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
all-is the fact that 37 per cent of the population in Latin America were receiving no health services of any kind. The majority lives in rural areas or in the marginal districts of major cities. This sector of the population suffers from a heavy burden, as is shown by its high morbidity and mortality rates. Acute communicable diseases, malnutrition, and illiteracy are major problems. Inadequate diets, a consequence of the low levels of personal income, are translated in turn into high infant and maternal mortality. Mass migration from rural areas to the cities is not at all surprising. It is expected that by 1980 the overall population of the areas will have increased by 100 million, and that one-fourth of all the inhabitants will be located in cities of 500,000 or more and another 50 to 55 per cent will be found in urban centers of 20,000 to 500,000 population. The weight of this geographical distribution seems certain to be reflected in a heavy demand for health services and in environmental deterioration.
The 10- Year Health Plan Preparatory Stage With the foregoing facts in mind, the Governments of the region decided to take advantage of the lessons offered by the previous decade and to undertake, in a renewed effort, joint plans for the solution of problems expected during the decade of the 1970s. The Directing Council of the Pan American Health Organization, having agreed on the need for a joint assessment of achievements and problems, convened a Third Special Meeting of the Ministers of Health in October, 1972. To provide a political frame of reference, it was decided to also examine the social implications of health in the Americas as part of the approach to the United Nations Second Development Decade. The Govemments asked PAHO to prepare the reference material, to assemble basic information on outstanding health problems, and to formulate proposals with regard to targets and strategies for the hemisphere. The information provided by the PAHO/country joint 4-year programming system, together with other data from the countries, served as the basis for a study carried out in 52 program areas. For each of these areas there was a summary of the present situation, with emphasis on the governing internal and external factors; an analysis of the problems expected during the decade; and suggested targets, with strategies for accomplishing them, based on the national goals adopted by the individual governments. All of this material was summarized in the Basic Reference Document.2 The proposals contained in the Basic Reference Document were thoroughly studied by each country well in advance of the meeting. Working groups at the national level reviewed the proposals and prepared specific recommendations in each program area. This was probably the most important stage in the evolution of the 10-Year Health Plan. It provided an opportunity to orient the criteria of the national health authorities with respect to the real meaning of each goal. Hence the various national delegations arrived at Santiago well prepared for their task. The outcome of the 1058 AJPH OCTOBER, 1975, Vol. 65, No. 10
meeting was the 10-Year Health Plan for the Americas, 1971-1980. At the XXI Meeting of the PAHO Directing Council, which followed immediately thereafter, it was resolved to incorporate the recommendations of the Ministers into the policy of the Organization and take the necessary steps to implement the plans and programs envisaged in the Plan. Content The Plan itself is divided into three parts. The first presents a brief conceptual analysis of areas such as ecology,
maternal and child health, nutrition, health manpower, community participation, and use of investments. The second reviews the existing problems in 32 program areas and proposes actions to be taken for their solution. The third, which is the core of the endeavor, sets forth the goals of the 10-Year Health Plan for the Americas. The Ministers considered the adoption of a national health policy in each country, taking into account its particular stage of economic and social development, as a basic requisite for achievement of the goals under the Plan. Perhaps central to the success of the entire Plan are the goals relating to the extension of minimal health services to the 37 per cent of the population not now receiving services of any kind-for in Latin America and the Caribbean area, health services now reach only 63 per cent of the people. Moreover, the coverage diminishes in direct relation to the size of the locality. A major effort will need to be made to extend minimum services to all persons living in accessible communities of less than 2,000 population. Basic and specialized services will be extended, where possible, to the rest of the population. The extension of services will, in most cases, be accomplished by the development of a regionalized health system in which priority is to be given to: (1) reduction of morbidity and mortality due to communicable diseases and completion of the campaign to eradicate malaria; (2) development of sectoral and intersectoral programs in maternal and child health aimed at the reduction of mortality in children under 1 year of age by 30 per cent, and in children from 1 to 4 years of age by 60 per cent; (3) reduction of maternal mortality by 30 per cent; and (4) intensification of nutrition programs aimed at reducing protein-calorie malnutrition in children under 5 years of age. As part of the nutrition goal, the Ministers also recommended the adoption of formal national food and nutrition policies, intersectoral in their approach, to ensure the availability of food of adequate nutritional quality to meet the needs of all population groups. Priority is placed also on the strengthening of water supply programs. It is planned to provide piped water to 80 per cent of the urban and 50 per cent of the rural population, with sewerage-services to 70 per cent of the urban and 50 per cent of the rural population. Priority attention is also to be given to the development of programs for the control of water, air, and soil pollution. These problems will inevitably become more pressing with the growth of industrial development and urbanization.
With regard to supporting services, there is agreement on the need to establish organized nursing systems in at least 60 per cent of the countries, with due attention to the levels of medical care services provided in urban and rural areas. The coverage of public health laboratories responsible for diagnosis and the production of biologicals will have to be greatly extended. The Ministers recognized that fulfillment of these goals will require special attention to infrastructure development, both with respect to the expansion of national health systems and as it relates to increased operational capacity at the institutional and sectoral levels. Inter- and intrasectoral coordination, together with administrative reform, are important factors in infrastructure development. Emphasis is also placed on human resources development. A regional average of 8 physicians, 4.5 nurses, 14.5 nursing auxiliaries, 2 dentists, and 2.2 dental auxiliaries per 10,000 inhabitants is projected. The Plan provides for the training of 125,000 nurses and 360,000 nursing auxiliaries during the 1970s. A general goal for the decade calls for an increase in life expectancy at birth by 5 years in those countries where the present figure is under 65. One of the unique features of the Plan is that the targets are defined not only in terms of health indices and resources but also in terms of the necessary strategies for PAHO, given the key role it has been asked to assume. Implementation The targets and strategies of the 10-Year Health Plan are hemisphere-wide in scope, in many cases set within established ranges. These proposals must now be translated into national plans and programs. Some are already being carried out by the Governments, but adjustments are required and new fields need to be developed. To this end, the Directing Council of PAHO has recommended to the Member Governments that they review their national health policies and plans in the light of the regional health goals, their local health situation, and the financial resources available. A simplified guide has been prepared to
facilitate an analysis of the 10-year targets, to measure the contribution each country may make toward the achievement of the hemispheric goals, and to establish the basis for a uniform system of comparison and evaluation. Several countries have already taken action in this area. Brazil, the Dominican Republic, Ecuador, El Salvador, Guyana, Honduras, Jamaica, Mexico, Panama, and Trinidad and Tobago have organized national ad hoc groups under the aegis of their respective ministries of health to analyze the hemispheric goals and to formulate national ones. Similar initiatives are being taken by other countries as well, and very shortly the 10-Year Health Plan, supported by national plans, will, in a dynamic sense, be underway. Following instructions from the Ministers of Health, PAHO convened a working party of personnel responsible for planning and information and one of health economists with a view to designing an evaluation system that can be adapted to the conditions of each country and still be flexible enough to give comparable results for region-wide evaluation. At the hemispheric level, evaluation will be carried-out in three stages. The first, to be effected in 1974, will be aimed at determining how many countries have adopted the baseline, how many have set targets in the fields covered by the 10-Year Health Plan, and how many have formulated corresponding strategies. The second stage, to be carried out in 1977, will be designed to see how actual achievements stand up to the goals that were set for the mid-decade. The final stage, to be completed in 1981, will consist of matching the results for the whole 10 years against the overall targets fixed. Finally, the entire matter of the financing of the health sector, as well as the costing of services, will be approached by means of specialized working parties to be appointed by the Organization to assist the Governments as requested. REFERENCES 1. Pan American Health Organization. Facts on Health Progress, 1971. PAHO Scientific Publication 227, Washington, DC, 1971. 2. Pan American Health Organization. III Special Meeting of Ministers of Health of the Americas (October 1972). Basic Reference Document. Washington, DC, 1972.
SOCIETY OF TOXICOLOGY ANNUAL MEETING The annual scientific meeting of the Society of Toxicology will be held at the Marriott Hotel in Atlanta, GA, on March 14-18, 1976. Anyone interested may attend. Abstracts of the presented papers will appear in Toxicology and Applied Pharmacology, Vol. 37, No. 1, July, 1976. Program, accommodations, and registration information for the meeting will be sent to all members of the Society and to those nonmembers presenting papers. All others should contact Dr. Gale C. Boxill, Secretary, Society of Toxicology, Wyeth Laboratories, Inc., Box 861, Paoli, PA 19301, for this information.
HEALTH PLAN FOR THE AMERICAS 1059
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
all-is the fact that 37 per cent of the population in Latin America were receiving no health services of any kind. The majority lives in rural areas or in the marginal districts of major cities. This sector of the population suffers from a heavy burden, as is shown by its high morbidity and mortality rates. Acute communicable diseases, malnutrition, and illiteracy are major problems. Inadequate diets, a consequence of the low levels of personal income, are translated in turn into high infant and maternal mortality. Mass migration from rural areas to the cities is not at all surprising. It is expected that by 1980 the overall population of the areas will have increased by 100 million, and that one-fourth of all the inhabitants will be located in cities of 500,000 or more and another 50 to 55 per cent will be found in urban centers of 20,000 to 500,000 population. The weight of this geographical distribution seems certain to be reflected in a heavy demand for health services and in environmental deterioration.
The 10- Year Health Plan Preparatory Stage With the foregoing facts in mind, the Governments of the region decided to take advantage of the lessons offered by the previous decade and to undertake, in a renewed effort, joint plans for the solution of problems expected during the decade of the 1970s. The Directing Council of the Pan American Health Organization, having agreed on the need for a joint assessment of achievements and problems, convened a Third Special Meeting of the Ministers of Health in October, 1972. To provide a political frame of reference, it was decided to also examine the social implications of health in the Americas as part of the approach to the United Nations Second Development Decade. The Govemments asked PAHO to prepare the reference material, to assemble basic information on outstanding health problems, and to formulate proposals with regard to targets and strategies for the hemisphere. The information provided by the PAHO/country joint 4-year programming system, together with other data from the countries, served as the basis for a study carried out in 52 program areas. For each of these areas there was a summary of the present situation, with emphasis on the governing internal and external factors; an analysis of the problems expected during the decade; and suggested targets, with strategies for accomplishing them, based on the national goals adopted by the individual governments. All of this material was summarized in the Basic Reference Document.2 The proposals contained in the Basic Reference Document were thoroughly studied by each country well in advance of the meeting. Working groups at the national level reviewed the proposals and prepared specific recommendations in each program area. This was probably the most important stage in the evolution of the 10-Year Health Plan. It provided an opportunity to orient the criteria of the national health authorities with respect to the real meaning of each goal. Hence the various national delegations arrived at Santiago well prepared for their task. The outcome of the 1058 AJPH OCTOBER, 1975, Vol. 65, No. 10
meeting was the 10-Year Health Plan for the Americas, 1971-1980. At the XXI Meeting of the PAHO Directing Council, which followed immediately thereafter, it was resolved to incorporate the recommendations of the Ministers into the policy of the Organization and take the necessary steps to implement the plans and programs envisaged in the Plan. Content The Plan itself is divided into three parts. The first presents a brief conceptual analysis of areas such as ecology,
maternal and child health, nutrition, health manpower, community participation, and use of investments. The second reviews the existing problems in 32 program areas and proposes actions to be taken for their solution. The third, which is the core of the endeavor, sets forth the goals of the 10-Year Health Plan for the Americas. The Ministers considered the adoption of a national health policy in each country, taking into account its particular stage of economic and social development, as a basic requisite for achievement of the goals under the Plan. Perhaps central to the success of the entire Plan are the goals relating to the extension of minimal health services to the 37 per cent of the population not now receiving services of any kind-for in Latin America and the Caribbean area, health services now reach only 63 per cent of the people. Moreover, the coverage diminishes in direct relation to the size of the locality. A major effort will need to be made to extend minimum services to all persons living in accessible communities of less than 2,000 population. Basic and specialized services will be extended, where possible, to the rest of the population. The extension of services will, in most cases, be accomplished by the development of a regionalized health system in which priority is to be given to: (1) reduction of morbidity and mortality due to communicable diseases and completion of the campaign to eradicate malaria; (2) development of sectoral and intersectoral programs in maternal and child health aimed at the reduction of mortality in children under 1 year of age by 30 per cent, and in children from 1 to 4 years of age by 60 per cent; (3) reduction of maternal mortality by 30 per cent; and (4) intensification of nutrition programs aimed at reducing protein-calorie malnutrition in children under 5 years of age. As part of the nutrition goal, the Ministers also recommended the adoption of formal national food and nutrition policies, intersectoral in their approach, to ensure the availability of food of adequate nutritional quality to meet the needs of all population groups. Priority is placed also on the strengthening of water supply programs. It is planned to provide piped water to 80 per cent of the urban and 50 per cent of the rural population, with sewerage-services to 70 per cent of the urban and 50 per cent of the rural population. Priority attention is also to be given to the development of programs for the control of water, air, and soil pollution. These problems will inevitably become more pressing with the growth of industrial development and urbanization.
With regard to supporting services, there is agreement on the need to establish organized nursing systems in at least 60 per cent of the countries, with due attention to the levels of medical care services provided in urban and rural areas. The coverage of public health laboratories responsible for diagnosis and the production of biologicals will have to be greatly extended. The Ministers recognized that fulfillment of these goals will require special attention to infrastructure development, both with respect to the expansion of national health systems and as it relates to increased operational capacity at the institutional and sectoral levels. Inter- and intrasectoral coordination, together with administrative reform, are important factors in infrastructure development. Emphasis is also placed on human resources development. A regional average of 8 physicians, 4.5 nurses, 14.5 nursing auxiliaries, 2 dentists, and 2.2 dental auxiliaries per 10,000 inhabitants is projected. The Plan provides for the training of 125,000 nurses and 360,000 nursing auxiliaries during the 1970s. A general goal for the decade calls for an increase in life expectancy at birth by 5 years in those countries where the present figure is under 65. One of the unique features of the Plan is that the targets are defined not only in terms of health indices and resources but also in terms of the necessary strategies for PAHO, given the key role it has been asked to assume. Implementation The targets and strategies of the 10-Year Health Plan are hemisphere-wide in scope, in many cases set within established ranges. These proposals must now be translated into national plans and programs. Some are already being carried out by the Governments, but adjustments are required and new fields need to be developed. To this end, the Directing Council of PAHO has recommended to the Member Governments that they review their national health policies and plans in the light of the regional health goals, their local health situation, and the financial resources available. A simplified guide has been prepared to
facilitate an analysis of the 10-year targets, to measure the contribution each country may make toward the achievement of the hemispheric goals, and to establish the basis for a uniform system of comparison and evaluation. Several countries have already taken action in this area. Brazil, the Dominican Republic, Ecuador, El Salvador, Guyana, Honduras, Jamaica, Mexico, Panama, and Trinidad and Tobago have organized national ad hoc groups under the aegis of their respective ministries of health to analyze the hemispheric goals and to formulate national ones. Similar initiatives are being taken by other countries as well, and very shortly the 10-Year Health Plan, supported by national plans, will, in a dynamic sense, be underway. Following instructions from the Ministers of Health, PAHO convened a working party of personnel responsible for planning and information and one of health economists with a view to designing an evaluation system that can be adapted to the conditions of each country and still be flexible enough to give comparable results for region-wide evaluation. At the hemispheric level, evaluation will be carried-out in three stages. The first, to be effected in 1974, will be aimed at determining how many countries have adopted the baseline, how many have set targets in the fields covered by the 10-Year Health Plan, and how many have formulated corresponding strategies. The second stage, to be carried out in 1977, will be designed to see how actual achievements stand up to the goals that were set for the mid-decade. The final stage, to be completed in 1981, will consist of matching the results for the whole 10 years against the overall targets fixed. Finally, the entire matter of the financing of the health sector, as well as the costing of services, will be approached by means of specialized working parties to be appointed by the Organization to assist the Governments as requested. REFERENCES 1. Pan American Health Organization. Facts on Health Progress, 1971. PAHO Scientific Publication 227, Washington, DC, 1971. 2. Pan American Health Organization. III Special Meeting of Ministers of Health of the Americas (October 1972). Basic Reference Document. Washington, DC, 1972.
SOCIETY OF TOXICOLOGY ANNUAL MEETING The annual scientific meeting of the Society of Toxicology will be held at the Marriott Hotel in Atlanta, GA, on March 14-18, 1976. Anyone interested may attend. Abstracts of the presented papers will appear in Toxicology and Applied Pharmacology, Vol. 37, No. 1, July, 1976. Program, accommodations, and registration information for the meeting will be sent to all members of the Society and to those nonmembers presenting papers. All others should contact Dr. Gale C. Boxill, Secretary, Society of Toxicology, Wyeth Laboratories, Inc., Box 861, Paoli, PA 19301, for this information.
HEALTH PLAN FOR THE AMERICAS 1059
