The Region has in recent years proved capable of seizing many of the opportunities presented by the global economy. While overall GDP growth has not matched the levels of the world�s most successful regions, the Americas have experienced six years of sustained economic expansion-the longest and largest such expansion since the 1960s. This growth has helped put the Region on track to meet the first Millennium Development Goal (MDG), reducing extreme poverty by half by 2015. In 2007, according to the U.N. Economic Commission on Latin America and the Caribbean (ECLAC), 12.7 percent of the Region�s population was living in extreme poverty, down 44 percent from 1990. This means the Region has advanced 87 percent toward MDG #1 in just 68 percent of the allotted time.

Economic expansion has also spurred increases in the Region�s social spending, which grew an average of 10 percent between 2002�2003 and 2004�2005. Despite this increase, per capita levels remain low compared with other regions in the world. Moreover, there are enormous differences between countries; social expenditure per capita is 15 times greater in the highest-spending country than in the lowest. Most important, much of the Region�s social spending is directed toward social security systems that are linked to participation in the formal work force. Social programs aimed at fighting poverty, such as conditional cash transfer programs, generally receive a much smaller share of the pie. These shortcomings in social spending are reflected in the Region�s slower progress in reducing non-extreme poverty and in the failure to reduce high levels of inequality.

Recent demographic trends have major, but mixed, implications for the Region�s social development. Lower fertility rates have eased pressure on family breadwinners and government services but have also created new health challenges associated with an aging population. Internal migration has diminished in recent years and has shifted from rural-urban flows toward greater movement between and within cities and countries. An emerging concern is growing residential segregation in cities, which results from and reinforces patterns of inequality and exclusion. In the least urbanized countries, rural-urban migration remains a powerful and often destabilizing force that exacerbates existing social inequalities between rural and urban groups. International migration, which continues to increase, benefits the Region through growing remittances but also drains human resources in vital areas such as science, technology, and health.

Social exclusion in the Region continues to occur on the basis of income, age, gender, race or ethnicity, and disability, affecting individuals� and groups� access to health and quality of life. This is nowhere clearer than among the Region�s nearly 50 million indigenous people, whose historic exclusion manifests itself in poorer status on a wide range of health indicators, including malnutrition, child and maternal mortality, and life expectancy.

In the area of environment, the Region of the Americas continues to face significant pressures, including, but not limited to, climate change. Deforestation, erosion, and desertification are affecting all of the Region�s countries to one degree or another, threatening food and water security and increasing the population�s vulnerability to natural disasters. Unplanned urban and industrial growth have led to growing air, water, and soil contamination, which are a particular threat to the Region�s children, who are more vulnerable to their health effects. Water and sanitation coverage has expanded, yet more than one in five of the Region�s inhabitants still lack access to such services. While these trends affect the health situation throughout the Region, their negative impacts are greatest in the small island states of the Caribbean and in the Region�s poorest countries, which have less capacity to respond.

Apart from its effects on economics and the social determinants of health, globalization presents special opportunities and challenges in public health for PAHO Member States. Increased trade and migration and progress toward economic integration have led to increased permeability of national borders. This has contributed to the global spread of new diseases such as HIV/AIDS, SARS, West Nile fever, and H5N1 influenza (�avian flu�) as well as others that were once largely controlled, including tuberculosis, dengue, malaria, and yellow fever. This growing interdependence and shared vulnerability have led to new collaboration between countries, reflected in the regional integration processes as well as in specific efforts related to health. Examples in the Americas include coordination among PAHO Member States and United Nations agencies to prevent and prepare for highly pathogenic H5N1 avian influenza-efforts that so far have prevented even a single case of the disease in the Region. With PAHO leadership, countries are also collaborating strategically to prevent and control diseases including yellow fever, dengue, tuberculosis, malaria, and human rabies. Examples of these efforts are described in more detail in Chapter 3.

At the global level, the new International Health Regulations (IHR), which took effect in June 2007, provide a framework for cooperation to prevent the international spread of diseases and other health threats. With support from the PASB, PAHO Member States are strengthening their public health structures to facilitate full compliance with the IHR by the target date of 2012.

Growing international cooperation has also brought important progress in establishing and supporting common development goals, as the international community strives to transform globalization into a more balanced and harmonious process. These efforts are most eloquently embodied in the United Nations Millennium Declaration and the MDGs and can also be found in joint statements and agreements emerging from Regional summits on issues of human development, in which PAHO has been an active participant (see Chapter 3). They reflect a growing international consensus that puts health at the center of the development process and, with its emphasis on equity, reaffirms the concepts of universalism and health as a basic human right. While the right to health is enshrined in 19 of the 35 constitutions of PAHO Member States and in the Constitution of the World Health Organization (WHO), this new prominence on the international development agenda provides an important stimulus for public health action in general and, in particular, for the promotion of universal access to health care. In the Region, these processes are influencing how countries define and pursue their own development goals.

The MDGs and related efforts have helped increase overall levels of international development assistance, although Latin America and the Caribbean have received a relatively small share of the increase. The increases have been accompanied by new efforts to make assistance more effective, chief among them the High-Level Forum on Aid Effectiveness (which issued the 2005 Paris Declaration), through which donors and international cooperation agencies are harmonizing their own priorities and procedures to help countries make better use of development aid. This process has included surveys and diagnostics of countries� capacities to absorb assistance through the use of effective policies and strategies and through results-based management techniques. The United Nations reform process similarly is aimed at making the work of U.N. development agencies more effective, more coherent, and more responsive to country needs and priorities. The U.N. Development Assistance Framework (UNDAF) and the Common Country Assessments (CCA) provide a planning framework for the work of all U.N. agencies at the country level, based on common objectives and cooperation strategies and with a system for programming resources and proposals for monitoring and evaluation. The PAHO Country Cooperation Strategy (CCS), which lays out the roles and functions of the PASB in supporting countries� national health plans and other health actions, is directly linked to CCA/UNDAF (see also Chapter 3). For PAHO, this coordinating mechanism not only facilitates planning, it presents a unique opportunity to promote intersectoral action on health and to address the most critical social determinants of health.

No contextual factor is more important to health progress in Latin America and the Caribbean than the state of health systems. Historically based on different models of social protection, most of the Region�s health systems were originally structured to serve distinct population groups defined primarily by their roles in the formal labor market. The result was a series of subsystems with different modes of financing, forms of affiliation, and standards of care. The health sector reforms of the 1980s and 1990s, which were linked to macroeconomic adjustment, failed to address these problems, focusing instead on cost-effectiveness and financial sustainability. Rather than integrate public health systems, the reforms promoted decentralization and a greater role for the private sector. In the process, they left health systems segmented and fragmented, and weakened the role of the State in providing leadership and direction for public health.

Solving these systemic problems in the Region�s health sector has been a major focus of new efforts by PAHO Member States to integrate their health systems and strengthen the ability of the State to perform its steering role in public health. These are part of larger efforts to strengthen the role of the State in ensuring equity and sustainability in development through its distribution of fiscal spending between areas and programs, levels of government, and geographical regions, thereby responding more appropriately to peoples� needs. The PASB is supporting these efforts by promoting the Essential Public Health Functions of the State and through technical cooperation programs on health policies and systems, human resources development, and health services organization. Also important is the PASB�s work in promoting primary health care strategies in conjunction with WHO�s Global Task Force on Primary Health Care, co-chaired by PASB Director Mirta Roses. An important development was the endorsement by PAHO Member States in 2005 of primary health care as the best strategy for organizing the Region�s health systems to achieve both greater equity and sustainability.

Building on these efforts, the PASB in 2006�2007 played a catalytic role in the development of a Regional framework to guide national and international health planning and action in PAHO Member States. The culmination of this process was the launch in 2007 of the Health Agenda for the Americas 2008�2017.

The adoption of the Health Agenda for the Americas by PAHO Member States is an important achievement in itself, but its success will depend on how effectively the Region�s countries, the PASB, and their international partners work to achieve its goals. In this respect, strategic planning is an essential means to ensure that this work is guided by well-defined objectives, supported by effectively allocated resources, and aimed at measurable results. The PASB has made strategic planning a central component of its own work and is actively promoting its use in PAHO Member States.

Chapters 2�4 detail these efforts through examples from the countries, at the subregional level, and from the PASB itself.