The Pan American Health Planning Program

The Pan American Health Planning Program DAVID A. TEJADA DE RIVERO, MD Background Health planning as an organized and defined activity began in 1961 with the Charter of Punta del Este. There were some efforts before that date, however, which helped to set the stage for the 10-Year Public Health Program launched on the occasion of the signing of the Charter. In 1956 and 1957, respectively, the Directing Council of the Pan American Health Organization (PAHO) held technical discussions on the subjects "Methods for the Preparation of National Health Plans" and "Bases and Methods for the Evaluation of Health Programs." In 1961 a planning unit was established at PAHO headquarters in Washington, DC, and expert groups were appointed to deal with specific problems-such as environmental health, medical services, and nutrition. These groups had three main objectives: to develop planning methods and techniques, to provide training in health planning, and to render technical assistance to the countries. One of the groups worked in association with the staff of the Center for Development Studies (CENDES) and the School of Public Health, both of the Central University of Venezuela, and the Venezuelan Ministry of Health and Welfare on a PAHO-sponsored project for the production of a manual for training health planning officials. Used in a training course in Venezuela and later in two international courses, the manual was redrafted in 1964 and became the nucleus of the "PAHO/CENDES method."' It is not the intention here to describe this methodology or to chronicle its successes and limitations. This has already been done most ably by Garcia Gutierrez in this series. By 1965, enough experience had been gained in the field of health planning to permit certain conclusions to be drawn, and accordingly PAHO convened a study group, which met at Puerto Azul, Venezuela, to take stock of developments to date. The following appraisal resulted from this meeting: * The lack of scientific knowledge on the subject and the weaknesses inherent in the PAHO/CENDES methodology make it imperative to establish a research program directed toward finding the means to overcome these difficulties; * It would be advisable to establish an institution to promote and direct these research activities, to At the time of this study Dr. Tejada de Rivero was Director, Pan American Health Planning Center, Santiago, Chile. He is now Assistant Director-General, World Health Organization, Geneva, Switzerland. organize and oversee international training courses, and to collaborate in high level national training programs. Accordingly, that same year PAHO drafted a proposal for the creation of a Pan American Health Planning Center. Endorsed by 14 countries,* the project was then submitted to the United Nations Development Program (UNDP) with a view to obtaining financing. After a preliminary study, the Governing Council of that agency approved it in January, 1968. The undertaking finally became "operational" in the latter part of 1970 with the signing of the agreement and plan of operations by the sponsoring countries. PAHO, UNDP, and the signatoryi countries assumed responsibility for financing the program, and the Pan American Sanitary Bureau, in its capacity as Regional Office of the World Health Organization for the Americas, was entrusted with organizing and directing it. The preliminary work along these lines had already been started in May, 1968, with the appointment of several staff members and the initiation of research activities. Training activities were carried on through the international courses in Santiago, Chile, which up until the end of 1970 had followed their traditional format, with the participation of the Latin American Institute for Economic and Social Planning (ILPES). Organization of the Pan American Health Planning Program As provided in the plan of operations, which is designed to implement the basic health planning policies of PAHO, the Program has four areas of action: advisory services, training, research, and information. Advisory activities in the field of health planning are carried on through regular PAHO channels. The other three-research, information, and training-are the responsibility of the ad hoc Pan American Health Planning Center, which has its headquarters in the United Nations building in Santiago, Chile. Pan American Health Planning Center Aim and Objectives The overall aim of the Center is to contribute the establishment and strengthening of health planning processes in the countries of the region through the creation and dissemination of knowledge and the training of personnel. * Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Honduras, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. 1052 AJPH OCTOBER. 1975, Vol. 65, No. 10

In order to fulfill this purpose, the following tasks have been set: * Promotion and development of training for professional health planning personnel through international courses, national basic courses designed according to subregional country groups, advanced seminars, refresher seminars, seminars on specific topics of particular importance, special regional short courses, and in-service training; * Definition and development of a metric research model for analysis of the processes as a whole; determination of ways it may be put to practical application; and study of specific components or variables of the model through the definition of submodels and through research thereon in specific countries, as well as special research of other types; * Establishment of a hemisphere-wide information service to make available up-to-date knowledge on the status of the planning processes in the different countries and on similar experiences outside the region; * Collaboration with other organizations and institutions as well as with the various technical branches in PAHO/WHO; * Evaluation of the Center's program and definition and preliminary study of subjects, areas, or fields not included in the research program that are considered to be of relevance. Responsibilities In line with the orientation given by the Director of PAHO in September, 1970, the Center has the following responsibilities. Training. * To promote the development of "basic" courses, which should be designed on a subregional basis so as to take into account the needs of the entire region; to provide advisory services in the preparation and programming of the course content and in the organization, administration, and teaching of the classes, as well as in the provision of teaching materials; * To offer refresher courses for those who have already attended the "basic" courses and special courses on fields or subjects that are important to the planning process-these courses to be given away from Center headquarters whenever other countries offer the necessary facilities; * To organize training programs in addition to the traditional formal courses-for example, seminars and in-service training. Research. * To conduct research on the Link Model* and those submodels that feed it which, because of their complexity, cannot be carried out in the countries; * A metric research computer-based model, to be described in greater detail below. * To decentralize research operations by promoting and supporting studies in the countries that will contribute to the development and/or improvement of planning techniques-with the Center recommending the areas of variables that should be studied and providing advisory services up to the final phase of each research study. Information. * To obtain information on health planning and the development of its processes both in the Americas and in other regions; * To analyze the information gathered; * To disseminate information aimed at promoting and guiding the planning processes, motivating officials at the political and administrative decision-making levels, and informing and encouraging those working directly in health planning-in the last case with emphasis on field experiences. Advisory Services to the Countries. * Upon the request of the PAHO Headquarters Office, to participate in rendering direct advisory services to the countries in the area of health planning; * To participate in the training of national planning officials and PAHO consultants. Internal Development Activities. * To collaborate in the intemal planning and programming process within PAHO with a view to seeking and studying solutions to technical and methodological problems; * To develop an internal working program on subjects, areas, or fields that are considered worthy of attention, with a view to promoting their further development in the countries once the corresponding definitions and orientations have been given. Structure and Administration The executing agency for the project is PAHO/WHO, which plans and directs its operations and designates the principal technical adviser. This adviser is appointed in consultation with the participating Governments. The activities of the project are organized through a training division and a research division, although the activities carried out also include advisory services to the Governments and information. With regard to the latter, the project serves as a center for the collection and dissemination of information on progress achieved in the countries in their planning processes. The organizational structure of the Center provides for a director, a secretariat, a training division, a research division, and an information service (Figures 1 and 2). The three program units have been set up for purely formal reasons; in practice, it is intended that the entire staff of the Center work together as a team, everyone participating insofar as possible in all activities. [he plan of operations envisages eight professional positions, which correspond to the director, three training officers, two research officers, and two information officers. HEALTH PLAN FOR THE AMERICAS 1053

World Health Organization/Pan Amerkan Health Organization PAN AMERICAN HEALTH PLANNI G PROGRAM FOURTEEN COUNTRIE OF THE REGO OF THE AMERICAS Argentina Ecuador Paraguay Brazil D Salvador Peru Chile Honduras Uruguay Colombia Nicaragua Venezuela Costa Ria Panama 0 Unie Nations Develpment Program (Special Fund) Prian AeknfafPaliProgram FIGURE 1 Secretarial services have been contracted from the ILPES office and include an administrative secretary, two secretaries, and one chauffeur-messenger who is also in charge of printing, maintenance of vehicles and equipment, purchasing, printing, and reproduction. Since January, 1971, the Government of Chile has provided the services of an information officer for the control of management of library documentation, and it has also offered the services of two assistants whenever needed. With regard to space, the Government of Chile has provided a subsidy of E 361,000 for temporary quarters in the United Nations building. Adaptation to the Center's physical requirements, carried out with help of the Economic Commission for Latin America (ECLA), has been completed. PAHO has contributed by providing new furniture for the Center's offices. Activities Training. Although the PAHO/CENDES methodology made it possible to achieve significant progress in health 1054 AJPH OCTOBER. 1975. Vol. 65. No. 10 I 0 ==IV l* I I m ~~~~~~I I TASKS ACTiviTiEs RESOURCES 1. To continue and expand plans for training the 1. Training: basi courses, special and advanced 1. Experts US$1,890,000 health planning personnel of PAHO and ILPES. courses, avisory services to school of public healt and departments of preventive Ikll 2. Retional personinel US$ 581,110 2. To promote and conduct research. 2. Reseic program wilk te countries: methodo- 3. Seretfaril and other stal services USS 65,800 3. lo compil and disseminate information, lgical problems, interal bnectioning of the sector, 4 Internatioul felowships USS 528,100 4. To strengthen the advisory services of PAHO analsis of the reltoship betwe h to the Government wih a view to improving and ti rest Of the socioeconomk system. 5. National felowshis USS 458,190 their h planning processes. 3. Center for e cohoction ad dissemimtion of 6. Equipment and supplies USS 180,100 information on the progress of the processes and T. Miscelaeous costs USS 24,900 publicatio of manuals. 4. Abisory services for the improvement of ke 8. 6eneral WHO costs USS 199,600 processes. CEIITER HEADOUARTERS ORGAIZATION Sanliago, Chile (in coordination with ILPES) Execuling Apecy: Wold Health Organizatfioqf han Aercn Heal Organization Pan American Health Planning Program. planning activities from both the conceptual and the practical standpoint, the experience acquired through its use and at the same time the increasing accuracy being achieved in defining the components of the health planning process showed that by itself it was not sufficiently effective for a comprehensive study of the health sector at all levels and of all components of the process. The redefinition of the areas of action carried out in 1970 with a view to implementing the Pan American Health Planning Program was based on these considerations, and it led naturally to substantial changes in the training programs. The working party of PAHO planning consultants that met that same year at Caraballeda, Venezuela, recommended that the courses deal with the practical problems with which planners are faced in addition to the theoretical and technical aspects of the PAHO/CENDES method. This recommendation was based on the belief that the slowdown in the health planning processes in some of the countries had to do not with the application of the PAHO/CENDES method as such but rather with the fact that planners were

SECRETARIAT Duties 1. Administer the management of correspondence. 2. Take dictation, prepare drafts, and type docments ald Correspondene. 3. Keep the files up to date. 4. Perform secretarial duties during courses and seminars given at Program hedquarters. S. Implement provisions regarding the maintenance and care of office faclities, hrniture, equipment, supplies, and vehicles. I FIGURE 2 PAN AMERICAN HEALTH PLANNING CENTER OPERATION AND STAFF OR11ANIZATION DIRECTOR Duties 1. ProgrM the ctivities of he Center and oversee their implementation. 2. Coordinate the work of the units of the Center. 3. Be responsible for equipment, materials, transport, and local expenditures. 4. Act as liaison between the Center and the Latin AMerican Institute for Economic and Social Planning. 5. Participate actively in periodical evaluations of the Program. U El TRAININ6 DIVISION RESEARCH DIVISION INFORMATON SERVIE Duties Duties Duties 1. Participate in the programming of 1. Pariciate in the programming of 1. Paricipate in the programming of training ativities and be responsible research activities and be responsibk information activities and be refor their implementation. for their implementation. sponsible for their implementation. 2. Propose the names of persons to Kt 2. Propose the names of persons t act 2. Propose the names of the persons to as directors. coodirectors, or coordi- as prinipal research technicians in ct as correspondents in the coinnators o courses, seminars, or short charge of research projects. in the tries, and serve as one of the bases in courses, in the name of the Center. nae of te Center. the information network. 3. Report on the progress of training 3. Report on te progress of research ativities, activities. 3. Report on the progress of informa- tion Ktivities. 4. Coordinate training ctivities with re- 4. Coordinate research ctivities with 4. Coordinate inlformation ctivities with searck and information, participating in training and information, particpting training and research, participating th latter two whenever necessary. in Ike later two whenver necessary. in the latter two whenever necessary. Pan American Health Planning Center: operation and staff organization. I- HEALTH PLAN FOR THE AMERICAS 1055

not familiar with complementary techniques that could, and should, have been used. The training program may be considered in two stages: the first from 1962 to 1970, and the second beginning in 1971. During the first stage emphasis was placed on training for the preparation of plans and the establishment of the formal elements of the process, such as organization of sectoral planning units, local planning, and use of available resources. During the second stage the stress shifted to: (1) increased dynamism in the approach to the planning processes; (2) simultaneous consideration of local, sectoral, regional, and institutional facets; (3) harmonization of structural change in the health sector with that required for overall socioeconomic development; (4) attention to the political-administrative components of the process; (5) use of other techniques (sectoral diagnosis, institutional analysis, investment programming) in conjunction with the useful aspects of the PAHO/CENDES method; (6) identification of the problems hindering attainment of the imageobjective desired as a prerequisite to proposing viable solutions; and (7) flexibility with respect to the use of other techniques available. Two other important features of the training program during this second stage have been the diversification of the instruction provided in the various types of courses ("basic" courses, seminars, in-service training, etc.) and the effort to hold them away from the Center in Santiago, in countries offering the necessary facilities. Basic Training in Health Planning. Over the period 1962-1970 nine international courses were taught at the headquarters in Santiago, Chile, with the assistance of ILPES, ECLA, the School of Public Health and the National Health Service of Chile, the Latin American Demographic Center (CELADE), and other institutions. A course in English, organized in cooperation with the University of the West Indies, was offered in Jamaica in 1970. Naturally, adjustments were made from time to time in the course content on the basis of teaching experience. This was particularly the case with the 1968, 1969, and 1970 courses, which were held after the Pan American Health Planning Center had begun its preliminary operations. However, the changes were not of a fundamental nature. In 1970 the orientation and content of the intemational courses, now called "basic" courses, were substantially revised. In line with the recommendations of the Program's Technical Advisory Committee, efforts have been made to decentralize these courses by offering them away from Santiago, in countries that have sufficient resources to carry them out. They are now subregional in focus and are given under the primary responsibility of the schools of public health and the Ministries of Health in the countries where they are taught. The first such course was held in San Jose, Costa Rica, and lasted 16 weeks, for a total of 450 hours. It provided a basis for evaluating the changes, both philosophical and pedagogical, planned for other future ones, and the results made it possible to look forward with optimism to those scheduled for 1972 and 1973 in Medell;n, Colombia; Lima, Peru; Buenos Aires, Argentina;' and Mexico City. Training in Special Subjects and Advanced Training. In order to deal in depth with those aspects or components of the planning process that are particularly important and to cover ones that had been previously neglected because of lack of appropriate techniques for studying them, the Center organized a series of seminars on specific subjects. Other Training Activities. As far as possible, the Center collaborates with other training institutions in the preparation of materials and, in some cases, in the teaching of classes. In response to requests made by countries through PAHO/WHO headquarters, it may collaborate in the preparation of curricula, the provision of teaching materials, and provision of technical advice on national courses in health planning. Research The aim of the Research Division of the Center is to generate practical knowledge concerning the variables and problems involved in the health planning processes. For this purpose, attention has been centered on the development of a parametric model, using numerical experimentation, to cover the entire spectrum of such variables, both sectoral and extrasectoral-the so-called Link Model. The Division has also engaged in various other research activities, most of them connected with the development of submodels that use numerical experimentation and, within the context of the Link Model, are intended to complement it and provide certain elements of immediate practical use in the planning processes. These include, for example, the submodels of investment, financing, human resources, policy analysis, chronic diseases, and communicable diseases. Lastly, the Division has conducted research in areas not directly related to the numerical experimentation models referred to above. In order to carry out this ambitious program, the Center has in mind to decentralize research and is therefore promoting and giving special support to projects that can be executed in the countries and that help in the formulation and improvement of planning methods or are connected with aspects that may enhance the Link Model. In such cases the Center is responsible for making recommendations on the areas and aspects to be studied and for rendering advisory services so that tangible results may be achieved for immediate application. Information From the initiation of the Center in 1968 until 1971, in the absence of a formally established information service, the personnel of the Training and Research Divisions produced a series of studies that were used for teaching purposes by the Center and various outside institutions on request. Also, bibliographic material and documents on the health planning processes produced by other institutions were accumulated and used for the courses. At the same time, with the support of an information 1056 AJPH OCTOBER. 1975. Vol. 65, No. 10

officer assigned to the Center by the Government of Chile, a start was made on compiling, filing, and distributing the studies produced by the Center. In addition, a few special documents were produced-for example, "Socioeconomic and Health Planning in Latin America," in English, designed to provide information on the present status of health planning in the English-speaking countries, and "The Use of Demographic Data and Treatment of the Population in Health Planning." Finally, information documents about the Center's activities were prepared and disseminated. The regular Information Service has now been established, and work is going ahead on the preparation of manuals and methods developed by the Center. Also, within the Service a special unit on documentation has been formed. A growth in the demand for information from interested individuals and institutions is foreseen. Collaboration with Other Institutions To the extent that resources permit, the Center collaborates with teaching institutions throughout the region, including those in the United States of America, giving lectures and courses on health planning or the health aspects of development planning and providing advisory services on training for health planning. REFERENCE 1. Pan American Health Organization. Health Planning: Problems of Concept and Method. PAHO Scientific Publication 111, Washington, DC, 1965. The 10-Year Health Plan for the Americas ABRAHAM HORWITZ, MD The Past Decade The Regional Health Program established at Punta del Este by the countries of the Americas for the period 1961-1970 was a major milestone in the joint effort to improve health conditions in the Western Hemisphere. As the health component of a broad plan for economic and social development which later became part of the first United Nations Development Decade, it set specific goals for child health, communicable diseases control, nutrition, environmental health, development of health services, and health manpower for the 10-year period, calling also for an increase in life expectancy at birth by 5 years as a central objective. This framework served as a guide for the formulation of national health programs and projects. Progress and results were examined in two special meetings of the Ministers of Health, held, respectively, in 1963 and 1968. The appraisal made for Latin America as a whole in 1971 and published by the Pan American Health Organization (PAHO) under the title Facts on Health Progress, 19711 shows that considerable advances were registered in several fields in this regional effort. Extension of life expectancy at birth reached two-thirds of the stated goal, while reduction of mortality in the 1- to 4-year age bracket attained 80 per cent of its target-although only limited progress occurred in the group under 1 year of age. In communicable diseases, advances were made in the eradication of malaria, 185.5 million people from the originally malarious areas having been freed of the threat of At the time of the symposium, Dr. Horwitz was Director, Pan American Health Organization, Washington, DC. He is now Director Emeritus. the disease. The last smallpox cases in the Western Hemisphere were reported in Brazil more than 4 years ago, in April, 1971. A decline in tuberculosis death rates, and also in new cases, was registered. Poliomyelitis incidence fell sharply. There was some reduction in whooping cough and diphtheria. The area of nutrition and the feeding of the vulnerable age groups continued to be of concern, despite the efforts undertaken during the decade. The overall goal to provide piped water to 70 per cent of the urban population was achieved or surpassed in 21 of 24 countries. However, as of 1971 only 31 million of the 131 million rural inhabitants had access to such benefits. More than $2 billion were invested in water supply programs during the period. Health services coverage received particular attention from the Governments, but the programs could not keep pace with the increase in population. The same was true of health manpower, especially physicians and nurses. There was a significant increase in the Governments' awareness of the importance of improving available resources and assuring efficient investment of external capital. The weakness of administrative structures and methods was recognized, and the subject was given attention by national authorities. Despite efforts to coordinate health plans with overall programs for economic and social development, much remained to be done in this area. Population growth, rising at rates upwards of 3 per cent a year in most cases, was a cause for real concern. Several countries moved aggressively to initiate programs of maternal and child health and family planning, and these activities were rapidly gaining momentum as of the end of the decade. Among the most pressing problems detected at the close of the 10-year period-perhaps the most urgent one of HEALTH PLAN FOR THE AMERICAS 1057