Social determinants of health in the Americas
- Conceptual Foundation of the Social Determinants of Health
- Setting the Scene
- Core Regional Challenges
- The Social Determinants of Health Approach to Core Regional Challenges
- Advances Achieved in the Key Action Areas Identified by the Rio Declaration (2011)
- Towards Sustainable Development
- Full Article
The social determinants of health (SDH) are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (). These forces and systems include economic policies and systems, development agendas, social norms and policies, and political systems. These conditions can be highly inequitable and lead to differences in health outcomes. The experience of such conditions may simply be unavoidably different, in which case they are considered inequalities, or they may in fact be unnecessary and avoidable, in which case they are considered inequities and therefore appropriate targets for policies designed to increase equity.
In the Region of the Americas, evidence exists on how the SDH influence a wide range of health outcomes and efforts towards universal health, as reflected in both the development of the Millennium Development Goals (MDGs) and the ways in which they were pursued by countries. Analyzing these determinants is particularly relevant in the Americas, given that health inequity and health inequality continue to constitute the principle barriers to sustained development in the Region. Those living in the Region tend to be disproportionately affected by the poor conditions of daily life, which are shaped by structural and social factors (macroeconomics, ethnicity, cultural norms, income, education, occupation). These conditions and factors are responsible for pervasive and persistent health inequalities and inequities throughout the Americas.
The Pan American Health Organization’s Strategy for Universal Access to Health and Universal Health Coverage notes that recent improvements achieved in health throughout the Americas were due in part to advances in economic and social development of the countries, the consolidation of democratic processes, the strengthening of health systems, and the political commitment of countries to address the health needs of their populations (). The strategy recognizes that policies and interventions addressing the SDH and fostering the commitment of society as a whole to promote health and well-being, with an emphasis on groups in conditions of poverty and vulnerability, are essential requirements to advance toward universal access to health and universal health coverage. There is a clear need to continue efforts to overcome exclusion, inequity, and barriers to access and the timely use of comprehensive health services. Improved intersectoral action is required to impact policies, plans, legislation, regulations, and joint action beyond the health sector that address the SDH.
Conceptual foundation of the social determinants of health
The concept of the SDH incorporates a broad set of determinants extending beyond those that are only social in nature. The basic components of the SDH conceptual framework include (a) the socioeconomic and political context, (b) structural determinants, and (c) intermediary determinants (). Figure 1 outlines some of the key social, economic, cultural, and environmental aspects influencing health outcomes. Combined with individual behavior, genetic factors, and access to quality health care, these factors are thought to account for all, or virtually all, health outcomes (). It is critical to both distinguish between factors that mitigate risk concerning the extent to which they are modifiable–in other words, whether the differences in health outcomes they cause represent inequities or inequalities–and to consider the probable relationship between these factors and policies designed to influence them (). In considering the value, effectiveness, and appropriateness of policies in this regard, the SDHs offer the opportunity to position health as a public good, that is to say, having benefits for all of society that are not reduced by the marginal health gains of one individual but may in fact have exponentially positive effects on the health of other individuals ().
Figure 1.The social determinants of health conceptual framework
Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Geneva: World Health Organization; 2007. ().
The SDH approach is widely regarded as a highly effective means of addressing health inequities that promotes action across a range of factors that affect individual and population health outcomes, many of which are beyond the reach of the health sector. The approach has developed substantially over the past number of years, punctuated by two core calls to action. In 2005, the World Health Organization launched a Commission on the Social Determinants of Health (CSDH) and charged it with the responsibility of gathering evidence on inequities, as a way to understand the SDH and their impact on health equity, and issue recommendations for action (). The CSDH’s final report (2008) issued three recommendations for action: to improve daily living conditions; to tackle the inequitable distribution of money, power, and resources; and to measure and understand the problem and assess the impact of action (). The Rio Political Declaration on Social Determinants of Health (2011) also had substantial implications for this agenda in the Region. The Declaration emphasizes the need for an SDH approach and served as a call to action on interrelated principles addressing the SDH approach as well as broader, related concepts including equity and human development.
Clear emphasis has been placed on the importance of multisectoral action in addressing the SDH, the unacceptability of stark health inequities, and health as a human right. Grounded in equity, action on the SDH in the Region of the Americas requires recognition of the complex and often long-term causes of ill health and health inequity, through research in both social science and epidemiological disciplines. A growing body of evidence has led to intensified action across the global health spectrum with notable national-level engagement in the Region of the Americas. By addressing the fundamental “causes of the causes” of good and ill health, the SDH approach has the potential to remove some of the fundamental barriers that impact health and address some of most intractable health issues in the Region that are closely associated with dimensions of inequity, supporting the progressive transition towards universal health.
Setting the scene
The Region of the Americas has much to celebrate in terms of the progress in health over the past 5 years. As we reach the end of the era of the Millennium Development Goals (MDGs), it is valuable to briefly review progress made during this period in order to contextualize the current health landscape in the Region and address key areas where there is still much work to be done. Significant progress has been recorded in terms of reaching the health-related MDG, particularly in terms of overall levels of nutrition, life expectancy, poverty, under-5 mortality, HIV, malaria, and tuberculosis. Targeted efforts at the local, national, and regional levels in each of these areas have been facilitated by economic development, resulting, for example, in improved levels of nutrition and lower levels of associated child stunting.
At the same time, the review of progress made during this period combined with the assessment of the current health landscape in the Region highlights key areas where there is still much work to be done. Pursuit of the MDG contributed to improved outcomes in health for the Region; however, it also highlighted challenges with regard to equity of outcomes. While the achievements made during this time period can be lauded, other challenges have appeared in their place. In some areas, progress has stagnated. For example, despite reaching the MDG target of halving the rate of extreme poverty (), the reduction in rates in the Americas has slowed to a near halt in recent years (). This has severe implications for the Region as poverty has a direct impact on access to decent housing, services, education, transport, and other vital factors for overall health and well-being (). In fact, poverty is arguably the single largest determinant of health (). A recent publication from the World Bank Group on chronic poverty estimated that one in four people in Latin America and the Caribbean (LAC) are still living below the poverty line (). Compounding concerns over mobility, the United Nations Development Program (UNDP) estimates that over 200 million people in the Region subsist just above the poverty line of US$ 4 a day, outside of the middle classes not yet included in income classifications as poor (). These individuals are considered to be at high risk of falling into poverty should a financial crisis or natural disaster strike. This type of transient poverty (that is, poverty experienced as the result of a temporary fall in income or expenditure) generates variability and thus inequality in the poverty status of individuals ().
Additionally, the favorable trends that have been reflected in national and regional averages mask the gaps in progress that remain both within and between countries. A more nuanced look at the regional and national averages disaggregated by income and social strata reveals substantial gaps in equity between and within countries in the Region (). Most notably, in 2015, while the Region of the Americas had one of the highest reported average for life expectancy at birth (76.9) (), a closer look at country-specific data reveals that the difference in life expectancy at birth between countries was as great as 18 years (). The Region’s apparent success with regard to eradicating poverty also demonstrates the MDGs focus on national averages rather than on progress at subnational levels and across different population groups (). The Economic Commission for Latin America and the Caribbean (ECLAC) 2014 edition of Social Panorama of Latin America confirmed that not everyone in the Region has reaped the same benefits on this front as the downward trend in poverty over the last 15 years was greater among the wealthiest groups than among the most disadvantaged (). Many individuals categorized as chronically poor were unable to escape poverty during this time period. Labor income was a powerful driver behind the immense reduction in poverty over the last decade. The chronically poor face greater barriers to entering the labor force, reducing their opportunity for employment and exacerbating the cycle of chronic poverty. Poverty also continues to be concentrated within certain ethnic groups. In the Region of the Americas, indigenous peoples remain among the poorest and, in some areas, the income gap between them and other population groups has grown even wider ().
These findings highlight the concerns that programming to achieve the MDGs did not go far enough in terms of reaching less advantaged populations. Regional successes relate disproportionately to the “low-hanging fruit” of those already better served by public services. This paradox highlights the genuine limitations of the MDG-era achievements. While true success has been achieved in terms of global health indicators, many of these successes fall short when viewed through the equity lens.
Core regional challenges
Monitoring inequities and the factors that determine them is a challenge for existing information systems, requiring changes in the types of data the health sector collects. Information gathering entails choosing basic health indicators, stratifying criteria, and applying indices to measure both inequities and inequalities (). Conversely, it also offers the opportunity to measure multiple facets of health outcomes: who we are, how we live and die, and which events and circumstances play deciding or influential factors in determining these outcomes, at both the individual and population levels. Though numerous MDG targets were achieved, it must be noted that, almost universally, progress by wealthier, more privileged members of society exceeded that of the more disadvantaged. Furthermore, MDG targets that were not achieved indicate continuing Regional challenges in addressing health outcomes related to gender, sexual and reproductive health, communicable diseases, noncommunicable diseases, mental health, and access to care. This section examines the inequities and inequalities related to a sample of Region-specific issues in reproductive and maternal health, communicable and noncommunicable diseases, and mental health that will require more concerted action on the social determinants of health to improve health outcomes in these areas.
Reproductive and maternal health
The health of mothers can directly affect the health of their children. The cycle that is created from this dynamic potentially allows health inequalities to remain concentrated in certain populations for generations. While progress was made in terms of reducing the under-5 mortality rate during the MDGs era, on a global scale, maternal mortality remains incredibly high, reflecting the presence of inequities in access to health services, such as routine reproductive health care. A lack of access to basic services results in many unmet health care needs, such as contraceptive needs, unintended pregnancies, undiagnosed sexually transmitted infections, and undiagnosed cancers.
In order for barriers to be addressed and for progress to be made, it is imperative that social policies recognize the role of gender as a strong structural determinant of health. For example, women have higher health care costs than men due to their greater use of health care services. At the same time, women are more likely than men to be poor, unemployed, or engaged in work that does not provide health care benefits (). That said, gender alone does not account for all of the barriers women face in accessing care. Access to the necessary resources for health attainment is further restricted by the intersections between gender inequality and other important determinants of health such as income, education, age, ethnicity, and sexual orientation, leaving vulnerable populations at an especially high risk. For example, in Latin America and the Caribbean, women from the poorest quintile have greater unmet health needs, such as the need for contraception, compared to women from the wealthiest quintile (). Lower levels of income and ethnic background have been associated with early sexual initiation. Early sexual initiation is often associated with risks of both adolescent pregnancy among young women and adverse sexual health outcomes, such as sexually transmitted infections, thereby exposing less-advantaged populations to a double burden of infectious disease and barriers to women’s socioeconomic mobility (). Additionally, women in rural communities do not have equal access to convenient, affordable, or culturally appropriate reproductive health services and education. Women from racial/ethnic minorities frequently experience social and economic exclusion—yet another example of an unequal situation that produces health inequities at numerous moments throughout the life course, particularly during pregnancy and childbirth.
Within the Region of the Americas, reducing maternal mortality also remains a persistent challenge despite the fact that numerous Member States reported having adopted policies, programs, or plans for gender and health. This has troubling implications for the Region’s ability to meet the needs of women, despite the avowed political commitment. National and subnational inequalities in the maternal mortality rate are prominent (). Data from 2015 revealed stark differences between countries in the maternal mortality rate per 100,000 live births, with numerous countries reporting rates far below or far above the Regional average of 81 per 100,000 live births (Figure 2) (). These findings echo the point that has been made from a variety of Regional stakeholders, that the focus must remain on gaps in achievement of the MDGs, recognizing that however challenging the achievement of MDG targets was, there is still considerable work to be done to ensure that these targets are met on an equitable basis ().
Figure 2. Maternal mortality rate (per 100,000 live births), 2015
Source: World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Population Division.Trends in maternal mortality: 1990 to 2015. Geneva: WHO; 2015.
Available from: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1.
The incidence of major infectious diseases has declined globally since 2000. Regardless, communicable diseases remain a prominent global challenge. For many years, the “big three” of HIV, tuberculosis, and malaria have overshadowed others, leading to the emergence of the “neglected diseases” category, also referred to as “neglected tropical diseases” (NTD). The SDG recognize NTD as a major global threat, with an estimated 1.7 billion people across 185 countries requiring treatment for NTD in 2014 (). The pressing concern of NTD, as well as other vector- and water-borne diseases, led to the adoption of the target 3.3 within the SDG, “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”
NTD encompass a group of pathologies that disproportionally impact resource-constrained areas of the world, subject to inadequate response systems, resources, and the ability to mitigate harm, in addition to the level of harmful environmental exposures. Numerous determinants affect the spread of communicable diseases. These determinants include, but are not limited to, water and sanitation, housing and population clustering, climate change, gender inequity, sociocultural factors, and poverty. The relationship between these determinants and health and equity is rather complex given that these determinants are often overlapping. For example, housing and population clustering can be viewed as an intermediary social determinant for NTD as it has direct links with poverty as a structural social determinant. It must be recognized that the spread of these diseases is often perpetuated by multiple environmental and social determinants coupled with a lack of resources for prevention and care, and due attention afforded to the issue by policymakers.
Noncommunicable diseases and mental health
Noncommunicable diseases (NCD) have been identified as a major challenge to sustainable development in the 21st century and are therefore central to the post-2015 development agenda (). The rise of NCD has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets. Efforts to address these risk factors have been met with numerous challenges, many of which are attributed to the prioritization of wealth over health by other sectors. There has been substantial growth in the provision of processed foods and products that are linked to higher levels of obesity, diabetes, and other diet-related chronic diseases ().
NCD represent a substantial disease burden in the Americas in terms of both mortality share and impact upon disability-adjusted life year (DALY) rates (). Looking at the proportional mortality in the Americas, the burden of NCD appears staggering, with the overall proportion of deaths attributed to NCD ranging from 60% to 89% (Figure 3) (). Moreover, not all social groups are affected by NCD in the same way. NCD risk factors are much higher among poor populations. In fact, substantial differences in DALYs across income levels exist in the Americas (). There is also a strong correlation between low education levels and high rates of NCD in low-, middle-, and high-income countries. Given this, there has been a shift towards interventions focused on risk factors and their related environmental, economic, social, and behavioral determinants. Additionally, differing characteristics of inequity and inequality within and between countries require country-specific contexts to be taken into consideration when addressing NCD. Changing demographics give cause for concern, as does the impact of increasing economic prosperity on individual health once a particular threshold is passed. For example, a 2016 study on socioeconomic status and health in adolescents found a positive correlation between socioeconomic status and sedentary behavior, which is associated with risk of NCD, suggesting that this group may respond to interventions that target this behavior (). In these cases, health does not always follow wealth, highlighting the complex nature of inequalities and the social determinants of health ().
Figure 3. Proportional mortality in the Americas by subregion, 2012
Source: Escamilla-Cejudo JA, Sanhueza A, Legetic B. The burden of noncommunicable diseases in the Americas and the social determinants of health. In: DCP3 Disease Control Priorities. Section 2: socioeconomic dimensions of the impact of NCD. 3rd ed. Seattle: Disease Control Priorities Network; 2013:13–22. ().
Mental health also has been inextricably linked to NCD and their outcomes. The prevalence and social distribution of mental health disorders has been well documented in high-income countries, but there is a growing recognition of the issue in low- and middle-income countries. Evidence suggests that social risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the risk (). Accordingly, mental health disorders can be shaped by various social, economic, and physical environments () operating at different stages of life—not only in early life when there is a higher predisposition to develop a mental health disorder, but also at older ages, and during working and family-building years (). The impact of these social determinants on mental health can be accumulated over the life course (hence the importance of employing the “life course perspective” in considering fundamental causes of health and morbidity), increasing the severity of mental health disorders and/or the incidence of new ones.
Studies have shown that the more relevant SDH associated with mental health disorders include income, education level, gender, age, ethnicity, and geographic area of residence. For example, increased rates of depression and substance use are systematically associated with lower income levels (). The poor and disadvantaged suffer disproportionately from common mental disorders (depression, anxiety, suicide, etc.) and their adverse consequences (). In addition to household income, low educational attainment, material disadvantage, and unemployment are other factors leading to common mental disorders (). Gender is another important social determinant: certain mental health disorders are more prevalent in women than in men (), and, in fact, women frequently experience the impact of social, economic, and environmental determinants in different ways than men (). For example, women report more suicide attempts while men commit more fatal suicides (). Regarding substance abuse, though men are more likely to engage in risky behavior and develop drug-related problems, women suffering from addiction are less likely to seek treatment for substance abuse due to societal barriers in place ().
In the Region of the Americas, there is increasing interest in the relationship between working conditions and mental disorders, particularly depression and anxiety. Mental health disorders affect many employees in the Region, a fact that in the past has been overlooked because these disorders have tended to be hidden in the workplace. As a consequence, mental health disorders often go unrecognized and untreated, not only damaging an individual’s health and career but also reducing productivity at work ().
The social determinants of health approach to core Regional challenges
Given the close links between health equity and the underlying determinants of health, an integrated and systematic approach to address the underlying determinants of health is essential for reducing health inequities. The idea that health is created in the context of everyday life as opposed to being limited to health service-oriented settings was articulated in the 1986 Ottawa Charter for Health Promotion (). The Ottawa Charter drew strong links between the principles of health promotion and the SDH, both of which consider health to be an ecological phenomenon, created and modified by the wider system of factors that influence how individuals, as well as population groups, experience daily life and long-term trends throughout the life course. Taking into account the contextual determinants of health and health behaviors, a vigorous health promotion response is another essential component to addressing health challenges ().
Recently, health promotion in the Region has focused on the creation of healthy and supportive municipalities, workplaces, housing, schools, and universities. As part of this strategy, there has been a reactivation of the various health-promoting networks at the Regional level, namely Healthy Cities, Municipalities and Communities; Health-Promoting Universities; and Health-Promoting Schools. For example, while both Mexico and Cuba have maintained full coverage of Healthy Cities for over 20 years, numerous cities in the Region of the Americans have joined this movement in recent years. Prominent cities include Medellín, Cali, and Bogotá in Colombia; Curitiba, Guarulhos, and São Paulo in Brazil; La Granja, Chile; Cienfuegos, Cuba; and Buenos Aires, Argentina.
Building on the Declaration of Alma-Ata, the Ottawa Charter also highlighted the need for all sectors to invest in health and the need for the expansion of the concept of health determinants in order to “build healthy public policies.” Currently, a strategic approach to harness action across all sectors, known as Health in All Policies (HiAP), is being implemented in countries. The Helsinki Statement on Health in All Policies (2013), articulated HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve populations health and health equity” (). HiAP emerged from the increasing recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors. HiAP is known as the “operational arm” of the SDH approach precisely because many of the health inequities outlined have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health. In order to truly achieve equity in health, the “one size fits all” approach must be avoided. The various policy interests involved in the conditions that produce healthy (or unhealthy) outcomes require coordination, stewardship at the highest level of government, mutual appreciation for distinct priorities and capacities of different sectors, and skills in communication and negotiation that have not traditionally been part of the public health sphere. HiAP establishes a strategic approach that provides advocates and policy makers with guidance to address the “causes of the causes” of ill health and to develop intersectoral effective action.
In line with the Helsinki Statement, the HiAP approach promotes sustained collaboration among sectors whose policies and practices have significant influence on health outcomes such as those discussed (). It sets out concrete priorities and practices to support positive action on the SDH (). The approach has been well received in the Region of the Americas, the first WHO Region to establish a Regional Plan of Action on Health in All Policies (2014) (). The Regional Plan of Action on HiAP marks a significant milestone in the global acceptance of the HiAP approach to encourage collective and coordinated action for health. Progress since then in the Americas includes a series of guiding documentation and activity designed to support Member States in implementation, largely under the rubric of the aforementioned HiAP initiative and including the Road Map for the Plan of Action on Health in All Policies (), the creation of a Health in All Policies in the Sustainable Development Goals Task Force and Working Group, and the Commission on Equity and Health Inequalities in the Region of the Americas. Additionally, countries including Brazil, Chile, Mexico, and Suriname (see Box), have recently embarked on consolidating actions in this area through capacity building and planning that will ensure that health is firmly placed at the crux of national policy development and planning. Such action is being complemented by PAHO through the work of Commission on Equity and Health Inequalities in the Region of the Americas.
The Suriname experience—implementing health in all policies to address the social determinants of health
Source: Pan American Health Organization. Health in All Policies in the Americas. Health in All Policies approach: quick assessment of health inequities. [Internet]; 2015. Available from: http://saludentodaslaspoliticas.org/en/experiencia-amp.php?id=29.
Given the strong overlap of the goals, means, and priorities associated with the SDH approach, health promotion, and HiAP, progress made on one front has great potential to simultaneously advance the others. Additionally, the successful implementation of HiAP and health promotion throughout the Region demonstrates that the factors that affect health and well-being can be addressed through the establishment of sustainable public policies, the creation of intersectoral partnerships, the development of supportive environments, the active participation of local governments and communities, and the strengthening and sustainability of new and existing networks (). The focus on an inclusive and participatory approach and collaboration across sectors is echoed by the global community’s recent commitment to implement the 2030 Agenda and the Sustainable Development Goals (SDG).
Advances achieved in the key action areas identified by the Rio Declaration
Within the Americas, individual countries and Regional bodies have made considerable progress in implementing the SDH agenda. Practitioners, policymakers, and the public alike have been receptive to this equity-oriented approach, advancing a range of initiatives to address some of the gross health inequalities that feature nationally and regionally using SDH tools. The Rio Political Declaration on Social Determinants of Health continues to serve as a guiding principle for the successful implementation of the SDH approach. In line with the recommendations of the Commission on Social Determinants of Health (), the Rio Declaration established five key action areas on SDH at the global, national, and local levels (). These key areas optimize the potential of the approach to reduce inequities and achieve targets set by the Region and help build momentum within countries for the development of dedicated national action plans and strategies. Accordingly, a review of the advances and progress in addressing the SDH over the last 5 years, within the context of the Rio Declaration, is merited.
1. Key area: improve governance for health and development
Improving health means improving governance in health and development. The three main arguments supporting this assertion are as follows: (1) health is unevenly distributed, (2) many health determinants are dependent on political action, and (3) health is a critical dimension of human rights and citizenship (). Improved governance is therefore essential to advance human health and development. In this context, the term governance refers to the interaction between governments (including their different constituent sectors) and other social organizations, how governments and organizations relate to civil society, and how decisions are taken in a complex and globalized world ().
Improving governance for health and development and addressing the social determinants involves transparent and inclusive decision-making processes that give voice to all groups and sectors involved (). Actions within this area pertain to government structures and the development of social and environmental policies and programs that aim to reduce inequity in health. In order to provide guidance to countries, the following five principles of good governance have been identified to better address the SDH ():
- Legitimacy: Processes focused on the implementation of policies that impact the SDH must ensure legitimacy by providing a voice to all stakeholders involved, including those affected by the decisions.
- Direction: Work on the SDH requires a clear, strategic vision for promoting the SDH agenda.
- Performance: The mechanisms for decision-making on the SDH must be responsive to all stakeholders and encourage participation.
- Accountability: All actors must be held accountable for the decisions made in respect to the shared goals.
- Fairness: Decision-making should be fair and aim to reduce inequalities in health.
These principles demonstrate that effective governance requires a range of conditions, including the creation of conducive policy frameworks; accountability and ongoing participation of civil society and nontraditional partners; and emphasis on shared values, interests, and objectives among partners. Successful implementation of an SDH approach to improve health and well-being requires the establishment of governance mechanisms that delineate the individual and joint responsibilities of different actors and sectors in the pursuit of health and well-being.
A lack of coordination among different actors and conflicting interests can constitute a significant barrier to advancing development. This touches on another important concept, namely the commercial determinants of health, defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (). Historically, there has been criticism from the public health sector regarding the influence of the corporate sector on health and well-being. There are four main channels through which corporate influence is exerted: (1) marketing, (2) lobbying, (3) corporate social responsibility strategies, and (4) extensive supply chains. The focus on lifestyle choices has been extensively analyzed, particularly in regards to tobacco marketing and the marketing of unhealthy commodities towards children (). There is now a growing body of evidence to suggest that the tobacco, food, drink, and alcohol industries have on occasion employed tactics and strategies to undermine public health, and policymakers have faced difficulties to effectively mitigate against the impact of such strategies.
Action across all sectors—Regional approach to reducing traffic-related injuries and deaths
Source: Pan American Health Organization. Progress report on plan of action on road safety. 54th Directing Council of PAHO; 67th
Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 September 28-October 2 (CD54/INF/5)
An example of intersectoral action for health at work is Mexico’s National Agreement for Healthy Food (). This agreement is an intersectoral initiative to address the determinants of obesity, by regulating access to food and beverages and providing supportive environments for healthy lifestyles. The agreement received political support from the highest levels of the federal government, and has been implemented through several federal government agencies including finance, social development, education, economics, agriculture, rural development, workplace safety, and health. The program focuses on reducing inequity by giving particular attention to the prevalence of overweight and obesity in children, low-income populations, and indigenous communities. Under the agreement, the food and beverage industries were held accountable for their role in health outcomes, particularly those of children. The objective here was to work with the food and beverage industries to contribute to health more positively by incorporating health-promoting principles into their campaigns while at the same time limiting the marketing of unhealthy foods and beverages towards children. Since the program was first implemented, much progress has been made, particularly in terms of the regulation of media advertisements and the sale and distribution of unhealthy foods and beverages in schools ().
2. Key area: promote participation in policy-making and implementation
Successful action on the SDH requires the participation of communities and civil society groups in the creation of policies, and the monitoring and evaluation of their implementation. Civil society has a critical role to play in identifying priority areas for action, generating evidence for work on the SDH, and by holding policymakers and program implementers accountable for the actions they undertake and the commitments they make. Governments can play an active role in promoting participation by offering incentives, subsidizing costs, and ensuring legitimacy and transparency. Improving transparency in policy-making on the determinants of health is critical for the adoption and implementation of successful and inclusive policies.
A recent report from the World Bank and PAHO, Toward universal health coverage and equity in Latin America and the Caribbean evidence from selected countries, noted that governments have made progress in supporting and promoting the participation of civil society in the policy-making process (). Bolivia, Ecuador, and Venezuela, among other countries, have have inscribed social participation in their constitutions as a means of reducing social and economic inequality (). Additionally, as of 2014, nine countries and territories reported having specific mechanisms in place to engage communities and civil society in the policy development process across sectors.
Case Study: Ecuador’s National Plan of Good Living
Sources: National Secretariat of Planning and Development. Good living: a better life for everyone 2013–2017 [Internet]; 2013.
Throughout the Region, efforts have also been made to engage previously excluded populations. As of 2014, 10 countries and territories reported having specific strategies in place to involve marginalized groups in policy discussions at the local, subnational, and national levels (). Actions are ongoing to promote mental health and well-being in indigenous populations. Indigenous populations are disproportionately affected by an array of common mental disorders. These groups have different ways of conceptualizing their health issues and of organizing care, as determined by historical, geographic, and cultural factors. Argentina, Brazil, Canada, and Chile, among others, have promoted fora for dialogue with the participation of indigenous practitioners, clinical health, public health, anthropology, and mental health specialists, where each of the actors share their knowledge and best practices spanning different indigenous communities.
3. Key area: further guide the health sector towards reducing health inequalities
Reducing health inequities and inequalities through transformation of the health system is core to PAHO’s Strategy for Universal Access to Health and Universal Health Coverage, adopted in 2014 (). The strategy expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the SDH and health inequities. It argues that “universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and provide a society-wide commitment to fostering health and well-being” (). The strategy makes the case that gender, ethnicity, age, and economic and social status are social determinants that have a positive or negative impact on health inequities, the reduction of which is a core objective of universal health.
In the Region, Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, Jamaica, Mexico, Peru, and Uruguay have implemented an array of policies to increase the scope and equity of health programs (). There has also been Regional progress in expanding health care services and resources to persons with disabilities. In October 2014, ministers of health throughout the Americas pledged to improve access to health and rehabilitation for people with disabilities and to safeguard their rights. To demonstrate this commitment, the Regional Plan of Action on Disabilities and Rehabilitation was approved by PAHO Member States in 2014. This plan calls for a stronger, more integrated health sector response in supporting persons with disabilities, their families, and caregivers. Countries that have demonstrated notable efforts towards a more integrated health sector response in supporting persons with disabilities, their families, and caregivers include Chile, Guyana, and Mexico ().
The strategies adopted by countries to transform the health system moving towards universal health are presented elsewhere in this chapter, specifically in the discussions relating to access to health services, improved health governance and stewardship, and health financing. Here, however, it is important to note that efforts to address health inequities, as they relate to the SDH, must vary depending on the context of the country, existing health inequities, and the structure of social and health systems. For example, in examining the health situation of women in La Paz, Bolivia, critical variations were found in several conditions: cancer (especially cervical-uterine cancer), maternal mortality, sexual and reproductive health, the impact of HIV/AIDS, and domestic and intrafamily violence. Women reported significantly lower health care coverage and minimal participation in the promotion and care of their own health. Evidence suggests that this was due to discrimination, mistreatment, and the lack of available services that address needs specific to women. The STAR Health Services initiative was developed by the health department in La Paz from 2004 to 2006 later focusing on the Pampahasi Bajo health services (). The initiative aimed to improve health conditions by strengthening the management of services, ensuring “quality with a focus on gender” and the development of processes that empower women in their community (primarily migrant Aymarans and those living in poor areas).
During the first phase of the initiative, gender considerations were successfully integrated into the primary health care framework. These adjustments included improvements in signs posted, the use of native language and curtains for privacy, easier scheduling,, more accessible and informative literature, the organization of health service teams, better treatment of patients, the monitoring of user satisfaction, and the development of a community education program that raised awareness and strengthened the respect for women’s health care rights. The initiative served to reestablish the role of the health team as an “agent of change” responsible for confronting gender-based issues and promoting gender sensitivity within the existing healthcare delivery system. It demonstrated the need for collaborative planning among health staff and community organizations to address differentiated needs and to respond appropriately to the inequities at hand.
4. Key area: strengthen global governance and collaboration
Ensuring political coherence requires action on the SDH both within countries and internationally. International collaboration towards the adoption of coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health is an important component in advancing an SDH approach. Reforming global governance for health is a necessary component for achieving global health with justice, as this goal requires international and domestic responsibilities that are centered on human rights (). For example, the Framework, was developed in response to the globalization of the tobacco epidemic to demonstrate the commitment of all countries to combating this health crisis. Thirty countries in the Region of the Americas are State Parties to the Convention (). Brazil was one of the first signatories of the WHO Framework Convention on Tobacco Control, and created an intersectoral commission called the National Commission for the Implementation of the Framework Convention on Tobacco Control and its Protocols. Tasked with developing and implementing policies to reduce tobacco consumption, 18 different governmental sectors collaborated to produce the National Policy for Tobacco Control (). They also passed other legislative changes to regulate tobacco product costs and marketing, and even to provide technical and financial support for small-scale tobacco farmers to diversify their crop production.
Some more recent prominent international conferences that address health and development include the Third International Conference on Financing for Development, the 2015 UN Summit (during which the Sustainable Development Goals were adopted), the 2015 UN Climate Change Conference, and the Seventh World Urban Forum, to name a few. These conferences have considered including commitments for advancing global health and its determinants (). For example, the Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects of climate change on health.
The Paris Agreement for Climate Action: a global commitment
Sources: UN Climate Change Newsroom. Paris Agreement signature ceremony [Internet]; 2015. Available from: http://newsroom.unfccc.int/media/632121/list-of-representatives-to-high-level-signature-ceremony.pdf. United Nations. Paris Agreement-status of ratification [Internet]; 2016. Available from: http://unfccc.int/paris_agreement/items/9444.php.
5. Key area: monitor progress and increase accountability
It is imperative that the implementation of policies that address the SDH be informed by evidence. The availability of data, or lack thereof, adversely impacts decision-making in policy development and public health action, and in shaping what research can or will be done. Building the evidence base for intersectoral action that addresses the SDH will be necessary to improve our understanding of populations that experience the greatest levels of inequality, and the interventions that are required to address inequities and disparities. This is particularly relevant for many low- and middle-income countries where there are significant limitations in the available data, namely, disaggregated data for socioeconomic status, ethnicity, and education levels as well as other important health determinants ().
As a result of the priorities established in the MDG agenda, there is a greater preponderance of data related to reproductive, maternal, and child health, allowing for a more detailed analysis of socioeconomic inequalities in these areas. However, countries are now being tasked with meeting SDG 17, which specifically calls for the “availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts.” The need to address this challenge is of particular relevance when developing monitoring mechanisms for SDG 3, to ensure healthy lives and promote well-being for all at all ages. The limited data associated with NCD as well as measures for universal health coverage means that countries will need to build capacity in assessing health inequalities as they relate to the SDH and these health priority areas. The Health Inequality Monitoring Framework developed by the WHO along with the Health Equity Monitor, as part of the Global Health Observatory, provides a guide and resource to countries when building monitoring capacity. Ensuring the comparability of data is essential for sharing successes and challenges when addressing health inequalities at the national level. The Region of the Americas has already taken action on this front through the inclusion of indicators measuring inequality in the 2014–2019 Strategic Plan of the Pan American Health Organization. Countries are responding to the challenge of generating disaggregated data by establishing observatories for the measurement of inequalities and health inequities. Already, Uruguay and Colombia have established national observatories that use the WHO Framework for monitoring inequalities, and Mexico is in the process of establishing its own health inequity monitoring system.
Monitoring the progress made during the MDG era has played an important role in identifying key areas for future action as well as core health issues that still remain to be addressed. The Region of the Americas has shown a strong commitment to identifying these key areas. Throughout the Region, countries have begun establishing national/regional networks of multisectoral working groups and stakeholders to evaluate the impact of government policies on health and health equity. As of 2014, six countries reported having these networks in place. Additionally, in May 2016, ECLAC presented a document, Horizons 2030: equality at the centre of sustainable development, which takes an in-depth look at the key challenges and opportunities for implementation of this approach in the Region (). The Member States of ECLAC also recently adopted resolution 700(XXXVI) establishing the Forum of the Countries of Latin America and the Caribbean on Sustainable Development, a body responsible for monitoring and reporting on implementation of the wider 2030 Agenda. A series of priorities has been articulated by ECLAC to support this approach, which both strengthens and reinforces the connections between the SDH, equality, and sustainable development, namely, strengthening the regional institutional architecture, enhancing analysis of the means of implementation of the 2030 Agenda at the Regional level, supporting the integration of the SDG into national development plans and budgets, and promoting the integration of the measurement processes to build SDG indicators into national and regional strategies for the development of statistics and statistics capacity (). Several of these components—particularly strengthening statistics capacity at the country level, which facilitates examination of the population groups benefiting most and least from certain policies and interventions—have profound implications for achieving equity and improving health.
Additionally, monitoring and surveillance systems have been identified as key to guiding the adoption of new programs and policies. Given the varying national contexts within the Region, programming must be sensitive to the landscape of social determinants within each country. Therefore, country-specific programming is required as opposed to a broad-brush Regional approach. A number of new surveillance initiatives have been developed in order to better understand the arising health needs that vary within and between countries. In 2013, UN-Habitat introduced a measure for prosperity, the City Prosperity Index, with the intention of helping decision-makers design appropriate policy interventions (). Since its creation, the City Prosperity Index has been applied in numerous cities in the Region, including Buenos Aires, Ciudad Obregón, Fortaleza, Guadalajara, Guayaquil, Guatemala City, Lima, Medellín, Mexico City, Montreal, New York, Panama City, Quito, São Paulo, and Toronto. Moving forward, the relationships between health outcomes and social stratification variables must be clearly established, and developing accountability mechanisms in policy-making will be essential.
Towards sustainable development
The 2030 Agenda for Sustainable Development named eradicating poverty, in all forms and dimensions, as one of the greatest challenges facing humanity as well as a core component to achieving sustainable development (). The 2030 Agenda and the 17 SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the population. Poverty is explicitly highlighted in Goal 1 of the SDGs, which calls for an end to poverty by 2030 (). Achieving this goal entails targeting the most vulnerable populations through poverty-reduction strategies. These strategies involve the development and use of cross-sectoral development frameworks that tackle the cause and effect of poverty in a country (). Based on the broad consensus of leading development agencies, successful poverty-reduction strategies must be results oriented, comprehensive, country specific, participatory, collaborative, and long term (). In the Region, a large number of countries have expanded coverage and noncontributory benefits to specific populations through poverty reduction strategies in the form of special plans and programs. In several countries, these programs have contributed to reducing poverty and extreme poverty, particularly in rural areas.
Conditional cash transfers (CCT), which are programs through which cash can be transferred to families in extreme poverty, have been recognized as evidence-based mechanisms for both reducing poverty and improving health. These programs also serve as important contributors to human development and social protection. CCT programs have a long-standing history throughout the Region. From the earliest transfer programs in the mid- to late 1990s in Mexico to the Federal District in Brazil, practically every country within the Region has deployed these types of programs. Positive outcomes are evident in significant, albeit modest, improvements in school enrollment, education outcomes, and overall early childhood development. Progress in health has been demonstrated across several indicators including infant mortality, maternal health, immunization, access to nutritious food, and quality of services accessed. As poverty often manifests itself in the form of hunger and malnutrition, the success of these interventions in regards to food and nutrition are particularly relevant for vulnerable groups and those living in extreme poverty. That said, contextual goals and benchmarks that respond appropriately to domestic priorities are critical to this process (). It is worth noting that the greatest advances in these trends have occurred in countries with modest welfare gaps such as Argentina, Brazil, Chile, Uruguay, and, to a lesser extent, Panama. However, Ecuador, Bolivia, El Salvador, and, to a lesser extent, Mexico, have positively escaped this generalization as these countries have enacted successful initiatives despite having very low fiscal commitment. As both poverty and growing inequality are detrimental to economic growth and undermine social cohesion, practical solutions such as these that pertain to the common challenges of human development will be crucial moving forward.
Conditional cash transfers: improving outcomes for the most vulnerable
The Uruguay Grows with You program outlines another platform for success, which runs highly focused activities targeting the most vulnerable citizens. The impact on those enrolled has been substantial thus far, reducing the level of depression in mothers and pregnant women from 31% to 16% since 2012. Other actions include the inclusion in social safety nets, such as family allowances and housing programs, and the construction of inclusive policies. The latter is especially important as the development of inclusive policies helps promote economic opportunities for the poor.
Both in Uruguay and Peru, contextual implementation was key, yet in each case, and elsewhere in the Region, integrating different institutional sectors into an overall strategy has allowed policymakers to create all-encompassing strategies to combat poverty in novel and effective manners.
As the Region transitions from the MDGs into the new 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs), addressing health inequities must be seen as priority. It is important to benefit from the lessons learned and address unfinished business through the new development agenda (). This new Agenda is the product of an unprecedented inclusive and collaborative process and is unique in that it integrates all three dimensions of sustainable development (economic, social, and environmental) around people, the planet, prosperity, peace, and partnership. The targets set by the SDGs seek to go beyond the scope of MDGs while addressing the most important social, economic, environmental, and governance challenges of our time. The SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the world’s population (). The implementation of the SDGs provides a unique opportunity to address the “causes of the causes” and shape health outcomes through a stronger focus on the differential distribution in access to health services. Whereas traditional approaches to public health and health promotion addressing risk factors centered around individual “risky” behavior remain relevant, increasingly (regionally and globally) attention is shifting to examine macroscale processes involving trade, global markets, and geopolitical relationships as determinants of health (). Surveillance systems will need to be enhanced for the wider social monitoring of the goals of SDH, the SDGs, and HiAP.
The Strategy for Universal Access to Health and Universal Health Coverage constitutes a call for action, for the health sector to progressively expand integrated quality health services, and beyond the health sector, in the implementation of health policies, plans, and programs that are equitable and efficient and that respect the differentiated needs of the population. Health is a key component of sustainable human development, and universal access to health and universal health coverage are essential for the achievement of better health outcomes in order to ensure healthy life and promote the well-being of all.
As countries continue to develop people-centered, robust, and resilient health systems, efforts must continue to intensify intersectoral action focusing on areas outside of the health sector to improve equity, health, and well-being, in accordance with the 2030 Agenda, for Sustainable Development and the Sustainable Development Goals and the SDGs. The breadth and ambition of the 2030 Agenda for Sustainable Development, and the interlinked nature of the 17 SDGs, require a national, regional, and global response that harnesses cooperative action across sectors. From the education of women and girls to taxation of nonnutritious foods, from healthy living spaces to health financing, universal health will only be achieved through a concerted effort to address the social determinants of health, and the development of key strategic partnerships involving actors well outside of the health sector.
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