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In the Americas, health sector reforms are facing the challenge of strengthening the steering and leadership role of health authorities. An important part of that role consists of fulfilling the essential public health functions (EPHFs) that are incumbent on all levels of government. For that, it's crucial to improve public health practice, as well as the instruments used to assess the current state of public health practice and the areas where it needs to be strengthened. For that purpose, the Pan American Health Organization has started an initiative called "Public Health in the Americas," with the objective of defining and measuring EPHFs, as a way of improving public health practice and strengthening the leadership provided by health authorities at all levels of government. This article summarizes conceptual and methodological aspects of defining and measuring EPHFs. The article also analyzes the implications that measuring performance on these public health roles, responsibilities, and activities would have for improving public health practice in the Americas.

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This article discusses the epidemiologic and programmatic bases for action as well as the political, historical and technical background for "The Initiative for Restructuring of Psychiatric Care in Latin America." It discusses also the broad implications of this health policy, the modus operandi of its implementation and monitoring, and the chief obstacles that it has encountered. Lastly, it briefly sketches the results obtained thus far.

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Both the epidemiological and program bases for action are reviewed as well as the political, historical, and technical background of the Initiative for a Re-structuration Psychiatric Care in Latin America. Attention is also paid to (a) the wide repercussion of this new-old health policy, (b) procedures for its implementation, and (c) the main obstacles the Initiative has been facing to date. Results obtained so far are reviewed.

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Both the epidemiological and program bases for action are reviewed as well as the political, historical, and technical background of the Initiative for a Re-structuration Psychiatric Care in Latin America. Attention is also paid to (a) the wide repercussion of this new-old health policy, (b) procedures for its implementation, and (c) the main obstacles the Initiative has been facing to date. Results obtained so far are reviewed.

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A case is made that a new frontier of international health is developing technical cooperation among countries of the Americas for narrowing and eventually filling the gap between them. Several initiatives of PAHO are cited.

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PIP: Approximately 700,000 infants die annually in the Americas from causes that could be prevented by low-cost interventions and technologies. The main determinants of infant mortality in the Americas are the socioeconomic status of the family, environmental factors, and some specific maternal and child health problems. Progress in reducing infant mortality has varied widely among the countries. From 1960-1985, the infant mortality rate declined 21% in Bolivia, while it decreased 64% in Costa Rica, but even in the most recent 5-year period, Bolivia and Haiti still had infant mortality rates above 100/1000. Unfortunately, an increase in the gross national product does not automatically translate into greater expenditures on health; conversely, significant improvements in health can be achieved in the absence of high levels of economic progress. Parental education, especially the mother's, is 1 of the most important factors affecting infant mortality. Regrettably, per capita public spending on education declined between 1980 and 1984 in Latin America and the Caribbean. The sizable migrations, both voluntary and involuntary, have contributed to infant mortality. The lack of potable water and sanitation facilities contributes to the spread of disease and higher infant mortality. The priority problems accounting for the largest portion of neonatal and infant mortality in the region are 1) perinatal problems and lack of prenatal care, 2) intestinal and respiratory infections, 3) vaccine-preventable diseases, 4) malnutrition, and 5) high-risk fertility behavior. Since the introduction of the Expanded Program on Immunization and the Program for the Control of Diarrheal Diseases in the 1970s, the level and character of infant mortality have changed dramatically in the region. Vaccine-preventable diseases are no longer among the 5 principal causes of infant mortality. The highly effective technologies used in the fight against diarrheal diseases have removed them from 1st place among causes of infant death in a number of countries. As a result, perinatal causes now rank 1st in 21 countries of the region. Low birth weight is a major factor associated with perinatal and infant mortality. 1 of the most important means of reducing infant mortality is to improve the social and economic situation of families--for example, by educating women and providing the social support necessary for a healthy family.^ieng

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In this article the term health manpower is applied to members of society who have acquired specific training and taken on responsibilities in health work. The different aspects of manpower development are viewed strictly from the standpoint of policy. They include the regulatory role of government and the influence of superstructure factors on decisions about health. There is a detailed discussion of the power relationships between decision-making groups and the organization of health services, and also of the role of knowledge as a power factor. The implementation of proposals on manpower depends on the operation of a sociopolitical process in which technical people who have the scientific ability and political sensitivity must participate to bring about changes that will benefit the majority.

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PIP: Universities should constitute the critical conscience of a society and should serve as the principal instruments for promoting needed changes. The highly politicized social processes in Latin America have been characterized by inertia and resistence to change. The university as a reflection of society has perpetuated itself as a conservative structure whose main function has been to consolidate the status quo. In the area of health care, the university should provide training for the personnel required to fill the needs of the population as a whole, but in fact training has responded to the needs of only the wealthier and more powerful population sectors who are able to voice their demands. The university, in its function of forming professionals, does not respond to the health needs of the population but rather to social needs expressed in effective demand. Another problem is that the quest for technology has produced imbalances and rigidity in the health care system. At present, health systems in Latin America devote 80-90% of their resources to secondary and tertiary level care. The demand for health promotion and primary health care has thus far failed to produce significant changes in the structure of services or distribution of resources. Evaluation and revision of the role of technology will be prerequisities for achievement of the goal of health for all in an equitable, effective, efficient, and participatory way. There have been various movements and initiatives in the training of health professionals in the 20th century, from the early focus on technical and scientific training to a more recent effort to improve educational technologies. Movements requiring the university to take a more active role in the provision of health care to the entire population have for the most part been limited to isolated trials. Primary health care is based on the 3 fundamental concepts of equity, effectiveness, and the need for all of society and not just health professionals to participate in health care. Projections for the year 2000 indicate that 180 million persons will be added to the Latin American population, all them in cities. The population will contain more elderly persons requiring complex care. At present, not even the most simple and easily preventible health problems have been solved, but the challenges posed by chronic degenerative diseases will increase as the population ages. Only a revolution in the field of health, in which primary health care is fully utilized as a strategy for the entire health care system and technology is brought under control to serve the needs of the population, will enable the new challenges to be met. The process will demand that health be considered an integral part of development and not a residual benefit of the manipulation of economic variables. It will also demand greater cooperation between different societal sectors and different nations. The university should take an active role in the needed transformations.^ieng

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