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Noting the need to expand the availability of qualified HRH for the transformation of health systems in the Americas, in September 2018 the 56th PAHO Directing Council approved the Plan of Action for Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 (Document CD56/10, Rev. 1). The Plan of Action provides a comprehensive analysis of the health work force in the Americas, based on the Strategy on Human Resources for Universal Access to Health and Universal Health Coverage (Document CSP29/10) that was approved by the 29th Pan American Sanitary Conference in September 2017; extensive input from Member States; and three subregional consultations. It specifically notes the need to ensure that gender, ethnicity, migration, and human rights issues are considered in health workforce policies and plans.

One of the major challenges facing the Region of the Americas is the deployment of multidisciplinary teams at the first level of care to address the needs of vulnerable populations in underserved areas. Ten countries—Belize, Dominica, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, and Suriname—participated in a PASB-coordinated workshop held in Washington, D.C., in October 2018, on National Health Workforce Accounts (NHWAs) that was intended to improve management skills, data generation, and workforce planning. Subsequently, PASB organized intersectoral workshops for capacity-building in workforce planning in four countries—Belize, Guatemala, Paraguay, and Suriname—and worked with Belize to develop that country’s Strategic Plan on Human Resources for Universal Health 2019-2024. The Bureau also collaborated with Member States to advance health workforce planning based on scenario modeling and competencies, and rolled out an initiative on managing workforce data and integrating the NHWAs for policy development and planning based on the needs of the whole health system.

The Strategy on Human Resources for Universal Access to Health and Universal Health Coverage notes that within the Region, though education in the health sciences has grown exponentially in the past few decades, there is insufficient regulation of related processes, with resulting concerns about the quality of training, the relevance of many academic programs, and professional practice. However, an increasing number of training institutions are redefining their social responsibilities and commitment to the communities they serve by developing professional profiles consistent with the health needs of the population and demonstrating their social accountability. In late 2018, the Bureau finalized a new Indicators for Social Accountability Tool (ISAT) that can be used to monitor the advancement of a social mission in professional education for health. In March 2019, PASB participated in the 21st Pan American Conference on Medical Education in Cartagena, Colombia, and collaborated in the development of the Cartagena Declaration on Medical Education and Social Accountability, linking the challenges of medical education to the PHC strategy.

With PASB’s support, Argentina organized a regional meeting of the Regional Network for Interprofessional Education in the Americas (REIP) in 2018, where representatives from 15 countries[19] discussed implementation of the network’s guidelines and biennial work plan 2018-2019. The Regional Network was established with the support of the ministries of health of Argentina, Brazil, and Chile during a regional technical meeting on interprofessional education (IPE) held in Brasilia in December 2017, and has promoted several webinars and produced technical documents to help countries to develop their own IPE plans. As of mid-2019, 19 countries[20] had plans to implement strategies for IPE and collaborative practice in health.

In order to address and improve the skills mix within health systems, PASB launched an Advanced Nurse Practice initiative as part of interprofessional education and collaborative practice in six countries: Brazil, Colombia, Chile, Mexico, Peru, and Uruguay. The Bureau also developed the document Strategic Directions for Nursing in the Region of the Americas, which was launched on International Nurses’ Day in May 2019.

The mobility of HRH continues in the Region, from rural to urban areas and from less well-resourced countries to better-resourced ones. PASB worked with 12 countries[21] adversely affected by health workforce mobility to develop strategies to improve planning and forecasting related to HRH, and retention of the existing work force. As part of this process, and in order to achieve the goals established in the Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023, the Bureau supported the development of advanced intersectoral strategic health workforce plans in five countries: Belize, Costa Rica, Guatemala, Paraguay, and Suriname.

In the Caribbean subregion, the Bureau cooperated with the Caribbean Regional Nursing Body in the finalization of the Regional Strategic Plan for Nursing and Midwifery 2020-2024 and finalized a study on migration of the health work force in the Caribbean. Twenty-six countries and territories[22] participated in the study, the preliminary findings of which were presented to the Caucus of CARICOM Ministers of Health in September 2018, prior to 56th Directing Council of PAHO. The results showed that almost 60 percent of the health professionals who are still residing in their home countries and who participated in the study stated that they would migrate if given the opportunity. The number of places available in nursing schools in the Caribbean subregion is estimated to be sufficient to meet the needs of the subregion, but shortages of nurses result from an attrition rate of 55 percent during training and the migration to other countries of 73 percent of those who graduate. These findings highlight challenges that Caribbean countries face with health workforce education and retention, especially regarding specialized nursing; health workforce planning; and regulation of migration. PASB worked with countries in the subregion to address these issues, supporting the development and implementation of integrated HRH plans, with notable progress made in Antigua and Barbuda, Dominica, Saint Kitts and Nevis, and Saint Vincent and the Grenadines.

In January 2019, PASB collaborated with the High Council of Central American Universities (CSUCA) and SE-COMISCA, the Executive Secretary of the Council of Ministers of Health of Central America and the Dominican Republic (COMISCA), to prepare a road map for the accreditation of careers in health in Central America and the Dominican Republic, with a focus on family and community health programs. SE-COMISCA and the General Secretariat of CSUCA also signed a memorandum of understanding that included the development and professional training of HRH in the Central American subregion, and identified strategic lines of action. The latter include adaptation to health sector programs of the qualifications framework for higher education; identification of the criteria and process for accreditation of professional and technical careers in health; harmonization of subregional health curricula; and mobility of health professionals in Central America and the Dominican Republic. By April 2019, this subregional initiative resulted in a mapping of family and community health training programs in eight countries—Belize, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—and defined a pool of competencies for the first level of care and family health physicians. A proposal for the phased implementation of a health career pathway was completed and validated by the countries.

Also in Central America, work began on a multicentric study of factors that influence career choices at the first level of care among social service physicians. The sample includes 2,545 interns and social service physicians from more than 25 schools of medicine in Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua.

In the South American subregion, PASB’s technical cooperation provided opportunities for South-South cooperation and exchange of experiences to facilitate implementation of the regional Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023. These opportunities included:

The Virtual Campus for Public Health continued its functions as a valued resource for learning. A total of 40 countries and territories[23] participated in continuing education strategies and programs for health personnel through the VCPH or equivalent e-learning networks, and as of December 2018, the VCPH had reached 550,000 users.

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SHAA 2030 Goal 4: Health financing

Within a macroeconomic context that is limiting the availability of financial resources for health systems and services in many countries, especially in small island developing States (SIDS), there has been renewed focus on examining financing strategies, fiscal space for health, and opportunities for efficiency gains within health systems and services. Only four countries—Canada, Cuba, United States of America, and Uruguay—have reached and maintained the goal of 6 percent of GDP dedicated to heath financing, the level generally considered necessary to achieve universal health.

Average out-of-pocket spending on health remains high in the Region, constituting nearly one-third of total expenditure on health. Most Member States do not have coverage schemes to provide all essential medicines without direct payment at the point of service, and out-of-pocket payments for medicines and health technologies range from 30 to 70 percent of overall out-of-pocket spending for health. This is the second-largest item—after human resources—in public health budgets, and constitutes a major barrier to access to needed health services for a significant portion of the population, with many families facing an ongoing risk of falling into poverty as result of catastrophic health expenses.

Several countries, including Anguilla, Antigua and Barbuda, Bahamas, Grenada, and Jamaica, began discussing health financing reforms, including the option of implementing national health insurance (NHI) programs. By mid-2019, Anguilla had completed draft NHI legislation; Antigua and Barbuda developed its System of Health Accounts, supported by collaboration between the Bureau and the Health Economics Unit (HEU) at the University of the West Indies (UWI) St. Augustine Campus in Trinidad and Tobago; Grenada had reviewed its package of benefits, as well as funding sources and the governance framework for the NHI; and Saint Kitts and Nevis had initiated an actuarial assessment of its NHI package of benefits.

PASB coordinated a Caribbean Subregional Dialogue on Health Financing, held in Barbados in August 2018, in support of CARICOM Member States’ commitment to advance to UH. The Subregional Dialogue brought together high-level government officials from CARICOM countries, representatives from the main Caribbean subregional institutions, and international experts to discuss challenges in financing health services in the Caribbean and identify opportunities for strengthening subregional collaboration on the issue. PASB’s technical cooperation on payment systems for IHSDNs continued, with the goal of reducing fragmentation by implementing financing mechanisms to promote IHSDNs based on the PHC strategy.

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Member States continued to make important advances in building the capacity of regulatory systems and in developing medicines and health technologies as core strategies to increase access to medicines and technologies that meet international standards in quality, safety, and efficacy.

By mid-2019, the Caribbean Regulatory System (CRS), an innovative subregional regulatory body for the Caribbean managed by the Caribbean Public Health Agency (CARPHA) and established with PASB’s technical cooperation, had registered or tentatively registered
37 products, and was on pace to add 60 recommended medicines during 2019, almost twice the total recommended medicines in 2017 and 2018. The approved medicines included a cure for hepatitis C contained in the WHO Essential Medicines List, and a number of medications for NCDs. By June 2019, the CRS had received nearly 200 reports of adverse events and substandard and falsified medicines through VigiCarib, its pharmacovigilance and post-market surveillance program. Like the CRS itself, VigiCarib was developed on the premise that a regional approach would facilitate pooling of resources, sharing of information, coordination of activities, and efficiencies of scale in CARICOM Member States, and contribute to overall health system strengthening.

The CRS is increasingly recognized as an effective model for SIDS with limited human resources. In February 2019, PASB and CARICOM presented the CRS initiative to ministers of health of the Pacific Islands at a meeting convened by the WHO Regional Office for the Western Pacific (WPRO) in Fiji. Based on the CRS experience, the Pacific Islands decided to move forward with their own regional regulatory approach, looking to CARICOM as a leader in this area.

In August 2018, as part of efforts to strengthen the drug regulatory agencies in Central America and the Dominican Republic, a pilot project was initiated for the joint review of drug dossiers. The project brought together technical personnel from each country’s drug regulatory agency, with the goal of improving the registration process for new pharmaceutical products in the Central American subregion and creating synergies to increase access to safe and effective medications. The pilot project was supported by PASB, USAID, and the World Bank.

 PASB collaborated with WHO to produce the first Global Benchmarking Tool (GBT) to evaluate national drug regulatory capacity. GBT will allow countries around the world to identify strengths and gaps in their regulatory capacities and to prioritize critical areas for systematic and transparent institutional development. The GBT utilizes elements of PASB’s own regional tool, which has been applied to regulatory systems in the Americas over the past 10 years and which was improved through extensive consultations with drug regulatory authorities from around the world. In April 2019, a pilot application of the GBT was concluded in El Salvador, yielding results that will be used to validate the tool and methodology throughout the Region.

PASB organized the 9th Conference of the Pan American Network for Drug Regulatory Harmonization (PANDRH) in El Salvador in October 2018, with the theme of “Commemorating 20 years of PANDRH and 40 years of Alma-Ata: the contributions of regulatory harmonization to achieving Health for All.” Two hundred participants attended from various sectors and institutions, including WHO, PAHO, national regulatory authorities, the pharmaceutical industry, nongovernmental organizations (NGOs), and professional associations. PANDRH Member States adopted concept notes and recommendations on the current state of the regulation of advanced therapy medicinal products, regulatory reliance principles, and regulatory systems models for small states/markets with limited resources. The documents provide valuable guidance for countries in their efforts to strengthen pharmaceutical quality, safety, efficacy, and regulatory systems.

In a related effort, PASB organized a pricing network meeting for Member States that are part of the Health Technology Assessment Network of the Americas (RedETSA). Held in Buenos Aires in November 2018, the meeting focused on the role of health technology assessment in expanding effective and equitable access to medicines. PASB also developed a list of priority medical devices for the first level of care—the first such list—to guide countries in the rational selection and use of medical devices. The list comprises 257 medical devices identified through an evidence-based approach that was validated by Member States. The objectives are to increase the availability of these devices at the first level of care and ensure the responsiveness of the health centers within IHSDNs. The Bureau also proposed a new model for the assessment, selection, incorporation, prescription, dispensing, rational use, and monitoring of medicines and health technologies; the model is being piloted in Paraguay.

In order to contribute to improvements in quality and safety, PASB’s technical cooperation enabled assessments of radiotherapy services, which were completed in 17 countries[24] in 2018. In Belize, PASB partnered with the International Atomic Energy Agency (IAEA) for an assessment of radiology quality control standards and radiation safety risk, with a view to enhancing radiology services and radiation protection in the country.

The PAHO Strategic Fund supported negotiations—led by MERCOSUR—with manufacturers of HCV medicines that resulted in reductions of up to 40 percent in the cost of one of the critical antiviral medicines. The Strategic Fund also collaborated with MERCOSUR Member States on a negotiating strategy for 2019 to procure HCV and oncological medicines.

Maintaining and enhancing immunization

 Immunization remains a flagship program in the PHC strategy and is a driving force for UH. In 2018, regional vaccination coverage for the third dose of the diphtheria, tetanus, and pertussis (DPT) vaccine remained at 88 percent, and 22 countries and territories[25] increased their vaccination coverages from the 2017 levels.

 PASB’s technical cooperation during the review period sought to maintain quality immunization programs and included regional workshops on the rapid response to measles, rubella, or polio outbreaks; yellow fever; and timely and quality notification through the PAHO/WHO-UNICEF Joint Reporting Form. At subregional level, there was a training workshop for all managers of the Expanded Program on Immunization (EPI) in the Caribbean, and in-country activities took place in 22 countries and territories[26] to build national capacity in areas such as cold chain and effective vaccine management; data quality assessment; vaccination in large cities;
EPI planning and operation; and electronic immunization registries.

Four countries added new vaccines to their national immunization schedules during the reporting period: Guatemala introduced the HPV vaccine and Haiti introduced the pneumococcal vaccine in 2018, while Saint Lucia and the Turks and Caicos Islands introduced the HPV vaccine in 2019. A total of 40 countries and territories[27] in the Region are now using the HPV vaccine. Despite that progress with the HPV vaccine, in 2019, one of the two global suppliers announced its exit from the regional and global markets, leaving only one source of supply for the vaccine, at least until 2022. This market situation gives cause for concern regarding the supply and price of the vaccine. Vaccine hesitancy in relation to HPV vaccine also presents a challenge, with less than optimal uptake of the vaccine despite the increases noted. PASB will continue its close working relationships with countries to prevent HPV vaccine stockouts and to strengthen its evidence-based advocacy for increased uptake of the vaccine.

Evaluations were conducted of the British Virgin Islands immunization program, the National Immunization Technical Advisory Group in Chile (CAVEI), and the PAHO regional immunization program (RIP).

PASB mounted an extensive response in the field to outbreaks of vaccine-preventable diseases in the Region. This included technical cooperation with the Bolivarian Republic of Venezuela (hereafter, Venezuela) to develop a broad-reaching vaccination campaign that immunized close to 9 million children aged 1 to 4 years. PASB mobilized technical experts to assist the response to outbreaks, including measles in Argentina, Brazil, Colombia, Ecuador, Peru, and Venezuela; diphtheria in Haiti and Venezuela; and yellow fever in Brazil. The Bureau also worked with health authorities in all countries in LAC to enhance preparedness for potential outbreaks. In addition to ministries of health, partners in this work included the Global Initiative for the Elimination of Measles and Rubella, the U.S. CDC, and UNICEF. PASB mobilized approximately US$ 9 million[28] to support these activities.

PASB’s flagship Vaccination Week in the Americas (VWA) initiative celebrated its 17th anniversary in April 2019 under the theme of “Protect your community. Do your part.” During that celebration, 65 million people were vaccinated in 45 countries and territories. Given the resurgence of measles in the Region, VWA 2019 took on special urgency. For example, the U.S. CDC indicated that 981 individual cases of measles had occurred in 26 states over the period 1 January to 31 May 2019, the largest number of cases reported in the United States of America since 1992 and since measles was declared eliminated in 2000.[29] Other highlights of VWA 2019 included:

PASB negotiated and finalized an important agreement with the University of Texas Medical Branch for the administration of a patent that protects a breakthrough Zika vaccine. The Bureau also provided legal support to expand country participation in the PAHO Revolving Fund and the PAHO Strategic Fund, including ongoing negotiations with Mexico, certain provinces in Argentina, and several governmental entities in Colombia.

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In continued recognition of the ever-expanding need for and critical importance of timely, quality, updated health and health-related information, PASB maintained its technical cooperation to advance the IS4H framework. The framework was launched in 2016 to address the need for subnational data to monitor the health-related SDG targets and, more generally, to ensure that policy- and decisionmakers have the data they need to formulate health interventions that truly "leave no one behind."

During the reporting period, PASB collaborated with the CARICOM-supported IS4H Technical Working Group to produce a road map for improving the Caribbean subregion’s health information systems.[34] The road map was subsequently endorsed by CARICOM and the Council of Ministers of the Organization of Eastern Caribbean States (OECS).

Following a call for IS4H proposals,[35] PASB awarded grants to 36 grantees from 27 countries and territories[36] to implement projects in 2019 aimed at making information systems more interoperable and interconnected. The Latin American and Caribbean Network for the Strengthening of Health Information Systems (RELACSIS) leveraged its alliances and partners throughout the Americas to ensure that IS4H-related technical information and webinars were disseminated free of charge to network members and other audiences. This action provided Member States with a medium for sharing successful practices and receiving information on PASB-recommended methodologies, tools, policies, and strategies related to IS4H.

Within the same framework, PASB worked with 15 countries and territories[37] to apply the IS4H maturity assessment tool and formulate recommendations for improving their health information systems. PASB also collaborated with the Inter-American Development Bank (IDB) to use the IS4H maturity assessment tool to direct investments for information systems and digital health. Other partners in these efforts included USAID; GAC; the Italian Hospital of Buenos Aires, which is a WHO Collaborating Center; and academic partners, including the University of Illinois, the University of Utah, and Harvard University.

Vital registration data comprise important components of IS4H, but are often inaccurate and incomplete. During the period under review, the Bureau organized five regional trainings and three virtual courses for 500 coders working in vital registration in Latin American countries. The learning interventions included a November 2018 training for coders from 19 countries[38] to conduct intentional searches for maternal deaths among all sources of death registration within countries—that is, an audit of death certificates—in order to identify maternal deaths that were not originally included in the total count. The training used the methodology for the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) that was developed by Mexican Center for the Classification of Diseases (CEMECE), which is a WHO Collaborating Center for the Family of International Classifications.  

Two regional workshops—in August 2018 with 16 countries[39] and March 2019 with 12 countries[40]—trained professionals from ministries of health and national statistics offices in a methodology used by the UN Maternal Mortality Estimation Inter-agency Group (UN MMEIG)[41] to estimate maternal mortality and by the UN Inter-Agency Group for Child Mortality Estimates to measure stillbirths and child mortality. Following the training, PASB engaged national teams from targeted countries to identify strategies for strengthening the quality and coverage of data to better inform governments’ interventions and UN estimates.

Both the SHAA2030 and the 2030 Agenda for Sustainable Development call on Member States to monitor both national and subnational progress towards the respective goals and targets for improving the health and well-being of all populations. The global SDG mandate has presented significant challenges for PASB and the countries of the Americas, since the Bureau’s ongoing data collection through the Regional Core Health Data Initiative does not cover 10 of the 27 SDG 3 indicators, and many countries do not collect subnational data disaggregated by key sociodemographic stratifiers. Progress toward the SHAA2030 goals will be tracked primarily through the impact and outcome indicators of the proposed PAHO Strategic Plan 2020-2025, which were identified in consultation with the 21-member Strategic Plan Advisory

Group (SPAG)[42] and which will be presented for approval by the 57th Directing Council in September 2019.

The Health Information Platform for the Americas (PLISA) is the Organization’s repository for data collected on 170 core health indicators (365 when disaggregated); mortality data shared by Member States; and health issues ranging from antimicrobial resistance to immunizations. PLISA underwent improvements during the reporting period, allowing countries to exchange epidemiological data, leverage their analysis capabilities for dengue and Zika, and follow up on key indicators, including the case fatality rate for dengue. Ongoing efforts are focused on expanding PLISA’s capacity to include epidemiological information on chikungunya, leishmaniasis, malaria, and other vector-borne diseases.

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During the review period, PASB continued its technical cooperation to facilitate and enable evidence-based policy development, decision-making, and planning, spearheaded by the Latin America and Caribbean Center of Health Sciences (BIREME), a PAHO specialized center located in Brazil.

An additional 35,000 new documents were indexed into LILACS, PAHO’s bibliographic index of the Region’s scientific and technical health literature, and over 20,000 terms updated in English, French, Spanish, and Portuguese in DeCS, the Organization’s vocabulary for indexing scientific information. LILACS served as a cornerstone for two new virtual health libraries:

The International Database of GRADE[43] Guidelines (BIGG), a database of new evidence, was launched in 2018. BIGG gathers public health and practice evidence-informed guidelines produced by WHO, PAHO, government institutions, and national and international scientific associations in several countries that meet PAHO/WHO-recommended standards. BIGG was integrated into the PAHO VHL, with more than 600 indexed guidelines and links to the full text, offering high-quality, evidence-informed recommendations for public health and its practice. Also in 2018, a new interoperability framework was developed that facilitates the continuous updating of the Global Index Medicus (GIM) with technical and scientific literature from across WHO regions; the GIM portal is expected to be revamped in late 2019.

The Repository of Legislation on Risk Factors in NCDs was launched in August 2018. The Repository provides access to the legal frameworks that countries have developed to combat chronic diseases. It has demonstrated benefits in systematizing the organization and monitoring of and access to NCD-related legislation in Member States. It aims to strengthen stewardship and governance in advancing to UH, and also provides a model for collating health legislation.

Within the framework of the regional program for research in tropical diseases/PAHO Small Grants Program,[44] the Bureau strengthened countries’ capacity to conduct implementation research. In the reporting period, five implementation research projects were approved and funded for tuberculosis, malaria, and leishmaniasis. The Bureau also implemented the TDR Structured Operational Research and Training Initiative (SORT IT), which aims to improve the capacity of national public health workers in protocol design and writing, data analysis, scientific writing, and results dissemination. During the reporting period, training was conducted for public health workers in Ecuador, Paraguay, and Uruguay through integrated operational research and capacity-building related to disease-specific programs and health systems.

Starting in mid-2018, PASB, in collaboration with Mexico’s CEMECE, UNICEF, UN MMEIG, USAID, and Argentina’s Ministry of Health:

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Advances continued in the institutionalization of disaster management programs. As of the end of 2018, 26 countries and territories[46] had a formal health disaster management program;29[47] had a health emergency response plan; 23[48] had health emergency response teams in place; 27[49] had health emergency operations centers; and 30[50] had a national emergency coordination committee within the ministry of health. However, despite notable progress, gaps still remain. For example, of the 26 countries and territories with formally established disaster programs, only 20[51] have programs that are staffed full-time and have a dedicated budget.

Over the period under review, PASB continued—and enhanced, where needed—its technical cooperation with countries facing disasters due to natural hazards or other emergencies, including issues related to mass migration, climate change, and disease outbreaks. These responses covered immediate and ongoing situations, post-event and recovery phases, and climate change adaptation. The responses involved collaboration with national health and other authorities, and regional and international partners, to identify and fill gaps, and build national and subnational capacities to mitigate and respond to various scenarios.

PASB’s work to improve Member States’ resilience to emergencies and disasters was undertaken in collaboration with key partners, including the Spanish Agency for International Development Cooperation (AECID); U.S. CDC; USAID’s Office of U.S. Foreign Disaster Assistance (USAID/OFDA); U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response (HHS/ASPR); United Kingdom Department for International Development (DFID); European Union (EU) European Civil Protection and Humanitarian Aid Operations (ECHO); UN Central Emergency Response Fund (CERF); WHO Contingency Fund for Emergencies (CFE); and the Governments of Macau, New Zealand, and Switzerland.

Strengthening capacity for decision-making during emergencies in Chile, Dominican Republic, and Haiti

PASB, in coordination with the ministries of health and the national health services in Chile, Dominican Republic, and Haiti, and with support from partners, organized workshops on coordination and decision-making mechanisms for health emergency response operations.

These workshops, conducted within the framework of the IHR, aimed to strengthen the capacity of technical personnel to make decisions during health emergencies and to develop, update, and disseminate the standard operating procedures. This would enable a timely, coordinated, and comprehensive health response in which all components of the health sector are represented within a multi-risk response plan.

Representatives from the Member States noted the impact of climate change on the occurrence of disasters and stressed the relevance of the workshops in helping countries in the Americas to respond appropriately and reduce the impacts of emergencies and disasters. The importance of physical or virtual health emergency operating centers in bringing together political and technical aspects, and contributing to timely execution of emergency plans, was underscored.

Mass migration and growing public health needs in Venezuela and neighboring countries

Between 2015 and 2018, over 3 million Venezuelans migrated to other countries in the Region and beyond, due to the ongoing political and socioeconomic situation in the country. The crisis has severely impacted Venezuela’s health system capacity, resulting in shortages of health workers, medicines, and health commodities and supplies, as well as inadequate maintenance of critical health equipment and essential services such as water, electricity, medical gases, food provision, and waste disposal. These developments have put at risk or reversed health gains, and the interruption of epidemiologic surveillance systems and weakening of immunization programs have caused a reemergence of diseases that were previously eliminated, such as measles and diphtheria, or controlled, such as malaria. Neighboring countries—Brazil, Colombia, Ecuador, and Peru—continue to receive large numbers of Venezuelan migrants and serve as the first stop for those in transit to other locations in the Americas. This migratory flow constitutes a risk for the spread of communicable diseases across the Region of the Americas.

PASB has been scaling up its technical cooperation to strengthen health service networks in Venezuela and neighboring countries to deal with active disease outbreaks and growing health needs. During the review period, the Bureau collaborated with national authorities and external partners to develop the Master Plan for HIV, Tuberculosis and Malaria Control in Venezuela, and hosted a meeting of partners and stakeholders to present and discuss the Master Plan. The Master Plan attracted funds totaling
$5 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) for the purchase of ART through the PAHO Strategic Fund.

The Bureau mobilized over $20 million from the international community to support the adaptive capacity of national and local health systems, and collaborated with national authorities and other health partners to support local health services and provide essential health care to the most vulnerable groups, among both migrants and the host population. In Colombia, Ecuador, and Peru, efforts focused on improving access to and capacity for delivery of essential health services, and on strengthening national and decentralized health surveillance, information management, and monitoring systems for outbreak detection and control.

In Venezuela, PASB increased short-term, high-impact interventions to strengthen institutional and community capacity for outbreak surveillance and control; for clinical management of cases related to high-impact, high-consequence pathogens; and for preparation for emerging health threats. In 2018, through funding from strategic partners and its own resources, PASB procured 82 tons of essential medicines and medical supplies for prioritized health facilities, main health programs, and strategic NGO partners. In the first three months of 2019, the Bureau procured an additional 80 tons of medicines and supplies, including products for the management of complicated malaria, measles, and diphtheria; reproductive health emergencies; and NCDs.

The Bureau provided technical cooperation and logistical support for the implementation of a national measles and diphtheria vaccination campaign that reached nearly 9 million children. PASB assisted with direct procurement of 9 million doses of measles-rubella vaccine and 1.5 million doses of tetanus-diphtheria (Td) vaccine, as well as syringes and safety boxes; recruitment of eight international experts and 30 national professionals; provision of transportation for field operations, including in the remote areas of the states of Amazonas and Delta Amacuro; and training of vaccinators and health professionals. PASB also established the Incident Management System (IMS) in May 2018, deploying over 60 professionals from PAHO Headquarters and country offices to collaborate in technical, administrative, and logistics management.

In partnership with MERCOSUR, the MERCOSUR Social Institute, the Amazon Cooperation Treaty Organization (ACTO), and ORAS, PASB supported the work of border health technical working groups that, among other issues, addressed the health challenges associated with mass migration in the South American Chaco, the Andean altiplano, and the Amazon Basin.

Technical cooperation has increased considerably in Venezuela and neighboring countries to address the critical needs linked to the prolonged and complex mass migratory phenomenon. However, important gaps remain in ensuring continued availability of and nondiscriminatory access to critical health services for the most vulnerable groups.

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Emergency Medical Teams

The Emergency Medical Team (EMT) initiative aims to enhance emergency preparedness and support the rapid and efficient deployment of national and international medical teams to provide coordinated, quality clinical care, in order to significantly reduce loss of life and prevent long-term disability from disasters due to natural hazards, outbreaks, and other emergencies. The EMT initiative focuses on capacity strengthening and response at local and national levels, supports national health authorities in their leadership role, and leverages countries’ national capacities to support each other.

The majority of the work by PASB with EMTs, to date, has been on the introduction of the EMT initiative to countries and territories in the Region; the development of operational tools and Medical Information and Coordination Cells (CICOMs), which are designed to facilitate handling of information and coordination of EMTs during emergencies and disasters; and the strengthening of the logistical and operational capacities of EMTs. The Bureau’s work with Member States has involved the identification, registry, mentoring, strengthening, and classification of local and national EMTs, and the adoption of the initiative’s global standards. The initiative also includes over 30 NGOs from LAC involved in humanitarian health assistance, and facilitates sharing and analysis of good practices, technical concepts, and operational issues in EMT development and response, for continuous improvement.

As of December 2018, 39 countries and territories[52] have officially introduced the EMT initiative at national level and are actively being supported by PASB to build national and local capacity in the area of health emergency management and create their own national EMTs. More than 500 health emergency management personnel from the countries have been sensitized and trained in EMT coordination mechanisms, and five regional courses for EMT coordinators have been held in Panama (2015), Costa Rica (2016), Chile (2017), United States of America (2018), and Barbados (2019). These interventions contributed to the establishment of a regional roster of 112 trained EMT coordinators from 35 countries and territories,[53] ready for deployment nationally, regionally, and globally to support the coordination of emergency medical assistance.

During the reporting period, 23 Member States[54] officially designated national EMT focal points to represent their countries in the Regional EMT Group. Three national institutions or organizations have had their EMTs verified as international teams by WHO: U.S. Team Rubicon, the Ministry of Health of Ecuador, and the Costa Rican Social Security Fund. Additionally, 30 teams are currently enrolled in a mentoring process to achieve the WHO international classification. Also, five countries—Chile, Colombia, Costa Rica, Ecuador, and Peru—are actively implementing national procedures to request and deploy EMTs, and they are pursuing implementation of CICOMs, with PASB’s technical cooperation.

The Bureau worked with the Barbados Defense Force and the Regional Security System (RSS) in the Caribbean to complete training for and procurement of the field hospital that will be used by the Eastern Caribbean response teams. The hospital setup will be certified as EMT Level 1 by WHO in July 2019, and work was initiated to strengthen the hospital to reach EMT Level 2 status by 2020, with support from the Government of the United States and the Government of China.

Strengthening IHR core capacities

The IHR provide the overarching framework for Member States to collaborate in addressing global health security. The legally binding regulations require States Parties to notify the WHO IHR focal point—hosted by the PASB for the Region of the Americas—of events, irrespective of origin or sources, that may have international public health implications. Such events may eventually be determined to constitute public health emergencies of international concern, based on defined criteria. Strengthening countries’ core capacities to implement the IHR remains an important priority for PASB’s technical cooperation, and work under the IHR umbrella during the reporting period was executed with support from U.S. CDC, GAC, and Brazil’s national voluntary contributions.

Epidemic intelligence (EI) is the cycle of organized and systematic collection, analysis, and interpretation of information from all sources in order to detect, verify, and investigate potential health risks. The activities captured throughout this cycle are core functions under the IHR. EI requires an efficient global early warning system and network that publishes risk assessments from all events that may have public health implications in the IHR National Focal Point Event Information Site within 48 hours of the completion of the assessment.

A critical aspect of the fulfillment of the IHR is the capacity of countries to communicate efficiently and accurately, both internally and externally, on events that may constitute a public health emergency of international concern, on a 24-hour basis. Between 1 July 2018 and 17 May 2019, 117 events that occurred in the Americas were registered in the internal WHO Event Management System: 10 required documentation with rapid risk assessment; information regarding 8 events was disseminated through the secure WHO Event Information Site for National IHR Focal Points; and information regarding 3 events was published on the public WHO Disease Outbreak News web page.

Consequent on its risk assessment and analysis functions, PASB issued a total of 28 Epidemiological Alerts and Updates between 1 July 2018 and 17 May 2019, mainly related to vaccine-preventable diseases. The Epidemiological Alerts and Updates included recommendations to address the events, and were the only publicly available authoritative source of updated information related to events in Venezuela.

The period covered by this report coincided with the introduction of a revised IHR reporting tool.[55] The tool, which includes changes in the delineation of essential public health functions related to the IHR core capacities, facilitates the mandatory submission of States Parties’ Annual Reports to the World Health Assembly, pursuant to Article 54 of the IHR. Thirty-three (94 percent) of the 35 States Parties in the Americas submitted Annual Reports to the 72nd World Health Assembly in May 2019. Thirty-one of the States Parties submitting Annual Reports for 2018[56] had their data analyzed: 17 (55 percent) indicated that they had tested, reviewed, and updated at least one of the instruments constituting their national health emergency framework; 11 of 31[57] (35 percent) indicated that budgets were distributed in a timely manner and executed in a coordinated fashion; and 19 of 31 [58] (61 percent) indicated that an emergency public financing mechanism was in place across relevant sectors, allowing structured reception and rapid distribution of funds for responding to public health emergencies. 

The average scores for the Region of the Americas were close to or above 60 percent, and the scores related to 12 of the 13 IHR core capacities[59] were above the global average, with the health service provision core capacity being the exception. The highest average regional score, 92 percent, continued to be for events associated with zoonotic hazards, while the core capacities on human resources and response to events associated with chemical hazards had the lowest scores: 65 percent and 63 percent, respectively. Nevertheless, the status of the core capacities among subregions in the Americas remained heterogeneous. The highest average subregional scores were consistently observed for North America, and the Caribbean subregion accounted for most of the core capacities with the lowest average scores, in the areas of legislation and financing; zoonotic events and the human-animal interface; surveillance; human resources; risk communication; points of entry; chemical events; and radiation emergencies.

The 2018 IHR Monitoring and Evaluation Framework (IHR MEF) includes one mandatory component, the State Party Annual Report, and three voluntary ones: After-Action Review of Public Health Events, Simulation Exercises, and Voluntary External Evaluations (VEE). During the reporting period, PASB worked with Grenada to host a VEE, based on the 2018 Joint External Evaluation (JEE) tool, and the Bureau is supporting Argentina, Dominican Republic, and Haiti in their preparations to host (or rehost, in the case of Haiti) VEEs during the second semester of 2019. Four States Parties included VEEs in their Biennial Work Plans 2018-2019, and four additional States Parties expressed their interest in hosting a VEE. PASB supported Simulation Exercises in Bolivia, Brazil, and Dominican Republic, and After-Action Reviews of Public Health Events in Brazil and Dominican Republic.

Strengthening infection prevention and control (IPC) is a core capacity under the IHR. During the reporting period, PASB provided training on IPC, outbreak investigation, and surveillance and containment of health care–associated infections (HAIs) in 30 countries and territories.[60] The Bureau continued to advocate for national prioritization of the IPC-HAI agenda, use of the WHO framework for implementation of IPC core components, and nomination of
IPC national focal points. Technical cooperation with specific countries included:

Influenza pandemic preparedness and response capacities were strengthened in 23 countries[61] through PASB’s technical cooperation. Outputs included assessment of national surveillance systems, enhanced utilization of data for evidenced-based policy-making, and assessment of the severity of seasonal influenza. Outcomes included not only an improvement in national capacities in influenza pandemic preparedness and response but also broadening of the regional network of professionals to support countries in the event of a pandemic. In addition, Argentina and Trinidad and Tobago received training in influenza laboratory quality management and biosafety; Bolivia and Dominican Republic strengthened their multisectoral rapid response teams; and Colombia, Dominican Republic, El Salvador, Haiti, Jamaica, Mexico, Paraguay, and Suriname had their capacity built for effective deployment of pandemic vaccines and supplies.

Cholera outbreak in Haiti

In 2018, 3,786 suspected cases of cholera were reported in Haiti, primarily in the departments of Artibonite and Centre, the lowest annual number since the start of the epidemic in 2010. In 2019, as of mid-April, 308 suspected cases were reported, with the last laboratory-confirmed case reported in early February 2019.

The steady reduction in reported cholera cases can be attributed to the concerted support provided by international partners. This includes the uninterrupted technical cooperation that PASB has undertaken with the Haitian Ministry of Public Health and Population (MSPP) and other national authorities, including the National Potable Water and Sanitation Agency (DINEPA), with support from CERF and the World Bank. The Bureau supported epidemiological surveillance, laboratory capacity, medical case management, and vaccination.

Since July 2018, the system of “labo-moto nurses”—a network of field nurses established in December 2017 to transport samples from acute diarrhea treatment centers (CDTAs)—has been functional in 6 of the 10 departments that reported nearly all suspected cases. Other initiatives included the provision of cholera sampling materials (Cary Blair) to CTDAs; training of CTDA health workers to collect samples from persons with cholera in compliance with biosecurity standards; and provision of laboratory test results to CTDAs. Between July 2018 and April 2019, the labo-moto nurses transported 1,556 cholera samples, supplied 2,041 Cary Blair to the CTDAs, and trained 1,299 CDTA health workers.

The initiatives contributed to a significant increase in nationwide reported cases from 2017, when less than 30 percent of suspected cholera cases were sampled. There was 80 percent sampling in 2018, and 97 percent in 2019 (as of mid-May); the increase in sampling and confirmation of suspected cases of cholera in this Key Country has led to a better understanding of cholera transmission and has informed decision-making to better orient the use of limited in-country resources.

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Yellow fever outbreak in Brazil

The most significant yellow fever (YF) outbreak in Brazil in recent history began in 2016, and, as of June 2019, 2,236 confirmed human cases, including 759 deaths and 2,542 epizootics, had been reported, primarily along the east coast and in the Southeast Region. Of these, 82 confirmed human cases and 48 epizootics were reported between 1 January and 9 June 2019. As of mid-2019, PASB continued to work under an “alert mode,” and monitored the outbreak in collaboration with the national health authorities. The Bureau’s ongoing technical cooperation included epidemic intelligence, monitoring vaccination activities, mapping cases and epizootics, and periodic reporting on the evolution of the outbreak.

In December 2018, the Bureau convened a meeting with officials from the ministries of health of Argentina, Brazil, and Paraguay in the Brazilian city of Foz do Iguaҫu to discuss response strategies in the event of possible emergence of YF in the border areas. Participants agreed on a common response strategy adapted to the health structure of each country, based on comprehensive interventions, including vaccination, urban vector control, and epizootic surveillance. Relevant actions included vaccination in municipalities with low vaccination coverage; initiation of media campaigns; training of health professionals in YF surveillance and control; and strengthening of nonhuman primate surveillance for early detection.

PASB’s technical cooperation enhanced country-specific preparedness and response for YF in Argentina, Peru, and Suriname, focusing on strengthening countries’ laboratory networks, epizootic and epidemic surveillance, clinical management, and geographic risk assessments in line with the IHR. Predictive tools for YF forecasting, prevention planning, and early outbreak and response were also developed.

Adequate laboratory diagnosis and detection capacities are critical for countries to detect and report public health emergencies of international concern, as required under the IHR. During the reporting period, PASB contributed to training in:

1. viral isolation and cellular cultivation in Argentina
2. laboratory detection and diagnosis of arboviral diseases and influenza, including a bioinformatics course at the Minas Gerais Federal University in Brazil, in which personnel from Argentina, Cuba, Mexico, Panama, and Paraguay participated
3. molecular detection of yellow fever and Mayaro virus, in the context of co-circulation, for laboratory staff in Barbados and Jamaica
4. molecular detection of arboviruses in mosquitoes for laboratory personnel, held in Brazil, in which persons from Chile and Jamaica participated

PASB was also instrumental in providing laboratory supplies to countries to address the challenges that many face—including budgetary constraints, insufficient providers, and customs regulations—in obtaining critical laboratory reagents and materials.

1. Specific reagents for molecular detection of Mayaro virus were provided to the National Institute of Public Health in Guayaquil, Ecuador, enabling the first-time confirmation of the presence of the virus in the country in April 2019.
2. Laboratory supplies and critical reagents for in-house molecular detection and serology of arboviral and other viral diseases were provided to 26 countries.[1] This supply mechanism, which uses the same source of materials and the same protocols for all the countries, ensures continuity of the laboratory component of national virus surveillance and the use of quality reagents and standard materials within the laboratory network. This procedure also facilitates comparability of results and efficient troubleshooting, particularly related to molecular detection.

The External Quality Assessment Program (EQAP) for laboratory performance was expanded to include endemic and emerging viruses and to ensure the accuracy of serological and molecular laboratory platforms for the diagnosis of arboviral diseases and influenza. Twenty-eight laboratories from 24 countries[63] are currently participating in the EQAP.

In 2018, PASB conducted the first external quality assessment (EQA) for yellow fever molecular diagnosis for the Region of the Americas. The EQA panel was designed, coordinated, and distributed by the Bureau in collaboration with the Robert Koch Institute (RKI) in Germany. The EQA was planned to assess performance in national public health laboratories and at subnational level, and panels were sent to 31 laboratories in 21 countries.[64] The overall results showed concordance with the expected results in 30 of 31 laboratories (97 percent), a validation of the benefit of the training activities and the implementation of reference methods and procedures across the Region.

During the review period, PASB collaborated with IAEA, the World Organization for Animal Health (OIE), and the WHO Collaborating Center for the Public Health Management of Chemical Exposures (WHO CC UNK-179) to support States Parties in strengthening intersectoral mechanisms to address this threat.

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Strengthening emergency preparedness and disaster risk reduction in the health sector

PASB’s technical cooperation contributed to the strengthening of national capacities in emergency preparedness and disaster risk reduction through training in mass casualty management and incident command management systems, and the development and finalization of multihazard disaster management plans. The Bureau developed, disseminated, and promoted guidelines and tools to strengthen countries’ capacity for health emergencies and disasters, including:

EF4 tornado in Havana, Cuba

On 27 January 2019, a tornado categorized as EF4 (out of 5 levels on the Enhanced Fujita [EF] Scale) hit Havana directly. The unprecedented meteorological event affected approximately 532,000 inhabitants in 5 of the 15 municipalities of the Cuban capital, causing significant infrastructural damage, including to critical health facilities and public service systems. In total, 19 health institutions were damaged, including the Hijas de Galicia maternal hospital, which has the highest number of births in the capital city and the second highest nationally, and serves as a reference center for perinatal management. Following the tornado, the hospital had to be completely evacuated, affecting the continuity of essential health care for the most vulnerable groups, including children and pregnant women.

In response to this event, PASB activated its emergency response mechanism and provided direct support to the Cuban authorities to assess and attend to immediate humanitarian needs. The Bureau mobilized experts in damage assessment to accompany Ministry of Health officials in field visits and determine the most urgent actions to be taken, and provided support to monitor water quality in affected municipalities in order to avoid a complex epidemiological situation in the context of deteriorated environmental conditions.

PASB mobilized a total of $300,000 from CERF and the Government of Switzerland to support priority health sector responses, including rapid restoration of critical services in the damaged health facilities; strengthening of epidemiological surveillance; and control of water- and vector-borne diseases to prevent outbreaks. Repairs to damaged infrastructure and procurement of essential health supplies and equipment, including for vector control, epidemiological surveillance, and laboratory functioning, were identified as priorities for the restoration and strengthening of affected health services.

PASB, in collaboration with DFID, and with additional support from GAC, coordinated implementation of the third year of Phase II of the Smart Hospital initiative in the seven targeted countries: Belize, Dominica, Grenada, Guyana, Jamaica, Saint Lucia, and Saint Vincent and the Grenadines. The initiative aims to strengthen health facilities by combining improvements in safety and greening—the latter addressing, for example, renewable and sustainable energy and water use—to address gaps, boost resilience, and generate operational savings. During the review period, the achievements included:

Within the context of the Safe Hospital initiative, PASB updated and published the Hospital Safety Index (HSI) guidelines in Spanish and English, and, in October 2018, trained 50 persons from 18 countries[65] in the use of the updated guidelines.

Emergencies disproportionately affect populations in conditions of vulnerability, including persons with disabilities, who are usually excluded from disaster risk management policy-making and planning. This further increases their vulnerability and creates difficulties in responding to their needs after a disaster. In order to address this situation, PASB supported countries’ efforts for greater involvement of persons with disabilities and their families in health emergency risk management. In line with Article 11 of the UN Convention on the Rights of Persons with Disabilities—"Situations of risk and humanitarian emergencies"—the Bureau supported the implementation of corrective measures in prioritized hospitals, targeting structural and nonstructural elements linked to the inclusion of these persons, and preparing health personnel to respond to emergencies and disasters with an approach of "no one left behind.”

PASB developed practical tools to ensure that hospital response plans incorporate arrangements for persons with disabilities, and supported the piloting of the guidelines in three countries: Chile, Ecuador, and Mexico. The methodology used—Disability Inclusion in Hospital Disaster Risk Management (INGRID-H)—is a simple, practical, and results-oriented methodology to assess and improve the level of inclusiveness of a health facility with regards to persons with disabilities, in the event of a disaster. The piloting included assessment of health facilities, training of staff, and procurement of basic supplies to make the facilities more inclusive. The pilot studies contributed to the finalization and validation of the guidelines in September 2018, and their dissemination, in Spanish and English, in early December 2018. Peru reviewed the methodology in June 2019, and Chile and Mexico are implementing follow-up activities. There are plans to extend its application to other areas, including Emergency Medical Teams and community responses.

Developing countries of the Americas, and the most vulnerable populations in those countries, are disproportionately affected by climate change. Twenty-eight Member States[66] identified health as a priority topic in their Nationally Determined Contributions (NDCs), which represent their efforts to reduce their countries’ emissions and adapt to the impacts of climate change. Those Member States also made commitments to build evidence on, prevent, prepare for, and quickly respond to climate-related threats. The Bureau provided technical cooperation in the preparation of health chapters within climate change National Adaptation Plans in Brazil, Chile, Colombia, Cuba, El Salvador, Guatemala, Honduras, and Saint Lucia. The Bureau is also in the process of developing country profiles on climate and health. These various diagnostic and planning tools strengthen health leadership engagement, provide evidence for advocacy, and facilitate resource mobilization efforts.

In partnership with CARICOM and its Member States and specialized agencies, the Bureau provided technical cooperation in the preparation, launch, and initiation of implementation of the Caribbean Action Plan on Health and Climate Change 2019-2023. The Action Plan urges Caribbean participation in the WHO Special Initiative on Climate Change and Health in Small Developing Island States, and its four strategic lines of action are aligned with the four key areas of the Special Initiative—empowerment, evidence, implementation, and resources. The Action Plan aims to protect Caribbean populations from the adverse health effects of climate change by developing climate-resilient health systems, increasing awareness, mainstreaming funding opportunities to support countries, and promoting intersectoral mitigation actions in the health sector. The EU has approved a grant to PASB for 7 million euros for a collaborative project called “Climate Resilient Health Systems in the Caribbean,” which is expected to begin during the second half of 2019. It is anticipated that this project will benefit CARIFORUM Member States.

PASB advocated for health at a meeting of Caribbean SIDS in August 2018 in San Pedro, Belize, to prepare for the September 2019 High-Level Mid-term Review of the SAMOA] SIDS Accelerated Modalities of Action] Pathway. The SAMOA Pathway document was produced at the Third International Conference on Small Island Developing States, which was held in 2014 in the island nation of Samoa. The 2018 Caribbean SIDS preparatory meeting resulted in the San Pedro Declaration. In that Declaration, the countries identified the need to enhance citizen and private sector engagement at the national level and to effectively mainstream the SAMOA Pathway (which covers the period 2015-2025) into national development plans. The Caribbean countries also reaffirmed that climate change was one of the greatest challenges of the time and acknowledged that its impacts, including sea level rise, continue to pose a significant threat to Caribbean SIDS and their efforts to implement the SAMOA Pathway.

The Bureau’s advocacy contributed to the participation of representatives from Caribbean SIDS in the Inter-regional Preparatory Meeting for the Mid-term Review held in Apia, Samoa’s capital city, in late 2018, which resulted in the Apia Outcome. The Apia Outcome reaffirms the SAMOA Pathway as an overarching framework for guiding SIDS in their global, regional, and national development efforts, and as an integral part of the 2030 Agenda for Sustainable Development.

In the South American subregion, the Bureau organized training for health and climate change officials to help them prepare the November 2018 Declaration of Ministers of Health of MERCOSUR and Associate States on Climate Change and Health.[67]

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PASB’s technical cooperation for NCD prevention and control intensified during the review period. The Bureau contributed to Member States’ preparation for, and was represented at, the Third High-level Meeting of the UN General Assembly on the Prevention and Control of NCDs (HLM3-NCDs) held in September 2018. The HLM3-NCDs Political Declaration reaffirmed the political commitment of the heads and representatives of States and governments, to accelerate and scale up the implementation of commitments made in the 2011 Political Declaration and the 2014 Outcome Document of the previous HLMs of the UN General Assembly on NCD prevention and control. The 2018 Political Declaration acknowledged that some countries had made progress in addressing the commitments, but recognized the significant challenges that many others faced. The Declaration noted that the burden of NCDs continued to increase disproportionately in developing countries, where NCDs cause 85 percent of premature deaths, that is, those occurring in persons between 30 and 69 years of age.

The 2018 Political Declaration also affirmed that interventions should focus on the five main NCDs—cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, and mental health and neurological conditions—and five main risk factors: tobacco use, unhealthy diet, harmful use of alcohol, physical inactivity, and air pollution. The countries committed to, among several other measures, the implementation of cost-effective, affordable, and evidence-based interventions and good practices, including the WHO “best buys” and other recommended interventions for the prevention and control of NCDs.

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Cardiovascular diseases – the HEARTS initiative

The Bureau continued promoting the Global HEARTS initiative in countries of the Americas as a comprehensive package of best practices for the prevention and management of cardiovascular diseases. HEARTS addresses Healthy lifestyles, Evidence-based protocols, Access to essential medicines and technologies, Risk-based management, Team-based care and task-sharing, and Systems for monitoring. Its four core components comprise a simplified, evidence-based hypertension treatment algorithm; the availability and affordability of a core set of high-quality antihypertensive medications; a registry of hypertensive patients for monitoring and performance evaluation; and task-sharing in a team-based approach at the first level of care.

During the review period, four new countries implemented HEARTS: Argentina, Ecuador, Panama, and Trinidad and Tobago, joining Barbados, Chile, Colombia, and Cuba as participants in the initiative. The four new countries added 22 health centers to the total number of health facilities implementing the initiative, for a total coverage of approximately 800,000 people in the eight participating countries.

Support for HEARTS implementation—which is ongoing—was provided through webinars, virtual courses, and dissemination of new tools such as the HEARTS technical modules and the Monitoring and Evaluation Framework for Hypertension Control Programs developed by PASB and the World Hypertension League (WHL). Approximately 460 health care professionals at the first level of care—including physicians, nurses, and nurse assistants—were trained in Argentina, Ecuador, Panama, and Trinidad and Tobago, and 8,030 persons in those countries were accredited as having successfully completed virtual courses on the management of hypertension at the first level of care and the secondary prevention of cardiovascular diseases. By mid-2019, these virtual courses had reached 82,354 health professionals at the first level of care in
29 countries and territories.[68] A threat to the sustainability of the initiative is the high turnover of health workers. To address this issue, a network of individuals trained in HEARTS implementation at all levels of the ministries of health is being established, through training-of-trainers programs.

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Diabetes

The Bureau’s technical cooperation to combat NCD risk factors and obesity, strengthen implementation of the PHC strategy and IHSDNs, and improve self-management benefit persons with diabetes as well as those with other NCDs.

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Cancer

Following the WHO Director-General’s global call for cervical cancer elimination in May 2018, and building on PASB’s substantial previous work in this area, the Bureau rallied support for the new regional Plan of Action for Cervical Cancer Prevention and Control 2018-2030 (Document CD56/9). The Plan of Action, approved by the 56th PAHO Directing Council, commits Member States to implement high-impact interventions on a population-based scale along the continuum of health education and promotion, HPV vaccination, cervical cancer screening and diagnosis, and treatment for precancer and invasive cancer, with interventions tailored to the needs of priority populations in conditions of vulnerability.

Countries pledged to improve cervical cancer program organization and governance, including information systems and cancer registries; strengthen primary prevention through information, education, and HPV vaccination; improve cervical cancer screening and precancer treatment through innovative strategies; and increase access to services for invasive cancer diagnosis, treatment, and palliative care. These lines of action will put the Region of the Americas on the pathway to elimination of cervical cancer as a public health problem. In support of this goal, during the review period the PAHO Revolving Fund supplied over 1.6 million doses of
HPV vaccine to countries.

As part of its comprehensive strategy for cervical cancer prevention and control, Saint Kitts and Nevis included HPV vaccination in its national immunization program, and PASB contributed to the development of an action plan and training for Ministry of Health personnel and key stakeholders such as the media, faith-based organizations, parents, and adolescents. Although many countries are currently offering HPV vaccination as part of their immunization programs (see section “Maintaining and enhancing immunization” above), reaching the estimated 37 million girls in the targeted age group of 9-14 years remains a challenge, as coverage in most of the countries is less than the recommended 80 percent of this population.

Trinidad and Tobago is the only country in the Region of the Americas participating in the WHO cervical cancer costing study, which uses the WHO cervical cancer prevention and control costing tool (C4P). Trinidad and Tobago is also contributing to the regional campaign, “It is time to end cervical cancer”, that was launched in November 2018 in support of the regional Plan of Action for Cervical Cancer Prevention and Control 2018-2030. The campaign presents stories on cervical cancer prevention and control interventions in various countries in the Region, and relevant materials were disseminated to all countries for their use.

The Bureau’s technical cooperation resulted in updating of cancer control plans and treatment protocols, public outreach and education, and improvement in cancer information systems, in selected countries and in collaboration with key partners.[69]

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Other NCD issues

While focusing on the five main NCDs, PASB continued its interprogrammatic work on chronic kidney disease of nontraditional causes (CKDnT) in Central America,[70] and a progress report examining how Member States are advancing in addressing this priority health issue was prepared for the PAHO 57th Directing Council in September 2019. Countries that include Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama have developed integrated responses to increase the capacity of their health services for diagnosis and appropriate care and management. In addition, the countries are increasing their capacity to improve surveillance, by integrating epidemiological surveillance with environmental and occupational surveillance strategies.

PASB’s technical cooperation highlighted the significant gap between demand and availability of organs for transplant in the Region of the Americas. The regional Strategy and Action Plan on Donation and Equitable Access to Organ, Tissue, and Cell Transplants 2019-2030 was developed, based on voluntary donation and the observation of WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, for presentation to the 57th Directing Council in September 2019, aiming to create and expand active kidney transplant programs in every country of the Region, but particularly in Central America and the Caribbean.

PASB’s technical cooperation strengthened NCD surveillance systems in several Member States during the review period.

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NCD risk factors

PASB, in keeping with regional frameworks such as the Strategy for the Prevention and Control of NCDs 2012-2025 (Document CSP28/9, Rev. 1), the Plan of Action for NCD Prevention and Control 2013-2019 (Document CD52/7, Rev. 1), the Plan of Action for the Prevention of Obesity in Children and Adolescents 2014-2019 (Document CD53/9, Rev. 1), and the WHO Best Buys and Other Recommended Interventions for the Prevention and Control of NCDs, strengthened its technical cooperation to reduce NCD risk factors during the review period. Emphasis was placed on advocacy for fiscal policies to reduce the consumption of unhealthy products, such as increases in taxes on tobacco and alcohol products; the imposition of taxes on sugary drinks that raise the price by at least 20 percent, as recommended by WHO;[72] enhancing nutrition literacy and ensuring front-of-package labeling (FoPL) of products to facilitate informed choices; restrictions on the provision and marketing of unhealthy foods and beverages to children; and interventions in school, community, and workplace settings to promote and enable healthy nutrition and increased physical activity. Advocacy also highlighted a possible co-benefit of increased taxation of unhealthy products, namely a boost in health financing, with some or all of the revenue raised going to NCD prevention and control and other priority programs.

An unhealthy diet featuring foods and nonalcoholic beverages high in fats, sugar, or salt—based on criteria such as those in the 2016 PAHO Nutrient Profile Model—and physical inactivity contribute significantly to obesity, overweight, diabetes, hypertension, and heart disease. The regional consumption of salt is 10 grams per person per day, twice the level recommended by WHO. Increases in obesity and overweight in the Region are evident, particularly in childhood, with 7 percent of children aged less than 5 years being overweight, a proportion that exceeds the global average of 6 percent.[73] These patterns are a cause for concern, as they herald increases in the already crippling burden of NCDs in the Region.

The Bureau’s technical cooperation contributed to the development, implementation, updating, and/or assessment of national frameworks—including legislation, policies, plans, and guidelines—for the reduction of NCD risk factors and prevention and control of obesity and overweight, especially in children and adolescents, in 13 countries and territories:[74]

Law 30021 for healthy nutrition of children and adolescents in Peru

Peru approved a manual on advertising warnings related to Law 30021, which deals with the promotion of healthy nutrition for boys, girls, and adolescents. The manual regulates the use of black octagons with text stating "high in" sodium, sugar, or saturated fats and "contains trans fats" given on the front label of processed food products. The manual also regulates the advertising of such products in different media, and its approval and publication finalizes the regulations to enable the full entry into force of Law 30021.

Documentation of the process and experience for the development, approval, and implementation of Law 30021 in Peru provides a valuable model and tool for countries wishing to introduce nutritional labeling as part of their interventions to reduce modifiable NCD risk factors.

In complementary action, Peru increased the selective tax on sugary drinks, tobacco, alcohol, and fossil fuels. The new tax revenue will contribute to NCD prevention and control, reduction of violence and road traffic injuries, and protection of the environment.

The Bureau worked at regional and subregional levels to contribute to the promotion of healthy nutrition.

Brazil is leading a regional network for action for cardiovascular disease reduction through the reduction of salt intake.

In the Caribbean, the CCHD initiative “Advancing public health policies to address overweight and obesity in Chile and the Caribbean Community” between the Government of Chile and CARICOM, which was launched in 2017, continued. The initiative aligns well with CARICOM efforts in this area, including the July 2018 endorsement by CARICOM Heads of State and Government of FoPL as a priority.

In Central America and the Dominican Republic, the Bureau coordinated with the Institute of Nutrition of Central America and Panama (INCAP) to implement the toolkit of the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes as well as subsequent relevant World Health Assembly Resolutions (NetCode). PASB also collaborated with INCAP and COMISCA to develop a Central American subregional strategy for the reduction of salt consumption.

Front-of-package labeling in the Caribbean

The CARICOM Regional Organization for Standards and Quality (CROSQ) is currently leading the revision of the CARICOM Regional Standard: Specification for Labelling of Pre-packaged Foods (CRS 5:2010), to integrate front-of-package labeling provisions. The proposed “high in” approach to FoPL is a key policy to allow consumers quick and easy identification of prepackaged foods that are high in nutrients associated with the growing epidemic of NCDs and obesity in the Caribbean.

CROSQ’s regional process involves collaboration with various stakeholders, including civil society, private sector, academia, ministries of health, and other government sectors, such as finance, trade, and agriculture. A series of stakeholder consultations were held by national bureaus of standards across the Caribbean, and committees were established to develop national positions on the draft standard. A third round of stakeholder consultations is expected to take place during the second semester of 2019, before a final draft is produced and presented to the CARICOM Council for Trade and Economic Development (COTED).

This initiative has stirred public debate on the right to know the nutritional content of food products, with CSOs, such as the Healthy Caribbean Coalition, leading public education campaigns on this and other issues related to obesity and NCD prevention and control. The initiative has also triggered private sector engagement, and some industry entities have voiced concerns, proposing voluntary approaches and alternative FoPL systems that would not be as effective in achieving the intended public health objective.

Through this initiative, the Caribbean is closer to implementing the “high in” FoPL system, which will not only facilitate healthier choices by consumers but also serve as an enabling policy for other effective approaches, such as taxation, school-based nutrition policies, and the restriction of marketing to children, by clearly identifying processed and ultra-processed products that should be targeted by these measures. In order to achieve better policy alignment, COTED has called for a joint meeting of ministers of trade and of health to discuss and harmonize positions, and childhood obesity and alcohol reduction have been identified as priority policy areas.

During the review period, the Bureau’s technical cooperation addressed adequate physical activity as an important component of obesity and overweight prevention and part of integrated NCD risk factor reduction efforts at national and subregional levels.

Belize: A memorandum of agreement was developed between the Mayors Association of Belize and the Ministry of Health for the promotion of wellness parks in all six districts of the country.

Brazil: Physical activity was included as a component of a national intersectoral converging agenda for action involving government, academia, civil society, and UN agencies. The other components of the agenda are air pollution and sustainable mobility.

Caribbean subregion: Since the launch of “Jamaica Moves” by the Ministry of Health in that country in 2017, with the aim of facilitating increased physical activity among the population, the effort expanded to the subregional level when CARICOM Heads of State and Government endorsed the “Caribbean Moves” initiative in September 2018.Supported by the PASB, the scheme spread to other countries in the subregion, such as Barbados, where “Barbados Moves” was launched in October 2018 as part of a National Wellness Initiative, and Trinidad and Tobago, where “TT Moves” was launched in April 2019.

Ecuador: A project funded by the Korean International Agency for Cooperation (KOICA) created inter- and multisectoral networks, which include academia and civil society, to strengthen primary care and health literacy, promote healthy nutrition and physical activity in schools, and prevent Zika virus infection. As a result of the project, which ended in February 2019, street food vendors began selling healthier options; schools implemented extracurricular hours for physical activities, resulting in increased physical activity among students; school district water supplies were disinfected in order to provide safe drinking water for school children; and health services were strengthened to improve NCD prevention and control.

Overall, the Region of the Americas is on track to reach the 2025 target of a 30 percent reduction in the age-standardized prevalence of tobacco smoking among both males and females 15 years and older. According to the WHO global report on trends in prevalence of tobacco smoking 2000-2025,[76] the regional target for this indicator for 2025 is 14.2 percent; however, the projected prevalence for the Region for 2025 is lower, at 13 percent.

During the reporting period, the Bureau provided technical cooperation to support countries’ implementation of the WHO Framework Convention on Tobacco Control, based on the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (Document CSP29/11).

Antigua and Barbuda approved comprehensive tobacco control legislation that made it one of 20 countries[77] in the Region that have mandated smoke-free environments; one of 21 countries[78] that require health warnings; and one of the 7 countries—Antigua and Barbuda, Brazil, Colombia, Guyana, Panama, Suriname, and Uruguay—that have banned tobacco advertising, promotion, and sponsorship—all measures that are aligned with the FCTC.

Barbados, Grenada, Saint Kitts and Nevis, Trinidad and Tobago, and Venezuela reviewed their tobacco legislation.

Brazil achieved the highest level of implementation of the MPOWER package, having implemented the six measures at the best practice level. MPOWER is intended to assist country-level implementation of effective FCTC interventions to reduce the demand for tobacco, and Brazil is the second country in the world (after Turkey) to achieve this landmark level. In recognition of this achievement, WHO and the Government of Brazil will launch the WHO Report of the Global Tobacco Epidemic 2019 in Brazil in July 2019.

Brazil and Colombia joined Argentina and Chile in imposing taxes on tobacco products that represent more than 75 percent of the final retail price.

Canada and Uruguay adopted plain packaging of tobacco products.

Guyana developed an antitobacco communication campaign for radio and television, billboards, posters, flyers, and print and social media. The campaign followed the country’s enactment in 2017 of tobacco control legislation that is among the most comprehensive in the Region.

Saint Lucia finalized a bill to amend its Public Health Act, with the aim of establishing smoke-free public spaces; as of mid-2019, the bill was under consideration for Cabinet approval. An 8-month antitobacco campaign was initiated in April 2018 using print and social media, television, and radio.

In August 2018, PASB hosted a regional conference in Washington, D.C., in preparation for two events to be held in October 2018: the Eighth Conference of the Parties to the FCTC (COP8) and the First Meeting of the Parties to the Protocol to Eliminate Illicit Trade in Tobacco Products (MOP1). The August regional conference allowed the exchange of experiences among FCTC Parties from the Americas and provided an opportunity to develop a more cohesive regional platform in preparation for COP8 and MOP1. PASB continues to facilitate coordination between the Parties to both treaties.

In 2018, the Bureau collaborated with the Ministry of Health and the Solidarity Fund for Health (FOSALUD) in El Salvador, the FCTC Secretariat, the UN Development Program (UNDP), and RTI International to prepare an investment case for tobacco control in that country. The development of investment cases has proven to be a powerful tool to support the design of tax policy on tobacco and to engage sectors beyond health in the implementation of the FCTC.[79]

PASB’s collaborators and partners in this work include the Campaign for Tobacco-Free Kids, the International Union Against Tuberculosis and Lung Diseases, the Framework Convention Alliance, the American Cancer Society, Johns Hopkins University, the University of Illinois at Chicago, the InterAmerican Heart Foundation, and Vital Strategies.

PASB’s technical cooperation to reduce the risk factor of air pollution during the reporting period is described below under SHAA2030 Goal 11.

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Road safety

In support of the WHO Global Road Safety Report 2018,[80] regional data collection and analysis on the key legislative and public health interventions and their impact was conducted in 30 countries in the Americas.[81] The analysis for the Region of the Americas, also detailed in the fourth regional report on road safety published in 2018, Road Safety in the Americas, revealed that deaths from traffic injuries increased slightly, from 153,714 in 2013 to 154,997 in 2016, although mortality rates remained relatively stable, at 15.6 per 100,000 population in 2016, compared to 15.9 per 100,000 population in 2013.

The most vulnerable road users—pedestrians, motorcyclists, and cyclists—had the highest rates of road traffic deaths and injuries, and deaths of motorcycle users in particular increased. Overall, road traffic deaths remain the second-leading cause of death for young adults aged 15–29 years in the Region of the Americas, highlighting the need to prioritize road safety on the adolescent health agenda. The regional report shows that some aspects of road safety management, legislation, and postcrash care have improved in several countries. The report also provides an important tool to monitor progress and stimulate Member States to improve road safety, through the identification of key gaps and opportunities.

Reducing alcohol consumption and road injuries in Guatemala

In Guatemala, PASB took a leadership role in collaborative and cross-sectoral government efforts to strengthen the implementation and enforcement of the legal framework for reducing deaths related to alcohol and road traffic injuries. The OFID-funded initiative strengthened the capacity of managers in the Transit Department, National Civil Police (PNC), Municipal Police Officers (PMT), and health professionals in the emergency rooms of one of the largest national hospitals to conduct brief interventions.

In conjunction with the Ministry of the Interior, the Bureau organized a public forum for debate on the legal aspects of driving while intoxicated, the first time that authorities and officials from the National Institute of Forensic Sciences, the Association of Judges and Magistrates, the Institute of Criminal Public Defense, the Office of the General Prosecutor for Human Rights, the Dean of the Law School, the national municipal police, and national civilian transportation discussed this important issue. As a result of the forum, all participating entities signed an agreement to establish a technical working group, prepare a protocol, and revise the existing law on driving while intoxicated. This constitutes a major step for Guatemala in addressing alcohol- and traffic-related road safety issues through a collaborative approach.

PASB collaborated with the Executive Secretary of the Commission Against Addictions and Illicit Drug Trafficking (SECCATID) and the Ministry of the Interior at central, municipal, and community levels to strengthen the prevention and control of harmful alcohol consumption and the consumption of psychoactive substances. A specific aim of this initiative, which was supported by the Government of Sweden as part of a joint program for comprehensive rural development, was to protect indigenous populations from serious health issues due to harmful use of alcohol.

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Mental health and neurological disorders

During the review period, the Bureau’s technical cooperation in addressing mental health and neurological conditions continued, within the framework of the WHO Mental Health Gap Action Program (mhGAP). The premise of the program is that, with appropriate and adequate care, psychosocial assistance, and medication, millions of persons could be treated for depression, schizophrenia, and epilepsy; prevented from suicide; and enabled to lead normal lives, even where resources are scarce. The mhGAP initiative aims to scale up services for mental, neurological, and substance use disorders in countries. It provides tools for use in nonspecialized health settings, including the mhGAP Operations Manual (updated in 2018), mhGAP Intervention Guide, and mhGAP training manuals. By mid-2019, 25 countries and territories[82] in the Region had implemented mhGAP.

Strengthening the Mental Health Gap Action Program in countries

Anguilla, Saint Kitts and Nevis, and Saint Vincent and the Grenadines: These countries initiated implementation of the mhGAP, integrating mental health into the PHC strategy and focusing on the modules on depression and suicide, to reduce stigmatization and facilitate early diagnosis and management. Training of trainers to oversee continued mhGAP training of health care providers was a principal focus of the Bureau’s technical cooperation: 20 persons were trained in Anguilla, 35 in Saint Kitts and Nevis, and 30 in Saint Vincent and the Grenadines.

Argentina: A plan was developed for the phased, effective implementation of the mhGAP initiative, resulting in improved skills and capacity of central, provincial, and local health teams to undertake interventions at the first level of care. A total of 250 professionals were trained, and the phase of accountability for the local implementation of mhGAP was initiated, with the design of monitoring indicators that will allow adjustments to the implementation of the strategy.

The Bahamas: In 2018, a suicide prevention campaign and training of 25 health care professionals from the Family Islands took place, aiming to increase access to community-based mental health services. In interventions involving multisectoral groups—with representatives from the ministries of health, education, and national security, as well as other partners—a mental health literacy module was integrated into the Health and Family Life Education curriculum in eight secondary schools, and a violence prevention pilot project was initiated in one primary and one secondary school in New Providence, the most populous island of the Bahamas. These school-based projects aim to identify, link to care, and reduce stigmatization of children with mental health conditions, or those who are perpetrators or victims of youth violence.

Belize: Interventions included capacity-building for physicians and nurses in the mhGAP guidelines; training of trainers in mental health literacy for 65 personnel of the ministries of health and of education; and development of the National Strategic Plan for the Prevention and Control of Suicide. A key partner in improving mental health literacy was Dalhousie University (Canada), a PAHO/WHO Collaborating Center.

Colombia: By the end of 2018, 1,800 health professionals at the first level of care and in basic hospitals had been trained in mhGAP, covering almost the entire country. This is the only example in the Region of training with such a wide reach; it was carried out through the VCPH, using the expertise of four universities in the Region. The personnel trained through this initiative, will empower attention to mental health conditions at the first level of care in Colombia. This work can serve as an example for low- and middle-income countries, where as many as 75% of the people who have mental disorders do not have access to the treatment they need.

Dominican Republic: Important advances were made in reforming the model of mental health care to focus on the person, family, and community through deinstitutionalization, with replacement of the psychiatric hospital by a psychosocial center; creation of mental health units in provincial, municipal, and regional hospitals; investment in community health centers and reinforcement of the first level of care; and creation of other psychosocial rehabilitation services such as day care centers and residential facilities for persons with chronic mental disorders. A National Mental Health Plan 2019-2022 was developed in alignment with the PAHO Plan of Action on Mental Health 2015-2020.

Ecuador: The National Mental Health Plan was revised to strengthen the community-based approach.

Guyana: Important progress was made in integrating mental health into the first level of care, with the development of a road map for the introduction of community-based mental health services, establishment of a mental health unit to lead the implementation of both a mental health strategy and a suicide action plan, and the training of 233 health care providers in mhGAP.

Paraguay: Interventions for mental health reform included creation of a technical working group for the reform of mental health care and gradual transformation of the traditional psychiatric hospital–centered model to a holistic, community-centric approach. This is an important intervention, given that in 2003 and 2008 the country was sanctioned by the International Court of Human Rights for violating the rights of persons with mental health conditions, in relation to their health care.

Peru: The National Plan for Strengthening Community Mental Health Services 2018-2021 was approved, signaling the country’s institutionalization of mental health reform and a model based on human rights. The community mental health model includes extension of the budget for mental health and financing of the implementation of the Plan; establishment of 106 community mental health centers in 24 regions; strengthening of services at the first level of care, with 170 facilitators of the mhGAP program trained in Lima and the provinces; formulation of a package of political and regulatory tools, including sectoral policy for mental health, and standards for community mental health centers and protected homes; and development of a proposal for a CCHD project involving Chile, Paraguay, and Peru to exchange good practices in community mental health and promote mutual strengthening of relevant services in the countries.

Trinidad and Tobago: The Mental Health Policy and Plan was reviewed, and stakeholder consultations were initiated in 2019 to obtain final approval. The final version was agreed upon, and drafting of the implementation plan began. The country also developed a suicide prevention strategy, with its official launch planned for World Mental Health Day 2019, in keeping with the theme of this year’s observation, “Mental health promotion and suicide prevention.” Training on mhGAP in all Regional Health Authorities and an assessment of the impact of the training on mental health services and care were initiated by the Mental Health Unit, with PASB support.

Turks and Caicos Islands: A review and update of the country’s mental health legislation were initiated, with the aim of reducing stigmatization, fostering greater multisectoral collaboration, and ensuring linkages to community-based, in-country care—as appropriate—for persons with mental health conditions. PASB provided access to online mental health training resources for health care personnel.

Cognizant of the psychosocial impact of disasters and humanitarian emergencies on the general population, responders, and health care workers, PASB’s technical cooperation also focused on improving mental health and psychosocial support (MHPSS) for disaster-affected populations. Relevant interventions were implemented in nine countries: Antigua and Barbuda, Brazil, Colombia, Ecuador, Grenada, Nicaragua, Saint Lucia, Trinidad and Tobago, and Venezuela.

Enhancing psychosocial support in disasters and humanitarian emergencies

In Antigua and Barbuda, a mental health and psychosocial support (MHPSS) needs assessment was undertaken, an action plan developed, and 30 shelter managers trained in psychological first aid (PFA).

In Brazil, a proposal was developed for strengthening local capacity in MHPSS to manage persons affected by disasters and humanitarian emergencies.

The British Virgin Islands implemented a project aimed at building resilience at the individual and community levels in response to the devastation of Hurricanes Irma and Maria in 2017. This initiative utilized a multipronged approach that includes helping individuals to address the lingering psychological impact of the disasters; enhancing the capacity of health care workers, first responders, and other community workers to take care of their own mental health needs, while responding to the needs of others; and building resilience for future adverse events. The project also supported participating communities in the development of community-level resiliency plans, and included a national communication campaign to enhance awareness and educate the population on maintaining mental health in disaster situations.

In Colombia, interventions made through the Health for Peace initiative addressed advocacy and the development of institutional and community capacities in areas marked by armed conflict, recognizing issues related to mental health and psychoactive substance abuse, and paving the way for continued implementation of relevant strategies in 2019.

At the Colombia-Venezuela border, psychosocial support and mental health care was provided to both the migrant population and health professionals experiencing burnout.

In Ecuador, strengthening of the skills of health teams to respond to the situation of cross-border migration was included in the revised National Mental Health Plan.

In Grenada, Saint Lucia, and Trinidad and Tobago, training was conducted to strengthen national capacity for mental health support during disasters and for PFA.

In Nicaragua, a program was developed, involving the Ministry of Health and the Ministry of Families, for mental health care during and after the sociopolitical crisis that the country experienced in 2018. The program trained 120 facilitators in the standardized management for PFA and built the capacity of mental health teams of the Local Systems of Comprehensive Health Care (SILAIS) and Family and Community Health Teams (ESFAC), providing them with skills for the timely detection, prevention, and care of mental health conditions in affected individuals and families.

Teams from four Caribbean countries and territories—Belize, Bermuda, Cayman Islands, and Jamaica—were trained for the implementation of an evidence-based mental health literacy model intervention in schools. In addition, the first-ever country-level investment case for mental health in Jamaica was completed. The investment case demonstrated that for every 1.00 Jamaican dollar devoted to scaling up treatment for depression, anxiety, and psychosis, the expected return on investment is 5.50 Jamaican dollars.

Substance use

PASB continued its work to strengthen intersectoral cooperation at the regional and country levels to improve access to and quality of treatment for substance use disorders. The main challenge remains how to effectively engage national health authorities in the effort to strengthen the public health dimension of policies to reduce substance use and its complications. Even though the focus of such policies is shifting from a repressive and punitive perspective to a more comprehensive approach that includes a public health component, strategies and resources remain skewed toward repressive and judicial interventions.

The Bureau participated in the validation of the International Standards for the Treatment of Drug Use Disorders prepared by WHO and the UN Office on Drugs and Crime (UNODC), as well as the standard criteria for accreditation of drug demand reduction programs prepared by the Cooperation Program on Drugs Policies (COPOLAD).[83] As a result, the Bureau was particularly well positioned to support 18 countries[84] as they implemented these standards during the reporting period.

The Bureau also worked to strengthen collaboration with global, regional, and subregional partners, including UNODC, the OAS Inter-American Drug Abuse Control Commission (CICAD), and CARICOM, in the development and updating of drug policies using a public health approach. PASB also undertook technical cooperation with national agencies responsible for drug policies in 14 countries[85], and this work helped to position PAHO as a key actor in the reorientation of current drug policies toward a more comprehensive, balanced, and integrated approach. During 2018 and 2019, PASB renewed its memorandum of understanding with CICAD, establishing specific projects to improve access to and the quality of treatment for substance use disorders through public health services networks. Project beneficiaries include ministries of health, national drug control commissions, and CSOs in Argentina, Bahamas, Jamaica, Panama, and Peru. PASB worked with the Bahamas to complete and adopt standards of care for drug treatment facilities run by both public sector agencies and NGOs.

In its technical cooperation to reduce the harmful use of alcohol, PASB worked with Guyana, Jamaica, and Suriname to develop national alcohol strategies and plans of action. In the Dominican Republic, health care providers were trained in the assessment and diagnosis of fetal alcohol spectrum disorders (FASDs), which led to the creation of the first diagnostic center for FASDs in the country in early 2019. The Bureau developed and launched a self-learning virtual course on alcohol and pregnancy in English, Spanish, and Portuguese, and by late June 2019, 4,500 students had taken the course.

PASB coordinated an ongoing regional study on alcohol, drugs, and road injuries in emergency rooms, with piloting of effective interventions for reduction of alcohol use in Dominican Republic, Jamaica, and Peru. In addition, the Bureau prepared and published a regional report[86] on the level of implementation of policies for the reduction of the harmful use of alcohol in Member States, measuring their progress in executing the 2010 WHO Global Strategy to Reduce the Harmful Use of Alcohol. The Global Strategy was endorsed by PAHO Member States and made operational for the Region of the Americas through the 2011 PAHO Plan of Action to Reduce the Harmful Use of Alcohol (Document CD51/8, Rev. 1). The 2018 regional report suggested that there is ample room for PAHO Member States to develop more comprehensive and stringent alcohol policies, and the Bureau urged countries to use the report and its scoring scheme to monitor and compare their progress in this area of work.

In Turks and Caicos Islands, the WHO alcohol survey instrument was used to document, identify, and reduce gaps in its policies to decrease alcohol consumption, while in the Central American subregion, the Bureau used an interprogrammatic approach to work with the PARLACEN and SE-COMISCA to develop and obtain approval for a declaration targeting comprehensive alcohol regulation, the first in the subregion.

Subregional approach to alcohol reduction policies in Central America

PASB played a key role in the development of a proposal for the Central American Parliament aimed at strengthening and harmonizing alcohol legislation in Central America and the Dominican Republic, in line with WHO’s SAFER alcohol control initiative. SAFER promotes Strengthening restrictions on alcohol availability; Advancing and enforcing drink-driving countermeasures; Facilitating access to screening, brief interventions, and treatment; Enforcing bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion; and Raising prices on alcohol through excise taxes and pricing policies.

The proposal was approved in March 2019 during a workshop attended by 120 members of PARLACEN and was formally ratified by the plenary of PARLACEN in April 2019; it applies to all Member States of the Central American Integration System (SICA).

The PARLACEN resolution declared that harmful use of alcohol is a serious public health problem and recognized that there is no safe level of alcohol consumption. The resolution also called on all Central American countries and the Dominican Republic to update and strengthen legislation aimed at limiting the availability of alcohol; preventing drink-driving; banning alcohol marketing, promotion, and sponsorship; reducing alcohol demand through price control policies and taxation; preventing influence by the alcohol industry on public health policies; and guaranteeing access to trustworthy information about the use of alcohol.

The resolution also established, for the first time, an obligation of SE-COMISCA to compile and report to PARLACEN detailed information on countries’ fulfillment of the resolution. This work illustrates a promising area of public health action promoted by PASB and known as “community legislation”.

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PASB continued its technical cooperation toward ending the epidemics of HIV and AIDS, STIs, and tuberculosis; eliminating malaria, neglected infectious diseases, and mother-to-child transmission of selected communicable diseases (as described under SHAA2030 Goal 1); combating hepatitis, waterborne diseases, and other communicable diseases; fighting antimicrobial resistance; and mitigating food safety risks.

HIV and AIDS, STIs, tuberculosis, and malaria

The Organization continued to advance universal access to effective HIV treatment through technical cooperation to increase uptake of WHO’s recommendations on ART initiation in people living with HIV, regardless of the CD4 count (the “Treat All” policy). As of mid-2019, 29 (83 percent) of PAHO’s 35 Member States had adopted those recommendations, while the remaining 6 were in the process of updating their policies.

The Bureau collaborated with regional partners and WHO reference laboratories to support the expansion of HIV drug resistance surveillance and HIV treatment optimization in response to the emerging threat of resistance to commonly used first-line medicines. As of mid-2019,
16 countries[87] had completed drug resistance surveys; 5 others—El Salvador, Haiti, Paraguay, Peru, and Uruguay were conducting such surveys; and 8 others—Argentina, Bolivia, Brazil, Cuba, Guatemala, Haiti, Jamaica, and Venezuela—had begun transitioning to regimens based on dolutegravir (DTG), which WHO recommended as first-line treatment in its July 2018 Interim Guidance for HIV Treatment. Ten countries—Argentina, Bolivia, Chile, Costa Rica, Guatemala, Guyana, Honduras, Paraguay, Peru, and Venezuela—procured DTG through the PAHO Strategic Fund.

According to global estimates reported in the August 2019 issue of the Bulletin of the World Health Organization, the prevalence and incidence of four curable STIs—chlamydia, gonorrhea, trichomoniasis, and syphilis—remained high, with an average of over 1 million new infections each day in 2016. These estimates are similar to those published in 2012, both globally and by region, and underscore the continuing public health challenge posed by these four STIs.

In line with the regional Plan of Action for the Prevention and Control of HIV and Sexually Transmitted Infections 2016-2021 (Document CD55/14), PASB has prioritized actions to address infections with syphilis and gonorrhea, and prevent infection with HPV. These actions include work to roll out rapid diagnostic testing; standardize and simplify diagnostic algorithms for syphilis among pregnant women and key populations in El Salvador, Guatemala, Honduras, and Nicaragua; and pilot interventions in Barbados, Jamaica, Suriname, Trinidad and Tobago, and the six independent Member Countries of the OECS (Antigua and Barbuda, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines). The work in the Caribbean was done in partnership with the multi-country Global Fund grant for the OECS and CARPHA. In the past year, the Bureau has published the Epidemiological Alert for the extended-spectrum cephalosporin resistance in Neisseria gonorrhoeae and has provided technical cooperation to improve national antimicrobial resistance surveillance to guide treatment.

Despite advances in its prevention and control, tuberculosis remains a significant public health issue. PASB contributed to Member States’ preparation for, and was represented at, the first High-level Meeting on Ending Tuberculosis of the UN General Assembly held in September 2018. The Political Declaration from this HLM[88] calls for greater efforts and investments towards the ending the tuberculosis pandemic by 2030 and sets specific measurable milestones to be achieved by 2022. During the period under review, PASB’s technical cooperation with countries was guided by the regional Plan of Action for the Prevention and Control of Tuberculosis 2015-2019 (Document CD54/11, Rev. 1), the WHO 2018 End TB Strategy, and the September 2018 HLM Political Declaration. The Bureau gave priority to countries with high-burden tuberculosis, and actions included strengthening prevention, diagnostic, and treatment interventions, as well as managerial capacity. The interventions emphasized groups in conditions of vulnerability, interprogrammatic and intersectoral approaches, and active civil society participation. Innovative initiatives, such as Tuberculosis Control in Large Cities and the tuberculosis elimination initiative, were promoted.

The Bureau undertook technical cooperation with all 18 of the Region’s Global-Fund-eligible countries[89] as part of the Fund’s application process. By mid-2019, all the countries had succeeded in accessing new funding for HIV, tuberculosis, and malaria, with a total allocation of $351.3 million for the Region. As of April 2019, there were 42 active grants in 18 countries and six multicountry proposals. PASB also supported activities related to sustainability and transition (“transition readiness assessment”) in 8 countries “graduating” out of the Global Fund during the reporting period—Belize, Costa Rica, Cuba, Dominican Republic, El Salvador, Panama, Paraguay, and Suriname.

PASB collaborated with the Global Fund in other areas, including the joint agreement to strengthen pharmaceutical supply chains and reduce the risk of essential medicine shortages and stockouts in eight countries—Bolivia, Cuba, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay; the Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE) initiative; and the regional project to strengthen tuberculosis laboratory networks in
20 countries.[90]

As part of the implementation of the regional Plan of Action for Malaria Elimination 2016-2020 (Document CD55/13), PASB successfully supported Argentina and Paraguay in completing their malaria elimination certification processes in July 2018 and May 2019, respectively. Other countries that are very close to eliminating malaria, particularly Belize, Costa Rica, El Salvador, and Suriname, received PASB’s ongoing support to consolidate the interruption of transmission. The Bureau supported all endemic countries with the adaptation of plans and strategies towards malaria elimination, and provided technical and financial resources for initiatives in countries with high-burden areas where there is renewed political interest, such as Colombia, through the Pact for the Elimination of Malaria and in Peru, through the Municipalities for Zero Malaria initiative.

The Bureau promoted actions with greater impact at the local level through the development of a technical framework to address the malaria foci and consolidation of collaborative efforts against malaria in some of the highest-burden municipalities in Brazil, Colombia, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Peru, and Venezuela.

In 2018, the PASB became part of the new Regional Malaria Elimination Initiative (RMEI), assuming the role of lead entity for technical cooperation. RMEI targets Central American countries, Colombia, and the Dominican Republic, in partnership with the IDB, and leverages new technical approaches, capacity development, mobilization of resources, and a renewal of political interest. Other partners include COMISCA and the Bill and Melinda Gates Foundation.

Neglected infectious diseases

These diseases are often seen as markers of inequities, given that they are more common among populations living in poor socioeconomic conditions, with a low income, limited education, little or no access to basic services such as potable water and adequate sanitation, and barriers to accessing health services.

In its technical cooperation to address the elimination of lymphatic filariasis (LF) during the review period, PASB mobilized $1.5 million per year for two years—$1 million from USAID and $500,000 from the Ending Neglected Diseases (END) Fund—and supported the LF elimination program in Guyana.

The elimination of Rhodnius prolixus, the domestic vector of Chagas disease, as a public health problem was validated in Guatemala, Honduras, and Nicaragua during the reporting period. This means that the Central America subregion and Mexico are now free of the vector responsible for most of the endemicity of Chagas disease in that geographic area. Similarly, Paraguay was certified as having eliminated vector transmission by Triatoma infestans of Trypanososma cruzi, the parasite that causes Chagas disease, in the Presidente Hayes department and therefore in all its territory. The successes represent significant achievements for these Key Countries, given the recognized challenges in eliminating vector-borne transmission of Chagas disease.

The Region is on the verge of eliminating human rabies transmitted by dogs. There has been a marked reduction in human cases of dog-mediated rabies, and during the period under review only two countries—Dominican Republic and Haiti—reported cases of this infection, a total of six. Both countries are implementing prevention programs, and in Haiti there was a significant increase in access to rabies postexposure prophylaxis by persons in conditions of vulnerability. PASB facilitated the donation to Haiti of 15,000 doses of human rabies vaccines from Brazil, and 3,000 doses from Paraguay. Eight countries reported canine rabies—Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Haiti, and Venezuela—and 27 countries and territories[91] procured rabies immunological products (human/animal vaccines and immunoglobulin) through the PAHO Revolving Fund. Mexico finalized external validation for elimination of dog-mediated human rabies, as noted in the 2018 Third Report of the WHO Expert Consultation on Rabies.

PASB’s technical cooperation contributed to the implementation of pre-exposure prophylactic programs for sylvatic rabies in the Amazonian regions of Brazil, Colombia, and Peru, and to herbivore rabies prevention in Guyana, reducing the impact of the disease on indigenous and other populations in conditions of vulnerability.

Assessment of the epidemiological situation regarding brucellosis was initiated in Brazil, Ecuador, Panama, and Paraguay, focusing on improving national control programs and collaboration between the animal health and public health sectors. PASB continued its support for the South American Initiative for the Control and Surveillance of Cystic Echinococcosis/Hydatidosis, and provided technical cooperation for the documentation of interruption of transmission of schistosomiasis in Antigua and Barbuda and Saint Lucia.

Incidents with venomous animals have high morbidity rates and are a cause of mortality worldwide. In May 2018, the 71st World Health Assembly adopted resolution WHA71.5 “Addressing the burden of snakebite envenoming,” aiming to reduce related deaths, dysfunctions, and suffering. In the Region of the Americas, LAC countries are particularly affected by incidents involving venomous snakes—mainly in rural areas—and other venomous animals such as scorpions, spiders, caterpillars, and bees. During the reporting period, PASB, through the Pan American Foot-and-Mouth Disease Center (PANAFTOSA), a PAHO specialized center located in Brazil, convened the first meeting of official laboratories producing antivenom in Latin America, and initiated coordination of a technical guide as reference material for the diagnosis and treatment of incidents involving venomous animals in the Region.

Hepatitis

In addition to the efforts described under SHAA2030 Goal 1 regarding the elimination of mother-to-child transmission of hepatitis B through EMTCT Plus, PASB focused on supporting the scale-up of quality hepatitis B and C testing and treatment in the Region. With the publication of the 2018 WHO hepatitis C care and treatment guidelines recommending pangenotypic direct-acting antivirals, the Bureau supported alignment of national guidance in Argentina, Brazil, Colombia, Ecuador, and Peru, and initiated a Caribbean-wide process for the development of hepatitis C guidelines, a first in hepatitis treatment. The alignment of national hepatitis B testing and treatment guidelines with the 2015 WHO hepatitis B guidelines was supported in the Caribbean, Ecuador, and Peru.

For the first time, the Bureau convened a Caribbean subregional meeting on the prevention and control of hepatitis. Also for the first time, an integrated meeting of heads of hepatitis, HIV, and tuberculosis programs in Latin American countries was held, in Guatemala in November 2018. National planning for hepatitis control was initiated or supported in several countries, including Ecuador, Guatemala, and Peru; Honduras became the first Central American country to draft a national hepatitis strategy; and Colombia published the first integrated national strategy for HIV, STIs, tuberculosis, and hepatitis in the Region.

PASB made substantial efforts in supporting countries to better understand current and future epidemiological and health system costs associated with hepatitis B and C epidemics, including: the development of an investment case for hepatitis and implementation of mathematical modeling and a consensus-building process to project disease burden and the economic impact of action to address the epidemics in Brazil and Chile; and hepatitis program reviews in Bolivia, El Salvador, and Peru; the review in El Salvador was conducted in partnership with the U.S. CDC.

Vector- and waterborne diseases

As described in previous sections on outbreaks, emergencies, and disasters, and below in sections on water, sanitation, and hygiene, the prevention and control of vector-borne diseases such as dengue, chikungunya, and Zika virus and waterborne diseases such as cholera continue to pose challenges for several countries in the Region of the Americas. Major reductions in cholera in the island of Hispaniola—from 3,895 suspected cases reported in 2018 to 452 in the first half of 2019—signal advances toward elimination. However, as noted in the regional Strategy for Arboviral Disease Prevention and Control (Document CD55/16) approved by the 55th Directing Council in 2016, enhanced efforts are needed to control several mosquito-borne diseases.

PASB’s technical cooperation continued to focus on further reduction of cholera in the island of Hispaniola; addressed capacity-building for effective vector control programs through training in mosquito identification, vector surveillance, and insecticide resistance in Dominica, Saint Kitts and Nevis, and Saint Vincent and the Grenadines; and assessed the Rodent Control Program in Barbados, with recommendations to strengthen the program as a means of preventing outbreaks of leptospirosis and Hantavirus.

Fighting antimicrobial resistance

Antimicrobial resistance (AMR) is both a growing threat to health gains and a serious challenge for the attainment of SHAA2030 Goal 10 and several other SHAA2030 goals and targets, including those related to maternal, newborn, and under-5 mortality, and some related to NCDs. With funding support from Canada, Germany, and the U.S. CDC, PASB launched a new special program on AMR in 2018 to enhance Member States’ actions—based on their context, needs, and priorities—to lessen the impact of AMR.

Progress in this area is reflected in countries’ development and implementation of AMR national action plans (NAPs) under the “One Health” approach. By the end of 2018, 16 countries[92] in the Americas had NAPs in place, and 13 others[93] were developing such plans. PASB provided direct technical cooperation to 8 countries—Cuba, Dominican Republic, El Salvador, Guatemala, Guyana, Haiti, Paraguay, and Suriname—to develop NAPs during the reporting period.

In November 2018, the European Commission endorsed the proposed “Working together to fight AMR” initiative. The initiative, coordinated by PASB and implemented in collaboration with the UN Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE), has the overall objectives of tackling AMR by engaging with major global players and strategic countries and of advancing the WHO Global Action Plan on AMR (2015) by sharing experiences, advocating best practices, and stimulating actions in seven South American countries: Argentina, Brazil, Chile, Colombia, Paraguay, Peru, and Uruguay.

PASB assisted countries in implementing multidisciplinary, evidence-based operational interventions for antimicrobial stewardship programs:

A Hospital Antimicrobial Use Point Prevalence Survey was conducted in Barbados, Guyana, and Saint Lucia, and a standardized tool was developed in a secure web-based application to capture data for the survey on antibiotic use.

Practical guidelines were published for decisionmakers in support of health workers and for the implementation of cost-effective AMR stewardship interventions.[94]

Seven countries—Costa Rica, Cuba, Guyana, Mexico, Nicaragua, Paraguay, and Peru—were supported to implement antimicrobial stewardship programs.

A one-week training in AMR detection, surveillance, and analysis was held for microbiologists and health information officers from the Caribbean subregion.

The Bureau facilitated the development of a two-year CCHD initiative between Argentina and CARICOM aimed at strengthening national and regional AMR detection and surveillance in the 14 independent CARICOM Member States.[95] The initiative aims to build technical capacity to conduct high-quality testing for the detection of AMR, collate and analyze AMR laboratory data, and use the laboratory results to monitor trends and improve prescribing practices, as well as to foster AMR policies, prevention, and interventions. The initiative contributes to the implementation of the WHO Global Antimicrobial Surveillance System (GLASS), which was launched in 2015 to support the implementation of the Global Action Plan on Antimicrobial Resistance. It also supports Caribbean countries in achieving compliance with the IHR, and as of mid-2019, PASB was seeking to mobilize resources to allow the Dutch and United Kingdom territories in the Caribbean to participate in the initiative.

The Bureau participated in the 2019 meeting of the United States of America Presidential Advisory Council Combating Antibiotic-Resistant Bacteria (PACCARB) and in several PACCARB meetings and discussions regarding surveillance, antimicrobial stewardship, and infection prevention and control. The Bureau also played a prominent role in ensuring that AMR was included in the Declaration from the G20 Leaders’ Summit held in Argentina in late 2018.

The PASB took part in negotiations with the Government of Denmark, the World Bank, and the Consultative Group for International Agricultural Research (CGIAR) to reach an agreement for the establishment of the International Centre for Antimicrobial Resistance Solutions (ICARS) in Denmark. ICARS will strengthen the global fight against AMR, serving as an independent global knowledge center and resource for national and international bodies, and promoting tailored and economically feasible solutions that take into account all aspects of the One Health approach, with particular focus on low- and middle-income countries.

In related work, PASB partnered with the U.S. CDC and Canada to support a meeting of the Regional Network for Antifungal Resistance Surveillance of Invasive Mycotic Diseases. The Network will coordinate regional surveillance and strengthen national capacities in the implementation of the Global AMR Surveillance System. Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Guatemala, Mexico, Panama, Peru, Venezuela, and the United States of America are part of the regional organization, which is developing a surveillance protocol for antifungal resistance in Candida species, a common source of hospital-acquired bloodstream infections. A pilot project using the protocol in Latin America is planned for 2020.

Food safety

Food safety and food inspection, based on risk analysis, are vital components of a modern food control system. PASB worked at the Caribbean subregional level to strengthen risk-based regulation by national food safety authorities in the subregion, and a key output during the review period was the development of a generic manual on risk-based inspection. The manual targets national food safety authorities responsible for ensuring food safety in the interests of public health, consumer protection, and international trade. The manual is consistent with Codex Alimentarius guidelines and standards, particularly principles and approaches for national food control systems and food hygiene, as well as the other codes of practice, such as for fish, dairy, meat, and street foods. The manual was validated by senior food inspectors who were trained on risk-based food inspection at a subregional workshop, and serves as both a training tool for use by national food safety authorities and a template for the creation of national manuals for Caribbean food inspectorates. 

The Inter-American Network of Food Analysis Laboratories (INFAL) encompasses 250 member laboratories from 31 countries.[96] In 2018, approximately 5,000 technical laboratory personnel from 19 countries[97] were trained through INFAL webinars. The Network also coordinated one interlaboratory comparison in microbiology with 41 participants from 23 countries.[98]

PASB also undertook technical cooperation at the national level.

Food safety systems were assessed in Costa Rica, El Salvador, and Suriname, and the implementation of recommendations for their strengthening was initiated.

Honduras received funding in the amount of $150,000 from the FAO/WHO Codex Trust Fund to strengthen its national Codex Committee, with activities lasting until 2021; the Bureau provided technical cooperation for the implementation of the project.

In Peru, PASB undertook technical cooperation with the General Directorate of Environmental Health and Food Safety of the Ministry of Health (DIGESA), in collaboration with the National Agrarian Health Services of the Ministry of Agriculture and Risk (SENASA) and the National Fisheries Health Agency of the Ministry of Production (SANIPES), to develop food safety risk communication guidelines.

In Trinidad and Tobago, a national food safety policy was developed and approved by the national Cabinet.

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Strengthening mechanisms to measure and track inequities and progress towards Sustainable Development Goals and targets is a priority for the PASB. The Bureau convened a regional meeting in March 2019 titled “The Sustainable Development Goals in Health in the Americas: Challenges for the Monitoring of Equity and Proposals for Progress.” The event initiated the establishment an Organization-wide, equity-focused, framework to monitor regional and country-level progress towards the SHAA2030 and SDG 3 targets. Potential methodologies for measuring inequalities related to the 27 SDG 3 indicators were examined, and the meeting produced a map linking each indicator with routine data collection mechanisms to determine baseline and target data. Participants in the meeting included personnel from across PASB’s technical departments and several PAHO/WHO country offices, as well as experts from WHO in Geneva, the WHO Regional Office for Europe, the Federal University of Pelotas in Brazil, the Institute for Health Metrics and Evaluation (IHME), and the Johns Hopkins University Bloomberg School of Public Health.

PASB’s work in health promotion addresses the social determinants of health and is a critical component of technical cooperation with Member States to advance the SHAA2030. During the review period, the new framework for relevant technical cooperation, the regional Strategy and Plan of Action on Health Promotion within the Context of the Sustainable Development Goals 2019-2030 (Document CD57/10), was developed through an extensive consultative process. The process included a regional meeting in Brazil, which drew 70 participants from 31 countries and territories,[99] and 35 national consultations involving ministries of health and representatives from other sectors, including academia and civil society.[100] The finalized document was approved by the 164th Session of the Executive Committee for presentation to the 57th Directing Council in September 2019.

The degree to which health promotion is used as a crosscutting approach varies among countries, and there is need for all Member States to include health promotion in their national health policies and plans as an approach that includes not only health education activities but also intersectoral work, community participation, and other aspects of the PHC strategy. Seventeen countries[101] have health promotion policies; 9 include health promotion in their national health plans: Argentina, Chile, Colombia, Costa Rica, Cuba, Ecuador, Jamaica, Mexico, and Peru; and 7 have a national strategy on health promotion: Chile, Costa Rica, El Salvador, Guatemala, Mexico, Panama, and Peru.

In order to strengthen the implementation of the SHAA2030 at the local level and advance health-promoting policies, PASB worked with the Latin American Federation of Cities, Municipalities and Associations of Local Governments (FLACMA) to reinvigorate the healthy cities and municipalities movement in the Region. The Bureau contributed to the creation of a special Health Commission within FLACMA to focus on health promotion, HiAP, and the implementation of the SHAA 2030 and the 2030 Agenda for Sustainable Development at the local level.

PAHO has celebrated Wellness Week in the Americas annually in September since 2011, modeled after the annual Caribbean Wellness Day established by CARICOM heads of State and government through their seminal 2007 Port-of-Spain Declaration on NCD prevention and control, and celebrated each September. The Wellness Week initiative seeks to mobilize a range of actors with the potential to positively impact their communities, including health promoters, staff from ministries of health, mayors, community leaders, and civil society in general. The slogan of Wellness Week 2018 was "Building healthy communities for everyone," highlighting the importance of health promotion in everyone's decision-making, in all settings, to improve the lives of all. The 2018 campaign highlighted stories of persons from eight countries—Barbados, Belize, Bolivia, Colombia, Cuba, Ecuador, El Salvador, and Jamaica—undertaking health promotion interventions in their communities.

In mid-2018, PASB began a review of current approaches for addressing health equity in its technical cooperation. The review examined the coherence and effectiveness of health equity mandates and technical cooperation undertaken in fulfillment of the PAHO Strategic Plan 2014-2019, and analyzed barriers to the implementation of health equity initiatives within the Organization. The assessment concluded that much work in health equity had been concentrated on the measurement of inequalities and on approaches within the UH and social determinants frameworks, and proposed strategies for a broader range of health equity approaches.

In September 2018, the Commission on Equity and Health Inequalities in the Americas, which was established by the Director of PAHO in 2016 under the chairmanship of Sir Michael Marmot, submitted to the 56th Directing Council an executive summary of its findings on the social causes and contexts of ill health in the Region and proposals for effective action to address them. In April 2019, PASB received the Commission’s final report, which contains 12 recommendations framed around three principal factors influencing health equity: structural drivers (political, social, cultural and economic structures; structural racism; and climate change), conditions of daily life (early life and education, working life, income and social protection, violence, environment and housing, and health systems), and governance systems and the observance of human rights. The report also recognizes the intersection and compounding effects of the various forms of disadvantage, and, in response, PASB established an interprogrammatic group to analyze optimal alignment of the Bureau’s work with the Commission’s recommendations. A related information document was developed, and it will be presented to PAHO’s 57th Directing Council in September 2019, coinciding with the regional launch of the Commission’s final report.

In January 2019, PASB secured funding from a significant new partner, the Robert Wood Johnson Foundation, to support a priority focus on equity in health. The resources target knowledge gaps on the scope and effectiveness of national and subnational policies to reduce health inequities; enhancement of knowledge exchange with health equity networks that include civil society, academia, and program implementers; and development of guidance, tools, and training on pro-health equity policy-making and planning for Member States.

During the review period, the Bureau conducted and published a systematic review of HIV, STIs, and viral hepatitis among indigenous and Afro-descendant people in Latin America.[102] The study identified gaps in existing data on the burden of these diseases and highlighted the need to improve national surveillance by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; to develop a Region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and to implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.

PASB conducted extensive national and subnational consultations with indigenous peoples, Afro-descendants, Roma people, ministries of health, and other relevant entities using a variety of modalities—including face-to-face and virtual meetings—to inform the development of the PAHO Strategy and Plan of Action on Ethnicity and Health 2019-2025 (Document CD57/13). The aim was to ensure that all perspectives were incorporated into this new framework, which will be presented to the 57th Directing Council in September 2019. The framework builds on the 2006 Health of Indigenous Peoples of the Americas initiative (Document CD47/13); aligns with the OAS-PAHO Plan of Action for the Americas for Implementation of the International Decade for People of African Descent 2016-2025; implements the guidance in the PAHO Policy on Ethnicity and Health, adopted by the 29th Pan American Sanitary Conference in 2017 (Document CSP29/7, Rev. 1); and takes into consideration the 2018 PAHO Health Plan for Indigenous Youth in Latin America and the Caribbean and the 2018 PAHO Health Plan for Afro-descendant Youth in Latin America and the Caribbean. Once approved, the new Strategy and Plan of Action will provide significant guidance for advancing health equity in the Region of the Americas.

PASB collaborated with the National Center for Intercultural Health in the Ministry of Health of Peru to promote the inclusion in health registries of the self-identification of indigenous, Afro-Peruvian, and other peoples. Such identification allows analysis of disaggregated data, identification of inequities, and development of specific actions to address the needs of people in conditions of greatest vulnerability and exclusion. Also in Peru, the Bureau supported the piloting of a WHO qualitative tool for use in conducting situation analyses of demand-side barriers to effective access to health faced by people working in the informal economy. The pilot focuses on the situation of Venezuelan migrants, and the results will inform initiatives to advance UH in Peru.

A pro-equity methodology called the Cross Cutting Themes[103] (CCTs) Criteria Tool was developed in 2017 under the IHSLAC project. PASB has refined and piloted a more integrated version of the instrument, creating an online platform with user-friendly guidance and examples to facilitate use of the methodology. The new version was applied in PAHO/WHO country offices for reporting on the IHSLAC project at the end of 2018. PASB plans to use the new methodology and platform more widely to create, monitor, and keep updated a database of the approaches that both the Bureau and Member States use to address the CCTs.

Advancing gender equality in health

Gender inequality is well recognized as a significant underlying driver of health inequity among men, women, and those with diverse gender identities. This inequality is mediated through socially and culturally determined male-female differences in exposures, behaviors, and access to health care, and through biases in health service provision and health research, among other factors.

During the reporting period, PASB undertook a study to review regional and country efforts towards gender mainstreaming in health (GMH). The study included an analysis of gender mainstreaming definitions and institutional requirements in regional policy documents and mandates; a systematic review of documented results of gender mainstreaming in national health policies and programs, focusing on gender and health priorities in SDG 3 and SDG 5; a review of PAHO documents, scientific publications, and information available on the web; and conducting semi-structured interviews with experts. These components were complemented by the development of three case studies—in Guatemala, Guyana, and Peru—focusing on stakeholders’ experiences and lessons learned from the mainstreaming of gender in the respective health sectors. The studies were completed with the countries’ participation, and for each country PASB organized virtual presentations of the findings and recommendations and facilitated collaboration among partners to stimulate further work.

The comprehensive FASB study and the case studies in the three countries have led to a series of recommendations on GMH: setting minimum requirements for institutional as well as programmatic interventions; documenting effective and successful strategies and their results; expanding the scope and definitions, with measurable operational plans and a focus on results; and strengthening capacities for gender-based analysis and monitoring and evaluation. The recommendations were presented at an expert group meeting during the Women Deliver 2019 Conference held in Vancouver, Canada, in June 2019.

PASB’s technical cooperation contributed to the strengthening of capacities for gender analysis in Grenada, Saint Lucia, and Saint Vincent and the Grenadines, with the intent to extend similar interventions to other eastern Caribbean countries. The initiative involved the development of gender profiles on specific health topics—such as HIV and STIs—in collaboration with each ministry of health and its partners, to provide baseline information for monitoring advances and developing new initiatives.

In efforts to strengthen the capacity of Caribbean health systems to respond to violence against women, a training-of-trainers exercise was implemented in that subregion on evidence-based health system responses to survivors of intimate partner and sexual violence. The main objectives of this work were to strengthen health care providers’ capacity to identify, and provide care for, survivors of violence, and to strengthen the collaboration between government and CSOs that provide care to women survivors. The intervention was undertaken in collaboration with the Public Health Agency of Canada (PHAC) and the Johns Hopkins University School of Nursing (JHSON-CC), which is a PAHO Collaborating Center for HRH. Other partners included UNFPA, UNICEF, UN Women, the World Bank, and CARICOM.

In late 2018, the Bureau signed a memorandum of understanding with the World Professional Association for Transgender Health (WPATH), a nonprofit, interdisciplinary, professional and educational organization devoted to transgender health, to develop a five-module virtual course on LGBT health. The course will be hosted by the PAHO VCPH and is expected to be launched by the end of 2019.

In 2018, the Director of PAHO developed a report on LGBT health and barriers in accessing health services (Document CD56/INF/11, Corr.) with input from PASB’s LGBT interprogrammatic working group. The presentation of the report to the 56th Directing Council in September 2018 fulfilled a mandate established in 2013 through PAHO resolution CD52.R6 “Addressing the causes of disparities in health service access and utilization for LGBT persons.” The findings and recommendations of the Director’s report aim to guide countries’ efforts to eliminate barriers that LGBT persons experience in accessing health services, particularly by promoting social and financial protection in a nondiscriminatory manner, and protecting their right to health.

Improving adolescent health

Adolescents face many barriers to receiving the full range of quality, age-appropriate preventive, promotional, and curative services that they need. Where services exist, they may be fragmented and not aligned with the health care needs of young people. Multisectoral approaches and interventions targeting families, schools, and communities, and efforts to identify and target the most vulnerable groups of young people with evidence-based interventions, remain limited in number and scope.

PASB’s technical cooperation in adolescent health contributes to advancing a number of SHAA2030 targets, in particular those related to NCDs and mental health disorders, communicable diseases, road traffic incidents, violence, substance abuse, maternal mortality, and sexual and reproductive health. In 2018, PASB finalized a regional report on the status of adolescent health in the Americas,[104] based on 19 regional indicators and information on the implementation of the PAHO Adolescent and Youth Regional Strategy and Plan of Action 2010-2018. The report reveals that significant progress has been made at regional and country levels in the development and implementation of actions for adolescent and youth health, including the establishment of adolescent health programs in most countries; the availability and use of strategic information; expansion of health services for adolescents; capacity-building of stakeholders in a range of adolescent health topics; and introduction of school- and family-based interventions. However, the report also notes that not all groups have benefited equally from this progress, and adolescent mortality has remained stagnant, with homicides, suicides, and traffic fatalities as leading causes of death in this age group.

The regional report’s recommendations include provision of adequate funding for multisectoral adolescent and youth health programs that address the social determinants of health; establishment of an adolescent-responsive health system; implementation of school-, family-, and community-based interventions to protect and promote children’s and adolescents’ health; utilization of evidence-based approaches that target groups in conditions of vulnerability; monitoring and evaluation to inform strategic planning and timely adaptation of programs and services; and engagement of young people as agents of change.

WHO’s Global Accelerated Action for the Health of Adolescents (AA-HA!), launched in 2017, provides guidance for developing comprehensive, evidence-based, multisectoral adolescent health plans and strategies that are aligned with the SDGs and the Global Strategy for Women’s, Children’s and Adolescents’ Health. During the period under review, PASB trained teams from eight countries—Brazil, Dominican Republic, Ecuador, El Salvador, Haiti, Honduras, Panama, and Peru—to apply the AA-HA! guidance, and supported four countries— Belize, Honduras, Guyana, and Suriname—to develop a new generation of adolescent health plans.

In addition to supporting the use of WHO’s Innov8 tool to review interventions for the reduction of adolescent pregnancies, PASB supported the use of the tool to analyze adolescent health programs. Innov8’s eight-step analytic process for health programs aims to operationalize the SDGs’ commitment to “leave no one behind,” and its application results in recommendations for concrete actions to address health inequities, support gender and ethnic equality, address critical social determinants of health, and progressively realize UH and the right to health.

The Bureau supported the translation and implementation of the WHO 2019 publication “Handbook for conducting an adolescent health services barriers assessment (AHSBA) with a focus on disadvantaged adolescents.” The AHSBA is a methodology for identifying subpopulations without effective health service coverage and the most important barriers that they face. Mexico has requested the implementation of the ASHBA during the next year.

Environmental health, water, sanitation, and hygiene

PASB’s technical cooperation over the reporting period contributed to the reduction of insults and threats to the health of the environment, and to enhancing water, sanitation, and hygiene in countries and selected subregions.

In collaboration with ministries of health, environment, and energy, the Bureau conducted a situational assessment of national readiness to reduce the residential use of solid fuels and kerosene using the Household Energy Assessment Rapid Tool (HEART) in Honduras, Mexico, Panama, Paraguay, and Peru. The HEART toolkit is a novel method to stimulate conversation between sectors following the Health in All Policies guidelines. Using the toolkit with the countries allowed PASB to engage the respective health sectors in relevant discussions and produce a report for each country that provides a diagnosis of the situation and a road map to improve access to clean energy for all.

As part of the global BreatheLife campaign—a joint initiative of WHO, UN Environment, and the Climate and Clean Air Coalition—PASB helped build capacities to address ambient air pollution in several Member States. This technical cooperation included a workshop in Colombia on air monitoring systems, emissions inventories, and transport, as well as support for the development of road maps for action in Argentina, Honduras, and Paraguay.

The Bureau supported the training of environmental health officers and other stakeholders in British Virgin Islands, Montserrat, and Saint Kitts and Nevis in monitoring indoor air quality. In addition, country capacity was enhanced in the area of onsite wastewater management, and specific country guidelines were developed and adopted.

In the Central American subregion, PASB proposed and negotiated an initiative on air quality and health with the PARLACEN, which endorsed it by resolution in May 2019. The resolution recognizes poor air quality as a public health issue and as a significant environmental risk factor for NCDs that should be prioritized and adequately addressed. The resolution requires SE-COMISCA and the Central American Commission for Environment and Development (CCAD) to establish or strengthen technical norms for air quality to protect people’s health; urges SICA Member States to review their legal frameworks in this area; and calls for the creation, with PASB technical cooperation, of an observatory on air quality in the Central American subregion. PASB proposed a model law for use in creating or strengthening legislation related to air quality, which was also approved by the PARLACEN.

With funding from UN Environment and the Global Environmental Facility (GEF), the Bureau undertook technical cooperation on the elimination of lead in paint, organizing the first regional workshop on the subject in June 2019. PASB also began work on other GEF projects for the implementation of the Minamata convention on mercury, in Argentina (thermometer replacement), the Caribbean (skin lightening products), and Uruguay (dental amalgam phasedown).

PASB applied the WASH Protocol in Health Care Facilities to evaluate health care facilities in six countries—Bolivia, Guatemala, Honduras, Panama, Paraguay, and Peru—on measures related to water, sanitation, hygiene, drainage, health care waste, and vector control. This information, which will form the basis for the integration of WASH into national health policies and plans, was the core source of regional data for the WHO-UNICEF Joint Monitoring Program’s WASH in Health Care Facilities: Global Baseline Report 2019, which was published in April 2019. Partners and supporters in this work included WHO, UNICEF, the IHSLAC project, and the Government of Peru.

In Brazil, the Bureau coordinated and implemented TrackFin, a methodology for tracking financing for WASH at the subnational level. In addition, the Bureau applied the Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) methodology in 25 countries and territories.[105] Both instruments revealed substantial gaps in countries’ understanding and tracking of financing to the WASH sector, which makes it difficult to generate evidence-based planning and budgeting decisions. PASB will continue to promote the TrackFin methodology and support a regional study on the affordability of WASH services within a human rights framework. Partners and supporters in this work include the Association of Regulators of Water and Sanitation of the Americas (ADERASA), AECID, FIOCRUZ Brazil, the Government of Peru, and WHO.

Migration and health

In 2018, Member States faced important challenges regarding health and migration, described above under SHAA2030 Goal 8, “Outbreaks, emergencies, and disasters.” Additionally, noting State-led actions on international migration, PASB convened a high-level meeting in Washington, D.C., in November 2018, where ministers of health and other representatives from 32 countries and territories[106] across the Region of the Americas identified a series of actions aimed at improving the health response to the mass migration that is occurring in the Region.[107] Based on that input and in further consultation with Member States, PASB published the Guidance Document on Migration and Health, which outlines people-centered actions, a multi-hazard approach, and shared responsibility among national and subnational institutions and authorities, and the public and private sectors.

Enhancing country focus and international cooperation for health

The results of PAHO’s technical cooperation are manifest in its Member States, and PASB continued to tailor its country-level interventions according to national priorities and needs, identified through development of a Country Cooperation Strategy (CCS) for each country. Each CCS is fully aligned with SHAA2030, SDG 3, and related SDGs, as appropriate to the national situation. Each CCS also guides the Organization’s work with and in the country, as well as reflects the midterm vision for technical cooperation with the respective Member State. During the reporting period, CCSs were completed in 10 countries—Antigua and Barbuda, Barbados, Bolivia, Brazil, Chile, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines—and evaluated in 4: Costa Rica, Dominican Republic, Mexico and Panama.

Guided by the principle of “leaving no one behind” and attendant to the needs of the eight designated Key Countries, which face critical structural, economic, and social challenges, PASB advanced implementation of the PAHO Key Country Strategy. Close monitoring and adjustment of technical cooperation with these countries during the review period, including a formal review of the technical cooperation with Haiti, resulted in timely and effective interventions in the countries, which maximized PASB’s added value and impact.

PASB has a long history of championing and contributing to the promotion of South-South and triangular cooperation, initially through its technical cooperation among countries (TCC) initiative, and now through the CCHD program, the successor to TCC. CCHD not only leverages the expertise within the Organization, but also—as importantly—identifies and mobilizes the know-how within countries themselves to formulate tailored solutions to health issues. During the reporting period, the experiences of cooperation among PAHO Member States were documented in publications by the UN Office of South-South Cooperation (UNOSSC),[108] the Ministry of Foreign Affairs of Argentina,[109] and WHO.[110]

For the second consecutive year, PASB and the Ibero-American General Secretariat (SEGIB) joined forces to contribute to the visibility and understanding of South-South and triangular cooperation in the health sector in the Region of the Americas, by developing and publishing a collaborative report.[111] This 2018 edition, which was launched during the Second High-level UN Conference on South-South Cooperation (BAPA+40) held in Buenos Aires, Argentina, in March 2019, presents country profiles for each of the Member States that reported to SEGIB. The report also analyzes the contribution of South-South and triangular cooperation to the SDGs beyond SDG 3, demonstrating the multisectoral approach of the projects.

Over the review period, five projects were approved through the CCHD initiative, facilitating exchanges among 25 countries and territories,[112] of which 6 are Key Countries. The five projects were:

towards universal health for the population of the South American Chaco, involving Argentina, Bolivia, Brazil, and Paraguay;

advancing public health policies to address overweight and obesity in Chile and the CARICOM, involving CARICOM and Chile;

improvement of maternal and child health at the northern border of the Dominican Republic and Haiti, involving the Dominican Republic and Haiti;

strengthening national and regional antimicrobial resistance detection and surveillance in CARICOM Member States, involving Argentina and CARICOM;

generating critical information for planning and monitoring cancer control programs in Latin America, involving Argentina, Colombia, El Salvador, Guatemala, Panama, Paraguay, and Peru.

 PASB allocated $1.9 million to this cooperation modality and mobilized $1.2 million in in-kind contributions from the participating Member States. All the projects contributed directly to selected SHAA2030 and SDG 3 targets, as well as to SDGs 2 and 17. In addition, PASB worked to strengthen the offices of international relations of the ministries of health and launched a community of practice for representatives of those offices in November 2018. The objectives of this community of practice are to facilitate improvements in national governance for global health and international cooperation for health, and promote health diplomacy and cooperation among countries.

PASB’s country focus was also enhanced through close collaboration with Member States in critical planning, budgeting, and assessment exercises, including the joint end-of-biennium evaluation process; development of the proposed PAHO Strategic Plan 2020-2025, along with indicators for the Plan and the SHAA2030, through the SPAG; development of the new regional Budget Policy; and preparation of the proposed Program Budget 2020-2021. More details are provided in Part 3 of this report under “Planning and budgeting.”

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