The South American Health Council Quinquennial Plan (2010-2015)

UNASUR HEALTH South American Health Council

2010-2015 FIVE YEAR PLAN Union of South American Nations Presented by the International Coordination Committee to the SOUTH AMERICAN HEALTH COUNCIL

Version Approved April 30th, 2010

CONTENTS Page

INTRODUCTION

3

1.

HEALTH INTEGRATION IN SOUTH AMERICA

4

2.

SOUTH AMERICAN HEALTH SITUATION

6

3.

UNASUR HEALTH RESOLUTORY FRAMEWORK

11

4.

VALUES, PRINCIPLES AND STRATEGIC INDICATORS

14

5.

STRATEGIC MAP

16

6.

STRATEGIC GOALS, OUTCOMES AND ACTIVITIES

17

7

FINANCE MODES, RESOURCE

30

8.

FIVE YEAR PLAN MANAGEMENT

31

9.

MONITORING & EVALUATION

32

ANNEX A

34

ANNEX B

36

ANNEX C

41

ANNEX D

43

BIBLIOGRAPHY

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INTRODUCTION

On the May 23rd, 2008, twelve Heads of State and Government subscribed Constitutive Treaty of the South American Union of Nations for the "purpose of building in participatory and consensual manner a common space for integration and unity of the cultural, social, economic and political aspects of our peoples while prioritizing political dialogue, social policies, education, energy, infrastructure, financing and the environment, among others, with a view to eliminate socio-economic inequality, in order to achieve social inclusion, and participation in civil society, to strengthen democracy and reduce asymmetries within the framework of strengthening the sovereignty and independence of the States."1 “South American integration constitutes a an alternative for the growth and attainment of our national development projects emphasizing social exclusion, reduction of poverty, and diminishing foreign vulnerability, while making it possible for our region to have a more solid and competitive presence in the world.” 2 UNASUR member States, also belong to other regional integration organizations (CAN, MERCOSUR, ACTO), and participate as well in other regional integration instances as associate Sates. This is an expression of our needs, which have been recognized for decades, to generate mechanisms that will contribute to reduce individual vulnerabilities and allow for the construction of our common identity, to successfully face the challenges of Globalization, and reaching sustainable and equitable development. This integration process must, nevertheless be accompanied by public policies which generate basic health, education, sanitation, employment and income to ensure full the exercise of democratic principles and human rights and diminishing the asymmetries in the region" The Heads of State which gathered together in the City of Salvador de Bahía, on the 16th of December of 2008, decided to create the South American Health Council, whose purpose is to build a common space for integration on matters of Public Health, incorporating the efforts and achievements of other regional integration mechanisms, promoting common policies and coordinated activities among UNASUR member States.

On November 24th, 2009, the health ministers of the member States resolved on the need to formulate a Five Year Plan (2010-2015) for the South American Health Council which has been assembled by the Epidemiological Barrier, Universal Health Systems, Universal Access to Medication, Health Promotion Indicators and the Human Resources Management Technical Groups, technically compiled and coordinated by the current Protempore Chair, the Ministry of Public Health of Ecuador.3

1 2 3

Constitutive Treaty of the south American Union of Nations.

"Peru and the South American Union of Nations" website, Ministry of Foreign Affairs of Peru.

Annex A details the methodology used to compile the present docoment, Five Year Plan.

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1.

HEALTH INTEGRATION IN SOUTH AMERICA

Current Experiences in South American Health Integration The region began with economic integration processes first and then successively with social integration. The most recent processes stand out: MERCOSUR, the Andean Integration System and ACTO. On Health issues, the Andean Health Organism: Convenio Hipólito Unanue (ORAS CONHU) is an International Governmental Agency created by the ministries of Public Health for the specific purpose of integrating, and developing coordinated actions to face common problems and contributing to ensure the right to universal health access. ORAS CONHU is led by the Board of Health Ministers of the Andean Region (REMSAA) and it has a permanent Secretary General.

The ORAS CONHU has a Strategic Plan for 2009 - 2012, which prioritizes Andean Health Integration, the South American Epidemiological Barrier, the development of universal health systems, universal access to medication, public health promotion and social determination actions and finally, the development and management of human resources in Public Health.

MERCOSUR is another regional integration process, which possesses specialized fora on health issues. On one side within the Common Market Council (CMC) there is a meeting of Public Health Ministers (sector) of MERCOSUR (RMS), the purpose of this international instance is to harmonize health policies between member States and associate States. The RMS Intergovernment Commission handles issues such as AIDS/HIV, Dengue fever, Medications Policy, Donations and Transplants, Risk Management, among others. Work Sub Group Nº 11 (SGT 11) which is part of General Market Group (GMC) is another technical forum, which is responsible for normalizing national standards in order to facilitate free circulation of goods, persons and services, within the member countries. SGT 11 has three Commissions’, which work on issues related to best practices in pharmacology, chemical pharmaceutics, blood and blood derivates, medical products, minimum acceptable standards for health services, port of entry, airport and border controls, technological assessments, etc. Worthy of mention is the fact that SGT 11 submits Draft Resolution Proposals to the GMC, which in turn must be incorporated into the internal ordainment of each Member State, once they are approved, and therefore become mandatory.

Finally, the Amazon Cooperation Treaty Organization - ACTO [Organización del Tratado de Cooperación Amazónica OTCA], crated in 1978, which promotes joint cooperation and development actions within the Amazon basin. Differently from, the Andean Integration System and MERCOSUR, it has very specific objectives, hence by its own nature and composition it functions by appointed commissions, one of which is the Special Health Commission of the Amazon (CESAM).

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The ACTO agenda includes the following priority areas i) develop institutional capacity, ii) environmental health, including the management of trans-border resources of the Amazon River basin water shed, iii) transmissible diseases, with emphasis on malaria and epidemiological surveillance network, iv) sustainable development of the Amazon territories, v) improving the quality of life and health care access for the Amazon population.

The most recent regional integration effort has been the creation of the South American Health Council (UNASUR Health) which proposes "consolidation of South America as a space of which Public Health is an integral part contributing to everyone's wellbeing and development, incorporating and integrating the sub-regional efforts and achievements of MERCOSUR, ORASCONHU, and ACTO (8) On April 21st, 2009 the Member States of the South American Health Council proposed a Health Agenda which prioritizes five (5) work areas i) Epidemiological Barrier, ii) Development of universal health systems, iii) universal access to medication, iv) public health promotion and determination actions, and v) the development and management of human resources in Public Health.

The South American Health Council considers health as a driver for transformation of human beings and the economic development of the region and determines its actions on the consensuated values contemplated in the agreement for its creation on november 28th,20084:  Health is an essential right of human beings, of society and a vital component and part of human development,  For its wide political and social acceptance it is considered an important driver for the concert and integration of nations which compose UNASUR  Health must be an integrated into the higher concept of social protectionl and, as such should play an important role in harmonic social development  UNASUR Health may consider the appropiate guidelines of the Pan American Health Organization (PAHO) Member States  The Region has experience and capacities which may be movilized to favor the integration of UNASUR nations  Promote the reduction of existing assymetries between health systems of member States to strengthen regionl health capacity  Promote citizen responsability and participation on health issues, in all thigs public which benefit society at large,  Keep ever present the principles of solidarity, complementarity, respect for diversity and inter-culturality in the institutional development of UNASUR Health and in the promotion of health cooperation initiatives while recognizing the different national realities.

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Taken from the decision to establish South American Health Council of UNASUR, Agreement of the Ministers of Health of UNASUR, Rio de Janeiro, 28 November 2008.

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2.

HEALTH SITUATION IN SOUTH AMERICA5

Health in the context of development and social determination Public Health in the countries of South America - beyond the particularities of each one - occurs within a political, economic and human development context whose evolution is closely linked to all the changes the world has undergone during the last three decades, a period in which globalization, role changes, state reforms, social security crisis and economic growth stand out, but with a widening of the inequity and social exclusion gap. This context has influenced public health through demographic transition, changes in the epidemiological profile and environmental changes.

The social context contains a series of social determinants, which have relevance on public health. Within each country the different development opportunities, are expressed in different health opportunities which in turn interrelate and influence the permanence of economic deprivation, poverty, exclusion of market benefits and social protection, together with other conditions that affect quality of life, opportunities for better health and which contribute for socioeconomic inequity to strongly contribute to health inequity. Among the socially relevant health determinants: income, employment, poverty, education, housing conditions, water, basic sanitation, and rural location standout; along with certain ethnic, cultural, and migration conditions; which jointly concentrate on the most vulnerable, excluded population groups with deprived life conditions and less opportunities for access to health services.

The environmental context has been impacted by the political, economic and social evolution of the different countries, with deteriorating environmental conditions (such as deforestation or soil erosion) unplanned urban and industrial growth which is quite unhealthy, not to mention air, water and soil pollution. Natural disasters (and manmade disasters) and environmental deterioration have direct and indirect consequences on public health. Nevertheless, global concern is growing on that respect, the countries are strengthening legislation, controls and sanitary supervision, and the adoption of the International Sanitary Regulation is relevant.

Although there is a high degree of sensitisation for social determinants among South American countries, these factors sometimes exceed government efforts as well as society at a whole.

Generally speaking the countries have undertaken different policies and cross-sectoral plans for social development, and important partial results have been achieved in many areas (such as poverty reduction, increased employment, better fresh water and basic sanitation improvements) The unconcluded agenda is still challenged to continuously face crucial issues such as food security and nutrition, mother-child population, health promotion, vector management, basic sanitary conditions, and other public health factors, which favor the prevalence of avoidable transmissible diseases. It is also important to consider the significant national and international efforts that seek compliance with the Millennium Development Goals, as well as statements and bilateral agreements emerging from regional summits on issues relative to human development.

Health Conditions

5 Extracted from "South American Health 2008" a view of the situation foccusing on prioritary health care aspects of South American Health Agenda., PAHO/WHO Santiago de Chile, 2009.

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The population growth in the countries of South America has been uneven, with a gradual decline in the explosive growth rhythm and age composition, which shows an aging trend. This situation has contributed to the epidemiological transition process, with an absolute and relative increase of the prevalence and incidence of age related problems and needs, which come with aging. Health conditions - specially risk factors, preventable diseases and mortality - have some components which are closely linked to social determinants; to cross-sectoral health promotion and prevention; and timely and effective access to preventive care, medical treatment, and rehabilitation that will contribute to preserve and improve the health of the population, specially among the most vulnerable groups. Health conditions are also associated to the demographic and epidemiological profiles of the different countries and population groups, the most relevant mortality and avoidable morbidity represent the most significant amount of preventable diseases, complications and avoidable deaths, at least the premature ones.

Co-existing damages due to transmissible diseases subject to prevention and control and chronic degenerative diseases, characterize a double disease burden. Transmissible diseases cause 10.6% of deaths. Malignant neoplasia causes 17.1%, diabetes 4.1%, ischemic heart diseases 9,4%, vascular brain diseases cause 8.7%, and external causes 12.7%. Maternal/infant mortality is higher in countries with lower income levels (like Bolivia, Paraguay, PerĂş) that concentrate highly avoidable death causes. Health inequalities within the countries are reflected by highly avoidable health events (such as malnutrition, maternal/infant mortality and transmissible diseases) closely related to social disparity. The issue with domestic boundaries is currently an important Public Health priority, and we have examples of positive experiences with agreements and cooperation between South American countries in this regard.

Health Systems Health Systems in countries of South America have reached diverse levels of development. Their organization and structure differ in methods of financing and assurance, legal and normative structure, role-played by the central government (state), integration (coordination, segmentation, and fragmentation) participating sectors (public, social security, private) and finally the organization and integration of the support network itself. The national health systems of several countries suffered radical changes in their organization, structure, financing, and performance, especially in regards to state reforms that involved the health sector, particularly during the 90's decade.

The health coverage of the population is provided by different subsystems, among which the public system, social security, the private system, and others like the one provided by the armed forces (each country has a different proportion). The coverage provided by a comprehensive health system is high in countries such as Chile, Brazil, and Venezuela. Social Security with health coverage reaches two thirds of the population in Chile and Colombia, reaches half the population in Argentina, while the other countries have lower population coverage. The private sector (for profit and non profitable) covers approximately one forth of the populations in Ecuador and slightly less than one fifth in Chile, with an even lower coverage among the other countries.

There are other sectors either state owned or private, which have their own health systems (special regime, such as the case of the armed forces, police, and organized workers groups).

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Global coverage reach is universal in most of the countries, although it is limited in countries with lower economic development, according to available information (between 2001 & 2006) approximately 45% of Bolivia's population had no access to health services, and 72% had no social security or medical insurance, in Peru, 42,1% had had no social security coverage or private health insurance, in Paraguay, 38,6% of the population had no access to health services and 81,1% had no social security coverage or private health insurance. During 2006, in Ecuador, 27% of the population had no access to health services and 76% had no social security coverage or private medical insurance.

Sector reforms had diverse effects on national health systems. Among the results that standout, is functional separation, in which insurers, loan agencies, fiscalizers and private citizens participate along with the State. This incentivates decentralization, and private sector growth (direct or indirect privatization of the assurance and provision of public health services), changes forms and sources of financing, the performance of assistence services, focusing on effective planning, payment and control of health assistance services provision, and the search for new mechanisms to increase health systems coverage (such as the creation of basic services packages and the extension of social protection), especially those destined to cover marginal and destitutepopulation groups.

Meanwhile, a series of problems emerged, such as segmentation, low integration, competition among service sectors and even within the services network itself. An increase in private spending in many of the countries risked limiting effective access to health assistance services.

The regulatory function of the Ministry of Public Health was weakened (diminished regulation of inssurance markets and health services) there was a deficit on Public financing for health, which in turn caused a reduction in network performance and efficiency, especially for the Public health system, which led to the prioritization of paleative treatment actions over preventive health care.

Internal solidarity and global network efficiency and performance of the public health system was reduced. The decentralization process was incomplete and uncoordinated, which contributed to increase the fragmentation of the helth services, with solidarity lost within the system and greater inequity in terms of health care access and results.

The benefits and problems atributed to the reform process of the health systems, brings new challenges among which standout: the need to strengthen the regulatory function of the health and sanitation authority, to strengthen and monitor the essential functions of Public Health, to seek integrating mechanisms for the Public Health network (while respecting local autonomy) with equity and solidarity criteria, to recover the levels financing levels and critical resources allocation to assure an efficient performance for the health system and strengthen primary health care(poor, vulnerable and marginal populations must continue to be prioritary).

Regulation of the health insurance and health care provision services is crucial, especially considering the current international financial crisis which could compromise the financing of the health system itself.

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Human Resources Health care staff are crucial in health systems. South America currently has approximately 656.000 doctors 210.000 nurses, and 330.000 dentists, which translates into rates of 16.9 5,4 8,8 per 10.000 habitants respectively. Between 1995 & 2005, the availability of doctors increased 20%. A positive growth has been maintained for health human resources, but a shrinking trend has been confirmed for that growth. Nevertheless, population continues to grow, and currently there are several limiting factors that place the amount, distribution and capability of health personnel at risk, especially within the public health system and among the poorest countries.

There are frequent shortages, poor distribution and inadequate preparation for health care personnel to respond to health needs, these obstacles are accentuated by internal and external migration. As a result, the distribution of health personnel is uneven, it concentrates in urban areas, with important misbalances in several professional fields: planning in human resources continues to be poor both in quantity and quality, a noticeable flaw, while the training continues to be traditional. Urban areas have 8 to 10 times more doctors than rural areas. This is accentuated by the migration flow of professionals within the national territory (for instance, from public to private sector, and from rural to urban locations) and international migration towards countries that offer better professional expectations.

An important number of countries in the region do not have their requirements in medical personnel to offer minimum coverage (25 health workers per 10.000 inhabitants). In this sense, current priorities relate to the need for better planning among healthcare personnel, their availability, distribution (according to needs and equity criteria) conditions compatible with decent work, an ethical code regarding migratory flows and appropriate training and education according to real needs. With this context in mind, since 2007, 20 regional goals for Health Human Resources have been determined based on identified challenges within the framework of A Call To Action (PAHO/WHO - Toronto, 2005), which have the support of the Member States and are linked to renewed Primary Health Care (PHC) commitments (Santiago, 2008).

Policy and Access to Medications6 Access to medication and strategic medical supplies are essential parts of the right to health, a fundamental right of all human beings and an essential requisite that should be guaranteed by governments. Nevertheless, a significant amount of people in the world and in the countries of UNASUR face limited access to these services.

To that end the development of a southamerican medication policy which swill define the activities to improve universal access to medications for the UNASUR Member States was propossed.

The main axxis for the South American Medication Policy has been the adoption of the following directives:

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Section added by the "Universal Access to Medication" Technical Group, April 27th, 2010.

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1. To guarantee access and equity in health activities including access to medication, vaccines, and other strategic health supplies; 2. To guarantee pharmaceutical assistance services at different levels of Health Care, while considering the necessary articulation and observance of established regional priorities.

3. To implement "Essential Medication Lists" as an instrumental part of UNASUR' universal access to medication policy and national 4. To develop, validate, educate and train human resources; 5. To extend the current installed capacity of public and national pharmaceutical laboratories to produce medication, in order to address health system needs, considering UNASUR established regional health priorities; 6. To promote, strengthen technology transference and modernization at public and national pharmaceutical laboratories to produce medication and immune biological products of strategic relevance for health systems, by establishing Health Research Facilities or Productive Centers to increase innovation, and levels of competence; 7. To implement regional research projects and policies for technological transference, development, and production in order to increase the capacity, sustainability, complementarity, for the scientific and technological development of the countries; 8. To implement regional scientific and technological activities by involving research facilities and universities, in order to develop technological innovations that address the interests, needs and priorities of UNASUR countries; 9. To define activities that research the use of medicinal plants and phyto-therapheutic medications in Health Care while respecting and safeguarding the ancestral knowledge and biodiversity that exists in these countries; 10. To strengthen the sanitary monitoring systems of the countries to guarantee access of the population to safe, effective health services and good quality products; 11. To establish mechanisms in order to determine, negotiate, and regulate prices for medications and strategic supplies; 12. To promote rational use of medications, particularly regarding such activities as promotion, advertizing, prescription, sales and use; 13. To work with other UNASUR countries before diverse international fora and articulate joint activities together defending sanitary interests in their behalf.

14. To make use of the flexibilities foreseen in ADPIC, recognized by the Doha Declaration and confirmed by the World Public Health Innovation and Intellectual Property Strategy, as essential elements of public health policy, particularly in regards to access to medication and health technology strategies; 15. To de-incentivate granting of undue, abusive or unjustified patents, while improving the quality of the patents to be granted; 16. To support the development, production and introduction of generic versions of medications, as a mechanism to extend universal access to medication within the framework of rational use.

3.

UNASUR HEALTH OPERATIVE FRAMEWORK

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UNASUR Background

On December 8th, 2004, gathered together in the city of Cusco, Peru, the Presidents of twelve independent states of South America7, decided to constitute the Community of South American Nations (UNASUR), under the premise that the convergence of political, economic, social, cultural and security interests of the South American States constitutes a potential factor to strengthen and develop their internal capacities, and to better insert themselves in the International Community of Nations.

Through the Cochapamba Declaration of December 9th, 2006, the Heads of State decided, as their first ruling principle for the integration of South America, to establish solidarity and cooperation in their common search for greater equity, reduction of poverty, curtail asymmetries, and strengthen multilateralism as the axis for international relations.

In the institutional scope, the South American Community of Nations was endowed with the following instances:     

Yearly meetings between Heads of State and Government Semestral Meetings of Ministers of Foreign Affairs Sectorial Ministerial Meetings Meeting of High Commissioners Protempore Chairmanship

During the Extraordinary Meeting of Heads of State and Government, celebrated in Brasilia, on May 23rd, 2008, the South American Union of Nations Constitutive Treaty was subscribed.

Article 11 of the Treaty, lists the following as the judicial sources of UNASUR: 1.

2.

3.

4.

5.

The Constitutive Treaty of UNASUR and the additional instruments The Agreements celebrated between the Member States of UNASUR based on the additional instruments, mentioned in the preceeding point The Decisions reached within the Council of Heads State and Government The Resolutions reached within the Council of Ministers of Foreign Affairs The Dispositions reached within the Council of Delegates

So far to date, the will to consolidate three additional Councils has been confirmed, which are the following: defense, health and energy, and the creation of four more: the struggle against drug traffic, social development, infrastructure and education.

According to Article 5 of the Constitutive Treaty, additional institutional instances may be convened and conformed: Ministerial Sectoral Meetings, Ministerial Level Councils, and Work Groups and others as required, of either permanent or temporary nature, in order to fulfill the mandates and recommendations of competent bodies. These instances shall be held accountable for the performance of their duties through the Council of Delegates, which will then raise it to

7

Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay and Venezuela. Mexico and Panama are observing countries.

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the Council of Heads of State and Government or the Council of Ministers of Foreign Affairs, as corresponds.

Article 6, on the other hand, establishes the faculty of the Council of Heads of State and Government to convene Ministerial Sectoral Meetings and to create Ministerial Level Councils.

South American Health Council

In the Cusco, of 2004, Constitutive Declaration, the Presidents reaffirmed their essential commitment to the struggle against poverty, the elimination of hunger, the generation of decent employment and the universal access to health and education, as fundamental tools for people’s development.

Likewise, the Constitutive Treaty of UNASUR stipulates the universal access to health services constitutes a specific objective of the block (Art. 3, pt. j).

The Heads of State and Government, gathered together in the City of Salvador de Bahia, on December 16th, 2008 decided the creation of the South American Health Council, considering the need of the block to have a consultative and cooperation entity in matters of health, and approved the following: The South American Health Council' purpose is to build a common space for integration on matters of Public Health, incorporating the efforts and achievements of other regional integration mechanisms, promoting common policies and coordinated activities among UNASUR member States.

The South American Health Council (Consejo Suramericano de Salud - CSS) is a permanent instance composed by the Ministers of Health of UNASUR, whose creation is based on Articles 3, cl. j, 5 and 6 of the Constitutive Treaty of UNASUR, adopted in Brasilia, on May 21st, 2008.

The importance of the conformation of CSS is rooted in the constitution of a South American political institution with competence on sanitary issues, facing problems or challenges which transcend national borders while developing shared values and interests, that will facilitate the interaction of sanitary authorities of Member States through consensus.

The South American Health Council is composed the Ministers of Health of the State Members of UNASUR. It is the highest-level decision instance in matters of health, supported by:  A coordinating committee formed by main and alternate delegates from each Member State, plus one representative from each: MERCOSUR, ORAS CONHU, ACTO, PAHO, which act as observers, in transit. The main purpose of this committee is to promote the achievement of the Councils goals, coordinating positions on strategic issues, preparing drafts for Agreements and Resolutions and doing the follow up work for the different Technical Groups.

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 The Technical Secretariat under the charge of the Protempore Chair (PTC) plus two delegates from the prior and the future PTC country, in order to guarante work continuity.8  Technical Groups responsible for proposal, plan and project analysis, drafting, preparation and development aimed at achieving South American Health integration, according to the guidelines established by the Work Plan. Technical Group management must be supported by the current integration processes (MERCOSUR, ORAS-CONHU, ACTO, PAHO and CARICOM).

The Council Chair corresponds to the Minister of Health from the same country which occupies the Protempore Chair of UNASUR, and whose responsibility is to coordinate activities from all instances and to direct the Technical Secretariat.

In Agreement 01/09 of April 21st., 2009, the Health Ministers established the attributes of the Coordinating Committee, the Technical Secretariat and the conformation of the Technical Groups.

Judicial Nature of the South American Health Council Agreements Article 12 of Constitutive Treaty of UNASUR, establishes that the approval for due process of the norms must be adopted by consensus. Likewise, it establishes that normative procedures resulting from UNASUR bodies shall be mandatory for Member States once they have been incorporated into the judicial ordainment of each country, according to the corresponding internal procedures.9

8

Currently the activities are carried out entirely by the countries exercising the protempore chair position (PTC) The need to incorporate UNASUR normative procedures into the internal judicial ordainment helps to forsee that the operative framework would be similar to that of MERCOSUR, where resolutions addopted lack validity until they are incorporated by the Member States.

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4.

VALUES, PRINCIPLES AND STRATEGIC INDICATORS

The Five Year Plan articulates objectives, strategic goals and activities through cross cutting indicators, which operatively translate, the values which inspired the constitution of UNASUR, and the principles of the South American Health Council.

UNASUR Values The UNASUR Constitutive Treaty, signed in Brasilia on May 31st, 2008, contemplates the following values of integration: Human Rights. To establish the recognition of human rights as the cross cutting axis for development which considers human beings as active subjects for the transformation of their societies, in which the right to health constitutes the pivotal energetic force of the people in the process for South American integration.

Solidarity. As the collaborative effort for advancement and shared responsibility for common health activities in the region.

Equity. Define action policies that address social, gender, economic, political, environmental and cultural inequalities among the population, specially the most vulnerable groups.

Participation. To determine social oversight for health policies.

South American Citizenship. To point out guidelines for South American citizenship, to create a sense of belonging and a desire to build a society in which the main purpose for life is regional Good Living (SUMAK KAUSAI).

UNASUR Health Principles The principles reached by consensus among the Member States of UNASUR and the Extraordinary Summit Meeting held on December 16th, 2008, in Salvador de Bahia, Brazil, in regards to health issues: 1. Is the driver for the concertation and integration of nations 2.

To value regional capacities in health

3. Respect for diversity and interculturality

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Strategic Indicators 1. High risk and borderline geographycal areas. The actions proposed by UNASUR health shall prioritize populations which are located in: hard to reach, ruraly disperse, urban marginal settlements, where armed conflict and forcefull displacement, makes them prone to diverse diseases.

2. Vulnerable and excluded populations. The target population for UNASUR health is that in which people have very little or no: i) state presence or access to health services, ii) communication and unequal market economy, iii) extreme poverty conditions.

3. Interculturality. UNASUR health would be incline towards legitimazing diverse cultures, without harming their cohesion, autonomy or identity.

4. Institutional work and development networks. Networking will be promoted as a mean for information and experience exchange which will contribute to strengthen the knowledge of Member States on health issues.

5. Standards, procedures, and instrument armonization and ratification. To achieve common language and protocols which will allow improved communication in the region.

6. Research and innovation. Decisions will be made regarding activities where diverse areas will be prioritized for research in order to generate new ideas, concepts and products to overcome common health problems.

7. Information and communication. Mechanisms will be identified to make advances in health integration more evident.

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5.

STRATEGIC MAP

To consolidate South America as a space for integration that contributes to everyone’s health.

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6.

GOALS, STRATEGIC OUTCOMES AND ACTIVITIES

The Five Year Plan (Quinquennial) 2010 - 2015 includes the following Working Areas that were determined by the South American Health Council.

1. South American Health Vigilance & Response Network 2. Universal Health System Development 3. Universal Access To Medication 4. Health Promotion And Determinants 5. Human Resource Development And Management The following parts present the Goals, Strategic Outcomes and Activities by Working Area.

Annex B includes a Summary Table Of Goals, Outcomes And Activities By Working Areas.

Annex C includes Indicators For Goals And Outcomes.

Annex D includes Summarized Budget 2011 - 2015.

Because of the dynamic nature of the Region's Health Problems, the Ministers of Public Health have disposed for the Coordinating Committee and the Technical Groups to develop the following issues to be incorporated into the Five Year Plan: 

Food Sovereignty

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Famine, Food, Nutrition

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Environmental Health

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Health Conditions at Borders



Health of Immigrant Population

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Emergencies and Natural Disasters

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Gender Issues

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Mental Health

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Inter-Culturallity

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Sanitary Race

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Violence

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6.1 - S. AMERICAN HEALTH MONITORING & RESPONSE NETWORK Strategic Objective Establish an Epidemiological Monitoring and Response Network for Transmissible, Chronic Non-transmissible Diseases & Public Health Events Results and Activities

Result 1 Indicators for selected regional risk, morbidity, and mortality rates.

Activities 1.1 Definition of indicators.

1.2 Definition of sources available for building of the indicators. Development of management proposals for sources lacking in the country.

Result 2 Information System for the notification of priority illnesses in the region, implemented at a sub-national and national (VIGISAS/RAVE).

Activities 2.1 Build a Unified List of priority illnesses for the region.

2.2

Identification of the history and problems relating to participation of the countries in the notification systems (VIGISAS/RAVE).

2.3

Identification of the opportunities and threats for the integration of a unified system.

2.4

Establishment of the commitments for reactivation and strengthening of participation.

Result 3 Monitoring and Evaluation System (M&E) for the Monitoring Network.

Activities 3.1. Implementation of the Monitoring and Evaluation System (M&E) throughout all countries.

3.2. Establishment of commitments for the monitoring and evaluation of the monitoring network.

3.3. Assignment of the responsible party for the administration and consolidation of the information.

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Result 4 Basic Capabilities for the Monitoring and Control of ESPIN & ESPII implemented according to the International Public Health Regulations (RSI).

Activities 4.1 Strategic and investment plan to strengthen the national capabilities.

4.2

Plan for monitoring and updating the national capabilities.

4.3

Establish a monitoring and early warning system for the region.

Result 5 Dengue-UNASUR Network to Mitigate the Impact of Dengue in the Region is working.

Activities 5.1 The South American Monitoring Network incorporates strategic information about Dengue in the region.

5.2 Monitoring and Evaluation System of the Strategies for prevention, control and mitigation of Dengue established for the region.

5.3 Strategic Fund established for the operating of the network.

5.4 Death from Grave Dengue reduced in the region.

Result 6 Consensus strategies implemented for the prevention and control of chronic non-transmissible illnesses in the region.

Activities 6.1. Prepare surveys and results for risk factors of illnesses.

Result 7 Promote a South American Immunization Program.

Activities 7.1. Develop the proposal for the South American Immunization Program.

1.2. Strengthen the immunization program to protect the achievements and work on the incomplete Agenda, confronting the challenges for the introduction of new vaccines.

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6.2 - DEVELOPMENT OF UNIVERSAL HEALTH SYSTEMS

Strategic Objective Form Universal Health Systems in the South American countries, recognizing the right to health, with an inclusive approach.

Results and Activities Result 8 Improve the equity and access to universal and integrated healthcare systems.

Activities 8.1. Review laws to verify if the right to healthcare it is effective in the national regulations.

8.2. Promote the formation of integrated networks for healthcare services, based on the PHC. 8.3. Ensure that the financing mechanisms for services are guaranteed so that manner of insuring persons does not constitute an access barrier.

8.4. Strengthen the reciprocity and complementarity of healthcare services delivery among the countries, especially in border regions.

8.5. Advance towards the harmonization of healthcare accounts and impact studies of the reciprocity and complementarity.

8.6. Strengthen the regulatory function of the national Health Authorities within the perspective of the transformation process, oriented towards the formation of universal systems.

Result 9 Create & implement a Universal Healthcare System Monitoring & Evaluation mechanism.

Activities 9.1. Arrive at a consensus on the group of indicators that permit measuring the universality and equity of the health systems.

9.2. Prepare a regional base line.

9.3. Periodic monitoring and analysis of the group of consensus indicators

Result 10 Guarantee health system democratization through citizen empowerment in the decision making process, and with their active participation.

Activities 10.1. Prepare guidelines for the incorporation of the opinion of users and the public participation in the production process of health services.

10.2. Monitor the advancements of the public participation.

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6.3 - UNIVERSAL ACCESS TO MEDICATION Strategic Objective Develop strategies and work plans in order to improve the access to medicine.

Results and Activities Result 11 Recommendations to strengthen & coordinate productive capacity of prescribed medication in the region.

Activities 11.1. Determine the need for medicines and other supplies for health, aimed at the morbidity-mortality profile of each country.

11.2. Map the identified public and private, national and international, capacities of each country to produce medicines and other supplies for health.

11.3. Identify the concentrations in the pharmaceutical market relating to the supply of medicines according to therapeutic classes.

Result 12 Reduce Medicine entry barriers that originate from the existence of intellectual property rights.

Activities 12.1. Promote the application of a homogonous UNASUR guide where criteria that guarantee quality of pharmaceutical patents are incorporated, from a public health perspective.

12.2 Promote the application of a guide for the application of obligatory licenses.

12.3 Build a database of patents.

12.4 Create a database of patent oppositions.

Result 13 Reduce entry barriers caused by the lack of incentives for medicine development & innovation.

Activities 13.1. Define a research priority agenda for the countries in the region, based on public health needs.

13.2. Map research centers and lines, aiming for the creation of a research network.

13.3. Reach a consensus on alternative mechanisms for the promotion of innovations.

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Preparation of a political price proposal that favors access to medicines.

Activities 14.1. Implementation a Medicine price database for UNASUR. 14.2. Promote new price negotiations and joint purchases of medicines and supplies that consider mechanisms to separate obstacles and barriers faced in previous experiences.

14.3. Share experiences and promote cooperation in aspects linked to the economic regulation of medicines, to promote its implementation in countries where it is feasible.

Result 15 Preparation and promotion of strategies that favor the rational selection and use medicines.

Activities 15.1 Develop criteria for the selection of essential medicines.

15.2 Promote the compulsory use in the UNASUR countries of a list of essential medicines in purchases, in clinical protocols and in their coverage.

15.3 Promote the harmonization of official protocols for treatments.

15.4 Promote rational access to medicines by means of the harmonization of ethical and alternative criteria and mechanisms to strengthen the regulation over the promotion and advertising of medicines.

Result 16 Bring about a harmonized monitoring and control system for UNASUR medicines in order to promote access to safe, effective and quality medicines.

Activities 16.1. Promote mechanisms to harmonize an information system for the monitoring control of medicines and share information between regulatory authorities with purpose of strengthening the access to medicines.

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16.2. Strengthen public health regulations through homogenous criteria for the registry of medicines.

Result 17 South American policy for universal access to medicines has been prepared.

Activities 17.1. Prepare a comparative document on medication policies.

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17.2. Prepare a document covering South American Universal Health Care policies, considering treatment with conventional medications as well alternative medicinal plants and natural products.

Result 18 Promote production and use of generic medicines.

Activities 18.1. Make recommendations & incentives to strengthen the production of generic medicines.

18.2. Make recommendations to strengthen the incentives for the prescription of generic medicines by their generic name, by healthcare professionals, and their acceptance on behalf of the public.

For the achievement of these results it is necessary to strengthen the training processes for professionals in the healthcare, sector that cover the following subjects:  Evaluation of healthcare technologies.  Evaluation of pharmaceutical patents.  Rational use of medication.

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6.4 - HEALTHCARE PROMOTION & SOCIAL DETERMINANT ACTIVITIES

Strategic Objective Strengthen the promotion of healthcare and action over the social determinants with the objective of reducing inequalities in each of the member countries by means of generating information, inter-sectional coordination and the community participation in the creation, execution and monitoring of public health policies.

Results and Activities Result 19 Basic indicators covering equity in healthcare, evaluation criteria for policies for reduction of inequities and monitoring mechanisms have been established by consensus.

Activities 19.1. Creation of a work group among the countries with the responsibility of defining basic indicators and common criteria for the evaluation of policies for equity in healthcare.

19.2. Establishment of a work group in each country to collect information for the basic indicators.

Result 20 Contents of promotion of healthcare and social determinants incorporated in institutions and exchange programs of the technical group for development management of human resources in healthcare.

Activities 20.1. Define and collect program contents for education and training covering PS DS for different parties with different profiles through an ad hoc work group.

20.2. Provide the program contents to the technical group for development management of human resources.

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Result 21 Methodologies and strategies for intersectional cooperation and social participation in healthcare available for the implementation of policies.

Activities 21.1. Exchange of intersectional cooperation and social participation experiences throughout the network.

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21.2. Systematization of inter-sectional social participation.

21.3. Evaluation of intersectional and social participation experiences through investigative projects.

21.4. Promote public and private financing for promotional activities for healthcare, independent of their manner of financing.

Result 22 Make social communication mechanisms available to guarantee access to information about PS and DSS to the different segments of society.

Activities 22.1. Generate communication programs for the PS and DSS incorporated in the Web page of the South American Council for Healthcare of UNASUR. 22.2. Produce a Bulletin and other methods of broadcasting of PS and DSS of UNASUR. 22.3. Promote and participate in events about PS and DSS, including those brought about by international organisms.

Result 23 Protocols of investigation for multicenter projects jointly established and implemented in the public policy areas oriented towards equity in intersectional health for the promotion of healthcare, actions over DSS, and social participation in healthcare.

Activities 23.1. Propose lines of investigation in the PS and DS areas.

23.2. Establish an ad hoc work group in charge of the development process of the multicenter investigation process and provide proposals to make their implementation feasible, in coordination with the investigative groups and i institutions existing at a national level.

23.3. Create a regional project database in the PS and DS areas.

Strategic Objective Encourage the cooperation with the diverse institutions of UNASUR with the objective that these policies, programs and proposed actions consider the impact on healthcare and its determinants.

Results and Activities Result 24 Strategies defined to promote dialogue and analysis of the impact on healthcare of the policies of the different councils of UNASUR.

Activities 24.1. Identify and analyze the policies of the different councils of UNASUR with relation to their impact on healthcare.

24.2. Undertake and participate in meetings with the different councils of the UNASUR, highlighting the PS and DS. 24.3. Spread information through different communication tools to the different councils of the UNASUR, highlighting the PS and DS. 24.4. Provide the different Councils of the UNASUR with methodologies for the analysis of the impact of their policies on healthcare.

24.5. Strengthen action initiatives for the reduction of inequities in healthcare such as: networks or intersectional collectives related to gender and healthcare, interculturallities, climactic change, sovereignty and food supply security.

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6.5 - HEALTHCARE HUMAN RESOURCES DEVELOPMENT & MANAGEMENT

Strategic Objective Strengthen the direction, formulation, implementation and management of the human resources of healthcare in general and, specifically, in the technical areas of the Healthcare Agenda of the UNASUR.

Results and Activities Result 25 Sustainable human resources policies in each country, including the technical areas of the Healthcare Agenda of the UNASUR and greater information covering the development process of personnel in the areas of the Healthcare Agenda.

Activities 25.1. In each country strengthen the Rectory and Governance of the Ministries of Health in the areas of Work Management and Education and Training of Human Resources in Healthcare.

25.2. In each country promote the coordination of the development of human resources in the Ministries of Health, in general in the areas of the Healthcare Agenda of UNASUR. 25.3. Strengthen the institutions that permit governance in the area of human resources.

25.4. Promote strategic information systems for the development and management of human resources, with a regional focus and common and comparative parameters.

Result 26 Reduction of the migration of personnel and its impact on the healthcare systems in the region, with an emphasis in the areas of the Healthcare Agenda.

Activities 26.1. Development of an analysis of the situation covering the factors that influence the migration of healthcare personnel in the Region.

26.2. Develop strategies for overcoming the causes of migration, promoting the reduction in gaps in distribution.

Result 27 Development of investigation and promotion of leadership in priority areas based on the promotions of the ISAGS.

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Activities 27.1. Creation of the South American Government Institute of Health (ISAGS) and, through its intermediaries, the implementation of seminars, courses, internship programs and other initiatives for the improvement of leadership at the healthcare systems level and, in particular, in the areas of interest of the Healthcare Agenda of the UNASUR. 27.2. Promotion of special investigations and studies to support the development of healthcare systems in the region.

Result 28 Promote permanent education in the network of supporting institutions in the priority areas of the Healthcare Agenda of the UNASUR. Activities 28.1. Promote the development, at a national level, of the supporting institutions of the healthcare systems to assure the permanent education and training of human resources.

28.2. Establish networks of supporting institutions with the purpose of establishing technical cooperation among them and guarantee the convergence of actions in the area of education of personnel.

28.3. Establish a Grant Programs for the development of human resources in critical areas of implementation of the Healthcare Agenda of the UNASUR.

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7.

FINANCING METHODS & RESOURCE MOVEMENT

Sources of Financing The sources of financing under the Five-Year Plan will consist principally of: i) Voluntary National Funds and ii) Foreign financing.

Voluntary National Funds: the Member Countries will destine a voluntary annual amount to finance the ordinary approved expenses in the annual budget of the FiveYear Plan. This amount will reflect the priority that UNASUR Healthcare grants to the identified activities necessary to obtain the programmed Results.

Foreign Financing: through the Protempore Secretariat, negotiations to raise financing for the contemplated Activities contemplated in the Five-Year Plan may be undertaken. For the presentation of proposals or projects, each Technical Group, or among them, will send the forms to the Protempore Secretariat for processing and formalizing before the identified financing entity.

Harmonization and Aligning of Cooperation The implementation of the Five-Year Plan will be based on the principles of harmonization and alignment of the national and international cooperation. In this environment, to the extent possible, the use of national structures and systems will be promoted and the establishment of parallel structures for the execution of the Plan will be avoided (except for functional arrangements like those described in the section referring to the Management of Five-Year Plan).

For the purpose of harmonizing and aligning cooperation, a table of cooperating parties in healthcare will be formed and it will be presided over by the Protempore Presidency through its Secretariat. The table of cooperating parties in healthcare will meet each two years to evaluate the advancements and agree on the support for the coming year. Within the meetings of the table of cooperating parties in healthcare, the Coordinating Committee will act as technical liaison.

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8. FIVE-YEAR PLAN MANAGEMENT Political Responsibility The South American Council for Health has the political responsibility for the accomplishment of the objectives in the Five-Year Plan, it assigns the resources necessary to reach them and orders the evaluations and adjustments necessary during implementation. The Council tends to seeing that the execution of the Five-Year Plan is aligned with the regional commitments to create a stage for integration in healthcare and that said compromises are fulfilled within, and by, each Member Country.

Responsibility for Implementation The implementation of the Five-Year Plan will be the responsibility of the Coordinating Committee that will support the Technical Groups. The Technical Groups existing to date are the following:  Epidemiological Shield  Development of Universal Healthcare Systems.  Universal Access to Medicines.  Healthcare promotion and procedures for determinants.  Development and Management of Human Resources.

The make up, attributes and functioning of the Technical Groups is regulated by Annex II of Agreement 1 of the Resolution of the South American Healthcare Council dated April 21, 2009.

If during the implementation of the Five-Year Plan, the Coordinating Committee identifies the need to modify or create new Technical Groups, the Coordinating Committee will propose approval to the South American Healthcare Council.

During the implementation of the Five-Year Plan, the Coordinating Committee will be responsible for the intersectional and technical cooperation with other institutions of the UNASUR. For this purpose, institutional strengthening is foreseen through the South American network of offices for international relations/cooperation for healthcare (REDSSUR – ORIS).

The Ministries of Health of the Member Countries, on their behalf, will execute those activities of a national nature, necessary for the fulfillment of the objectives of the FiveYear Plan.

Operating Plan and Annual Budget Each year, the Coordinating Committee, supported by the Technical Groups, will draft an Operating Plan and Annual Budget that will contain the specific responsibilities by activity and the estimated amounts for their execution. The South American Healthcare Council will approve the Operating Plan and the Annual Budget.

Financial Management The responsibility for the assignment and proper management of the virtual fund of financial resources corresponds to the Protempore Presidency through its Secretariat.

The virtual fund may be managed through a fund management entity. Upon making a change of management of the Protempore Presidency, an accounting of the use of funds will be undertaken, supported by a technical-financial report.

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9.

MONITORING AND EVALUATION

The architecture for the Monitoring and Evaluation of the 2010- 2015 Five-Year Plan will be drafted based on the Hierarchy of Objectives as observed in the following graph.

M & E ARCHITECTURE

UNASUR Health - FIVE-YEAR PL FIVE YEAR PLAN OPERATIVE GOALS

INSTRUME

Indicator Table

EVALUATION è GOALS

Yearly Operative Plan

OUTCOMES MONITORING

Contrac

ACTIVITIES

DECISION MAKING & IMPROVEMENT Improvement Activities

Ministers Population Cooperation

Monitoring The Protempore Secretariat will undertake the monitoring of the Five-Year Plan and will present to the Coordinating Council reports on advancements.

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Coordinating Council will report annually to the South American Council for Healthcare concerning the advancement of the implementation of the Five-Year Plan according to the goals defined for the group of consensus monitoring indicators.

The creation of a virtual domain is contemplated which will permit the socialization of the advances of goals, activities and results. To undertake the monitoring process of the Five-Year Plan, there will be a monitor that will permit tracking of indicators and drafting of reports on the advancements.

Evaluation The fulfillment of the strategic results of the Five-Year Plan will be evaluated externally at the midpoint of the period of implementation (June 2013). The results of the intermediate evaluation will be used to reformulate the results to guarantee the fulfillment of the Strategic Objectives of the Five-Year Plan.

At the end of the period of the Five-Year Plan (2015), an evaluation of the impact of the Five-Year Plan in South America will be undertaken. The findings of said evaluation will be the input for the drafting of the following Five-Year Plan.

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ANNEX A

2011 – 2015 FIVE-YEAR PLAN CONSTRUCTION METHODOLOGY The South American Healthcare Council for the 2011-2015 Five-Year Plan posed the following descriptive phases.

PHASE 1: Definition of contents of Plan The Coordinating Council identified the contents and sections that will make up the Five-Year Plan as a function of the values and principles of UNASUR Healthcare.

PHASE 2: Participatory Preparation On the 24th of November of 2009 in the Meeting of the South American Healthcare Council, an ad hoc Commission was designated to draft the Five-Year Plan based on the contributions of the Technical Groups, whose coordination would be under charge of the Protempore Secretariat of Ecuador (SPEc).

The SPEc drafted a methodological proposal for the participative preparation of the 2011-2015 Five-Year Plan that was approved on the 22nd of December of 2009 by the ad hoc Commission. Each member country of the ad hoc Commission coordinated, in an interactive manner, the preparation of one section of the Plan.

The work was distributed in the following manner:   

The South American political context was prepared by Peru.

The South American healthcare situation was prepared by Paraguay.

The resolutory framework of UNASUR Healthcare was under charge of Argentina.

The SPEc prepared a standard format for the formulation of the Strategic Objectives and Results and Lines of Action that was, subsequently, sent to the Technical Groups.

The five Technical Groups met in person or virtually to prepare the Objectives, Results and Lines of Action, as well as a first budget for the Activities.

PHASE 3: Consolidation and Crosscheck with Resolutions The Technical Groups sent their inputs to the SPEc, which was in charge of consolidating, editing and drafting, with the technical support from ORAS-CONHU and OPS/OMS. This consolidation process included three tasks: i) An exhaustive review of the Resolutions of the South American Healthcare Council approved to date. This exercise permitted assuring that the decisions of the South American Healthcare Council were integrated with the objectives, results and lines of action.

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ii) Establishment of hierarchy of objectives, results and lines of action, with the objective of maintaining internal consistency in the Five-Year Plan. ii) Secondary review of documents with guidelines and current situation of other agendas like Healthcare Agenda for the Americas, Objectives for Development of the Millennium and other regional Action Plans.

The product of this exercise was an initial version of the 2011-2015 Five-Year Plan that was presented to the Coordinating Committee in a meeting that was held in Rio de Janeiro from March 2-4.

PHASE 4: Validation of the Initial Version of the Five-Year Plan This phase permitted discussing, analyzing and validating the initial version of the Five-Year Plan by the Coordinating Committee during the workshop held March 2 4, 2010.

The methodology followed during the workshop was the following: i) Discussion of the sections of Political Context, Healthcare Situation and Resolutory Framework. ii) Establishment of work groups for the revision and validation of proposal of objectives, results and lines of action, the articulation of work areas and possible mechanisms for the raising of resources and financial management. iii) Undertake plenary meetings for the discussion of the results of the work groups and reach a consensus on the contents of the Five-Year Plan.

For the undertaking of group work, instructions and formats were drafted that permitted the collection of observations by the SPEc to make the adjustments agreed to in the preliminary version of the Five-Year Plan.

PHASE 5: Integration of Adjustments to the Initial Version of the Five-Year Plan In this phase, the SPEc integrated the consensus observations and adjustments to the initial version of the Five-Year Plan contributed by the Coordinating Committee (Rio de Janeiro, 2-4 March).

In addition, the corresponding indicators and goals corresponding to the strategic objectives and results were included, as well as the definition of a virtual domain to undertake the monitoring of the Five-Year Plan.

In this phase, the SPEc consolidated a budget for the Five-Year Plan.

As a result of this phase, a new document was produced, that was reviewed technically.

PHASE 6: Verification of Internal Consistency In this phase a subsequent quality control of the document was made by means of a triangulation between Strategic Outlines, Strategic Objectives and Results, Lines of Action and Indicators and Goals, verifying the feasibility of the Five-Year Plan.

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The preliminary version of the Five-Year Plan obtained, was distributed to the Coordinating Committee for observations. The observations were incorporated in the document.

As a result of this phase, a preliminary version of the Five-Year Plan was produced, that was presented to the South American Healthcare Council for approval.

PHASE 7: Approval of the Five-Year Plan (2011-2015) Finally, the preliminary version was presented and approved in the ordinary meeting of the South American Healthcare Council held on April 28th in Cuenca, Ecuador.

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