REVIEW

 

National nursing strategies in seven countries of the Region of the Americas: issues and impact

 

Estrategias nacionales de enfermería en siete países de la Región de las Américas: problemas y repercusión

 

 

Rebecca O. ShasanmiI; Esther M. KimII; Silvia Helena De Bortoli CassianiIII

IHuman Resources for Health, World Health Organization (WHO), Abuja, Federal Capital Territory, Nigeria
IICommission on Graduates of Foreign Nursing Schools International, Philadelphia, Pennsylvania, United States of America
IIINursing and Allied Health Personnel, Pan American Health Organization (PAHO), Washington, DC, United States of America. Send correspondence to Silvia Cassiani, email: cassianis@paho.org

 

 


ABSTRACT

OBJECTIVE: To identify and examine the current national nursing strategies and policy impact of workforce development regarding human resources for health in seven selected countries in the Region of the Americas: Argentina, Canada, Costa Rica, Jamaica, Mexico, Peru, and the United States.
METHODS: A review of available literature was conducted to identify publicly-available documents that describe the general backdrop of nursing human resources in these seven countries. A keyword search of PubMed was supplemented by searches of websites maintained by Ministries of Health and nursing organizations. Inclusion criteria limited documents to those published in 2008-2013 that discussed or assessed situational issues and/or progress surrounding the nursing workforce.
RESULTS: Nursing human resources for health is progressing. Canada, Mexico, and the United States have stronger nursing leadership in place and multisectoral policies in workforce development. Jamaica shows efforts among the Caribbean countries to promote collaborative practices in research. The three selected countries in Central and South America championed networks to revive nursing education. Yet, overall challenges limit the opportunities to impact public health.
CONCLUSIONS: The national nursing strategies prioritized multisectoral collaboration, professional competencies, and standardized educational systems, with some countries underscoring the need to align policies with efforts to promote nursing leadership, and others, focusing on expanding the scope of practice to improve health care delivery. While each country wrestles with its specific context, all require proper leadership, multisectoral collaboration, and appropriate resources to educate, train, and empower nurses to be at the forefront.

Key words: Human resources; nursing administration research; health manpower; nursing services; legislation, nursing; Argentina; Canada; Costa Rica; Jamaica; Mexico; Peru; United States.


RESUMEN

OBJETIVO: Determinar y analizar las actuales estrategias nacionales de enfermería y la repercusión política del desarrollo de la fuerza laboral en materia de recursos humanos para la salud en siete países seleccionados de la Región de las Américas: Argentina, Canadá, Costa Rica, Estados Unidos, Jamaica, México y Perú.
MÉTODOS: Se llevó a cabo una revisión de la bibliografía con objeto de seleccionar documentos públicamente accesibles que describieran la situación general de los recursos humanos de enfermería en los siete países. Se complementó una búsqueda de palabras clave en PubMed con otras búsquedas en los sitios web creados por los ministerios de salud y las organizaciones de enfermería. Los criterios de inclusión limitaron los documentos a aquellos publicados entre el 2008 y el 2013 que trataran o evaluaran temas coyunturales o los progresos en torno a la fuerza laboral de enfermería.
RESULTADOS: Se producen avances en materia de recursos humanos de enfermería para la salud. Canadá, Estados Unidos y México cuentan con un liderazgo de enfermería más dinámico y políticas multisectoriales de desarrollo de la fuerza laboral. Jamaica muestra iniciativas entre los países del Caribe para promover prácticas de investigación colaborativas. Los tres países seleccionados de América Central y del Sur impulsaron la creación de redes para reactivar la formación de enfermería. No obstante, las dificultades generales limitan las oportunidades de repercutir en la salud de la población.
CONCLUSIONES: Las estrategias nacionales de enfermería dieron prioridad a la colaboración multisectorial, las competencias profesionales y los sistemas de formación estandarizados. Algunos países subrayan la necesidad de alinear las políticas con las iniciativas de promoción del liderazgo de enfermería, y otros se centran en la ampliación del ámbito de la práctica con objeto de mejorar la prestación de los servicios de salud. Mientras que cada país lidia con su contexto específico, todos ellos requieren un liderazgo adecuado, la colaboración multisectorial y recursos apropiados para formar, capacitar y facultar al personal de enfermería con objeto de que ocupe una posición de vanguardia.

Palabras clave: Recursos humanos; investigación en administración de enfermería; recursos humanos en salud; servicios de enfermería; legislación de enfermería; Argentina; Canadá; Costa Rica; Jamaica; México; Perú; Estados Unidos.


 

 

The global nursing shortage presents challenges that potentially delay health care delivery and thwart the goal of universal health coverage (UHC). Human resources for health (HRH) are affected not only by the nursing shortage, but also by insufficient resources, mismanaged workforce data, restricted policies, and limited availability of educators (1). The scope of policy decisions for human resources in nursing has not been comprehensively explored in regional contexts.

The emphasis on UHC across the Region of the Americas has brought a unique opportunity to evaluate the health workforce's capacity for meeting the Region's health needs. Nurses present a cost-effective solution for meeting health care demands (2, 3). The issue, as the International Council of Nurses (ICN) reported, is that the baseline nurse-to-population ratios differ among countries as widely as 100-fold (4). WHO indicates that, "availability and consumption of HRH is an important indicator of the strength of health" (5). Sources state the lack of adequate staffing affect the safety and quality of care delivery (6, 7). National policies must implement investments in quality of education, increased supply and adequate distribution, and appropriate resources for professionals, in order to recognize the impact of the workforce to care for global communities.

The purpose of this review was to identify and examine the current national nursing strategies and policy impact of workforce development regarding human resources for health in seven selected countries in the Region of the Americas: Argentina, Canada, Costa Rica, Jamaica, Mexico, Peru, and the United States. Utilizing the available literature, this review presents research that ascertains the baseline, ongoing progress, and achievements in these countries.

 

MATERIALS AND METHODS

This review of the literature was performed in July-September 2013. The seven countries-Argentina, Canada, Costa Rica, Jamaica, Mexico, Peru, and the United States-were chosen because they spanned North, Central, and South America, including the Caribbean. A digital search was conducted to identify and select documents from four areas: PubMed Central (National Center for Biotechnology Information, U.S. National Library of Medicine, Bethesda Maryland, United States); international/national nursing organization websites/databases; Ministry of Health (MOH) online documents; and the websites of PAHO and WHO. Selected studies met the following inclusion criteria: (a) published during the 5 years from 2008-2013; (b) discussed nursing workforce development in the specified countries; and (c) presented content relevant to nursing supply, strategy, distribution, education, and/or development.

On PubMed, the keywords used for retrieving studies were: nursing, future, workforce, strategy, distribution, education, supply, human resources, development, health workers policy, shortage, forecasting, demand, national, strategic, strategy AND the country name. In order to expand the search, keywords were also translated into Spanish and Portuguese. Titles and abstracts were reviewed for relevance in three research topics: (a) identification of national nursing strategy from 2008-2013; (b) role of a chief nursing officer (CNO) affiliated with the MOH; and (c) availability of current literature. On PubMed, 50 documents were retrieved, but 15 studies were excluded per the criteria.

After a thorough analysis of the available literature, a content synthesis was performed. Definitions were coded and condensed into themes corresponding with the five critical areas mentioned in the Toronto Call to action document (8) as follows: (i) define long-term policies for development, (ii) distribute appropriate quantity and skill level of workers, (iii) assess migratory forces of workers, (iv) dedicate practice to quality and safety, and (v) implement academic-practice partnerships germane to nursing workforce development.

 

RESULTS

A combination of documents identified from the review of the literature and those from governmental entities painted a fuller picture of the nursing workforce among these countries (Annex 1). The eight resources from government entities included the national policy agenda of each country that had one available. The digital search yielded a total of 52 documents (35 from PubMed; Table 1) that met inclusion criteria.

 


Table 1 - Click to enlarge

 

While all the countries had elements of national strategies enacted, only five of the seven countries had their own national nursing plan (Annex 2). Six countries had a CNO within the MOH. Although Jamaica did not have a national nursing strategy, its MOH did have a CNO. As for Peru, it was the only country among the seven that did not have a national nursing strategy or a CNO in its MOH at that time.

The literature search revealed sources of available data regarding the supply of nurses in the workforce. Canada, Mexico, and the United States had identified mechanisms for surveying the number of nurses, their distribution, and for forecasting workforce growth needs/shortages. Jamaica was currently developing metrics for capturing this data. Nurse-to-population ratios varied by country, with Canada having the highest ratio at 10.4 : 1 000 (9) and Costa Rica, the lowest at 1.82 : 1 000 (10). Trends in workforce distribution reflect an urban-centric distribution within each country. Canada and Jamaica specifically highlighted attrition challenges among newly trained nursing workforce, mostly due to migration (11-12). Within large urban centers, countries within the Americas face challenges of high workload, inadequate supplies, and poor access. Literature from Argentina, Jamaica, and Peru specifically highlighted this disparity (12-14).

Themes regarding nursing education were strongly emphasized. Literature from Argentina, Costa Rica, and Peru propose further policies required for accreditation standards (15-17). Education initiatives have ranged from development of national programs within diverse socioeconomic populations to international partnerships among global partners (14-15). Argentina and the United States produced literature that discussed government financial incentives to encourage students to pursue nursing (18-20). Five countries-Argentina, Canada, Costa Rica, Mexico, and the United States-had nursing strategies that emphasize proper training as a necessary component of overall workforce development.

Country analyses

The following is a brief analysis by county, listed in geographic order from north to south.

Canada. The National Expert Commission convened by the Canadian Nurses Association (CAN) (Ottawa, Ontario, Canada) developed A Nursing Call to Action in 2012 (6). The strategic theme was described as, "using nurses more effectively is key to a transformed system that will better balance acute care with primary care that is patient-centered, holistic, and offers many more services in communities and patients' homes" (6). The Commission called for multisectoral engagement to address key areas to support this type of nursing workforce. The plan of action for 2012-2017 incorporates extensive community involvement and actionable strategies under the guidance of the CNO of Health Canada (Ottawa, Ontario, Canada).

With over 34 million people, Canada's nurse/midwife-to-population ratio is 10.4 : 1 000 (9). Canada has seen an increase of 4.8% in the nursing workforce from 2007-2010, totaling 268 500 registered nurses (RNs; 6). Meanwhile, overall work- force shortages have created challenges to the supply of nurses (21). Migration and inadequate distribution continues to pose a problem. Apprehension about the work environment exists, so students select employment solely in urban areas or migrate elsewhere (11). Methods to improve distribution to underserved areas have adopted financial incentives as a way to retain nurses, and this has demonstrated promising results (22). Policy coordination among immigration and labor forces of foreign-trained nurses also expects to help meet the demand (23).

Canada has uniquely invested in regional training centers as a way of providing education and research opportunities for graduate and doctoral candidates. Centers built to promote nursing research may encourage regional schools to form consortiums to support best practices for improving integration and funding mechanisms (24). These programs clearly emphasize the fundamental value of nursing education to promote its workforce (21).

Canada has set the bar high for other countries. Its endeavors to improve its nursing workforce focus on both urban and rural areas, particularly in geographic areas with fewer resources. Efforts to expand its nurse-to-population ratio include inviting a regulated foreign nursing workforce to reduce the country's health disparities.

United States of America. The United States has been seen as a leader in nursing workforce development. A multisectoral committee, funded by the Robert Wood Johnson Foundation (Princeton, New Jersey, United States), devised the Institute of Medicine's (IOM) Future of Nursing: Leading Change, Advancing Health report (25). The collection of the IOM reports has been a catalyst for the federal government's role in health care reform.

The United States has a population of over 313 million, and a nurse/midwife-to-population ratio of 9.8 : 1 000 (26). Though there is overall growth (84.8 %) of employed RNs, ineffective distribution of trained nurses raises concerns, particularly in the western and northeastern parts of the country (3). Several obstacles, such as the aging workforce, predict "entry into nursing must continue to grow over the next two decades at a rate of 20% per decade in order to meet that demand" (19). Specific areas of the country, such as the Midwest, have targeted partnerships with schools to distribute trained nurses to meet the needs of the rural population (3).

The Affordable Care Act (ACA) has provided additional funding for nursing education. In 2012 alone, the Government of the United States invest- ed US$ 58.7 million to bolster the nursing workforce through grant awards to educational institutions (18, 19). The United States has conducted an annual survey on nursing workforce through the National Sample Survey of Registered Nurses by the Health Resources and Services Administration (HRSA). Per the 2013 report, The U.S. Nursing Workforce: Trends in Supply and Education, the nursing workforce grew to 3.1 million, reflecting a 14% increase in RNs and 6% increase in licensed practical nurses (27). The CNO within the Office of the Surgeon General of the United States Department of Health and Human Services collaborates with policymakers to impact nursing leadership.

The United States consists of the largest population to report a marked increase (13%, 2005-2010) in its nursing workforce supply (28). The multidisciplinary approach is encouraging; however, extensive research on this topic is difficult to track. Workforce data metrics should be improved for accurate analyses. With HRSA no longer publishing a comprehensive survey of the nursing workforce, there are gaps in monitoring future workforce trends (29).

Mexico. Based on the World Health Assembly's Resolution 42.27 (30), Mexico has effectively implemented a national policy focused on primary health care through management and information technology. In 1995, Mexico established the Management Information System Human Resources in Nursing (SIARHE) with the assistance of the CNO. It is designed to accurately track the distribution and allocation of its nursing workforce by gathering data on nursing staff at institutions that compose the national health system.

The current national strategic plan for nursing workforce development is titled Technical Guide for Human Resources Allocation in Nursing (31). This guide has been implemented at the subnational level to shape HRH. Utilization of SIARHE data guides strategic planning, distribution, and capacity utilization of nurses. While the government has invested in forecasting metrics, work productivity has yet to produce definite outcomes (13).

Dilemmas with the workforce arise from a lack of formal education restricting nursing professional roles (13). The transition from training to clinical practice presents a daunting task. In one study, of the 40 000 graduates from health profession schools (of which 30% were nursing students), 32% did not pass professional competency exams (32). These graduates entered the workforce despite reservations about their own skills.

The Mexican government has invested 6.2% of its gross domestic product on health (33). Mexico has a population of approximately 114.8 million, with a nurse-to-physician ratio of 1.9 : 1 and a nurse/midwife-to-population ratio of 3.7 : 1 000. Currently, Mexico does not meet the OECD nurse: physician ratio of 2.8 : 1 (33, 34).

Mexico has had a long history of efforts to develop and implement a national nursing strategic plan. The CNO manages the country's resources regarding its workforce. Accreditation for nursing education demands additional support. Despite noted improvements, further work to expand the scope of practice of nursing specialties is crucial.

Jamaica. There was no national nursing strategic plan available for Jamaica at the time of the study, though the Nursing and Midwifery Act of 2005 defined the role of nurses, midwives, and nursing assistive personnel (35). The CNO collaboration within the MOH and Nursing Council Jamaica (NCJ) regulated the scope of practice and education policies. The NCJ comprises leaders known for their advocacy role in promoting nursing leadership to develop a national nursing plan. A recent project successfully integrated a database system to address human resources within public and private sectors (36).

Jamaica's population of roughly 2.8 million has a nurse/midwifeto-population ratio of 1.09 : 1 000 (37). Health professionals face concerns about resources and infrastructure that hamper the ability to maintain adequate nursing staffing (36). Insufficient training regulations and limited health technology also present additional challenges.

Evidence-based practice, however, has been a priority through the newly minted Caribbean Journal of Nursing, launched in 2013. It is an open access, peer-reviewed, scientific journal that aims to promote original research and academic manuscripts ranging from education to practice in the Caribbean (38).

Jamaica recognizes that the challenges of workforce shortages demand a coordinated approach, strengthened by research and data capacity in health care management (36). The Caribbean Community (CARICOM) has written a white paper supporting the development of tertiary education and nursing in the Caribbean. The document, based on the International Labor Organization's recommendations made at the 15th COSHOD conference, highlights that tertiary education promotes the single market economy within the country (39). PAHO/WHO recently collaborated with CARICOM to discuss a nursing education agenda (40).

Costa Rica. The Costa Rica national strategy is a policy document developed by the College of Nurses of Costa Rica. The document, National Nursing Policy 2011-2021, outlines several variables as chief drivers in workforce development. Topics include interdisciplinary collaboration, education, and resource management. The CNO oversees such proposals, serving as the Chief of the Strategic Planning Unit of Health Interventions (17).

Costa Rica's emphasis on strategic plan- ning focuses on the needs of its indige- nous population. WHO reports stated workforce data distribution supporting a total of 3 653 nursing personnel, and a nurse/midwife-to-population ratio of 9.3 : 10 000 (10, 41). The MOH report, Primer Foro Nacional de Salud de los Indígenas, details the steps to provide health services to the remote Chirripo Indigenous territories, a population where most individuals (68.8%) are consistently unable to gain access to primary health care. The MOH, Social Security Fund, and the National Commission for Indigenous Affairs specifically decided to train indigenous volunteers for delivery of health services in the Chirripo territories (42).

Costa Rica has identified a national strategic plan, a CNO, and an indigenous pipeline to promote workforce development. Collective strategies have created a unique vision to promote health care delivery, combining rural-university partnerships and educators in the field. Government policies and resource distribution must reinforce such efforts for maintenance. Innovative project proposals are required for implementation of policy changes.

Peru. There was no publicly-available national nursing strategy for Peru found at the time of this review. However, the MOH had joined with the Ministry of Labor (MOL) to propose ideas to improve the nursing workforce environment. Ministerial Resolution No. 849-2012 (43) proposes and implements a nursing remuneration scale that can be fiscally supported. This Resolution formed a working committee with the Federation of Nurses and the Director of Human Resource for Health Development of the Peru MOH (MINSA) (43).

Peru has a population of more than 29 million, with a nurse/midwife-to-population ratio of 1.27 :1 000 (44). The highly urbanized population presents challenges in distribution, as the nursing workforce is assigned according to city, jungle, and coastal settings (3). In areas where physicians are scarce, nurses provide the majority of necessary health care services.

The Peru MOL reported nursing staff to be underutilized by 12%. Nurses must be present in leadership to influence administrative decisions. Workforce development efforts tackle disparities in levels of higher education with innovative policies. Even large cities, such as Lima, report only 8.3% of female staff with tertiary degrees in nursing (45). The impact of shortages is evidenced by overwhelming pressures to maintain suf- ficient infrastructure and balance work-load. Dissatisfaction in professional roles persists as well. Care providers recently went on strike regarding work conditions and remuneration in 2013 (46). Unfortunately, demands to regulate salaries, prepare faculty, and promote interdisciplinary models for care impede prog- ress (47).

The Government of Peru has recognized the value of collaborating across international borders. Joint programs engage in distance education to provide a bilingual 6-week online course (14). The use of online education presents an immense opportunity.

Peru faces challenges to improve its nursing workforce development. The country has experienced an economic boom in recent years, with a gross domestic product exceeding 5% (6.2%) in 2012 (2). This growth underscores its developments to improve health resources. Commitments to innovative education partnerships, expansion of programs availability, and encouragement of advanced nursing degrees are promising; however, the development of education accreditation standards is still a work in progress.

Argentina. The Argentine national nursing strategic plan is titled National Plan for Nursing Development (20). The document prioritizes the critical nature of nursing and human resources to health outcomes. The strategic plan incorporates quantifiable goals and an evaluative mechanism to track deliverables along with fiscal allocation. Goals highlight education and funding measures, such as primary care nursing training centers offered at public universities, and monitoring funds for scholarships, incentives, and professional activities, such as pension plans (20).

Literature from Argentina showcases a multidisciplinary approach to nursing workforce development. The use of in-service training serves an essential component in regard to improvement, management, and supervision (48). Yet, responses from undergraduate nursing students convey requests to supplement their training (49). Undergraduate accreditation standards require additional resources to ensure the quality of its overall nursing education.

There was no available data on the supply of nurses in Argentina; rather topics have focused on the dearth of nursing faculty. Sustained efforts included a special partnership with Loma Linda University (Loma Linda, California, United States), which provides an online Masters program with courses offered in English and Spanish. The one condition of the program requires that the international candidates serve as faculty in their home countries for a given length of time after graduation. The program's second cohort was composed of students from 13 countries; 45 of the 49 enrollees graduated from Loma Linda University's School of Nursing with a Master's Degree (16).

Argentina has developed a strong nursing national strategic plan with a CNO in its MOH. The national strategic plan emphasizes collaborative education, but available literature tends to highlight professional silos, by population (neonatal) or location (urban). Broader workforce assessments are required, particularly in rural areas. Development of strong workforce data metrics will aid collection of this information.

 

DISCUSSION

This review presents the fundamental nursing strategies of seven countries in the Region of the Americas available publicly in 2008-2013. It revealed that five of seven-Argentina, Canada, Costa Rica, Mexico, and the United States-had retrievable national nursing strategies. These countries, plus Jamaica, had CNOs in place within their MOHs.

Overall, these national nursing strategies prioritized multisectoral collaboration, professional competencies, and standardized educational systems. Argentina, Canada, Costa Rica, and the United States underscored necessary policies to align with workforce improvements that promote nursing leadership. Canada, Costa Rica, and the United States propose expanding the scope of practice to improve health care delivery among populations.

Argentina, Mexico, and the United States identified inefficient data management trackers for workforce supply and distribution. Suggestions for workforce development proposed the following: integrated partnerships among nurses in local communities (Argentina, Canada, and Costa Rica); in-service training (Argentina, Canada, Costa Rica, and the United States); and innovative methods, often using technology, in education and training (all seven countries).

Lastly, multisectoral stakeholders and governmental leadership must ensure that nursing advocates are available and vocal at every stage of planning, implementation, and evaluation. The Third Global Forum on Human Resources for Health, hosted by WHO and PAHO, was held in Recife, Brazil, on 10-13 November 2013. The assembly of leading experts in human and health resources crystalized the need to engage in further discussion and to partner to improve the global nursing workforce. Testimonies shared among the global nurses presented diverse, yet similar, themes with regard to the future of the nursing workforce. Pursuing UHC as the goal, nurses and midwives advocated to be present at the decisionmaking table: "[We] have a lot to offer, but we need to have much better data about [supply and distribution] and [workforce] capacity to respond to the changing needs of society" (50).

Limitations

Because the study included only seven select countries (out of 47) that span the PAHO Region of the Americas from north to south, generalizations should be made with this limitation in mind.

Methodology was initially just searches of available literature on PubMed and individual MOH websites, but was subsequently expanded to multiple search engines and national/international organization sites. Direct requests to the MOHs attempted to verify information retrieved on national strategies and chief nursing officers. Four of the seven countries lacked publicly-available information about nursing data on their MOH websites. It is possible that restricted-access limited the results to fewer sources than are actually available.

Lastly, keyword searches had to be translated into Spanish to retrieve documents from the MOH websites of Argentina, Costa Rica, Mexico, and Peru. Nursing terminology varies in diverse countries, addressing the categorical difference of "who is a nurse." Many academ- ic publications are only available in English, denying the opportunity of numerous quality manuscripts in their native language to become recognized. Given this underlying global discrepancy, the authors had limited resources to perform an extensive translation of documents found in their native language. Note none of the authors are native Spanish speakers.

Conclusions

Results suggest many obstacles hinder the ultimate goal of effective care delivery in the Region of the Americas. From regulation standards to the political climate, each country struggles with its own burden to prepare an efficient nursing workforce to meet population needs. Workforce development depends on proper leadership, multisectoral collaboration, and appropriate resources to educate, train, and empower nurses to be in the forefront. Despite seemingly overwhelming challenges, nurses can be advocates for universal health coverage. Evidence stemming from these countries in the Region of the Americas demonstrates the potential, efforts, and focus on improve nursing workforce development in order to provide safe, equitable, and quality health care.

For countries struggling to develop their own national nursing strategies, the PAHO/WHO program on HRH can offer technical guidance. Innovative strategies are underway to develop partnerships among countries in the Region, to share best practices, and to foster a culture of collaboration in the area of nursing HRH. For the next gen- eration to tackle impending challenges, multisectoral involvement and governmental will are needed to ensure that nurses are present and heard at every stage of planning, implementation, and evaluation to meet population demands with the goal of UHC around the globe.

Results suggest many obstacles hinder the ultimate goal of effective nursing care delivery in the Region of the Americas. From regulation standards to the political climate, each country struggles with its own burden to prepare an efficient nursing workforce to meet population needs. Workforce development depends on proper leadership, multisectoral collaboration, and appropriate resources to educate, train, and empower nurses to be in the forefront. Despite seemingly overwhelming challenges, nurses can be advocates for universal access to health and universal health coverage.

Conflicts of interest. None.

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 PAHO.

 

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Manuscript received on 31 October 2014.
Revised version accepted for publication on 6 April 2015.

 


ANNEX 1 - Click to enlarge

 

 


ANNEX 2 - Click to enlarge

 

Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org