Caribbean Cooperation in Health Phase IV (CCJ IV) - Summary of the Regional Health Framework 2016 -

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Caribbean Cooperation in Health Phase IV (CCH IV)

Summary of the Regional Health Framework 2016 – 2025

Regional Public Goods for Sustainable Health Development

Caribbean Cooperation in Health Phase IV (CCHIV)

Summary of the Regional Health Framework 2016 – 2025 “Regional Public Goods for Sustainable Health Development”

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“....CCH IV emphasizes multi-sectoral action and regional public goods (RPGs) to address common challenges in areas where a regional approach holds the best potential to add value to national efforts.” Caribbean Cooperation in Health Phase IV (CCHIV) 2

Summary of the Regional Health Framework 2016 – 2025 “Regional Public Goods for Sustainable Health Development”


CONTENTS Introduction.................................................................................................... 5 History of Caribbean Cooperation in Health..................................... 7 Consultative Approach to the Development of the CCH IV........ 8 International and Regional Context.................................................... 10 Regional Public Goods as a Strategic Approach............................12 The CCH IV Framework............................................................................15 Implementation through CCH Action Plans......................................17 Governance arrangements for the CCH IV....................................... 18

The CARICOM Secretariat wishes to acknowledge PAHO for its technical cooperation in the evaluation of CCH III and the development of CCH IV.

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“....CCH providing a framework for CARICOM Member States to efficiently and effectively address common health and development challenges”

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Summary of the Regional Health Framework 2016 – 2025 “Regional Public Goods for Sustainable Health Development”


Caribbean Cooperation in Health Phase IV (CCH IV) Summary of the Regional Health Framework 2016 – 2025 Introduction The Caribbean Cooperation in Health

joint action. The intention is to build

(CCH) advances the Caribbean

the capacity of Member States to

Community (CARICOM) objective

improve the conditions for health for all

of enhanced functional cooperation

by developing and maintaining cost-

found in Article 6 of the Revised

effective and efficient health systems.

Treaty of Chaguaramas, with the aim to achieve more efficient operation

Over the years, the focus of the CCH

of common services and activities; to

has evolved in line with the changing

promote greater understanding among

international and regional context

its peoples and the advancement of

and to meet the needs of CARICOM

their social, cultural and technological

Member States. Each iteration of

development; and to intensify joint

the CCH framework has delivered

activities in areas such as health,

significant health gains. In 1984, CCH

education, transportation, and

I sought to optimize resources by

telecommunications.

promoting technical cooperation among countries and securing funding

Functional cooperation in health

for priority health areas. During this

has been a long-standing successful

period, the Region achieved the historic

feature of cooperation in the Region.

elimination of indigenous measles in

The CCH IV provides a framework for

1991 and in 2002, the elimination of

CARICOM Member States to efficiently

rubella.

and effectively address common health and development challenges

CCH II, covering the period 1999-2005,

through functional cooperation and

saw massive scaling up of the regional

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response to HIV. through PANCAP, an

States towards sustainable health

acknowledged global best practice.

development.

CCH III, 2006-2015, advanced regional cooperation for health, including

1984 - the CARICOM Conference

through the landmark Port of Spain

of Ministers Responsible for Health

Declaration on NCDs in 2007 and the

(CMH) accepted the need for a

establishment of the Caribbean Public

mechanism for health development

Health Agency (CARPHA) and on-going

through increasing collaboration

work of the Pan Caribbean Partnership

and promoting technical

Against HIV (PANCAP). Other

cooperation among countries in the

significant outcomes include regional

Caribbean. The work developing this

cooperation around the implementation

mechanism was fostered by PAHO

and evaluation of the 2007 Port-

in support of the Regional Health

of-Spain Declaration; enhanced

Officials. It was adopted in 1986: It

surveillance, laboratory and risk

certainly has become the umbrella

communication; and near elimination of

under which Regional Health

mother-to-child transmission (MTCT) of

Development is sheltered

HIV and Syphilis.

CCH I 1986 – 1995

CCH II 1997 -2005

CCH III 2007 – 2015

CCH IV 2016 - 2025

Developed through a lengthy and widespread consultative process, the CCH IV seeks to advance regional cooperation in health through the provision of regional public goods (RPGS) that enable, complement and add value to the efforts of Member

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History of Caribbean Cooperation in Health CCH I saw achievement of Universal

CCH II saw in the Nassau Declaration a

Childhood Immunisation by 1990 and

definition of Regional Super Priorities

facilitated the Certification of the

in Health and the production of the

Region as Polio-free in 1994. During that

Report of the Caribbean Commission on

period the efforts to Eliminate Measles

Health and Development, which gave

and Rubella commenced with the “Big

NCDs the highest ranking for attention.

Bang” in 1991. Intense work by CFNI

PANCAP the Regional Mechanism, a

to use Growth Charts and individual

Global Best Practice evolved to address

efforts at the Member State level to

the HIV threat in

provide infant food to under-5s almost

the Region.

eliminated severe malnutrition. Over the period The first iteration of the CCH, adopted

2006-2015, the

in 1984, focused on optimizing resource

CCH III advanced

use, promoting technical cooperation

regional

among countries, and mobilizing

cooperation

resources for priority health areas. This

for health in

approach delivered significant health

five functional

gains, including the eradication of the

cooperation

indigenous transmission of measles and

areas:

the elimination of rubella.

A healthy

The CCH II, A New Vision for Caribbean

Caribbean

Health, covered the period 1999-

environment

2005 and reflected a stronger focus

conducive to

on the intrinsic value of health for

promoting

human development. Joint action was

the health

promoted in eight priority areas: health

of its people

systems development, human resource

and visitors.

development, family health, food and

Improved

nutrition, chronic non-communicable

health and quality of life for

diseases, communicable diseases,

Caribbean people throughout the

mental health and environmental health.

life cycle.

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Health services that respond

Ebola; near elimination of mother-

effectively to the needs of the

to-child transmission (MTCT) of HIV;

Caribbean people.

and improved Regional Registration

Adequate human resource

Processes for Health Professionals in

capacity to support health

keeping with the aims of the Single

development in the Region.

Market and Economy.

Evidence-based decision making as the mainstay of policy

Building on these advances, and in line

development in the Region.

with the original intent of CCH, the fourth iteration does not attempt to

CCH III built on the eight priority

address all health issues nor to define

areas established under CCH II to

all actions required to improve health

emphasize actions at the regional

in countries throughout the Region.

level that were crosscutting, multi-

Rather, the CCH IV emphasizes multi-

sectoral, people-centered, enabling

sectoral action and Regional Public

and focused on social determinants

Goods (RPGs) to address common

of health. Key outcomes have been

challenges in areas where a regional

the establishment of the Caribbean

approach holds the best potential to

Public Health Agency (CARPHA); the

add value to national efforts. It further

on-going work of PANCAP; regional

reflects a greater understanding of the

cooperation for implementation

need for a whole-of-society approach

and evaluation of the 2007 Port-of-

that harnesses the capacities of a

Spain Declaration on the prevention

range of stakeholders across sectors

and control of NCDs; enhanced

and at all levels, to tackle the complex

surveillance, lab services and risk

health and development challenges

communication to mitigate the risks

facing Caribbean countries.

of global outbreaks such as SARS and

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Summary of the Regional Health Framework 2016 – 2025 “Regional Public Goods for Sustainable Health Development”


Consultative Approach to the Development of the CCH IV The development of the CCH IV Framework was coordinated by a Steering Committee led by the

Advancing the CCH

CARICOM Secretariat, CARPHA, and

IV, Caribbean Regional

the Pan American Health Organization/

Strategic Planning Consultation 22-23 February 2016, Port of Spain, Trinidad

World Health Organization (PAHO/

The Framework builds on an

WHO). The involvement of Chief

independent evaluation of the CCH

Medical Officers and technical experts

III and a regional consultation on

ensured relevance to the needs of

“Advancing the Caribbean Cooperation

Member States, integration of on-going

in Health to Benefit the Regional

activities, and attention to compliance

Public Good: Review of the CCH III and

with international obligations and to

Strategic Planning for CCH IV” that

meeting emerging challenges.

was held in Port of Spain, Trinidad in

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February 2016. Over 50 regional and

Strengthen governance and

national stakeholders representing

accountability systems, including

Member States, regional technical

monitoring and evaluation and

agencies, development partners,

reporting.

academia and civil society participated.

Align with global and regional

Further consultations took place at

priorities, including PAHO/

the 24th and 25th Meetings of the

WHO indicators and Sustainable

Chief Medical Officers (CMOs), in June

Development Goals (SDG) targets.

2016 and April 2017 respectively, and

Develop and execute a multi-year

directly with Ministries of Health, other

communication and dissemination

sector ministries, CARICOM Regional

strategy for CCH IV.

Institutions, Non-Governmental

Utilize a longer timeframe to align

Organizations (NGOs), the United

with global commitments such as

Nations System and other international

the SDGs, and to better achieve and

partners.

sustain regional goals and objectives •

Re-organize priority areas and

Important recommendations arising

consider the inclusion of new

from the evaluation of the CCH III were

issues such as health financing and

considered in the development of the

accountability.

CCH IV:

Fltr: Virginia Asin (St. Maarten), Roger McLean (UWI), Vincent Atkins (CARICOM) Trevor Hassell (Health Caribbean Coalition)

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International and Regional The CCH IV is framed within the

IV through an

context of current global and regional

upgraded Port of

development and health agendas.

Spain Declaration. Other issues such

The Sustainable Development Goals

as Caribbean Health

(SDGs) and the Samoa Pathway provide

Security have emerged.

excellent frameworks for the CCH IV,

The Global Health Security Agenda

with both health-specific goal and

is seen as an appropriate vehicle to

targets and several others that address

advance CARICOM MS attainment

such related priorities such as food and

of International Health Regulations

nutrition security, water and sanitation,

compliance. A Roadmap for the roll-

climate change, violence prevention.

out of the Regional Strategy on Health Security provides opportunities for

The CARICOM Strategic Plan 2014-

further development of Identified Public

2019 seeks to ensure economic, social,

Goods. It will also provide excellent

environmental and technological

opportunities for national and Regional

resilience within the Region. Critical

level multisector engagement in

health issues are included in the priority

meeting IHR compliance.

area of Building Social Resilience. The persistent economic challenges COHSOD’s embrace of a Caribbean

facing MS threaten to erode the health

One Health Policy in 2014 adds a multi

gains since independence. This constant

sector dimension to communicable

stress severely affects the ability

disease health acknowledging Human,

of MS to make coherent long-term

Veterinary and Ecological factors in

investments in Health. Decisions are

communicable disease epidemiology.

often driven by the need to interdict

The Health Caribbean Coalition HCC has

illness than to promote wellness. As a

added a needed dimension to disease

result the mitigation measures needed

control particularly NCDs. Their ability

to address NCDs, Violence and Mental

to create public awareness creates

Health including substance abuse are

additional support for the societal

woefully inadequate and lag behind

penetration of health policy.

the brilliant advocacy demonstrated by Heads of Government in the 2007

Whilst Non-Communicable Diseases

Port of Spain Declaration. The looming

remain the important priority for CCH

problems of an ageing population

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in some MS will ultimately affect

CCH IV will begin to address the

investments in Health. The effect of

health systems improvements required

climate change can be seen in the

to satisfy the needs of Universal

growing severity of hurricanes and

Health coverage. These will touch the

the attendant disasters of increasing

Health Information systems; Humans

magnitude, which they cause to the

Resources diversity required; Policies on

physical health infrastructure and

commodities and Regulatory Systems

increase in insect vector borne diseases.

to enhance quality.

Health and Economic Challenges Facing Member States • higher dependency ratios with fewer people paying NIS contributions, • high levels of chronic disease and increasing dementia in the elderly, • increasingly severe and frequent natural disasters, • mosquito-borne viral diseases, and • increasing prevalence of violence and injuries. 1

Abdukadri A, Cunningham-Myrie C, Forrester T. Economic burden of diabetes and hypertension in CARICOM States. 2009 Sept. Available from: https://www.researchgate.net/publication/269990209_Economic_burden_of_diabetes_and_hypertension_in_CARICOM_states)

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Regional Public Goods as a Strategic Approach CCH IV will have as its main deliverable

on the Prevention

regional public goods. These goods

and Control of NCDs,

are intended for enhancement of

Caribbean Wellness

collective approaches to health policy

Day, the Plan of Action

formulation in particular the support of

for Prevention and

a strengthened enabling environment

Control of Childhood Obesity,

for their development in particular in

2014-2019 and the State of Public

MS capacity against constraints for

Health in the Caribbean Report that

policy formulation. These goods will not

reviews the public health situation in

constrain individual effort in any MS to

the Region and provides statistical and

address specific national needs.

technical information to aid decisionmaking.

The Region has benefited from knowledge generation and sharing

In CCH IV, RPGs include, but are not

through 61 years of the Annual

limited to, shared legislative and policy

Caribbean Health Research

frameworks, standards, regulations and

Conference.

guidelines; shared capacity through regional technical agencies and

Regional health policies have included

common training programs; shared

the 2007 Port-of-Spain Declaration

quality assurance mechanisms; common

The OECS Pharmaceutical Procurement Service (PPS) is an example of how pooled procurement can reduce costs and enhance the efficiency of health service delivery. Since its implementation in 1986, the OECS PPS has been able to reduce the market cost of medicines in the region by 20 percent and in so doing, collectively saves regional governments an average of USD $4 million a year (OECS PPS).

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“...focus on shared challenges that can be addressed more effectively through regional action.”

approaches to addressing shared

regional and international challenges to public health; shared research

tourism •

to identify effective and replicable practices; shared financing approaches,

Regional partnership of health and Caribbean guaranteed minimum package of health services

including pooled procurement.

Common health promotion campaigns

Common training programs

At the 25th Meeting of Chief Medical

for health and other personnel,

Officers in April 2017, CMOs identified

including in partnerships and

the following priority RPGs to guide the

negotiation

implementation of CCHIV:

Common clinical guidelines and auditing tools for national NCD

Strengthened legislative framework for health, including legal briefs and

programs •

model legislation •

Regional legislation for nutritional

policy •

labelling •

Regional health information systems policy

Regional approach to trade

legislation and regulation in support of reducing childhood obesity •

Regional data sharing and ethics

Caribbean Regulatory System for

Regional strategy to stimulate private sector partnerships

Resource mobilization strategies for reaching non-traditional funders.

essential medicines

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The CCH IV Framework The vision of the CCH IV is that Carib-

have less illness and disability through-

bean people will be happier, healthier

out their lives. The mission is to build

and more productive, each respected

the capacity of countries to improve

for their individuality and creativity, and

the conditions for health for all, espe-

living more harmoniously within cleaner,

cially among vulnerable groups, and to

greener environments. Its goal is for

develop and maintain cost-effective and

people to be resilient, live longer and

efficient health systems.

VISION. MISSION. GOAL

VISION

Caribbean people will be happier, healthier and more productive, each respected for their individuality and creativity, and living more harmoniously within cleaner, greener environments

MISSION

To build the capacity of countries to improve the conditions for health for all, especially among vulnerable groups, and to develop and maintain cost-effective and efficient health systems

GOAL

For people to be resilient, live longer and have less illness and disability throughout their lives. • By 2025, Life Expectancy for the total population in each Member State will be increased by 3 years • Disability Adjusted Life Years (DALYs) for all ages and both sexes will be reduced by 10% in 10 years.

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A key focus is strengthening primary

The CCH IV Framework identifies five

health care and promoting health in

strategic priority areas, each with a key

all policies to address the social de-

expected outcome. The principal mode

terminants of health. This requires the

of implementation of CCH IV will be the

whole of society to engage for effective

production of Regional Public Goods

multi-sectoral, evidence-based interven-

(RPGs) (see section below on Regional

tions.

Public Goods (RPGs).

CCH IV Strategic Priorities and Outcomes

Strategic Priority Area

Strategic Outcome

Health Systems for universal access to health and universal health coverage2

Better quality services for health promotion, disease prevention and treatment provided to a larger proportion of the population at affordable costs so that no family is impoverished as a result of treatment of an illness.

Safe, resilient, healthy environments

Regional health security improved through actions to manage and mitigate the effects of climate change, reduce environmental and occupational threats and through building a disaster-resilient health sector, with emphasis on vulnerable populations.

Health and well-being of Caribbean people throughout the life course

Health and well-being of Caribbean people enhanced throughout all stages of their lives.

Data and evidence for decision making and accountability

Regional capacity enhanced to generate and use quality data and evidence for more effective policy, programs and monitoring.

Partnership and resource mobilization for health

Traditional and non-traditional partnerships increased for improved synergies in policy and strategy development and for mobilization of additional resources for health.

2 Strategy for Universal Access to Health and Universal Health Coverage. PAHO 53rd Directing Council; 66th Session of the Regional Committee of WHO for the Americas. Washington, DC 29 September – 3 October 2014. Available from: http://www.paho.org/uhexchange/index.php/en/uhexchange-docments/ technical-information/26-strategy-for-universal-access-to-health-and-universal-health-coverage/file

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Implementation through CCH Action Plans To guide implementation and resource

CCH IV into their program budgets,

mobilization, a series of three-year CCH

and with Member States monitoring

Action Plans (CCHAP) will be devel-

execution through routine reports.

oped to identify measurable results,

Lead organizations will coordinate

outputs, activities, responsible organi-

the achievement of the results for a

zations and budgets. These rolling plans

strategic priority and will implement

provide the opportunity for adjustments

key actions with support from other

in the CCH IV framework, if necessary,

organizations. The CCH Secretariat,

to meet changes in the regional context.

comprised of the CARICOM Secretariat (CCS) Health Desk, CARPHA

As far as possible, regional efforts will

and PAHO/WHO, is responsible

utilize existing institutional arrange-

for coordinating the production of

ments, with implementing partners

RPGs.

integrating commitments specific to

Governance arrangements for the CCH IV

CARICOM Regional Institutions

Caribbean Community Secretariat

CARICOM Member States

Regional & International Development Partners

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Strengthened governance of the CCH IV Governance arrangements for the

Effective multi-sectoral governance

CCH IV build on existing mechanisms

of the CCH will enable better

such as the Conference of Heads of

oversight, accountability and

Government, the Council on Health

alignment in all areas of health and

and Social Development (COHSOD),

development. The multi-sector

the Council for Trade and Economic

governance identified is reflective to

Development (COTED), the Meeting

the complexities of the current health

of the Chief Medical Officers and the

issues such as NCD prevention, IHR

CCH Secretariat to ensure leadership

and Health Systems Regulation.

by, and accountability to, Member

To this end, a Regional Steering

States. The modus operandi and lines

Committee will enable non-health,

of authority and accountability of

civil society, academia and private

these structures are well-established

sector partners to be engaged in

and will be maintained over the

implementation, decision-making and

lifetime of the CCH IV.

oversight of collaborative activities

Governance arrangements for the CCH IV CONFERENCE OF HEADS OF GOVERNMENT Lead Prime Minister on Health COHSOD Annual Meeting supported by CCS

Ministers of Health CCH STEERING COMMITTEE Selected CMOs from group of countries (X5)

Representatives Civil Society, Youth

Representatives of other selected sectors (Private Sector, Labour, Region Institutions)

CCH SECRETARIAT Body of CMOs

CARPHA

PAHO/WHO

CARICOM

M&E Working Group

Supported by CCS Meets twice a year

Monthly meetings convened by CCS

National and Regional Implementing Agencies (for each Strategic Priority)

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and approaches. Operationalizing

This innovative approach has

the Steering Committee will

been approved by the Ministers

require developing processes

of Health3, and represents a

and procedures to manage and

significant step forward for the

support a partnership framework

Region, with the potential to better

for engagement with non-health

align strategies and efforts across

and non-traditional partners with

multiple sectors and to strengthen

measures to manage conflict of

the CARICOM Secretariat and the

interest, as well as identifying

governance structure of CARPHA.

the resources and capacity for

It builds on lessons learned from

secretariat support and meetings.

PANCAP, a regional collaboration

Face-to-face Regional Steering

that has successfully harnessed the

Committee meetings may be built

contributions of more than sixty

on to existing annual meetings of

diverse partners, to achieve progress

the Chief Medical Officers and of

in the fight against HIV and AIDS.

Health Officials in Washington, DC in September.

3

Endorsed by Ministers at the 30th Meeting of the Council for Human and Social Development (COHSOD)- Health. September 2016

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Strengthening multi-sectoral collaboration for health in the Caribbean

The Steering Committee for the CCH IV will enable: Opportunities and mechanisms for routine multi-sectoral collaboration Dedicated resources and time for effective multi-sectoral collaboration Open, inclusive, and informed discussion among key stakeholders A policy process and policies shaped and influenced by multi-sectoral inputs The monitoring and assessment of collaborative partnerships for learning and improvement Evidence generated and shared on the cross-sectoral benefits of achieving the stated health goal through a multi-sectoral response.4

4

Health Policy Project. 2014. Resource Guide on Multisectoral Coordination

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Monitoring and Evaluation Monitoring progress of CCH IV

and into a central repository managed

takes place at both the national and

by CARPHA, to facilitate tracking

regional levels. CMOs are responsible

of regional progress. Reporting will

for reporting country progress

be incorporated into annual reports

against agreed targets and lead

at the CMO’s Meeting and indicator

regional agencies are responsible for

dashboards will be disseminated to

monitoring and reporting progress in

Member States and key partners.

their assigned strategic priority areas.

This will assign CMOs greater accountability for CCH deliverables.

Within the CCH IV Steering

Regional data in the key priority areas

Committee, CARPHA is working

will be used to institutionalize data-

to design and operationalize an

informed decision making.

M&E Plan. The monitoring system builds and strengthens existing

CCH IV evaluations will be

surveillance and data collection

commissioned and managed by

protocols, to avoid duplication or

the University of the West Indies

the need for additional reporting.

(UWI) or PAHO with input from the

An indicator framework will include

Steering Committee, MOHs and

reference sheets outlining definitions,

other key stakeholders. The results

numerators and denominators,

of the triennial and final evaluations

planned data analysis and indicator

will be disseminated throughout the

limitations. Reporting templates will

Region on various media platforms

be developed for Ministries of Health

and as part of regional meetings.

at the Member State-level and at the

Findings and recommendations will

regional level, for the lead agency for

be used to generate an action plan

each strategic priority area. Data will

for continuous quality and program

be deposited in CMO Annual Reports

improvement.

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Communicating for Caribbean Cooperation in Health The evaluation of the CCH III identified the lack of a

understanding of the CCH IV include: • A brief designed to be accessible

communication strategy as an

to a wide, non-technical target

important gap that contributed to

audience across sectors that will

a widespread lack of awareness

ensure that Member States and

among stakeholders. Effective

residents are aware of the regional

communication is recognized

public goods and services that are

to be critical for establishing

being made available to them, and

and sustaining multi-sectoral

A ‘quick reference’ version that

partnerships for advocacy,

highlights linkages to SDGs,

mobilizing resources, producing

CARICOM strategic goals, Regional

and utilising regional public goods,

Health Security and profiles

and engaging in governance

CCH IV to support multi-sectoral

for the CCH IV. Communication

engagement and investment by

products to promote awareness and

partners.

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Resourcing the Regional Public Goods Strategic Priority Area 5 of the

Regional clearinghouse of funding

CCH IV proposes the following

opportunities for health to share

collaborative approaches to resource

with Member States; •

mobilization:

Traditional and non-traditional partnerships;

Research to build business case for investment in health;

Regional policy for engagement of the private sector.

Applied training courses for health officials and professionals in

Three-year CCH Action Plans

partnerships and negotiation skills

(CCHAPs) and the monitoring and

to support resource mobilization;

evaluation framework are critical for

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International experience with funding public goods The main potential contributors to the resourcing of RPGs are: • • • •

National governments International agencies and bilateral partners Regional private sector International corporations, as developers and suppliers of relevant technologies.

The following mechanisms may be used to fund the production of regional public goods: • • • •

Voluntary contributions by States; Ear-marked national taxes coordinated between countries; Taxes imposed and collected at the regional level; Market-based mechanisms such as trading of emission rights.

understanding the resource needs

to diversify funding sources

associated with the provision of

and encourage multi-sectoral

priority RPGs, and for measuring the

collaboration. The whole-of-society

results of this investment. So too,

approach underlying the CCH IV

is operationalizing a governance

provides an opportunity and impetus

structure that can stimulate and

to leverage existing investments,

nurture new partnership approaches

including in non-health sectors.

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References Organisation of Eastern Caribbean States.

peoples and the advancement of their social,

2017. OECS Pharmaceutical Procurement Ser-

cultural and technological development; (iii)

vice (PPS) grows from strength to strength.

intensified activities in areas such as health,

https://pressroom.oecs.org/oecs-pharma-

education, transportation, telecommuni-

ceutical-procurement-service-grows-from-

cations. Accessed: https://idatd.cepal.org/

strength-to-strength

Normativas/CARICOM/Ingles/Revised_Treaty_of_Chaguaramas.pdf

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Caribbean Cooperation in Health Phase IV (CCHIV) 28

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