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Estrategia de Cooperación en el País 2017-2021: Belize

28 juillet 2017 Organisation mondiale de la santé

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Belize 2017 - 2021

Country Cooperation Strategy Belize 2017-2021 1

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

PAHO/WHO Country Cooperation Strategy Belize 2017-2021 3

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

Table of Contents Abbreviations 6 Executive Summary 9 1. Introduction 13 1.1 Overview of the PAHO Policy Framework 13 1.2 Geography of Belize 14 1.3 The CCS Development Process 14 I.4 Overall role and responsibilities of PAHO/WHO 15

2. Health and Development Situation 19 2.1. Political, macroeconomic and social context 19 2.2 Health Status of the Population (burden of disease) 20 2.3 Health systems response in Belize 23 2.4 Cross-cutting issues (equity – “leaving no one behind”, gender, health and sustainable development, environmental health, climate change, food and nutritional security) 24 2.5 Development partners’ environment 27 2.6 Review of PAHO/WHO’s Technical Cooperation over the past CCS Cycle 28 3.1 Strategic Priorities and related Focus Areas 3.2 Aligning SPs and FAs to the HSSP 2014-2024, the PAHO Strategic Plan Outcomes, CCH IV, the SDG Targets and UNDAF Outcomes. 31 34

3. The Strategic Agenda 31

4. Implementation of the Strategic Agenda: Implications for the Secretariat 41 4.1 Coordination and management 41 4.2 Core Resources needed for implementation 41 4.3 Implications Matrix 42 4. 4 Risks 48 5.1 Monitoring 51 5.1 Mid-term evaluation 51 5.2 Final evaluation 51

5. Monitoring and Evaluation 51

References 52 Annexes Annex 1. Horizon 2030 54 Annex 2. SDGs and the 2017-2021 UN MSDF for the Caribbean 55 Annex 3. Key Stakeholder Analysis 57 Annex 4. Strategic Priorities and Focus Areas 63 Annex 5. Strategic Priorities and Focus Areas 65

PAHO/WHO Country Cooperation Strategy

Abbreviations BCRIP BHIS BWP CARICOM CCH CCS CO COMISCA CSF EDF EU FA FAO FCTC FNS GoB GDP GDI GSDS HiAP HIA+17 HIV HDI HRH HSSP IHR INCAP JEE KHMH LDCs LGBT LFS MDGs MHDSTPA MOH MICS MSM NCDs NGO NHI NHPSP PAHO/WHO PER PHC PWR RAWA RTA SDGs Belize Climate Resilient Infrastructure Project Belize Health Information System Biennial Work Plan The Caribbean Community Caribbean Cooperation in Health Country Cooperation Strategy Country Office Council of Ministers of Health of Central America and the Dominican Republic Critical Success Factor European Development Fund European Union Focus Areas Food and Agricultural Organization Framework Convention on Tobacco Control Food Nutrition and Security Government of Belize Gross Domestic Product Gender Development Index Growth Sustainability and Development Strategy 2016-2019 Health in All Policies Health In The America’s 2017 Human Immunodeficiency Virus Human Development Index Human Resource for Health Health Sector Strategic Plan, 2014 -2024 International Health Regulations Institute of Nutrition of Central America and Panama Joint External Evaluation Karl Heusner Memorial Hospital Least Developed Countries Lesbian, Gay, Bisexual and Transgender Labor Force Survey Millennium Development Goals Ministry of Human Development, Social Transformation and Poverty Alleviation Ministry of Health Multiple Indicator Cluster Survey Men who have sex with Men Noncommunicable Diseases Nongovernmental Organization National Health Insurance National Health Policy and Strategic Plan Pan American Health Organization/ World Health Organization Public Expenditure Review Primary Health Care PAHO/WHO Representative Registration & Clinical Activity Web Application Road Traffic Accident Sustainable Development Goals

Belize 2017 - 2021 SISCA SICA SIDS SP TC THE UH UHC UNAIDS UNDAF UNDP UNFPA UNICEF UNWOMEN UN MSDF WHO Central American Social Integration System Central American Integration System Small Island Developing States Strategic Priority Technical Cooperation Total Health Expenditure Universal Health Universal Health Coverage The Joint United Nations Programme on HIV/AIDS United Nations Development Assistance Framework United Nations Development Programme United Nations Population Fund United Nations Children’s Fund United Nations Women United Nations Multi-Country Sustainable Development Framework World Health Organization

$ Unless otherwise specified, the currency used in this report refers to the Belizean dollar. BZ$2.00 = US $1.00 or BZ$1.00 = US$0.50

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

Executive Summary

he Pan American Health Organization/World Health Organization (PAHO/WHO) provides technical cooperation through the PAHO/WHO Country Office in Belize. The Country Cooperation Strategy outlines the medium-term vision that will guide PAHO/WHO’s work Belize in support of the country’s National Health Sector Strategic Plan 2014-2024. PAHO/WHO works with the MOH (as its main counterpart) and other partners to strengthen health sector capacity and advance priority programs. The priorities of the CCS are also aligned to the PAHO Strategic Plan 2014-2019 (HSSP), “Championing Health: Sustainable Development and Equity” and to the health and health-related Sustainable Development Goals (SDGs) and encouraging greater multisectoral collaboration in the country. PAHO is committed to ensuring that all people have access to the health care they need, when they need it, with quality and without fear of falling into poverty. Through its work, PAHO promotes the concepts of Universal Health and Health in All Policies (HiAP). This five (5) year CCS builds on the achievements of the 2008-2011 CCS and the technical cooperation provided by the PAHO HQ and the Country Office since 2011. The development process was participatory involving all levels of PAHO and a wide range of stakeholders at the national level. It used a results-based management framework approach to clearly identify results at each level, the relationship between planning and accountability and the respective responsibilities of Belize, PAHO and other relevant agencies. The (Country Coperation Strategy) CCS’ Strategic Agenda lays out the Strategic Priorities (SPs) and Focus Areas (FAs) for PAHO’s Technical Cooperation with its member countries. The SPs constitute the medium-term priorities for PAHO/ WHO’s cooperation with Belize, on which the Organization will concentrate the majority of its resources over the CCS cycle. The CCS FAs are the “what”, reflecting the expected achievements required to realize the strategic priority. Each focus area should link directly with at least a HSSP priority, a PAHO Strategic Plan outcome, indirectly with a health or health-related SDG target and the development priorities of the UN MSDF for the Caribbean. Based on the findings of the recently completed Health in Americas 2017 Chapter for Belize, consultations with senior technical officers from the Ministry of Health and considering national, subregional and global frameworks as well as the PAHO Strategic Plan 2014-2019, four (4) SPs were identified for the focus of PAHO’s technical cooperation for the 2017-2021 Country Cooperation Strategy.

PAHO/WHO Country Cooperation Strategy

Focus Areas: 1.1 Revise and or develop national health legislation and inclusive policies to advance health equity, the procurement of appropriate, affordable medicines and other health technologies and strengthen intersectoral actions that address the social determinants of health. 1.2 Redefine the health financing mechanism to include the expanded roll-out of the National Health Insurance system to ensure equitable access to health services across Belize. 1.3 Strengthen the Belize Health Information System (BHIS) to improve coordination with RAWA and the comprehensive use of data for evidence-based decision making and monitoring and evaluation. 1.4 Strengthen primary healthcare networks and the resolution capacity to meet expanding health needs in Belize.

Strategic Priority 2: Human resource for health (HRH) management and capacity strengthened to parallel the health needs of the growing population. The retention and the deployment of health care staff will be necessary to ensure the right mix of skills that can deliver high quality service in both rural and urban areas across Belize.

Focus Areas: 2.1 Advocate for the use of recommendations of previous PAHO HRH assessments of the gaps and needs to ensure the recruitment, deployment and retention of a skilled workforce that can meet the regional core indicators for HR and equitably deliver health services across Belize especially in the rural areas. 2.2 Build and/or reorient the capacity of healthcare professionals to meet the emerging health trends and needs of the Belizean population. 2.3 Strengthen HRH management within the Ministry of Health to develop and/or adapt HRH policies and plans that define the strategic direction and the integration of HRH into other sectors.

Belize 2017 - 2021 throughout life and across generations. It promotes health and well-being from preconception to old age.

Focus Areas: 3.1 Support and promote the implementation of interventions and strategies that engage and empower communities to adopt healthier lifestyles that reduce the risk factors related to developing noncommunicable diseases and/or contracting communicable diseases. 3.2 Advocate for social programs and policies within the public sector for the early detection and intervention to address problems related to gender-based violence, urban violence and road safety. 3.3 Strengthen national capacities to implement comprehensive strategies that prevent and treat mental and substance abuse disorders within a framework of human rights and respect for human dignity.

Strategic Priority 4: Health emergencies that can become emerging threats of public health concern are addressed. This SP focuses on strengthening Belize’s capacities in prevention, risk reduction, preparedness, surveillance, response, and early recovery in relation to all types of human health hazards that may result from emergencies or disasters. Special attention will be given to the continued implementation of the IHR recommendations, the continued monitoring of the outbreak of new diseases such as Zika and the continued development of policies that address climate change and food security because of Belize’s vulnerability.

Focus Areas: 4.1 Strengthen the coordination of the preparedness and response mechanisms to address health emergencies including natural disasters (hurricanes and earthquakes), and the impact of climate change. 4.2 Continue to monitor new and evolving outbreaks such as Zika and take the appropriate response measures. 4.3 Implement the IHR external evaluation recommendations which include preparing a multisectoral roadmap linking existing institutional and operational planning mechanisms and structures and increasing horizontal cooperation with other countries. Key cross-cutting themes of gender, equity, human rights, and ethnicity will be taken into consideration to implement the strategic agenda of this CCS. The implementation of the Strategy will be coordinated through the PAHO/WHO Belize Country Office but the responsibility for its implementation lies with the entire Secretariat. As such, there will be support from the subregional level through its office in Barbados and Central America, the regional level through the technical departments at headquarters in Washington and from the global level in Geneva. There will also be close coordination with partners such as CARPHA, COMISCA, INCAP and other regional institutions. The monitoring and evaluation will also be in accordance with the time line established for the monitoring and evaluation of the Biennial Work Plans (BWPs). A midterm review will be conducted in 2019, the year the PAHO Strategic Plan is scheduled to end, and a final evaluation will be conducted during the final year of implementation.

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

1. Introduction 1.1 Overview of the PAHO Policy Framework The Pan American Health Organization/World Health Organization (PAHO/WHO) provides technical cooperation through the PAHO/WHO Country Office in Belize. The Country Cooperation Strategy (CCS) was developed in keeping with the “2016 Guide for the Formulation of a WHO Country Cooperation Strategy (CCS)” which reflects a medium-term vision to guide PAHO/WHO’s work in and with Belize in support of the country’s National Health Sector Strategic Plan 2014-2024. PAHO is committed to ensuring that all people have access to the health care they need, when they need it, with quality and without fear of falling into poverty. Through its work, PAHO promotes the concepts of Universal Health(UH) and Health in All Policies (HiAP).The priorities of the CCS are also aligned to the PAHO Strategic Plan 2014-2019, “Championing Health: Sustainable Development and Equity” and to the health and health-related Sustainable Development Goals (SDGs) and encouraging greater multisectoral collaboration in the country. The SDGs recognize that eradicating poverty and inequality, creating inclusive economic growth and preserving the planet are linked and have as an overarching theme: “Leaving no one behind”. They promote a comprehensive, integrated approach to sustainable development. Only one SDG, SDG 3, is dedicated entirely to health “To ensure healthy lives and promote well-being for all at all ages”. It includes nine (9) targets which cover major health priorities and four (4) “means of implementation” targets. It addresses a wide range of health issues from road traffic injuries and tobacco control, to the health workforce and noncommunicable diseases (NCDs) — the most conspicuous health concern that was omitted from the MDGs. However, Health also benefits from the achievement of the other SDGs. The key principles that guide PAHO/WHO’s technical cooperation with countries which are similar to those of the SDGs are: • • • • Country ownership of the development process; An evidence-based and results-based focus; Harmonization and alignment with PAHO/WHO’s work across all levels of the Organization; Strengthening and harmonization of work with partners and other sectors.

The timeframe of the CCS is flexible in order to be able to align with the PAHO planning cycle. During operational planning the CCS strategic priorities will influence the programs, the planned results and the resource allocation of the biennial work plan (BWP). It is also aligned with key global and regional health agendas such as universal health and health in all policies.

PAHO/WHO Country Cooperation Strategy

1.2 Geography of Belize1 Belize, which was formerly known as British Honduras until 1973, lies on the eastern or Caribbean coast of Central America, bounded on the north and part of the west by Mexico, and on the south and the remainder of the west by Guatemala. The inner coastal waters are shallow and are sheltered by a line of coral reefs, dotted with islets called ‘cayes’, extending almost the entire length of the country. It is 274 kilometers long and 109 kilometers wide with a total landmass, including the cayes, of 22,700 square-kilometers. A large part of the mainland is forest. The climate is subtropical to tropical, tempered by trade winds. Annual rainfall varies from an average of 1,295 millimetres in the north to 4,445 millimetres in the extreme south. The dry season usually extends from February to May and there is sometimes a dry spell in August.

1.3 The CCS Development Process This five (5) year CCS builds on the achievements of the 2008-2011 CCS and the technical cooperation provided by the PAHO HQ and the Country Office since 2011. An online questionnaire was developed and administered electronically to key stakeholders who have partnered with PAHO to implement technical cooperation or received technical cooperation. Respondents were asked to provide information on: activities they had collaborated with PAHO/WHO on over the past 8 years; PAHO/WHO’s main strengths and weaknesses; areas in which they thought their agency could collaborate with PAHO/WHO in the future; and what strategic priorities (SPs) should be addressed in the PAHO/WHO 2017-2021 CCS for Belize and why. A Working Group (WG) chaired by the PAHO/WHO Representative for Belize, comprised of the key PAHO Technical Officers and national representatives was responsible for coordinating and providing oversight for its development. The recently completed Health in Americas 2017 Chapter for Belize was used to develop the health status of the population and identify the main challenges. A National Consultation was held in December 2016 with key stakeholders and decision-makers from the Ministry of Health, (MOH), UN Agencies resident in Belize, other development partners and key nongovernmental organizations. The overall goals were to: • identify, discuss and gain consensus on the common strategic priorities (SPs) and the related focus areas (FAs) for PAHO’s Technical Cooperation, 2017-2021 discuss the implementation, management, coordination, monitoring and evaluation of the CCS endorse the final 2017-2021 CCS by the Government of Belize and PAHO. The development process was participatory involving all levels of PAHO and a wide range of stakeholders at the national level. It was developed using a results-based management framework approach to clearly identify results at each level, the relationship between planning and accountability and the respective responsibilities of Belize, PAHO and other re-

Figure 1. Map of Belize

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Belize Government website. Available from

http://www.belize.gov.bz/index.php/physical-features, accessed November 2016.

Belize 2017 - 2021 levant agencies. It consists of 4 SPs and 13 focus areas (FAs) for technical cooperation. Each SP: • • • • makes a specific contribution to address a health concern within Belize is aligned with MOH Belize Health Sector Strategic Plan 2014-2024 (HSSP) and the PAHO BWP is aligned to a particular outcome in the 20142019 PAHO Strategic Plan “Championing Health: Sustainable Development and Equity” is mapped to one (1) or more of the nine (9) health targets within SDG 3 – “Ensure healthy lives and promote well-being for all at all ages” and the other health related SDG targets Its mission is to lead strategic collaborative efforts among Member States and other partners to promote equity in health, combat disease, and improve the quality of, and lengthen, the lives of the peoples of the Americas. It provides technical cooperation to its member countries and promotes cooperation between countries to advance their health goals. The objectives of PAHO’s technical cooperation are to: • • • • Support the attainment of national, sub-regional, and regional health goals; Strengthen the capacity of each country to influence and take advantage of international cooperation in health; Give health a preeminent place in national development plans; Reflect the interests and perspectives of each country in the global development agenda including Governing Bodies such as the World Health Assembly (WHA) and the Directing Council (DC).

The CCS was also developed in keeping with other regional and international frameworks and plans: • • • • • • • The Caribbean Cooperation in Health (CCH) The Caribbean Charter for Health Promotion The Declaration of Port of Spain: Uniting To Stop The Epidemic of Chronic NCDs The PAHO/WHO Subregional Cooperation Strategy for the Caribbean The United Nations, Multi-Country Sustanaible Development Framework (MSDF) The 2030 Agenda for Sustainable Development Goals (SDGs); The Health Agenda for Central America and the Dominican Republic 2009 – 2018.

PAHO is committed to ensuring that all people have access to the health care they need, when they need it, with quality and without fear of falling into poverty. Through its work, PAHO promotes the concepts of Universal Health and Health in All Policies (HiAP). • Universal Health - Access and Coverage: all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, affordable, effective, quality medicines, while ensuring that the use of these services does not expose users to financial hardship, especially groups in conditions of vulnerability. Health in all Policies (HiAP): provides Member States in the Americas with technical guidance in defining their own path towards HiAP, taking into account the social, economic, political, legal, historical, and cultural challenges, as well as current and future health challenges and priorities.

The achievement of each SP is the joint responsibility of the Government of Belize and PAHO. The strategy also highlights four cross-cutting themes: gender, equity, human rights and ethnicity that will be applied across all SPs and FAs in the CCS. PAHO/WHO recognizes that this CCS will be implemented in an environment of limited financial and human resources and as a result will focus its technical cooperation on those health priorities that will add value to the programs being implemented in Belize.

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1.4 Overall role and responsibilities of PAHO/WHO Founded in 1902, PAHO is one of the oldest international public health agencies in the world. It is recognized as both a specialized health agency in the Inter-American System and the Regional Office for the Americas in the World Health Organization.

PAHO/WHO Belize Country Office Belize’s relationship with PAHO/WHO began in the 1950s when it known as British Honduras. In 1984 a formal agreement was signed between PAHO/ WHO and Belize to provide technical cooperation to

PAHO/WHO Country Cooperation Strategy the Ministry of Health, other ministries, regional and international agencies and NGOs to strengthen health sector capacity and advance priority programs to improve the health of the people of Belize. PAHO/WHO’s presence in Belize has grown from a small office providing program coordination to a full representation with 15 staff members. PAHO/WHO works with the MOH (as its main counterpart) and other partners to strengthen health sector capacity and advance priority programs through the PAHO core functions of: leadership, research, knowledge management, norms and standards, ethical and evidence-based policy, technical cooperation for sustained capacity, health situation and health trends.

The PAHO Strategic Plan and the Biennial Work-Plans (BWP) The activities and interventions implemented by the PAHO/WHO Belize Office are closely aligned to the PAHO Strategic Plan 2014-2019, “Championing Health: Sustainable Development and Equity”. This Plan builds upon important past achievements, the strengths of its Member States, and the competence of the Pan American Sanitary Bureau (PASB). It sets out the Organization’s strategic direction, based on the collective priorities of its Member States and country focus, and specifies the results to be achieved during the period 2014-2019. Its vision focuses on healthy living and well-being and reaffirms health as a key element of sustainable development. There are 6 categories and 34 program areas, the new program areas are in italics.

Table 1. PAHO Strategic Plan - Categories and Program Areas 1. Communicable diseases 1. HIV/AIDS and STIs 2. Tuberculosis 3. Malaria and other vector-borne diseases (incluiding Dengue and Chagas 4. Neglected tropical and zoonotic diseases 5. Vaccine preventable diseases (including maintenance of polio eradication) 6. Antimicrobial resistance 7. Food safety 2. Noncommunicable diseases and Risk Factors 1. Noncommunicable diseases and risk factors 2. Mental health and substance abuse disorders 3. Violence and injuries 4. Disabilities and rehabilitation 5. Nutrition 3. Determinants of Health and Promoting Health Throughout the Life Course 1. Women, maternal, newborn, child and adolescent and adult health, and sexual and reproductive health

2. Ageing and health 3. Gender, equity, human rights and ethnicity mainstreaming 4. Social determinants of health 5. Health and environment 4. Health Systems 1. Health governance and financing, national health policies, strategies and plans 2. People- centered integrated health services 3. Access to medical products and strenghtening regulatory capacity 4. Health systems information and evidence 5. Human resuorces for health 5. Health Emergencies 1. Infectious hazard management 2. Country health preparedness and the International Health Regulations (2005) 3. Health emergency information and risk assesment 4. Emergency operations 5. Emergency core services 6. Disaster risk reduction and special projects 7. Outbreak and crisis response 6. Corporate services / Enabling functions 1. Leadership and governance 2. Transparency, accountability and risk management 3. Strategic planning, resources coordination and reporting 4. Management and administration 5. Strategic communications

Source: PAHO – Planning Budget 2018/2019 presentation. The new areas are in blue italics.

Belize 2017 - 2021 The Plan has nine (9) impact goals: 1. 2. 3. 4. 5. 6. 7. Improve health and well-being with equity. Ensure a healthy start for newborns and infants. Ensure safe motherhood. Reduce mortality due to poor quality of health care. Improve the health of the adult population with an emphasis on NCDs and risk factors. Reduce mortality due to communicable diseases. Curb premature mortality due to violence and injuries by tackling major risks of adolescents and young adults (15-24 years of age). 8. Eliminate priority communicable diseases in the Region. 9. Prevent death, illness, and disability arising from emergencies.

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

2. Health and Development Situation 2.1. Political, macroeconomic and social context Political Belize obtained its independence from Britain in 1981 and is the only English-speaking country in Central America. It is a member of the Caribbean Community (CARICOM) and its related institutions, the Central American Integration System (SICA), the Commonwealth, the United Nations, the Organization of American States and the Association of Caribbean States and has established diplomatic relations with many countries. In spite of a long-standing dispute with Guatemala over claims to the territory, the two countries have continued negotiations and maintained diplomatic relations. The Government operates on the principles of Parliamentary Democracy based on the Westminster System with two legislative houses – the Senate and the House of Representatives. Her Majesty, Queen Elizabeth II is the constitutional Head of State and is represented in Belize by a Governor-General, who must be a Belizean. The Cabinet consists of a Prime Minister, other Ministers and Ministers of State who are appointed by the GovernorGeneral on the advice of the Prime Minister. There are six administrative districts: Belize, Cayo, Corozal, Orange Walk, Stann Creek and Toledo.

Economy Belize is a small, upper-middle income country with a population of approximately 377,9682. It has a GDP per capita of $9,658 in 20163 and has undergone significant economic transformation over the last two decades, mainly due to the growing tourism industry and to the discovery of commercial oil in 2005. Tourism and agriculture are the main sources of income and employment. The main agricultural exports are sugarcane, citrus, bananas and marine products. Tourism’s role in the national economy has been increasing, employing 28% of the population and representing 21% of GDP, while agriculture employs 10% of the labor force and contributes 13% of GDP, mostly through exports4. The national unemployment rate is 8% with youth and women unemployment being substantially above the national average. Females are generally three times more likely to be unemployed than males. Belize employs seasonal and migrant labor from neighboring countries, however monitoring of the work permits is not very robust and many laborers remain in the country. Price rises are moderate with inflation being 1% in the first half of 2016. Belize’s most recent budget for Fiscal Year(FY) 2016/17 forecast expenditures of BZ$1,148 M. However, budget deficits, rapid debt build up and unbudgeted contingent liabilities that currently dominate the government’s financial and budgeting options, may potentially impact the provision and quality of health care. In addition, with its small-size economy, high dependence on imports, and exposure to natural disasters, the country is particularly vulnerable to terms-oftrade shocks and volatility. http://www.sib.org.bz/ Belize budget speech, 2016 4 http://www.worldbank.org/en/country/belize/overview 2 3

PAHO/WHO Country Cooperation Strategy Social The population of Belize is very diverse and multicultural due to its geographic location to other countries in Central America and it historical links to the English-speaking Caribbean. English is the official language of Belize; however, English Creole is widely spoken by many Belizeans. Spanish is also common and mainly spoken by the majority of the people in the Orange Walk and Corozal Districts, north of Belize and the Cayo District in the west. Data from the 2015 Multiple Indicator Cluster Survey indicate that 96% of the population reported using improved sources of drinking water. The last study on poverty in 2009 found that 41.3% of the population was on or below the poverty line. This percentage included 15.8% regarded as indigent or extremely poor. At that time, Belize’s poverty line was $10.00 per day or an annual consumption not exceeding BZ$3,429.00 for a family of five (5). Education is compulsory for children aged between 6 and 14. Primary and Secondary education is free but most of the schools are operated by the churches. The literacy rate in 2010 among the adult population was marginally less than 80%7. The Government maintains a special school for mentally challenged children and another for children with physical challenges. The University of Belize opened in 2000 and the main campus moved to Belmopan in 2004. The University of the West Indies maintains a School of Continuing Education in Belize City. The vulnerable populations in Belize tend to include the population living in poverty, including children and the elderly, and the Lesbian, Gay, Bisexual and Transgender (LGBT) population. Human trafficking remains a concern as Belize is now rated as Tier 3, the worst possible rating by the US State Department since it is a source, transit, and destination country for men, women, and children subjected to sex trafficking and forced labor8. Sex trafficking and forced labor of Belizean and foreign women and girls, primarily from Central America, occur in bars, nightclubs, brothels, and domestic service. LGBT men, women, and children are vulnerable to sex and labor trafficking9. Migration continues to transform Belize’s population with especially its ethnic composition. In 2000, immigrants in Belize accounted for 14.8% of the total population. This migrant population (mainly from Guatemala, the Republic of El Salvador and Honduras) has made important contributions to the development of Belize especially in relation to its ethnic and cultural diversity. However, they also require health, education and basic services. The Belizean authorities have taken important strides in regularizing foreigners but the management of immigration remains a major challenge for the Government, especially in terms of achieving integration and social cohesion.10 In addition, around 15% of the population that was born in Belize currently lives abroad mainly in the United States or Canada. However, this strong emigration also costs Belize in terms of reduced capabilities, limited workforce, and social disintegration.

2.2 Health Status of the Population (burden of disease) In the Growth and Sustainable Development Strategy 2016 – 2019, the Government cited “adequate access to health care” as a critical success factor. Accomplishing this objective would be seen as tangible progress towards achieving pillar 4 - The Bricks and Mortar: Healthy Citizens and a Healthy Environment- of the National Development Plan - Horizon 2030. This pillar emphasizes “Universal access to affordable and high quality healthcare that provides citizens with preventative and curative health services throughout their lives.”

Demographic Trends Belize has a young and rapidly growing population with 46% of the population in its teenage years or younger and 6.5% of the population being 60 years and older. The largest ethnic group is comprised

5 Belize Multiple Indicator Cluster Survey. 2015. Statistical Institute of Belize. http://www.sib.org.bz/Portals/0/docs/publications/other%20 statistical%20reports/MICS_REPORT_2012_FINAL.pdf 6Belize Country Poverty Assessment Report 2009, Table 3.4: pg52. The Caribbean Development Bank Accessed November 2016. 7Statistical Institute of Belize, 2016 http://www.sib.org.bz/ 8http://www.state.gov/documents/organization/258878.pdf Accessed November 2016. 9http://www.state.gov/documents/organization/258878.pdf. Accessed November 2016. 10 http://www.iom.int/countries/belize. Accessed January 2017.

Belize 2017 - 2021 Figure 1: Population Age and Sex Structure, Belize 2016

mainly of Mestizo (52.9%), then Afro-descendant Creoles (26%), Garifuna (6.1%) and the indigenous Maya (11.3%)11. Other ethnic groups - German and Dutch Mennonites, Chinese, Arabs and Africans account for a small percentage of the population. The population’s intercensal growth rate between Census 2000 and 2010 was 2.65% (SIB: Census 2010:6) and at that relatively high rate, the population will double by year 2036. This growth rate is regarded as one of the highest in the region. Officially 45% of the population resides in urban areas, and the remaining 55% in the rural areas12. Census 2010 also noted that 14.2% of the country’s population is foreign born, with the single largest majority being from neighboring Guatemala. Figure 1 illustrates the population age and sex structure in Belize in 201613.

in 2015 was reported to be 28 per 100,000 live births.14 Children aged 5 to 14 years are more at risk of dying from accidents related to fire, drowning and transport. However, the causes of mortality among children less than one year and those five years and under continue to be as a result of hypoxia, birth asphyxia, respiratory conditions, and other conditions originating in the perinatal period, and congenital anomalies. In adolescents aged 15-19 years the major causes of death are related to road traffic accidents, homicide and injury purposely inflicted by other persons, and injury undetermined whether accidentally or purposely inflicted. Diabetes, cardiovascular diseases, cancers and chronic respiratory diseases are now responsible for approximately 40% of deaths annually, injuries and external causes account for 28% and communicable diseases, 20%, including HIV and acute respiratory tract infections15. Also 47% of the deaths due to NCDs were regarded as premature deaths in persons less than 70 years of age. Approximately 50% of females die of diabetes related causes. The leading causes of mortality for males are homicide, HIV and road traffic accidents.

Mortality Life expectancy was estimated at 73.7 years in 2014. As of 2012, the infant mortality rate was 15.7/1000 live births. This was an improvement from the previous year but it was still less than the two-thirds reduction required by the MDGs. The maternal mortality ratio 11 12

PAHO Health in the Americas 2017, Belize Chapter PAHO Health in the Americas 2017, Belize Chapter 13 Statistical Institute of Belize, 2016, http://www.sib.org.bz/ . Accessed November 2016 14 The World Bank. http://data.worldbank.org/indicator/SH.STA.MMRT. 15 Belize, PAHO Health in the Americas, 2017 (draft)

PAHO/WHO Country Cooperation Strategy Morbidity The top three causes of morbidity are responsible for almost half of all hospitalizations on a national level. They include complications of pregnancy, childbirth and puerperium (ranked 1st)16; injury, poisoning and certain other consequences of external causes (ranked 2nd); and acute respiratory infections (ranked 3rd). Belize is in the pre-elimination phase of malaria which has decreased approximately 95% between 2007 to 2012, from 845 to 37 cases respectively. The yearly incidence of tuberculosis has remained stable over the past decade. In 2009, there were 27 confirmed cases of Chagas infection detected in blood donations. The parasite exists in vectors that have been detected in the country, and it is suspected that Chagas cases occur every year. Continuous screening for blood donors by the MOH has enhanced the surveillance for Chagas. HIV remains problematic, but sexually transmitted infections do not appear as leading causes of morbidity.

Belize ratified the FCTC on December 15th 2005 and became a Contracting Party bounded by specific provisions within the treaty, which included, but was not limited to: the institution of a comprehensive ban on tobacco advertising, promotion and sponsorship within five years. In 2009, the MOH developed and publicly launched a policy to ensure smoke free environments in public places, to include all Government facilities and public transport. This never became legislation; however, more than 50 restaurants around the country are implementing the policy. Currently, with the assistance of the PAHO Country Office, a draft tobacco bill has been developed and is presently being reviewed by the office of the Solicitor General before its formal remittance to Cabinet. While the MDG Report 2013 noted that Belize was on target for meeting the goal of reversing the spread of HIV/AIDS in the general population, the 2015 National HIV Surveillance Report data showed an increase in the rate of newly diagnosed HIV cases in the 20+ years age groups for both sexes, with a predominance in the male population after the age of 25. The report also mentions concerns about adherence to treatment and persons presenting late for diagnosis.19 Violence, Accidents and Injuries - Last year, Belize recorded 60 road fatalities, and its rate of 18/100,000 was the fourth highest among the seven (7) countries in Central America. Crime in Belize City has been partially attributed to the increase in gang violence – mostly on the south side of Belize City – and drug trafficking. Due to its small population and high murder rate per capita, Belize consistently ranks among the top 10 in the world for homicides, according to the United Nations Office on Drugs and Crime, with an average of around 40 homicides per 100,000 residents. 20 The MOH Epidemiological Unit’s 2012 statistics reported that of the total number of gender-based violence cases countrywide, 88% are inflicted by men on women. The remaining 12% of reported cases are women abusing men.21 One of the most common forms of violence perpetuated against women is abuse by their husbands or other intimate male partners and

The Burden of Noncommunicable (NCDs) and Communicable Diseases (CDs)

NCDs have become increasingly prominent in the disease profile over the last decade. The common risk factors include an unhealthy diet which includes fats, sugars and salt, tobacco use, the harmful use of alcohol and physical inactivity. The International Diabetes Federation notes that Belize has the highest prevalence of diabetes in North America and the Caribbean with an age adjusted comparative prevalence of 16.5%, and a raw prevalence rate of 14.2%.17 Belize health interventions for controlling and reducing lifestyle diseases include the provision of basic medication and an increased emphasis on prevention and healthy living. In an effort to address the ever-increasing public health threat of tobacco consumption, Belize signed on to the Framework Convention on Tobacco Control (FCTC) on September 26, 2003. As a result, the MOH began to implement small initiatives to encourage a smoke free environment in its offices, vehicles, hospitals and the Philip Goldson International Airport. This also saw the establishment of a National Tobacco Control Committee with multi-sectoral representation. 18

16 It must be noted that included in the number one cause of MORBIDITY are normal deliveries, 94% of mothers deliver within a health facility and these are reported as persons being hospitalized. This is within the context of promoting a safe delivery and contributing to a safe motherhood and ensuring healthy newborns (MOH Strategic Plan). 17 International Diabetes Federation. 2015. “IDF Diabetes Atlas 7th Edition. www.diabetesatlas.org 18 Belize National Tobacco Control Plan (BNTCP) 2007-2012 http://health.gov.bz/www/tobacco-control/204-fctc. Accessed January 2017. 19 http://www.unaids.org/sites/default/files/country/documents/BLZ_narrative_report_2016.pdf 20 https://www.osac.gov/pages/ContentReportDetails.aspx?cid=19620 , Accessed November 2016. 21 Enriquez. Jeremy A, Domestic violence in Belize, May18, 2014, http://belizeinamerica.net/domestic-violence-in-belize/

Belize 2017 - 2021 is seen as a cross-cultural phenomenon that transcends social, economic, and religious boundaries.22 Emerging Diseases – The first case of Zika was confirmed in Belize in May 2016, and by the end of September 2016, there were 46 confirmed cases of Zika of which 6 were pregnant women.23 All four serotypes of Dengue have been confirmed in Belize and its prevalence in urban communities is three-fold that of rural communities. Other Health Problems - The country’s mental health program needs to be strengthened, broadened, and integrated into the mainstream services. In addition, as life expectancy continues to increase, people will be living longer and there will eventually be a higher hospital utilization rate as well as a higher cost per capita due to the prevalent problems of hypertension and diabetes. Corozal District (2016). The NHI is responsible for the delivery of Primary Care services through a network of Primary Care Providers that focuses on the health of a defined geographic and population base. All three areas where the NHI exists, (Southside Belize City, the Southern Districts and Corozal) have been objectively identified as poor.

International Health Regulations In order to achieve compliance with the International Health Regulations 2005 in a timely manner, the Ministry of Health, Belize, in collaboration with the Pan American Health Organization, between 20082009 underwent a process of national self-assessment and planning to identify and address gaps in national core capacities required for implementation of the Regulations. The results and recommendations of these assessments formed the basis for the development of a Plan of Action aimed at addressing the ability of its existing national structures and its resources to meet at least the minimum requirements for response and to ensure that the core capacities would be met and be functional by June 2012. In 2016, following on several more years of internal evaluations and requests for extensions, the MOH Belize made a request for an external evaluation, and an assessment mission visited from 4 to 8 July 2016 to conduct an International Health Regulation (IHR) External Evaluation. In line with the targets defined in the Joint External Evaluation (JEE) Tool for the 19 core capacities of the IHR, the experts identified strengths and developed a gap analysis. On the basis of the gap analysis, recommendations were made which will assist the country of Belize to develop a road map for further Action Plan aiming at meeting IHR requirements.

2.3 Health systems response in Belize Health Sector Strategic Plan 2014-2024 (HSSP) aims to develop an integrated health services delivery network that is based on primary care so as to achieve a greater outcome and impact on the health of the population, while at the same time being more efficient and sustainable. The Ministry of Health recognizes that there are national and regional political challenges that affect the provision of health care services that need to be addressed and realizes that there must be a measure of shared responsibility with other partners. The HSSP provides an overall framework of health priorities that contribute to the overall national development goals in Belize. As part of the Health Sector Reform initiative, the MOH reorganized its services into four Health Regions (Northern Region, Central Region, Western Region and Southern Region), headed by Regional Health Managers. All the regional hospitals are urban-based and the rural population is served by a network of health clinics, health posts and mobile health clinics. The National Health Insurance (NHI) scheme was initially introduced as a pilot in the South Side of Belize City (2002) and later extended to the Southern Region (2006), and more recently, to the 22 23

Health Financing Belize’s health system is substantially dependent upon public financing. For the 2016/2017 financial year, Government has budgeted approximately BZ$126.4M to the MOH. This equates to approximately 11% of the national budget and 3.5% of GDP. Analysis of health system performance in countries that have increased and improved access to health services has shown that

A Gender-Based Analysis of HIV/AIDS in Belize, Ministry of Health and PAHO, June 2010, Report_GBA_HIV_Belize_June2010.pdf. http://health.gov.bz/www/general-health/891-ministry-of-health-continues-to-caution-public-as-new-zika-cases-emerge. Accessed November 2016.

PAHO/WHO Country Cooperation Strategy Public Health Expenditure around 6% of GDP was required to be able to establish a good health system with the basic tenet of Universal Health Coverage. and other instruction courses that are financed by the health budget or by funding partners.

Human Resources Data on registered medical personnel and per capita health personnel data are detailed in Table 2 below. This table shows the unchanged levels of health professionals in the midst of population increases and therefore reducing ratio of health care professionals

Health Information Systems The Ministry of Health uses a Health Information System (BHIS) to record patient data, and to integrate data sources electronically to facilitate data analysis and reporting of health information. While MOH uses BHIS, the National Health Insurance (NHI) uses a different system known as RAWA.

Table 2: Registered Medical Personnel 2010-2015 Year Physicians Physicians per 10,000 population Dentists Dentists per 10,000 population Nurses Nurses per 10,000 population Community Health Workers CHW per 10,000 population Pharmacists/ Dispensers Pharmacists/ Dispensers per 10,000 population 2010 241 7.5 12 0.4 469 14.5 208 6.4 112 3.5 2011 241 7.5 12 0.4 469 14.5 208 6.4 112 3.5 2012 395 11.5 44 1.2 423 12.3 287 8.4 112 3.5 2013 371 10.6 44 1.2 451 12.9 282 8.1 112 3.2 2014 371 10.3 44 1.2 451 12.6 282 7.9 112 3.1 2015 371 10.1 44 1.1 451 12.3 282 7.7 112 3

per 10,000 population. The distribution of these professionals is usually urban-based, specifically in Belize City. The country has no medical school or Faculty where physicians can be trained. However, various categories of nurses, pharmacists and social workers are formally trained at the University of Belize. The chronic shortage of certain categories of health care professionals means that Belize is a net medical personnel importing country requiring recurrent expenditures to acclimatize new health workers. This is also a high turnover since many healthcare professional leave Belize to find jobs in the United States or the Caribbean. Continuing education for health workers takes the form of workshops, seminars 24

2.4 Cross-cutting issues (equity – “leaving no one behind”, gender, health and sustainable development, environmental health, climate change, food and nutritional security) Equity and Gender Equity24 is a central theme of the SDGs and supports the concept of “leaving no one behind”. In many countries, some people live with social, political and

PAHO defines equity as “Achieving health equity requires that women and men, girls and boys have fair opportunities and access to conditions and services that will help them achieve optimal health. Equity in health demands that we care about the range of human experiences and work towards making health care and policies responsive to all people, by paying attention to their diverse identities as people, and by paying attention to the diversity in their daily lives.”

Belize 2017 - 2021 economic disadvantages that contribute to poor health. Even though Health has only one SDG, it has been positioned as a major contributor to the other SDGs.25 The 2014-2019 PAHO Strategic Plan is committed to championing health, sustainable development and equity, and identifies certain key cross-cutting themes that should be addressed at country-level which include gender, equity, human rights and ethnicity. Belize has been selected as one of the countries to sit on the PAHO Commission on Equity and Health Inequalities in the Americas. This Commission will look at the social, economic, cultural, environmental behavioral and structural drivers of different outcomes across populations and the entire life course. Through the Ministry of Human Development, Social Transformation and Poverty Alleviation (MHDSTPA) in Belize efforts are being made to facilitate policy development and to implement programs that promote social justice and equity, enabling people to be selfsufficient, responsible and productive citizens. Over the years, Belize has seen an improvement in its Human Development Index(HDI)26 from 0.644 in 1990 to 0.715 in 2014. However, this is still below the average rate for Latin America and the Caribbean which is 0.748. Belize’s Gender Development Index (GDI) in 2014 was 0.958.27 Even though laws exist, gender inequality and gender-based violence continue to be sensitive issues that need to be addressed. The MOH’s 2010 National Gender-based Surveillance report indicated that there were a total of 1,227 cases of reported domestic violence in Belize.28 As a result, the main goal of the Women’s Department within MHDSTPA is to promote gender equality and equity, enabling women and men to be actively involved in and enjoy all benefits of development. It strives to facilitate economic development and the empowerment of women, to minimize the incidence of gender-based violence in an effort to contribute to creating a protective environment and to advocate for gender sensitive policies, plans, programs and projects. The Revised National Gender Policy 2013, (RNGP) identifies and examines the inequities experienced by both men and women and suggests strategies to correct gender disparities as well as gives direction for the co-ordination and implementation of the policy. However, despite all the progress that has been made to ensure gender equality and equity, barriers still exist to achieving the parity between men and women that is essential for true development.29 Recognizing this, the theme for Women’s Month in 2016 focused on “parity” to demonstrate that “equality cannot be achieved without unity, a unity that calls for inclusion, partnership and visioning for all. It is important that everyone, men and women, understand that their actions contribute to and greatly affect this movement towards parity.”30

Policies and Plans on Environmental Health, Climate Change and Health, and Sustainable Development Horizon 2030 and the Growth and Sustainable Development Strategy 2016-2019 The 4 pillars of Horizon 2030 are: • democratic governance for effective public administration and sustainable development; • education for development - education for life; • economic resilience: generating resources for long term development; • the bricks and the mortar - healthy citizens and a healthy environment.

Belize’s approach to sustainable development is articulated in “Horizon 2030: The National Development Framework for Belize 2010-2030” which outlines four key pillars for achieving a higher quality of life for all people in Belize, now and in the future. Recognizing that an integrated systematic approach based on the principles of sustainable development will be required, Belize also developed The “Growth and Sustainable Development Strategy 2016-2019” (GSDS), the primary planning document that sets out the critical success factors (CSF) and specific actions to be taken over the next three years (2016-2019) to achieve the longer term goals of Horizon 2030.

WHO Provisional Agenda item 13.2 Health in the 2030 Agenda for Sustainable Development, 8 April 2016. The HDI is a summary measure for assessing long-term progress in three basic areas of human development: a long and healthy life, access to knowledge and a decent standard of living. 27 The GDI measures gender gaps in human development achievements by accounting for disparities between women and men in three basic dimensions of human development - health, knowledge and living standards using the same component indicators as in the HDI. It shows how much women are lagging behind their male counterparts and how much women need to catch up within each dimension of human development. 28 http://www.humandevelopment.gov.bz/wp-content/uploads/2013/03/Sexual-Violence-handbook.pdf 29 http://humandevelopment.gov.bz/index.php/service-units-2/womens-department/ 25 26 30

http://humandevelopment.gov.bz/wordpress/wp-content/uploads/2016/03/Womens-Month-Booklet-2016-final-version.pdf

PAHO/WHO Country Cooperation Strategy Climate Change and Disaster Preparedness Belize has a long low-lying coastline on which approximately 50% of the population and business centers are located at sea-level. It also has the largest barrier reef in the hemisphere, which was designated a UNESCO World Heritage site in 1996. The United Nations Framework Convention on Climate Change identified Belize as one of the countries that is most vulnerable to the adverse effects of climate change. It is projected that the effects of natural disasters are expected to intensify in severity and frequency in the future. Over the years, hurricanes and flooding have caused tremendous damage to the country and its economy. It is estimated that an average 3.3% of GDP was lost annually between 1993 and 2012 from disasters.31 Belize has also been designated as a protected area for conservation purposes since nearly a quarter of its land and marine territory fall under some type of protection designation and over a million hectares of forest cover supporting fragile ecosystems. Of particular concern to health is the on-going devastation being caused in the Chiquibul National Forest, on Belize’s western border with Guatemala and the illegal gold mining near the headwaters of the Macal River. This river merges with the Mopan River to form the Belize River, which is the country’s largest waterway and a source of drinking water for nearly a half of its population. As a result, natural environment, disaster risk and climate change are to be mainstreamed into all relevant development decision-making during the planning and implementation of the GSDS. Sustaining terrestrial and marine protected areas that ensure water and food security has also been highlighted. Belize Climate Resilient Infrastructure Project (BCRIP),32 funded through a loan from the World Bank, was launched in 2014 to address the impacts of climate change on the country’s social and economic development as part of the National Climate Resilient Investment Plan. Food and Nutritional Security Belize considers food security to be fundamental to human and economic development and it is 31 32

determined to strengthen its governance mechanisms for designing, implementing and monitoring its programs and public policies for Food & Nutrition Security (FNS). The main objective of the National Policy of Food and Nutritional Security is to guarantee security and food sovereignty through local sustainable production, supply, access and security use, high quality of nutritive, diversified and culturally acceptable foods for all Belizeans with the purpose of improving welfare and life quality.33 Under the National FNS Policy, a Food & Nutrition Security Commission has been established to coordinate activities among the different sectors. In Belize, the Food and Agricultural Organization (FAO) supports the development and implementation of the Food and Nutrition Security and School Feeding Programs and participates in the “Mesoamerica Without Hunger Initiative” in four communities of the Toledo District which is one of the poorest districts in Belize. Through work with INCAP (Institute of Nutrition of Central America and Panama)34 emphasis has been placed on strengthening primary level health services to respond and meet nutritional needs through interventions for prevention and clinical care with the integration of the WHO´s growth patterns of children under five years as a tool for the nutritional surveillance information system within the Ministry of Health, is also one of the activities being implemented. Main Issues and Challenges Based on the health and development issues mentioned above the main issues and challenges are summarized below: a. Noncommunicable and Communicable Diseases • NCDs are the most critical health problems facing the country. Diseases of the heart, malignant neoplasms and diabetes and their related risk factors could impose long-term costs on the health system. • The increase in homicides has had a great impact on the mortality trends for males. • Even though relevant policies exist in Belize, gender-based violence continues to be a serious development and public health concern and that needs to be addressed by both women and men.

Carnerio, Franciso, Belize right Choices Bright Future, Systematic Country Diagnostic, The World Bank Group, January 2016 http://www.projects.worldbank.org/P127338/climate-resillient-infrastructure?lang=en&tab=overview 33 http://www.incap.int/index.php/en/technical-cooperation-in-the-region/belize 34 INCAP specializes in research in clinical nutrition deficiencies in food and nutrition.

Belize 2017 - 2021 • There has been an increase in the rate of newly diagnosed HIV cases in the 20+ years age group in both sexes, with predominance in the male population after the age of 25, and concerns about adherence to medication and persons presenting late for diagnosis. There is a diverse range of emerging diseases which include the Zika virus, Chikungunya, and Dengue. Even though Belize has been categorized as an Upper Middle Income Country (UMIC) by the World Bank, it has been able to benefit from the Official Development Assistance (ODA) that supports key national health priorities especially in the areas that address specific diseases and the strengthening of the health system. ODA received through multilateral and bilateral agreements that address health and health related issues are aligned to national development pillars of Horizon 2030 and the CSF of the GSDS. The regional and national partners who have collaborated with PAHO Belize to implement activities in Belize are listed in Annex 3.

•

b. Determinants of health and promoting health throughout the life course • Maternal mortality figures remain lower than that required by the 3.1 SDG target (as per the latest 2015 WHO report). • The growing challenge of “aging healthily” as people live longer, and increasing costs associated with meeting their health needs. c. Health System and Services • There is a chronic shortage of certain categories of health care professionals as well as a high turnover which means that Belize is a net medical personnel importing country. • There is a disproportionate distribution of healthcare professionals with most being located in Belize City. • The financing of health services provided should be revised and the NHI expanded. • The expected burden of NCDs now and in the future will require revising the policies and procedures for collecting data, pooling risks and the financing of the various services, to ensure solid progress toward Universal Health (UH). • There appears to be limited coordination between the BHIS and the RAWA systems. d. Preparedness and Disaster Belize’s economic development is centered on its natural resources – tourism, agriculture, fishing and offshore oil drilling – and therefore continues to be susceptible to the effects of climate change and climate variability.

Collaboration with the United Nations system at country-level The Belize United Nations Development Assistance Framework (UNDAF) 2013-2016 was developed nationally and was one of six (6) UNDAFs developed in the Caribbean. In 2016, this national approach was changed to the development of one common UN Multi-Country Sustainable Development Framework (UN MSDF) for the Caribbean for the period 20172021.35 The goal of the UN MSDF is to provide the tools, partnerships, and resources needed to achieve national and sub-regional development priorities, in an inclusive and equitable manner, as reflected in the SDGs and the principle of “leave no one behind”. The UN MSDF also contributes to the fulfillment of the SIDS Accelerated Modalities of Action (SAMOA) Pathway and the CARICOM Strategic Plan 2015-2019. Eighteen (18) English- and Dutch-speaking Caribbean countries and Overseas Territories are covered under this UN MSDF. This PAHO CCS for Belize is aligned to Caribbean UN MSDF and PAHO Belize will be involved with the operationalization of the UN MSDF through the implementation of a Country Implementation Plan (CIP)36 developed by the United Nations Country Team (UNCT). The other members of UNCT resident in Belize include the United Nations Development Programme (UNDP), United Nations Family Planning Agency (UNFPA), United Nations Children’s Fund (UNICEF), the United Nations High Commission for Refugees (UNHCR), United Nations Office for Project Services (UNOPS) and the International Organization for Migration (IOM). The other non-resident agencies that also implement activities in Belize are the: Food

2.5 Development partners’ environment Partnership and development cooperation

The CIP is the management tool that will ensure greater coherence, efficiency and effectiveness of the UN’s assistance to Belize

PAHO/WHO Country Cooperation Strategy and Agricultural Organization (FAO), International Labour Organization (ILO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), United Nations Environment Programme (UNEP), and the International Atomic Energy Agency (IAEA). • Caribbean Public Health Agency (CARPHA), a new single regional public health agency for the Caribbean which began operations in January 2013. It was legally established in July 2011 by an InterGovernmental Agreement signed by Caribbean Community Member States. CARPHA’s mission is to provide strategic direction, in analyzing, defining and responding to public health priorities of CARICOM, in order to prevent disease, promote health and to respond to public health threats and emergencies. Its vision is “A Caribbean, in which the health and wellness of the people are promoted and protected from disease, injury and disability, thereby enabling human development in keeping with the belief that the health of the Region is the wealth of the Region.” Areas of technical cooperation to Belize include mortality data coding, laboratory strengthening, vector control management and health and tourism.

Country Contributions to global and regional agenda Inter-American System Under the Inter-American system, Belize benefits from initiatives and programs of both Central America and the Caribbean. It has membership in: • Central American Integration System (SICA) Belize became a member in December 2000. SICA is comprised of Belize, Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and Panamá. The Dominican Republic is an Associate Member of SICA, and the Republic of China on Taiwan, Mexico, Spain, Germany, Chile and Italy participate as Observers. The Central American Social Integration System, (SISCA) a component of SICA, includes COMISCA, (the Council of Ministers of Health of Central America and the Dominican Republic) and the Mesoamerican Integration and Development Project Caribbean Community (CARICOM) which is comprised of twenty (20) countries – fifteen (15) Member States and five (5) Associate States stretching from the Bahamas in the north to Suriname and Guyana in South America and Belize in Central America. Through the Council for Human and Social Development (COHSOD), CARICOM promotes the improvement of health, education, and living and working conditions for the Caribbean Community. Belize has been a full participating member since 1974 .

Through the signing of specific agreements and memoranda of understanding PAHO/WHO provides technical cooperation to these subregional integration bodies. 37

2.6 Review of PAHO/WHO’s Technical Cooperation over the past CCS Cycle Recommendations and Lessons Learned Mid-term review (MTR) of the Country Cooperation Strategy (CCS) 2008-2011 In September 2010, the PAHO/WHO Belize Country Office conducted a rapid, qualitative mid-term review (MTR) of the Country Cooperation Strategy (CCS) 2008-2011. The objectives were to: determine the degree to which the CCS 2008-2011 had been implemented; determine PAHO/WHO’s contribution to the implementation of the National Health Agenda of the Ministry of Health (MOH) Strategic Plan;

•

37 The key PAHO/WHO measures supported include: the Health Plan for Central America and the Dominican Republic approved by COMISCA and aligned with the PAHO Strategic Plan 2014-2019; COMISCA Subregional Plan for the prevention and control of the Zika Virus in Central America and the Dominican Republic; COMISCA Strategy for the Prevention and Control of Overweight and Obesity in children, 2014-2025 and other COMISCA. agreements for tobacco control, International Health Regulations, monitoring of pesticide use and strengthening national regulatory authorities; the Mesoamerican preparation of national plans on Malaria, Dengue, Chikungunya, and Zika virus, road safety and primary health; and the CARICOM Caribbean Cooperation in Health IV.

Belize 2017 - 2021 provide updates to the situation analysis and the strategic agenda; make recommendations for revisions; and identify implications for the strategic agenda. The MTR concluded that: • • • The 2008-2011 CCS strategic priorities remained valid and were similar to PAHO/WHO’s CCS, 2008-2011 The MOH’s national health priorities were well articulated in the CCS’s four priority areas of action: improving the health status of the population; addressing key health determinants; strengthening health sector policies and organization; and enhancing PAHO/WHO’s response The importance of PAHO/WHO’s work was widely embraced and recognized.

MTR also identified the following strengths and weaknesses: Strengths a. PAHO/WHO’s organizational capacity, international linkages and ability to mobilize valuable resources for the country. Weaknesses a. Perception that the Organization is bureaucratic, has a top-down mentality, and has rules and regulations that make project development somewhat difficult, constrained by Organizational agendas, and areas of action undertaken are too wide. b. There was limited cooperation with other UN Agencies and NGOs, which was attributed to PAHO/WHO’s specific agenda and the assignment of technical advisors to specific programs. c. Concerns that there was insufficient direct engagement with health care personnel on the ground (outside of meetings and workshops). PAHO/WHO’s work in Belize was seen as being “too limited.” d. Health publications are not readily available and user-friendly material for those with sub- levels of literacy was needed. e. Seems to be an imbalance between the “attention” given to communicable diseases and that given to NCDs. f. Lack of human and financial resources at the country level threatened PAHO’s ability to respond.

b. The professional leadership capacity provided to the MOH supported advancing needed health initiatives to solve Belize’s health problems with a Central American/Caribbean focus. c. The cadre of professional technical staff with strong technical skills in capacity building, research, and training, which cannot be sourced from other organizations in the country. d. PAHO/WHO’s ability to work with successive governments and NGO’s.

29 • • • • • • • reducing the burden of NCDs and the related risk factors especially with regard the continued enforcement of the FCTC regulations, the integration of substance abuse policy into all public health programs, improving food safety polices, the continued support to the school-based nutrition programs; improving the quality of data collection for mental health; the strengthening of capacity and retention of the human resources in health especially with nurses and midwives; expanding the NHI especially for the elderly; focusing on environmental health with greater attention to the effects of global warming; revising the legislation for health information systems to support the electronic collection of data and its use for evidence-based decision making; improving regulatory functions within the Ministry of Health.

The 2017-2021 CCS was seen as a useful document that could support the MOH in achieving: • the objectives outlined in the HSSP especially those at the primary health care level • the health-related critical success factors in the country’s GSDS • by linking this CCS with the SDGs and the UN MSDF, it will improve PAHO/WHO’s collaboration with other partners and support Belize’s ability to achieve the targets at the regional and global levels.

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

3. The Strategic Agenda 3.1 Strategic Priorities and related Focus Areas The CCS’ Strategic Agenda lays out the Strategic Priorities (SPs) and focus areas (FAs) for PAHO’s Technical Cooperation with its member countries. The SPs constitute the medium-term priorities for PAHO/ WHO’s cooperation with Belize, on which the Organization will concentrate the majority of its resources over the CCS cycle. The CCS FAs are the “what”, reflecting the expected achievements required to realize the strategic priority. Each focus area should link directly with at least a HSSP priority, a PAHO Strategic Plan outcome, indirectly with a health or health-related SDG target and the development priorities of the UN MSDF for the Caribbean. The SPs are as follows:

Strategic Priority 1: Strong and resilient health systems achieved through improved governance, leadership and management that support universal health (access and coverage for all). This SP focuses on the PAHO/WHO technical support needed to assist the MOH in achieving Universal Health by strengthening health systems. Universal Health means that everybody has access to and is covered by a wellorganized and well financed health system regardless of their age, gender, race, class place or income. In keeping with the strategic goals laid out in their HSSP 2014-2024, the MOH will require continued support with the strengthening of leadership and governance at all levels to facilitate the development of inclusive legislative frameworks and policies that are people-centered, and which promote efficiency and equity. The continued roll-out of the NHI will be critical to ensure equitable access to health services across Belize. The strengthening of the BHIS and the potential incorporation of RAWA will facilitate the timely and systematic collection, organization and retrieval of data for a broad range of purposes, including prompt monitoring and reviews to facilitate informed decision-making.

The FAs for this SP are: 1.1 Revise and or develop national health legislation and inclusive policies to advance health equity, the procurement of appropriate, affordable medicines and other health technologies and strengthen intersectoral actions that address the social determinants of health. 1.2 Redefine the health financing mechanism to include the expanded roll-out of the National Health Insurance system to ensure equitable access to health services across Belize. 1.3 Strengthen the Belize Health Information System (BHIS) to improve coordination with RAWA and the

PAHO/WHO Country Cooperation Strategy comprehensive use of data for evidence-based decision making and monitoring and evaluation. 1.4 Strengthen primary healthcare networks and the resolution capacity to meet expanding health needs in Belize.

Strategic Priority 3: Health and wellness promoted throughout the life course using an integrated primary health care approach to reduce non-communicable diseases and their risk factors, communicable diseases, mental health disorders, urban violence and injures. This SP is closely aligned to pillar 4 - The Bricks and Mortar: Healthy Citizens and a Healthy Environmentof the National Development Plan: Horizon 2030. This pillar states that “Good human health is more than the absence of illness. It encompasses the concept of wellness, the ability to peacefully enjoy family and community in a clean and uplifting environment.” The life course approach considers how multiple determinants interact and affect health throughout life and across generations. It promotes health and wellbeing from preconception to old age. To reduce the burden of NCDs, emphasis will be placed on diseases of the heart and lungs, malignant neoplasms, and diabetes including their main risk factors tobacco use, unhealthy diet, physical inactivity and substance abuse - including alcohol. Interventions addressing mental health, violence and injuries and disabilities will also be included under this SP. Communicable disease interventions will focus on HIV, tuberculosis, vector-borne diseases, neglected tropical diseases, and vaccine preventable diseases. Most of the gains in this priority will be made by influencing policies in other sectors. The MOH through the establishment of a “Social Sector Cabinet”38 will improve the implementation of the Health in All Policies approach. This will ensure that other sectors such as Education will be receptive to a health curriculum that deals with the major health issues; and that agriculture is sensitive to the fact of food security.

Strategic Priority 2: Human resource for health (HRH) management and capacity strengthened to parallel the health needs of the growing population. The human resources in Belize are critical and are needed to improve the delivery of health care services across Belize especially to people living in rural areas. The retention and the deployment of health care staff will be necessary to ensure the right mix of skills that can deliver high quality service in both rural and urban areas across Belize. This will also help the MOH to meet the regional Core indicators for HR which establishes the approved ratio of personnel per population. Strengthening of the HRH management will involve the development of polices and plans, and building the capacity of the public health workforce to provide public health interventions and high-quality health care to meet the growing needs of and the demands on the MOH.

The FAs for this SP are: 2.1 Advocate for the use of recommendations of previous PAHO HRH assessments of the gaps and needs to ensure the recruitment, deployment and retention of a skilled workforce that can meet the regional core indicators for HR and equitably deliver health services across Belize especially in the rural areas. 2.2 Build and/or reorient the capacity of healthcare professionals to meet the emerging health trends and needs of the Belizean population. 2.3 Strengthen HRH management within the Ministry of Health to develop and/or adapt HRH policies and plans that define the strategic direction and the integration of HRH into other sectors.

The FAs for this SP are: 3.1 Support and promote the implementation of interventions and strategies that engage and empower communities to adopt healthier lifestyles that reduce the risk factors related to developing noncommunicable diseases and/or contracting communicable diseases.

8 The Social Sector Cabinet under the leadership of the MOH was proposed by the MOH as an approach that could assist with the implementation of this SP.

Belize 2017 - 2021 3.2 Advocate for social programs and policies within the public sector for the early detection and intervention to address problems related to genderbased violence, urban violence and road safety. 3.3 Strengthen national capacities to implement comprehensive strategies that prevent and treat mental and substance abuse disorders within a framework of human rights and respect for human dignity. emergencies including natural disasters (hurricanes and earthquakes), and the impact of climate change. 4.2 Continue to monitor new and evolving outbreaks such as Zika and take the appropriate response measures. 4.3 Implement the IHR external evaluation recommendations which include preparing a multisectoral roadmap linking existing institutional and operational planning mechanisms and structures and increasing horizontal cooperation with other countries. The SPs and related FAs for the 2017-2021 CCS for Belize can be found in Annex 4.

Cross-cutting Issues Key cross-cutting themes of gender, equity, human rights, and ethnicity will be taken into consideration to implement the strategic agenda of this CCS. Mainstreaming a gender perspective will assess the implications for women and men of any planned action, including legislation, norms and standards, policies or programs, in all areas and at all levels. A human rights-based approach will be used to implement interventions and activities.39

The FAs for this SP are: 4.1 Strengthen the coordination of the preparedness and response mechanisms to address health

39 A human rights-based approach places emphasis on analyzing the human rights claims of the rights holders and the corresponding obligations of the duty bearers, as well as the immediate, underlying, and root causes of the non-realization of rights; assessment of the capacity of rights holders to claim their rights and of the duty bearers to fulfill their obligations, with development and implementation of strategies to build the capacities; monitoring and evaluation of both outcomes and process, guided by human rights principles; and incorporation of recommendations from treaty bodies and mechanisms into programming, including support for synchronizing national laws with treaty obligations. PAHO Seminar on the Right to Health, Belize 2009.

PAHO/WHO Country Cooperation Strategy

3.2 Alignment of SPs, FAs to the MOH HSSP, 2014-2024, the PAHO Strategic Plan Outcomes, CCH IV, SDG Targets and UN MSDF Table 3. Mapping Matrix CCS Strategic Priority 1. Strategic Priority 1: Strong and resilient health systems achieved through improved governance, leadership and management that support universal health (access and coverage for all)

CCS Focus Area

HSSP Strategic Objective and Related Expected Outcomes SO2 - Strengthening the Organization and Management of Health Services EO - The steering role of the MOH strengthened

PAHO Strategic Plan 2030 SDG Targets Outcomes 2014-2019 OCM 4.2 Increased access to people-centered, integrated, quality health services 3.8 Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all 3.b Support research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration40 which affirms the right of developing countries to use to the full the provisions in the TRIPS agreement regarding flexibilities to protect public health and, in particular, provide access to medicines for all OCM 4.1 Increased national capacity for achieving universal health coverage 3.c Increase substantially health financing and the recruitment, development and training, and retention of the health workforce in developing countries, especially in LDCs and SIDS 3.8 Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all OCM 4.4 All countries have functioning health information and health research systems 3.8 Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all

UN MSDF (Caribbean) Outcomes A Healthy Caribbean Outcome 1 - Universal access to quality health care services and systems improved Outcome 2 - Laws, policies and systems introduced to support healthy lifestyles among all segments of the population

34 1.2 Redefine the health financing mechanism to include the expanded roll-out of National Health Insurance system to ensure equitable access to health services across Belize SO3 - Achieving Greater Equity, Cost Effectiveness and Efficiency in the Allocation and Use of Health Resource EO -Equity, effectiveness and efficiency in the allocation and use of funds improved

A Healthy Caribbean Outcome 1 - Universal access to quality health care services and systems improved

1.3 Strengthen the Belize Health Information System (BHIS) to improve coordination with RAWA and the comprehensive use of data for evidence-based decision making and monitoring and evaluation

SO5 - Strengthen Capacity for Human Resources for Health Planning to meet present and future Health sector needs EO - Utilization of data for evidence-based planning and decision making

A Healthy Caribbean Outcome 1 - Universal access to quality health care services and systems improved

40 Doha Declaration affirms the right of developing countries to use to the full the provisions in the TRIPS agreement regarding flexibilities to protect public health and, in particular, provide access to medicines for all

Belize 2017 - 2021

CCS Strategic Priority 1.

CCS Focus Area

HSSP Strategic Objective and Related Expected Outcomes SO1 - Integrated health services based on Primary Health Care for improved Health outcomes EO - Health system organized to increase accessibility to health services in an equitable manner.

PAHO Strategic Plan Outcomes 2014-2019 OCM 4.2 Increased access to people-centered, integrated, quality health services

2030 SDG Targets

UN MSDF (Caribbean) Outcomes A Healthy Caribbean Outcome 1 - Universal access to quality health care services and systems improved

Strategic Priority 2: Human Resource for Health (HRH) management and capacity strengthened to parallel the health needs of the growing population

1.4 Strengthen primary healthcare networks and the resolution capacity to meet expanding health needs in Belize.

3.8 Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all

SO4 - Strengthen Capacity for Human Resources for Health Planning to meet present and future Health sector needs EO - Health facilities adequately staffed

OCM 4.5 Adequate availability of a competent, culturally appropriate, well-regulated, well-distributed, and fairly treated health workforce

A Healthy Caribbean Outcome 1 - Universal access to quality health care services and systems improved

35 An Inclusive, Equitable, and Prosperous Caribbean Outcome 1 - Access to quality education and life-long learning increased, for enhanced employability and sustainable economic development

SO4 - Strengthen Capacity for Human Resources for Health Planning to meet present and future Health sector need EO - The availability of a cadre of well-trained and competent health workers with the capacity to deliver quality health services SO4 - Strengthen Capacity for Human Resources for Health Planning to meet present and future Health sector needs EO - Human Resource planning and management functions increased

3.c Increase substantially health financing and the recruitment, development and training, and retention of the health workforce in developing countries, especially in LDCs and SIDS

2.3 Strengthen HRH management within the Ministry of Health to develop and/or adapt HRH policies and plans that define the strategic direction and the integration of HRH into other sectors

3.c Increase substantially health financing and the recruitment, development and training, and retention of the health workforce in developing countries, especially in LDCs and SIDS

An Inclusive, Equitable, and Prosperous Caribbean Outcome 1 - Access to quality education and life-long learning increased, for enhanced employability and sustainable economic development

PAHO/WHO Country Cooperation Strategy

CCS Strategic Priority 1.

CCS Focus Area

HSSP Strategic Objective and Related Expected Outcomes SO1 - Integrated Health Services Based on Primary Health Care for improved Health outcomes EO - Improve quality of care according to defined standards

PAHO Strategic Plan Outcomes 2014-2019 OCM 2.1 Increased access to interventions to prevent and manage noncommunicable diseases and their risks factors OCM 1.1 Increased access to key interventions for HIV and STI prevention and treatment

2030 SDG Targets

UN MSDF (Caribbean) Outcomes A Healthy Caribbean Outcome 2 - Laws, policies and systems introduced to support healthy lifestyles among all segments of the population

3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

3.3 By 2030, end the epidemics of AIDS, OCM 1.3 Increased country tuberculosis, malaria capacity to develop and and neglected tropical implement comprehensive diseases and combat plans, programs, or strahepatitis, water-borne tegies for the surveillance, diseases and other prevention, control, and/ communicable diseases or elimination of malaria and other vector-borne 3.2 By 2030, end diseases preventable deaths of newborns and children OCM 1.4 Increased country under 5 years of age, capacity to develop and with all countries aiming implement comprehensive to reduce neonatal plans, programs, or stramortality to at least tegies for the surveillance, as low as 12 per 1,000 prevention, control and/or live births and under-5 elimination of neglected, mortality to at least as tropical and zoonotic low as 25 per 1,000 live diseases births 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

3.2 Advocate for social programs and policies within the public sector for the early detection and intervention to address problems related to gender-based violence, urban violence and road safety.

SO1 - Integrated Health Services Based on Primary Health Care for improved Health outcomes EO - Improve quality of care according to defined standards EO - Health system organized to increase accessibility to health services in an

OCM 2.3 Reduced risk factors associated with violence and injuries with a focus on road safety, child injuries, and violence against children, women, and youth

3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents

A Safe, Cohesive, and Just Caribbean Outcome 2 - Equitable access to justice, protection, citizen security and safety reinforced

Belize 2017 - 2021

CCS Strategic Priority 1.

CCS Focus Area

HSSP Strategic Objective and Related Expected Outcomes SO1 - Integrated Health Services based on Primary Health Care for improved Health outcomes EO - Increased coordination in health service delivery among providers and stakeholders to ensure continuity of care

PAHO Strategic Plan Outcomes 2014-2019 OCM 2.2 Increased service coverage for mental health and psychoactive substance use disorders OCM 3.3 Increased country capacity to integrate gender, equity, human rights, and ethnicity in health

2030 SDG Targets

UN MSDF (Caribbean) Outcomes A Healthy Caribbean Outcome 2 - Laws, policies and systems introduced to support healthy lifestyles among all segments of the population

Strategic Priority 4: Health emergencies that can become emerging threats of public health concern are addressed

3.3 Strengthen national capacities to implement comprehensive strategies that prevent and treat mental and substance abuse disorders within a framework of human rights and respect for human dignity

3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

4.1 Strengthen the coordination of the preparedness and response mechanisms to address health emergencies including natural disasters (hurricanes and earthquakes), and the impact of climate change.

SO1 - Integrated Health Services Based on Primary Health Care for improved Health outcomes EO - Health system organized to increase accessibility to health services in an equitable manner

OCM 5.3 Countries have an all-hazards health emergency risk management program for a disaster-resilient health sector, with emphasis on vulnerable populations OCM 5.5 All countries adequately respond to threats and emergencies with public health consequences

37 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks A Sustainable and Resilient Caribbean Outcome 1 - Policies and programs for climate change adaptation, disaster risk reduction, and universal access to clean and sustainable energy in place Outcome 2 - Inclusive and sustainable solutions adopted for the conservation, restoration, and use of ecosystems and natural resources

4.2 Continue to monitor new and evolving outbreaks and take the appropriate response measures

SO6 - Development of Quality Improvement framework to ensure stakeholder accountability

OCM 5.2 All countries are able to build resilience and adequate preparedness to mount a rapid, predictable and effective response to EO - Quality improvement major epidemics and Framework for all levels pandemics of the health system designed and implemented

PAHO/WHO Country Cooperation Strategy CCS Strategic Priority 1. CCS Focus Area HSSP Strategic Objective and Related Expected Outcomes PAHO Strategic Plan Outcomes 2014-2019 2030 SDG Targets UN MSDF (Caribbean) Outcomes A Sustainable and Resilient Caribbean Outcome 1 - Policies and programs for climate change adaptation, disaster risk reduction, and universal access to clean and sustainable energy in place

4.3 Implement the IHR external evaluation recommendations which include preparing a multisectoral roadmap linking existing institutional and operational planning mechanisms and structures and increasing horizontal cooperation with other countries

SO7 - Efficient and Effecti- OCM 5.1 All countries have the minimum core ve Health Infrastructure Development capacities required by the International Health Regulations (2005) for EO - Physical health all-hazard alert and environment for response health care delivery to clients improved. EO - Preventive Maintenance program established SO1 - Integrated Health Services based on Primary Health Care for improved Health outcomes EO - Improve quality of care according to defined standards

3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

Belize 2017 - 2021

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

4. Implementation of the Strategic Agenda: Implications for the Secretariat 4.1 Coordination and management The implementation of the Strategic Agenda will be coordinated through the PAHO Country Office but responsibility for its implementation lies with the entire Secretariat. As such, there will be support from the subregional level through its offices in Barbados and Central America, the regional level through the technical departments at headquarters in Washington, and from the global level in Geneva as needed. Efforts will be made to use existing agreements, protocols, guidelines, and other frameworks for health, and build on previous initiatives and interventions to avoid duplication and to complement the work of other agencies and partners in the Caribbean and in Central America that also implement health-related programs in Belize. The program areas listed in category 6 of PAHO’s Strategic Plan 2014-2019 will be important factors for guiding the implementation of the CCS. These factors include leadership and governance; transparency, accountability, and risk management; strategic planning, resource coordination, and reporting; management and administration; and strategic communication. The BWPs will be developed to align with the focus areas of the Strategic Agenda and implementation will start during the second year of the 2016-2017 Biennium.

4.2 Core Resources needed for implementation Financial

Since 2016 PAHO has been using an integrated budget results-based approach for planning and budgeting. This approach is approved as total financial resource requirements, independent of the sources of financing. The successful implementation of the CCS and the sustainability of its achievement will require a Resource Mobilization Strategy so as to renew and increase funding from existing donors, as well as attracting new donors. This is in addition to the joint resource mobilization and partnership strategy for to implement the UN MSDF.

Communication The PAHO/WHO Country Office will take a more proactive approach to improve the communication of PAHO’s work and its impact both nationally and regionally to increase its visibility and strategic positioning as a public health agency. The CO will also assist the MOH in facilitating communication between the Central American and Caribbean concerning health initiatives.

Human The current human resources are adequate with specific re-profiling of the HSS functions to encompass a wider scope (health system; environmental health and sustainability; and health throughout the life course).Where specific experts are needed; mobilization within the various levels of the Organization will be required.

PAHO/WHO Country Cooperation Strategy The successful implementation of the SPs and FAs will require competences and skills in the following areas: • • • • • • • • • • Health systems, including health financing, human resources for health and health information systems Environmental health and sustainability, climate change, and disaster risk reduction and response Non-communicable diseases and risk factor prevention and control, mental health, violence and injury prevention, and health promotion Communicable diseases, including HIV and STIs, vector control, emerging and re-emerging diseases and the human-animal interface Health throughout the life course, including interventions targeting specific population groups, multisectoral approaches, social determinants of health, health in all policies, and PAHO’s crosscutting themes of gender, equity, human rights and ethnicity Strategic partnerships, resource mobilization, and communication using innovative technology Even though Belize is located in Central America the persons with the expertise should have the ability to communicate effectively English

4.3 Implications Matrix • The technical staff within the CO reviewed the political, technical and administrative implications for the Organization to ensure the successful implementation of the strategic agenda of this CCS. Table 4 below explores whether the CO has the core capacities and if not the implications for sourcing it from the subregional offices (Central America and the Caribbean), HQ or at the global level. To contract specific experts/ consultancies, to mobilize expertise within the organization or from Collaborative Centers are implications described more from the technical perspective in the table and not from the economic angle, since it is not possible to quantify the financial resources at this time.

Belize 2017 - 2021 Table 4. Implications Matrix Priority Focus Areas Type of Implication Country Office Has the capacity to oversee the implementation Sub regional (Caribbean and Central America) Expertise needed to review of Legislation Regional Global Remarks

Strategic Priority 1: Strong and resilient health systems achieved through improved governance, leadership and management that support universal health (access and coverage for all)

1.1 Revise and or develop national health legislation and inclusive policies to advance health equity, the procurement of appropriate, affordable medicines and other health technologies and strengthen intersectoral actions that address the social determinants of health. 1.2 Redefine the health financing mechanism to include the expanded roll-out of National Health Insurance system to ensure equitable access to health services across Belize.

Technical 80% Political 20%

Expertise needed for: medicines health technologies Health Equity and health inequalities

Belize has been selected to be part of the PAHO Commission on Equity and Health Inequalities

Technical Political

Has the capacity to oversee the implementation but will require additional training in key areas e.g. Health Economics Has the capacity to oversee the implementation but will require additional training in key areas Expertise needed to transform into information system for health

Expertise needed for Health Financing

Political assistance relates to the sensitivity of the issue

43 Expertise needed to transform into information system for health Expertise needed to transform into information system for health Political assistance relates to the sensitivity of the issue in Belize

1.3 Strengthen Technical 90% the Belize health Political 10% information system (BHIS) to improve coordination with RAWA[1] and the comprehensive use of data for evidence based decision making and monitoring and evaluation. 1.4 Strengthen primary healthcare networks and the resolution capacity to meet expanding health needs in Belize. Technical

Has the capacity to oversee the implementation but will need assistance in adapting lessons learnt from PHC systems in other settings

Financial resources and expertise needed for PHC system strengthening

Expertise needed for PHC system strengthening

PAHO/WHO Country Cooperation Strategy

Priority

Focus Areas

Type of Implication

Country Office Has the capacity to oversee the implementation but will require additional support

Sub regional (Caribbean and Central America) Expertise needed in review legal framework and legislation , HR planning and development

Regional

Global

Remarks

Strategic Priority 2:

2.1 Advocate Political for the use of Human resource Technical recommendations of for health (HRH) previous PAHO HRH management and assessments of the capacity strengthened gaps and needs to to parallel the health ensure the recruitneeds of the growing ment, deployment population and retention of a skilled workforce that can equitably deliver health services across Belize especially in the rural areas Technical 2.2 Build and/or reorient the capacity of healthcare professionals to meet the emerging health trends and needs of the Belizean population

Expertise needed in legal, HR planning and development

Expertise needed in legal, HR planning and development especially as it relates to SDG3

Increased political will and linked to the economic situation in country

Has the capacity to oversee the implementation but Need to source additional technical capacity as required in key specialist areas

Expertise needed to identify the trends in mobility of human resources

Expertise needed to reorienting capacity of healthcare professionals

Expertise needed to reorienting capacity of healthcare professionals especially in the area of midwifery

2.3 Strengthen HRH management within the Ministry of Health to develop and/or adapt HRH policies and plans that define the strategic direction and the integration of HRH into other sectors

Technical

Expertise needed in HRH planning

Belize 2017 - 2021

Priority

Focus Areas

Type of Implication

Country Office

Sub regional (Caribbean and Central America)

Regional

Global

Remarks

Strategic Priority 3:

3.1 1 Support Technical and promote the Health and wellness implementation of promoted throughout interventions and the life course social marketing using an integrated strategies that enprimary health care gage and empower approach to reduce communities to non- communicable adopt healthier diseases and their lifestyles that reduce risk factors, communithe risk factors recable diseases, menlated to developing tal health disorders, noncommunicable urban violence and diseases and/or injuries contracting communicable diseases. 3.2 Advocate for social programs and policies within the public sector for the early detection and intervention to address problems related to gender-based violence, urban violence and road safety. Technical

Technical and financial Expertise available for resources needed to in social marketing implementation of the interventions but additional assistance needed to build techniques for community engagement for adoption of healthy lifestyles Need to source additional technical capacity and financial resources as required (e.g Consultancies) Expertise needed in Urban violence (health and human security)

HQ has offered technical and financial assistance with Malaria elimination

Technical assistance for Malaria elimination

Expertise needed in Urban violence (health and human security) Expertise needed to review road safety legislation Expertise needed in mental health and substance abuse

Expertise needed in GBV surveillance

Health and human security project is scheduled to end in 2017 but the concept is to be integrated into other health plans. CO office needs to strengthen relationships with other Dept. e.g. Transportation

3.3 Strengthen Technical national capacities to implement comprehensive strategies that prevent and treat mental and substance abuse disorders within a framework of human rights and respect for human dignity Strategic Priority 4: Health emergencies that can become emerging threats of public health concern are addressed 4.1 Strengthen the coordination of the preparedness and response mechanisms to address health emergencies including natural disasters (hurricanes and earthquakes), and the impact of climate change. 4.2 Continue to monitor new and evolving outbreaks and take the appropriate response measures Technical

Need to sour- Expertise needed in ce additional mental health and technical substance abuse capacity as required (e.g. Consultancies)

Expertise exists but will require additional resources (financial and human) in the face of any major incident

Expertise required for outbreak investigations and climate change

CO will have to coordinate with the New PAHO and WHO Units since this is a new initiative

Technical

Expertise Expertise for exists but analyzing and will require interpreting data additional resources (financial and human) for monitoring

Expertise for analyzing and interpreting data

PAHO/WHO Country Cooperation Strategy

Priority

Focus Areas

Type of Implication

Country Office Expertise exists for implementation but will require additional resources

Sub regional (Caribbean and Central America) Expertise in key areas such points of entry, chemical emergencies and radiology

Regional

Global

Remarks

4.3 Implement Technical the IHR external evaluation recommendations which include preparing a multisectoral roadmap linking existing institutional and operational planning mechanisms and structures and increasing horizontal cooperation with other countries

Expertise in key areas such points of entry, chemical emergencies and radiology

Belize 2017 - 2021

PAHO/WHO Country Cooperation Strategy

4. 4 Risks The implementation of this CCS will occur in an uncertain environment which can both pose threats to success as well as offer opportunities for increasing success. This uncertainty (whether positive or negative) of outcome, is defined as a risk. The PAHO Country office assessed both the external (political, economical, legal and environmental) and the internal (operational – delivery and capacity) risks that could affect the achievement of the desired results of the CCS in Belize and identified the following:

because key senior decision makers have multiple roles and responsibilities.

SP2 Limitations with the funding of the MOH’s health workforce development affects budgetary allocations and incentives for deployment from the urban to rural areas in Belize. • The ability to attract and retain health personnel to support succession planning within the MOH. • Economic conditions in Belize continue to influence the migration of health professionals to other countries.

General • Further reductions in human and financial resources from PAHO/WHO severely compromises the ability of the PAHO Country Office to deliver the results set out in the CCS. The unavailability of appropriate expertise from both Central America and the Caribbean that can communicate in English. Additional resources mobilized from other sources have limited flexibility. Limited access to reliable information at the country level impedes timely decision making. Changes in the political will and commitment of the Government of Belize to implement this CCS. Even though it is an opportunity to work with both Central America and the Caribbean it can delay implementation and the achievement of results.

SP3. • Competing national priorities reduce the attention given to NCDs and their risk factors, including interventions for mental health and disabilities at the primary health care level. Limited financial resources are allocated at the national level for the prevention and control of NCDs. Limited enforcement of legislation and regulatory capacity to manage the NCD risk factors (including alcohol substance abuse, road safety and violence) at the national level. Limited integration and collaboration with other sectors to address the life style issues and social determinants of health. Low priority is given to violence prevention efforts especially gender based violence at the national level. A shift in health priorities at the global, regional, or national level results in diminished financial support for communicable disease programs. Persons living with HIV/AIDS and other key populations such the LGBT who continue to face stigma and discrimination.

• • •

• •

• • • •

SP1 • • • • • Fragmentation in health services limits the achievement of equitable health outcomes that are better aligned with people’s needs and expectations. Limited budgetary allocation for improving and integrating the health information system. Investments in technology and infrastructure are not necessarily made based on evidence based decision making. Interventions at the primary health level are undermined by frequent rotation of personnel and the lack of a critical mass of health care providers. Leadership in certain departments is compromised

SP4 • Weaknesses in verification mechanisms make it difficult to assess the actual achievement of the IHR core capacities.

Belize 2017 - 2021 • Belize remains vulnerable to the damaging effects of natural disasters especially hurricanes which has a devastating effect on the economy and the infrastructure.

The PAHO/WHO country team will manage these risks to determine which ones are likely to occur and should be pursued by taking the necessary corrective actions. They will also continually assess the environment to identify new risks and changes in current risks. This risk assessment will be documented and included in progress reports on the status of the implementation of the CCS.

PAHO/WHO Country Cooperation Strategy

Belize 2017 - 2021

5. Monitoring and Evaluation The monitoring and evaluation of this CCS will form an important component for assessing the Organization’s performance in Belize. The methodology will be in keeping with the PAHO/WHO results-based management approach used for monitoring and evaluating programs and will be led by the PAHO/WHO Country Office with the support of the RO and HQ. A participatory approach which involves key stakeholders such as decision-makers within the MOH and other health-related Ministries, implementers of the CCS, partners, beneficiaries and funders will be used.

5.1 Monitoring Monitoring of this CCS will be ongoing and will focus on ensuring: • • the CCS SPs and FAs are reflected in the country’s BWP and the manner of implementation; the core staff of the PAHO/WHO Country Office have the appropriate core competences for delivering results in the FAs.

Ongoing monitoring will also be conducted through the PAHO Strategic Plan Monitoring System which is jointly monitored by the PAHO Secretariat and Member States. The SPMS is designed to facilitate the joint assessment of outcome and output indicators by national health authorities and PASB. The system contains all the programmatic information required to monitor and assess implementation of the PAHO Strategic Plan 2014-2019 and the Program and Budget 2016-2017, including the compendium of indicators with technical definitions and criteria to assess the achievement of each outcome and output indicator.

5.2 Mid-term evaluation A mid-term evaluation will be conducted in 2019, the year in which the PAHO Strategic Plan is scheduled to end. It will address: • • • • • • • • • the progress achieved with the implementation of the FAs and the SPs in Belize, the continued relevance of the SPs and the FAs to determine if they are still consistent with the HSSP objectives and the country level discussions that have occurred to mainstream the SDGs, the challenges and risks that are affecting implementation and may require the revision of the SPs and FAs (this is part of the Country Offices’ risk management strategy), the availability of the mix of competences and skills, whether the FAs are being implemented in a resource-efficient and cost-efficient manner, the use of the CCS as an advocacy tool to mobilize resources both within PAHO and externally with other partners, whether the FAs are being used to inform the outcomes in the UN MSDF, whether key information is being shared with partners on an ongoing basis.

5.3 Final evaluation This final evaluation will be more comprehensive than the mid-term review and will be conducted at the end of the cycle of the CCS. The evaluation framework will be developed in collaboration with the MOH and other key partners and will assess relevance, efficiency, effectiveness and overall impact of the CCS. The critical success factors, the impediments and the lessons learnt will be applied to the next CCS cycle and shared with the Government of Belize, within the Organization and with other partners.

PAHO/WHO Country Cooperation Strategy

References 1. Abstract of Statistics 2013, Statistical Institute of Belize. 2. Annual Programmatic Report, National TB/HIV/AIDS & Other STI. (2014) Ministry of Health. Belmopan. 3. Approved Estimates of Revenue and Expenditure for Fiscal Year 2016/2017. Ministry of Finance, Government of Belize. http://cdn.gov.bz/belize.gov.bz/files/ApprovedBudget%202016-17.pdf (Accessed: 9 July 2016). 4. Belize Basic Indicators 2010 Report, Volume No. 8, (2011) Epidemiology Unit, Ministry of Health, Belmopan. 5. Belize National Tobacco Control Plan (BNTCP) 2007-2012 Available at: http://health.gov.bz/www/tobacco-control/204-fctc. 6. Belize Country Poverty Assessment Report 2009, The Caribbean Development Bank (Accessed: November 2016). 7. Belize Multiple Indicators Cluster Survey. Key Findings. (2016) Belmopan. 8. Belize Multiple Indicator Cluster Survey. (2011) Statistical Institute of Belize. http://www.sib.org.bz/Portals/0/docs/publications/other%20statistical%20reports/MICS_REPORT_2012_FINAL.pdf 9. Belize Health Sector Strategic Plan 2014-2024, Ministry of Health. 10. Belize Population & Housing Census: Country Report 2010. Statistical Institute of Belize. Belmopan. 11. “Central American Behavioural Surveillance Survey (BSS) of HIV/STI Prevalence and Risk Behaviour in Most-at-Risk Populations in Belize. (2014) Ministry of Health, Belmopan. 12. Channel 5News. (http://edition.channel5belize.com/archives/135617). (Accessed: 28 September 2016). 13. “Fertility rate, total (births per woman)” The World Bank. http://data.worldbank.org/indicator/SP.DYN. TFRT.IN?name_desc=false. (Accessed: 9 July 2016) 14. Horizon 2030: A development Framework for Belize. Available at: http://www.belize.gov.bz. 15. Human Development Report 2015. http://www.undp.org. 16. Gayle, Herbert & Mortis, Nelma et al. (2010) “Male Social Participation and Violence in Urban Belize: An Examination of their Experiences with Goals, Guns, God, Gangs, Gender, God and Governance.” Belize City. 17. Growth and Poverty Reduction Strategy for Belize 2016 – 2019. Ministry of Economic Development, Government of Belize, Belmopan. 18. “Incidence (includes HIV+TB)” Tuberculosis Profile, World Health Organization website 19. https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=BZ&outtype=html. (Accessed: 10 July 2016) 20. Hillson, David “When a risk is not a risk”, (Accessed: January 2017). 21. International Diabetes Federation. (2015) “IDF Diabetes Atlas 7th Edition. 22. International Office of Migration (IOM) website. http://www.iom.int/countries/belize (Accessed: January 2017) 23. Lalta, Stanley (2013) “Final Report on Analysis of Existing Health Accounts of the Ministry of Health, Belize.” Consultancy Report Prepared for PAHO, Belize. 24. National Gender-based Surveillance Report (2010) Ministry of Health, Government of Belize. 25. Regional Economic Outlook, International Monetary Fund, Available at: 26. http://www.imf.org/external/pubs/ft/reo/2015/whd/eng/pdf/1015/chap2.pdf

Belize 2017 - 2021

27. PAHO Health in the Americas 2017, Belize Chapter. 28. “Survey of Diabetes, Hypertension and Chronic Disease Risk Factors” Central America Diabetes Initiative (CAMDI) Pan American Health Organization (PAHO) (2011) (Accessed: 10 July 2016). 29. http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=16710&Itemid 30. United Nations Sustainable Development website. https://sustainabledevelopment.un.org/sdgs. (Accessed: July 2016). 31. United Nations Office on Drugs & Crime. (2014) “Global Study on Homicides 2013.” 32. United States Department of State. (2016) “Trafficking in Persons Report 2016”. Available at: http://www. state.gov 33. WHO Evaluation Practice Handbook, World Health Organization 2013.

PAHO/WHO Country Cooperation Strategy

Annexes • • • • • Annex Annex Annex Annex Annex 1. Horizon 2030 2. Summary of the Main Issues and Challenges Annex 3. Key Stakeholder Analysis 4. SDGs and the 2017-2021 UN MSDF for the Caribbean 5. Strategic Priorities and Focus Areas

Belize 2017 - 2021

Annex 1 Horizon 2030 Horizon 2030 embodies the vision for Belize in the year 2030 and the core values that are to guide citizen behavior and inform the strategies to achieve this common vision for the future. It represents the consolidated views of many stakeholders–young and old, men and women, students and teachers, politicians and voters, employers and employees, public and private sectors, farmers, tourism operators and artists. Vision: Belize is a country of peace and tranquility, where citizens live in harmony with the natural environment and enjoy a high quality of life. Belizeans are an energetic, resourceful and independent people looking after their own development in a sustainable way. The Horizon 2030 Framework covers several thematic areas that are organized under 4 main pillars: • Democratic governance for effective public administration and sustainable development • Education for Development – Education for Life • Economic resilience: Generating resources for long term development • The Bricks and the Mortar – Healthy Citizens and a Healthy Environment. Growth and Sustainable Development Strategy 2016-2019 The “Growth and Sustainable Development Strategy 2016-2019” (GSDS) is the country’s primary planning document that sets out the critical success factors (CSF) and specific actions to be taken over the next three years (2016-2019) to achieve the longer term goals of Horizon 2030. It is also designed to build synergies between economic, social and environmental policies; harmonize the regional and international commitments to which Belize is a signatory; and support the achievement of the SDGs. The health sector’s development agenda in Belize is guided by the “The Bricks and Mortar-Healthy Citizens and a Healthy Environment” pillar of Horizon 2030 and CSF2, and CSF3 in the GSDS – “Enhanced social cohesion and resilience” (enhanced equity) and “Sustained or improved Health of Natural, Historical and Cultural Assets” respectively.

PAHO/WHO Country Cooperation Strategy

Annex 2. Summary of the Main Issues and Challenges Main Issues and Challenges Based on the health and development issues mentioned above the main issues and challenges are summarized below: a. Noncommunicable and Communicable Diseases • • • • • NCDs are the most critical health problems facing the country. Diseases of the heart, malignant neoplasms and diabetes and their related risk factors could impose long-term costs on the health system. The increase in homicides has had a great impact on the mortality trends for males. Even though relevant policies exist in Belize, gender-based violence continues to be a serious development and public health concern and that needs to be addressed by both women and men. There has been an increase in the rate of newly diagnosed HIV cases in the 20+ years age group in both sexes, with predominance in the male population after the age of 25, and concerns about adherence to medication and persons presenting late for diagnosis. There is a diverse range of emerging diseases which include the Zika virus, Chikungunya, and Dengue.

b. Determinants of health and promoting health throughout the life course • • Maternal mortality figures remain lower than that required by the 3.1 SDG target (as per the latest 2015 WHO report). The growing challenge of “aging healthily” as people live longer, and increasing costs associated with meeting their health needs.

c. Health Systems • • • • • There is a chronic shortage of certain categories of health care professionals as well as a high turnover which means that Belize is a net medical personnel importing country. There is a disproportionate distribution of healthcare professionals with most being located in Belize City. The financing of health services provided should be revised and the NHI expanded. The expected burden of NCDs now and in the future will require revising the policies and procedures for collecting data, pooling risks and the financing of the various services, to ensure solid progress toward Universal Health (UH). There appears to be limited coordination between the BHIS and the RAWA systems.

d. Health Emergencies • Belize’s economic development is centered on its natural resources – tourism, agriculture, fishing and offshore oil drilling – and therefore continues to be susceptible to the effects of climate change and climate variability.

Belize 2017 - 2021 Annex 3. Key Stakeholder Analysis Name of Agency Role fulfilled by Subregional Initiatives/ Development Partners/ International Funding Institutions Subregional Initiatives Caribbean Community (CARICOM) /COHSOD) [1] Subregional Cooperation - Caribbean Cooperation in Health IV which is the framework that guides public health in the Caribbean Community. Subregional Cooperation - Elimination of motherto-child transmission of HIV (EMTCT) 3.2 End preventable deaths of newborn and children under 5 years of age 3.3 End epidemics of AIDs, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases Subregional Cooperation 3.a Strengthen the implemen- Findings of Evaluation of tation of the World Health Port of Spain Declaration Organization presented at COSHOD Framework Convention on Tobacco Control in all countries, as appropriate Subregional Cooperation - Elimination of Measles and the Introduction of Inactivated Poliovirus Vaccine 3.2 End preventable deaths of newborn and children under 5 years of age Guides the implementation of public health at the national level and is aligned to the objectives in the HSSP 2014-2024. Regional HSSP Obj 1. Integrated health services based on primary health care for improved health outcomes. HSSP Obj. 2 Strengthening the organization and management of health services Regional All the health targets under SDG 3 (3.1-3.9) Guides the implementation of public health at the national level and is aligned to the objectives in the HSSP 2014-2024. Regional Health-related SDG target Major Programmatic area of support within country Net Contribution

Guides the implementation of public health at the national level and is aligned to the objectives in the HSSP 2014-2024.

Regional

3.b Support research and development of vaccines, medicines for communicable and noncommunicable diseases that primarily affect developing countries, and provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health

Subregional Cooperation - International Health Regulations

3.d Strengthen capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

GSDS CSF 3. Sustained or improved health of natural , environmental, historical and cultural assets

Regional

PAHO/WHO Country Cooperation Strategy

Name of Agency

Role fulfilled by Subregional Initiatives/ Development Partners/ International Funding Institutions Policy dialogue - Declaration on a course of action to address the Zika virus

Health-related SDG target

Major Programmatic area of support within country

Net Contribution

CARICOM Head of Government 27th Intersessional Meeting

3.3 End epidemics of AIDs, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

HSSP Obj 1. Integrated health services based on primary health care for improved health outcomes.

Regional

HSSP Obj. 2 Strengthening the organization and management of health services HSSP Obj. 5 Strengthening of the Belize Health Information System to support evidence-based planning in the provision and delivery of health care HSSP Obj 7. Efficient and effective health infrastructure development Guides the implementation of public health at the national level and is aligned to the objectives in the HSSP 2014-2024. Regional

CARICOM/ CARPHA

Subregional Cooperation - Regional Health Information System Task Force and its strategic remit Subregional Cooperation - Health systems strengthening

3.8 Achieve Universal Health Coverage

Regional

SICA/COMISCA[2]

Subregional Cooperation - All the health targets under SDG 3 (3.1-3.9, 3a, 3b, 3c, 3d) Approval of the Health Plan for Central America and the Dominican Republic 2016-2020

Regional

Subregional Cooperation – San Salvador Declaration: “towards equity and social justice through a regional approach to the social determinants of health”

Committed to using a determinants of health approach in all SICA policies and to carry out studies and

Regional

analyses of the determinants of health to develop policies oriented toward justice, equity, and social cohesion. 3.3 End epidemics of AIDs, tuberculosis, malaria and neglected tropical HSSP Obj 1. Integrated health services based on primary health care for improved health outcomes.

Subregional Cooperation – Approval of the Subregional Plan for the Prevention and Control of the Zika Virus in Central America and Dominican Republic

diseases and combat hepatitis, water-borne diseases and other communicable diseases HSSP Obj. 2 Strengthening the organization and management of health services

Belize 2017 - 2021

Name of Agency

Role fulfilled by Subregional Initiatives/ Development Partners/ International Funding Institutions Subregional Cooperation – Agreement 5, related to the protocol for control of illicit trade of tobacco products Subregional Cooperation – Agreement 6, related to the strengthening of the International Health Regulations (IHR) core capacities Subregional Cooperation -Agreement 7, related to the importance of the regulatory function in the monitoring of pesticide use Subregional Cooperation

Health-related SDG target

Major Programmatic area of support within country

Net Contribution

SICA/RESSCAD[3] Agreements of the 31st RESSCAD, held 15-16 Oct 2015

3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate 3.d Strengthen capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks 3.9 Reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.3 End epidemics of AIDs, tuberculosis, malaria and neglected tropical

Sensitizing and promoting political actions for ratification of the Protocol to Eliminate Illicit Trade in Tobacco Products.

Regional

Meso-america Project

GSDS CSF 3. Sustained or improved health of natural , environmental, historical and cultural assets

Preparation of National Plans for malaria, dengue,

diseases and combat hepatitis, chikungunya, and Zika virus; water-borne diseases and other communicable diseases road safety; and primary health care. HSSP Obj 1. Integrated health services based on primary health care for improved health outcomes. HSSP Obj. 2 Strengthening the organization and management of health services Development Partners European Union (EU) – Development Cooperation through the 11th European Development Fund Multiannual Indicative Programme (2014-2020) Development Cooperation specific areas of focus energy, health and public financing 3.8 Achieve universal health coverage Overall Objective: To contribute to high performing 10.0 Euros and improved health sector for the improved health and well- being of the population. Specific Objectives: 1. Implement integrated health services based on primary health care for improved health outcomes; 2. Strengthen the organization and management of the health services; 3. Develop efficient, effective and disaster resilient health infrastructure. 3.9 Reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.d Strengthen capacity for early warning , risk reduction and management of health risks. JICA’s support to Belize focuses on poverty reduction, environmental protection and disaster prevention.

Japan International Cooperation Agency (JICA)

Technical Cooperation training using Volunteers from Japan

PAHO/WHO Country Cooperation Strategy

Name of Agency

Role fulfilled by Subregional Initiatives/ Development Partners/ International Funding Institutions Technical Cooperation

Health-related SDG target

Major Programmatic area of support within country

Net Contribution

Organization of American States (OAS)

3.2 End preventable deaths of newborn and children under 5 years of age 11.b By 2020, substantially increase the number of cities and human settlements adopting and implementing integrated policies and plans towards inclusion, resource efficiency, mitigation and adaptation to climate change, resilience to disasters, and develop and implement, in line with the Sendai Framework for Disaster Risk Reduction 20152030, holistic disaster risk management at all levels

1. In collaboration with UNICEF identified gaps in the birth registration system.

60 Caribbean Development Bank (CDB)

2. Technical cooperation project, sponsored by the Government of Taiwan and managed by the Pan American Development Foundation (PADF) entitled, “Community Preparedness and Resilience” designed to build capacity in designated Belize communities to make them better prepared to deal with natural and manmade disasters, and to respond effectively to extreme weather and other effects of climate change. Financial Institutions Technical Assistance Skills training Skills training for health-care professionals, improvements in health and educational facilities and the construction and rehabilitation of spaces for children, the elderly, infirm, or those living with HIV/AIDSGSDS CSF 2: Enhance Social Cohesion and Resilience GSDS CSF 3: Sustained or improved health of natural , environmental, historical and cultural assets The Global Fund to Fight AIDS, Tuberculosis Technical Support –HIV and TB 3.3 End epidemics of AIDs, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases Global Fund HIV-TB grant 2016, which also includes funding for the National TB response. Focus includes strengthening case finding, training health workers in management of TB cases, and enhancing diagnostic capacity HSSP Obj 1. Integrated health services based on primary health care for improved health outcomes. Mesoamerica 2015 Health Initiative aimed at reducing maternal and infant mortality in the poorest districts, benefiting more than 30,000 young women and children. US$500,000 pledged for the first 18 month in 2015 US$9,418,453 disbursed. (HIV -US$7,531,104 and TB- US$1,887,349 ) Activities funded through the Social Investment Fund (SIF)

International Development Bank (IDB)

Technical Assistance

3.1 Reduce the global maternal mortality ratio to less than 70 per 100,000 live Births 3.2 End preventable deaths of newborn and children under 5 years of age

United Nations

Belize 2017 - 2021

Name of Agency

Role fulfilled by Subregional Initiatives/ Development Partners/ International Funding Institutions Technical Assistance

Health-related SDG target

Major Programmatic area of support within country

Net Contribution

United Nations Country Team (UNCT) [4]

Agencies work on programs in areas such as health including HIV/AIDS, education, good governance, environmental sustainability, and disaster risk reduction. The aim is to reduce poverty and ensure human rights are accessible by all Belizean. UNDP serves Principal Recipient (PR) for Global Fund

[1]PAHO 158th Session of The Executive Committee, Washington, D.C., USA, 20-24 June 2016, CE158/INF/14, 30 April 2016. [2] PAHO 158th Session Of The Executive Committee, Washington, D.C., USA, 20-24 June 2016, CE158/INF/14, 30 April 2016. [3] PAHO 158th Session Of The Executive Committee, Washington, D.C., USA, 20-24 June 2016, CE158/INF/14, 30 April 2016 [4] UNCT includes (the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the Pan-American Health Organization (PAHO/ WHO).

PAHO/WHO Country Cooperation Strategy

National Organizations who have collaborated with PAHO National Organizations National Council on Aging National Cancer Society Belize Council for the Visually Impaired Belize Red Cross Belize Agricultural Health Authority Road Traffic Committee Kidney Association of Belize National AIDS Commission National Cancer Society Belize Council for the Visually Impaired Technical Assistance The management of NCDS in the elderly and training of care givers of the elderly and the development of the strategic plan Development National Plan for Cancer Development Strategic Plan Disaster response Vector borne diseases , food safety and one health Invited to be part of the Steering Committee and developed impact study on road safety. Review the legislation on road safety Reproduction of educational material PAHO sits on the NAC Development National Plan for Cancer Development Strategic Plan

Belize 2017 - 2021 Annex 4 SDGs and the 2017-2021 UN MSDF for the Caribbean At the United Nations Sustainable Development Summit on 25 September 2015, world leaders adopted the 2030 Agenda for Sustainable Development, which includes a set of seventeen (17) Sustainable Development Goals (SDGs) to end poverty, fight inequality and injustice, and tackle climate change by 2030, (Figure 3). Each goal is important in itself and they are all interconnected.

Figure 2. The Sustainable Development Goals Source: https://sustainabledevelopment.un.org/sdgs. Accessed July 2016 The SDGs, and the broader sustainability agenda, go much further than the MDGs, addressing the root causes of poverty. They recognise that eradicating poverty and inequality, creating inclusive economic growth and preserving the planet are linked and has as it overarching theme: “Leaving no one behind”. It promotes a comprehensive, integrated approach to sustainable development. The Goals will stimulate action over the next fifteen (15) years in five (5) areas of critical importance: People, Planet, Prosperity, Peace and Partnership. The SDGs recognize that eradicating poverty and inequality, creating inclusive economic growth and preserving the planet are linked and have as an overarching theme: “Leaving no one behind”. They promote a comprehensive, integrated approach to sustainable development. Only one SDG, SDG 3, is dedicated entirely to health “To ensure healthy lives and promote well-being for all at all ages”. It includes nine (9) targets which cover major health priorities and four (4) “means of implementation” targets. It addresses a wide range of health issues from road traffic injuries and tobacco control, to the health workforce and noncommunicable diseases (NCDs) — the most conspicuous health concern that was omitted from the MDGs. However, Health also benefits from the achievement of the other SDGs. UN MSDF for the Caribbean The goal of the UN MSDF is to provide the tools, partnerships, and resources needed to achieve national and sub-regional development priorities, in an inclusive and equitable manner, as reflected in the SDGs and the principle of “leave no one behind”. The UN MSDF also contributes to the fulfillment of the SIDS Accelerated Modalities of Action (SAMOA) Pathway and the CARICOM Strategic Plan 2015-2019.

PAHO/WHO Country Cooperation Strategy

Caribbean UN MSDF 2017-2021 Priority Areas: Priority 1 - an inclusive, equitable, and prosperous Caribbean: With an emphasis on the most vulnerable groups, promote social and economic inclusion and equity while improving social protection and [the] access to decent employment within a sustainable economy. Priority 2 - a healthy Caribbean: Improve health and well-being by addressing the ability of the state to provide services, increasing access to healthy nutrition, a healthy environment and knowledge as preventive measures. Sustainable health financing and direct action to address NCDs, SRH and HIV/AIDS and related stigma are also necessary for better health outcomes. Priority 3 - a cohesive, safe, and just Caribbean: Support the creation of conditions for a safe and just Caribbean while addressing the root causes that promote and perpetuate violence and insecurity. Priority 4 - a sustainable and resilient Caribbean: Support coherent efforts to strengthen the resilience of the Caribbean and its peoples by mitigating the effects of climate change, disasters and environmental degradation on sustainable development, livelihoods, and the economies.

Eighteen (18) English- and Dutch-speaking Caribbean countries and Overseas Territories are covered under this UN MSDF.

Belize 2017 - 2021

Annex 5. Strategic Priorities and Focus Areas CCS Strategic Priority 1. Strategic Priority 1: CCS Focus Area

1.1 Revise and or develop national health legislation and inclusive policies to advance health equity, the procurement of appropriate, affordable medicines Strong and resilient health systems achieved through improved governance, leadership and management that support universal health (access and other health technologies and strengthen intersectoral actions that address the social determinants of health. and coverage for all)

1.2 Redefine the health financing mechanism to include the expanded roll-out of National Health Insurance system to ensure equitable access to health services across Belize 1.3 Strengthen the Belize Health Information System (BHIS) to improve coordination with RAWA[1] and the comprehensive use of data for evidence-based decision making, monitoring and evaluation 1.4 Strengthen primary healthcare networks and the resolution capacity to meet expanding health needs in Belize.

Strategic Priority 2: Human Resource for Health (HRH) management and capacity strengthened to parallel the health needs of the growing population

2.1 Advocate for the use of recommendations of previous PAHO HRH assessments of the gaps and needs to ensure the recruitment, deployment and retention of a skilled workforce that can meet the regional core indicators for HR and equitably deliver health services across Belize especially in the rural areas. 2.2 Build and/or reorient the capacity of healthcare professionals to meet the emerging health trends and needs of the Belizean population. 2.3 Strengthen HRH management within the Ministry of Health to develop and/or adapt HRH policies and plans that define the strategic direction and the integration of HRH into other sectors.

3.1 Support and promote the implementation of interventions and strategies that engage and empower communities to adopt healthier lifestyles that reduce the risk factors related to developing noncommunicable diseases and/ or contracting communicable diseases. 3.2 Advocate for social programs and policies within the public sector for the early detection and intervention to address problems related to gender-based violence, urban violence and road safety. 3.3 Strengthen national capacities to implement comprehensive strategies that prevent and treat mental and substance abuse disorders within a framework of human rights and respect for human dignity.

Strategic Priority 4: Health emergencies that can become emerging threats of public health concern are addressed

4.1 Strengthen the coordination of the preparedness and response mechanisms to address health emergencies including natural disasters (hurricanes and earthquakes), and the impact of climate change. 4.2 Continue to monitor new and evolving outbreaks and take the appropriate response measures 4.3 Implement the IHR external evaluation recommendations which include preparing a multisectoral roadmap linking existing institutional and operational planning mechanisms and structures and increasing horizontal cooperation with other countries.

[1] RAWA – Registration and Clinical Activity Web Application that is used by the NHI.

PAHO/WHO Country Cooperation Strategy

Participants Ramon Figueroa CEO MOH Marvin Manzanero DHS-MOH Francis Morey Director, National Tuberculosis Program-MOH Eleanor Bennett Mental Health Coordinator-MOH Lizette Bell Planning Unit-MOH Ann Matute Senior Public Health Nurse Englebert Emmanuel L & A Unit Kim Bautista Vector Control Unit John Bodden Public Health Inspector-MOH Danini Contreras Director of Drug Inspectorate-MOH Pamela Scott Manager of the Road Safety Project Ministry of Economic Development Lorna Perez National Aids Program Surveillance Officer-MOH Ruth Jaramillo NHI Samira Gongora Pharmacist-MOH Gerhaldine Morazan Director-CML Javier Zuniga Manager-CHR Raphael Samos Chief Dental Surgeon-CHR Myra Pulido CHR Melissa Diaz CHR Sharon Cooper Espinosa CHR Wilfred Elrington

Foreign Minister Ministry of Foreign Affairs

Karen Bernard Deputy Resident Representative, UNDP Ilija Talev Officer In Charge, UNICEF Soufiare Adjali UNCHR Arturo Cantun US Embassy

Indira Card Program Liasion Officer UNFPA Tisa Grant Program Liasion Officer, UNFPA

Philip Folkemer US Embassy

Belize 2017 - 2021

Solomon Marin Police Officer Police Department Melanie Montero Belize Family Life Estella Humphreys Miguel Figueroa Director of Food Safety Belize Agricultural Health Authority Jose Moguel Belize Medical and Dental Association Catherine Godinez Nurses Association Ronald Stuart Belize Diabetes Association Amelio Matura Errol Longsworth National Drug Association John Briceno Leader of the People’s United Party

Heather Reneau National Cancer Society Carla Musa Belize Council for the Visually Impaired Chandra Cansino Belize Social Security Board Kirk Lainfiesta Administrator Kidney Association of Belize Enrique Romero Executive Director National AIDS Commission Tirso Galvez Chief Transport Officer Transport Department Caleb Orozco Director UNIBAM Orlando Habet Member of the House of Representative

PAHO/WHO Country Cooperation Strategy

Luis Roberto Escoto PAHO Representative Carlos Garzon PAHO Consultant Nicola Taylor PAHO Consultant Deysi Mendez Communicable Disease Advisor Jorge Polanco NCD/INCAP Advisor Ruby Dominguez Administrator

Guillermo Mendoza PAHO Gebre Yitades PAHO Consultant Carlos Ayala Health Systems & Services Advisor Francis Longsworth Mariam Besada Intern Paula Vasquez Executive Secretary

Acknowledgment "We express our gratitude to PWR – Honduras for the special support in the elaboration of this document and other communication products of the CCS. We recognize their job in the visual design, diagramation and reproduction of it. This work represents a succesful experience of technical coperation between two Country Offices of PAHO/WHO."

Luis Roberto Escoto PAHO Representative - Belize

Belize 2017 - 2021

PAHO/WHO Country Cooperation Strategy

Country Cooperation Strategy Belize 2017-2021

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 28 juillet 2017

Source Organisation mondiale de la santé