To Improve Nutrition, Food Safety and Food Security, Throughout The Life-Course, and in Support of Public Health and Sustainable Development

STRATEGIC OBJECTIVE 9
To improve nutrition, food safety and food security, throughout the

life-course, and in support of public health and sustainable
development
Scope
The work under this Strategic Objective (SO) focuses on improving nutritional
status, throughout the life course, especially among the poor and other
vulnerable groups, towards the achievement of the Millennium Development
Goals; especially the reduction of poverty and hunger, diminishing the impact
of infant morbidity and mortality, and achieving sustainable development.
The SO addresses food safety (ensuring that chemical, microbiological,
zoonotic and other hazards do not pose a risk to health) as well as food
security (access and availability of appropriate food).
INDICATORS AND TARGETS
• Proportion of underweight children under 5 years of age. Target: all

countries in Latin America and the Caribbean having met or on track to meet
Millennium Development Goal Target 2 (“Halve, between 1990 and 2015, the
proportion of people who suffer from hunger” as measured by indicator 4
“Prevalence of underweight children under five years of age”). Baseline in
1990: 10.3%
• Proportion of children under 5 years of age with anemia. Target: regional
average prevalence of anemia in children under 5 years of age is reduced by
0.5 percentage points per year. Baseline in 1990: 43%
• Proportion of women of reproductive age with anemia. Target: regional
average prevalence of anemia in women of reproductive age is reduced by
0.5 percentage points per year. Baseline in 1990: 26%
• Proportion of overweight and obese children under 5 years of age. Target:
all countries in Latin America and the Caribbean where the observed
incremental trend of overweight and obesity in both groups will stabilize or
decline.
• Proportion of overweight and obese adult women. Target: all countries in
Latin America and the Caribbean where the observed incremental trend of
overweight and obesity in adult women will stabilize or decline.
• 10% reduction in morbidity attributable to food-borne diseases by 2013,
measured by a combination of syndromic and etiologic agent-specific burden
of food-borne diseases studies. Estimated baseline 2007: 50 %.
Proposed Strategic Plan 2008-2012

June 2007
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ISSUES AND CHALLENGES
The basic malnutrition problems in the Region are infant underweight and stunting (major
determinants of infant and child mortality), micronutrient deficiencies, and overweight/obesity in
the general population, affecting approximately 140 million people. Most countries face a double
burden of disease with the coexistence of obesity and under nutrition jeopardizing efforts to
achieve development goals. This double burden of disease places enormous demands both on
governments, on account of the high cost of treatment, and on individuals and families, resulting
in higher costs to society in terms of disability days and loss of quality of life. The poor are more
affected than the wealthy, both in relative and in absolute terms. In addition, suboptimal
nutrition in all its forms, including micronutrient deficiencies, seriously compromises the efficacy
of other social and economic interventions owing to its direct impact on the immune system, and
increases the risk of disease, disability and death.
Limited access to enough food in order to meet energy requirements affects about 53 million
people in the Region. Poor dietary quality, alone and in association with infectious diseases, is a
determinant of growth failure, cognitive and intellectual impairment and other deficiencies.
Maternal nutrition during the reproductive period is essential to infant and young child nutrition;
and breastfeeding merits special recognition because of its short- and long-term effects on
maternal and infant health and nutritional status. Its benefits during infancy and early childhood
in all socioeconomic groups are indisputable. Inadequate complementary feeding practices are
also critical to children’s health and physical growth, particularly between the ages of 6 and 24
months. Reduced access and consumption of micronutrient-rich foods are responsible for the
high prevalence of anemia in women and children in the Region.
In rural and poor urban areas, overweight and obese parents, often suffering from specific
deficiencies such as Vitamin A, iron, calcium, folate, and zinc, are frequently found to have
stunted and anemic children. The rise in obesity and noncommunicable diseases in the Americas
is linked to poverty, inadequate diets, and sedentary lifestyles. The failure to achieve even the
minimum recommended levels of physical activity is also a matter for concern. A dominant
dietary pattern of over-consumption of high-energy foods is commonly associated with low
micronutrient intake and a downward trend in the consumption of fruit, vegetables and whole
grains. Increased consumption of foods that are rich in saturated fats, sugar and salt is linked to
lower prices of processed foods, new marketing strategies and to changes in diet from traditional
to processed foods. Home food production practices have also been reduced. The enrichment of
processed foods also needs to be reviewed in relation to obesity. Obesity is a disease as well as
an important risk factor for many non-communicable chronic diseases (NCD) such as type 2
Diabetes Mellitus, hypertension, ischemic heart diseases, stroke, specific types of cancer (breast,
endometrial, and colon), other diseases such as gallbladder disease and osteoarthritis, among
others. The factors mentioned above, when associated with a sedentary lifestyle, play a large
part in onset of the NCD epidemic in adulthood.
In the Americas, food safety activities are fragmented and developed by various actors whose
mandates are often not clearly defined.
In addition to improving public health, effective food safety systems are also vital to maintain
consumer confidence in the food system and to provide a sound regulatory foundation for
national and international trade in food, which supports economic development. Food safety is
considered among one of the priority criteria to assess in ranking the tourism destination
worldwide. Food-borne disease outbreaks due to lack of adequate food safety and potable water
have been major causes in disruption of many countries, in which tourism is the primary source
of revenue and employment.

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STRATEGIC APPROACHES
The principles guiding the design of this SO include a life course approach, enabling policy
environments at all levels, health promotion, primary health care, and social protection.
Furthermore, this SO encompasses five nutrition-related interdependent strategic areas:
• Development and Dissemination of Macro policies Targeting the Most

Critical Nutrition-related Issues: nutrition-relevant public policies will be
assessed with a view to identify and improve their contribution to optimal
nutrition, healthy eating, physical activity, overall health outcomes and enabling
institutional environments.
• Strengthening Resource Capacity through the Health and Non health
Sectors Based on Standards: Activities will encourage scaling-up of services
for the provision of quality comprehensive care for preventive health and
nutrition, with emphasis on maternal and child care, nutrition in adolescents, the
elderly, patients with HIV/AIDS, innovative supplementation and fortification
initiatives, and the prevention of obesity in vulnerable groups.
• Information, Knowledge Management and Evaluation Systems: Support
surveillance and evaluation of changes in dietary habits, food purchasing
behaviors, macronutrient contents of diets, patterns of physical activity, obesity,
and protective and risk factors for suboptimal nutrition and obesity and nutrition-
related chronic diseases.
• Development and Dissemination of Guidelines, Tools, and Effective
Models: Activities will encourage the dissemination of guidelines, norms and
state-of-the-art papers on the improvement of service delivery, successful
interventions and research findings.
• Mobilizing Partnerships, Networks, and a Regional Forum in Food and
Nutrition: Foster horizontal cooperation among countries and sharing regional
expertise, dissemination of lessons learned, and regional networks to move
forward nutrition in health and development agenda.
Cooperation at national, subregional, regional and global levels is required to improve

effectiveness and thus protection of the health of the consumer and enhance opportunities for
trade and tourism. The PASB should facilitate bilateral and multilateral cooperation for viable
agreements, joint projects, and missions, through the mobilization of trained national human
resources, technical cooperation among countries, and, food safety experts in specific areas,
where national capacity does not exist.
In supporting Member States’ efforts in the field of food safety, PASB will focus on the following
strategic approaches:
• To work with national governments to strengthen foodborne disease surveillance systems

and undertake burden of disease studies.
• To enhance institutional and human capacity in conducting systematic epidemiological
approaches to make decisions based on scientific evidence such as systematic reviews,
meta-analysis and risk assessments.

June 2007
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• To enhance institutional and human capacity to develop leadership in public health to
design integrated food safety systems based on risk analysis approach.
• To build partnerships, alliances and effective interactions with agencies of the UN and
OAS System, as well as with National Public Health Agencies and NGOs to achieve
sustainable and effective food safety policy implementation and increase technical
support and external resources.
• To strengthen relationships between the health, agricultural, and private sectors to
ensure that food safety interventions are planned and executed in an integrated manner
from farm to fork.
• To enhance risk communication and education in food safety and the application of basic
WHO guidelines for implementation of the five keys to safer food and the healthy food
market within the strategy of healthy settings.
.
ASSUMPTIONS AND RISKS
This SO can be achieved under the following assumptions:
• Access to adequate nutrition, food security and food safety are acknowledged by
governments to be human rights and necessary prerequisites for health and
development.
• Individual behavior will be backed up by health promotion and prevention, and
supportive environment to allow the public to make informed choices directed to prevent
malnutrition and diseases arising from unsafe food;
• Member States are committed to comprehensive and integrated policies and plans, and
to the development and strengthening of their national food security, nutrition and food
safety programs, on the basis of reliable and updated evidence.
• Effective networks and partnerships with other technical cooperation agencies are
established and fostered, involving all stakeholders at international, regional, subregional
and national levels.
• Inter-programmatic coordination of PAHO/WHO resources will be carried out with
increased in-house support, through the preparation of feasible projects and tapping
voluntary contributions from developed countries to WHO.
• Effective decision-making and communication mechanisms will be in place to maintain
strong and interactive coordination of efforts at the global, regional and subregional
levels. guided by PAHO’s Regional Strategy on Nutrition in Health and Development, the
Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and
Control of Chronic Diseases, including Diet, Physical Activity, and Health, and WHO’s
Global Food Safety Strategy.
• Scaling up of cost-effective food safety interventions for the management of food
hazards/risks.
The following risks may adversely affect achievement of the SO:
• Emergence of parallel health, nutrition, and food security and safety agendas due to lack
of communication and coordination among partners.
• Low investment and/or political commitment of governments concerning nutrition, food
security and food safety.

June 2007
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REGION-WIDE EXPECTED RESULTS
RER 9.1 Partnerships and alliances formed, leadership built and coordination and
networking developed with all stakeholders at country, regional and
global levels, to promote advocacy and communication, stimulate inter-
sectoral actions, and increase investment in nutrition, food safety and
food security.
RER
Indicator RER RER
Indicator # RER Indicator text Baseline Indicator Indicator
(end- Target Target
2007) 2009 2013
9.1.1 Number of countries assisted by PASB that have 18 22 30
achieved at least 2 of the following: (1)
legislation, (2) functional coordination
mechanisms (national development policies and
plans, food and nutrition policies and plans,
poverty reduction strategies), and (3) financial
resources allocation to support inter-sectoral
approaches and actions in the areas of food
safety, food security and nutrition.
9.1.2 Number of countries that have included nutrition, 10 15 25
food safety and food security activities in their
sector-wide strategies (health, education, and
agriculture), including a funding mechanism to
support nutrition, food security and food safety
activities in health and non-health sectoral
programs.
9.1.3 Number of countries with social marketing 14 18 25
campaigns recognizing and disseminating best
practices in health, nutrition and food safety
(targeted to general population, public, private,
and civil society organizations, and professionals,
among other groups).
9.1.4 Number of countries where local governments 20 24 35
apply strategies to integrate food safety,
nutrition and food security (including access to
safe livestock products) in at least 2 of the
following local processes: (1) sectoral planning in
health, education or agriculture; (2) integrated
development multi-sectoral plans; (3) social
mobilization campaigns; or (4) municipal and
community level projects.
9.1.5 Number of subregions with subregional plans of 0 3 4
action derived from the Regional Strategy on
Nutrition in Health and Development in
operation, that are successfully monitored and
evaluated, and lessons disseminated.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.1.6 Number of countries that are successfully 7 10 20
implementing, within the framework of MDGs
commitments, progress and challenges, at least
2 of the following local level initiatives: Food and
Nutrition in Faces and Places; WHO 5 Keys to
Safer Food in Healthy Schools (WHO 5 Keys) ;
Healthy Food Markets Initiatives (WHO HFMI);
Central American Network of Municipalities for
Development.
RER 9.2 Norms, including references, requirements, research priorities and

agenda, guidelines, training manuals and standards, produced and
disseminated to Member States in order to increase their capacity to
assess and respond to all forms of malnutrition, and zoonotic and non-
zoonotic foodborne diseases, and to promote healthy dietary practices.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.2.1 Number of improved and updated guidelines for 4 8 15
implementation, training manuals and
educational materials on topics related to new
nutrition, food security and food-safety
standards.
9.2.2 Number of countries successfully implementing 15 20 30
standards and recommendations included in
global and regional strategies, according to
national needs and priorities.
9.2.3 Number of countries incorporating improved 17 20 30
food security, nutrition, and food safety
standards, norms, and guidelines for Primary
Health Care in health service delivery systems.
9.2.4 Number of new norms, standards, guidelines, 0 1 5
tools and training materials for prevention and
management of zoonotic and non-zoonotic
foodborne diseases.

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RER 9.3 Monitoring and surveillance of needs, and assessment and evaluation of
responses in the area of food security, nutrition and diet-related chronic
diseases strengthened, and ability to identify best policy options
improved.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.3.1 Number of countries that have adopted and 0 15 30
implemented the WHO Child Growth Standards.
9.3.2 Number of subregions with operational 0 2 3
Observatories in Food Security, Nutrition and
Food Safety.
9.3.3 Number of countries that have nationally 13 18 26
representative surveillance data on major forms
of malnutrition at national and local levels.
9.3.4 Number of guidelines and tools for surveillance, 3 7 11
monitoring and evaluation of: nutritional
deficiencies and risk factors; socioeconomic
determinants; cost analysis; overweight and
obesity trends; effectiveness of key practices to
improve nutrition throughout the life course.
9.3.5 Number of countries that produce and publish 11 20 32
sound scientific evidence and reliable information
for public policy and programs on these topics:
• Nutritional deficiencies and risk factors in
different population groups
• Social, economic and health determinants of
food and nutrition insecurity
• Overweight and obesity in children and
adolescents.
• Program effectiveness
RER 9.4 Capacity built and support provided to target Member States for the
development, strengthening and implementation of nutrition plans and
programs aimed at improving nutrition throughout the life-course, in
stable and emergency situations.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.4.1 Number of countries supported by PASB that 5 12 20
have developed national programs that
implement at least 3 high-priority actions
recommended in the Global Strategy for Infant
and Young Child Feeding.
9.4.2 Number of countries with PASB support that 11 16 25
have developed national programs that have
implemented strategies for prevention and
control of micronutrient malnutrition.

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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
have developed national programs that
implement strategies for promotion of healthy
dietary practices in order to prevent diet-related
chronic diseases.
have developed national programs that include
of nutrition in comprehensive responses to
HIV/AIDS and other epidemics.
have strengthened national preparedness and
response to food and nutrition emergencies.
9.4.6 Number of tools for monitoring and evaluation of 3 6 7
national programs in food security, nutrition and
food safety.
9.4.7 Number of countries with undergraduate and 16 20 30
graduate academic programs that develop a
competent workforce, in health and non-health
sectors, for public policy, plan and program
design, implementation, monitoring and
evaluation in nutrition, food security and food
safety, in stable as well as humanitarian crisis
situations.
RER 9.5 Foodborne diseases surveillance, prevention and control systems

strengthened and food hazard monitoring programs established.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.5.1 Number of countries with established operational 16 22 30
and inter-sectoral collaboration for the
surveillance, prevention and control of foodborne
diseases.
9.5.2 Number of countries that have initiated or 2 9 20
strengthened programs for the surveillance and
control of at least one major foodborne zoonotic
disease.
9.5.3 Number of South American countries that have 4/11 11/11 11/11
achieved at least 75% of the Hemispheric foot
and mouth disease Eradication Plan objectives.

June 2007
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RER 9.6 Capacity built and support provided to National Codex Alimentarius
Committees and the Codex Commission of Latin America and the
Caribbean.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
9.6.1 Number of Latin American and Caribbean 36/36 36/36 36/36
countries receiving support from the FAO/WHO
Codex Trust Fund to participate in relevant
Codex Meetings.
9.6.2 Number of countries receiving PASB support to 18 22 30
build national integrated food safety systems
with a component of foodborne diseases
surveillance and food contamination monitoring
with links to WHO networks: International Food
Safety Authorities Network (INFOSAN) and
Global Outbreak Alert and Response Network
(GOARN).

June 2007
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To improve the organization, management and
delivery of health services
Scope
This Strategic Objective (SO) focuses on working with countries to strengthen health
services in order to provide equitable and quality health care for all people in the
Americas, especially the neediest populations. This work is accomplished by
equipping countries with proven best practice tools, knowledge solutions, and
expertise, and by activating networks and partnerships that catalyze and sustain
positive change. The Regional Declaration on the New Orientations for Primary
Health Care and PAHO’s position paper on Renewing Primary Health Care in the
Americas (CD46/13, 2005) provide the framework to strengthen the health care
systems of the countries in the Americas.
Improved health, as reflected in the achievement of other SOs, is the best indicator of the
successful functioning of health services. Overall progress towards this particular SO will be
assessed by the number of countries that can demonstrate progress in terms of the following
composite indicators:
• Coverage for a range of priority health interventions (for communicable and

noncommunicable diseases). Target: significant improvement in at least 50%
of countries.
• Technical and organizational quality, including compliance with minimum
standards of care and patient safety and improved responsiveness. Target:
significant improvement in at least 50% of countries.
• Efficiency as measured by a score for outputs of health services related to a
given set of financial and human resources inputs. Target: significant
improvement in at least 50% of countries.
• Countries reporting progresses on their implementation of primary health
care-based health systems according to the Regional Declaration. Target: at
least 40% of countries.
The Region of the Americas is one of the most unequal regions of the world, not only in terms of
income distribution, but also in terms of access to social services. There are profound inequities
in access to health services among the different countries of the Region, as well as within
individual countries. It is estimated that 125 million people living in Latin America and the
Caribbean do not have access to basic health services (about 27% of the population). While in
Canada 100% of children are delivered by trained health personnel, this figure is only 24.2% in

June 2007
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Haiti, 31.4% in Guatemala and 60.8% in Bolivia. Within countries, inequities affect primarily low-
income, rural and indigenous populations. Although average rates of utilization of health services
have improved in recent years, inequities still persist, or have worsened.
Several types of barriers explain inequities in access to health services. The most common ones
are cultural (language, lifestyles, health beliefs), social (level of education), economic (ability to
pay, having health insurance), organizational (hours of work, availability of personnel and
medicines, availability of personnel trained to meet the health needs of population groups such
as older adults, etc.) and geographical (distance) barriers. These barriers account for a large
proportion of people that do not utilize health services and instead self-medicate, consult with a
pharmacist, go to a traditional healer, or do nothing about their health problems.
Until now, most efforts of governments, NGOs, donors, bilateral and multilateral agencies have
been tackling inequities in access to health services by expanding coverage of basic services in
underserved areas. Although positive, this approach has been supply-driven, paying little
attention to local cultural preferences and social realities. Users and consumers have been left
out of important decision-making regarding their health services. Moreover, some of these
efforts have been hindered by organizational problems such as lack of personnel, shortages of
medicines and/or inadequate hours of operation.
Another important challenge in the Region of the Americas is the poor quality of health care. The
lack of quality leads to ineffective, inefficient and costly health services, as well as to low
satisfaction with services. The problems of quality can be found at all levels of the system, from
the individual provider level all the way up to the facility and system levels.
A very frequent problem in most countries of the Region is the poor resolution capacity of
primary care services. In addition to their poor effectiveness and efficiency, most primary care
services are reactive, fragmented, disease-oriented and predominantly curative. Primary care
services have little or no individual and community participation, poor inter-sectoral collaboration
and no accountability for results.
Another important problem is the poor performance of hospitals in terms of clinical outcomes and
patient safety. Hospitals are not doing enough in terms of providing the best care possible to
their patients. Patients are constantly submitted to ineffective, unnecessary or even harmful
diagnostic/therapeutic procedures. This situation leads to inefficient use of resources as well as
to high fatality, hospital infection and early readmission rates. A measure of ineffective or
unnecessary procedures is the level of variation observed in the use of procedures among
hospitals of similar characteristics.
The lack of coordination among the different levels of care and points of service is another
frequent problem of health services. This leads to fragmented and inopportune care, to
duplication of services and unnecessary increases in health costs.
A particular problem of organizing and managing services relates to emergency care systems. In
many cities of the Region, emergency services have not been systematically organized and are
not properly managed. A recent survey done by PAHO in 12 countries of the Region, found that
eight of those countries have pre-hospital care administered mainly by voluntary organizations.
Even though the development of emergency service systems is not a priority for most countries
(only five of the countries surveyed provide state funding for emergency services), the increased
incidence of motor vehicle and other severe injuries together with acute medical conditions are
placing more demands for having an effective emergency care system.

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The main foundation for promoting effective health services with good management practices is
the availability of reliable, timely and accurate information for decision-making and the
translation of information into knowledge and action. Information and knowledge are essential
for exposing underlying factors related to services being delivered, and the basis for modifying
the status quo and improving the health of populations. Health services which utilize information
resources to promote better organization and management of their resources, improve access,
eliminate inequity, and promote effectiveness are better equipped to achieve the MDGs.
There is a plethora of information available that consolidates knowledge and evidence on

provision of health services. However, these resources are not always available to those who
need them or organized to guide decisions regarding the management and provision of health
services for the population. On the other hand, needs-based knowledge on countries' health
services status is scarce. The inequity that exists in access to health services information and
knowledge must be addressed so that knowledge is accessible, disseminated and shared among
countries. Understanding of the countries' health services status is essential for the delivery of
sound technical cooperation projects.
The most important approaches are derived from the principles and operational elements of
Primary Health Care (PHC) based health systems. These principles include, among others,
universal accessibility and coverage on the basis of health needs, community and individual
participation and self-reliance, inter-sectoral action in health and appropriate technology and
cost-effectiveness in relation to available resources. The PHC approach will permeate and cut
across all of the technical cooperation strategies.
• PAHO/WHO’s Working Document CD46/13 and the Regional Declaration of the New
Orientations for Primary Health Care will become the basis of the technical cooperation
strategy. Universal access to information and knowledge will help to overcome inequities
in access to these resources and to share vital information among countries of the
Region.
• A significant approach for technical cooperation will be to build on lessons learned and
developments that already exist in the countries, and the exchange of experiences and
best practices among the different countries of the Region. This approach enables
articulation and advocacy for key regional initiatives in the area of health services
delivery.
• Development of new tools and instruments will require appropriate testing and validation
in specific country locations, and at the regional and local levels. This approach will
encompass the definition of geographical boundaries for a defined population through
community-based demonstration projects.
• The establishment of meaningful partnerships, alliances and networks within the
Organization, as well as outside of the Organization is required: government, universities,
research centers, collaborating centers, professional associations and others.
Service delivery cannot be improved without the basic conditions of economic, social and political
stability. Yet, for many low-income countries these conditions do not prevail. Thus there is a
need for close synergy with work on SO 5.

June 2007
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Much of the increase in health funding from external sources is focused on the achievement of
disease-specific outcomes (particularly in relation to AIDS). There is thus a risk that program
implementation reinforces separate vertical programs. Although some functions need to be
carried out separately, most service delivery needs to be carried out by a single network of
facilities. The objective of reducing exclusion is likely to be compromised if governments focus
only on the public sector network. Similarly, there is a risk that they will concentrate exclusively
on primary or first contact care at the expense of dealing with inequities and inefficiencies in the
hospital sector.
RER 10.1 Countries supported to provide equitable access to quality health care
services, with special emphasis on vulnerable population groups, and
with health services that reflect recognized standards, best practices
and available evidence.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
10.1.1 Number of countries that have increased access 14 18 21
to basic health care services as a result of PASB's
initiatives on Extending Social Protection in
health and Primary Health Care renewal.
10.1.2 Number of countries that have strengthened 11 19 24
national programs for quality improvement of
service delivery.
10.1.3 Guideline for patients’ rights and duties and In Developed In use at
assessing quality of health care services progress and country
developed; and new strategies for health validated level
services delivery in hardship and distant
locations developed.
RER 10.2 Organizational and managerial capacities, including information

systems, of service delivery institutions and networks in Member States
are strengthened with a view to improving service delivery performance.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
10.2.1 Number of countries that have incorporated 5 14 23
health services productive management
methodologies.
10.2.2 Management information tools that enable In Tools Tools in use
evidence-based decision making, performance progress developed throughout
evaluation developed, such as the Windows and region
Managerial Information System – WINSIG. validated

June 2007
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RER 10.3 Mechanisms and regulatory systems are in place in Member States to
ensure collaboration and synergies between public and non-public
service delivery systems that lead to better overall performance in
service delivery.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
10.3.1 Number of assisted countries that have adopted 3 20 24
PASB's policy options and mechanisms for
integrating the health care delivery network,
including public and non-public providers.
10.3.2 In Tools Tools in use
Tools for integrating health services delivery progress developed throughout
systems developed. and region
validated
RER 10.4 Service delivery policies and their implementation in Member States
increasingly reflect the Primary Health Care approach, particularly in
relation to social participation, inter-sectoral action, emphasis in
promotion and prevention, integrated care, family and community
orientation, and respect for cultural diversity.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
10.4.1 Number of countries that report progress in 1 15 23
implementing PHC-based Health Systems
according to PAHO's Position Paper and Regional
Declaration on PHC.
10.4.2 In Standards Standards
Standards and self-evaluation methodology for
progress developed in use
evaluation of primary care developed and
and throughou
applied in countries.
validated t region

June 2007
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To strengthen leadership, governance and the evidence base
of health systems
Scope
PAHO/WHO technical cooperation will be geared to boosting the policy-making and

technical capacity of Member States to ensure a single orientation consistent with the
social values and objectives that guide health systems. This will ensure improved
governance of their health systems, and enable the national health authority to
competently exercise its role as the steering agency, and to adopt a multi-sectoral
approach, including the incorporation of non-governmental stakeholders. This work is
essential, as the main characteristic of the majority of systems in the Region of the
Americas is institutional and organizational fragmentation and segmentation, which
result in exclusion and inequity.
• Number of countries that have established national health commissions (or equivalent)
that set health-related priorities at national level, with multi-sectoral participation.
Target: TBD
• Reduction of social exclusion in health and inequities in access to health systems. Target:
TBD
• Existence of regulatory and oversight mechanisms in the health systems. Target: TBD
• Methodological instrument for evaluating performance at the different levels of the health
systems and performance evaluation exercises conducted in the systems. Target: TBD
• Progress in bridging the knowledge gap and increasing the use of scientific knowledge in
public health policy-making from its currently low levels. Target: TBD
• Experience shows that managing health systems in the best interest of citizens requires
vision, leadership, and policies that strike a balance among the many demands on the
systems; but what is needed above all is a complex series of institutional measures that
at present are only partially available.
• The majority of the countries of the Region are encountering technical and political
problems in the definition, governance, sustainability, and evaluation of public health
policies and in clearly defining health objectives, creating sector development plans, and
intervening in the regulation of sector markets in defense of their citizens. In many
countries, the Ministry of Health has little capacity to manage the growing number of
actors and agents, the financing and execution networks with which it must deal,
relations with public agencies (ministries of finance and planning, national legislative
bodies, etc.), international agencies, multilateral, bilateral and nongovernmental
organizations, and the different types of private companies and civil society
organizations.

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• During the five year period 2001-2005 PAHO/WHO addressed the development of theory
and practice in regard to the steering role in health as a priority challenge in State
modernization. The Organization has promoted a profound regional and subregional
debate and exchange of views on the conceptualization, sphere of activity, and
mechanisms for strengthening the steering capacity in health, using as a basic input the
wealth of experience amassed by the countries of the Region of the Americas,
particularly during the reform processes in the 1990s.
• Strengthening of the steering role in the health sector should be guided by the goal of
reducing inequities in health conditions within the framework of integral sustainable
development, and of eliminating unjust inequalities in terms of access to personal and
non-personal health services and the financial burden that access to them implies.
According to the 2003 calculation of the HP/HSS Unit, 230 million people in LAC have no
health insurance and 125 million lack permanent access to basic health services.
• Part of the problem is the limited availability and use of quality scientific knowledge and
information for decision-making including reliable vital and health statistics and
epidemiological data. Many countries in the Region lack the mechanisms and information
necessary for responsible, transparent management. There is limited capacity to conduct
health research of national interest, including health systems research, or to set up and
maintain a reliable health information system and translate research findings into policy
and practice; the countries have difficulty striking a balance between responding to the
international demand for health information and attention to their own knowledge and
information needs.
• There are difficulties reconciling the competing demands for the limited resources
available for health services and programs, and making decisions on how to organize
them to maximize resource utilization and make it possible to perform the essential
public health functions.
• It is necessary to increase the health authority’s capacity to effectively interact with other
sectors (including civil society) that influence social, economic, and environmental health
determinants.
Achieving this SO will require support for the Member States in developing sustainable structures
and processes that, with the participation of the different relevant actors, have the necessary
competencies to create the health systems that the countries need and determine most effective
and efficient way to administer the health sector. Similarly, efforts should be made to ensure
that the national health authority has the information and competencies it needs to examine and
develop compulsory rules and regulations, guidelines, and incentives that will foster equal
conditions for all actors in the health system, and above all, the protection of citizens’ right to
have access to health. To the extent that governments decentralize to more closely address
community concerns, it will be possible to establish and promote mechanisms for assigning
effective responsibilities, resources, and management guidelines to protect the national health
priorities agreed upon.
Strengthening responsible management will require building a culture of investment and action
with respect to scientific information and data, as well as the establishment of timely, functional,
reliable, and relevant health information systems.
One of the main conditions will be building and sustaining the necessary capacity for conducting
research on public health and on health policies and health systems of national interest, including
health systems research, in order to set up and maintain reliable health information systems and

June 2007
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translate research findings into policy and practice. It is necessary to improve mechanisms to
ensure that the right knowledge reaches the right people (policymakers, administrators, experts,
development partners, and the general public) to develop an effective decision-making process
and monitor performance throughout the health system.
To support the activities of the Member States, PAHO/WHO will focus on:
• Maintaining technical cooperation approach for the countries appropriate to the political,
cultural and social context in order to strengthen governance/steering role.
• Helping strengthen the steering capacity of the National Health Authority in order to
develop public health policies consistent with national policies and to allocate resources
according to public policy objectives.
• Guaranteeing TC for the creation of national information systems that will make it
possible to generate, analyze, and utilize reliable information from population-based
sources (surveys, civil registry), as well as clinical and administrative data sources,
through collaboration with partners (e.g., the United Nations, other agencies, and the
Health Metrics Network).
• Helping build national capacity to conduct research for policy-making, to evaluate health
system performance, and to summarize the national experience to provide orientation
grounded in scientific data.
• Formulating a PAHO’s policy in health research and strategies to improve research on
health systems and policies, as well as public health, with the participation of the
Member States.
• Facilitating the sharing and dissemination of health information and information
technologies, knowledge, and experiences among and within the countries; improving
access to information and knowledge; and bridging the current gap between knowledge
and practice in health on a regional scale.
• Supporting policies to develop highly trained, motivated, and committed human
resources to assume responsibility for individual and institutional development plans and
performance evaluation.
The following assumptions apply:
• There is political commitment and a basic consensus that the State is responsible for the
health of the entire population.
• There is a change in the way external partners operate in terms of financing and
execution, in particular by putting the principles of the Paris Declaration on Aid
Effectiveness into practice, so that they strengthen, rather than undermine, national
activities aimed at improving governance/the steering role.
• Effective partnerships are created and effective participation of stakeholders at the
national, subregional, and regional level is maintained; especially important in this regard
are the international and regional organizations that invest in information, as well as a
number of bilateral donors.
• Progress is made in governance, the State steering capacity, and the strategic
management of development in general, not simply in the health sector.

June 2007
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• The countries and development partners make increasing use of objective data for
resource allocation.
The following risks could adversely affect attainment of the SO:
• Lack of international and national investment in this area, especially in the middle-income
countries, where the majority of the Region’s poor reside.
• Unsustainable public policies and lack of inter-sectoral coordination.
• Poor coordination and harmonization among the major international partners.
• A preference for investing in short-term unsustainable solutions.
• Lack of reliable data and information for decision-making and monitoring and evaluation
of policies and programs.
RER 11.1 Strengthen the capacity of the national health authority to perform its
steering role, improving the preparation of policies, regulation, strategic
planning, orientation, and execution of the reforms, and the inter-
sectoral and inter-institutional coordination in the health sector in the
national and local areas.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
11.1.1 Number of countries which demonstrate an TBD TBD TBD
improvement in the performance of the steering
role (policy-making, strategic planning, execution
of reforms and inter-institutional coordination in
the health sector at the national and local levels)
through the existing mechanisms (Essential
Public Health Functions).
11.1.2 Number of countries that have institutionalized TBD TBD TBD
regulatory agencies of sector operation (such as
authorities) and generated regulatory
frameworks.
11.1.3 Number of countries that have generated 7 TBD TBD
medium and long term sectoral plans or defined
National Health Objectives.
11.1.4 Number of subregions implementing a strategy 0 2 5

of promotion and support for processes of social
dialogue and consensus-building of public
policies for the strengthening of the health
systems based on primary health care.

June 2007
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RER 11.2 Contribute to the improvement of health information systems at
regional, subregional, and national levels; for the analysis, management,
monitoring, and evaluation of the public policies and health systems to
achieve the health objectives at all levels.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
11.2.1 Number of countries that have implemented the 3 7 15
monitoring and performance evaluation process
of the health information systems based on the
standards of WHO/PAHO and the HMN
supported by the Bureau.
11.2.2 Number of countries that have permanent and 3 8 40
active plans to strengthen the vital health
statistics, including the production of information
and the use of international classifications (ICD)
in accordance with international standards
established by PAHO/WHO and the Metric Health
Network.
11.2.3 Number of countries that have implemented the 9 13 21
Regional Core Health Data Initiative and that
steadily produce and publish the basic health
indicators at sub-national level (first or second
administrative level).
RER 11.3 Contribute to the access, equitable dissemination, and utilization of

knowledge and scientific evidence in the decision-making processes.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
11.3.1 Number of countries that use the basic health 40 40 40
indicators and other available statistical
information to support the analysis of priority
evidence-based health problems.
11.3.2 Number of countries that have improved their 5 7 10
analysis capacities for generating information
and knowledge in health with technical
cooperation from PAHO.
11.3.3 Number of effective research activities on 0 2 4
coordination methods and leadership in the area
of the health.

June 2007
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RER 11.4 Facilitate the generation of knowledge in priority areas, including
research on health systems, with participation of different stakeholders
of society, ensuring they meet the high methodological and ethical
standards.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
11.4.1 Number of countries whose national health TBD TBD TBD during
research systems meet the internationally agreed during during 2007
upon minimum standards (to be defined by 2007 2007
WHO).
11.4.2 Number of countries that adhere with the TBD TBD TBD
Mexico Summit commitment to devote at least during
2% of the health budget to research. 2007
11.4.3 Number of LAC countries with Ethical- Bioethical 14/36 20/36 30/36
National Commissions aimed at monitoring
compliance with ethical standards in scientific
research.
11.4.4 Functional Regional Advisory Committee on The Functional Alignment
Health Research. Regional Regional and
ACHR is ACHR coordination
being meeting between the
revitalized regularly Regional and
Global ACHR
RER 11.5 Contribute to the opening and strengthening of dialogue mechanisms

and social and political consensus-building, at different levels, with
participation from the relevant stakeholders for the improvement of
policies and health systems.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
11.5.1 Number of countries (health ministries and 10 15 25
schools of public health) adopting knowledge-
management strategies to bridge the gap
between knowledge and its application.
11.5.2 TBD 10 20
Number of countries that have access to
essential scientific information and knowledge.
11.5.3 Number of countries that have cyber health TBD 12 30

frameworks and services based on scientific
data.

June 2007
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To ensure improved access, quality and use of medical
products and technologies
Scope
Medical products include chemical and biological medicines; vaccines; blood and
blood products; cells and tissues mostly of human origin; biotechnology products;
traditional medicines and medical devices. Technologies include, among others,
those for diagnostic testing, imaging, and laboratory testing. The work undertaken
under this Strategic Objective (SO) will focus on making more equitable access (as
measured by availability, price and affordability) to essential medical products and
technologies of assured quality, safety, efficacy and cost-effectiveness, and on their
sound and cost-effective use. For the sound use of products and technologies, work
will focus on building appropriate regulatory systems; evidence-based selection;
information for prescribers and patients; appropriate diagnostic, clinical and surgical
procedures; supply systems, dispensing and injection safety; and blood transfusion.
Information includes clinical guidelines, independent product information and ethical
promotion.
• Ensured improvement in access to essential medical products and

technologies with their rational use within LAC and support through
recognition in countries’ constitution or national legislations. Target: more
than 60% of countries.
• Quality of medical products and technologies being monitored and ensured
in LAC. Target: more than 75% of countries monitored.
• Supply systems strengthened in LAC as to planning and procurement of
quality medical products and technologies. Target: at least 70% of
countries.
• Developmental stage of national regulatory capacity. Target: national
regulatory authority assessed; 47% of countries with basic-level, 28% with
intermediary level and 25% with high-level regulatory functions in place.
From the simplest of health care systems to the most advanced, in rich and poor countries alike,
health technologies form the backbone of health services. Yet access to health technologies is at
the same time one of the most distinct differences between rich and poor countries in all regions
of the world, including the Americas. The highest disparities in income distribution are seen
within countries in the Americas, which are reflected in the access to health technologies. Strong
health systems invariably rely heavily on access to and use of health technologies. Together,
they form a dense mesh throughout the health services into which they are interwoven. A strong
mesh of health technologies is one of the most fundamental prerequisites for the sustainability

June 2007
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and self-reliance of health systems. Health technologies evolve or are invented as solutions to
perceived health problems and are initially evaluated and applied for that purpose. As experience
in their use accumulates, health technologies may come to be used, either directly or after slight
modifications, to address many other problems than those for which they were initially
developed. Some technologies are inherently safe, but the vast majorities are not and require
systematically established quality assurance and quality control measures if undesired effects are
to be avoided in their application. Indeed, for many technologies, it is desirable to ensure that
any adaptation is coordinated under national legislation and their application under supervision
by regulatory authorities. Even though most developing countries cannot afford the vast variety
of health technologies, if the elements that make up this mesh are carefully chosen, a country
may still be able to offer its citizens a safe and reliable health service to its citizens, even where
resources are limited.
The economic impact of medical products and technologies is substantial, especially in developing
countries. While spending on pharmaceuticals represents less than one-fifth of total public and
private health spending in most developed countries, it represents 15 to 30% of health spending
in transitional economies and 25 to 66% in developing countries. In most low income countries
pharmaceuticals are the largest public expenditure on health after personnel costs and the
largest household health expenditure. And the expense of serious family illness, including drugs,
is a major cause of household impoverishment. Despite the potential health impact of essential
drugs and despite substantial spending on drugs, lack of access to essential drugs, irrational use
of drugs, and poor drug quality remain serious global public health problems. The concept of
essential drugs incorporates the need to regularly update drug selections to reflect new
therapeutic options and changing therapeutic needs; the need to ensure drug quality; and the
need for continued development of better drugs, drugs for emerging diseases, and drugs to meet
changing resistance patterns.
An additional concern to Member States are the free-trade agreements that are being negotiated
or implemented in different subregions, and their impact on access of populations to new
products launched in the market. PAHO has been following very closely this situation and has
been advising countries in relation to access to anti-retroviral therapy and has helped with the
subregional and national negotiations.
Most national immunization programs in the region utilize vaccines that have been procured
through PAHO’s revolving fund. These vaccines have their quality assured by the WHO
prequalification system that includes not only the assessment of the manufacturer and the
vaccines but also the assessment of the National Regulatory Authority (NRA) of the country as
the responsibility for the oversight is delegated to the NRA. Assessment of NRAs has become an
important tool to identify their strengths and weaknesses in the compliance with the 6 regulatory
functions: a) registration; b) surveillance of vaccine use; c) lot release system; d) access to a
quality control laboratory; e) inspection of manufacturers; and f) evaluation of clinical results.
The strengthening of NRAs will also help towards the creation of a network of regulatory
authorities that can serve as a basis for product quality in the region. So far two NRAs have
been declared fully compliant (Brazil and Cuba) and five have undergone preliminary
assessments. Several causes have been identified as problems for non-compliance: the lack of
organizational and independent structures, lack of qualified human resources, lack of
coordination of activities and poor infrastructure.
Few countries have invested in improving their vaccine production facilities: Brazil, Cuba, Mexico
and Venezuela. Two manufacturers are already pre-qualified to supply vaccines to UN agencies:
Biomanguinhos in Brazil for yellow fever and CIGB in Cuba for hepatitis B. A second Brazilian
manufacturer has requested prequalification of two of its products: DTP and DTP+hepB. PAHO is

June 2007
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identifying how to collaborate with these manufacturers to address the issue of regional vaccine
self-sufficiency and production of certain vaccines of regional or local public health relevance
such as pandemic flu vaccine or Argentinean hemorrhagic fever vaccine.
The World Health Organization (WHO) and the International Federation of Red Cross and Red
Crescent Societies (IFRCRCS) have estimated that, for a community to have enough blood to
cover its needs, a number of blood units that is equivalent to 5% of the population, or 50 per 1
000 inhabitants, must be collected each year. The aggregated donation rate for the Region of
the Americas is 24.5 per 1 000, with 20 million units of blood collected for a population of 815
million. Of 42 countries and territories of the Region of the Americas, only one country, Cuba,
achieves the WHO/IFRCRCS standard. The inequity in the availability of blood among countries
of the Region of the Americas is also manifested within the countries, with some major urban
areas having access to the majority of blood available.
Not only does promotion of voluntary blood donation assure sufficiency and, therefore,
availability of blood but also contributes to its safety. Voluntary blood donors are less likely to be
infected with transfusion-transmitted infections (TTIs), especially if they donate repeatedly. In
Latin America and the Caribbean, only Aruba, Cuba, Curacao, and Suriname collect 100% of their
blood units from voluntary, altruistic, non-remunerated donors; Bermuda and British Virgin
Islands do so from over 98% of them. Bolivia, Dominican Republic, Honduras, Panama and Peru
report paid donation of blood. The units of blood must be screened for the presence of markers
of TTI before being transfused. The high prevalence rates of TTI markers among blood donors
and the number of unscreened blood units result in the transmission of infections to patients.
There is a strong correlation of blood safety and availability and efficiency of the national blood
system. Data from countries in the Region, including Canada and the United States, indicate that
those countries with higher donation rates per 1,000 inhabitants have blood services that process
higher number of blood units per year, are more likely to have high proportions of voluntary
blood donors, and to have universal testing.
Access to image diagnosis services in most countries in our Region is far from the situation that
developed countries implement, where the annual frequency is above 1,000 studies/ 1,000
inhabitants In countries in our Region that are considered of health care level II (22 countries in
the Region), the value is around 150 studies/ 1,000 inhabitants and in Level III countries,
comprising five countries, this value is near 20 studies/ 1,000 inhabitants. Access is also
misbalanced due to the costs of theses services, poor insurance coverage and concentration in
large urban areas. As quality is essential to achieve the expected results of diagnosis, quality
evaluation has been carried out in several countries (Argentina, Bolivia, Colombia, Cuba),
demonstrating the need to implement quality assurance programs. A lack of professionals has
also been detected, including radiology, technology and medical physics.
Access to radiotherapy services is even more critical. Developed countries have 4 to 5 high-
energy radiotherapy units per million inhabitants and most countries in our region have less than
one and some countries much lower numbers (Nicaragua, El Salvador, Honduras, Guyana, Peru,
Haiti), also with few professionals. Costs associated with these services, both as a capital
investment as well as the projection for working and maintenance need a well structured
planning and management, not present in most countries. Frequently the costs are higher than
those in developed countries, as we also find an unequal geographic distribution and timing of
use. More complex equipments, such as computerized tomography, Nuclear Magnetic
Resonance, linear accelerators and high dose brachytherapy, involve even more critical issues.

June 2007
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The area of physical infrastructure and technology incorporated within the health services has not
experienced major changes during the last biennium. There is a continuous deterioration and
outdating of infrastructure and equipment and governments do not have a clear idea of the
status in the private sector. Several donors and banks are working simultaneously, and
sometimes duplicating efforts in this area, while most governments lack specific programs to
regulate the importation, distribution, use and disposal of equipments.
As communicable diseases are an important burden of morbidity and mortality, jointly with low
levels of development and scarce local resources, national laboratory networks should be
supported and reoriented towards a more intensive role in health surveillance. The public health
role of the laboratory includes the sustainable implementation of a system for quality assurance
within the laboratory networks, a strong interaction with epidemiologic surveillance in disease
control, an integrated response over outbreaks and follow-up of the epidemiologic investigation
process, besides registration and authorization for clinical laboratories, the development of
external evaluation programs and voluntary access to accreditation.
• Advocacy and support to Member States in the development, implementation and

monitoring of national medicine policies that facilitate accessibility and affordability of
medicines.
• Advocacy for implementing tools for improving cost efficient medicine supply systems
with emphasis in the public health services and targeted population groups.
• Strategic Fund for procurement of public health supplies through PAHO, facilitated to
assure continuous availability of low-cost quality products for priority public health
programs.
• Support Member States in discussion on the implementation of a public health approach,
the WTO TRIPS flexibilities and the Doha Ministerial Declaration within their legal
framework and during the negotiation of bilateral and regional free-trade agreements.
• Support Member States and subregional integration initiatives in their effort to advance
in drug regulatory harmonization by strengthening the Pan American Network for Drug
Regulatory Harmonization (PANDRH) initiative.
• Strengthen and qualify a group of National Regulatory Authorities to provide the quality
support for PAHO’s Strategic Fund and Revolving Fund procurement of medicines,
vaccines and medical devices for countries in the region.
• Advocacy for the awareness and guidance to Member States to the rational use of
medicines.
• Ensure that there is adequate access to quality vaccines and biologicals within the Health
Systems.
• Coordinate a Regional Program in Transfusion Blood Safety to assure availability of
quality blood, which includes promotion of voluntary blood donation, development of
effective and efficient national blood systems and accurate screening of 100% of the
blood.
• Support provided to strengthen diagnostic imaging and radiation therapy services,
enforce regulations to protect against ionizing and non-ionizing radiation, and boost the
capacity to respond to radiological or nuclear emergencies.
• Strengthen the capacity to operate and maintain the physical plant and equipment of the
health services network in the countries of the Region.

June 2007
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• Support Ministries of Health in the regulation and operation of medical devices and
medical equipment in general.
• Support the institutional development of Public Health Laboratories and strengthen
quality of clinical laboratory operations.
The principal assumptions underlying this SO are that:
• Access to medical products and technologies will continue to be a strategic issue in

overall Health Agenda of Ministries of Health.
• Decentralization of financial resources from WHO will ensure sustainability to major
issues related to ensuring access to quality products and technologies.
• Strengthening of Regulation within a sub-regional approach will ensure circulation of
quality products and technologies in our Region.
• Strengthening of supply systems will ensure appropriate delivery of health products and
technologies.
• Strengthening of regional initiatives, such as the PAHO Strategic Fund and PANDRH.
• Inter-agency coordination and joint efforts dealing with the issue are to be continued.
• Human resources capacity is being enhanced in the Region to confront major challenges
regarding access to products and technologies.
The key risks for progress are identified as:
• The sub-regional approach is not sustainable and there is lack of operational funds for
supporting Member States.
• Lack of political will in certain countries as to maintain this issue in the political agenda.
• Investments in technology and infrastructure without proper assessments and evaluation
of needs.
• Negotiation and implementation of free trade agreements introduce restrictive issues that
hamper access to medical products and technologies in the Region.
• Difficulties in harmonizing procedures and standards regarding quality of products and
technologies.

June 2007
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RER 12.1 Development and monitoring of comprehensive national policies on

access, quality and rational use of essential public health supplies
(including medicines, vaccines, herbal medicines, blood products,
diagnosis services, medical devices and health technologies) advocated
and supported.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
12.1.1 Number of countries supported to develop and 15/36 23/36 27/36
implement Policies and Regulations for essential
medical products and technologies.
12.1.2 Number of countries receiving support to design 20/36 21/36 21/36
or strengthen comprehensive national
procurement and supply systems.
12.1.3 In Developed In use by

Regional norms and guidelines for the operation
progress and countries
of the Strategic Fund to support the
validated
strengthening of supply systems in countries.
12.1.4 36% 90% 100%
100% voluntary non-remunerated blood
donation.
RER 12.2 International norms, standards and guidelines for the quality, safety,
efficacy and cost-effectiveness of essential public health supplies
developed and their national/ regional implementation advocated and
supported.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
12.2.1 Regional assessments of countries to measure 2 5 7
their capacity for regulation of essential medical
products and technologies.
12.2.2 Norms and guidelines for pre-qualification of In Developed In use by
providers and products in the region. progress and countries
validated

June 2007
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RER 12.3 Evidence-based policy guidance on promoting scientifically sound and
cost-effective use of medical products and technologies by health
workers and consumers developed and supported in regional and
national programs.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
12.3.1 Number of national or regional programs 2 4 6
receiving support for promoting sound and
cost-effective use of medical products and
technologies.
12.3.2 11/36 16/36 20/36
Number of countries provided with support to
promote sound and cost effective use of medical
products and technologies.
12.3.3 Number of countries with a national list of 30 31 34
essential medical products and technologies
updated within the last five years and used for
public procurement and/or re-imbursement.
12.3.4 Number of regional guidelines for national 0 4 6
policies on safe and effective use of essential
medical products and technologies.
RER 12.4 Support development of policies and legal frameworks, and enhance
human resource capacity to reduce barriers to access to essential public
health supplies.
RER
Indicator RER
Indicator # RER Indicator text Baseline Indicator RER
(end- Target Indicator
2007) 2009 Target 2013
12.4.1 Number of countries supported with the 11 20 24
necessary tools to develop policies and legal
frameworks and enhance human resource
capacity to reduce barriers to access to
essential public health supplies.
12.4.2 Guideline and tools (including roster of In Available Implemented
experts) to address barriers to access in progress
countries.

June 2007
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To ensure an available, competent, responsive and productive health
workforce in order to improve health outcomes
Scope
The work under this Strategic Objective (SO) is guided by the Objectives and
Challenges of the Toronto Call to Action (2005), the Health Agenda for the Americas
and the frame of reference for developing national and subregional plans and a
regional strategy for the Decade of Human Resources in Health (2006 - 2015). It
addresses the different components of the field of human resource development,
management operations, and regulation of the field by health authorities, and the
different stages of workforce development—entry, working life and exit—focusing on
developing national workforce plans and strategies.
• Density of the health workforce (disaggregated by country, gender, and occupational

classification, where possible). Target: TBD
• Equitable distribution of health workers (disaggregated by country, sex, and occupational
classification, where possible). Target: TBD
• Number of countries facing critical health workforce shortages. Target: Reduction of
25% by 2013.
Data from the Region of the Americas show:
• 12 million men and women work in health services.

• 70% of those in the health-care workforce are women.
• There are 4.58 million doctors, nurses, and dentists in the Region.
• 60 to 70% of national health budgets cover salaries.
A clear correlation exists between the density of health workers and attainment of adequate
levels of coverage with essential health interventions, such as immunization and skilled care in
delivery. The more health workers there are per inhabitant, the higher the likelihood of infant,
child, and maternal survival. Many countries have not met the expected targets of intervention
coverage established in the Millennium Declaration. The World Health Report 2006, for example,
has identified many countries in which the density of health workers falls below the minimum
level established. In the Americas the scarcity is not as acute or as huge as in Africa, but serious
problems exist in some professional categories and in distribution.

June 2007
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The nursing shortage is particularly acute. This shortage has promoted migration from
developing to developed countries, the effect of which is especially felt in the Caribbean:
• Caribbean countries have a 35% nursing vacancy rate.

• In Jamaica and Trinidad and Tobago the rates are even higher, above 50%.
• Canada will have some 60,000 unfilled positions in the next six or seven years.
• The nursing shortage in the United States currently tops 168,000, and this figure will
increase in the near future.
Although countries in general have an apparently sufficient number of doctors and nurses, a
disproportionate number of these professionals settle in urban areas, creating critical shortages in
rural areas:
• Ecuador - The capital city, Quito, has 12 nurses per 10,000 inhabitants, while the
average for the whole country is 5.3 per 10,000.
• Nicaragua - 50% of the health workforce works in the capital city of Managua, serving
only 20% of the population.
• Paraguay - There is 1 nurse per 2,000 inhabitants in the capital, and 1 nurse per 9,000
inhabitants in the rest of the country.
• Uruguay - 80% of the doctors live in the capital, serving only 45% of the population.
There are many reasons for these acute shortages and distribution inequalities. There are also
push and pull factors that cause many health professionals to leave their health posts, resulting
in geographical imbalances between rural and urban areas within a country and among countries
and subregions, with significant migration from developing countries toward more developed
ones. The migration of health workers leads to serious consequences for health systems in
developing countries, already suffering the effects of years of poorly managed health care
reforms and economic stagnation.
Even when the necessary number of professionals exists, health team composition is often off
balance:
• Brazil - Doctors comprise 66% of total health professionals.

• El Salvador - There in only one nurse for every two doctors.
• Dominican Republic - There is only one nurse for every eight doctors.
• Uruguay - 66% of all doctors are specialists.
• Nineteen Latin American Countries have more doctors than nurses.
The Americas have identified the challenges. Twenty-nine countries of the Region and a
significant number of international agencies met in Toronto, Ontario, Canada to discuss the
challenges facing the health workforce in the Region. Participants at the meeting agreed on a
call to action that calls on all countries to mobilize political will, resources, and institutional actors
to contribute to developing human resources in health, as a way of achieving the Millennium
Development Goals and universal access to quality health services for all populations in the
Americas by 2015.
Improving human capacity is no easy task. All the countries are making a sustained effort as
part of the Decade of Human Resources in Health (2006-2015), whose goals are to:

June 2007
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• Strengthen leadership in public health.
• Increase investment in human resources.
• Coordinate and integrate actions in all areas.
• Ensure the continuity of supportive policies and interventions.
• Improve information gathering for decision-making.
Main Objectives for the Decade 2006-2015:
• Define policies and long-term plans to adapt the health workforce to the health needs of
the population and develop the institutional capacity to implement these policies and
review them periodically.
• Put the right people in the right places, obtaining an equitable distribution of health
workers in the different regions based on the different health needs of the population.
• Regulate the movements of health professionals to guarantee access to health care for
the entire population.
• Establish ties between health workers and health organizations that encourage
commitment to the institutional mission, to guarantee quality health services for the
entire population.
• Develop mechanisms for collaboration and cooperation between the academic/training
sector (universities, schools) and the health services in order to adapt the education of
health professionals to a model of universal care that provides equitable, quality services
that meet the health needs of the entire population.
• Fulfilling this SO implies ensuring effective technical cooperation to advance the

development of an available workforce, in the right places, in adequate numbers, and
with the skills necessary to meet the health needs of the population, within the context
of each country’s health system.
• This will require the improvement of the health workforce through national, subregional
and regional plans, strengthening national capacities for comprehensive human resource
management, and creating and promoting partnerships at all levels. It is essential to
maintain information systems on health personnel for evidence-based formulation of
integrated policies and national strategic plans on human resources in health.
Information on best practices should be compiled and disseminated, based on scientific
criteria, for development, training, and management of health personnel. Similarly,
sufficient funds are needed to finance the health workforce, which will call for
consultations and negotiations with the ministries of finance, labor, and education as well
as international development agencies.
• It will also be necessary to expand capacities and improve the quality of educational and
training institutions; and ensure an appropriate skill mix and equitable geographical
distribution of the health workforce through effective deployment and retention
measures, through context-specific incentives.
• In supporting Member States’ efforts, PAHO will gather and share the knowledge (data,
information, and evidence) needed to change current practices, so that health workforce
challenges are addressed and guarantee continuous improvement of health workers’
general performance. Specifically, the Bureau will:

June 2007
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• Support the strengthening of national health workforce leadership, to mobilize resources
for the health workforce, and design, implement, monitor, and evaluate health workforce
policies and plans in the context of the Decade of Human Resources in Health (HRH)
2006-2015, and ensure that they are responsive to health needs.
• Support the establishment of HRH monitoring in the countries, ensuring its sustainability.
• Respond to countries in HRH crisis.
• Facilitate agreements with other agencies, to have more effective financial mechanisms
for health resources development and the management of domestic and international
migration.
• Strengthen national educational systems, especially schools and universities, to support
training for all types of health workers, developing appropriate skills and competencies.
• Strengthen the knowledge base, supporting national capacity to develop health
workforce information systems and promote human resources research.
• Support mechanisms for creating subregional networks of institutions of excellence, for
example, to develop health workforce observatories, to generate information for
evidence-based policy-making, monitoring, and evaluation.
• Collaborate on setting norms and standards for the health workforce, including
development of internationally agreed-upon definitions, classification systems, and
indicators.
• Support efforts for horizontal integration and cooperation among countries to implement
joint strategies and address health workforce migration issues.
• Regional, subregional, and national efforts to promote the health workforce

development, included in the Toronto Call to Action, will continue.
• Cross-sector and interagency partnerships in support of health workforce development
will continue to promote the active participation of all direct stakeholders, including civil
society, professional associations, and the private sector.
• The following risks may adversely affect achievement of the SO:
• Financing of health workforce development remains at low levels.

• The issue of human resource development continues to be neglected.
• Affected countries remain unable to take the lead and manage responses to crises by
themselves.
• Developed countries continue active recruiting, thus provoking uncontrolled
migration.
• Market forces continue to exert excessive pressure in favor of out-migration and the
exodus of professionals (brain drain).

June 2007
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RER 13.1 Plans, policies, and regulations of human resources developed; at the
national, subregional, and regional levels; in order to improve the
performance of health systems based on primary care.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.1.1 Number of countries with 10-year Action Plans 13 16 28
for strengthening the health work force, with
active participation from stakeholders and
governments.
13.1.2 Number of countries that have a unit in the 3 12 20
government responsible for the planning and
preparation of policies for the development of
human resources for health.
13.1.3 Number of countries with programs for an 8 11 15
increase in production of human resources for
health with priority on the strengthening of
Primary Health Care.
13.1.4 Number of countries with regulation mechanisms 12 16 20
(quality control) for education and health
practices.
13.1.5 Number of subregions with regulation 1 2 3
mechanisms (quality control) for education and
health practices.
RER 13.2 Set of baseline data and information systems in human resources
developed at the national, subregional, and regional levels.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.2.1 Number of countries that have a database for 10 22 29
situation and trends of the health workforce,
which is updated at least every two years.
13.2.2 Number of countries that will participate in a 0 13 27
Regional Indicators System on Human Resources
for Health (including indicators of geographical
distribution, migration, labor relations and the
development trends of health professionals).
13.2.3 Number of countries with a national group 18 29 40
integrated in the network of Human Resources
for Health Observatories.
13.2.4 Number of countries that develop promotion 5 8 14
strategies for research in human resources for
health.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.2.5 Development of a regional indicator system to 0 1 1
monitor the progress of critical challenges and
development of regional profiles of the situation
of RHS within the Health Agenda for the
Americas framework.
RER 13.3 Strategies and incentives developed to generate, attract, and retain the
health workers (with the appropriate competencies) in relation to the
individual and collective health needs, especially considering the
neglected populations.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.3.1 Number of countries with recruitment and 6 15 20
retention policies for health workers to
strengthen Primary Health Care.
13.3.2 Number of countries that have implemented 6 10 20
incentive systems and strategies to achieve the
geographical redistribution of its health workers
toward unprotected areas.
RER 13.4 Capacity for management strengthened in the countries, in order to

improve the performance and the motivation of the health workers,
including the development of healthy and productive working conditions
and environments.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.4.1 Number of countries with which PASB has forged 2 4 6
strategic alliances for the development of
national and subregional plans in human
resources, within the Toronto appeal for action
framework.

June 2007
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RER 13.5 Education strategies and systems strengthened at the national level, for
developing and maintaining health workers’ skills in the context of
health practice and the health status of the population, focusing on
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.5.1 Number of countries with joint planning inter- 12 25 35
institutional Commissions of training institutions
and health services for the continuous update of
labor competencies.
13.5.2 Number of countries with explicit national 4 10 15
policies for the adaptation of pre and post
graduate education with the health priorities and
RER 13.6 Increased understanding of and solutions to the problems facing

national health systems as a result of the international migration of
health workers in the medium and long terms.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
13.6.1 Number of subregions that participate in a 2 3 4
monitoring network of health worker migration.

June 2007
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To extend social protection through fair, adequate and
sustainable financing
Scope
This Strategic Objective (SO) reflects the guiding principles set out in resolution
WHA58.33 and PAHO Resolution CSP26.R19 in 2002: Extension of Social Protection in
Health: joint PAHO-ILO initiative. Work will focus on:
• Sustainable collective financing of the health system and social protection.
• Protection of households against catastrophic health expenditures.
• Elimination or reduction in economic, geographical, cultural, ethnic, and
gender barriers to access arising from the organization of the system.
• Elimination of (a) the differences in guaranteed rights to access products,
services, and opportunities in health and (b) discrimination based on
ethnicity, gender, age, religion, or sexual preference.
• Elimination or reduction of institutional segmentation in systems and
operational fragmentation of the service network.
• Adequate and timely access to quality health services with equity.
• Advocacy to put health on government agendas.
• Alignment, harmonization and coordination of the international cooperation to
support national efforts for health development (in the orientation of Rome’s
Declaration and the Paris High Level Forum directives)
• Increase in the percentage of public expenditure for health, with emphasis on primary
care expenditure. Target: TBD
• Decrease in the proportion of households that fall below the poverty line due to health
expenditure. Target: TBD
• Decrease in the number of countries with a high proportion of out-of-pocket expenditure
in health. Target: TBD
• Increase in the percentage of the population with explicit ensured rights of access to
products, services, and opportunities in health. Target: TBD
• Increase in the percentage of the population with regular and timely access to health
services. Target: TBD
• Increase in the number of countries with research capacity to assess social exclusion and
inequities in health in addition to system financing and expenditure, as a strategic
measure to increase efficient and equitable public expenditure and establish collective,
universal social protection policies. Target: TBD
• Increase in the number of countries able to coordinate, harmonize, and align
international cooperation in health. Target: TBD

June 2007
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• The way a health system is financed and organized is a key determinant of the
population’s health and well-being.
• Expenditure levels, especially public expenditure, are still insufficient for an adequate
supply of health services, which means that families are forced to make out-of-pocket
payments that affect household finances and lead to an increased risk of poverty.
• Major segments of the population do not have regular and timely access to health
services and continue to experience disparities in access due to economic, geographical,
cultural, and ethnic factors, as well as gender, age, religion and sexual preference.
• Health system segmentation and fragmentation lead to greater inequity and inefficiency
in the use of sector resources, as well as further reductions in the access of poorer and
more vulnerable populations.
• Engage in advocacy, emphasizing the need for greater funding in regional and national
plans that is predictable, sustainable, and collective in nature, as well as participation in
partnerships that further this aim.
• Offer technical cooperation to countries and Ministries of Health to ensure that health has
an important place on the domestic development agenda, and support countries in
developing and sustaining high levels of efficient, responsible, and transparent
management.
• Develop reliable data and knowledge to inform policy options on equitable collective
funding mechanisms to reduce dependency on direct payments from households.
• Strengthen national capacity to evaluate policy options to reduce inequalities in income
as an underlying cause of health disparities and establish national strategies to increase
social and financial protection in health.
• Strengthen national capacity to generate strategic health intelligence through applied
research, innovative comparative studies, use of analytical methodologies, and
knowledge management.
• Strengthen national capacities, especially in the Ministries of Health and social security
agencies, to promote social dialogue to reach a consensus with civil society and relevant
stakeholders on national health objectives and social protection strategies.
• Strengthen national government capacities to evaluate the situation and fluxes of
international cooperation resources and for the development of policies and instruments
of alignment, harmonization and coordination of the international aid for health
development.
Achieving this SO requires that:

• Regional, subregional, and national partnerships are established, particularly with
international financial institutions, Economic Commission for Latin America and the
Caribbean (ECLAC), International Labor Organization (ILO), International Social Security
Association (ISSA), Inter-American Conference on Social Security (CISS), Inter-American
Center on Social Security Studies (CIESS), subregional integration agencies such as
Central American Integration System (SICA), Southern Common Market (MERCOSUR),
Caribbean Community (CARICOM), Bolivarian Alternative for the American People

June 2007
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(ALBA); and bilateral development partners and ministries of labor/social security,
finance/treasury, planning, central banks, and national statistics institutes, as well as
universities and research centers.
• Countries undertaking health system reforms are interested in the search for universal,
equitable access to health services for their people and want the resources for this
purpose to be allocated and available to the health sector.
• Countries’ experiences vary, and the lessons learned in national processes can serve as
valuable input for technical cooperation among countries.
Potential risks are:
• Recent increases in the countries’ funding for health could be tied to attention to a few
specific health problems and not to a vision that integrates financing with universal care.
• Greater funding from external sources could increase system segmentation and weaken
sector institutions, undermining the steering role due to parallel and segmented
financing, insurance, and service delivery mechanisms.
RER 14.1 Support to the Member States in the development of institutional

capacities for the analysis of policy options in economic and financing,
political, social and sanitary matters; in order to improve the
performance of the financing mechanisms of the health system and of
social protection in order to eliminate/to reduce economic barriers of
access, to promote financial protection, equity and solidarity in financing
of services and health actions, and the efficient utilization of resources.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.1.1 Number of countries with institutional 7 10 15
development plans for policy and regulations to
improve the performance of financing
mechanisms for the health system and social
protection.
14.1.2 Number of countries with Units of Analysis in 10 13 18
economic, financial and functional health
expenditure, which use that information in order
to develop relevant policies in regard to the
elimination/reduction of economic barriers of
access, increase in financial protection, equity
and solidarity in financing of services, and
efficiency in the utilization of resources.
14.1.3 Number of countries that have conducted 11 15 20
characterization studies of social exclusion in
health at national or sub-national levels.
14.1.4 Number of countries with extension policies of 8 10 12
social protection in health with the objective of
universal coverage.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.1.5 Number of policy-briefs, analytical documents, 20 28 40
applied research, innovative and/or comparative
case studies, methodologies, and instruments on
exclusion / social protection, economy /
financing / health systems expenditure, equity /
efficiency in the utilization of developed and
disseminated resources.
RER 14.2 Implemented measures of promotion, information, and technical

cooperation at regional, subregional, and national levels to raise stable
and additional funds allocated to health.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.2.1 Number of countries that have 6 9 12
developed/improved processes of planning
and/or monitoring of international cooperation in
regards to Poverty Reduction Strategy Papers,
Sector-Wide Approaches, Medium Term
Expenditure Frameworks and other long-term
financing mechanisms.
14.2.2 Regional promotion strategy of the ongoing Consultation Regional Regional
exchange of information, knowledge, and process for strategy strategy
lessons learned about coordination and countries formulated formulated
alignment of the formulated and with high and agreed and agreed
implemented international cooperation. dependency upon by upon by
on 40% of the 70% of the
international countries of countries of
cooperation the region the region
and with high with high
respective dependency dependency
PWRs. on on
international international
financial financial
assistance assistance

June 2007
- 130 -
RER 14.3 Develop and implement a methodological and analytical framework in
Member States to evaluate sustainability, solidarity, equity, and capacity
for household financial stability in the social protection system in health,
based on available secondary information.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.3.1 Methodological and analytical framework to Methodolo Methodological Necessary
evaluate the sustainability, solidarity, equity, gical and and analytical information
and capacity for household financial stability analytical framework identified in
in the social protection system in health, framework developed and 3 additional
developed and validated by experts and not validated, with countries
national authorities, and necessary available necessary (total 8
secondary information identified in the information countries)
information systems from the countries. identified in 5
countries
14.3.2 Number of country studies finalized with a 0 3 5
methodological and analytical framework to
evaluate sustainability, solidarity, equity, and
household financial stability in the social
protection system in health.
RER 14.4 Development and periodic dissemination of information on financing and

health expenditures, including a strategy to apply existing knowledge,
incorporated in the regional Plan and national research agendas on
health systems and policies, with an emphasis on the extension of social
protection in health.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.4.1 Regional-PAHO Core Data Initiative and the 80% 90% 100%
Statistical Annex of WHR/WHO with up-to-date
information on financing and health expenditure
for 100% of the region.
14.4.2 Number of countries with national research 6 10 15
agendas on systems and health policies, with
emphasis on the extension of social protection in
health, and utilization of information on financing
and health expenditure.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.4.3 Regional research agenda established and under 0 Regional Regional
way, on systems and policies of health, with research research
emphasis on the extension of social protection in plans on plans on
health, based on the utilization of information on health health
financing and health expenditure. systems and systems and
policies policies
developed being
and implemented
approved by
Member
States
14.4.4 Number of countries that have institutionalized 13 18 25
the periodic production of National Health
Accounts aligned with the U.N. system.
RER 14.5 Technical cooperation developed for insurance processes and

mechanisms and/or expansion of coverage; and experiences and lessons
learned shared among Member States.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.5.1 Number of countries that have shared 37 41 41
experiences and lessons learned regarding
insurance and/or expansion of coverage.
14.5.2 Number of policy-briefs, analytical documents, 10 16 25
applied research, innovative and/or comparative
case studies, methodologies and strategic
instruments, programs, insurance plans and
mechanisms and/or the expansion of coverage
that have been developed and disseminated.
14.5.3 Regional and subregional comparative studies on 0 Regional Comparative
experiences in insurance and/or expansion of comparative subregional
coverage, with the objective of reaching study studies of (1)
universal protection. completed North America,
and (2) Central
disseminated America and
the Caribbean,
and (3) South
America
completed and
disseminated

June 2007
- 132 -
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.5.4 Number of professionals from countries and 220 300 400
international cooperation agencies trained by
PAHO in development strategies, programs,
insurance plans and mechanisms, and/or
expansion of coverage, with the objective of
reaching universal protection.
RER 14.6 Improve regional coordination of international cooperation in health and

strengthen country capacity for coordination at the subregional and
national levels in order to meet national health development targets.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
14.6.1 Number of countries in which actions by primary 3 5 8
donors to the health sector are in line with and
conform to governmental plans and priorities.
14.6.2 Number of countries in which the coordination of 7 8 10
international cooperation in the Ministries of
Health has been strengthened.

June 2007
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To provide leadership, strengthen governance and foster partnership
and collaboration with countries, the United Nations system and other
stakeholders in order to fulfill the mandate of PAHO/WHO in advancing
the global health agenda as set out in WHO's Eleventh General
Programme of Work, and the Health Agenda for the Americas
Scope
This Strategic Objective (SO) facilitates the work of the PASB to achieve all other SOs.
It recognizes that the context for international health has changed significantly. The
scope of this objective covers three broad, complementary areas: 1) leadership and
governance of the Organization; 2) the PASB’s support for presence in, and
engagement with individual Member States, the United Nations System and other
stakeholders; and 3) the Organization’s role in bringing the collective energy and
experience of Member States and other actors to bear on health issues of global and
regional importance.
• Number of countries implementing health-related resolutions and agreements

adopted by the Health Assembly and PAHO Governing Bodies. Target: more than
half the Member States (19 countries) by 2013.
• Number of countries that have a Country Cooperation Strategy (CCS) agreed by
the government, with a qualitative assessment of the degree to which
PAHO/WHO resources are harmonized with partners and aligned with national
health and development strategies. Target: 30 by 2013 (baseline: 0 in 2006-
2007).
• Degree of attainment by Official Development Assistance for Health of Paris
Declaration benchmarks on harmonization and alignment.9 Target: 100% of
benchmarks met by 2013.
PAHO’s governing bodies – the Pan American Sanitary Conference, the Directing Council, the
Executive Committee and its Subcommittee of Program, Budget and Administration (SPBA) –
provide strategic and policy direction for the PASB, which is lead and managed by the Director
and senior officers at regional and country level.
9
Paris Declaration on Aid Effectiveness: Ownership, Harmonisation, Alignment, Results and Mutual Accountability, Paris,
2 March 2005. WHO is working with OECD, the World Bank and other stakeholders to adapt the Paris Declaration to
health. The following targets will gradually become more health focused as the process evolves: 50% of Official
Development Assistance implemented through coordinated programmes consistent with the national development
strategies; 90% of procurement supported by such Assistance effected through partner countries’ procurement system;
50% reduction in Assistance not disbursed in the fiscal year for which it was programmed; 66% of Assistance provided in
the context of programme-based approaches; 40% of WHO country missions conducted jointly; 66% of WHO country
analytical work in health conducted jointly.

June 2007
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The governing bodies need to be serviced effectively, and their decisions implemented in a
responsive and transparent way. Clear lines of authority, responsibility and accountability are
needed within the PASB, especially in a context where resources, and decisions on their use, are
increasingly decentralized to locations where programs are implemented.
At all levels, the Organization’s capabilities need to be strengthened to cope with the ever-
growing demand for information on health. The Organization should be equipped to
communicate internally and externally in a timely and consistent way at global, region and
country levels–both proactively and in times of crises–in order to demonstrate its leadership in
health, provide essential health information, and ensure visibility.
There is a need for strong political will, good governance and leadership at country level.
Indeed, the State plays a key role in shaping, regulating and managing health systems and
designating the respective health responsibilities of government, society and the individual. This
means dealing not only with health-sector issues but with broader ones, for instance reform of
the civil service or macroeconomic policy, which can have a major impact on the delivery of
health services. The PASB, for its part, needs to ensure that it focuses its support around clearly
articulated country strategies, that these are reflected and consistent with PAHO/WHO’s medium-
term strategic plans and that the Organization’s presence is matched to the needs and level of
development of the country concerned in order to provide optimal support.
At Regional level, certain mechanisms could be strengthened to allow stakeholders to tackle

health issues in a transparent, equitable and effective way. PAHO/WHO should help to ensure
that national health policy-makers and advisers are fully involved in all international forums that
discuss health-related issues. This is particularly important in a time of social and economic
interdependence, where decisions on issues such as trade, conflict and human rights can have
major consequences for health. The numerous actors in public health, outside government and
intergovernmental bodies, whether activists, academics or private-sector lobbyists, need to have
forums so that they can contribute in a transparent way to global and national debates on health-
related policies; they also play a part in ensuring good governance and accountability.
The growing number of others involved in health work has also led to gaps in accountability and
an absence of synergy in coordination of action. Global health partnerships offer the potential to
combine the different strengths of public and private organizations, along with civil society
groups, in tackling health problems and inequities.
With an increasing number of sectors, actors and partners involved in health, PAHO/WHO’s role
and strengths need to be well understood and recognized.
In this context, PAHO/WHO needs to continue to play a proactive role, and to devise innovative
mechanisms for managing or participating in global, regional, subregional and national
partnerships in order to make the international health architecture more efficient and responsive
to the needs of Member States.
Achieving the SO will require Member States and the Bureau to work closely together. More
specifically, key actions should include leading, directing and coordinating the work of PAHO;
strengthening the governance of the Organization through stronger engagement of Member
States and effective Bureau support; and effectively communicating the work and knowledge of
PAHO/WHO to Member States, other partners, stakeholders and the general public.
In collaborating with countries to advance the global and regional health agendas, PAHO/WHO
will contribute to the formulation of equitable national strategies and priorities, and bring country

June 2007
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realities and perspectives into global policies and priorities. The different levels of the Bureau
would be coordinated on the basis of an effective country presence that reflects national needs
and priorities and integrates common principles of gender equality and health equity. At national
level the Bureau will promote multi-sectoral approaches; build institutional capacities for
leadership and governance, and for health development planning; and it will also facilitate
technical cooperation among countries (TCC).
Other actions include promoting development of functional partnerships and a global, regional
and subregional health architecture that ensures equitable health outcomes at all levels;
encouraging harmonized approaches to health development and health security with
organizations of the United Nations system, other international bodies, and other stakeholders in
health; actively participating in the debate on reform of the United Nations system; and acting as
a convener on health issues of global, regional, subregional and national importance.

The following assumptions underlie achievement of the SO:
• That commitment from all stakeholders to good governance and strong leadership is
maintained; and Member States and the Bureau comply with the resolutions and
decisions of the governing bodies.
• That the current relationship of trust between Member States and the Bureau is
maintained.
• That accountability for actual implementation of action decided on will be strengthened
in the context of the results-based management framework.
• That possible changes in the external and internal environment over the period of the
PASB Strategic Plan will not fundamentally alter the role and functions of PAHO/WHO;
however, PAHO/WHO must be able to respond and adapt itself to, for instance, changes
stemming from reform of the United Nations system.
Among the risks that might affect achievement of the SO consideration could be given to possible
consequences of the reform of the United Nations system; opportunities would be increased if
PAHO/WHO takes initiatives and plays a proactive role in this process. Also, the increasing
number of partnerships might give rise to duplication of efforts between initiatives, high
transaction costs to government and donors, unclear accountability, and lack of alignment with
country priorities and systems; remedial action would be needed if this development occurs.
RER 15.1 Effective leadership and direction of the Organization through the
enhancement of governance, and coherence, accountability and synergy
in PAHO/WHO´s work to fulfill its mandate in advancing the global,
regional and subregional health agendas.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.1.1 Proportion of PAHO Governing Bodies resolutions 40% 45% 55%
adopted that focus on policy and strategies to be
implemented at regional, subregional and
national levels.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.1.2 Proportion of documents submitted to governing 95% 100% 100%
bodies within constitutional deadlines, in all
official languages.
15.1.3 Percentage of oversight projects completed 90% 98% 100%

under the biennial Workplan which seek to
evaluate and improve processes for risk
management, control and governance.
15.1.4 Development and implementation of a None System System
monitoring system for institutional development. developed fully
and implement
approved by ed
EXM
15.1.5 Corporate policies and staff performance reflect Baseline 20% over 50% over
use of institutional development approaches: survey baseline baseline
results-based management, knowledge-sharing, conducted
inter-programmatic teamwork, and
gender/ethnic equity, among others.
15.1.6 The Organization is functioning within its legal 95% 100% 100%
framework as mandated by the Governing
Bodies and established rules and regulations.
15.1.7 An Accountability Framework to support In Approved by Full
Delegation of Authority to country level approved progress Governing implement
and implemented. Bodies ation
RER 15.2 Effective PAHO/WHO country presence established to implement the

PAHO/WHO Country Cooperation Strategy (CCS) that is 1) aligned with
Member States' national health and development agendas, and 2)
harmonized with the United Nations country team and other
development partners.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.2.1 Number of countries using Country Cooperation 20/35 30/35 35/35
Strategies (CCS) as a basis for planning the
PASB's country work and for harmonizing
cooperation with the United Nations CCA/UNDAF.

June 2007
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RER RER RER
Indicator Indicator Indicator
Indicator # RER Indicator text
Baseline Target Target
(end-2007) 2009 2013
15.2.2 Number of countries where PAHO/WHO’s 20/35 30/35 35/35
presence reflects the respective Country
Cooperation Strategy.
15.2.3 Number of countries in which a joint (PASB, 10/35 30/35 35/35
government and other stakeholders)
assessment of the biennial Workplan is
performed to define the contribution of the
PASB to national health outcomes.
15.2.4 Number of subregions that have a Subregional 0/4 1/4 4/4
Cooperation Strategy (SCS).
15.2.5 TBD TBD TBD
Number of Technical Cooperation among
Countries (TCC) projects .
15.2.6 Framework Fully Ongoing

developed implemented
Framework for key countries implemented.
in 5 key
countries
15.2.7 Number of Subregional Fora conducted that 0 3 5
develop position papers and policy
recommendations for the improvement of
public health in the respective subregion.
RER 15.3 Regional health and development mechanisms established, including

partnerships, international health and advocacy, to provide more
sustained and predictable technical and financial resources for health, in
support of the Health Agenda for the Americas.
RER RER RER
(end-2007) 2009 2013
15.3.1 4% 10% 20%
Proportion of trade agreements in the
Americas that appropriately reflect public
health interests.
15.3.2 Number of countries where PAHO/WHO is 38/38 38/38 38/38
leading or actively engaged in health and
development partnerships (formal and
informal), including in the context of reforms
of the United Nations system.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.3.3 Number of agreements with bilateral and TBD 10 25
multilateral organizations and other partners, during
including UN agencies, supporting the Health 2007
Agenda for the Americas.
15.3.4 Proportion of Summit's Declarations reflecting 60% 65% 75%
commitment in advancing the Health Agenda for
the Americas.
15.3.5 Number of position papers and policy 3 5 5

recommendations developed and adopted by
Regional, Subregional and National Health Fora.
15.3.6 Number of well-regarded regional partners on 0 5 10

the board of the Regional Public Health Forum
for the Americas.
RER 15.4 PAHO is the authoritative source of public health information and
knowledge, with essential multilingual health knowledge and advocacy
material made accessible to Member States, health partners and other
stakeholders through the effective exchange and sharing of knowledge.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.4.1 Number of countries that have access to relevant TBD TBD TBD
health information and advocacy material for the
effective delivery of health programs as reflected
in the country cooperation strategies.
15.4.2 Content, information processing, and utilization TBD TBD TBD
data available for web pages, blogs, list servers,
virtual health library, WHO's Health InterNetwork
Access to Research Initiative (HINARI) and
Global Information Full Text (GIFT) projects,
News Agency, OpenLink, and other corporate
knowledge management tools.
15.4.3 TBD TBD TBD
Number of multilingual pages available on the
PAHO web site.
15.4.4 Number of information products (Journal, books, TBD TBD TBD

CDs, web pages, catalogs/fliers) published and
disseminated for free or sold per biennium.

June 2007
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RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
15.4.5 Number of Communities of Practice using 2 TBD TBD
synchronous and asynchronous technologies for
technical areas and administrative units
designed, implemented, and supported.
15.4.6 The organization synthesizes knowledge and TBD TBD TBD
translates into contextually appropriate Policy
and tools for Member States and institutional
strengthening.
15.4.7 PAHO Journal of Public Health recognized as first TBD TBD TBD
among Public Health Publications by Peer
Reviews.
15.4.8 Content, information processing, and utilization TBD TBD TBD
data available for Lessons Learned and Staff
Travel and Consultant Report System.

June 2007
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To develop and sustain PAHO/WHO as a flexible, learning organization,
enabling it to carry out its mandate more efficiently and effectively
Scope
The scope of this objective covers the functions that support the work of the Bureau
in countries, technical centers, subregions, and technical and administrative areas at
headquarters. It includes strategic and operational planning and budgeting,
performance, monitoring and evaluation; coordination and mobilization of resources,
management of financial resources, and other administrative functions. The entities
implementing this SO ensure the efficient flow of available resources throughout the
Organization; management of human resources; provision of operational support,
including procurement services; the management of information technology; and
legal services.
• Achievement of RERs under SOs 1-15 (the main function of SO 16 is to enable

the programmatic work covered under SOs 1-15 to occur efficiently and
effectively). Target: 80% of Regional wide Expected Results indicators achieved
(at least 75%) by 2013
• Cost-effectiveness of the enabling functions of the Organization, i.e. the share of
overall budget spent on this SO relative to the total PASB budget. Target: TBD
As noted, the functions performed under SO16 exist principally to enable the efficient and
effective operation of the functions culminating in SOs 1-15. Therefore, the issues and
challenges that affect the entire Organization also apply to this SO. That being said, there are
some specific challenges faced by the “support functions”:
• Partners and contributors are expecting increasing transparency and accountability in

terms of both measurable results and use of financial resources.
• PAHO’s implementation of result-based management remains incomplete; while results-
based planning and budgeting are in place, the extent to which managers are
incorporating performance data and analysis into their day-to-day decision-making
processes must be enhanced.
• Financial management is a challenge in a situation in which near 50% of the budget are
voluntary contributions. Regular monitoring and reporting on resources across the
Organization has improved. However, more flexibility is required in the financing
together with more effective use of funds internally for better alignment of resources
with the program budget and lowering of transaction costs.

June 2007
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• The increasing percentage of the Organization’s budget that comes from voluntary
contributions (as opposed to regular budget) presents challenges, especially given the
high ratio of staff costs to non-staff costs.
• Human resource management is an issue when the average age of professional staff is
50 years old and approximately 31% will be retiring over the next five to seven years.
• Gender balance and geographic representation at all levels.
• Delegation and accountability models that ensure efficiency while maintaining controls
are being developed, and will be implemented during the period.
In order to achieve the SO and respond to the above challenges, broad complementary
approaches are required. Significant efforts have been made in institutional strengthening to
enhance the Bureau’s administrative and managerial capabilities, efforts that are showing results.
These approaches will be intensified during the coming years, and include the move from an
organization managed mainly through tight, overly bureaucratic controls to post facto monitoring
in support of greater delegation and accountability; the shift of responsibility for, and decision-
making on, the use of resources closer to where programs are implemented; improvement of
managerial transparency and integrity; reinforcement of corporate governance and common
Organization-wide systems; and strengthening of managerial and administrative capacities and
competencies in all locations, in particular at country offices.
It is assumed that the changes in the external and internal environment that are likely to occur
over the six-year period of the plan will not fundamentally alter the role and functions of PAHO.
Nonetheless, managerial reforms should help shape PAHO into a more flexible organization that
is able to adapt to change.
The Bureau will continue its efforts to “do more with less” without compromising the quality of its
services. This strategy is not without risk and must not be carried out to the detriment of
institutional knowledge, quality, appropriate controls and accountability. This objective is
inherently linked to the work of the rest of the Organization: increasing workload in other SOs
will require increased resources to support that work, even if the relationship is not necessarily
linear.
Active support is needed from Member States through, for instance, timely funding of the
Organization’s program budget, including voluntary contributions.

June 2007
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RER 16.1 PASB is a result based organization, whose work is guided by strategic
and operational plans that build on lessons learnt, reflect country and
subregional needs, are developed jointly across the Organization, and
are effectively used to monitor performance and evaluate results.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
16.1.1 Results Based Management strategy approved In Approved by Full
by Governing Bodies and applied throughout the progress Governing implement
Organization. Bodies ation
16.1.2 The PASB Strategic Plan (SP) and respective In PB 10-11 SP 13-17
Program Budgets (PBs) are results-based, take progress developed and PB
into account the country-focus strategy and with these 12-13
lessons learnt, are developed by all the levels of characteristi developed
the Organization, and approved by the cs with these
Governing Bodies. characteris
tics
16.1.3 Percentage of Regional Program Budget Policy 30% 65% 100%
final targets fully implemented.
16.1.4 Number of PASB entities whose biennial 0/80 20/80 80/80
Workplans are results-based and explicitly
address the country focus strategy as defined in
CCSs.
16.1.5 For each biennium, proportion of monitoring and 50% 80% 100%
assessment reports on Expected Results
contained in the Strategic Plan and Program
Budget submitted in a timely fashion, after a
peer review.
16.1.6 Percentage of PASB entities where the Strategic 6% 60% 100%
Alignment and Resource Allocation (SARA)
exercise aligns staff competencies and resources
to the strategic direction of the Organization.
16.1.7 Proportion of Regional Public Health Plans 0% 100% 100%
elaborated and implemented by Member States,
with the collaboration of the PASB, as per
established guidelines.
16.1.8 Proportion of managers and project officers 0% 50% 100%
trained and certified on RBM, planning, project
management, and operational planning and
monitoring and accountability mechanisms.
16.1.9 Model for PASB subregional level management In Approved by N/A
mechanism approved by Member States. progress Governing
Bodies
16.1.10 Number of PASB subregional levels fully 1/4 2/4 4/4
functional based on model agreed with Member
States.

June 2007
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RER 16.2 Monitoring and mobilization of financial resources strengthened to
ensure implementation of the Program Budget, including enhancement
of sound financial practices and efficient management of financial
resources.
RER RER RER
(end-2007) 2009 2013
16.2.1 PASB compliance with International Public International International International
Sector Accounting Standards. Public Sector Public Sector Public Sector
Accounting Accounting Accounting
Standards Standards Standards
not approved by fully
implemented Member implemented
States,
analysis
completed,
and financial
systems
ready for
implementa-
tion in 2010.
16.2.2 Proportion of strategic objectives/regional TBD 50% 100%
wide expected results (RERs) with
expenditure levels meeting or exceeding
program budget targets.
16.2.3 Proportion of voluntary contributions that TBD 15% 20%
are un-earmarked.
16.2.4 Proportion of unfunded Program Budget TBD TBD TBD
planned amounts met during the biennium,
by RER.
16.2.5 Amount of voluntary contributions funds TBD TBD TBD
returned to partners (in US$).
16.2.6 Sound financial practices as evidenced by an TBD Unqualified Unqualified

unqualified audit opinion. Audit Audit
Opinion Opinion
16.2.7 Overall return on the investment portfolio of TBD TBD TBD
the Organization.
16.2.8 Proportion of voluntary contributions TBD TBD TBD
proposals requiring major revisions.
16.2.9 Proportion of PWRs empowered to mobilize 0% 50% 100%
resources.

June 2007
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RER 16.3 Human Resource policies and practices promote a) attracting and
retaining qualified people with competencies required by the
organization's plans, b) effective and equitable performance and human
resource management, c) staff development and d) ethical behavior.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
16.3.1 Proportion of entities with approved human 15% 75% 100%
resources plans for a biennium, linked to the
corporate HR strategy.
16.3.2 Proportion of staff assuming a new position (with 15% 75% 100%
competency based post-description) or moving
to a new location during a biennium in
accordance with HR strategy.
16.3.3 New recruitments reflect UN standards on TBD TBD TBD
gender balance and geographic representation.
16.3.4 Human resources performance evaluation No Yes Yes
system utilized by all staff, and linked to biennial
Workplans, competency model and staff
development plans.
16.3.5 Proportion of staff with appeals, grievances and TBD TBD TBD
disciplinary actions to the size of the workforce.
RER 16.4 Information Systems management strategies, policies and practices in

place to ensure reliable, secure and cost-effective solutions, while
meeting the changing needs of the PASB.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
16.4.1 Proportion of significant IT-related proposals, 0% 40% 80%
projects, and applications tracked on a regular
basis through portfolio management processes.
16.4.2 Level of compliance with service level targets 0% 50% 75%
agreed for managed IT-related services.
16.4.3 Number of country offices and centers using 36 36 36
consistent, near real-time management
information.

June 2007
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RER 16.5 Managerial and administrative support services, including procurement,
enabling the effective and efficient functioning of the Organization.
RER RER RER
(end-2007) 2009 2013
16.5.1 Level of user satisfaction with select Low Medium High
managerial and administrative services (satisfaction (satisfaction (satisfaction
(including security, travel, transport, mail rated less rated 50%- rated over
services, cleaning and food services). than 50%) 75%) 75%)
16.5.2 Proportion of standard operating procedures 0% 50% 100%
utilized by PASB staff during regional
emergencies.
16.5.3 Proportion of Internal benchmarks met or 60% 70% 80%
exceeded for specialized services, such as
translation.
16.5.4 Proportion of procurement actions, service 60% 80% 95%
contract agreements and administrative
(delegation of authority) processes
completed within benchmark limits.
RER 16.6 A physical working environment that is conducive to the well- being and
safety of staff in all entities.
RER
Indicator RER RER
(end- Target Target
2007) 2009 2013
16.6.1 Proportion of contracts under the PASB 100% 100% 100%
infrastructure capital plan for approved
project(s) for which all work is substantially
completed on a timely basis.
16.6.2 Proportion of PASB entities that have 65% 75% 100%
implemented policies and plans to improve staff
health and safety in the workplace, including
Minimum Operating Safety Standards (MOSS)
compliance.
16.6.3 Proportion of entities (HQs, PWRs, and Centers) 75% 90% 100%
that improve and maintain their physical
infrastructure, transport, office equipment,
furnishings and information technology
equipment as programmed in their biennial
Workplans.

June 2007
- 146 -

To Improve Nutrition, Food Safety and Food Security, Throughout The Life-Course, and in Support of Public Health and Sustainable Development

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To Improve Nutrition, Food Safety and Food Security, Throughout The Life-Course, and in Support of Public Health and Sustainable Development

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STRATEGIC OBJECTIVE 9

To improve nutrition, food safety and food security, throughout the

INDICATORS AND TARGETS

• Proportion of underweight children under 5 years of age. Target: all

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

• Development and Dissemination of Macro policies Targeting the Most

Cooperation at national, subregional, regional and global levels is required to improve

• To work with national governments to strengthen foodborne disease surveillance systems

Proposed Strategic Plan 2008-2012

This SO can be achieved under the following assumptions:

The following risks may adversely affect achievement of the SO:

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

RER 9.2 Norms, including references, requirements, research priorities and

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

RER 9.5 Foodborne diseases surveillance, prevention and control systems

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

INDICATORS AND TARGETS

• Coverage for a range of priority health interventions (for communicable and

ISSUES AND CHALLENGES

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

There is a plethora of information available that consolidates knowledge and evidence on

ASSUMPTIONS AND RISKS

Proposed Strategic Plan 2008-2012

REGION-WIDE EXPECTED RESULTS

RER 10.2 Organizational and managerial capacities, including information

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

PAHO/WHO technical cooperation will be geared to boosting the policy-making and

INDICATORS AND TARGETS

ISSUES AND CHALLENGES

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

ASSUMPTIONS AND RISKS

The following assumptions apply:

Proposed Strategic Plan 2008-2012

The following risks could adversely affect attainment of the SO:

REGION-WIDE EXPECTED RESULTS

11.1.4 Number of subregions implementing a strategy 0 2 5

Proposed Strategic Plan 2008-2012

RER 11.3 Contribute to the access, equitable dissemination, and utilization of

Proposed Strategic Plan 2008-2012

RER 11.5 Contribute to the opening and strengthening of dialogue mechanisms

11.5.3 Number of countries that have cyber health TBD 12 30

Proposed Strategic Plan 2008-2012

INDICATORS AND TARGETS

• Ensured improvement in access to essential medical products and

ISSUES AND CHALLENGES

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

Proposed Strategic Plan 2008-2012

• Advocacy and support to Member States in the development, implementation and

Proposed Strategic Plan 2008-2012

ASSUMPTIONS AND RISKS