Objective. To monitor compliance with national sodium reduction targets for prepackaged foods marketed in Costa Rica, and to compare it with current international standards. Methods. Nutritional labeling information was collected from products sold in two supermarket chains in 2022. Sodium content (mg/100 g), sodium energy density (mg/kcal), and compliance with national targets for 2022 and with international standards (Pan American Health Organization, 2022 and 2025; World Health Organization, 2021 and 2024) were analyzed. The results were compared with evaluations performed in 2015 and 2018 (p <= 0.05). Photographs of the labels used for comparison were obtained in 2015, 2018, and 2022. Results. A total of 7402 products were registered, of which 872 met the criteria for analysis. The highest sodium levels and greatest variability were observed in condiments (0-32 750 mg/100 g), cured and processed meats (569-4800 mg/100 g), and sauces (0-4050 mg/100 g). Subcategories (stocks, seasonings for rice, ham, sausages, tomato-based sauces, and bread with cheese) exceeded national targets. Bakery products had the lowest sodium levels and the least variability; savory bread and whole wheat bread were within the specified limits. Sodium energy density ranged from 0.8 to 86.0 mg/kcal, with 5 categories exceeding the recommended values. Compliance with national targets was 84.5%; with PAHO recommendations 43.6% and 34.7% (for 2022 and 2025, respectively); and with WHO recommendations 39.2% and 33.3% (for 2021 and 2024, respectively). There were no significant differences between 2022 and the years 2015 and 2018. Conclusions. There is no evidence of sustained progress in reducing sodium in prepackaged foods in Costa Rica. Mandatory regulatory measures are required to drive improvements in public health.
Access to medicine is a central component of the right to health. Exponential increases in the price of medicines and the emergence of high-priced innovative therapies on the market have put the sustainability of the system at risk. For this reason, the province of Buenos Aires (Argentina) changed its drug policy from historically decentralized management by each health care provider to a policy based on centralized procurement, integrated processes, increased public production of medicines, and the development of information systems. This article compares both management models (decentralized versus centralized and integrated) in terms of economics and access. Implementation of a centralized and integrated policy quadrupled the public production of essential medicines, increased access to medicines for registered users by 1 071.2%, improved the capacity to monitor traceability, and generated savings of 27.18% per unit in the procurement of pharmaceuticals compared to the usual mechanism of decentralized procurement by hospitals. In terms of impact, US$ 32 590 645.66 was saved, based on demand. Centralized and integrated management of drug procurement, production, storage, and distribution resulted in significant reductions in purchase prices, improved distribution, and optimized drug traceability compared to decentralized management models.
Intra and after action reviews (IARs and AARs) are essential for the management of public health emergencies. This article reports on the experience of developing an IAR and AAR method by the Ministry of Health in Brazil, highlighting its conceptual and organizational foundations and its application in different public health emergency contexts from 2023 to 2025, a period during which 10 evaluations were conducted nationwide. The method was developed through a participatory process, based on a literature review and consultations with national and international experts, and was validated by consensus. The reviews were carried out in partnership with state health departments, using methodologies such as in-person workshops, structured debriefings, response action assessment tools, and individual instruments, often in combination. The number of participants ranged from 40 to 80 professionals, including managers, technical staff, and representatives from multiple sectors. The duration of activities ranged from meetings lasting a few hours to 2-day workshops. The reviews revealed good practices, challenges, and next steps that informed the updating of contingency plans and the incorporation of lessons learned into national and subnational policies and guidelines, synthesized in a Guide for After Action Review of Public Health Emergencies published by the Ministry of Health. This experience underscores the importance of incorporating IARs and AARs as strategic components of public health emergency preparedness and response. The process strengthens organizational learning, enhances the legitimacy of actions, and contributes to building a culture of continuous monitoring.
Objective. To apply the NOA method, which integrates the dimensions of need, opportunity, and accessibility, to evaluate the effectiveness of kidney, liver, pancreas, heart, and lung transplants in Brazil. Methods. This retrospective cohort study used data from the Brazilian Transplant Registry regarding transplant need (the sum of the number of patients on waiting lists in 2022 and the total number of patients added to the lists in 2023). Opportunity considered the number of transplants from living and deceased donors in Brazil; for the latter, a correction factor derived from data from the Global Observatory on Donation and Transplantation was applied. Accessibility represented the sum of the number of organ transplants from deceased and living donors. A percentage score was generated to measure transplant performance relative to supply in relation to demand. Utilization and completed transplant rates were also estimated. Results. Performance ranged from 10% for kidney transplants, reflecting the mismatch between the waiting list and available grafts, to 64% for heart transplants. The South region had the highest utilization rate, while the North showed low organ availability, technical difficulties, and limited installed capacity. Conclusion. The NOA method is an effective tool for measuring the performance of the donation and transplant system, identifying bottlenecks to guide public policies. In Brazil, it is urgent to implement strategies aimed at reducing regional disparities, strengthening technical capacity, and expanding equity and efficiency in access to transplantation.
Objective. To present the background, results, contributions, challenges, future prospects of the Regional Network of Focal Points for Prevention, Detection, and Response to Substandard and Falsified Medical Products (SF Network) in the Americas during the two decades of its existence. Method. A documentary review was conducted to identify the background, results, and future prospects of the SF Network. The time horizon considered was 1999-2025. The data are presented in narrative form. Results. At present, 28 countries in the Region of the Americas have active participation in the initiative. This has made it possible to: exchange information on nearly 650 incidents over the past 10 years; publish 12 technical documents on this subject; and convene 14 national meetings and workshops in the Region. The three key achievements of the initiative are collaborative work, the strengthening of market surveillance and control capacities among members, and the sustainability strategy. Conclusions. The achievements, experiences, and actions of the SF Network represent a success story that demonstrates the value and necessity of using models that facilitate exchange and collaboration between countries. The future of the SF Network should focus on new forms of member participation that strengthen the development of solutions and strategies, in relation to both known issues and emerging regional and global challenges.
This article proposes an analytical framework to reinterpret the segmentation and fragmentation of health systems in Latin America and the Caribbean, focusing on the asymmetric relationships between actors as a structural cause of inefficiencies and inequities. In contrast to the traditional approach, which attributes these problems to the mere coexistence of multiple financing and delivery schemes, the present proposal combines the structure-behavior-performance (SBP) paradigm from industrial economics with an analysis of the selection dilemma to explain how strategic incentives and power dynamics shape the functioning of the system. The framework shows that the expansion of the private sector in the region has accentuated asymmetries among insurers, providers, and the population, giving rise to practices such as population skimming and the prioritization of profitable services. These strategic behaviors, when interacting with segmented and fragmented market structures and weak regulatory frameworks, deepen inequalities and reduce the system's allocative efficiency. Effective regulation must go beyond institutional control: it must intervene in the strategic relationships between actors and modify both structures and behaviors. The framework identifies critical points for regulatory intervention and proposes tools to align incentives with equity and efficiency objectives. Finally, it should be noted that integrating systems institutionally is not enough if the relationships between actors are not regulated and the structural asymmetries that underlie the problems of access, quality, and sustainability in health are not addressed. This perspective offers a useful guide for redesigning more effective public policies in the region.
This article critically examines commensurability in public health-that is, the possibility of comparing phenomena according to a common standard, using indicators-as well as the scope and limits of such comparability when it is mistaken for complete understanding. It proposes a brief audit framework for constructing and interpreting indicators when commensurability is partial, using the maternal mortality ratio (MMR) as an example. With reference to the MMR, the article shows how definitions, time windows, and the quality of data recording affect comparability across contexts, and how performance pressure may induce reactive administrative or behavioral shifts, which must be empirically assessed. This paper does not argue against measurement or quantitative accountability; rather, it seeks to strengthen them through transparency of assumptions, reporting on quality and uncertainty, and the use of triangulation and auditing when incentives are high. It thus avoids both technocratic drift and the relativism that dismisses measurement on the grounds that it is constructed. It concludes by proposing that dimensions not captured by the indicator-lived experience, dignity, and trajectories of access and care-be granted specific status and formally integrated into the interpretation, through layering of evidence and case reviews.
Objective. To define the essential content and design elements for hypertension support delivered by community health workers (CHWs) in Puno, Peru, aligned with the HEARTS Initiative. Methods. We applied a human-centered design approach to co-create strategies for a CHW-led hypertension intervention through five interactive workshops with 24 CHWs, 32 healthcare workers (doctors, nurses, and administrators), and 18 community members with hypertension. Results. We identified five key recommendations on the objectives and needs of a CHW-led hypertension support program. First, improve patient-level health behaviors. CHWs can encourage heart-healthy diets, exercise, medication adherence in tandem with traditional remedies, and regular care-seeking through home-based behavioral education tailored to the local context. Second, improve facility-level hypertension care. CHWs can fill care gaps due to physician shortages, complicated healthcare systems, complex scheduling procedures, and language differences, while fostering more respectful healthcare. Third, link CHWs to the formal health system. Joint training, monthly meetings, and improved communication with formal healthcare providers can enhance CHW integration in the healthcare system and reduce concerns about CHWs overstepping their role in patient care. Fourth, train and equip CHWs. CHWs require training on hypertension and their roles in healthcare delivery, as well as compensation, appropriate and sufficient materials, and transportation assistance. Fifth, design educational materials on hypertension. Culturally relevant, pictorial materials with accessible language and regular content updates help engage patients. Conclusions. The human-centered design process enabled co-development of a culturally responsive, CHW-led hypertension support intervention that operationalizes HEARTS principles.
Objective. To assess the prevalence and risk factors of sexually transmitted infections (STI) among adolescent offenders held in correctional facilities. Methods. This quantitative cross-sectional study, carried out in Rio de Janeiro, Brazil, included interviews to collect sociodemographic and clinical data and knowledge about STIs. Rapid tests for detection of syphilis antibodies and HIV infection, and molecular urine tests for chlamydia and gonorrhea were performed. Statistical analysis included STI prevalence estimates and multivariate analysis to identify risk factors. Results. A total of 965 adolescents (average age: 16.1 years; 85.1% male) were included in the study. STI prevalence was higher in the female unit than in the male units: syphilis (45.6% vs. 7.7%), chlamydia (34.6% vs. 19.7%), gonorrhea (12.5% vs. 6.0%), and HIV (1.5% vs. 0.4%). The prevalence of “at least one STI” was higher in the female unit compared to the male units (68.4% vs. 27.3%; prevalence ratio 2.51). This high burden of STIs, which were often asymptomatic, was associated with multiple sexual partners and unprotected sex practices, reflecting important gaps in sex education in this highly vulnerable group who demonstrated limited knowledge on STI risk and prevention. Conclusions. This high prevalence of STIs, combined with limited knowledge of prevention, calls for comprehensive strategies associating systematic screening, timely treatment, and sexual health education into the routine activities of socio-educational institutions.
Objective. To estimate the prevalence of HTLV-1 infection among the family members of positive index cases referred to a specialized center in Peru and its distribution by type of relationship and presence of diseases associated with the infection. Methods. A retrospective study was conducted in which the records of the HTLV-1 Research Unit of the Alexander von Humboldt Institute of Tropical Medicine in Peru were reviewed. Index cases, defined as the first positive individual in each family group, were identified and the prevalence of HTLV-1 among their immediate family members (father, mother, siblings, children, and partners) was determined using a cluster estimator. Results. A total of 1255 index cases and 3431 family members were studied. The frequency among family members studied was 30.30%. The prevalence of HTLV-1 among family members was 36.43% (95% CI: 34.67-38.23) The specific frequencies were: 63.30% among mothers, 52.33% among fathers, 32.65% among siblings, 22.84% among children, and 57.19% among partners. Conclusion. The prevalence found suggests the existence of intrafamilial transmission in the cohort, which points to a need for further studies to identify associated risk factors. The findings highlight the need to implement a new screening strategy in the country in which close relatives of all HTLV-1-positive cases are tested. This approach should be reflected in public health policies.
Objectives. To independently evaluate the World Health Organization (WHO) Skin Neglected Tropical Diseases (NTDs) application, focusing on the diagnostic performance of its underlying artificial intelligence model for leprosy detection. The primary objective was to determine the proportion of images in which leprosy appeared among the model's Top-5 diagnostic predictions. The secondary objective was to qualitatively analyze diagnostic error patterns. Methods. A data set of 439 anonymized clinical images from confirmed leprosy cases (1996-2024) was analyzed, spanning the full clinical spectrum (indeterminate, tuberculoid, borderline/dimorphous, and lepromatous/Virchowian forms) and including reactional and atypical presentations. After excluding 16 images due to processing errors, 423 images were retained: 367 classical leprosy lesions and 56 reactional or atypical leprosy-related presentations. All images were evaluated using the WHO desktop version of the visual classifier. Top-5 sensitivity (recall) for leprosy was estimated, alongside a qualitative error analysis focusing on intrapatient inconsistencies and challenging lesion types. Results. The model achieved an overall Top-5 sensitivity (recall) of 84.9%, with higher sensitivity for classical lesions (87.2%) than for reactional or atypical presentations (69.6%). Qualitative review revealed inconsistent predictions for visually similar lesions from the same patient, and misclassifications concentrated among necrotic, inflammatory, and infiltrative lesions. Conclusions. The WHO Skin NTDs application demonstrates substantial promise as a clinical decision-support and educational tool, especially for classical leprosy. Performance gaps for reactional and atypical forms highlight the need for algorithmic refinement. Enhancing data set diversity and integrating patient-level context may improve diagnostic robustness.
Objectives:To assess exposure to lymphatic filariasis (LF), other neglected tropical diseases (NTDs), and malaria, as well as seroprotection against vaccine-preventable diseases (VPDs), using a hotspot-based integrated serosurveillance approach in urban areas of Guyana. Methods:To monitor the impact of interventions on LF transmission, one historically elevated LF hotspot - defined as a previously identified urban community with focal transmission - was selected in each coastal region (Regions III, IV, V, and X). A total of 300 individuals aged ≥6 years were surveyed in each hotspot using convenience sampling. Dried blood spots were tested at the U.S. Centers for Disease Control and Prevention using multiplex bead assay to analyze antigens from 12 pathogens: Wuchereria bancrofti and Brugia malayi (Wb123, Bm14, Bm33), Plasmodium vivax and Plasmodium falciparum (pvMSP1-19, pfMSP1-19), Strongyloides stercoralis (NIE), Taenia solium (rES33, T24H), Chlamydia trachomatis (Pgp3, CT694), Treponema pallidum (rp17, TmpA), and measles, rubella, tetanus, and diphtheria. Results:Reactivity to Wb123 and Bm14 was consistent with previous reports of elevated LF transmission in these regions. Seropositivity to P. falciparum and P. vivax was higher among adults. Seroprotection against measles and rubella was highest among children and older adults, with immunity gaps in young adults. Most participants showed minimal seroprotection against tetanus and diphtheria. Taeniasis and cysticercosis had low seropositivity across all sites. C. trachomatis and T. pallidum antigens showed age-related increases. Conclusions:Hotspot-based integrated serosurveillance using multiplex bead assay provides an efficient, targeted approach to monitor NTDs, malaria, and VPDs. Findings offer valuable insights for programmatic action, although interpretation should consider the hotspot-specific context when extrapolating results.
Yellow fever is a viral zoonosis of variable geographic distribution in the Americas. With no specific treatment for this vector-borne disease, vaccination is the best prevention available. This flavivirus has been circulating in the Americas since the late 15th century, and over the past decades, the virus has reemerged and is now endemic in 13 countries in South and Central America. Ecosystem changes may have had a role in this reemergence. The International Health Regulations were approved by the World Health Assembly in 2005 as a guidance document to support national policies with important measures for disease control and prevention of new epidemics. This article presents an illustrative case of the efforts of three ministries of health in the Americas (Dominican Republic, Ecuador, and Honduras) to implement international guidelines and reduce yellow fever transmission in the region. Using the One Health framework, we propose selected recommendations for the prevention and control of yellow fever outbreaks.
Spirometry is essential for the diagnosis and follow-up of patients with noncommunicable chronic respiratory diseases; however, it was not available in primary health care in Brazil. This article describes the implementation of telespirometry in primary health care units across 163 Brazilian cities. The program was a collaborative effort between the Brazilian Ministry of Health and the Telehealth Center of the Hospital das Clínicas of the Federal University of Minas Gerais/EBSERH and was conducted in several stages, including team formation and selection of participating municipalities; selection of spirometry equipment; development of software for test transmission; training of nonmedical primary care professionals to perform spirometry and pulmonologists to provide teleconsultations; system implementation; delivery of virtual and onsite training; and continuous monitoring with periodic reevaluation. A total of 163 municipalities were selected according to predefined criteria. Since the implementation of telespirometry on 1 January 2022, 203 technicians have been qualified through virtual and in-person training. By 1 November 2024, a total of 31 982 spirometry tests had been performed. Test quality improved substantially over time, with the proportion of exams classified as category A or B increasing from 54.4% in the first three months to 81.2% in the final three months of the program. These findings indicate that expanding access to spirometry is feasible through a structured, short-term training program combined with close monitoring of primary care staff and a remote quality-control system supported by appropriate electronic resources.
Objectives:To analyze the roles, responsibilities and scope of current government chief nursing and midwifery officers or equivalent senior leaders in the Region of the Americas. Methods:This was a descriptive observational study. All government chief nursing or midwifery officers or equivalent senior leaders from 35 countries in the Region of the Americas were considered eligible to participate. An online survey was conducted that included items on demographic variables, the officer's roles and responsibilities, and a self-assessment of competencies. Data were analyzed using descriptive statistics, disaggregated by role, subregion and country income level. Content analysis was used for responses to open-ended questions. Results:Twenty eight officers from 28 countries participated in this study, representing 80% of the 35 countries in the Americas. About 82.1% (23/28) of the officers or equivalent leaders were exclusively responsible for nursing issues. Most of the participants had the job title of chief nursing officer (53.6%, 15/28), were female (92.9%, 26/28) and were aged 55-64 years (46.4%, 13/28). Regarding leadership roles, 57.1% (16) of participants reported that their countries had an executive model, with the officer having line authority over nursing or midwifery, or both. The responsibilities of these officers were mainly related to leadership, influence and policy advice. In the self-assessment of competencies, participants rated themselves as less skilled in global health priorities and management. Conclusions:Although the role of a government chief nursing officer or midwifery officer exists in most countries in the Americas, there is a need to further strengthen it. It is important for governments and stakeholders to create a policy environment conducive to empowering these leaders, recognizing their strategic role in the human resources for health agenda, and in expanding the contributions of nursing and midwifery towards achieving more resilient and equitable health systems.
Objective. To determine the current state of Honduras’ health financing system. Methods. This study applied a qualitative design based on the World Health Organization’s Health Financing Progress Matrix (HFPM) to evaluate the health financing system in Honduras. Data were collected through 18 in-depth interviews with informants from diverse institutions, tailored to their expertise. The results were internally validated via a workshop including 12 additional experts. Thematic coding was used to classify findings across seven health financing assessment areas and 19 attributes. The HFPM’s desirable attributes framework allowed the researchers to classify the findings into four relevant categories: emerging (score of 1.00-1.99), progressing (score of 2.00-2.99), established (score of 3.00-3.99), and advanced (score of 4.00) Results. The overall score for Honduras’ health financing system was 1.72 of 4.00, indicating an emerging level of development. While attributes related to institutional capacity achieved a progressing score (2.02), domains regarding financial protection lagged at an emerging level (1.33). Critical weaknesses were identified in resource pooling (1.20) and in benefit entitlements and access conditions (1.20), both of which consistently showed low performance. Conversely, public financial management scored higher (2.40), though accountability and budget alignment gaps persist. Regarding Universal Health Coverage objectives, most dimensions scored below 2.00. Among the intermediate objectives, transparency and accountability scored the highest (1.83). Of the final objectives, quality approached progressing (2.33). Conclusion. The health financing system of Honduras exhibits limited institutional maturity and significant structural challenges in financing its health care system. Future reforms must effectively aim to reduce financial barriers for the population.
Objective. To evaluate the effect of using asynchronous geriatric consultations to reduce polypharmacy and unscheduled consultations in older persons in Chile. Methods. An asynchronous geriatric teleconsultation was introduced that enabled primary care teams to present clinical cases to a multidisciplinary geriatrics team, resulting in changes in chronic disease management and the optimization of pharmacological treatment. A total of 462 consultations between May 2022 and January 2024 were randomly analyzed. Descriptive analyses and hypothesis testing were used before and after the intervention, with follow-up at six months. The number of medications, potentially inappropriate medications, and unscheduled consultations were measured as outcome variables. Results. The use of geriatric teleconsultations was associated with a statistically significant reduction in the total number of medications prescribed, potentially inappropriate medications, and the frequency of unscheduled consultations among older persons. Conclusions. Telegeriatrics allows for multidisciplinary review of therapeutic regimens and has demonstrated a relevant clinical impact by suspending the prescription of pharmaceuticals and reducing unscheduled visits. It is a safe and effective tool for improving care and reducing health inequities in primary care.
Objective. To analyze the risk of Trypanosma cruzi transfusion and transplantation transmission in endemic countries in the Region of the Americas. Methods. A descriptive and comparative study on the prevention of iatrogenic transmission of T. cruzi was conducted in 21 endemic countries in the Americas (2012-2023) using sources from the Pan American Health Organization, national reports, and scientific databases. The prevalence of antibodies in donors, the proportion of voluntary donors, screening coverage, and transmission events were analyzed. Trends were evaluated with the Mann-Kendall test, and differences between groups by voluntary donors with the Wilcoxon test, using Stata 14.0 and p<0.05. Results. The median overall prevalence of T. cruzi in blood donors steadily declined between 2012 (0.45%) and 2023 (0.16%). There is an association between a higher percentage of voluntary donation and a lower prevalence of infection. Screening coverage between 2021 and 2023 is complete. Seventy-seven percent of countries that screen for T. cruzi have programs for external evaluation of local performance. The risk of infection in polytransfused patients ranged from 1.8% to 1.3% when screening was incomplete. In relation to transplantation, the prevalence of T. cruzi infection in organ and tissue donors was 0.9% in Argentina and 0.54% in organ donors in Colombia. Although the frequency of infected donors is low, the risk of parasite transmission through organ transplantation (with the exception of the heart) ranges from 18% to 23%. Early detection in recipients through PCR is essential for beginning treatment in a timely manner and preventing complications. Conclusions. Increasing voluntary blood donations and implementing surveillance systems are the greatest challenges to eliminating Chagas disease in the Region by 2030.
