Carissa F. Etienne

Primary health care and the social determinants of health: essential and complementary approaches for reducing inequities in health

Increasing focus on health inequities has brought renewed attention to two related policy discourses - primary health care and the social determinants of health. Both prioritise health equity and also promote a broad view of health, multisectoral action and the participation of empowered communities. Differences arise in the lens each applies to the health sector, with resultant tensions around their mutual ability to reform health systems and address the social determinants. However, pitting them against each is unproductive. Health services that do not consciously address social determinants exacerbate health inequities. If a revitalised primary health care is to be the key approach to organise society to minimise health inequities, action on social determinants has to be a major constituent strategy. Success in reducing health inequities will require ensuring that the broad focus of primary health care and the social determinants is kept foremost in policy - instead of the common historical experience of efforts being limited to a part of the health sector.

Universal health coverage is a development issue

864 www.thelancet.com Vol 380 September 8, 2012 The recent Rio+20 United Nations Conference on Sustainable Development, in Rio de Janeiro, Brazil, took place 20 years after the fi rst global conference on the environment and development and 10 years after the World Summit on Sustainable Development. Although much of the discussion focused on the environment, poverty reduction, and sustaining economic growth, the resultant resolution contained an important paragraph for the global health community:

Equity in health systems

The Latin America and Caribbean (LAC) region has experienced remarkable progress in terms of economic development and health outcomes, enjoying a relatively good position in the developing world context. Unfortunately, this apparent privileged position in terms of accomplishments is based on regional averages that hide troubling and persistent inequalities among and within the countries. These inequalities are closely associated with political marginalization, inequitable and poor access to public health care services, which threaten the health gains of the last few decades and jeopardize growth and development. Levels of mortality and morbidity differ greatly by economic and social factors and geographic boundaries both within and between countries of the Region and are concentrated among disadvantaged populations, who also experience earlier onset of chronic diseases and higher levels of disability. Inequalities in life expectancy are observed when people in Haiti are expected to live 62.2 years on average, as compared to 79.4 years for people

Putting health policy and systems research on the map

For four decades, the World Health Organization (WHO) has helped to pioneer the development of the field of health policy and systems research (HPSR). In 1974, WHO Director-General Halfdan Mahler, recognizing the importance of research on the development of sustainable health-care delivery systems, called for an emphasis on health services and systems research.1 Two years later, the Advisory Committee on Medical Research, established by WHO in 1959, endorsed the definition of health services and systems research as “the systematic investigation and evaluation of specific aspects relative to the development and functioning of health services in their relationship with health related factors”.1 These initial efforts were important in increasing awareness of the value of HPSR and in stimulating scientific discourse about its nature and scope, as reflected by the numerous definitions and frameworks for HPSR that have followed since. Towards the end of the twentieth century, WHO helped to bring together as a unified community the diverse disciplines of research that contributed to health systems strengthening. The establishment of the Alliance for Health Policy and Systems Research (AHPSR) in 1999 as a partnership hosted by WHO marked an important milestone for the field of HPSR.2 It not only legitimized HPSR by demonstrating strong commitment and investment of human and financial resources by WHO and global funding agencies, but also provided a platform for international partnership and collaboration and created an identity for this growing field. The value of HPSR was further reinforced by the release of The world health report 2000, which made clear the prominent role of HPSR in improving health systems performance.3 This recognition of the need for and validation of HPSR as a field helped to stimulate growth within the community of researchers and triggered an increase in overall investments by global funding agencies. WHO then shifted its efforts to bridging the worlds of research and policy-making. In 2004 it convened the Ministerial Summit on Health Research in Mexico City, and in 2008 it co-sponsored the Global Ministerial Forum on Research for Health in Bamako, Mali. Both meetings provided policy-makers with a unique opportunity to engage with diverse stakeholders, including academics, funding agencies and the media;4,5 both were pivotal in building linkages to facilitate the use of evidence generated through HPSR in health policy and management decision-making. From these discussions emerged innovations, among them various knowledge translation platforms and the Evidence-Informed Policy Network (EVIPNet) established by WHO, designed to move research into practice. This firm commitment towards the use of evidence was carried forward by WHO’s current Director-General, Margaret Chan, who in 2008 formed the High Level Task Force on Scaling Up Research and Learning for Health Systems.6 More recent actions have further advanced the field of HPSR by helping to identify research priorities and facilitating interactions between evidence generators and evidence users. Prominent among them are the launch in 2010 of WHO’s Research for Health strategy, the organization of global symposia on health systems research in Montreux, Switzerland, and Beijing, China, and the establishment of a society of health system researchers known as Health Systems Global.7,8 Now, with the launch of the Strategy on Health Policy and Systems Research on 1 November 2012, WHO is helping to institutionalize HPSR and facilitate evidence-informed decision-making. To this end, the strategy will promote greater integration of research and decision-making in an effort to embed the evidence generated through research at every stage of the policy-making process. This will result in greater transparency, accountability and mutual learning. The strategy proposes options to strengthen collaboration between researchers and decision-makers and draws on lessons from countries, in all stages of development, that are creating institutional mechanisms to support evidence-informed decision-making. The success of this strategy depends on all stakeholders, and WHO will do its part to ensure that the strategy’s aims are reflected in the work it undertakes and supports. As a first step towards implementing the new strategy, an inter-cluster platform will be established within WHO to facilitate coordination, alignment of priorities and a unified position on HPSR. This platform will promote a “systems approach” to the delivery of health programmes and encourage the use of HPSR to achieve this objective. Second, in collaboration with partners, WHO will lead efforts to monitor, on a biennial basis, Member States’ capacity for investing in and conducting HPSR, as well as their use of the evidence generated by HPSR. By doing so, it aims to help Member States and funders of research to optimize existing resources and identify priorities for future investments. Finally, in collaboration with relevant organizations, including McMaster University in Canada, which hosts Health Systems Evidence,9 WHO will support the establishment of a global repository of evidence generated through programme evaluations, the grey literature and assessments of best practices. This repository will complement the evidence emerging from the peer-reviewed literature and will provide a strong basis for health decision-making and health systems strengthening.

Keynote Address (November 2016): Zika Virus Disease in the Americas: A Storm in the Making.

Abstract. More than 700,000 cases of Zika virus (ZIKAV) disease have been officially reported to the Pan American Health Organization (PAHO) from 48 countries and territories of the Americas. The response led by the PAHO and partners suggests major lessons of this outbreak. A seemingly innocuous pathogen became the new villain, causing fear, economic losses and, most importantly, debilitating birth defects and neurological problems, reaffirming the well-known war principle of never to underestimate ones opponent. The ZIKAV tested public health capacities under the International Health Regulations, highlighting the need for continued investment in health security. Last but not least, the lack of appropriate tools was another reminder of the pressing need for innovative solutions to persistent problems. Latin America and the Caribbean have approximately 500 million persons living in areas at risk for transmission of ZIKAV. The fight against ZIKAV is not a 100-m race, but rather a marathon in which science and public health need to work hand in hand for the benefit of our peoples.

Salud mental como componente de la salud universal

Carissa F. Etienne1 La Organización Mundial de la Salud define a la salud como “un estado de completo bienestar físico, mental y social, y no solamente la ausencia de afecciones o enfermedades”. La salud mental es, según esta definición, un componente fundamental de la salud. Una buena salud mental permite a las personas hacer frente al estrés normal de la vida, trabajar productivamente y realizar su potencial contribuyendo a sus comunidades. En la Región de las Américas, los trastornos mentales, neurológicos y por uso de sustancias están entre los principales contribuyentes a la morbilidad, la discapacidad, las lesiones y la mortalidad prematura, y aumentan el riesgo de presentar otros problemas de salud; en 2013 entre 18,7% y 24,2% de la población de la Región ha tenido una enfermedad mental (1). Aunque la salud mental es un componente esencial de la salud, existen brechas críticas de tratamiento (es decir, personas con enfermedad mental grave que no reciben tratamiento) que llegan hasta el 73,5% en los adultos y el 82,2% en los niños y adolescentes. En el 2014, la Organización Panamericana de la Salud y sus Estados Miembros adoptaron el Plan de acción sobre salud mental para guiar las intervenciones de salud mental a realizar en la Región de las Américas entre el 2015 y el 2020 (2). El Plan identifica cuatro líneas estratégicas: 1) Formular e implementar políticas, planes y leyes en el campo de la salud mental para lograr una gobernanza apropiada y eficaz; 2) Mejorar la capacidad de respuesta de los sistemas y servicios de salud mental, a fin de proporcionar una atención integral y de calidad en el ámbito comunitario; 3) Elaborar e implementar programas de promoción y prevención en el ámbito de los sistemas y servicios de salud mental, con particular atención al ciclo de vida; y 4) Fortalecer los sistemas de información, la evidencia científica y las investigaciones. La investigación es un componente básico para un adecuado proceso de elaboración de políticas, planificación y evaluación en materia de salud mental. La obtención de nuevos conocimientos a través de la investigación hace posible que toda política o decisión se base en datos contrastados y en prácticas óptimas. Por otro lado, la existencia de datos pertinentes y actualizados permite seguir de cerca las medidas aplicadas y determinar los servicios que pueden mejorarse. Actualmente la mayor parte de la investigación en salud mental discurre en países de altos ingresos y bajo el control de estos, un desequilibrio que es preciso corregir para que los países de ingresos bajos o medianos se doten de estrategias costo-efectivas y culturalmente apropiadas para atender a sus necesidades y prioridades en materia de salud mental. El presente número sobre salud mental de la Revista Panamericana de Salud Pública pretende dar a conocer algunas de las iniciativas de investigación en la Región, en sus diversos contextos y culturas. Los artículos de este número están relacionados con la implementación del Plan de acción sobre salud mental e incluyen investigación culturalmente validada en relación con la carga de morbilidad y la evaluación de los progresos realizados en las políticas y la organización de servicios en materia de salud mental. Ocho de ellos son artículos de investigación original; algunos hacen un análisis exhaustivo sobre el impacto de la gobernanza en el desarrollo de los modelos de atención en Chile y Ecuador. Otros artículos documentan los avances y obstáculos de la reforma psiquiátrica en Brasil, así como la descentralización de servicios en Jamaica y El Salvador. Se describe además el interesante proceso de implementación de los hogares protegidos en Perú y el uso de la consultoría en atención primaria como una herramienta para disminuir la * Traducción oficial al español efectuada por la Organización Panamericana de la Salud. En caso de discrepancia prevalecerá la versión original (en inglés). 1 Directora, Organización Panamericana de la Salud, Oficina regional para las Américas de la Organización Mundial de la Salud, Washington, D.C., Estados Unidos de América. Forma de citar (artículo original) Etienne CF. Mental health as a component of universal health. Rev Panam Salud Publica. 2018;42:e140. https://doi.org/10.26633/RPSP.2018.140

Cuba hacia la Salud Universal

Carissa F. Etienne1 Forty years after Alma-Ata, implementation of the Strategy for Universal Access to Health and Universal Health Coverage –Universal Health– (1) of the Pan American Health Organization (PAHO) has emerged as the main tool for achieving health for all in the 21st century. The countries of the Region of the Americas have made varying degrees of progress on this path and, since 2014, a significant number of them have established road maps and frameworks for monitoring and evaluating their progress toward Universal Health. Cuba is one of the countries that shows the greatest progress in this regard; hence the importance of better understanding its experience in the construction of its national health system, as well as the scope of its achievements. Cuba’s successes in health are recognized worldwide and reflect a firm and systematic commitment on the part of the country’s highest authorities to developing health, since 1959. Knowing (and understanding more fully) which public policies have been implemented in the health sector, which programs have had the greatest success in achieving the health indicators that Cubans enjoy today, and how the intersectoral and primary health care approaches have been essential to these achievements offers useful lessons, considerations, and definitions for other countries that are advancing toward Universal Health. This special supplement of the Pan American Journal of Public Health presents Cuba’s experience in the 60 years it has been building its national health system. It identifies lessons learned and allows a better understanding of current approaches, as well as the challenges: maintaining what has been achieved, planning new achievements, and continuing to strengthen a model centered on people, families, and communities, with free services at the point of contact, quality care, and an intersectoral approach with community participation. Cuba is a case study of great interest for all, having achieved a life expectancy at birth of 78.4 years in 2016, low infant mortality (4.6 per 1 000 live births), and the elimination of 11 vaccine-preventable diseases and malaria in the early 1970s. More recently, it became the first country in the world to certify the elimination of mother-to-child transmission of HIV/AIDS and congenital syphilis. The resiliency of its national health system, its capacity for preparedness and response to emergencies and epidemic outbreaks, the presence of over 48 000 health collaborators in 62 countries, the significant interventions of Cuba in emergencies such as the Ebola outbreak in western Africa in 2014, and the earthquakes in Ecuador (2016) and Mexico (2017)––to give only a few examples––as well as having graduated more than 28 000 physicians from over 100 countries, all reflect the significance of the Cuban experience in the progress toward Universal Health and the importance of understanding better how all this was achieved. The Cuban national health system is based on values that are consistent with those promoted by PAHO, focusing on solidarity, equity, and the right to health. A key aspect of the construction of the national health system and the scope of its achievements has been the political will to prioritize health within its human development strategy. This prioritization is reflected in public spending far above the 6% that PAHO recommends, putting Cuba among the few countries in the Region to achieve that indicator. Without a doubt, another key aspect of Cuba’s success in the health sector has been the innovative approaches the country has taken to solving the problems posed by a lack of human, material, and financial resources in its recent history. But perhaps the most fundamental characteristic of the Cuban national health system has to do with its peopleand family-centered approach to primary health care: focusing on communities, territorially and on an intersectoral * Official English translation from the original Spanish manuscript made by the Pan American Health Organization. In case of discrepancy, the original version (Spanish) shall prevail. 1 Director, Pan American Health Organization/ World Health Organization, Washington, D.C., United States of America Suggested citation (original article) Etienne CF. Cuba hacia la Salud Universal. Rev Panam Salud Publica. 2018;42:e64. https://doi.org/ 10.26633/RPSP.2018.64