1. Identified Challenges

The identified challenges focus on the structural limitations of existing institutions, the fragmentation of the cooperation architecture, and issues of accountability and legitimacy.

Institutional Limitations of PAHO/WHO

There is a perception that PAHO, given its institutional relationship with regional governments, is excessively subordinated to them, limiting its autonomy to act and to offer technical dissent when political decisions ignore evidence.

Other limitations include:

• Bureaucratic inertia and obsolescence: Institutions created under frameworks from 1945 are perceived as having limited capacity to rethink themselves to face 21st-century challenges.
• Duplication and “Unnecessary” Offices: It is mentioned that there is duplication of efforts and suggestions that PAHO “no longer needs so many country offices” in Latin America.
• Burocracia: Críticas a los funcionarios de carrera que influyen en la sucesión interna
• Disproportionate U.S. influence: The location of PAHO in Washington, D.C., generates strong U.S. influence, leading interviewees to question to what extent PAHO represents regional interests.
• Unfulfilled key functions: PAHO/WHO have not assumed crucial roles in the harmonization of human resources and technology registration.
• Limited engagement with other actors: Beyond the framework of Collaborating Centers, PAHO does not open space to other actors (academia, NGOs, private sector, etc.).

Coordination Challenges and Fragmentation

The global and regional health system continues to show signs of fragmentation, with a wide variety of regional platforms—such as MERCOSUR, the Andean Community, and PROSUR—that have had mixed results in health integration.

• Lack of complementarity: Multiple donor organizations work in the same geographic areas without effective coordination. There is duplication of efforts that requires restructuring.
• Independent Agendas: International organizations tend to operate based on their own agendas or those of their funders, rather than responding to the real needs of countries.
• Regional Disconnection: In the Caribbean, there is a significant gap between the CARICOM Secretariat and technical institutions such as CARPHA.
• Parallel Agendas: The existence of overlapping agendas from regional organizations that crosscut national priorities fragments and can distort public policy.

Governance, Legitimacy, and Accountability Problems

• Lack of accountability: There are no clear mechanisms for global institutions to be accountable to regional countries. Accountability cannot thrive without strong data and information systems.
• Excessive politicization: WHO is perceived as having become “more political than anything else.”
• Undue private sector influence: The private sector has dominated discussions and influenced public health policy—for example, on front-of-package labeling—even undermining technical advice from PAHO and CARPHA. Politicians often receive campaign funds from these companies, creating conflicts of interest.

Relationship with Countries

• Local disconnection and paternalism: There is a disconnect between the health system and realities on the ground. Institutional paternalism often replaces the leadership that should lie with national systems, weakening long-term development.
• Loss of regional voice: The region loses leadership capacity and negotiating benefits in global forums (such as COP or biodiversity) because countries speak as independent entities, unlike other regions (such as Africa) that speak as a bloc.

2. Identified Proposals

The proposals focus on the conceptual refoundation of the institutional architecture, the restructuring of PAHO, the creation of new coordination mechanisms, and the strengthening of the regional voice.

Deep Institutional Reform and Restructuring

• Conceptual Refoundation: Promote a new foundational conference (e.g., “Alma-Ata Conference for 2030” or a “Host Country Declaration in Latin America and the Caribbean”) to establish a renewed framework for the twenty-first century, fostering a revolution in primary health care.
• Technical Autonomy and Dissent: Implement mechanisms to ensure that PAHO and other technical institutions are able to express well-founded disagreement when governmental political decisions deviate from scientific evidence.
• Lean Structure: Create an “exceptionally lean, highly operational” structure that does not give rise to a diplomatic career path.
• Introduce temporary, mission-oriented assignments with personnel contributed by countries, disbanded once the task is completed.
• Rotating Location: Relocate PAHO’s headquarters to another country within the Americas to foster greater connection with regional realities.
• Rotating Location: Relocate PAHO’s headquarters to another country within the Americas to foster greater connection with regional realities.

New Institutions and Coordination Mechanisms

• Collective Mandates and High-Level Political Engagement: Governments should agree on a collective mandate (e.g., to PAHO) for the formulation of plans, rather than engaging through individual consultations. This mandate must stem from the highest political levels, involving Heads of State and Ministers of Finance.
• Creation of Regional Institutions: Propose the establishment of a Regional Health Institute to promote cooperation among countries, or a Latin American CDC, modeled after the Africa CDC, functioning independently from the WHO regional office.
• Strengthening ALASAG: Enhance its role as a regional academic platform for the generation, exchange, and dissemination of knowledge in global health.
• Revitalizing UNASUR Salud: Reinstate its function as a political coordination and regional health cooperation platform.
• Binding Mechanisms and Sanctions: Develop legally binding mechanisms with effective sanctions for non-compliance, comparable to systems in banking or aviation, given that current conventions lack enforceability.
• Compacts and Horizontal Coordination: Establish formal compacts, agreements defining shared commitments and priorities, between the region and global actors. Promote horizontal coordination through networks of centers of excellence and South-South cooperation mechanisms among countries and regions.

Governance and Accountability

• Inclusion of Non-Governmental Actors: Integrate academia, NGOs, civil society, and the private sector (with safeguards and conflict-of-interest disclosures) into governance processes. This requires strengthening the capacity of civil society organizations in strategic advocacy.
• Conflict of Interest Management: Implement concrete institutional mechanisms to manage and limit undue private sector influence on public health policymaking.
• Independent Advisory Councils: Establish well-functioning advisory committees that provide independent recommendations insulated from political fluctuations.
• Technology Harmonization: PAHO should assume responsibility for the harmonization of technology registration processes to enhance supply and reduce costs.
• Resetting Regional Relations: In the Caribbean, it is necessary to “reset” the relationship between the CARICOM Secretariat and technical institutions (such as CARPHA) to ensure that the Secretariat carries out political mandates, while technical institutions handle implementation.

3. Areas of Convergence and Tension

Areas of Convergence

Areas of Convergence: There is broad consensus that the global and regional health system is not functioning effectively and that the previous framework is “obsolete.”

• Need for PAHO/WHO Reform: There is near-unanimous agreement that PAHO/WHO must undergo reform, though there is no consensus on the depth of the changes required.
• Regional Priority: Strong consensus exists on prioritizing the regional over the global level and focusing on a “revolution toward primary health care.”
• Accountability and Transparency: There is a recognized need to strengthen governance, transparency in the use of funds, and accountability, supported by robust data systems.
• Political Legitimacy: Any transformation of the global architecture must derive from a high-level political mandate from countries themselves, rather than being led solely by “technocrats.”
• Conflict of Interest Management: There is widespread recognition of the importance of managing conflicts of interest, particularly those involving the private sector.

Identified Tensions

• Technical Autonomy vs. Political Control: A key tension arises around how much autonomy technical institutions should have to dissent from government decisions without losing political legitimacy or accountability.
• Regional vs. Global / Reform vs. Creation: There is debate over the appropriate balance between deeply reforming PAHO and creating new parallel regional institutions, such as a Latin American CDC.
• Gradualism vs. Radical Transformation: Some advocate for incremental improvements (coordination, alignment), while others call for a complete refoundation (e.g., a new foundational conference).
• Inclusion of the Private Sector: There is tension between the need to include the private sector—given its data, technology, and products—and the risk of policy capture and conflicts of interest, as seen in issues such as front-of-package labeling.
• Sovereignty vs. Integration: There is an inherent conflict between national autonomy (each country’s sovereignty) and the need to cede limited sovereignty in areas such as human resource and technology harmonization to achieve deeper regional integration, adopting/adapting the European Union model.
• New Agreements vs. Traditional Architecture: The emergence of new alliances among countries of the Global South—both within and beyond the region—could, if not properly articulated, generate further fragmentation and new geopolitical alignments that weaken traditional mechanisms of regional integration.

 

4. Proposed Questions for Working Groups

(select the questions that better allies to the group objectives)

The following is a compilation of proposed questions for the working groups, organized by thematic area to facilitate discussion.

Governance, Legitimacy, and Mandate

• How can a high-level political mandate for reform be built—one that involves Heads of State and Ministers of Finance?
• What model of governance would allow technical institutions to dissent from political decisions while maintaining legitimacy?
• How can technical autonomy be balanced with political accountability?
• Would a new foundational conference—similar to Alma-Ata—be useful, and what conditions would be necessary for it to succeed?
• How can reforms be designed to respond to the needs of countries rather than the agendas of donors?
• What models of co-governance would be viable for setting priorities when resources are scarce?
• How can Latin America regain a voice in global decision-making spaces (e.g., WHO, G20) amid its declining geopolitical relevance?

Structure and Institutional Reform (PAHO/WHO)

• Which specific elements of PAHO/WHO should be reformed first—governance, administrative structure, financing model, or technical functions?
• How can PAHO be reformed to better address regional needs without losing its technical capacity?
• Is it feasible for PAHO to assume functions related to the harmonization of human resources and health technologies? Which countries would be willing to cede sovereignty in these areas?
• How can PAHO’s bureaucracy be reduced without undermining technical capability? Which offices or functions are dispensable versus essential?
• How can bureaucratic capture be avoided while maintaining strong institutional technical capacity?
• What would be the advantages and disadvantages of rotating institutional headquarters among countries?

Coordination and Regionalism

• Is it viable and desirable to create an independent Latin American CDC, or is it preferable to strengthen PAHO’s technical role?
• How can effective coordination among the IADB, World Bank, PAHO, and CAF be achieved without creating “another new entity”?
• What concrete incentives do these institutions need to collaborate more effectively?
• What models of compacts between the region and global actors would be most effective?
• How can the relationship between the CARICOM Secretariat and technical institutions such as CARPHA be effectively “reset” to ensure complementarity?

Inclusion and Accountability

• How can non-governmental actors (NGOs, academia, private sector) be incorporated into PAHO’s governance without creating conflicts of interest or risks of capture?
• What concrete institutional mechanisms are needed to manage conflicts of interest and limit undue private sector influence on public health policy?
• How can legally binding accountability mechanisms with effective sanctions—similar to those in the banking sector—be designed?
• What role should independent advisory councils play, and how can their independence be guaranteed?

How can the role of civil society in governance be strengthened without provoking governmental resistance?