1. Identified Challenges

The documents highlight a central problem of extreme fragmentation and a lack of effective coordination that constrain the sustainability and impact of technical cooperation.

Limitations of Current Technical Cooperation

• Fragmentation and duplication of efforts. A multiplicity of actors operate with insufficient coordination, leading to duplicated efforts. At times, very similar projects funded by the same donor compete with one another. The lack of coordination among donors is widely perceived as a serious problem.
• Agenda misalignment. Technical cooperation often reflects donor agendas more than the national priorities that are genuinely needed. This results in vertical, short-term programs that focus on specific issues without adequate integration into the health system.
• Sustainability and ownership challenges. Projects frequently lack post-cooperation sustainability. In the absence of change in public policy, gains are lost once the cooperating organization withdraws. Top-down programs that ignore local priorities ultimately weaken long-term national leadership.
• Administrative overload. The need to engage multiple donors and comply with differing requirements (“multiple windows”) imposes a substantial administrative burden on countries.

Weaknesses in South–South Cooperation (SSC) and Regional Coordination

• Lack of Sustainable Financing. One of the greatest challenges is the absence of dedicated, sustainable financing for South–South cooperation. Regional cooperation lacks stable resources.
• Limited Institutionalization. Cooperation among countries is only weakly formalized or institutionalized, when it should be nearly a prerequisite. Experience-sharing and continuous mutual learning are not systematic.
• Absence of Effective Regional Platforms. There is a “plethora of platforms” (e.g., Mercosur, the Andean Community, Prosur) many of which have struggled to deliver sustained or meaningful outcomes, and some e.g. CARICOM that while functional can be improved. Mechanisms such as UNASUR Salud are inactive, lacking resources and a clear mandate. Latin America tends to speak as separate countries, thereby losing leadership capacity, in contrast to other regions. The Caribbean while having a mechanism to speak as one does not always do so.
• Political and Institutional Barriers. Ideological divergences among governments limit cooperation. In addition, the lack of regulatory harmonization (marketing authorization, pharmacovigilance) hinders cross-border collaboration.
• Asymmetries and Lack of Incentives. Some countries lag significantly and require greater support. There is insufficient recognition of, and resources for, more advanced countries to share their expertise, fostering a culture of competition rather than collaboration.

2. Identified Proposals

The proposals focus on institutionalizing cooperation, strengthening local capacity, and improving coordination among existing actors.

Strengthen South–South Cooperation and Institutionalize Exchange

• Creation of a Regional Fund. Establish a dedicated, sustainable financing mechanism for technical cooperation among countries in the region.
• Knowledge Platforms and Networks. Create a formal platform for expert exchange and a network of centers of excellence where countries can refer complex cases and train personnel.
• Regional Recognition. Strengthen regional cooperation by leveraging the technical capacity of the more advanced countries in the region, acknowledging that in several cases, the technical and human progress of these countries has evolved more rapidly than the institutional strengthening of their own systems.
• Strengthen Bilateral and Subnational Links. Promote cooperation among subnational governments to sustain cooperation flows even amid political polarization at the national level.

Improve Coordination among Existing Donors

• Harmonization of Requirements. Establish a standardized, mandatory “requirements framework” for all donors.
• Joint Mapping and Shared Information Platforms. Agree on priorities collectively before designing projects, and develop shared information platforms that map existing initiatives to prevent duplication.
• Strategic Alliances and a Single Entry Window. Strengthen coordination among major actors (IADB, World Bank, PAHO, CAF). Simplify procedures for countries, making cooperation more country-driven, and consider a possible “single entry window.”
• Reformed Role for PAHO. PAHO should serve as the key regional technical coordinator, focusing on technical support and the dissemination of best practices, rather than merely transmitting top-down guidelines or assistance.

Ensure Sustainability and National Ownership

• Capacity Transfer. Center cooperation on lasting capacity transfer and systems building.
• Support for Policy Change. Include policy-reform components to institutionalize improvements and prevent their dependence on the “government of the day.”
• Financing Models. Design projects with tapering co-financing, whereby external funding decreases gradually as domestic financing increases.

Institutionalize regional cooperation and technical harmonization:

• Strengthen Regional Bodies. Revitalize and reinforce existing entities such as the SICA Health Council. ALASAG can contribute as an academic and technical platform to support evidence-based regional collaboration. Alternatively, a new regional structure—such as a Regional Institute of Public Health—could be established, ensuring that existing institutions (e.g., CARPHA) are integrated. To be effective, such a regional institute would require legal and administrative autonomy and a clear, well-defined mandate.
• Speak as a Bloc. Establish a high-level coordination platform to enable Latin America and the Caribbean (LAC) to present a unified voice in international fora and global negotiations.
• Regulatory Harmonization. Promote mutual recognition of marketing authorizations and professional credentials (e.g., physicians and nurses) to facilitate workforce mobility and the provision of health services across the region. Efforts should draw inspiration from existing models, such as the European Medicines Agency (EMA) and the mechanisms already in place within the Caribbean.
• Focus on Regional Public Goods. Prioritize collective-action problems that cannot be resolved at the national level, such as pandemic preparedness, climate change, and noncommunicable diseases.

3. Areas of Convergence and Tension

There is broad agreement on the fundamental problems and overall direction of change, alongside clear tensions regarding how to implement it.

Areas of Convergence (Consensus)

1. Value of South–South Cooperation. Universal consensus on the importance of strengthening horizontal cooperation and the potential for peer learning across the region. Regional experience is highly valued, as many countries have already achieved significant development.
2. Need for Coordination. Strong agreement that fragmentation and lack of coordination among donors is a serious problem that must be addressed to avoid duplication.
3. Importance of National Ownership and Sustainability. Consensus that cooperation should strengthen—rather than substitute—local capacities (focus on capacity transfer, not just service delivery).
4. Role of PAHO. PAHO is universally recognized as the most important technical cooperation actor in the region, though a reform of its role is required to enhance technical effectiveness.
5. LAC–Caribbean Convergence. Recognition of the need for unity and deepening collaboration between Latin America and the Caribbean.

Identified Tensions

1. National Sovereignty vs. Binding Coordination. A fundamental tension exists between the need to create binding coordination mechanisms and countries’ desire to retain sovereignty over priorities and decisions. Formal coordination is criticized as lacking, yet few are willing to cede sovereignty.
2. Speed/Agility vs. Sustainability/Coordination. There is concern that excessive coordination could slow urgent interventions. The debate centers on how to balance rapid response with long-term capacity building.
3. Standardization vs. Local Adaptation. Debate persists over the extent to which common protocols and guidelines should be developed (to enhance efficiency and regulatory harmonization) versus the need to tailor interventions to each country’s specific realities and capacities.
4. External vs. Local Expertise. There is an ongoing tension around when it is appropriate to rely on international consultants versus when to prioritize and strengthen regional expertise and local knowledge
5. Governmental vs. Non-Governmental Cooperation. Collaboration and agility tend to be stronger among NGOs and research institutes than within governmental structures. This contrast has sparked debate on how to replicate the flexibility and effectiveness of non-governmental actors without further fragmenting the regional system.

4. Proposed Questions for Working Groups

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

The questions proposed in the documents address the main dilemmas and the need for concrete operational mechanisms to advance the reform.

I. On Coordination Mechanisms and Institutional Design

• Which regional platform could effectively coordinate multiple actors without generating additional bureaucracy, drawing on models such as SICA or OECS?
• How can the alliance among major actors (PAHO, development banks, etc.) be institutionalized with a binding mandate that goes beyond “good-will agreements”?
• What incentives can align the interests of international institutions with countries’ real needs?
• What is the minimum viable duration for a cooperation program to enable long-term reforms?

II. On South–South Cooperation and Incentives

• How can South–South cooperation be systematized and institutionalized beyond one-off projects?
• Is it viable to create a South–South cooperation fund financed by countries in the region, and who should govern it?
• What concrete incentives would motivate larger countries (Brazil, Mexico, Argentina) to provide technical cooperation to smaller countries without obvious reciprocity?
• Which models of networks of centers of excellence have worked in other regions?

III. On National Ownership and Sustainability

• Which mechanisms ensure that technical cooperation strengthens—rather than weakens—local capacities and ownership?
• How can the need for rapid response be balanced with long-term capacity development?
• What institutional mechanisms are needed to ensure that successful pilot experiences are institutionalized and do not depend on the “government of the day”?
• How can the effectiveness of knowledge transfer be measured and evaluated?

IV. On Harmonization and Regional Positioning

• How can Latin America and the Caribbean (LAC) speak as a bloc in international negotiations?
• What mechanisms are needed to link national regulations to regional technical-cooperation commitments so they become legally binding?
• Is it realistic to aim for harmonized marketing authorizations or professional credentials in a region with such diverse regulatory capacities?
• How can political barriers to cross-border health cooperation be overcome?

V. On Actors and Approach

• How can countries agree on two or three regional priorities when their needs differ?
• What role should non-traditional actors (academia, private sector, civil society) play in technical cooperation, and how can their agility be incorporated without further fragmenting the system?
• How can cooperation remain prioritized even as global agendas shift (e.g., toward climate change)?