Effective leadership is crucial to reforming health systems along the lines of the new vision of primary health care. Ministries of health must play a strong steering role vis-à-vis their health systems and mobilize additional advocates to present a strong, evidence-based case for needed reforms in dialogue with all sectors of government and society.

During 2008–2009, PAHO and its member countries carried out a number of initiatives aimed at promoting a primary health care orientation through cross-sector advocacy and dialogue, building of leadership capacity, and improvements in health information gathering.

In Argentina, PAHO has helped build support for health promotion and efforts that address the social determinants of health through the National Healthy Municipalities and Communities Program. The program mobilizes local actors to support and carry out actions that increase access to essential health services, promote environmental health, expand opportunities for education and employment, and encourage healthy lifestyles. PAHO has worked to strengthen the technical and institutional capacity of the program to build intergovernmental and intersectoral alliances that advocate for healthy public policies and actions at the national and local levels.

In the Bahamas, PAHO continued its support in 2008–2009 for the development of a Public Health Information System that will help standardize and computerize all medical records at the primary care level. The system will provide a consolidated patient database to facilitate analyses of morbidity, mortality, and other indicators to provide evidence for better decision-making at the national, community, and health facility levels. PAHO has also worked actively with the Ministry of Health to strengthen management of the national pharmaceutical system, helping develop a new regulatory framework for pharmaceutical supplies and providing critical review of a newly developed Pharmacy Act.

In Belize, the Ministry of Health has improved its health information collection, collecting and disaggregating data by age, sex, and geographical location. The Belize Health Information System was rolled out nationally in 2008, with technical cooperation from PAHO, the Health Metrics Network, and other partners, and is a model for an affordable, efficient, effective, and confidential computer system that will provide evidence for health decision-making. The system creates an electronic health record for every patient using the country’s primary care services and facilitates the identification and reduction of inequities. In 2008, PAHO provided special support for the application of gender analysis to health data, using HIV and road traffic injuries as examples.

As part of a five-year effort to help Member States reduce gender inequalities in health, PAHO organized a series of workshops in 2008–2009 for ministry of health personnel and members of civil society from the Caribbean, Central America, and the Andean Region on how to incorporate a gender approach into health analysis and planning for their countries’ health systems. PAHO also developed a series of information products and guides on disaggregation of data and other aspects of gender- and ethnic-based analysis. A related workshop in Colombia focused on indigenous populations and Afro-descendants. Examples of noteworthy progress during 2008–2009 in incorporating gender and ethnic perspectives included efforts involving the Integrated Management of Childhood Diseases (IMCI) strategy in Ecuador and the national health system of Paraguay. Also during 2008, PAHO organized a best-practices contest to highlight and disseminate efforts to integrate ethnicity and gender into health systems.

In the Dominican Republic, PAHO helped the Ministry of Public Health and Social Assistance organize the 2008 Dominican Forum on Primary Health Care, which brought representatives of the health sector together with political and community leaders to reach agreement on how to strengthen primary health care. PAHO also supported the ministry’s launch of a new Regional Strategy on Neonatal Health, in which 17 organizations committed themselves to the strategy as a way of advancing the Millennium Development Goals. The strategy includes a Plan of National Action and Profile of Child Health that uses data disaggregated at the provincial level to identify gaps and inequities in newborn health at the local level. PAHO also helped the ministry strengthen its Health Accounting Unit, by developing indicators for total health spending in 2008 and accounting methods to track spending on HIV/AIDS, medicines, and the country’s cost-free Health Risk Insurance program.

In Barbados and the Eastern Caribbean, PAHO is supporting the implementation of the Pan American Stepwise Survey for Chronic Noncommunicable Diseases and their Risk Factors to gather evidence to inform policy development and enhancement of health services. Dominica, Saint Kitts and Nevis, and Barbados have implemented the survey, and the British Virgin Islands and Grenada have begun the process.

To improve the evidence base for developing violence prevention programs, PAHO in 2008–2009 worked with the PAHO/WHO Collaborating Center for Violence and Health (CISALVA) at the Universidad del Valle in Cali, Colombia, to help establish violence and crime “observatories” in Colombia, El Salvador, Honduras, Nicaragua, and Panama. PAHO helped establish similar observatories for gender-based violence in Barbados, Bolivia, Chile, El Salvador, Grenada, Honduras, Nicaragua, St. Vincent, and Uruguay, to support analysis of and awareness-raising about violence against women, as well as the development of care models for battered women. In Mexico, PAHO worked with the PAHO/WHO Collaborating Center for Injuries and Violence Research at the National Institute for Public Health to develop interventions for battered women and male aggressors.

In addition, PAHO helped draft the 2008 Declaration of Ministers of Health on Violence and Injuries in the Americas, issued in Mérida, Mexico, which formed the basis for a resolution (CD48.R11) of the 48th PAHO Directing Council. The declaration calls for stronger action by governments and civil society to prevent and control violence and injuries, particularly through the construction of safe, healthy, and sustainable environments. The declaration also calls for better treatment for victims of violence and injuries and comprehensive care that includes health promotion and incorporates human rights, gender, and intercultural approaches. It also calls for improved emergency services, trauma care, and rehabilitation services and for more legal and social services for violence and injury victims. PAHO, in conjunction with other United Nations agencies, is also working with national and local governments in Brazil, Colombia, El Salvador, Honduras, Guatemala, and Suriname to develop programs to improve human safety and prevent violence.

In Ecuador, PAHO has helped the Ministry of Public Health evaluate and strengthen its steering role as part of a Health Sector Transformation process aimed at expanding access to quality care and reducing out-of-pocket spending on health. Areas identified as needing reinforcement included capacities for health policymaking, sectoral management and regulation, quality assurance systems, public health surveillance, integrated management of national and international cooperation resources, promotion of technological research and development in health, and implementation of a national health information system. The findings were incorporated as a key component of a proposal for health sector transformation that was approved in a national consultation.

In El Salvador, PAHO worked with the Ministry of Public Health and Social Assistance to develop a new Law on the National Health System, which seeks to strengthen the steering role of the ministry. The new National Health System places priority on family health and is based on a comprehensive primary health care model that has now been implemented in 40 percent of the country’s health units.

PAHO continued its support for efforts by Guatemala, Honduras, and Nicaragua to improve information for decision-making on access to medicines. The efforts began in 2007 when PAHO experts in essential medicines and health systems and social protection helped the three countries’ ministries of health carry out surveys in homes and pharmaceutical services to assess access to health services and essential medicines, using methodologies developed by PAHO and WHO to measure exclusion in health. The results of the surveys, analyzed during 2008–2009, showed a strong correlation between access to services and access to medicines, challenging the presumption that people can access medicines through free markets without having access to health care. The results pointed to the importance of creating health care networks that are accessible to people in their daily lives, through facilities near their homes that offer quality health care.

In Jamaica, PAHO in 2008 became a member of a task force set up by the Ministry of Health and the Environment to define strategies and plans to strengthen primary health care in the country. PAHO helped develop the first draft of these plans and is collaborating in a second stage of the process. PAHO is also working with the Inter-American Development Bank, the Ministry of Health, and the Planning Institute of Jamaica to analyze the impact of the global financial crisis on the health system, particularly on the recent abolition of user fees, increased demand for health services, and potential pressure on health care services.

PAHO is supporting Mexico’s efforts to integrate its highly segmented health system based on the principles of primary health care through advocacy, facilitation, mediation, and participation in negotiations and consultations in the National Health Council. During 2008, the council signed three agreements related to PAHO technical cooperation that focus on the development of integrated health services networks (RISS) based on primary health care. As part of these agreements, Mexico held a national consultation on RISS, and a delegation from the Mexican Ministry of Health, the Mexican Social Security Institute (IMSS), and two cabinet ministers participated in a regional consultation held in Belo Horizonte, Brazil. Additional events are planned for this year to facilitate debate on the conceptual and strategic foundations of these efforts. PAHO has also signed technical cooperation agreements focused on primary health care renewal with the IMSS and the Institute for Social Security and Services for State Health Workers (ISSSTE).

Paraguay’s Ministry of Health took important steps in 2008, with PAHO support and technical cooperation, to strengthen implementation of its primary health care strategy. In August 2008, the ministry launched a new national health policy known by its slogan, “Quality of Life and Health with Equity in Paraguay.” The policy is aimed at strengthening the health system according to the principles and elements of primary health care, including expanded coverage, guaranteed equity in access, improved quality of care, promotion of community participation, and better coordination among levels of care. To lead this process, the ministry created a new General Directorate for Primary Health Care.

Also with PAHO support, the ministry developed a six-month “contingency plan” aimed at increasing health coverage and combating exclusion, reducing out-of-pocket expenditures, improving quality of health services, fighting corruption, and reducing red tape. The plan included progressive implementation of a policy of free health services, carried out through resolutions and decrees. As part of this process, Paraguay in 2008 began developing structural reforms aimed at building a decentralized national health system. Among the first measures was the implementation of 38 Family Health Units, which are providing comprehensive health services to 133,000 people.

PAHO’s United States–Mexico Border Office in El Paso, Texas, spearheaded the formation of a technical advisory group that will develop intersectoral policies and lines of action to address the social determinants of health along the U.S.–Mexico border. The new advisory group grew out of a meeting in August 2008 that brought together experts from both countries to discuss the recently released report of the Commission on the Social Determinants of Health. The group will develop a conceptual framework for addressing the special challenges of the border area and will set out priority goals for work in this area, including strengthening knowledge and understanding of the dynamics of the social determinants of health in the border region.

PAHO collaborated with the United Nations Economic Commission for Latin America and the Caribbean (ECLAC) during 2008–2009 in two areas to strengthen the evidence base for regional policymaking on primary health care. In the first area, “strengthening of vital and health statistics,” work focused on incorporating an ethnic focus into health data and vital statistics and increasing the participation of indigenous people and Afro-descendants in upcoming censuses for 2010. In the second area, “evaluating progress on the Millennium Development Goals related to health,” the collaboration included a study on indigenous peoples and Afro-descendants in Latin America and a project on territorial inequalities and the MDGs.

PAHO’s Latin American Center for Perinatology and Human Development (CLAP) worked to strengthen interagency coordination and develop alliances and networks at the global and regional levels, among partners including the Spanish Agency for International Development Cooperation (AECID), IPAS, ACDI/VOCA, the European Union, UNICEF, UNFPA, and the March of Dimes. CLAP also promoted the establishment of networks of perinatal institutions in a growing number of countries, including Argentina, Bolivia, Colombia, Ecuador, El Salvador, Honduras, Nicaragua, Peru, Paraguay and Uruguay.

In 2008, PAHO promoted discussions in Member States on the recently released report of the Commission on the Social Determinants of Health and on how to address social determinants through synergistic policies and actions combining environmental health with the renewal of primary health care. A number of countries have already formed national commissions to develop policies in these areas, while others are beginning to implement programs that address the multiple conditions that affect the well-being of their populations.

PAHO’s immunization program once again spearheaded what has become the hemisphere’s flagship Pan American health initiative, Vaccination Week in the Americas. The 2008 initiative was kicked off with multiple launching events in border areas of the United States and Mexico, Central America and Panama, Brazil, Colombia, Peru, and Guyana. Participants included presidents, ministers and other high-level dignitaries, and celebrities Ricardo Montaner and Jerry Rivera. The initiative mobilized thousands of health workers and volunteers and used mass communication campaigns to expand vaccine coverage throughout the Region. Forty-five countries and territories took part, vaccinating nearly 60 million people against diseases including polio, measles, rubella, tetanus, yellow fever, and influenza. Many countries also took the opportunity to offer additional health services, including Pap smears, vitamin A supplementation, and tuberculosis screening.

PAHO partnered with UNAIDS and UNICEF to produce a report on HIV/AIDS that highlighted specific vulnerable populations, such as men who have sex with men, sex workers, and drug users, to better address gender vulnerabilities, human rights, and challenges to achieving universal access to treatment and prevention services for HIV.

PAHO also undertook a mapping initiative to gather data on the availability of sexual and reproductive health services as well as HIV prevention services and coverage for the adolescent population, to identify needs for primary care services in the Region for policy development and decision-making.

PAHO supported the creation of a new Pan American Alliance for Nutrition and Development by the United Nations Regional Directors for Latin America. The alliance aims to advance the Millennium Development Goals by strengthening and integrating international and national responses to nutrition, health, and development, through intersectoral and interprogramatic strategies, interventions and tools in areas including health, nutrition, education, water and sanitation, agriculture, trade, labor, social participation, gender, and human rights.

In 2008–2009, PAHO intensified its collaboration with faith-based organizations including the Latin American Episcopal Conference (CELAM), the Church of Jesus Christ of Latter-day Saints, and the Health Ministries of the General Conference of Seventh-Day Adventists (SDA), which has 15 million members and over 6,000 hospitals, clinics, and health centers worldwide. With support from PAHO and WHO, SDA organized a Global Conference on Health and Lifestyle in mid-2009 in Geneva, where participants shared knowledge and experiences about adopting WHO global health care norms in efforts to advance the health-related MDGs. More than 700 people participated.

PAHO worked during 2008–2009 to mobilize financial and technical resources and to facilitate country-level multisectoral coordination on child health. In partnership with international and national agencies including WHO, USAID, UNICEF, as well as nongovernmental and faith-based organizations, the private sector, and civil society, PAHO promoted the expansion of the Integrated Management of Childhood Illness strategy and other child health initiatives.

PAHO worked with the United Nations Development Program (UNDP) to channel part of a €528 million grant in support of U.N. reform and the achievement of the Millennium Development Goals (MDG Achievement Fund). By late 2008, PAHO/WHO had received approval for projects totaling US$3.7 million. PAHO Country Offices are participating in projects in Colombia, Costa Rica, Guatemala, Honduras, Panama, and Peru and elsewhere by preparing concept notes and joint U.N. program documents.

PAHO during 2008–2009 continued work under a four-year US$4 million grant from the U.S. Agency for International Development (USAID) to strengthen health systems and services in the context of primary health care and to improve the quality of health services throughout the Region. As part of the grant’s management, a technical coordinator helped identify synergies, maximize results, and promote a common vision among the multiple actors and projects involved in the umbrella agreement.