Priority actions in the first year as Director of PAHO

The main strategic actions that I would initiate in the first year at the head of the Pan American Sanitary Bureau would be the following:

1. Streamline the regional programme structure from the current six technical divisions and one special programme to no more than three technical areas: Health Systems, Policies and Services; Disease Prevention and Control; Health Promotion and Development. Current regional programme technical staff would be restructured into a much more flexible matrix of expertise, on the basis of priority regional health problems, and interdisciplinary coordination and collaboration would highly stimulated. The purpose of this reorganisation would be to reduce administrative and interprogrammatic friction (which is increasingly becoming an impediment to the efficient and effective deployment of scarce cooperation resources at regional level) by simplifying programme planning, implementation, and evaluation.

2. A review of the current organisation and operation of field level cooperation activities and, including PAHO/WHO country representations and PAHO Pan American Centers, the establishment of a high level commission formed by designated representatives of member countries and distinguished retired and active PAHO and WHO staff members, as well as representatives of other technical and financial cooperation agencies involved in health development in the Americas. The mandate of the Commission will be to report and recommend to the 2004 Executive Committee on specific measures that would need to be taken to ensure equity and effectiveness in the use of PAHO technical cooperation resources at country level. This would focus on ensuring adequate and necessary support to the institutional health development of the smaller and/or less developed member countries in the region, as well as more effective mobilisation of the technical resources that are currently available for deployment by the more developed member countries.

3. Another similar high level committee reporting to the Executive Committee in 2004 would be established. This would have the purpose of identifying and proposing effective mechanisms for strengthening member countries' participation in the monitoring and evaluation of the Secretariat technical cooperation programmes and activities, in order to complement and expand current evaluation systems, as suggested by various external auditors' reports. The objective of this Working Group would be strengthen the governance of the Organization and increase member countries' involvement in the strategic guidance of its work.

4. A third Working Group to be formed by representatives of member countries, as well as recognised experts in the fields of knowledge management, information dissemination, information technology, and other relevant disciplines. This group would develop a comprehensive strategy and proposal for the full incorporation of the new informational paradigm into PAHO's main role as the key intergovernmental instrument for knowledge management of health development in the Americas. This proposal would establish a medium and long term plan for the strategic transformation of PAHO as the leader in technical cooperation in health for the 21st century.

5. The fifth priority area of work would be to expand the base for mobilising financial and technical resources for health development in the region of the Americas. This would entail establishing a Country-Secretariat Task Force, with participation by representatives of the private and public sectors, in addition to member countries and bilateral donor government agencies. This task force would explore the feasibility of developing new sources of financial and technical support for regional and country level technical cooperation activities, in addition to strengthening existing ones. This activity is of great importance for the future solvency and sustainability of the Organization, given the growing trend towards budget reductions and other financial constraints.

Our expectation would be to have submitted to the 2004 Governing Bodies five specific proposals for the restructuring and strategic orientation of PAHO for the remainder of the five year period, so that by the end of 2007 the implementation of these proposals would have advanced sufficiently for their review and adjustment in subsequent years. This would be the mandate I would like to receive from our member countries for the 2003–2008 period.

Main health challenges over the next five years

More than any other geographical region, the American continent is characterised by social inequality. This inequality exists among and, moreover, within the countries.

Social inequalities associated with health are the foremost challenge for governments and international technical cooperation organisations, like the Pan American Health Organization (PAHO). New risks and dangers to health, such as HIV/AIDS, emerge and coexist with historical problems such as childhood malnutrition. These problems are concentrated in different vulnerable social groups that are, paradoxically, those least able to access and make use of health services. The current demographic transition points to an increase in the proportion of senior and middle aged citizens in most of the region's countries. This shift in the population pyramid will lead to changes in morbidity and mortality. Chronic diseases will predominate, presenting a challenge that some countries in the continent are already confronting.

During the past decade, large sectors of the population have remained outside the protection of social security systems, while the demand for government medical services has increased, especially curative services offered at clinics and hospitals. Simultaneously, the majority of the region's governments have developed successful programmes to increase primary health care coverage, such as immunisation. Maintaining these achievements is also a challenge for the health sector.

Challenges and the role of the Pan American Health Organization

During the 1980s, healthcare reforms were initiated and promoted in an attempt to respond to these problems. These reforms have sought to contain costs, expand access to care, create new sources for financing health care, and increase patient choice. The design of health systems, as part of a social response, has not always considered existing differences. Homogenisation has often meant that the development of health systems is the goal, rather than improving and contributing to the general health of the population.

PAHO must contribute to the formulation of answers appropriate to the political, social, economical, and health conditions in each country. The redefinition of international technical cooperation, within the framework of globalisation, is a starting point in meeting this goal. It is essential to consider the structural differences among the region's countries when redefining technical cooperation, while keeping in mind the following guidelines:

1. Redefine the role and organisational structure of the national offices and of the regional and national consultants.

2. Promote the development of regional programmes for the reduction, prevention, and control of health risks.

3. Contribute to the formulation, development, and evaluation of strategic projects for the reorganisation of healthcare services. This should be done within the framework of health system reforms and the processes for negotiation and mobiliation of financial and technical resources.

4. Support the development and transfer of health technology among the countries of the region.

5. Promote the collaboration of different international organisations in the development of national and regional health projects.

Structural and organisational changes to meet the new health challenges

The countries in the region have initiated complex health systems reforms that seek to link the goals of the health systems with the results they produce. Equity, quality, efficiency, and effectiveness are all areas in which goals can be linked to strategies and results. In this sense, it is appropriate to adjust the structure, organisation, and the technical cooperation process of PAHO to the conditions and needs of each country's health system. In general, PAHO should:

1. Allocate resources according to need—taking into account the sub regions.

2. Redefine the role of country offices in accordance with the structural, social, economic, political, and health conditions of each country so that technical cooperation better meets national needs.

3. Promote and develop procedures to maximise the use of resources available for technical cooperation, making it more effective, efficient, and adaptable.

4. Strengthen alliances with “institutions of excellence” within the region to leverage PAHO's activities and improve its technical capacity.

Promotion of regional scientific and technological development

The Americas are not a homogenous social universe, as cultural diversity is present within all the countries in the region. There are also important differences among countries in availability and access to education, as well as in their research and development capacity for improving health and quality of life of the population. An important quantity of healthcare technology is imported from industrialised countries, resulting in a dependency on a technology that has ever rising costs and limited application. Conversely, the collaboration of local scientific institutions with their international counterparts is frequently limited to the reproduction of models or the adjustment of strategies to national conditions—too often without considering the resources necessary to adequately study, understand, and thereby address the specific health problems of countries in Latin America and the Caribbean.