The dilemma facing Latin America and the Caribbean in the restructuring of the global health system

International health governance is undergoing a profound restructuring. Debates on pandemic treaty reforms, emergency preparedness financing, and global intellectual property mechanisms are moving forward at a rapid pace. However, this redesign carries a clear asymmetry in visibility: while major powers, Global North research centers, and philanthropic donors shape tomorrow’s priorities, Latin America and the Caribbean risks being sidelined, caught in a geopolitical blind spot of institutional reforms.

The regional paradox is striking. The continent possesses the world’s oldest specialized multilateral network, built around the Pan American Health Organization (PAHO), and boasts highly effective collective tools (such as the Revolving Funds for purchasing vaccines and essential medicines) which serve as international benchmarks for negotiating power and procurement management. Despite this, its health priorities are often displaced in global forums. Today, various continental institutions, from PAHO and the Economic Commission for Latin America and the Caribbean (ECLAC) to the Community of Latin American and Caribbean States (CELAC) and the Ibero-American Conference, are seeking to consolidate a coordinated stance on global health that puts the region's needs at the center of the new international architecture.

The difficulties Latin America and the Caribbean (LAC) faces in joining current debates stem from how priorities are distributed within the "Global South." This category groups highly diverse realities together as they compete to channel attention and resources in World Health Organization (WHO) forums and funding mechanisms.

Sub-Saharan Africa legitimately receives priority attention due to its high burden of communicable diseases and its reliance on concessional financing. Consequently, multilateral organizations typically design their vertical aid programs with this region as the primary reference, as it concentrates most of the world's low-income countries.

In contrast, Latin America and the Caribbean remains caught in the "middle-income trap." Its average macroeconomic indicators (such as GDP per capita and life expectancy) lead multilateral bureaucracies to classify almost all its nations as middle- or high-income countries. This classification excludes them from Official Development Assistance (ODA), concessional loans, and technology transfers.

This statistical label masks the fact that averages hide the deepest inequalities on the planet, where underfunded public healthcare systems coexist with highly complex private medicine. Furthermore, it financially penalizes a region carrying a double epidemiological burden (neglected infections alongside a surge in chronic and mental health conditions) that does not fit into the rigid programs designed in the Global North, ultimately blurring the region's voice and priorities in the reform of international health.

The COVID-19 pandemic was not a temporary episode for Latin America and the Caribbean (LAC), but a systemic trauma: with only 8.4% of the world's population, it accounted for 27.8% of cumulative global deaths, recording the highest excess mortality on the planet. This impact was driven by chronic social determinants (such as labor informality, overcrowding, and the neglect of primary healthcare) triggering a historic recession that reversed progress in poverty reduction and collapsed healthcare systems.

According to ECLAC’s report Universal, Comprehensive, Sustainable, and Resilient Health Systems: A Requirement for Inclusive Social Development, sustainable development is unfeasible without health as a pillar of social protection and economic growth. However, the document identifies three critical structural weaknesses in the region:

• Chronic underfunding: Average public spending on health stands at 4.8% of GDP, well below the 6% recommended by the WHO.
• Fragmentation: There is a severe lack of coordination among different levels of medical care.
• Segmentation: Multiple coexisting subsystems deepen inequalities in access.

To overcome this reality, ECLAC proposes reforms based on four pillars: universality, a comprehensive approach with continuity of care, financial sustainability, and resilience.

In parallel, climate change equity is also a priority focus. LAC suffers from high social vulnerability to extreme weather events. To address this, PAHO’s "Policy for Strengthening Health Sector Actions on Equity in Climate Change and Health" aims to protect the most underserved populations (impoverished communities, indigenous peoples, and migrants). This strategy promotes the resilience and decarbonization of health infrastructure, community participation, and intersectoral mitigation to prevent the climate crisis from widening existing health gaps.

Above all, the pandemic exposed a dangerous external dependence on medical countermeasures. Hoarding of supplies and "vaccine nationalism" by countries in the Global North pushed the region to the back of the line, exposing the limitations of traditional multilateralism.

This harsh lesson drove a shift toward regional self-sufficiency. In 2021, at the request of CELAC, ECLAC designed the Health Self-Sufficiency Plan, which does not aim for isolation, but rather for the creation of a continent-wide health industrial complex structured around three active lines of action:

1. Regulatory harmonization: Enabling leading agencies such as ANVISA (Brazil), COFEPRIS (Mexico), or ANMAT (Argentina) to mutually recognize their registrations to streamline the trade of regional medicines.
2. Clinical trial networks: Leveraging local scientific capabilities to conduct studies tailored to the region's epidemiological profiles.
3. Biotechnology consortia: Fostering technology transfer to locally manufacture next-generation vaccines (such as mRNA platforms) and ensure sovereign manufacturing in the face of future emergencies.

(1)  Economic Commission for Latin America and the Caribbean (ECLAC). Social Panorama of Latin America and the Caribbean 2025: How to Escape the Trap of High Inequality, Low Social Mobility, and Weak Social Cohesion. United Nations. November 2025.United Nations Development Programme (UNDP). Under Pressure: Recalibrating the Future of Development in Latin America and the Caribbean. Regional Human Development Report 2025. June 2025.

(2) Data on cumulative mortality as of February 2022. Economic Commission for Latin America and the Caribbean (ECLAC). The Sociodemographic Impacts of the COVID-19 Pandemic in Latin America and the Caribbean. 2022.

(3) Economic Commission for Latin America and the Caribbean (ECLAC). Universal, Comprehensive, Sustainable, and Resilient Health Systems: A Prerequisite for Inclusive Social Development, May 2026.

(4) Economic Commission for Latin America and the Caribbean (ECLAC). Statistical Yearbook for Latin America and the Caribbean, 2025.

(5) Economic Commission for Latin America and the Caribbean (ECLAC). Guidelines and Proposals for a Plan for Self-Sufficiency in Health Matters in Latin America and the Caribbean. Document prepared at the request of the Pro Tempore Presidency of CELAC. September 2021.

Faced with the customary gridlock of major multilateral assemblies, the discussion has found highly influential alternative channels. One of the most significant is the Latin America and the Caribbean dialogue on reforms to the global health system, a process driven by an academic consortium (comprising Monterrey Institute of Technology (Tecnológico de Monterrey), Universidad Mayor de Chile, the Institute for Clinical Effectiveness and Health Policy (IECS, Argentina), and the University of the West Indies (UWI, Jamaica)) with the support of Wellcome Trust under its regional dialogues initiative. The process brought together over a hundred actors, including ministries of health, academia, civil society, and development banks such as the Inter-American Development Bank (IDB), the Development Bank of Latin America and the Caribbean (CAF), and the Central American Bank for Economic Integration (CABEI), to build a common technical stance against the governance traditionally designed by the Global North.

The diagnostic from the Latin American and Caribbean Dialogue on Global Health points toward a profound reform of the World Health Organization (WHO). It proposes moving toward a decentralized model where central bodies focus on global policy leadership, evidence-based guidelines generation, and emergency coordination, while returning direct technical cooperation and implementation to regional mechanisms, which possess a closer and more legitimate understanding of local realities.

To materialize this vision and shield the region's health sovereignty, the consolidation of three strategic platforms conceived as regional public goods is proposed:

• Funding Coordination Platform: A governance space to align the agendas of multilateral development banks (such as the IDB and the World Bank) with national health plans. Its objective is to prevent the dispersal of resources, avoid duplication of efforts, and ensure that financing responds to the region's actual health priorities.
• Regional Health Technology Assessment (HTA) Mechanism: A platform to standardize cost-effectiveness analyses for new treatments and technologies. By generating shared scientific evidence, it equips ministries of health with a solid and coordinated technical position to negotiate prices with the global pharmaceutical industry.
• Latin American and Caribbean Consortium for Vaccine and Medicine Innovation and Manufacturing: A network aimed at consolidating existing biotechnological manufacturing capabilities in the region through public-private value chains, reducing dependence on external supplies during future crises.

The Dialogue warns that the viability of these proposals does not depend solely on political will (which is susceptible to changes in government), but on overcoming chronic structural and territorial barriers: armed violence and transnational crime that fragment territorial management, the restriction of fundamental rights in specific contexts, and severe economic inequality that limits the fiscal space of states. In the face of these barriers, the region's technical and collective health communities emerge as the key actors capable of sustaining stable, long-term technical consensuses.

(6) Tecnológico de Monterrey, Universidad Mayor, The University of the West Indies, Instituto de Efectividad Clínica y Sanitaria, Welcome Trust. Latin America & the Caribbean Dialogue on Reforming the Global Health Architecture. Dialogue Outcomes Document. November 2025.  This dialogue is framed within the Wellcome Trust's global initiative: Rethinking the Future of Global Health.

Translating Latin America and the Caribbean’s technical priorities into high-level political commitments is currently coordinated through two strategic spaces: the Ibero-American space and the EU-CELAC alliance. Both frameworks of scientific and political diplomacy act complementarily to consolidate regional health sovereignty and redefine the region's positioning on the global stage.

On one hand, the Ibero-American Conference has consolidated the region's internal political consensus. Its most recent milestone took place at the XVII Ibero-American Conference of Ministers of Health, held in Madrid on May 14, 2026, serving as a prelude to the XXX Ibero-American Summit of Heads of State and Government. The meeting culminated in the adoption of the Madrid Declaration, a document committing the community's nations to jointly demand a reform of the global health architecture to make it more transparent, democratic, and equitable.

This mandate not only enshrines access to medicines and local production as fundamental rights for inclusive social development, but also establishes commitments in three critical areas:

• Health security in emergencies: Creating coordinated rapid-response mechanisms for cross-border threats.
• Social and institutional well-being: Recognizing mental health as a right and designing policies to address the crisis in health human resources, tackling both job insecurity and the migration of professionals to high-income countries.
• Multilateral governance: Driving the successful conclusion of the WHO Pandemic Agreement, firmly backing the Pathogen Access and Benefit-Sharing (PABS) System.

On the other hand, the bi-regional dialogue space between the European Union (EU) and the Community of Latin American and Caribbean States (CELAC) represents a paradigm shift in health diplomacy. Unlike traditional multilateral platforms, this forum is not conceived under the old framework of development assistance or a "donor and recipient" dynamic, but rather as a strategic alliance based on co-investment, technology transfer, and industrial co-development.

The primary operational engine of this space is the European Union’s Global Gateway initiative, which has prioritized health resilience as one of its economic investment pillars. The agenda of this forum stands out due to its highly practical and productive approach, structured around three key dimensions:

• Co-production and technology transfer: The forum aims to directly connect the European scientific and innovation ecosystem with laboratories and manufacturing plants in Latin America and the Caribbean. This includes transferring advanced biotechnological platforms (such as messenger RNA technology) to enable the region to develop its own manufacturing capabilities for vaccines and complex therapies.
• Strengthening the health industrial complex: It promotes the injection of public and private capital to scale regional industrial capacities. The goal is for Latin America and the Caribbean to move away from relying on critical imports of active ingredients and medical devices, mitigating the supply chain vulnerabilities exposed during the COVID-19 crisis.
• Diversifying and securing global supply chains: For the European Union, the forum represents an opportunity to diversify its own medical suppliers, finding in Latin America a reliable strategic partner with solid technical capabilities and converging regulatory standards.

By framing health as a high-tech economic development sector, the EU-CELAC space not only aims to protect populations against future health emergencies, but also to boost cooperation between both regions. This cooperation contributes to Latin America and the Caribbean's transition toward a knowledge economy, where health sovereignty becomes a driver of sustainable industrial growth.

(7) La Moncloa.Ibero-America Reaffirms Its Commitment to Strengthening Cooperation in Health Matters. May 14, 2026

(8) XVII Ibero-American Conference on Health. Madrid Declaration. Ibero-American General Secretariat. Madrid; May 14, 2026.

Faced with the profound reconfiguration of the international health architecture, Latin America and the Caribbean (LAC) must play a role that recognizes its historical trajectory and structural challenges. The region does not seek to be a mere recipient of guidelines, but rather a co-designer of a more equitable global system. Its priority demands focus on three fundamental pillars.

Overcoming the "Middle-Income Trap" in Multilateral Financing

The region demands that international financial institutions replace eligibility criteria based strictly on macroeconomic averages (such as GDP per capita) with multidimensional indicators of vulnerability and equity. Currently, the classification of almost the entire region as "middle- or high-income" countries excludes them from Official Development Assistance, concessional loans, and non-commercial technology transfers. This label masks the fact that LAC carries the deepest inequalities on the planet, where underfunded public healthcare systems (with an average public spending of 4.8% of GDP, far from the 6% recommended by the WHO) coexist with a double epidemiological burden of infectious and chronic diseases that the rigid programs of the Global North fail to address.

Decentralizing Global Governance and Strengthening Regional Mechanisms

LAC demands a structural reform of the World Health Organization (WHO) toward a decentralized model. Under this framework, central bodies should focus on global policy leadership and issuing evidence-based guidelines, while direct technical cooperation and resource execution must be returned to regional-level organizations. The region possesses the world's oldest multilateral health network, structured around PAHO, and has highly effective collective tools, such as the Revolving Funds for vaccines and medicines, which are benchmarks for collective bargaining. Strengthening and delegating to these local mechanisms ensures that interventions respond to the territorial and epidemiological realities of each population in a much more agile and legitimate way.

Guaranteeing Genuine Technology Transfer for Industrial Sovereignty

The harsh lesson of the pandemic demonstrated that dependence on external supplies and the "vaccine nationalism" of the Global North jeopardize regional security. Therefore, the demand is to transition from an assistentialist "donor-recipient" model to a horizontal framework of technical co-development and health sovereignty. This involves operationalizing the ECLAC and CELAC Health Self-Sufficiency Plan through binding agreements for the transfer of advanced technology (such as mRNA and molecular diagnostic platforms), regulatory harmonization among leading agencies (ANVISA, COFEPRIS, ANMAT), and the creation of local biotechnology consortia. Alliances such as the PAHO-HERA agreement and the EU-CELAC forum must serve as platforms to position the region not only as a consumer, but as a strategic partner capable of manufacturing medical countermeasures and sovereignly diversifying global supply chains.

Conclusion 

The future of health security in Latin America and the Caribbean depends on the capacity of its institutions to sustain technical cooperation channels above the continent's structural barriers and territorial instabilities. Turning the region into an actor with its own voice in international health governance is directly tied to operationalizing the agreements of the Regional Dialogue driven by Wellcome Trust, as well as politically defending mandates such as the Madrid Declaration and the EU-CELAC agreements. Demonstrating the maturity of joint procurement funds and maintaining a unified technical stance are the indispensable steps required for the new global health architecture to evolve toward a truly decentralized, equitable, and democratic model.