1. Identified Challenges

The principal challenges revolve around the risk of erosion of existing strengths, inadequate financial sustainability, and structural fragmentation.

Risk of Erosion and Underutilization

• There is a risk that, in the context of ongoing geopolitical changes, effective elements may be weakened or eliminated during reform processes for multiple reasons, such as the absence of clear systematization.
• There is a tendency to underestimate or inadequately value existing systems that perform effectively.
• Current strengths are neither well-documented nor disseminated as regional best practices, reflecting a lack of systematic recording of successful experiences.
• Some regional cooperation centers possess extraordinary capacities but are not being fully utilized as regional hubs.

Financing and Sustainability

• Regional technical cooperation requires stronger and more sustainable funding.
• A substantial reduction in cooperation flows across Latin America has been reported, threatening functioning systems.
• As middle-income countries, the region is not “attractive” enough to global donors, who tend to focus on Africa and Asia: “we are not poor enough to attract their attention, nor rich enough not to need it.”
• Successful programs face declining funding; for instance, European Union financing has drastically decreased in some countries.
• Successful programs face declining funding; for instance, European Union financing has drastically decreased in some countries.

Fragmentation and Governance

• There is a multiplicity of uncoordinated actors with diverse funding sources, overlapping mechanisms, and vertical programs poorly integrated into national health systems.
• Each donor has its own priorities, generating “duplicated agendas” and “administrative overload for national officials.”
• Tensions persist between technical and political decision-making, as became evident during the COVID-19 pandemic.
• Although PAHO’s longstanding and historical technical expertise is widely valued, there is no consensus regarding (1) its resilience capacity, (2) whether it should lead reform, or (3) whether it should itself be the subject of reform.

2. Identified Proposals

There is broad agreement that the strategy should improve and strengthen what already works before creating new structures

Preserve and Optimize Technical and Financial Mechanisms

• Maintain PAHO’s technical assistance, widely recognized for its historical achievements. Its technical capacity should be preserved while other aspects are enhanced.
• Protect and strengthen PAHO’s Revolving and Strategic Funds. It is proposed that these mechanisms be expanded to include essential medicines, medical technologies, and other critical supplies. This could be achieved through “financial re-engineering to provide guarantees” and by increasing the number of suppliers to “commoditize” prices.
• Strengthen regional biological production capacities (e.g., Bio-Manguinhos in Brazil and Sinergium in Argentina) and develop similar capabilities in other countries to reduce external dependency.
• Support the work of NGOs (such as Partners in Health) that operate in countries and with vulnerable populations.

Strengthen Installed Regional Capacity

• Identify and strengthen national “centers of excellence” to serve as regional nodes for technical cooperation.
• Establish a formal network of regional reference centers in specialized areas.
• Maintain and enhance ORAS-CONHU (Andean Health Organization) as a participatory governance model where countries have a direct voice in decision-making.
• Preserve successful regional procurement models such as those of the OECS (Organization of Eastern Caribbean States), COMISCA (Council of Ministers of Health of Central America and the Dominican Republic), and MERCOSUR, which have reduced costs through economies of scale.
• Promote and strengthen South-South cooperation by assigning it a more prominent role to leverage successful experiences within the region.
• Encourage certain public-private partnerships, accompanied by declarations of non-conflict of interest and clear monitoring mechanisms.

Improve Efficiency and Governance

• Consider adopting the Cuernavaca Declaration¹ of the Latin American Alliance for Global Health (ALASAG), which seeks to give voice to universities and member institutions in academic and policy fora at international, national, and local levels, as a framework for regional cooperation.
• Enhance coordination among existing actors (IDB, World Bank, PAHO, CAF) rather than creating new institutions, emphasizing those that have proven effective (e.g., the Primary Health Care Alliance in the Americas).

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¹Alasag, Tobar, S., Marchiori-Buss, P., Lazcano-Ponce, E., Guerra, G., Alarcón-Heim, Álex, Dal Poz, M. R., Solimano, G., Ribeiro, H., Marques-Di Giulio, G., de Freitas-Lima Ventura, D., Sáenz-Madrigal, R. ., Tuesca-Molina, R., Vargas-Peña, G. S., Guerrero-Espinel, J. E., García, P. J., Iguiñiz-Romero, R., & Salgado-de Snyder, N. (2025). Declaración de Cuernavaca de la Alianza Latinoamericana de Salud Global. Salud Pública De México, 67(3 (may-jun), 299-301. https://doi.org/10.21149/16938

3. Areas of Convergence and Tension

The discussion on preserving what works reveals strong consensus regarding the technical value of regional institutions, but also significant tensions concerning governance and sustainability.

Convergences

• Value of Technical Cooperation: Consensus exists on the importance of PAHO’s technical cooperation, access to technical expertise, and the role of regional institutions such as PAHO, ORAS-CONHU, IDB, and CAF.
• Financial Mechanisms: Broad agreement on the need to preserve, maintain, and expand PAHO’s revolving funds and other pooled procurement mechanisms.
• Regional Capacity: Wide recognition of the need to identify and strengthen existing regional capacity (e.g., centers of excellence, biological production).
• Successful Models: Recognition of the success of regional immunization programs, primary health care strategies, and the need for robust surveillance systems.
• Approach to Reform: General agreement that this is not the time to dismantle the existing “architecture”, but rather to reduce duplication and fragmentation while preserving effective components.

Tensions

• Institutional Architecture: Tension between those advocating reform of existing institutions (e.g., PAHO) and those proposing the creation of new regional structures.
• Role of PAHO: While its technical expertise is historically valued, questions persist about its role, governance, and whether the organization itself should be reformed. Some favor its integration with ministries of health, while others argue it should operate “at arm’s length” to ensure independence.
• Technical vs. Political Balance: Debate continues over the extent to which technical institutions should engage in politically sensitive positions
• Sustainability and Autonomy: Functioning systems are threatened by declining funding. A persistent tension exists between reliance on international cooperation and the need for national ownership of successful programs.
• Private Sector Engagement: Divergent views exist on public-private collaboration, some see it as beneficial (e.g., vaccine technology transfer), while others express concern over potential conflicts of interest.
• Regionalism vs. National Sovereignty: A structure that is too weak risks irrelevance, while one that is too powerful may be perceived as a threat to national autonomy. The most viable proposal points toward a flexible and cooperative structure with horizontal governance and equitable representation, in which countries retain political control while sharing technical and informational capacities.

4. Proposed Questions for Working Groups (select the questions that better allies to the group objectives)

The following key questions, drawn from the reviewed documents, are proposed to guide the reform working groups:

Main Questions

1. What other regional initiatives should be preserved because they function well and generate tangible benefits for the population but were not considered in this summary?
2. What modifications should be implemented to improve their performance, institutionalize them, or ensure their sustainability within the region?
3. Which of these effective initiatives are most relevant for positioning the region in global debates with greater engagement and influence?

 

Other (Optional questions)

On Identifying and Preserving Strengths

• Which specific mechanisms within the current architecture have demonstrated the greatest effectiveness and should be preserved unchanged?
• How can we document and systematize regional “best practices” to ensure their preservation throughout the reform process?
• What evaluation mechanisms are needed to distinguish what should be preserved from what should be reformed?
• How can countries more effectively share successful experiences across the region?
• How can we ensure that reducing duplication does not inadvertently eliminate programs that are functioning well?

On Institutional Reform and Governance

• What criteria should guide decisions to reform an existing institution versus creating a new one?
• How can the technical capacity of institutions such as PAHO be preserved regardless of governance reforms?
• Which specific features of ORAS-CONHU could be replicated in other regional institutions?
• What institutional changes are needed to protect functioning systems during processes of global architectural reform?
• How can we ensure that effective elements do not depend excessively on specific personalities but are instead fully institutionalized?

On Financing and Scaling

• How can sustainable financing be secured for programs and systems that have demonstrated effectiveness (immunization, primary health care, surveillance, regional procurement)?
• How can we preserve and optimize PAHO’s revolving funds without allowing them to become inflexible or captured by a few suppliers?
• How can the Revolving Fund model be scaled to other products and services without losing effectiveness?
• How can successful models such as PANCAP or the OECS procurement system be scaled across Latin America more broadly?
• What incentives can encourage countries to invest in maintaining what works?

On Cooperation and Partners

• Which successful South–South cooperation models from other regions can inform strengthened cooperation in Latin America?
• What role should South–South cooperation play, and how can it be better institutionalized?
• What role should national centers of excellence play within a strengthened regional architecture?
• What role should the private sector have in preserving and enhancing effective cooperation mechanisms?
• How can national ownership of successful programs currently dependent on international cooperation be reinforced to reduce vulnerability to fluctuations in external funding?
• How can lessons learned during COVID-19 about rapid response and coordination be institutionalized?