ABSTRACT

The objective of this article is to summarize the evolution of the regional commitments of the Pan American Health Organization (PAHO) on health promotion and strategies to improve the health and well-being of women, children, adolescents, and older persons. PAHO regional strategies approved by Member States in the last 20 years are used as the main source of information. The article presents the challenges of making health promotion a public health strategy widely applied in the Region of the Americas and the efforts to renew Member States’ collective actions. The article also describes current PAHO efforts to include the positive aspects of health (i.e., well-being, optimal development, and functional ability) and the life course approach as opportunities to advance equity. The article reflects on immunization as a public good and the urgency to address the current challenges as a core element of the regional efforts to transform health systems after more than two years of the COVID-19 pandemic.

Keywords
Health promotion; healthy aging; immunization; Pan American Health Organization

RESUMEN

El objetivo de este artículo es resumir la evolución de los compromisos regionales de la Organización Panamericana de la Salud (OPS) en materia de promoción de la salud y estrategias para mejorar la salud y el bienestar de mujeres, niños y niñas, adolescentes y personas mayores. Se han empleado como principal fuente de información las estrategias regionales de la OPS aprobadas por los Estados Miembros en los últimos 20 años. En el artículo se presentan los desafíos de convertir la promoción de la salud en una estrategia de salud pública de amplia ejecución en la Región de las Américas y los esfuerzos para renovar las medidas colectivas de los Estados Miembros. Asimismo, se describe la labor actual de la OPS para incluir los aspectos positivos de la salud (como el bienestar, el desarrollo óptimo y la capacidad funcional) y el enfoque del curso de vida como oportunidades para fomentar la equidad. Finalmente, se reflexiona sobre la inmunización como bien público y la urgencia de abordar los desafíos actuales como elemento central de los esfuerzos regionales para transformar los sistemas de salud tras más de dos años de pandemia de COVID-19.

Palabras clave
Promoción de la salud; envejecimiento saludable; inmunización; Organización Panamericana de la Salud

RESUMO

O objetivo deste artigo é resumir a evolução dos compromissos regionais da Organização Pan-Americana da Saúde (OPAS) relativos à promoção da saúde e estratégias para melhorar a saúde e o bem-estar de mulheres, crianças, adolescentes e pessoas idosas. As estratégias regionais da OPAS aprovadas pelos Estados Membros nos últimos 20 anos são a principal fonte de informação. O artigo apresenta os desafios enfrentados para fazer da promoção da saúde uma estratégia de saúde pública amplamente aplicada na Região das Américas e os esforços para renovar as ações coletivas dos Estados Membros. O artigo também descreve os atuais esforços da OPAS para incluir os aspectos positivos da saúde (isto é, bem-estar, desenvolvimento ideal e habilidade funcional) e a abordagem de curso da vida como oportunidades para promover a equidade. O artigo faz reflexões sobre a imunização como um bem público e a urgência de abordar os desafios atuais como um elemento central dos esforços regionais para transformar os sistemas de saúde após mais de dois anos da pandemia de COVID-19.

Palavras-chave
Promoção da saúde; envelhecimento saudável; imunização; Organização Pan-Americana da Saúde

The Region of the Americas has been marked by a sharp reduction in fertility and a sustained reduction in mortality. Life expectancy at birth has increased, and the causes of mortality have shifted from communicable diseases to chronic conditions. Violence and the effects of environmental risks are recognized as important causes of loss of healthy years of life. These changes stemmed from the interaction of social, environmental, economic, and other forces. The Pan American Health Organization (PAHO), which includes the Pan American Sanitary Bureau and Member States, has adapted its work to these changes, incorporated new scientific knowledge, and promoted collective action to advance health with equity. The objective of this opinion paper is to describe the evolution of PAHO’s work on health promotion and strategies to improve the health and well-being of women, children, adolescents, and older persons. It also highlights some opportunities for more equitable actions. A particular emphasis is placed on PAHO’s flagship program on immunization. Regional strategies approved by Member States in the last 20 years and with a focus on equity and the health of women, children, adolescents, and older persons are the main source of information (Table 1).

WOMEN’S, CHILDREN’S, ADOLESCENTS’, AND OLDER PEOPLE’S HEALTH

Overall, more mothers and babies survive pregnancy, childbirth, and the postpartum period. The maternal mortality ratio decreased from 102 in 1990 to 59 maternal deaths per 100 000 live births in 2017 (¹1. World Health Organization; United Nations Children’s Fund; United Nations Population Fund; World Bank Group; United Nations Population Division. Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division [Internet]. Geneva: WHO; 2019 [cited 2022 Jun 30]. Available from: https://apps.who.int/iris/handle/10665/327595
https://apps.who.int/iris/handle/10665/3... ). The neonatal mortality rate declined from 18 in 1990 to 7 deaths per 1 000 live births in 2020 (²2. United Nations Inter-Agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality [Internet]. New York: UNICEF; 2020 [cited 2022 Jun 30]. Available from: https://childmortality.org/wp-content/uploads/2021/12/UNICEF-2021-Child-Mortality-Report.pdf
https://childmortality.org/wp-content/up... ). Over time, PAHO’s work has expanded from a focus on reducing maternal and neonatal deaths to include the prevention of stillbirth and premature births, the management of maternal near miss, maternal noncommunicable diseases and mental health, and the surveillance of congenital malformations. It is also supporting countries to improve access to and the quality of post-abortion care and modern contraception services, and the implementation of respectful care and women’s sexual and reproductive self-care.

Between 1990 and 2020, under-five mortality fell 69% (from 43 to 13 per 1 000 live births), and the probability of dying among children aged 5 to 14 years fell 60% (from 5 to 2 per 1 000 children aged 5–14 years). In contrast, adolescent mortality rate (10–19 years of age) has remained stagnant (²2. United Nations Inter-Agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality [Internet]. New York: UNICEF; 2020 [cited 2022 Jun 30]. Available from: https://childmortality.org/wp-content/uploads/2021/12/UNICEF-2021-Child-Mortality-Report.pdf
https://childmortality.org/wp-content/up... ). Further progress depends mainly on the effective collaboration between the health sector and sectors responsible for road safety, injuries, violence, food systems, and the control of alcohol and psychoactive drugs. PAHO has expanded its work from mainly addressing diseases to promoting effective multisectoral action, youth participation, support to caregivers, and health-promoting schools, among others.

The mortality of persons older than 60 years has also decreased. Despite living longer, older people spend a substantial amount of time with disability and illness that are preventable and manageable. Root causes can be found in their living conditions, including inadequate social protection for them and their caregivers—the majority of whom are women (³3. World Health Organization. World report on ageing and health [Internet]. Geneva: WHO; 2015 [cited 2022 Jun 28]. Available from: https://apps.who.int/iris/handle/10665/186463
https://apps.who.int/iris/handle/10665/1... ). PAHO’s work is focused on enhancing multisectoral collaboration, combating ageism, promoting inclusive age-friendly environments, aligning programs and services to older persons’ needs, and prioritizing actions to maintain functional ability and keep caregivers healthy and thriving.

The progress in survival is a significant achievement of the Region, but health inequalities persist at every life stage. The lower the socioeconomic status, the higher the exposure to adverse living conditions, poor quality of services, and discrimination, among others (⁴4. Pan American Health Organization. Just Societies: Health Equity and Dignified Lives. Executive Summary of the Report of the Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas [Internet]. Washington, DC: PAHO; 2019 [cited 2022 Jun 30]. Available from: https://iris.paho.org/handle/10665.2/51570
https://iris.paho.org/handle/10665.2/515... ). The following sections will present the regional commitments to tackle some of these challenges.

HEALTH PROMOTION TO ACHIEVE EQUITY: A RENEWED COMMITMENT

Equity has been central to PAHO’s work throughout its 120 years. Early in PAHO’s history, Member States recognized health promotion as the public health strategy to achieve equity. Today, it is widely acknowledged that inequities start early in life and accumulate over the life course (³3. World Health Organization. World report on ageing and health [Internet]. Geneva: WHO; 2015 [cited 2022 Jun 28]. Available from: https://apps.who.int/iris/handle/10665/186463
https://apps.who.int/iris/handle/10665/1... –⁵5. Organization for Economic Cooperation and Development. Preventing Ageing Unequally [Internet]. Paris: OECD Publishing; 2017 [cited 2022 Jun 28]. https://doi.org/10.1787/9789264279087-en
https://doi.org/10.1787/9789264279087-en... ). The commitment to health promotion and equity has been ratified several times. In 2019, Member States agreed that a renewed agenda was necessary because making health promotion a widely applied public health strategy remains a challenge (⁶6. Pan American Health Organization. Strategy and Plan of Action on Health Promotion within the Context of the Sustainable Development Goals 2019-2030 [Internet]. 57th Directing Council, 71st Session of The Regional Committee of WHO for the Americas. Washington, D.C., 2019 Sept 30-October 4. Washington, DC: PAHO; 2022 [cited 2022 Jun 7]. Available from: https://iris.paho.org/handle/10665.2/55925
https://iris.paho.org/handle/10665.2/559... ). Stronger actions are particularly needed to enable participation and make health a political choice across all sectors. Several countries have rich experiences of social participation, community empowerment and community-based health interventions, health-promoting schools, and collaboration between local governments and communities to improve health. The challenge has been the sustainability of those efforts. PAHO’s work on health promotion has increased, especially in light of health and social setbacks caused by the COVID-19 pandemic, and the urgent need to accelerate progress to achieve the Sustainable Development Goals (SDGs).

THE LIFE COURSE APPROACH: SUPPORTING THE RENEWAL OF HEALTH PROMOTION

A life course approach means understanding how social, environmental, economic, and other health determinants operate at every stage of human development to immediately influence health and build the basis for health, well-being, or illness later in life and in the next generation (⁷7. Pan American Health Organization. Building Health Throughout the Life Course: Concepts, Implications, and Application in Public Health [Internet]. Washington, DC: PAHO; 2020 [cited 2022 7 Jun]. Available from: https://iris.paho.org/handle/10665.2/53409
https://iris.paho.org/handle/10665.2/534... , ⁸8. Public Health England. Guidance. Health matters: Prevention - a life course approach [Internet]. London: PHE; 2019 [cited 2022 10 Oct]. Available from: https://www.gov.uk/government/publications/health-matters-life-course-approach-to-prevention/health-matters-prevention-a-life-course-approach
https://www.gov.uk/government/publicatio... ). The approach also brings attention to the sensitive periods when certain exposures have lifelong effects (i.e., pre-conception, pregnancy, the first years of life, and adolescence) and highlights factors that accumulate over time and raise disease risk or promote good health. The aspiration is to build healthy life trajectories and reduce the equity gaps from the start. PAHO is supporting countries to apply a life course approach to public policy and health programming. Some implications are the use of the social, environmental, and economic exposures to define priority actions, the promotion of well-being and the timing of interventions as central to improve quality of services, and the selection of new metrics (i.e., family support networks, adverse childhood experiences) to monitor progress (⁷7. Pan American Health Organization. Building Health Throughout the Life Course: Concepts, Implications, and Application in Public Health [Internet]. Washington, DC: PAHO; 2020 [cited 2022 7 Jun]. Available from: https://iris.paho.org/handle/10665.2/53409
https://iris.paho.org/handle/10665.2/534... , ⁸8. Public Health England. Guidance. Health matters: Prevention - a life course approach [Internet]. London: PHE; 2019 [cited 2022 10 Oct]. Available from: https://www.gov.uk/government/publications/health-matters-life-course-approach-to-prevention/health-matters-prevention-a-life-course-approach
https://www.gov.uk/government/publicatio... ).

MAKING WELL-BEING A GOAL FOR HEALTH AND OTHER SECTORS

Recent PAHO work is about the positive dimensions of health. Well-being—a positive state experienced by individuals and societies—is comprehensive in nature and connects multiple dimensions of the SDGs (⁹9. World Health Organization. Towards developing WHO’s agenda on well-being [Internet]. Geneva: WHO; 2021 [cited 2022 Jun 14]. Available from: https://www.who.int/publications/i/item/9789240039384
https://www.who.int/publications/i/item/... ). The 1978 Declaration of Alma-Ata (¹⁰10. World Health Organization. Declaration of Alma-Ata: International Conference on Primary Health Care [Internet], 1978 Sep 6-12; Alma-Ata, USSR. Geneva: WHO, 1978 [cited 2022 Jun 15]. Available from: https://cdn.who.int/media/docs/default-source/documents/almaata-declaration-en.pdf
https://cdn.who.int/media/docs/default-s... ) and 1986 Ottawa charter (¹¹11. World Health Organization [Internet]. Geneva: WHO; c.2022 [cited 2022 June 14]. Health Promotion. The 1st International Conference on Health Promotion, Ottawa, 1986. Available from: https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference
https://www.who.int/teams/health-promoti... ) reaffirmed that “Health is a positive concept emphasizing social and personal resources, as well as physical capacities.” Similar emphasis is present in other regional agreements on health promotion, social determinants of health, and primary health care. PAHO has brought these positive dimensions of health to the forefront of the regional discussions when working with Member States on two regional initiatives: the Decade of Healthy Aging (2021–2030) (¹²12. World Health Organization. Decade of Healthy Ageing 2020-2030 [Internet]. Geneva: WHO c.2020 [cited 9 July 2022]. Available from: https://cdn.who.int/media/docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en.pdf
https://cdn.who.int/media/docs/default-s... ) and the Plan of Action for Women’s, Children’s, and Adolescents’ Health (2018–2030) (¹³13. Pan American Health Organization. Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030 [Internet]. PAHO 56th Directing Council, Washington, D.C.; PAHO, 2018 September 23-27. Washington, DC: PAHO; 2018 [cited 2022 Jul 2]. Available from: https://iris.paho.org/bitstream/handle/10665.2/49609/CD56-8-en.pdf
https://iris.paho.org/bitstream/handle/1... ).

Healthy aging is “the process of developing and maintaining the functional ability that enables well-being in older ages” (³3. World Health Organization. World report on ageing and health [Internet]. Geneva: WHO; 2015 [cited 2022 Jun 28]. Available from: https://apps.who.int/iris/handle/10665/186463
https://apps.who.int/iris/handle/10665/1... ). Functional ability is defined as the dynamic interaction between the intrinsic capacity (i.e., genetic makeup and physical and mental capacities) and the environment (e.g., social, economic, and built environment, services, etc.). It refers to the ability to move around, build and maintain relationships, meet one’s own basic needs, learn and make decisions, participate, and contribute—all of which are built throughout one’s lifetime (³3. World Health Organization. World report on ageing and health [Internet]. Geneva: WHO; 2015 [cited 2022 Jun 28]. Available from: https://apps.who.int/iris/handle/10665/186463
https://apps.who.int/iris/handle/10665/1... ). Member States approved in 2009 the Plan of Action on the Health of Older Persons, Including Active and Healthy Aging (¹⁴14. Pan American Health Organization. CD49/8 - Plan of action on the health of older persons, including active and healthy aging [Internet]. PAHO 49th Directing Council, Washington, DC; PAHO, 2009 July 10. Washington, DC: PAHO; 2009 [cited 2022 Jun 21]. Available from: https://www.paho.org/hq/dmdocuments/2009/CD49-08-e.pdf
https://www.paho.org/hq/dmdocuments/2009... ) and renewed their commitments when supporting the United Nations Decade of Healthy Aging (¹²12. World Health Organization. Decade of Healthy Ageing 2020-2030 [Internet]. Geneva: WHO c.2020 [cited 9 July 2022]. Available from: https://cdn.who.int/media/docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en.pdf
https://cdn.who.int/media/docs/default-s... ). This is an opportunity to bring well-being to the public policy discussions and benefit people of all ages.

Similarly, the agenda for children and adolescents is currently about optimal health, well-being, and development from pre-conception, through fetal development, to 20 years of age (¹⁵15. World Health Organization; United Nations Children’s Fund. Investing in our future: a comprehensive agenda for the health and well-being of children and adolescents [Internet]. Geneva: WHO and UNICEF; 2021 [cited 2022 Oct 12]. Available from: https://apps.who.int/iris/handle/10665/350239
https://apps.who.int/iris/handle/10665/3... –¹⁷17. World Health Organization; United Nations Children’s Fund; World Bank Group. Nurturing Care Framework for Early Childhood Development: a framework for helping children survive and thrive to transform health and human potential [Internet]. Geneva: WHO; 2018 [cited 2022 Jun 1]. Available from: https://apps.who.int/iris/handle/10665/272603
https://apps.who.int/iris/handle/10665/2... ). The first two decades of life provide the foundation for human capital, resilience, and health and well-being in adulthood, old age, and future generations (¹⁵15. World Health Organization; United Nations Children’s Fund. Investing in our future: a comprehensive agenda for the health and well-being of children and adolescents [Internet]. Geneva: WHO and UNICEF; 2021 [cited 2022 Oct 12]. Available from: https://apps.who.int/iris/handle/10665/350239
https://apps.who.int/iris/handle/10665/3... ). Multisectoral efforts to promote early childhood development exist in several countries. Less advanced is the notion that the promotion of well-being and development must continue through middle childhood and adolescence, which adds the obligation to ensure meaningful participation of children and young people. The Plan of Action for Women’s, Children’s, and Adolescents’ Health is the first PAHO initiative to integrate actions across these formative years. The strategic actions aim to improve physical, mental, and social well-being through actions in multiple settings (families, schools, and communities) and equitable and quality health services (¹³13. Pan American Health Organization. Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030 [Internet]. PAHO 56th Directing Council, Washington, D.C.; PAHO, 2018 September 23-27. Washington, DC: PAHO; 2018 [cited 2022 Jul 2]. Available from: https://iris.paho.org/bitstream/handle/10665.2/49609/CD56-8-en.pdf
https://iris.paho.org/bitstream/handle/1... ).

Healthy aging and the promotion of optimal health, well-being, and development among children and adolescents apply a life course approach, use similar concepts, and have similar strategic implications: (i) human development and psychosocial well-being are positioned at the same level of priority as physical health; (ii) the significance of human relationships is elevated, in particular the role of caregivers; (iii) early actions targeting sensitive periods are called for; (iv) actions on multiple settings (e.g., households, schools, workplaces, long-term care) are reaffirmed; and (v) an intergenerational perspective is underscored. Further work is still needed to integrate well-being as a goal for health and other sectors.

IMMUNIZATION AS A PUBLIC GOOD: MORE THAN 40 YEARS OF SUCCESS

In 1977, PAHO created the Expanded Program on Immunization as the main strategy to eliminate and control vaccine-preventable diseases. This effort was reinforced by the establishment in 1978 of the Revolving Fund for Access to Vaccines to facilitate access to high-quality vaccines at the lowest price. The Region was the first in the world to achieve elimination of polio, measles, and rubella and congenital rubella syndrome. This remarkable success was the result of Member States’ sustained investment and political commitment, and the continuous production and use of updated scientific information.

Over time, the scope and complexity of PAHO’s work on immunization have increased. More than 16 vaccines are part of national vaccine schedules, and actions and investment in health systems include cold chain structure and capacity; procurement, quality control, and distribution of vaccine and supplies; development and enforcement of regulations; and a system to enhance healthcare workers’ skills. Immunization programs have also been the source of innovation when bringing vaccines to the hardest-to-reach communities due to geographic conditions, social upheavals, or the pandemic.

Despite achievements, serious challenges prevail. Compared to other areas of the world, the Region of the Americas shows the largest drop in DPT3 coverage¹1DPT3 coverage is the percentage of children aged 12–59 months who have received three doses of the combined diphtheria, tetanus toxoid, and pertussis vaccine. DPT3 is routinely used as a proxy to monitor vaccination coverage in general. in the last decade, from 94.4% in 2010 to 81% in 2020 (¹⁸18. United Nations Children’s Fund [Internet]. New York: UNICEF; 2021 Jul [cited 2022 Jul 12]; [about 1 screen]. Immunization coverage estimates dashboard. Available from: https://data.unicef.org/resources/immunization-coverage-estimates-data-visualization/.
https://data.unicef.org/resources/immuni... ). This drop has occurred in most countries, expanded to other vaccines, and has created a significant accumulation of susceptible individuals (¹⁹19. Pan American Health Organization. CD59/10 - Reinvigorating Immunization as a Public Good for Universal Health [Internet]. Washington, DC: PAHO; 2021 August 10 [cited 2022 Jul 11]. Available from: https://www.paho.org/en/documents/cd5910-reinvigorating-immunization-public-good-universal-health
https://www.paho.org/en/documents/cd5910... , ²⁰20. World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind [Internet]. Geneva: WHO; 2020 [cited 2022 Jul 13]. Available from: https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030-draft-4-wha_b8850379-1fce-4847-bfd1-5d2c9d9e32f8.pdf
https://cdn.who.int/media/docs/default-s... ). Several countries have already seen the return of previously eliminated diseases such as measles, yellow fever, and others. Factors contributing to this situation include the unequal access to vaccines, unreliable financing, high turnover of health workforce, limited surveillance and laboratory capacity, and the growing “infodemic”²2WHO defines an infodemic as an overabundance of information—some accurate and some not—that occurs during an epidemic. It spreads between humans in a similar manner to an epidemic, via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it. (²¹21. World Health Organization. An ad hoc WHO technical consultation managing the COVID-19 infodemic: call for action [Internet]. Geneva: WHO; 2020 April 7-8 [cited 2022 Oct 10]. Available from: https://www.who.int/publications/i/item/9789240010314
https://www.who.int/publications/i/item/... ) and vaccine hesitancy. The COVID-19 pandemic and, more recently, the monkeypox outbreak have exacerbated the already challenging situation of the national immunization programs. In 2021, Member States committed to strengthen governance and leadership of immunization programs, ensure and protect immunization-specific budgets, adopt innovative approaches, and incorporate technological, communication, behavioral, and data analysis tools (¹⁹19. Pan American Health Organization. CD59/10 - Reinvigorating Immunization as a Public Good for Universal Health [Internet]. Washington, DC: PAHO; 2021 August 10 [cited 2022 Jul 11]. Available from: https://www.paho.org/en/documents/cd5910-reinvigorating-immunization-public-good-universal-health
https://www.paho.org/en/documents/cd5910... , ²⁰20. World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind [Internet]. Geneva: WHO; 2020 [cited 2022 Jul 13]. Available from: https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030-draft-4-wha_b8850379-1fce-4847-bfd1-5d2c9d9e32f8.pdf
https://cdn.who.int/media/docs/default-s... ).

FUTURE CHALLENGES AND OPPORTUNITIES

The conviction of Member States to the values of equity and solidarity was expressed in the Declaration of the Ministers and Secretaries of Health endorsing the Sustainable Health Agenda for the Americas 2018–2030 (²²22. Pan American Health Organization. Sustainable Health Agenda for the Americas 2018-2030: a call to action for health and well-being in the region [Internet]. 29th Pan American Sanitary Conference, 69th Session of the Regional Committee of WHO for the Americas; Washington, D.C. Washington, DC: PAHO; 2017 (Document CSP29/6, Rev. 3) [cited 2022 Oct 10]. Available from: https://iris.paho.org/handle/10665.2/49170
https://iris.paho.org/handle/10665.2/491... ). It provides a solid base to accelerate actions to address the challenges described above. The following paragraphs reflect on some existing opportunities.

The potential of the digital transformation of public health

The future of public health will be transformed by digital technology (²³23. World Health Organization. Global strategy on digital health 2020-2025 [Internet]. Geneva: WHO; 2021 [cited 2022 Jul 4]. Available from: https://apps.who.int/iris/handle/10665/344249
https://apps.who.int/iris/handle/10665/3... ). Digital media are already integrated into daily life, particularly for children and adolescents. Along with the potential benefits, digital technologies may also bring risks for learning, mental and physical health, or social relationships (²⁴24. Hollis C, Livingstone S, Sonuga-Barke E. Editorial: The role of digital technology in children and young people’s mental health – a triple-edged sword? J Child Psychol Psychiatr [Internet]. 2020 July [cited 2022 Oct 12];61(8):837–41. https://doi.org/10.1111/jcpp.13302
https://doi.org/10.1111/jcpp.13302... ). An increased exposure to an overabundance of information is aggravated by the growing unethical use of digital marketing to influence health-related decisions and behaviors. Discussions are already taking place on making digital health an integral part of the health system, and doing so in a way that is ethical, safe, secure, reliable, equitable, and sustainable (²³23. World Health Organization. Global strategy on digital health 2020-2025 [Internet]. Geneva: WHO; 2021 [cited 2022 Jul 4]. Available from: https://apps.who.int/iris/handle/10665/344249
https://apps.who.int/iris/handle/10665/3... , ²⁵25. Pan American Health Organization. Eight Guiding Principles of Digital Transformation of the Health Sector. A Call to Pan American Action [Internet]. Washington, DC: PAHO; 2021 Jun 10 [cited 2022 Oct 10]. Available from: https://iris.paho.org/handle/10665.2/54256
https://iris.paho.org/handle/10665.2/542... ). PAHO’s main role is ensuring that inclusion and diversity of voices are part of the debates, especially those of young and older people, and ensuring that digital health is not discussed in isolation but within the broader framework of the health promotion strategy and the actions on the determinants of health.

Well-being for equity

Frameworks to promote well-being currently focus on specific age groups, such as early childhood (¹⁷17. World Health Organization; United Nations Children’s Fund; World Bank Group. Nurturing Care Framework for Early Childhood Development: a framework for helping children survive and thrive to transform health and human potential [Internet]. Geneva: WHO; 2018 [cited 2022 Jun 1]. Available from: https://apps.who.int/iris/handle/10665/272603
https://apps.who.int/iris/handle/10665/2... ) and old age (¹²12. World Health Organization. Decade of Healthy Ageing 2020-2030 [Internet]. Geneva: WHO c.2020 [cited 9 July 2022]. Available from: https://cdn.who.int/media/docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en.pdf
https://cdn.who.int/media/docs/default-s... ). Having a unified well-being framework that can be applied throughout the life course has the potential to position healthy trajectory, quality of life, functional ability, and optimal development as governmental goals. An international movement is gaining momentum to move toward measures that focus on the well-being of people and the planet. The 2022 Human Development Report and the Multidimensional Poverty Index (²⁶26. United Nations Development Programme. Human Development Report 2021/22: Uncertain times, unsettled lives: Shaping our future in a transforming world [Internet]. New York: UNDP; 2022 [cited 2022 Oct 10]. Available from: https://hdr.undp.org/content/human-development-report-2021-22
https://hdr.undp.org/content/human-devel... ) are some examples. Well-being—as a policy concept—may bring reinvigorated attention to participation, inclusion, and multisectoral action. A regional unified framework on well-being may offer new impetus to bringing the original principles and aspirations of Alma-Ata and the Ottawa Charter into this century and to revitalizing the energy needed to achieve the SDGs.

The future of immunization

The future of immunization in the Region presents many challenges. On the one hand, scientific advances, including new vaccines and innovative approaches to further strengthen the immunization programs, are already available. Examples are the newly developed vaccines against COVID-19 and malaria, vaccines under development against respiratory syncytial virus and other infectious diseases, as well as the role that immunization plays in reducing spread of antimicrobial resistant organisms (²⁰20. World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind [Internet]. Geneva: WHO; 2020 [cited 2022 Jul 13]. Available from: https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030-draft-4-wha_b8850379-1fce-4847-bfd1-5d2c9d9e32f8.pdf
https://cdn.who.int/media/docs/default-s... ). On the other hand, new and old challenges threaten the progress made so far. Immunization requires innovative approaches (such as digital intelligence, geo-referencing, and big data), as well as communication strategies to build social awareness and trust in vaccines, enhanced surveillance capacity, a strong health research agenda, optimized health workforce performance, and sustained governance, stewardship, and financing, among others (¹⁹19. Pan American Health Organization. CD59/10 - Reinvigorating Immunization as a Public Good for Universal Health [Internet]. Washington, DC: PAHO; 2021 August 10 [cited 2022 Jul 11]. Available from: https://www.paho.org/en/documents/cd5910-reinvigorating-immunization-public-good-universal-health
https://www.paho.org/en/documents/cd5910... , ²⁰20. World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind [Internet]. Geneva: WHO; 2020 [cited 2022 Jul 13]. Available from: https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030-draft-4-wha_b8850379-1fce-4847-bfd1-5d2c9d9e32f8.pdf
https://cdn.who.int/media/docs/default-s... ). After more than two years of the pandemic, there is momentum to transform health systems to better prepare for future crises. It is essential to find synergies between the reinvigoration of immunization as a public good and other regional strategic commitments. Solutions to the multiple challenges of immunization will require actions beyond the health sector, and discussions are already taking place to mobilize governmental actions.

CONCLUSION

The evolution of health in the Region has been one of significant achievements and challenges. Member States have reiterated a commitment to health promotion as the public health strategy to promote participation and apply a whole-of-society approach to achieving equity in health and well-being. However, these actions had several cycles of high and low interest and investment, and equity remains at the top of the Region’s unfinished public health agenda. The high political interest in health, triggered by the evident unequal effects of the COVID-19 pandemic, brings the opportunity to make previous and recent commitments a reality for those facing disadvantages and exclusion. While achievements are celebrated, some areas require bold and urgent action, and this is clearly the case of immunization. The current work on applying a life course approach to public policy and programming, the emphasis on well-being, and a renewed commitment to health promotion offer new opportunities to meet this complex time with urgency and determination.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or those of the Pan American Health Organization (PAHO).

Acknowledgments.

The authors would like to thank Sonja Caffe, Bremen De Mucio, Rodolfo Gomez, Carolina Hommes, and Patricia Morsch for their inputs.

REFERENCES

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