The hospitalization rate for ambulatory care-sensitive conditions serves as a valuable indicator for evaluating progress in strengthening the first level of care, including its economic implications for the overall healthcare system. During this reporting period, only two countries have made notable advances in this indicator: Mexico has integrated it into their National Sectoral Health Program 2022-2024 monitoring system, and El Salvador is currently in the process of collecting data for this indicator.
Measurement of this indicator has posed challenges for many countries in the region. While PASB has provided technical cooperation, tools, and support for this purpose, there is a need to enhance the commitment of countries further and improve countries’ capacities to utilize these resources effectively.

Many countries in the region are continuing their efforts to enhance the response capacity of primary care services. Countries such as Belize, Bolivia, Canada, Chile, and Honduras, among others, have formulated policies and strategies to improve access to primary care, support healthcare professionals, build capacities to address chronic diseases, enhance preventive and palliative care, and promote the integration of health networks, including the use of telehealth. Similarly, other countries such as Argentina, Costa Rica, Ecuador, and Guyana, have focused on strengthening governance, improving infrastructure, fostering intersectoral collaboration, and reinforcing maternal and child healthcare services. Despite these endeavors, much work remains to be done, particularly concerning the advancement of health service integration with a focus on equity. The sustained continuation of these efforts is crucial to achieving long-term impact on health outcomes.

Overall, although there was a regression from the baseline, countries achieved or are on track to achieve this outcome indicator to improve children's health and development. Some countries have a national strategy on maternal and newborn health under implementation, but improved monitoring and alignment of these strategies with the WHO/UNICEF Framework are needed. Strategies for moving forward include adoption and implementation of the WHO frameworks Parenting for Lifelong Health and Global Scale for Early Childhood Development in the region.

Work is ongoing to strengthen countries’ arboviral disease surveillance capacities, facilitating the monitoring of the largest dengue epidemic ever recorded in the Americas. Significant progress has been made via operationalization of collaborative surveillance through the implementation of Virtual Collaboration Spaces. In addition, a new Integrated Surveillance Manual for Arboviral Diseases has been completed following two consultation meetings with country experts.

DPT vaccination coverage has been affected by the pandemic. Although efforts are being made to improve coverage and reduce dropout rates, the goal is to ensure that the under-vaccinated are reached.

Since 2020, a decrease in vaccination coverage with the third dose of PCV vaccine has been noted. In 2023, a very slight improvement was noted compared to 2022 (81% vs. 80%). This, together with improvement in coverage of other vaccines (e.g., pentavalent), could indicate that PCV3 vaccination coverage has started to recover. It is important to closely monitor the progress of member states.

The countries of the Region have made great efforts to incorporate the vaccine into their national vaccination schedules; as of December 31, 2023, only 4 countries had not introduced the HPV vaccine. 26 countries in the Region are vaccinating children and 12 countries have switched to a single-dose schedule.

Countries in the region are moving toward implementing standardized, evidence-based protocols to improve the quality of diabetes care. However, in parallel with these efforts, the prevalence of obesity, one of the main risk factors for diabetes, continues to increase. This challenge makes it difficult to stop the sustained increase in diabetes, reflecting the need to redouble efforts and move toward a joint, integrated, and comprehensive response to diabetes and other non-communicable diseases and risk factors. Additionally, the need for updated, standardized, and internationally comparable population data makes it difficult to evaluate the progress achieved with this indicator. Strengthening population surveillance systems for non-communicable diseases, including diabetes, would have a positive effect on the monitoring of this indicator.

The year 2022 was primarily dedicated to recovering from the negative impact of the COVID-19 pandemic, with a particular emphasis on reinstating interrupted screening procedures. The Pan American Health Organization (PAHO) has been working toward facilitating the implementation of HPV testing as the primary screening procedure, and concurrently developing comprehensive national strategies aimed at eradicating cervical cancer through HPV vaccination.

In the period spanning 2022-2023, PAHO, in collaboration with the International Agency for Research on Cancer (IARC), worked on the CanScreen5 project, designed to comprehend the obstacles impeding the achievement of screening targets. Furthermore, they sought to devise methods to monitor progress through the utilization of standardized indicators. Subsequently, PAHO compiled and published a regional report that provides an overview of the current status of cervical cancer control within the region, utilizing all available data.

The mental health Gap Action Programme (mhGAP) continues to be broadly adopted across the Region to integrate evidence-based care in primary settings through non-specialist health workers.
107 MhGAP trainings were conducted in countries. 25 countries received training on the integration of MH into primary health care; 144,790 health personnel were trained. Among those countries that received training were Aruba, Saint Lucia, and Saint Vincent and the Grenadines. Increased integration of MH into primary health care can improve the continuum of care for mental health conditions. During the biennium, Belize showed an increase in mental health diagnosis at the outpatient level.
mhGAP implementation in Latin American countries showcases significant progress in key metrics, with 4,131 new trainers. For instance, Chile and Mexico have trained 5144 and 136,131 individuals respectively. Both countries have successfully integrated mhGAP into their national mental health policies. Paraguay, demonstrating notable advancement, has trained 103 individuals with 67 trainers, and successfully incorporated mhGAP into its national policy.

In the area of substance use, PAHO implemented workshops to improve the quality of healthcare services for people with substance use problems. A total of 22 participants from the six Caribbean Dutch Islands (Aruba, Curaçao, Sint Maarten, BON, STA, and SAB) attended the workshop in Curaçao.

This indicator is part of the 12 Global Road Safety Performance targets that resulted from the mandate of World Health Assembly Resolution 69.7, adopted in May 2016, in which Member States requested WHO to facilitate a transparent, sustainable, and participatory process with all stakeholders to assist interested countries in developing global performance targets for key risk factors and service delivery mechanisms to reduce road traffic fatalities and injuries. This indicator was adopted by Member States after a long process of technical consultations and will help guide action and ensure measurement of progress at the national and global levels.
Response time, which can be measured as the time in minutes elapsed from system activation to the arrival of specialized care at the scene, allows us to analyze the performance of the health system, especially in terms of the emergency care provision. This indicator facilitates analysis of the timeliness of emergency care and allows the identification of inefficiencies and gaps in the system in order to work on the necessary mechanisms to strengthen, expand, and rationalize emergency care. Although there is no consensus on a specific response time for traumatic injuries, countries were encouraged to set a response time target in their national road safety strategies and try to achieve it. This implies having a single telephone number for all emergency care services with whole-country coverage (all areas use this number, and no other numbers exist), integrated call-taking and dispatch services, and availability of ambulance services capable of providing high-standard care on scene, transfer and transport, handover and triage, etc. Data systems that measure key time intervals (such as by systematically recording and analyzing response time at the national or subnational level) are essential for improving performance and service quality. While these functions could be implemented in different ways depending on available resources, affordable and sustainable improvements can be made according to each situation, building on the WHO framework.
To achieve this outcome, the three levels of the Organization, along with Ministry of Health counterparts and other relevant stakeholders, are working to conduct emergency and critical care systems assessments using WHO’s ECCSA tool. This strategic planning tool was designed to help Ministries of Health assess their emergency care system, identify gaps, and set priorities for system development. This includes establishing laws and regulations, creating protocols to guide personnel on critical processes, ensuring compliance with standards through certifications, and implementing processes for the accreditation of service quality and safety. From 2022 to 2023, four ECCSAs were conducted in the Region.
Additionally, we promoted the implementation of a Train the Trainer strategy to implement the WHO/ICRC Basic Emergency Care training course in a cascading manner, strengthening the capabilities of first responders. Funding was secured to implement these and other WHO-developed tools to strengthen emergency care in priority countries.

Sexual violence is a particularly severe challenge in the Americas, requiring timely intervention by the health system to mitigate the consequences for survivors’ health and well-being. The need for comprehensive post-sexual assault (post-rape) care services in emergency health services is reiterated in the Strategy and Plan of Action on Strengthening the Health System to Address Violence against Women, which defines post-rape care to include:
a) First-line support and psychological first aid;
b) Emergency contraception to women who seek care within 5 days;
c) Referral to safe abortion if a woman is pregnant as a result of rape, where such services are permitted by national law;
d) Sexually transmitted infection and/or HIV post-exposure prophylaxis, per applicable protocols; and
e) Hepatitis B vaccination.
PASB has supported Member States in strengthening the health system response to sexual violence, including through improved health system protocols and health workforce training. A recent analysis of health system protocols found that text references to these essential post-rape care services remain limited. For example, 54% of Member States refer to first-line support in their protocols, while hepatitis B vaccination is mentioned by 43%, demonstrating significant gaps. While a text reference to these criteria does not necessarily mean corresponding services are readily available and accessible, it is an important starting point for them to be specifically mentioned in protocols that outline the health system’s response to violence. Importantly, one barrier in this area is the lack of health service evaluation tools to assess specific progress on post-rape care in line with established indicators. In response, PASB has collaborated with selected Member States in the development and piloting of a rapid service evaluation tool for post-sexual assault care. This tool has the potential to improve monitoring of this indicator beyond the pilot countries (Argentina, Colombia, Honduras, Peru), thereby helping to strengthen quality improvement of post-sexual assault care.