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.

The reduction in time to diagnose and treat malaria cases is an essential indicator for actions against malaria and is one of the main focuses of PAHO's technical framework for cooperation. Early access to treatment has been the cornerstone of the regional strategy, with actions ranging from maintaining diagnostic capacity and promoting the use of rapid tests to managing antimalarials, promoting microplanning, and implementing the DTI-R strategy.

Thanks to nominal information systems, all endemic countries monitor the timing of diagnosis and treatment. While a significant number of countries reported compliance with the indicator, partial compliance by two baseline countries may affect the overall performance of the indicator. All endemic countries continue to face challenges in shortening the time between the onset of symptoms and treatment and should prioritize actions to address the barriers the population faces in accessing treatment.

However, as noted in the technical specifications, this indicator is variable and difficult to achieve in settings of low transmission, penalizing those countries that achieve significant reductions in the number of cases. As transmission is reduced, cases take longer to be detected. Therefore, it is expected that baseline countries that are reducing malaria transmission, as well as other countries achieving significant reductions in case volume, will experience difficulties in achieving the indicator by 2025, despite making progress toward elimination.

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.

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.

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.

As part of the deinstitutionalization process, a mental health crisis management course was delivered to first responders in Saint Kitts and Nevis and the Bahamas. Deinstitutionalization processes were accelerated across several countries to shift toward community-based services. For instance, Paraguay made progress transitioning patients from a national psychiatric hospital into integrated community-based mental healthcare, supporting 156 patients through new municipal-level centers last year. Mobile crisis response gained more prominence as an alternative to hospitalizations. Another example is the Bahamas emergency response service, which has prevented avoidable hospital admissions. Similar assistance programs now run across 3 Argentine provinces.

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.

The number of countries that are reporting stigma data in health services has increased, but this has yet to become a systematic action to support stigma reduction and improve MSM access to health services.

Existing post-pandemic conditions continue to negatively impact the ability of countries to effectively implement field interventions to address this problem. Better achievements are expected in the next biennium (2024-2025).

Although the current rating of this indicator is “No progress”, countries have been able to address risk factors for communicable diseases through intersectoral action with the technical support provided by PASB. From the integrated public health perspective embedded in the One Health approach, countries are experiencing tangible improvements in public health outcomes. Notable advances include the implementation of national action plans for antimicrobial resistance, the development and strengthening of national food safety systems based on Codex Alimentarius, and improved access to lifesaving antivenoms through production by public health laboratories and their inclusion in the PAHO revolving funds.