The PAHO's Advisory Committee on Health Statistics (CRAES) meeting took place in the Pan American Health Organization headquarters in Washington, DC on August 11-13, 2009. The Committee meets periodically to analyze the status of health statistics in the Region of the Americas while promoting improvements in the coverage and the quality of vital and other statistics of interest to the health sector
Below is the opening remarks given by Dr. Mirta Roses Periago to the members of the CRAES and participants of international and governmental organizations of the regional countries
"I would like to extend the warmest welcome to you all. It has been almost six years since the Regional Advisory Committee on Health Statistics was last convened, although throughout these years, of course, the members have maintained contact. This has not been a silent period, but one of activity, and I am going to review some of the most important things that we have accomplished in these six years.
I believe that this meeting coincides with that of the Statistical Conference of the Americas and that some of you had conflicts because you had to cover the two areas of the institution. We must recognize that the meeting had to be postponed several times, among other reasons because some of the most critical participants here in the Organization had their hands full with the new virus. However, in the end we are very happy that you were able to accept our invitation.
In addition to the members of the CRAES, we have with us representatives from Brazil, Canada, Colombia, Mexico, Spain, and the United States and colleagues from the World Health Organization, both from the initiative of the Health Metrics Network and the Surveillance and Situation Analysis Area, and the WHO Collaborating Centers relevant to the areas on the agenda. Also with us are representatives from other agencies of the United Nations system, such as CELADE and UNICEF-- as well as UNFPA, who will soon be arriving from New York--and the Global Fund, which have taken an interest in this issue to our great satisfaction. I believe that this also reflects the importance, and this is a rather peculiar point in history, of having a renewed interest in the monitoring and evaluation of health policy through more accurate, reliable, and comparable data, the latter of which is very important.
As I have already mentioned, this has been a very active period. In 2004 we increased efforts once again to analyze the situation in the countries so that we could immediately implement the recommendations of the 2003 CRAES. In 2005, a major meeting of statistics directors was held in Buenos Aires, attended by the representatives of 26 countries with very disparate situations in terms of their systems, coverage, and quality. At that time, some 50% of births and deaths went unregistered in eight countries of the Region--a very troubling situation, not only in terms of the possibilities for health measurement, but, above all, in terms of the law (very important as we all know) in regard to certain situations, including the right to an identity and other important legal conditions that are the foundation for citizenship and the progress of democratic societies.
Between 2007 and 2008, based on intensive work with all the countries and once again implementing the recommendations of CRAES, two very important resolutions were drafted and submitted to the Governing Bodies: The Strategy for Strengthening Vital and Health Statistics and the Regional Plan of Action for Strengthening Vital and Health Statistics. Today we can say that all the countries identified as critical have a specific project. In the eight countries, Haiti among them, we have launched special initiatives, as we have in several other Caribbean countries, and whether it is through the initiative of the Health Metrics Network or PAHO's project with the U.S. Agency for International Development (AID), all the countries that are experiencing greater difficulties are receiving help from the Organization. And all countries, without exception, are linked with Strategic Objective 11 of the Strategic Plan of WHO, an objective that basically seeks to improve managerial capacity through the generation of evidence-a matter that is absolutely critical.
We have also worked on other matters recommended by CRAES in 2003: the Regional Core Health Data Initiative (in the agenda, all these aspects will be reviewed); a review of correction and adjustment methodologies for mortality rates; development; the dissemination and application of the Family of International Classifications (FIC); and the design of initiatives to strengthen the capacity of the countries and the Organization itself in the area of health situation analysis.
The greatest responsibility for follow-up on the recommendations of the CRAES still lies with the unit headed by Fátima Mariño; this may be the first opportunity that some of you have had to see her, because she has been in this post for less than a year. We have been very successful, and Fátima has worked very hard to link all the areas of the Organization with an interest, or responsibility, in generating data through the various programs and that, moreover, are stakeholders in the formulation and monitoring of the policies, regional plans, or strategies for which the units are responsible. And we are transferring this spirit a little to the counties; that is, we would like to see the participation of all sector stakeholders through the efforts of the different programs, which often have specific courses and can be distracting because they are ad hoc. However, properly channeled they can help strengthen the common system and be useful outside the sector. I believe that we are living in an environment in which information and communication technologies are tremendous allies that will enable us to carry out activities and realize dreams that we never could before, such as feeling like we are a participant in a common enterprise, in common forums that will permit information management and retrieval by all, bringing closer together those who generate information, those who use it, those who analyze it, those with an interest in research, those with an interest in policy-making, those with an interest in seeing the impact of the policies, or at least or making the relationship among them more leveled.
When I mentioned that we are at a very critical point in history, it was because next year, in 2010, we will be two-thirds of the way toward the deadline for meeting the Millennium Development Goals, and that is undoubtedly generating a very special demand. In addition, 2010 is an important year because of the magical figures from the rounds of censuses, and there will be considerable work ahead to prepare for them. I have the impression, but you are the experts, that there are a lot more expectations being pinned on the 2010 round of censuses than in past decades, when there was little respect for censuses and few attempts to develop alternative methods or work on estimates. I believe that with the global population dynamic the world is witnessing, globalization will have an impact on these activities, because the very intense population dynamics have it increasingly difficult to work with estimates, and the estimates must make some sense. They must help guide the formulation and reformulation of policies and lead to a greater appreciation of the censuses. Furthermore, they must be a critical aspect in the analysis of population distribution, for the purpose of sustainable development, infrastructure development, economic development, and the development of fiscal policies and, increasingly, social protection policies.
There is no doubt that when we talk about the "perfect storm" that we have witnessed in the past two or three years in terms of the different crises (the energy crisis, the climate change crisis, the crisis in food prices, the financial crisis, and others, especially the deceleration or contraction of economic growth), society as a whole has a greater need to show the impact of these crises. And if we want to show the impact of these crises in order to see what works and what doesn't, to protect ourselves or emerge from the crises, we need data. It is then when we realize we do not have the data and that the estimates made on the basis of assumptions, often based on earlier models or earlier situations or scenarios, do not have the sensitivity we need to justify or show or guide the population in terms of what the impacts are. Therefore, the media-which I believe we must take greater advantage of and I am going to call on the Committee to focus on this matter-have become another actor in this scenario, and we must be concerned not only about having timely and reliable data, but about communicating the data. The communication of vital and health statistics is becoming increasingly important, and we have seen this up close with the pandemic. There is a whole new discipline called risk communication, which deals with how to keep the public well-informed about the situation. According to Dr. Chan, the current situation calls neither for panic nor complacence. But where is the middle ground, so that we can explain this? As you know, the media post daily headlines everywhere in every format-print, electronic, visual, with figures and comparative figures--and this impacts governance, social relations, the State, and the private sector. This is a very critical issue and a heavy responsibility for us.
We have too many digressions, and when I refer to responsibility, it is the responsibility of the various agencies and organizations to use figures that are both understandable and comparable, because having so many different sources with such different data is creating missed opportunities for some countries. One example is the Millennium Challenge Account, which logically, has significant resources in the United States to provide assistance to countries that, according to certain parameters-all indicators based on rates and dependent on the information source-qualify (or not) to receive certain resources. That is, the implications of this digression are often serious, even grave, for the countries, as it affects how they are classified in the categories developed internationally: as beneficiaries or not; they may even be punished by some of these indicators.
It's a good thing that there are growing numbers of indicators in the social sector to measure government and societal performance, because before, we had only economic indicators. However, if social indicators are to be as relevant, we have a second responsibility, which is to harmonize the sources and the data that we use. And here we encounter great difficulties because even in the reports on the Millennium Development Goals, they are not clear. On the one hand, some of the indicators are not good from a technical standpoint, and on the other, the problem is how we measure them, what data and sources we use to measure them, and what estimates we use to report them.
As I said, there is a wealth of global reports from different agencies that report different data, and today, when we are improving the statistics of many countries, these same countries are being punished because of the use of estimates.
I would also like to call on the Committee to offer guidance and advice to the countries in this respect, because we are faced with an obstacle from the past, we come from very poor situations in which we used indirect methods, proxies, or modeling. I believe, then, that together, we must help ourselves to gradually move away from these as our systems improve, because if we don't, it will defeat the purpose. That is, if we hold to our former practices, which to a certain extent are practices based on the void that existed but also on a certain distrust about whether the systems were reflecting reality, we will go against the purpose of strengthening the systems to generate increasingly better data. We are trying to fill the void and counter distrust with a series of very valid instruments, but the call I am issuing is to consider how we are going to make this transition as the countries begin to get stronger and better, because as we all know, there is nothing better in statistics or epidemiology than improving the generation and production of the data that we use. But if we don't use them and we continue to lessen their value by the use of approximate methodologies, we are not going to achieve the stimulus, the resources, or the support that national systems need to advance.
In conclusion, I believe that today's growth scenario is very different than in 2003. Another of the recommendations and commentaries we had made concerned the strengthening of subnational health systems. I believe that this is also related to the earlier commentary that the local levels and different sectors are continuing to build capacity, which is essential for us, because we live in an inequitable Region - this is general knowledge and not an expression of the tyranny of averages - and we must move away from the tyranny of averages. But that's the way it is, and we must continue to move away from indicators that are so aggregated that they don't reflect reality and, above all, are incapable of showing gap reductions, which is the basic theme of our efforts to advance. When we talk about health for all and the attainment of the Millennium Development Goals, we are not talking about the maternal mortality rate dropping to a certain level according to the country's statistical system; what we want is that women not die, not a single woman.. Sometimes we forget that we are interested in the person and not the datum, although we need data about persons to be able to work. I believe that the significant progress that we have seen in the subnational systems is very important and that we must make greater and greater efforts. However, we must also advocate for the use not only of national averages but of information that is disaggregated by geography, by vulnerable groups, by sex, by ethnicity, because we know where they are, what the determinants of the profound inequity that characterizes are Region are, whether in rich or poor countries. Furthermore, in the past two decades, inequality in many of the more developed countries has grown, especially inequality in income and access.
We are in the country with the largest economy in the Region, and our colleagues from the United States know very well that the income and access gaps have widened; if that were not so, the U.S. Congress would not be debating health sector reform. The issue of how to respect, strengthen, encourage, and use disaggregated information and programmed systems, beginning at the local level, is also critical to progress. I would like to underscore something that I mentioned earlier, which is the matter of international comparability and how we have this commitment to work very closely with all the other agencies, because we must guide the countries in drafting their reports to the World Health Assembly of 2010-- the report two-thirds down the road-and in taking the necessary steps. That is what interests us-to make the dream of so many years, decades, and centuries a reality -- as soon as possible and hopefully before 2015: the dream that the right to a better quality of life and better health for all people will become a reality.
There are too many expectations. You are my advisers; take what you can and we will continue working toward our goal."
