Health Equity: 03/26/09

Thursday, March 26, 2009

[EQ] Coordination between primary and secondary healthcare in Denmark and Sweden

Coordination between primary and secondary healthcare in Denmark and Sweden

Sarah Wadmann, Research Assistant, Unit of Health Services Research, Department of Public Health, Faculty of Health Sciences, University of Copenhagen

Martin Strandberg-Larsen, PhD Fellow, Unit of Health Services Research, Department of Public Health, Faculty of Health Sciences, University of Copenhagen

Karsten Vrangbæk, Associate Professor, Department of Political Science, University of Copenhagen

International Journal of Integrated Care, Volume 9, 12 March 2009 - ISSN 1568-4156

Available online at: http://www.ijic.org/?000414

Introduction: Insights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, and discuss them in relation to interorganisational network theory.

Policy practice: The policy initiatives to improve collaboration between primary and secondary healthcare in Denmark and Sweden include legislation and agreements aiming at clarifying areas of responsibility and defining requirements, creation of links across organisational boarders. In Denmark many initiatives have been centrally induced, while development of local solutions is more prominent in Sweden. Many Danish initiatives target the administrative level, while in Sweden initiatives are also directed at the operational level. In both countries economic incentives for collaboration are weak or lacking, and use of sanctions as a regulatory mean is limited.

Discussion and conclusion: Despite a variety of policy initiatives, lacking or poorly developed structures to support implementation function as barriers for coordination. The two cases illustrate that even in two relatively coherent health systems, with regional management of both the hospital and general practice sector, there are issues to resolve in regard to administrative and operational coordination. The interorganisational network literature can provide useful tools and concepts for interpreting such issues.

Content:

Description of policy initiatives

Discussion of coordination weaknesses and policy strategies

Network structure

Suitability of coordination methods

* * *

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/ KMC 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
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] C=?iso-8859-1?Q?=E1ncer?= de mama: un reto para la sociedad y l os sistemas de salud

Cáncer de mama: un reto para la sociedad y los sistemas de salud

Suplemento especial de la Revista Salud Pública de México, del Instituto Nacional de Salud Pública

Cuernavaca, Morelos, México - Volumen 51, Suplemento 2 – Marzo del 2009

Disponible en texto completo en URL: http://bvs.insp.mx/rsp/anteriores/numero.php?year=2009&vol=51&num=2&tipo=suplemento

“………..El cáncer de mama constituye un problema de salud pública y es la primera causa de incidencia y mortalidad por cáncer en la mujer adulta en Latinoamérica y en el ámbito mundial. El cáncer mamario dejó de estar circunscrito a los países desarrollados y a mujeres con mayores recursos económicos, incluso ha desplazado al cáncer cervicouterino en varias regiones del mundo incluyendo Latinoamérica como primera causa de muerte por neoplasias malignas femeninas. Nos encontramos ante un problema de gran magnitud, poco reconocido como tal en la región, cuyo impacto rebasa la salud de la mujer en lo individual, y afecta a la pareja, a la familia, a la sociedad y al sistema de salud.

El volumen dimensiona el reto que representa el cáncer de mama para la salud, los sistemas de salud y la sociedad.
Está conformado en tres áreas principales:
- la perspectiva epidemiológica, que presenta, desde la óptica poblacional, el panorama de la enfermedad en términos de su magnitud y carga,
- sus tendencias a través del tiempo, y
- los factores de riesgo asociados a ella; el abordaje de los sistemas de salud, donde se discuten las barreras desde la demanda y la oferta.

Incluyendo la falta de infraestructura y recursos que condiciona un rezago en la detección oportuna, así como el tratamiento; y la participación de la sociedad civil a través de grupos organizados a nivel nacional e internacional, así como de la sociedad en su conjunto. .

Los sistemas de salud enfrentarán un enorme desafío, que ha sido ampliamente descrito en este número especial de Salud Pública de México que incluye 26 artículos originales y 2 testimonios, los cuales representan el trabajo de 70 autores de 22 instituciones de America Latina, Estados Unidos, Canadá y Europa.

El trabajo ofrece evidencia importante para motivar y comprometer el desarrollo de una respuesta y un enfoque integral que abarca los factores causales y de riesgo, la prevención, la detección y el tratamiento médico, además del impacto en la sociedad y en las mujeres y los hombres, las familias y las parejas que viven con la enfermedad…..”

Contenido

Sensibilización, detección temprana y combate a los prejuicios.
Claves en la lucha contra el cáncer de mama

Julio Frenk, Decano, Escuela de Salud Pública, Universidad Harvard. Boston, Massachusetts, EUA.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/editorial.pdf

Cáncer de mama: un reto para la sociedad y los sistemas de salud
Felicia Marie Knaul,⁽¹⁾ Lizbeth López Carrillo,⁽²⁾ Eduardo Lazcano Ponce,⁽²⁾ Héctor Gómez Dantés,⁽³⁾ Isabelle Romieu,⁽²⁾Gabriela Torres.⁽²⁾(1) Cáncer de mama: Tómatelo a Pecho y Observatorio de la Salud. Instituto Carso de la Salud
y Fundación Mexicana para la Salud. México. (2) Instituto Nacional de Salud Pública.
(3) Fundación Mexicana para la Salud, Observatorio de la Salud. México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/presen%20cancer.pdf

Global trends in breast cancer incidence and mortality

Peggy L. Porter, MD^. Divisions of Human Biology and Public Health Sciences. Fred Hutchinson Cancer Research Center.
Department of Pathology. University of Washington. Seattle WA, USA.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/1-mortality.pdf

Tendencias del cáncer de mama en América Latina y El Caribe
Rafael Lozano-Ascencio, MD, M en C^,(1,2,3) Héctor Gómez-Dantés, MD, M en C,⁽³⁾ Sarah Lewis, MSc,,
⁽³⁾ Luisa Torres-Sánchez, PhD,⁽⁴⁾ Lizbeth López-Carrillo, PhD.⁽⁴⁾

(1) Instituto para la Métrica y Evaluación en la Salud, Universidad de Washington. Seattle, Washington, Estados Unidos.
(2) Hospital Infantil de México, Federico Gómez. México, DF.
(3) Fundación Mexicana para la Salud, Observatorio de la Salud. México, DF.
(4) Instituto Nacional de Salud Pública, Dirección de Salud Reproductiva. Cuernavaca, Morelos, México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/2-Caribe.pdf

Breast cancer mortality in Mexico. An age-period-cohort analysis
Francisco Franco-Marina MC, MPH, MHSc,⁽¹⁾ Eduardo Lazcano-Ponce, Dr SP,⁽²⁾ Lizbeth López-Carrillo QBP, Dr PH.⁽²⁾
(1) División de Epidemiología. Instituto Nacional de Rehabilitación. México.
(2) Instituto Nacional de Salud Pública. México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/3-breast.pdf

Factores reproductivos y cáncer de mama: principales hallazgos en América Latina y el mundo
Gabriela Torres-Mejía, MD, PhD,(1) Angélica Ángeles-Llerenas, MD, MC.(1)
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/4-factores.pdf

The role of obesity, physical activity and dietary factors on the risk for breast cancer: Mexican experience
Isabelle Romieu, MD, MPH, ScD;⁽¹⁾Martin Lajous, MD, MS^.(1)
(1) Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/5-physical.pdf

Dieta y cáncer de mama en Latinoamérica Luisa Torres-Sánchez, DSP,
⁽¹⁾ Marcia Galván-Portillo, DrSP,⁽¹⁾ Sarah Lewis, MSc,⁽²⁾ Héctor Gómez-Dantés, MD, M en C,⁽²⁾ Lizbeth López-Carrillo, PhD.⁽¹⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/6-dieta.pdf

Screening for BRCA1 and BRCA2 mutations in breast cancer patients from Mexico: The public health perspective
Steven A Narod, MD.⁽¹⁾(1) Women’s College Research Institute, University of Toronto, Canada.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/7-screening.pdf

Bases genómicas del cáncer de mama: avances hacia la medicina personalizada
Alfredo Hidalgo-Miranda, PhD,⁽¹⁾ Gerardo Jiménez-Sánchez, MD, PhD^.(1)(1) Instituto Nacional de Medicina Genómica. México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/8-bases.pdf

Diferencias regionales en la mortalidad por cáncer de mama y cérvix en México entre 1979 y 2006
Lina Sofía Palacio-Mejía, D en Pobl,⁽¹⁾Eduardo Lazcano-Ponce, D en C,⁽²⁾Betania Allen-Leigh,
D en Antrop,⁽³⁾Mauricio Hernández-Ávila, D en C.⁽⁴⁾^{http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/9-diferencias.pdf}

Breast cancer: Why link early detection to reproductive health interventions in developing countries?
Felicia Knaul, PhD,⁽¹⁾ Flavia Bustreo, MD,⁽²⁾ Eugene Ha, MA,⁽³⁾ Ana Langer, MD.⁽⁴⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/10-countries.pdf

Breast cancer screening program in Canada: Successes and challenges
Verna Mai, MD, MHSc, FRCPC^,(1) Terrence Sullivan, PhD^,(1) Anna M. Chiarelli, PhD.⁽¹⁾(1) Cancer Care, Ontario, Canada.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/11-detection.pdf

Práctica de mastografías y pruebas de Papanicolaou entre mujeres de áreas rurales de México
Sandra G Sosa-Rubí, D en Econ, ⁽¹⁾ Dilys Walker, MD, PhD,⁽¹⁾ Edson Serván, M en Econ.⁽¹⁾(1) Instituto Nacional de Salud Pública. Cuernavaca, México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/12-mastografia.pdf

Equidad en el acceso al tratamiento para el cáncer de mama en Colombia
Ligia Constanza Velásquez-De Charry, MSc Epidemiol,⁽¹⁾Gabriel Carrasquilla, MD, DrPH,^(1,2)
Sandra Roca-Garavito, MD, MSc Epidemiol.⁽¹⁾^{(1) Centro de Estudios e Investigación en Salud (CEIS) de la Fundación Santa Fe de Bogotá.
(2) Facultad de Salud, Universidad del Valle. Cali, Colombia.}^{http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/13-equidad.pdf}

Recursos disponibles para el tratamiento del cáncer de mama en México
Este trabajo contó con el apoyo de la Red de Centros Estatales de Cáncer de México.
Alejandro Mohar MC, D en C,⁽¹⁾ Enrique Bargalló, MC,⁽²⁾ Ma. Teresa Ramírez, MC,⁽²⁾
Fernando Lara, MC,⁽²⁾ Arturo Beltrán-Ortega, MC.⁽²⁾(1) Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología de
México, Instituto de Investigaciones Biomédicas, UNAM.
(2) Instituto Nacional de Cancerología de México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/15-hospitales.pdf

Delay of medical care for symptomatic breast cancer: A literature review
Karla Unger-Saldaña, MD, MSc,⁽¹⁾ Claudia Infante-Castañeda, BS, MSc, DSc.⁽¹⁾(1) Facultad de Medicina de la Universidad Nacional Autónoma de México, Mexico City.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/16-delay.pdf

El costo de la atención médica del cáncer mamario: el caso del Instituto Mexicano del Seguro Social
Felicia Marie Knaul, PhD,^(1-3) Héctor Arreola-Ornelas, M en C,^(1,2) Enrique Velázquez, MD,⁽¹⁾
Javier Dorantes, Ing,⁽¹⁾ Óscar Méndez, Lic,^(1,2) Leticia Ávila-Burgos, PhD.⁽⁴⁾(1) Cáncer de mama: Tómatelo a Pecho y Observatorio de la Salud. Instituto Carso de la Salud y Fundación Mexicana para la Salud. México, DF.
(2) Competitividad y Salud, Fundación Mexicana para la Salud. México, DF.
(3) Programa Cáncer de Mama: Tómatelo a Pecho. Instituto Carso de la Salud. México, DF.
(4) Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/17-cancer.pdf

Costo-efectividad de políticas para el tamizaje de cáncer de mama en México
Atanacio Valencia-Mendoza, MCES,⁽¹⁾ Gilberto Sánchez-González, MCF,⁽¹⁾, Sergio Bautista-Arredondo, MCES,
⁽¹⁾ Gabriela Torres-Mejía, MCES,⁽²⁾ Stefano M Bertozzi, MD, PhD.^(3,4)(1) Dirección de Economía de la Salud, Instituto Nacional de Salud Pública.
(2) Dirección de Investigación en Enfermedades Cardiovasculares, Diabetes Mellitus y Cáncer, Instituto Nacional de Salud Pública.
(3) Centro de Investigación en Evaluación y Encuestas, Instituto Nacional de Salud Pública.
(4) Centro de Investigación y Docencia Económicas, Haas School of Business, UC Berkeley.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/17-cancer.pdf

Cancer in the world – a call for international collaboration
Mary K Gospodarowicz, MD,^(1,2,3) Eduardo Cazap, MD,(3,4) Alex R Jadad, MD.^(1,2)
(1) University of Toronto. Ontario, Canada.
(2) University Health Network. Toronto, Ontario, Canada.
(3) International Union Against Cancer. Geneva, Switzerland.
(4) Sociedad Latinoamericana y del Caribe de Oncología Médica. Buenos Aires, Argentina.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/19-world.pdf

Breast health global initiative (BHGI) outline for program development in Latin America
Benjamin O. Anderson, MD,⁽¹⁾ Eduardo Cazap, MD, PhD.⁽²⁾(1) Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
(2) International Union Against Cancer (UICC), Sociedad Latinoamericana y del Caribe de Oncología Médica, Buenos Aires, Argentina
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/20-initiative.pdf

Building a Latin American cancer patient advocacy movement: Latin American cancer NGO regional overview
Alessandra Durstine, MBA, MS,⁽¹⁾ Elizabeth Leitman, MPH, MIA.⁽²⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/21-building.pdf

Breast cancer advocacy: Changing perceptions
Ksenia P Koon, MS,⁽¹⁾ Tanya Soldak, MD,⁽²⁾ Julie R Gralow, MD,⁽¹⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/22-perceptions.pdf

El cáncer de mama en México: evolución, panorama actual y retos de la sociedad civil
María Elena Maza-Fernández ,⁽¹⁾ Elda Vecchi-Martini.⁽²⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/23-movement.pdf

Cáncer de mama en México: una prioridad apremiante*
Felicia Marie Knaul, PhD,^(1,2) Gustavo Nigenda, PhD,⁽³⁾ Rafael Lozano, MD, M en C,^(4,5,6)Héctor Arreola-Ornelas, M en C,^(2,6) Ana Langer, MD,⁽⁷⁾ Julio Frenk, PhD.⁽⁸⁾(1) Programa Cáncer de Mama: Tómatelo a Pecho y Observatorio de la Salud. Instituto Carso de la Salud y Fundación Mexicana para la Salud, México DF, México.
(2) Competitividad y Salud. Fundación Mexicana para la Salud. México, DF.(
3) Innovaciones en Sistemas y Servicios de Salud, Instituto Nacional de Salud Pública. Cuernavaca, México.
(4) Instituto para la Métrica y Evaluación en Salud, Universidad de Washington, Seattle. Washington, EUA.
(5) Hospital Infantil de México Federico Gómez. México DF, México
(6) Observatorio de la Salud: Instituto Carso de la Salud y Fundación Mexicana para la Salud. México. DF, México
(7) EngenderHealth, Nueva York. Nueva York, EUA.
(8) Decano, Escuela de Salud Pública, Universidad Harvard. Boston, Massachusetts, EUA.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/24-prioridad.pdf

Detección del cáncer de mama en México: síntesis de los resultados de la Encuesta Nacional de Salud Reproductiva
Lizbeth López-Carrillo, DSP^,(1) Leticia Suárez-López, DCPol y Soc^,(1) Luisa Torres-Sánchez, DSP.⁽¹⁾
(1) Centro de Investigación en Salud Poblacional. Instituto Nacional de Salud Pública, México.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/25-sintesis.pdf

Políticas públicas para la detección del cáncer de mama en México
Olga Georgina Martínez-Montañez, MC, MSP,⁽¹⁾ Patricia Uribe-Zúñiga, MC,⁽¹⁾ Mauricio Hernández-Ávila,MC, DC.⁽²⁾
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/26-politicas.pdf

Life in the balance: My journey with breast cancer*
This article was adapted from the original version published in The Globe and Mail, October 5, 2005.
Marla Shapiro, MD⁽¹⁾(1) Department of Family and Community Medicine, University of Toronto, Canada.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/27-testim%20A.pdf

Una mujer ante el cáncer de mama en México*
Este ensayo retoma los elementos de “I am a woman who lives with breast cancer”. Reproductive Health Matters 2008;16(32):133-138.1
Felicia Marie Knaul, PhD⁽¹⁾(1) Cáncer de mama: Tómatelo a pecho y Observatorio de la Salud. Instituto C so de la Salud y Competitividad y Salud, Fundación Mexicana para la Salud. México, D.F.
http://bvs.insp.mx/rsp/_files/File/2009/suplemento%202/28-testim%20B.pdf

* * *

    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] Investing in hospitals of the future

Investing in hospitals of the future

Bernd Rechel, Stephen Wright, Nigel Edwards, Barrie Dowdeswell, Martin McKee

World Health Organization 2009, on behalf of the European Observatory on Health Systems and Policies

Available online as PDF file [304p.] at: http://www.euro.who.int/Document/E92354.pdf

“……..Over the years, the hospital has evolved into the institution and buildings that we know and trust, through the advance of scientifi c medicine. Th ere have been revolutions in surgery (anaesthesia and asepsis), imaging (X-rays and magnetic resonance imaging (MRI)) and laboratory medicine (bacteriology and haematology), among many other fields. The locus of all these developments was the hospital, leading to its enormous significance today, although some activities are increasingly able to be carried out in other settings.

Hospitals are not only sites to provide health care: they carry out extensive programmes relating to research and development, education and training, and in their own right they are critical components of the urban fabric. Thus, although there are sure to be major evolutions in the nature and role of hospitals, the institutions themselves are unlikely to be displaced soon.

If only as a result of its importance as the place where scientific health care is focused, the hospital sector typically absorbs up to 50% of national expenditure on the health care system. This highlights the critical nature of the decision to invest capital in the construction of a hospital, given that this action commits society to a stream of future running costs which dwarf the original – already considerable – capital cost…..”

“…..Running through this book is the leitmotif of the critical nature of the model of care, explicit or perhaps even implicit, as a structure for the role of the hospital. “Form follows function”, and thus the shape and size of the hospital are determined by the services it tries to deliver. In planning a hospital, it is naturally the future demands that are most important, futures that are always uncertain because of unpredictable trends and technological developments.

Decision-makers should be aware that capacity is not usefully indexed simply by the number of beds, and space should be as “loose-fit” and flexible as can be designed and built. We can surmise that the more the underlying care processes can be systematized, the more efficiently and effectively flows of patients can be managed.

Perhaps inevitably, this volume raises more questions than it answers, and thus indicates a research agenda to come. ….”Philippe Maystadt President European Investment Bank

CONTENT

Part one: The changing context of capital investment

Chapter 1 Introduction: hospitals within a changing context Bernd Rechel, Stephen Wright, Nigel Edwards, Barrie Dowdeswell, Martin McKee

Chapter 2 New models of long-term care and implications for service redesign Pieter Degeling, Jonathan Erskine

Part two: Influencing capital investment

Chapter 3 Planning health care capacity: whose responsibility? Stefanie Ettelt, Martin McKee, Ellen Nolte, Nicholas Mays, Sarah Thomson

Chapter 4 Concept planning: getting capital investment right Knut Samset, Barrie Dowdeswell

Chapter 5 Capital investment and the health care workforce Bernd Rechel, James Buchan, Martin McKee

Part three: Economic aspects of capital investment

Chapter 6 Market competition in European hospital care Hans Maarse, Charles Normand

Chapter 7 Capital financing models, procurement strategies and decision-making Geert Dewulf, Stephen Wright

Chapter 8 Life-cycle economics: cost, functionality and adaptability Svein Bjørberg, Marinus Verweij

Chapter 9 Facility management of hospitals Kunibert Lennerts

Chapter 10 The economic and community impact of health capital investment Jonathan Watson, Simona Agger

Part four: Design issues

Chapter 11 Translating hospital services into capital asset solutions Bernd Rechel, Stephen Wright, Martin McKee

Chapter 12 Sustainable design for health Rosemary Glanville, Phil Nedin

Part five: Conclusions

Chapter 13 Conclusions and critical success factors Bernd Rechel, Stephen Wright, Nigel Edwards, Barrie Dowdeswell,Martin McKee

The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Offi ce for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the World Bank, the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine.

* * *

    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.