Institutional strengthening within the Pan American Sanitary Bureau

Annual Report of the Director 2018 Part 4: Institutional strengthening within the Pan American Sanitary Bureau

Institutional strengthening within the Pan American Sanitary Bureau

The PASB continued to hone its managerial and administrative systems for greater efficiency and effectiveness, closely aligning with ongoing WHO reform and strategic planning, while recognizing and respecting PAHO’s status as an independent international organization which, along with its Director, is directly accountable to the Member States of the Americas.

162nd Executive Committee

Strategic planning

As the PAHO Strategic Plan 2014-2019 comes to a close, the Bureau has initiated preparations for the development of the Strategic Plan 2020-2025, taking into consideration frameworks including, but not limited to, the SDGs, SHAA2030, and the WHO GPW 13. The process will also benefit from the final evaluation of the Health Agenda for the Americas 2008-2017 and the end-of-biennium assessment of the 2016-2017 Program and Budget. A road map for the elaboration of the new Strategic Plan was developed and endorsed by the 162nd Session of the Executive Committee in June 2018 (CE162/INF/2). PAHO’s Member States will be fully involved in the formulation of the Strategic Plan, through a strategic plan advisory group and consultations with countries.

Knowledge management

PASB strengthened its knowledge management and information-sharing processes with the establishment of the new Office of Knowledge Management and Publications (KMP) in January 2018. This Office includes knowledge management and institutional memory, publication services, and oversight of the PAHO/WHO Collaborating Centers and the Pan American Journal of Public Health. KMP will work to foster PASB’s scientific and technical publications, by increasing the outreach and impact among key audiences, including policymakers, and by supporting authors at national levels so as to ensure that relevant evidence is published.

Country focus and country-to-country cooperation

In line with its commitment to enhancing PAHO’s country focus, PASB continued to develop and implement CCSs outlining the medium-term strategy for the Bureau’s work in and with countries. During the reporting period, 14 CCSs were updated and included a focus on UH with a PHC approach. By June 2018, a total of 28 CCSs were current and updated.

Dr. Carissa F. Etienne, PAHO/WHO Director with Hon. Pablo Marin Minister of Health of Belize
Dr. Carissa F. Etienne, PAHO/WHO Director with Hon. Pablo Marin, Minister of Health of Belize.

During 2017, a new plan was developed for operationalizing the PAHO Key Country Strategy, which targets the eight countries recognized in PAHO’s 2012 Budget Policy (CSP28/7) as having the lowest health development indices. The plan will facilitate more effective PASB support to Key Countries to achieve their health objectives, including UH.

Framework of Engagement with Non-State Actors

In September 2016, PAHO Member States at the 55th PAHO Directing Council adopted the Framework of Engagement with Non-State Actors (FENSA) (CD55/8, Rev. 1) through Resolution CD55.R3. FENSA promotes and strengthens PAHO’s interaction with non-State actors (NSAs), including the private sector, while establishing the processes needed to assess risks to protect the Organization from conflicts of interest and undue influence. The Framework also provides a road map and specific steps that PASB follows when deciding on proposed engagements with non-State actors.

PASB coordinated with the WHO Secretariat to develop operational tools to implement FENSA in a manner that promotes engagement, while protecting and preserving the Organization’s integrity, reputation, independence, and public health mandate. The Bureau’s Office of Legal Counsel provided guidance on the Framework and interim processes for implementing it to PAHO/WHO Representatives and Department Directors. Since the implementation of FENSA, all new engagements are reviewed under this policy framework to encourage and enhance engagement with NSAs, and during 2017 PASB conducted over 100 standard due diligence and risk assessment reviews and hundreds of simplified reviews for low-risk engagements with NSAs.

Partnerships and resource mobilization

At regional, subregional, and national levels, PASB strengthened and expanded its relations with existing partner organizations while also seeking to forge new partnerships. In terms of financial partnerships, US$ 186.7 million in PAHO voluntary contributions were mobilized during the 2016-17 biennium from existing partners, 11 new partners, and organizations with which PAHO had no agreements during the previous five years. These partners and organizations include the Government of Luxembourg; OFID; Japanese International Cooperation Agency (JICA); Together for Girls; United States of America HHS Secretary for Preparedness/Response; South American Council on Health (ORAS); Council for International Organizations of Medical Sciences (CIOMS); Therapeutic Goods Administration, Department of Health, Australian Government; Pan Caribbean Partnership against HIV/AIDS (PANCAP); and the Binational Development Plan for the Ecuador-Peru Border Region.

PAHO OAS Scholarships

PASB continued activities related to its partnership with the OAS during the period, participating in the Summit Implementation Review Group (SIRG) and meetings of the Joint Summit Working Group (JSWG) to advocate for the inclusion of health priorities in the Summit of the Americas agenda. PASB also continued its support of the OAS-PAHO scholarship program, with the aim of contributing to health systems strengthening, advancing the policy on research for health, and enhancing strategic approaches to capacity-building in the health sector. As a result of this partnership, by the end of 2017, 27 countries[1] in the Region had benefited from 683 scholarships for professionals to complete postgraduate degrees, in Brazil and Mexico. PASB and OAS have formed an interagency working group to coordinate efforts and support for the countries of the Americas to achieve the 2030 Agenda for Sustainable Development Goals. As part of its work, the group aims to align the SDGs with the existing mandates of each agency.

Country-focused partnerships for UH through PHC

Belize: PASB is contributing to implementation of the IHSDN approach through the DFID-funded Smart Health Facilities project, and through the financing agreement signed between the Government of Belize and the EU to support a comprehensive health systems strengthening intervention. The project includes evaluation of the health reform implemented in Belize and redesign of the health system; the adoption of Smart Health Facilities interventions at community and regional hospitals; assessment of the service delivery and model of care; enhancement of the Belize Health Information System; and expansion of the national health insurance scheme. The project is also linked to improvement in primary care services for healthy nutrition and NCD prevention and control.

Brazil: PASB partnered with the Ministry of Health, the National Council of State Secretaries of Health (CONASS), the Federal University of Rio Grande do Sul, and the University of Brasilia to strengthen the SUS, with the development of methodologies for planning and scaling-up the workforce for PHC and emergencies, through the Project for Strengthening Labor Management. The SUS aims to provide universal access to health care services.

Caribbean: PAHO signed an agreement with the Caribbean Development Bank in June 2018 to execute a project with the theme of “building individual and social resilience to cope with the impacts of natural hazard events: enhancing capacity for mental health and psychosocial support in disaster management in the Caribbean.” Based on lessons learned from the 2017 hurricane season, the 18-month project, which began in April 2018, will not only build regional capacity, but will also provide an entry point to strengthen mental health services and their integration into PHC. Special attention will be paid to emphasizing the needs of groups that are often at greater risk during a disaster situation, including children; women; older persons; indigenous people; those with preexisting mental disorders; migrants; persons with disabilities; homeless persons; and those living in shelters. Given the potential impact of climate change on the small island developing states of the Caribbean, PAHO is working with CARPHA and the Caribbean Community Climate Change Center to mobilize resources to build climate-resilient health systems in the Caribbean, using a One Health approach. This approach will facilitate the inclusion of a sectoral health component in the National Adaptation Plans for climate change that Caribbean countries are developing.

Chile: PASB partnered with the University of Chile, the Ministry of Health, health professionals in clinics and hospitals, and pediatric professional associations to facilitate and finalize a study to monitor the implementation of the International Code of Marketing of Breastmilk Substitutes (the Code) and subsequent World Health Assembly resolutions. The Network for Global Monitoring of the Code, known as NetCode, is the entity that monitors implementation of the Code, and Chile was one of eight countries invited to participate in the application of a new NetCode protocol. Chile was the only country to complete the study, and it presented the results at the 3rd NetCode meeting, which was held at WHO Headquarters in Geneva in April 2018.

Colombia: The UN interagency “Health for Peace” project, which involves the UNFPA, the International Organization for Migration (IOM), PAHO, and the Ministry of Health, focused on key elements for rural health development and reduction of inequities among vulnerable and excluded populations. Funded by the UNDP-managed UN Multi-Partner Trust Fund for Post-Conflict in Colombia, the project established 27 Defined Spaces for Capacity-Building and Reincorporation (ETCRs) in 14 departments and 25 municipalities, focusing on PHC, sexual and reproductive health, and infant and nutritional health. Capacity-building was provided in community Integrated Management of Childhood Illnesses (IMCI) for 44 ETCR community leaders; in clinical IMCI and nutritional health for 47 health professionals; and in mental health for 48 PHC professionals.

Ecuador: PASB has been instrumental in the establishment of an intersectoral board for health promotion, which includes more than 25 local entities, representatives of public institutions, academia, and civil society. This has resulted in the creation of six intersectoral commissions to work in a coordinated manner on specific themes related to health promotion and disease prevention, and to address challenges at the policy level. The board has given parents, teachers, students, neighborhoods, street vendors, local health committees, and professional associations, and others the opportunity to play an active role in decision-making.

El Salvador: PASB contributed to the definition of the national health research agenda and the establishment of an interinstitutional commission, led by the National Institute of Health. The commission includes the seven entities that comprise the National Health System; academia; and national investigators, and aims to identify public health priorities and generate evidence to inform public policy. At the instigation of the commission, the Sustainable Sciences Institute of San Francisco trained 30 professionals to write scientific articles and in September 2017, teachers from the Cayetano Heredia Peruvian University trained 35 epidemiologists in outbreak investigation and control.

Grenada: PASB collaborated with the EU and national authorities to better define the PHC-focused EU budget support package being negotiated with the country. PASB also partnered with Dalhousie University to provide support for renewal of the HRUH Strategy and Policy and development of a costed action plan. PASB’s technical cooperation, in collaboration with the UNDP-administered India, Brazil, and South Africa (IBSA) Fund, the EU PHC grant, and the Cooperation Agreement with the UWI Health Economics Unit, has been critical for progress in the implementation of the National Health Insurance program in Grenada.

Guatemala: PASB promoted the participation of the Ministry of Health and representatives of AECID and the EU in the high-level meeting on universal health in the 21st century held in December 2017 in Ecuador. Since that meeting, PASB, AECID, EU, and the Ministry of Health in Guatemala have convened meetings to align their work plans and new projects with the implementation of the PHC-based model of health care and management in the country.

Nicaragua: PASB, including the VCPH, joined with Collaborating Centers for the International Classification of Diseases-10 in Argentina and Mexico in strengthening vital statistics through national and local capacity-building in registration and the correct completion of death certificates.

Communication for health

PASB adopted a new Communications Strategic Plan 2018-2022 in late 2017 that sets the stage for making Communication for Health, or "C4H," an area of PASB technical cooperation. C4H refers to health communication that seeks to influence behaviors and attitudes, and generate positive public health outcomes. Drawing on the growing body of evidence on the types of communication that are most effective, the approach emphasizes evidence-based, emotive, and exceptional content and storytelling that engage audiences and effectively communicate important health information. The approach seeks to amplify “front-line voices” across the public health spectrum to tell field-based stories of health needs and changes, and to provide health information in more persuasive ways for individuals, families, and communities, as well as policy- and decisionmakers. C4H emphasizes the engagement of new and younger audiences through targeted content on social media and other new platforms During the reporting period, PASB provided capacity-building in C4H to ministries of health in Guatemala, Guyana, Mexico, and Uruguay.

Communication for Health

PASB human resources

During the period under review, the Bureau took steps to streamline staff selection, improve human resources planning, increase work efficiencies, and enhance corporate learning. PASB joined WHO in launching a cloud-based talent-management software program, Stellis, which automates the recruitment and selection process from beginning to end. A revised selection process was also implemented. These initiatives reduced the average time from the date of vacancy closing to new staff appointment from approximately eight months to just five.

A new online platform was implemented to create a more accessible, streamlined process for redefining staff functions and positions, with linkages to organizational commitments and crosscutting areas.

PASB implemented a telework program in 2017 with the goal of achieving administrative efficiencies, improving work-life balance, and facilitating the recruitment and retention of a highly qualified workforce. Over 140 staff participated in telework in 2017, with 66% reporting that both work productivity and morale had increased as a result.

PASB also implemented iLearn, the WHO global learning management system, making it available to both employees and contingent workers. As of mid-2018, more than 200 different iLearn courses had been accessed by some 785 users across PAHO Headquarters, Country Offices, and Centers.

PASB’s Respectful Workplace Initiative, launched in 2015, continued to support the creation of a safe and respectful working environment. A three-hour iLearn course was launched to generate awareness among all PASB personnel of the early signs of conflict, and to offer guidance on how to approach difficult situations and find resolutions when conflict is inevitable. During the reporting period, 600 staff at Headquarters and in PAHO Country Offices were trained in conflict resolution and communication skills. Finally, a Respectful Workplace Recognition Award was created to reinforce and acknowledge positive and appropriate behaviors in the workplace.

In 2017, PASB’s Ethics Office automated its Declaration of Interest program, which requires staff in designated positions and categories to disclose any activities or interests that may give rise to conflicts of interest with the work or mandate of the Organization. A Declaration of Interest questionnaire was issued electronically to approximately 200 staff members, and it will be reissued on an annual basis. The Ethics Office reviews responses received from staff to determine possible conflicts of interest.

The 2017 Annual Report of the Audit Committee recommended that there should be complete separation of the investigation function from the Ethics Office in order to allow for enhanced performance of both the ethics function and the investigation function, in accordance with best practices. Following a decision by PASB’s Executive Management that was endorsed by the 161st Session of the PAHO Executive Committee in September 2017 (CE161/6), a new Investigations Office was established and began operations in January 2018. The transfer of this function to another entity will allow the Ethics Office to devote more time and attention to its advisory, training, and outreach roles, and more actively promote ethical behavior throughout the Organization.

PAHO event

The increased focus on promotion of an ethical atmosphere in the Organization is timely, given the negative attention received by some other international agencies because of allegations of sexual misconduct involving their senior staff. The Ethics Office will redouble its efforts and conduct additional training sessions at both Headquarters and in Country Offices to ensure that staff conduct themselves and the work of the Organization in a dignified, professional, ethical manner. In the age of the “Me Too” movement, the Ethics Office is creating a communications campaign to inform staff of their rights and obligations with respect to the treatment of their co-workers. This campaign will focus on staff members’ right to work in a harassment-free workplace and to speak up in uncomfortable situations, free from fear of retaliation. It will also send strong signals to potential harassers that their behavior is inappropriate and will not be tolerated at PAHO. In addition, the Ethics Office is working with the Office of the Ombudsman to create a training session addressing the specific issue of sexual harassment in the workplace.

The risk of fraud in organizations is also receiving increased attention. The Ethics Office is preparing an Organization-wide fraud policy and is including fraud in its training sessions, in order to mitigate the risk of fraud in PAHO, make it clear that the Organization has zero tolerance for fraud and corruption, and indicate that staff will be held accountable for their actions.

During the reporting period, the Ethics Office administered an Organization-wide election for staff representatives on the PAHO Board of Appeal. Some 1,650 votes were cast, and a full slate of staff representatives from both the general service and professional categories were elected and appointed to the Board of Appeal.

Enterprise risk management

The Enterprise Risk Management (ERM) program in PASB has continued to mature and demonstrate its usefulness. PASB’s ERM framework was first developed in 2011, and an ERM Standing Committee was established in 2015. ERM has been institutionalized in planning and operations processes, and the Bureau instituted a risk register and developed tools to facilitate cost center managers’ input into the register. ERM worked closely with the Department of Planning and Budget to integrate risk factors into the PAHO Program and Budget 2018-2019.

The Enterprise Risk Management (ERM) program in PASB has continued to mature and ulness. PASB’s ERM framework was first developed in 2011, and an ERM Standing Committee was established in 2015. ERM has been institutionalized in planning and operations processes, and the Bureau instituted a risk register and developed tools to facilitate cost center managers’ input into the register. ERM worked closely with the Department of Planning and Budget to integrate risk factors into the PAHO Program and Budget 2018-2019.

The Report of the Audit Committee, presented to the 162nd Session of the Executive Committee in June 2018 (CE162/9), noted that there has been good development and improvement in the institutional structure and review of risk. However, the Committee recommended that there be more explicit links between PASB’s internal control framework and risk management.

Financial management and budget

The PAHO Program and Budget 2018-2019 (OD354) was reviewed and approved by the 29th PASC in 2017. This planning cycle was the first in which PASB presented a full Program and Budget proposal to the Subcommittee on Program, Budget and Administration (SPBA) for review, prior to the Executive Committee. A total budget of US$ 619.6 million was approved for base programs, representing an increase of 1.1% over 2016-2017 figures. This increase was due to the increased WHO budget space allocation to the Region.

The Program and Budget 2018-2019 was been developed through a combination of bottom-up, results-based prioritization using the PAHO-Hanlon methodology, and costing in PAHO Country Offices and technical programs. The Program and Budget 2018-2019 sets out measurable programmatic results for two years and is the principal means of providing corporate accountability for the resources that PAHO receives from its Member States and development partners.

During the period under review, the Bureau implemented its first closure (2016-2017) and opening (2018-2019) of a biennium using the new PASB Management Information System (PMIS), an enterprise resource planning tool that integrates all core business processes. During its introduction, PMIS presented several major challenges to staff, who were learning the new system while simultaneously meeting daily operational challenges. PASB staff worked efficiently to resolve administrative issues that arose, with the overall result of relatively few delays in the rollout of operations for the new biennium. Notably, technical cooperation and day-to-day operations were not disrupted.

Several improvements were made to the PMIS, especially by eliminating redundant steps, and introducing collaboration spreadsheets that provide live data-sharing in a secure environment. In May 2018, PASB launched automatic production and electronic delivery of statements of account, invoices, and development partner reports to Member States in PMIS. This is expected to significantly improve timeliness and reduce administrative costs.

The PASB obtained an unmodified audit opinion for 2017, a major milestone for the Bureau in the first biennium of implementation of the new PMIS. Financial reporting was made more efficient and timely, supported by the automation of a number of processes previously done manually.

Staff from PASB’s Financial Resources Management department visited 18 Country Offices to perform financial reviews and verify compliance of operations with PAHO’s financial regulations and rules, and related policies and procedures. As a result of both in-person and virtual training across the Bureau, the quality of accounting data supplied by entities improved, with reduction in the need for adjustments.

Information technology and security

During the reporting period, PASB improved cybersecurity, including strengthened control of user access to systems through multifactor authentication, and increased user awareness. The Bureau also implemented disaster-recovery-as-a-service (replication and hosting of servers by a third party as backup in the event of a man-made or natural catastrophe) as a key element in the Organization’s Business Continuity Plan (BCP). Implementation of the BCP included deployment of a new PAHO alert system, integrated with PMIS and capable of alerting PASB staff to any emergency situation via voice, text, or email.

PASB improved cybersecurity, including strengthened control of user access to systems through multifactor authentication

PASB also improved its information technology services to enhance collaboration and communication among and between PAHO teams and partners within secure, managed, and cost-effective environments. The addition of Microsoft Office 365 to the PASB portfolio of cloud-based services enabled greater mobility, ensuring that staff can access their services, tools, and repositories directly at any time, from any location, and on any device. The use of Skype for Business enhanced responsiveness and agility by providing flexible and mobile virtual meetings, messaging, and file-sharing. The scheduling of technical cooperation meetings at PAHO Headquarters was enhanced through installation of a new, user-friendly, Web-based meeting reservation tool.

General services

In terms of physical infrastructure, a modern video and audio recording studio was completed at the PAHO Headquarters building for the production of professional-quality content in support of PAHO’s Communications Strategy.

A new, centralized vehicle replacement plan was implemented, under the Master Capital Investment Fund, and more than 60 obsolete vehicles were replaced across PAHO Country Offices and Centers, to ensure reliable support for technical cooperation activities in the countries.


Official Development Assistance (ODA) to the Region of the Americas has continued to decline, as financial resources from countries of the Organization for Economic Cooperation and Development Development Assistance Committee (OECD/DAC) have been directed primarily to Africa and Asia..

162nd Executive Committee

Resource mobilization efforts continue within a highly competitive environment and in an international context with unforeseen political challenges. Specifically, government changes within the Region, including governments that provide a significant percentage of the Organization’s voluntary contributions, may affect new opportunities and existing agreements—some of them annual commitments—with a significant impact on resource mobilization. Resource mobilization at the country level is uneven, with several substantial successes as well as untapped opportunities for both voluntary and national voluntary contributions.

In PASB’s resource mobilization efforts, partnerships, and alliances, there may be potential conflicts of interest with private partners that may affect the image and reputation of the Organization.

Notwithstanding the benefits of the digital era, information access and knowledge management and sharing are not always addressed sufficiently in the agenda of UN agencies and Member States. For example, the downsizing of libraries by PAHO and other UN agencies and the lack of knowledge sharing inside the organizations can result in lost information about the organizations’ legacies and heritage. This puts the new generation at a disadvantage even if they are willing to learn about these institutions’ achievements, which is problematic, given that these are the future decisionmakers, researchers, health authorities, and stakeholders.

Given the heightened awareness of security issues locally, nationally, and globally, the PAHO Headquarters building, located in Washington, D.C., requires upgrades to mitigate security risks for staff and visitors alike.

Lessons learned

PASB must manage the risks of fluctuating interest and exchange rates in order to minimize their impact on PAHO’s liquidity, investments, cash balances, and Miscellaneous Revenue. The Bureau must also mitigate the risk that political and economic instability might impact the ability of some Member States and development partners to meet their financial commitments to the Organization.

PAHO Mission to China

PASB should continue and intensify measures to reinforce its resource mobilization capacity, including diversifying its development partner base, by exploring opportunities with nontraditional or new partners (such as China, Korea, Russia, Singapore, and other countries) as well as pission of PAHO to Chinahilanthropic foundations and the private sector. The Bureau should also expand and strengthen training and capacity-building of its staff in Country Offices in resource mobilization and project design. Such efforts could facilitate resource mobilization and establish new partnerships; improve data gathering on, and analysis of, development partners, scenarios, and voluntary contributions; scale up management and corporate communications, which reinforce the Bureau’s ability to keep current partnerships and establish new ones; and promote the modality of national voluntary contributions (NVCs) with Member States. NVCs allow countries of the Region to work with PASB at the national level, directing their own resources to achieve national health goals and priorities. Resource mobilization at the country level can be enhanced through capacity-building, clear country-level targets, assignment of time and resources, and increased accountability.

The implementation of FENSA, with the conduct of due diligence and the assessment, avoidance, or management of risks and potential conflicts of interest, is critical to preserve and strengthen the Organization’s reputation as an honest broker, convener, and partner in public health.

PASB needs to work effectively to implement new techniques to organize and disseminate the information aimed at filling the digital divide that persists in the Region. Strategies include new methods to collect more concrete and tangible examples of work with the PAHO/WHO Collaborating Centers and to engage national authorities on the importance of this modality of technical cooperation. In addition, given that knowledge management is a crosscutting component of technical cooperation, there should be greater and sustainable inclusion of this component in the preparation and implementation of institutional policies, programs, and projects, as well as in technical cooperation with PAHO’s Member States.

The timeliness of delivery of goods and services, with the best prices available, will be improved by the Bureau’s expansion and enhancement of demand planning for goods and services, especially those purchased through the PAHO Strategic Fund and the PAHO Revolving Fund. PASB should improve communication with Member States in order to receive and provide information regarding goods and services procured and delivered as part of technical cooperation. Some products purchased for Member States are sold by monopolies or oligopolies, a situation that is further complicated when the product availability is insufficient to cover global demand. This was exemplified during the reporting period when efforts to procure inactivated polio vaccines proved challenging due to insufficient global availability. PASB should also explore ways to decrease the lead time for the delivery of goods during emergency situations and outbreaks in the Region, to enable an efficient response when products are not available or not in stock.

The Master Capital Investment Fund may provide an opportunity to plan and execute a project in the second semester of 2018 for strengthened access and security surveillance controls in the PAHO Headquarters building.

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[1] Argentina, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, Suriname, United States, Uruguay, and Venezuela