Health Equity: November 2007

Wednesday, November 21, 2007

[EQ] Public Health Capacity in Latin America and the Caribbean

Public Health Capacity in Latin America and the Caribbean: Assessment and Strengthening

Pan American Health Organization - PAHO/WHO
Area of Health Systems Strengthening - Health Policies and Systems Unit - 2007

Available online PDF [80p.] at: http://www.lachealthsys.org/index.php?option=com_docman&task=doc_download&gid=372

“….This document was developed based on an in-depth literature review. Sources included country assessments, journal articles, survey data, publications, international cooperation documents and national policy documents in English, Spanish and Portuguese. While the literature review was comprehensive, the paper could have benefited from additional grey literature from the countries in the Region, which can be difficult to locate and obtain since it is not widely disseminated. One of the goals of circulating this paper is the identification of additional examples of strategies and interventions for monitoring, evaluating and strengthening public health capacities by the countries at the national and sub-national levels.

In the first section of the document, the concepts and definitions of public health and the relationship between public health systems and health care systems are discussed. In addition, the rationale for using the term Public Health PH capacity instead of Public Health PH infrastructure is addressed.
The second section describes each of the elements of PH capacity in detail, outlines existing weaknesses, and identifies some strategies for strengthening and organizing PH capacities in the LAC Region.
The third section of the document discusses the application of several assessment tools developed by PAHO, WHO and other institutions in which the authors propose as inputs for assessing the current status of PH capacities.

The PH capacities as reflected in the literature and selected for this document are:

Public Health Workforce (PHWF) includes all workers whose primary responsibility is the provision of non-personal health services (core public-health). The PHWF can be divided in two categories: primary workforce including workers who are specifically in charge of public health activities or that hold job positions in public health; and secondary workforce, or those workers outside the health sector, usually from other ministries such as agriculture, transportation and education, international organizations and NGOs which also carry out public health activities.

Public Health Information Systems (PHIS) are defined as population-based and public health facility-based data sources. The main population-based sources of health information are census, household surveys and vital registration systems. The main public health facility-related data sources are public health surveillance, and data from the public health system and services, including systems for monitoring the PHWF, the allocation of financial resources, and public health technologies.

Public Health Technologies (PHT) include all of the physical resources and technologies used in the public health system, in addition to drugs and vaccines. These elements constitute the material foundation of the public health sector. They can also include equipment and medical devices, and support systems that allow the public health system to function adequately, such as public health laboratories, blood banks, etc.

Public Health Institutional and Organizational Capacity. Institutional capacity refers to the set of rules and norms that govern the functioning and operation of a public health system; it also determines the capability of the system to respond to public health challenges. Organizational capacity refers to an organization’s ability to effectively, efficiently and sustainably exercise its functions to contribute to the institutional mission and vision, and to the policies and strategic objectives of the organization. Organizational capacity is a component of institutional development and refers to the configuration/structure of organizations with a public health focus that function within a given institutional framework.

Public Health Financial Resources refers to the collection, utilization, and management of resources to carry out public health activities as well as the impact of these resources on the health of the population and the public health system…..”

Table of Contents

EXECUTIVE SUMMARY

PREFACE

I. INTRODUCTION
II. METHODS

III. KEY CONCEPTS AND DEFINITIONS

IV. ELEMENTS OF PUBLIC HEALTH CAPACITY

V. FROM CONCEPTUALIZATION TO OPERATIONALIZATION: ASSESSING THE STATUS OF THE PUBLIC HEALTH CAPACITY IN THE LAC REGION

VI. CONCLUSION

VII. ANNEX I – STRENGTHENING PH CAPACITY: COUNTRY EXPERIENCES

VIII. ANNEX II - IHR CORE CAPACITIES

IX. BIBLIOGRAPHY

* * * *

This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKM Area]

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
---------------------------------------------------------------------------------------------------

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] Social protection in health schemes for mother, newborn and child population

Social protection in health schemes for mother, newborn and child population:
lessons learned from the Latin American Region

Pan American Health Organization - PAHO/WHO
Area of Health Systems Strengthening - Health Policies and Systems Unit - 2007

Available line PDF [177p.] at: http://www.lachealthsys.org/index.php?option=com_docman&task=doc_download&gid=386

“…….The availability of comprehensive reproductive and child health care remains an unrealized goal in most of the world, and some countries have actually experienced stagnation or even reversals in their maternal and child health indicators (WHO, 2005). This reality has prompted policymakers and international cooperation agencies to focus on the implementation of different mother, newborn and child health protection schemes in order to improve access to care for these populations.

Although the impact of many of these interventions on health processes and outcomes is well-documented in the LAC Region, further comparative analysis is needed to identify lessons learned and to understand the role these interventions play in the broader institutional setting of existing health systems and their relationship with social determinants of health such as socio-economic status, gender, and ethnicity.

A cross-sectional descriptive analysis based on a literature/internet review and secondary sources was carried out. Seven social protection health schemes were analyzed.

This report argues that the improvement of mother, newborn, and child health can only be achieved through a holistic approach, combining interventions that address social, economic, cultural, age related and ethnic barriers to accessing health care. This multifaceted approach must be based on a long-term societal and political agreement…..”

“…..Selected schemes were grouped into different types according to the three components of social protection:

a. Health care coverage

b. Population coverage

c. Financial protection/Solidarity in financing

For the first dimension, health coverage, the following parameters were selected:

1. Degree of coverage - i.e. whether the benefits/services portfolio is comprehensive, complementary, or supplementary

2. Existence of a portfolio of entitlements

3. Type of provision

For the second, population coverage, the following parameters were chosen:

1. Degree of selectivity, i.e. whether the SPHS is universal or targets a specific group;

2. Population entitled to coverage

3. Conditions for access

4. Size of the risk pool

Concerning the third dimension, the following parameters were used:

1. Mode of financing

2. Source of funding

3. Type of risk pooling arrangement9

4. Resources management and management level - who manages the resources and at what government level the resource management is carried out….”

Content:

Executive Summary

1. Introduction

2. Background

3. Conceptual Framework

3.1) Description of the Social Protection in Health Schemes (SPHS) currently in place in the region

3.2) Analysis of the strengths and weaknesses of the SPHS

4. Analytical Framework

5. Case Studies

5.1) Universal Mother & Child Insurance (Bolivia)

5.2) The Family Health Program (Brazil)

5.3) Mother & Child Social Health Protection Policy (Chile)

5.4) Free Maternity and Child Care Law (Ecuador)

5.5) Mother and Child Voucher (Honduras)

5.6) OPORTUNIDADES Program (Mexico)

5.7) Integrated Health Insurance (Peru)

6. Results

7. Discussion and Lessons Learned

References

* * * *

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] Analyzing Health Equity Using Household Survey Data Analyzing: A Guide to Techniques and Their Implementation

Analyzing Health Equity Using Household Survey Data Analyzing: A Guide to Techniques and Their Implementation

Owen O'Donnell, Eddy van Doorslaer, Adam Wagstaff, and Magnus Lindelow

WBI Learning Resources Series - Published by the World Bank - 2007

Available online PDF [234p.] at:
http://siteresources.worldbank.org/INTPAH/Resources/Publications/459843-1195594469249/HealthEquityFINAL.pdf

“….Health equity has become an increasingly popular research topic during the course of the past 25 years. Many factors explain this trend, including a

growing demand from policymakers, better and more plentiful household data, and increased computer power. But progress in quantifying and understanding health equities would not have been possible without appropriate analytic techniques.

These techniques are the subject of this book. The book includes chapters dealing with data issues and the measurement of the key variables in health

equity analysis (Part i), quantitative techniques for interpreting and presenting health equity data (Part ii), and the application of these techniques

in the analysis of equity in health care utilization and health care spending (Part iii). The aim of the book is to provide researchers and analysts with a

step-by-step practical guide to the measurement of a variety of aspects of health equity, with worked examples and computer code, mostly for the computer

program Stata.

It is hoped that these step-by-step guides, and the easy-to-implement computer routines contained in them, will help stimulate yet more research in the field, especially policy-oriented health equity research that enables researchers to help policymakers develop and evaluate programs to reduce health inequities….”

Download: Complete Book (PDF 6.42MB)

Table of Contents (PDF 58kb)

Ch. 1: Introduction (PDF 119kb)

Ch. 2: Data for Health Equity Analysis: Requirements, Sources and Sample Designs (PDF 159kb)

Ch. 3: Health Outcome #1: Child Survival (PDF 107kb)

Ch. 4: Health Outcome #2: Anthropometrics (PDF 1.05MB)

Ch. 5: Health Outcome #3: Adult Health (PDF 156kb)

Ch. 6: Measurement of Living Standards (PDF 188kb)

Ch. 7: Concentration Curves (PDF 134kb)

Ch. 8: The Concentration Index (PDF 176kb)

Ch. 9: Extensions to the Concentration Index: Inequality Aversion and the Health Achievement Index (PDF 132kb)

Ch. 10: Multivariate Analysis of Health Survey Data (PDF 188kb)

Ch. 11: Nonlinear Models for Health and Medical Expenditure Data (PDF 194kb)

Ch. 12: Explaining Differences Between Groups: Oaxaca Decomposition (PDF 166kb)

Ch. 13: Explaining Socioeconomic-Related Health Inequality: Decomposition of the Concentration Index (PDF 95.5kb)

Ch. 14: Who Benefits from Health Sector Subsidies? Benefit Incidence Analysis (PDF 177kb)

Ch. 15: Measuring and Explaining Inequity in Health Service Delivery (PDF 123kb)

Ch. 16: Who Pays for Health Care? Progressivity of Health Finance (PDF 154kb)

Ch. 17: Redistributive Effect of Health Finance (PDF 78.9kb)

Ch. 18: Catastrophic Payments for Health Care (PDF 134kb)

Ch. 19: Health Care Payments and Poverty (PDF 107kb

* * * *

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] Impact Monitoring and Evaluation Framework: Background and Assessment Approaches

Impact Monitoring and Evaluation Framework: Background and Assessment Approaches

Australian Government’s Cooperative Research Centres (CRC) Association, 2007

Available online PDF [56p.] at: http://www.crca.asn.au/resource_materials/CRCA_Economic_Impact_Guide.pdf

The monitoring and evaluation framework consists of three parts:

1.      a paper describing the background and approaches informing the monitoring and evaluation model;

2.      a set of templates for inputs, activities, outputs, usage and impact that have been filled out with data from a hypothetical all sectors and

3.      a set of templates which can be used by CRCs in planning and carrying out data collection, and in organising this information to produce consistent statements about impact.

This discussion paper will provide a general overview of the approach to monitoring and evaluation – the input to impact chain – and the implications of this model for the Australian Government’s Cooperative Research Centres (CRC) Association

Content:

Overview of impact assessment
1.1 Project background and purpose
1.2 Overview of benefit channels
1.3 Key challenges in measuring impact
2 Framework for assessment
2.1 Impact evaluation model overview
2.2 The key features of an impact evaluation model
3 Adapting the assessment framework
4 Implications for framework
4.1 General monitoring and evaluation issues
4.2 Use of the framework
4.3 Adapting the framework
Appendix A
Sampling issues

Download the Economic Impact Analysis Guidebook

·         Guide [430 KB PDF file]

Templates [100 KB Excel file]

*      *      *     *

This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKM Area]

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
---------------------------------------------------------------------------------------------------

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health

Income redistribution is not enough:
income inequality, social welfare programs, and achieving equity in health

Barbara Starfield, Johns Hopkins University, Baltimore, Maryland, USA
Anne-Emanuelle Birn, Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Ontario, Canada

Journal of Epidemiology and Community Health - December 2007;61:1038-1041; doi:10.1136/jech.2006.054627

Abstract: http://jech.bmj.com/cgi/content/abstract/61/12/1038

Income inequality is widely assumed to be a major contributorto poorer health at national and subnational levels. Accordingto this assumption, the most appropriate policy strategy toimprove equity in health is income redistribution.

This paperconsiders reasons why tackling income inequality alone couldbe an inadequate approach to reducing differences in healthacross social classes and other population subgroups, and makesthe case that universal social programs are critical to reducinginequities in health. A health system oriented around a strongprimary care base is an example of such a strategy.

Correspondence to:
Barbara Starfield, Johns Hopkins University, 624 North Broadway, Room 452, Baltimore, Maryland, USA; bstarfie@jhsph.edu

* * * *

This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKM Area]

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
---------------------------------------------------------------------------------------------------

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] Assessing Alternative Financing Methods for the Canadian Health Care System

Assessing Alternative Financing Methods for the Canadian Health Care System
in View of Population Aging

Doug Andrews
SEDAP Research Paper No. 224, November 2007
The Program for Research on Social and Economic Dimensions of an Aging Population (SEDAP) is an interdisciplinary research program centred at McMaster University

Available online PDF [50p.] at: http://socserv.socsci.mcmaster.ca/sedap/p/sedap224.pdf

The cost of the Canadian health care system is approximately 10% of Gross Domestic Product (GDP). Survey-evidence suggests that Canadians do not wish to have additional funds spent on health care but believe that the system should be able to deliver better quality care. Due to low fertility rates and increasing life expectancy, the Canadian population is aging. Over the next 25 years, the dependency ratio will increase, primarily due to the aging of the “baby boom generation”

This will place twofold cost pressures on governments responsible for maintaining the health care system:

• As a consequence of increased life expectancy, on average, Canadians will have a longer period of health care consumption. Although age-specific cost may not increase, with an aging population aggregate annual health care expenditures are expected to increase.

• The dependency ratio is a proxy for the ability of the population to support itself. The increasing dependency rate may result in a slowdown in GDP growth, given constant technology.

In Section I, this paper attempts to quantify these factors. A single measure combining cost and quality is developed to demonstrate the magnitude of the challenge.

In Section II, this paper examines a number of different approaches to health care financing including user fees and alternative compensation methods for physicians. The paper highlights documented information from Canada and international experience on the implementation issues involved. The paper evaluates the desirability of implementing these approaches in Canada.

Content

ABSTRACT
INTRODUCTION

SECTION I - HEALTH CARE COST PROJECTIONS

• Current Cost of Health Care
• Projected Canadian Health Care Costs - 2031
• Other Writers’ Analyses
• Considerations Regarding The Productivity Growth Assumption.

SECTION II - DEMAND MANAGEMENT THROUGH FINANCING

• Health System Performance
• Supplier-induced Demand (SID
• Cost Sharing
• Alternative Physician Reimbursement Models

CONCLUSION
APPENDIX A – MODEL ASSUMPTIONS AND METHODS
ENDNOTES
REFERENCES / BIBLIOGRAPHY.

* * * *

This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKM Area]

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
---------------------------------------------------------------------------------------------------

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

Tuesday, November 6, 2007

[EQ] The Role of Civil Society in Promoting Health Equity

Civil Society Report - First Draft

World Health Organization - Commission on the Social Determinants of Health
June, 2007

Available online as PDf file [107p.] at: http://www.who.int/social_determinants/resources/cs_rep_2_7.pdf

“……Various definitions of civil society have been attempted. The London School of Economics Centre for Civil Society working definition is illustrative14:
“Civil society refers to the arena of uncoerced collective action around shared interests, purposes and values. In theory, its institutional forms are distinct from those of the state, family and market, though in practice, the boundaries between state, civil society, family and market are often complex, blurred and negotiated. Civil society commonly embraces a diversity of spaces, actors and institutional forms, varying in their degree of formality, autonomy and power. Civil societies are often populated by organisations such as registered charities, development nongovernmental organisations, community groups, women's organisations, faith-based organisations, professional associations, trade unions, self-help groups, social movements, business associations, coalitions and advocacy groups”.

….However, such conventional definitions of Civil Society do not seem to be able to capture the complex nature of Civil Society. A more rounded understanding of Civil society needs to take into account not only its variegated nature but also the fact that Civil Society operates in a contested space….”

Table of Contents

1. Civil Society and the Commission on Social Determinants of Health: Vision, Experiences and Values

1.1. Introduction: Historic Mission before the Commission

1.2. Two Imperatives for the Commission to Inform its Analysis and Recommendations

1.2.1 Remembering Alma Ata and the Primary Health Care Approach

1.2.2 Understanding the Role of Neoliberal Globalisation

1.3 Civil Society’s Expectations of the Commission on Social Determinants of Health

1.4 Locating Civil Society Roles, Actions and Concerns

1.4.1 What do we mean by Civil Society?

1.4.2 Role of Civil Society in Health

1.4.3 Civil Society Actions in Shaping Health Policies

1.4.4 Factors Shaping Civil Society Action and Knowledge

1.5 Civil Society Values

1.5.1 Towards a Rights Based Approach to Health

1.5.2 Empowerment for Health

2. Civil Society’s Work with the CSDH

3. Civil Society Positions on Key Determinants

3.1 Globalisation

3.2 Health Systems and Approaches to Health Care

3.3 Gender Dimensions of Health

3.4 Employment Conditions

3.5 War and Militarisation

3.6 Nutrition and Food Security

3.7 Urbanisation, urban settings and health equity

4. Case Studies on CS Actions and Concerns on Social Determinants of Health

4.1 Revival of Maya medicine in Guatemala and Impact on Social and Political Recognition.

4.2 Health System in Cuba

4.3. The Brazilian Health Care System

4.4. The Impact of Conflict on Health

4.5 The contribution made by Women's and Feminist Movements to Equity in Health: the Chilean experience

4.6 Case Study Based on Focus Group Discussion with Sudanese Refugees in Egypt

4.7. Right to Health Care Campaign of the Peoples Health Movement

4.8 Adult Literacy in a Campaign Mode: The Total Literacy Campaign in India

4.9 Female Genital Mutilation in Sub Saharan Africa: Violation of Women’s rights.

4.10 How Conflict, War and Sexual Violence have affected Social Determinants of Health in the Democratic Republic of Congo

5. Conclusions

Annexure I: Existing Covenants Relating to Right to Health

Annexure II: Summary of Civil Society work with the CSDH in different regions

- Asian Region

- Latin America

- Eastern Mediterranean

Case studies on the role of civil society in promoting health equity

Health and autonomy: the case of Chiapas (in Mexico)
Cuevas JH. (2007) Full text (English) [pdf 153kb] | Full text (Spanish) [pdf 140kb]

Civil society participation in programme implementation for intersectoral action on health equity and intersectoral
action for health: a case study of the Health Civil Society Network in East and Southern Africa
Musuka G, Chingombe I. (2007) Full text [pdf 78kb]

The contribution made by women’s and feminist movements to equity in health: the Chilean experience
Nazarit PS. (2007) Full text (English) [pdf 173kb] | Full text (Spanish) [pdf 159kb]

Civil society and health system in Cuba
Ochoa FR, Visbal LA. (2007) Full text (English) [pdf 120kb] | Full text (Spanish) [pdf 110kb]

Revival of Maya medicine and impact for its social and political recognition (in Guatemala)
Peren HI. (2007) Full text (English) [pdf 147kb] | Full text (Spanish) [pdf 151kb]

Civil society promotion of equity and the social determinants of health through involvement in the
governance of health systems: the case of the Community Working Group on Health in Zimbabwe
Rusike I. (2007) Full text [pdf 77kb]

* * * *

PAHO/WHO Website: http://www.paho.org/

EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.