fully incorporated into its own work.

As with gender and ethnicity mainstreaming, a great deal remains to be done in the Region in the area of health and human rights. Though the principle of health as a basic right is accepted in the vast majority of the Region’s countries and has been enshrined in several countries’ constitutions, generally speaking, legislation, policies, and plans related to health do not incorporate basic human rights principles, such as the right to freedom from discrimination or the right to privacy and informed consent. There is also an urgent need to raise awareness of the human rights of groups in situations of vulnerability, including women, children, adolescents, individuals of divergent sexual or gender orientation (LGTBI persons), people with HIV, older adults, and people with disabilities, among others. Discrimination against members of vulnerable groups is high in the Region, is closely linked to violence, and has serious repercussions on both physical and mental health. Better mechanisms are needed for monitoring, identifying, investigating, prosecuting, and penalizing violations of human rights in vulnerable groups, particularly in health services. There is also great need to strengthen the capacity of magistrates, public health personnel, prison staff, congressional delegates, police officers, and union members to deal effectively with human rights issues among these groups. In addition, training is needed on the American Convention on Human Rights, the Convention on the Rights of the Child (CRC), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). Finally, mechanisms are needed to monitor compliance with these and other human rights instruments in health services, prisons, and long-term care facilities for older persons, among other institutions.

Violence against women and children continues to be a major public health problem in the Region, with serious consequences for health, well-being, and behavior throughout the life cycle. Some progress has been made in improving the response to this violence, for example, through legal reforms and improved services for survivors. However, less has been accomplished in the area of prevention, despite an emerging body of evidence on effective approaches. PAHO/WHO technical cooperation in this area includes online training and capacity building seminars on primary prevention of violence against women and children, as well as the development of policy and clinical guidelines for the health sector response.

Mental health also remains a pressing issue on the Region’s unfinished agenda. Mental and neurological disorders represent some 21% of the total burden of disease in Latin America and the Caribbean, yet the resources available to address this burden are insufficient, inequitably distributed, and at times inefficiently used. The estimated proportion of people with mental disorders who need care and do not receive treatment (the treatment gap) is about 65%. Continuing stigma, social exclusion, and human rights violations significantly compound human suffering from mental disorders. Priority areas for action are the elimination of involuntary institutionalization and reorienting mental health services toward community-based care that is integrated into primary health care.

Despite major reductions in the burden of infectious diseases in the Americas, these diseases continue to disproportionately affect poorer countries and population groups. This inequity is most evident in the so-called “neglected diseases” or “diseases of poverty,” which together account for a greater share of the total burden of disease in the Region than malaria or tuberculosis. Addressing these diseases requires improving prevention, diagnosis, and treatment in primary health care services in at-risk areas as well as better epidemiological surveillance and adequate supplies of the necessary medicines at the local level. PAHO/WHO has joined with the Global Network for Neglected Tropical Diseases and the IDB in an initiative to eliminate 10 neglected diseases by 2015 by supporting and promoting such measures in affected countries.

Malnutrition also remains a problem in poorer groups, particularly indigenous and remote rural communities where educational levels are low. Chronic malnutrition affects an estimated 9 million children in Latin America, with a significant impact on both physical and cognitive development. Addressing this issue requires better surveillance and monitoring of malnutrition in children under 5 as well as guaranteed access to micronutrients for pregnant women and indeed all women of childbearing age. Also needed are information and health education strategies to raise awareness of the risks of malnutrition. Promotion of breastfeeding also remains a key intervention for preventing malnutrition.

In addition to malnutrition, environmental health conditions in rural and peri-urban areas continue to be an important unmet challenge. Indoor air pollution from open cook stoves is a major contributor to respiratory diseases among the rural poor. As noted in Chapter I, the Region as a whole is on track to meet the MDG target for drinking water, but 38 million people still lack access to improved water sources, while 117 million lack access to basic sanitation. Continued population growth and unplanned urbanization complicate efforts to reduce these numbers. Needed interventions include programs for monitoring of water quality, capacity building at the local level in potable water and solid waste management, promotion of clean water as a basic human right, and the dissemination of appropriate and acceptable technologies for waste disposal.

Emerging Challenges

PAHO/WHO and a growing number of partners are working to address NCDs through a life course approach, with interventions starting before conception, continuing through infancy and early childhood into adolescence and young adulthood, through middle age and into old age. Also critical to addressing NCDs are multisectoral strategies and a heath-in-all-policies approach.

For health systems, coping with NCDs will require continued strengthening of primary health care models, including integrated health services delivery networks, and a strong focus on health promotion and prevention to eliminate or reduce risk factors. This includes promotion of breastfeeding and nutrition education and counseling. Continued expansion of health protection systems is also critical, particularly to cover the growing numbers of older persons but also to reduce the costs of NCDs by promoting early detection through routine care and screening.

Population-wide interventions are known to be the most cost-effective interventions for NCDs. These include measures called for by the Framework Convention on Tobacco Control (FCTC), which all but one of the Region’s countries have signed and most have ratified. The countries have made notable progress in areas such as tax and price increases on tobacco products, smoking bans in indoor public spaces, and packaging and warning labels. Fewer countries have implemented the treaty’s recommendations on advertising and sponsorship. Continued implementation of FCTC provisions should be a top priority and will require countering (and when possible, exposing) efforts by the tobacco industry to undermine tobacco control.

PAHO’s regional Plan of Action to Reduce the Harmful Use of Alcohol calls for measures similar to those in the FCTC as well as others to reduce consumption of alcohol, which is a leading risk factor not only for NCDs but for mental disorders, injuries, domestic and interpersonal violence, youth mortality, HIV, and STIs. Population-level interventions are also needed to reduce salt consumption (to prevent hypertension), reduce consumption of sugar-sweetened beverages, and encourage increased consumption of fruits and vegetables.

External causes also remain a significant contributor to mortality and disabilities in the Americas. More than 1 million people in the Region were victims of homicide over the past decade, with males at eight times higher risk than females, and 15- to 24-year-olds at greater risk than other age groups. Another 1 million died from traffic injuries, in part because of continuing rapid urbanization without the necessary infrastructure and policies for prevention. Suicide rates are also high in the Americas, accounting for some 12% of all deaths from external causes. A public health approach is essential to reducing deaths and injuries from all these causes.

While the burden of chronic noncommunicable diseases has risen precipitously, infectious diseases have by no means disappeared from the epidemiological landscape of the Americas. The 2009 H1N1 influenza pandemic, while much milder than many had feared the next flu pandemic might be, suggested how difficult it would be for most health systems to cope with a more virulent novel influenza strain, much less some new disease as virulent and contagious as was SARS. Investments in countries’ public health systems are an essential component of societal preparedness.

Continuing globalization and expanding international travel will only increase the likelihood of a future outbreak in one country becoming a threat to others. It will be critical for countries to continue strengthening their core capacities for epidemic alert and response, as they have been doing as part of PAHO-supported efforts to comply with the International Health Regulations (IHR).

While the number of older people is growing rapidly, the number of young people currently living in the Region is the highest in history. Protecting and promoting the health of children and youths must be a top priority to ensure they develop to their fullest potential, become and remain productive citizens, enjoy equal or higher quality of life than their parents, and avoid or delay illness and the need for long-term medical care.

The MDGs reflected the growing international consensus on the importance of health to development and human well-being. Health is likely to play a central role in the next generation of international development goals, the proposed Sustainable Development Goals (SDGs), as well. As was true with the MDGs, it will be critical for public health advocates to promote the new goals on countries’ national agendas, to help identify the most effective and efficient policies and interventions, and to mobilize new and existing constituencies to hold governments accountable for reaching the goals.

It is also imperative that policymakers, lawmakers, planners, and others in positions of responsibility recognize that the decisions and the investments they make today will affect the health and well-being of future generations, just as the decisions and investments over the past century made possible the remarkable public health achievements we celebrate today.

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