The concepts underlying public health policy have been evolving, with a basic shift in paradigm away from policies and action focused on individual behavior modification toward other policies that address the environment in which people live, work, and socialize, thus facilitating decision-making in matters related to health. For over three decades, the United Nations has been issuing declarations that promote civil society and community involvement. Nonetheless, while citizen participation has intensified, in many cases it still does not live up to the spirit of those declarations. This section presents concrete examples of national, regional, and global accomplishments in this area. Future efforts should lead to a more inclusive society in which the voices of all sectors can be heard. This will require an increase in the transparency of processes, information, and financing mechanisms and in the openness of governments to facilitating this involvement. PAHO collaboration will be needed in this process and in the defense of public policies against the business interests of certain stakeholders in the private sector.
For historical and political reasons, the definition, concept, and types of organization and activities of civil society have been changing (). Civil society can be classified in a number of ways: by its constituents, by its relations with the State, by the goals that drive it, by the approaches it takes, etc. (). In the broader sense, civil society can be defined as everything outside the formal State apparatus—a definition that includes groups with very different interests, such as seemingly independent front groups created to surreptitiously defend third-party interests (). For the purposes of this document, however, the term “civil society” will refer to groups outside the government created to promote public health and the general good.
We understand “community” as a specific group of people who usually live in a particular geographic area and have the same values, mores, and culture as well as a social structure that reflects the type of relations that the group has forged over time. The members of a community acquire their personal and social identity by sharing the beliefs, values, and mores that the community has embraced in the past but could change in the future. Community members are conscious of their group identity and share common needs and a commitment to meet them (). Community health, however, is more than the sum of the health of the people in a community. Influenced by many factors, community health offers a context for understanding how the health–disease process is expressed. Its focus shifts from curative care to the broader concept of well-being, and understanding this requires consideration of the interplay among the social determinants of health ().
The purpose of public health policies is to guarantee the population’s right to health by promoting healthy individual behaviors and creating an environment that fosters them. For example, a public policy aimed at reducing the risk factors for noncommunicable diseases (NCDs) should facilitate access to healthy products (e.g., by ensuring that schools do not provide or sell ultra-processed products or sugary beverages) and discourage the consumption of harmful products (e.g., by raising the price of tobacco products and alcoholic beverages through taxation). In other areas, such as controlling the epidemic of human immunodeficiency virus (HIV), the policy should create an environment that eliminates stigma and discrimination against people with HIV and promotes respect for human rights as key to facilitating access to HIV testing and treatment services.
Civil society and community involvement in public health policy-making: from Alma-Ata to the 2030 Agenda for Sustainable Development
The importance of civil society and community involvement in the definition and design of health policies has been recognized in many international documents, some of which were issued more than three decades ago-for example, the Declaration of Alma-Ata on primary health care in 1978 () and the Ottawa Charter in 1986 (). These documents reaffirm that health is a basic human right and underscore the importance of individual and community involvement in the formulation of health policies, stating that the people have the right and duty to participate individually and collectively in the planning and delivery of their health care ().
In 2007, the United Nations Declaration on the Rights of Indigenous Peoples ensured that “Ways and means of ensuring participation of indigenous peoples on issues affecting them shall be established” (). Several more recent documents, such as the Adelaide Statement on Health in All Policies of 2010 () and the Rio Political Declaration on Social Determinants of Health of 2011 (), reinforce these concepts and point to the need for a new “social contract” involving government, civil society, and the private sector.
The 2030 Agenda for Sustainable Development revisits the issue, observing that the UN Charter’s protagonists are the peoples of the world and that, on this occasion, it is again “we the people” who are embarking on the road toward achieving the goals of the 2030 Agenda. This journey “will involve Governments as well as Parliaments, the UN system and other international institutions, local authorities, indigenous peoples, civil society, business and the private sector, the scientific and academic community – and all people” ().
These declarations and commitments notwithstanding, the old health paradigm of curative medical care focused on disease still prevails—a paradigm in which people are merely passive beneficiaries of treatments or public health measures designed and executed by health specialists and planners () — while the importance of the social, economic, cultural, and environmental determinants of health is either ignored or minimized. In other words, despite the Region’s countless experiences with community and civil society involvement in health policy-making in recent decades, some of which will be described further on, it is currently acknowledged that the majority of these experiences have not reflected the spirit of Alma-Ata. That is, while these experiences involve the population in the execution of measures, they do not do so in the planning and design of policies, programs, and strategies — a shortcoming that persists in the majority of cases and countries.
Civil society and community: their role in public policy-making
Although achieving changes in lifestyles unquestionably requires people’s active participation and commitment, it also calls for changing the environment in which they live. This is fundamental. As stated earlier, a well-conceived public health policy does not discourage healthy behaviors but, rather, facilitates them. Within this framework, both civil society and the community have an important role in promoting and demanding that health policies create a social, economic, and environmental context that guarantees people’s right to health. While the degree of individual, community, and government responsibility for the protection and exercise of the right to health is still a matter of debate, there is no doubt that the three levels are complementary and that none of them in itself can solve the complex health problems confronting modern societies.
Civil society can play several roles in the policy-making cycle (Figure 1) through its interaction with the public and private sector. One of civil society’s basic functions is to give a voice to vulnerable populations and communities who are utterly invisible for policy-making purposes. Since scientific knowledge about a health problem or its determinants can never substitute for the experience of the people living with the problem, it is essential that policy- and decision-making bodies be genuinely democratic ((em)demos(/em) = the people; (em)kratos(/em) = authority to decide) to ensure that policies provide solutions to problems that only people in situations of vulnerability can see and feel. This is the case for social organizations created and structured around specific problems — for example, organizations of people living with HIV; associations of patients with chronic diseases; lesbian, gay, bisexual, transgender (LGBT) organizations; and tobacco control or consumer protection associations, to name but a few — engaged in an arduous struggle to exercise rights that have been denied them or to promote rules and regulations that recognize their situation or conditions that jeopardize their health and quality of life.
Figure 1. Key components of the policy-making cycle
Source: Adapted from Court J, Mendizabal E, Osborne D, Young J. Policy engagement. How civil society can be more effective. London: Overseas Development Institute; 2006.
Through different mechanisms, social movements and civil society organizations have slowly taken a role in generating reforms and change () that break with the status quo and promote development policies and models based on the principle of living a decent life (known as sumak kawsay among some indigenous peoples of Latin America) and the common good. It should be noted, however, that according to Arnstein’s ladder of citizen participation (Figure 2), many of the experiences of the past 30 years can be classified in effect as nonparticipation or tokenism, especially when these processes have been promoted by government agencies or even nongovernmental organizations that execute projects with public or donor funds—in other words, when this participation is not a victory scored by the social organizations but a concession from the power structures ().
Figure 2. Arnstein’s levels of participation
Source: Adapted from Lofland J. Social movement organizations: guide to research on insurgent realities. New Brunswick: Transaction Publishers; 1996.
The levels at which participation takes place are usually a source of tension and confrontation with the power structure. It is therefore necessary, on the one hand, for civil society and the community to increase their participation, and on the other hand, for governments to be more open to participation by broadening the relevant entities and helping them ensure that this happens. Nevertheless, for an empowered civil society to exist, it must also have sustainable financing mechanisms that will enable it to carry out its activities. In an era of budget cuts, financial uncertainty is a major problem that must be solved, bearing in mind that the need to compete for increasingly limited resources often creates divisions and undercuts the efficiency and effectiveness of the activities ().
Some important factors in civil society relations with the private sector must be considered. While there are legitimate ways of interacting to promote the common good or make the sector take responsibility for its actions, potential conflicts of interest, both real and perceived, should be carefully looked at when considering associations of this type. Furthermore, particularly in the case of NCDs and their risk factors, there are stakeholders motivated by private business interests, and one of their tactics is to create, finance, and control nongovernmental organizations (actually front groups) to lobby public policymakers and distort policies to favor corporate products, practices, and policies that adversely affect public health. These front groups compromise social participation and democratic decision-making to the extent that they supplant genuine civil society representatives who defend the public interest and common good ().
Finally, it is important to underscore the key role of civil society and the community in social monitoring and accountability mechanisms related to state and private sector performance (). Civil society and community monitoring is essential for preventing commitments and action from being dissociated from the public interest, diverted from public health, or delayed, weakened, or distorted.
Vertical accountability mechanisms permit direct civil society and community advocacy at different stages of the policy-making cycle and in different democratic bodies and processes that are theirs by right. These mechanisms, independently spearheaded by civil society, contribute to monitoring and oversight of these processes and expose noncompliance and omissions. Sanctions are one of the elements critical to ensuring that mechanisms for accountability and compliance with commitments and action are effective. Although civil society cannot impose financial or administrative sanctions, it can report noncompliance and demand that the authorities do something about it. It can use its networks to impose social sanctions, exposing poor government performance or corporate noncompliance with the law and opposition to public health.
Civil society and community: successful experiences
Clear examples of successful civil society involvement in health policy- and decision making can be found both worldwide and in the Region of the Americas. Some of these are described below (Boxes 1-4).
Box 1. Community involvement in the response to HIV
In the Declaration of Commitment on HIV/AIDS of 2001, 189 UN Member States endorsed the principle of greater involvement by people living with HIV (GIPA). This principle was unanimously endorsed once again in the Political Declaration on HIV/AIDS of 2006. People living with HIV can participate at different levels of policy-making and planning, program design and implementation, advocacy and support for treatment, and other health services. Civil society groups in the Region of the Americas participate in bodies such as community advisory boards, national AIDS councils, the Global Fund’s Board of Directors, the UNAIDS Programme Coordinating Board, and the PAHO Technical Advisory Committee. Moreover, in HIV services, some countries have introduced peer support furnished by people living with the infection. The challenge for the Region and other parts of the world is the sustainability of community and civil society support, primarily due to financial constraints. In the context of withdrawal from the Global Fund, the principal civil society donor for HIV-related issues in the Region, the sustainability of civil society participation is cause for concern. Although there are some funding initiatives (in Mexico and Brazil, for example), a rigorous evaluation of their success or of feasible funding alternatives is lacking, more with respect to political advocacy than service delivery.
Box 2. Case study: Colombia. The role of civil society role in the implementation of grounds for legal abortion in Colombia
Until 2006, Colombia was one of the few countries in the world in which all abortion, without exceptions, was considered a crime, despite the contribution of unsafe abortion to maternal mortality and morbidity. This changed with Judgment C-355 of the Constitutional Court of Colombia, which decriminalized abortion in three cases: (i) when continuing the pregnancy threatens a woman’s life or health; (ii) when there is a serious fetal malformation; and (iii) when the pregnancy is the result of carnal abuse or rape.
Civil society efforts to guarantee the exercise of this right through the judgment’s enforcement have been essential, with organizations such as La Mesa por la Vida y la Salud de las Mujeres helping to ensure that the Court’s ruling is enforced. Two main activities have led to an increase in the delivery of timely and safe abortion services: (i) consensus-building for a comprehensive interpretation of the grounds for legal abortion, based on the human rights framework, and (ii) monitoring of the cases of women who encounter barriers to obtaining services. As a result of the “consensus on health grounds,” for example, more than 99% of legal abortions performed in 2015 in two of the main facilities that provide reproductive health services in the country are for health reasons, as defined by WHO.
It should be emphasized that La Mesa has not acted in isolation; on the contrary, its efforts have helped improve State responses through new regulations, the preparation of training content, and responses to critical issues through technical inputs.
Finally, monitoring the cases of women who encounter barriers has been essential for guaranteeing the accountability promoted by La Mesa. On the one hand, it has exposed barriers so that the State can find solutions (for example, by training providers), and on the other hand, it has been used to spur legal action, through new judgments handed down by the Court, to clarify the scope of legal abortion in Colombia and guarantee the change achieved in 2006.
Box 3. Case study: Brazil. National Board of Nutrition and Food Security
The history of Brazil is marked by growing access to democratic policy- and decision-making bodies. Enshrined in the Federal Constitution, social participation and control have also become a basic principle of policies and systems related to health and food and nutrition security, as well as other social policies. Several mechanisms have been established to facilitate civil society involvement in policy-making and the monitoring of policy implementation.
Councils in the three branches of the federative system (national, state, and municipal) have institutionalized civil society involvement in the drafting of health and nutrition and food security policies and the monitoring of their implementation. For example, the National Food and Nutrition Security Council must not only have a majority of civil society representatives (2/3 versus 1/3 government representatives) but must guarantee seats for traditional populations, such as indigenous peoples and quilombola groups, and it must be chaired by a representative of civil society. This Council advises the Executive Office of the President of the Republic on nutrition and food security matters, in addition to discussing, reviewing, and (re)orienting political priorities and the national food and nutrition security system to pressure the State to fulfill its obligation to guarantee the exercise of the human right to adequate and healthy food.
Source: Swinburn B, et al. Strengthening of accountability systems to create healthy food environments and reduce global obesity. The Lancet 2015;385(9986):2534–2545.
Box 4. The role of civil society in the formulation and application of the WHO Framework Convention on Tobacco Control
The global nature of the tobacco control problem led WHO to develop a solution that was also global: the WHO Framework Convention on Tobacco Control (FCTC). Civil society became involved even before the start of formal discussions, when WHO held two days of public hearings on the subject. In 1999, given the need for a global approach, the Framework Convention Alliance for Tobacco Control (FCA), an umbrella organization with hundreds of partner organizations worldwide, commenced operations. Although the FTCT negotiations involved meetings of government representatives, civil society participated in all of the meetings and had several roles, which included pressuring governments to support the best measures, providing information on best practices, and publicly divulging the names of countries whose positions were aligned with the interests of the tobacco industry. After the FTCE’s adoption by the World Health Assembly, civil society played a key role in defending the ultimate goal of obtaining the 40 ratifications needed for the Convention’s entry into force in February 2005.
Civil society efforts have continued without interruption to ensure that FCTC mandates are observed in all national legislation. In the Americas, civil society has been essential for advancing tobacco control and has been a strategic partner of PAHO in the Region.
In addition to providing technical support in several areas, the various organizations have remained vigilant, pressuring governments to meet their commitments and issuing public statements when they have not; these organizations have also publicized attempts at interference by the tobacco industry and those who defend its interests.
Mamudu HM, Glantz SA. Civil society and the negotiation of the Framework Convention on Tobacco Control. Global Public Health 2009;4(2):150–168.
Marcet Champagne B, Sebrié E, Schoj V. The role of organized civil society in tobacco control in Latin America and the Caribbean. Salud Pública de México 2010;52(Supplement 2).
Unfortunately, despite the significance of the preceding examples in terms of the enormous influence that civil society can have on the implementation and, especially, the enforcement, of public policies, certain factors can thwart or conspire against this influence. Some of them are related to civil society itself, as in cases where civil society is not well organized or when internal struggles for visibility and funding arise. Others are related to elements such as a lack of political will and interference by special interest groups. A glaring example of this is the fact that 12 years after the FCTC’s entry into force in the Region of the Americas, 30 countries are Parties to the Convention but 11 of them have yet to implement any of its measures at the highest implementation level ().
Several documents issued by the Governing Bodies of PAHO support civil society and community involvement, among them the Plan of Action on Health in All Policies (), approved in 2014. This Plan aims at improving health and promoting well-being through synergistic integration of the concepts of health promotion, social determinants of health, and human rights. The evaluation of health implications in policy-making is the basis for “health in all policies.” Community involvement is essential for raising awareness about the need for this evaluation and enlisting support for it—and this, in fact, is one of the objectives of the Plan.
That same year saw the approval of the Strategy for Universal Access to Health and Universal Health Coverage, which calls for all people and communities to have access, without any kind of discrimination, to comprehensive, appropriate, and timely quality health services, as well as to safe, effective, and affordable quality medicines, without exposing users, especially groups in conditions of vulnerability, to financial difficulties (). To this end, the Member States are requested to establish formal mechanisms for participation and dialogue to promote inclusive policies and implement plans, programs, and projects that will facilitate individual and community empowerment (). In its technical cooperation with the Member States, PAHO engages with civil society and facilitates coordination between State and non-State actors, often in its capacity as an entity for bringing the different stakeholders together.
Given the complexity of the current global situation—while recognizing the multiple agents that intervene in health policy decisions and bearing in mind the need to protect public health from conflicts of interest—WHO has devised a framework for collaborating with non-State agents that includes nongovernmental organizations, private sector entities, charitable foundations, and academic institutions (). This framework is an instrument for identifying risks and benefits while protecting and preserving the integrity and reputation of WHO and its public health mandates; it will also determine PAHO’s future relationship with these agents.
The 2030 Agenda for Sustainable Development is an action plan “for people, planet, and prosperity.” With regard to people, the Agenda states that its objectives are to end poverty and hunger and to ensure that all human beings can fulfill their potential in dignity and equality and in a healthy environment. It furthermore recognizes the need for a global partnership among governments, the private sector, civil society, and the United Nations that supports achievement of the objectives and goals.
Health is one of the key factors enabling individuals and populations to reach their full potential. This is recognized in Sustainable Development Goal (SDG) 3: “Ensure health and well-being for all, at every stage of life.” At the same time, it is important to remember the integrated and indivisible nature of all the goals and their related targets to guarantee the future of humanity and the planet.
The way forward should lead to a more inclusive society in which the voices of all sectors can be heard. This will require a civil society that is more empowered and aware of its responsibility in decision-making, in addition to transparent and equitable funding mechanisms that are free of conflicts of interest. Governments, in turn, should guarantee a place for civil society and communities in discussions and decisions on content and budgets. More transparent processes and public information are essential for the population to make decisions based on reality. PAHO’s role will be to urge governments to promote participatory bodies, provide them with the necessary technical assistance, and ensure due diligence in interactions with the non-State sector to protect public policies from the business interests of certain stakeholders in the private sector.
2. Pavón Cuellar D, Sabucedo Cameselle JM. El concepto de la “sociedad civil”: breve historia de su elaboración teórica. Araucaria: Revista Iberoamericana de Filosofía, Política y Humanidades 2009;11(21):63–92.
3. Hasenfeld Y, Gidron B. Understanding multi-purpose hybrid voluntary organizations: the contributions of theories on civil society, social movements and non-profit organizations. Journal of Civil Society 2005;1(2):97–112.
13. United Nations General Assembly. Draft outcome document of the United Nations summit for the adoption of the post-2015 development agenda. Annex: Transforming our world: the 2030 Agenda for Sustainable Development. 69th Session of the General Assembly. New York: UN; 2015 (A/69/L.85). Available from: http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/69/315.
14. Tejada de Rivero DA. Alma-Ata revisited. Perspectives in Health: The Magazine of the Pan American Health Organization 2003;8(2):2–7.
22. Swinburn B, Kraak V, Rutter H, Vandervijvere S, Lobstein T, Sacks G, et al. Strengthening of accountability systems to create healthy food environments and reduce global obesity. The Lancet 2015:385(9986):2534–2545.
24. Pan American Health Organization. Plan of action on Health in All Policies. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2014 Sept. 8 (CD53/10, Rev. 1).
In 2000, the United Nations (UN) General Assembly laid out the Millennium Development Goals (MDGs), an ambitious vision for global development with a groundbreaking approach to collaborative international action (). In the Americas, an unprecedented regional response allowed many countries to reach or surpass health-related goals to reduce child mortality, control infectious diseases, reduce poverty, and increase access to improved water and sanitation.
Figure 1. The “five Ps” (people, planet, prosperity, peace, and partnership) representing the broad scope of the 2030 Agenda for Sustainable Development, 2016-2030 Source: United Nations.
Nonetheless, persistent challenges present during the MDG era remain unresolved, and new challenges in the health landscape have since emerged. As a result, in September 2015, the UN General Assembly adopted Resolution A/RES/70/1, “Transforming our world: the 2030 Agenda for Sustainable Development” (). The product of numerous consultations and deliberations, the 2030 Agenda is an aspirational plan of action for people, planet, prosperity, peace, and partnership—the “five Ps” (Figure 1)—that shifts the world onto a sustainable and resilient path for global development over the next 15 years.Through an equity-based approach that emphasizes the needs and experiences of traditionally disadvantaged groups, the Agenda has the potential to transform the public health landscape in the Region of the Americas. By recognizing the interconnectedness of factors and interventions that influence human development outcomes, the 2030 Agenda and its Sustainable Development Goals (SDGs) outline a paradigm shift in policy-making, prioritizing actions that target the complex and intersecting structural determinants of social and economic development.
The SDGs contain just one explicitly health-oriented goal—SDG 3—out of a total of 17 (Figure 2), in contrast to the MDGs, which have three out of eight. However, many, if not all, of the SDGs include targets related to health, such as poverty, hunger, education, access to sanitation, and exposure to physical violence. While not explicitly included in SDG 3, these themes are among the most immediate determinants of health and well-being. The shift in focus between the two sets of global development goals represents a more nuanced understanding of the factors that affect health, and lays the groundwork for action across different sectors whose activities have significant effects on health but fall outside the purview of the health sector. Governments, the private sector, and civil society will need to innovate and adapt to meet the challenges laid out in the 2030 Agenda, which incorporates a broader and more multifaceted vision for health and development than ever before. A strong evidence base already exists to support this approach, and this chapter topic will extend the effort by highlighting useful strategies, mechanisms, and major global agreements to ensure that countries are prepared to achieve these global goals ().
Figure 2. Breakdown of the 2030 Agenda for Sustainable Development by goal (1–17), 2016–2030 Source: United Nations.
Equity: a renewed focus for sustainable development
The MDGs galvanized broad government action to achieve national targets related to specific diseases, maternal health, and child health, but in doing so frequently focused on the “low-hanging fruit” of populations already well served by services, leaving many behind. Despite many successes in reducing population averages of disease-specific incidence and maternal and child mortality, progress was not achieved equally within or between countries. As discussed extensively in “Social determinants of health in the Americas,” health outcomes in the Region are heavily influenced by income, gender, ethnicity, cultural identification, geographic location, and education, as well as access to services and infrastructure. The 2030 Agenda has the potential to address these gaps through the promotion of multisectoral programming that seeks to address the inequalities that persistently produce poor health outcomes, with particular attention paid to the social, economic, and environmental conditions in which people are born, live, work, learn, and age. This approach has profound implications for equity, a core principle of the 2030 Agenda.
In addition to the need to develop programs and interventions that promote health for vulnerable populations, monitoring their impact through data collection and analysis is crucial to ensure that the 2030 Agenda will achieve its promise of reducing health inequalities. Country capacity to measure Regional and national progress toward the SDG targets should be developed in the earliest phases of engagement with the 2030 Agenda in order for governments and policymakers to gain greater insight into which SDG-oriented activities are realizing their goal of reducing health inequalities. It will be especially important to establish equity-sensitive monitoring tools that show which populations are experiencing improvements and increased access to services while highlighting gaps that impede progress in addressing the needs of the most vulnerable and marginalized communities.
While the 2030 Agenda builds on the successes of the MDGs, it also articulates a critical political and conceptual shift in the development paradigm. The 2030 Agenda recognizes many of the lessons learned from the MDGs, which includes the need to explicitly address inequalities, requiring interventions designed to address the unequal distribution of health, disease, and resources. While the MDGs provided both a focal point and framework for government policy-making, a growing evidence base developed over the past 15 years has shown the need for a broader and more holistic understanding of health and human development (). Therefore, the 2030 Agenda encourages innovative multisectoral initiatives in which the health sector partners with actors from other areas of governance to address the key determinants of health affected by actions from systems and institutions outside the traditional scope of the health sector.
Figure 3. Breakdown of the Millennium Development Goal (MDG) agenda by goal (1–8), 2000&ndash2015 Source: United Nations.
The MDGs were focused on improving the health and living conditions of those in low-income countries (Figure 3 and Table 1), whereas the SDGs recognize that inequity and gaps in services, opportunities, and outcomes are present at all levels of economic development. Recognizing the limitations of the relationship between the traditional donor (high-income country) and recipient (low- or middle-income country), particularly in today’s globalized “market” of expertise, commerce, skills, and resources, the 2030 Agenda promotes innovative models for development governance, collaboration, and financing that encourage countries to engage creatively with the process of sustainable development. In this way, the SDGs are truly global in that they represent a shared commitment to address mutual challenges across the spectrum of economic development.
Beyond these key shifts, the 2030 Agenda places the 193 signatory countries at the center of SDG implementation. From the earliest stages of consultation, national and regional input has been key to defining goals, targets, and indicators. A case in point is the inclusion of noncommunicable diseases (NCDs) and universal health coverage (UHC) in the 2030 Agenda. Neither was included in the MDGs, but both were identified as major challenges for sustainable development, and ultimately became targets with associated indicators, in the final Agenda. This was an important achievement, particularly for the Region of the Americas, where UHC has long been a priority of policymakers and public health advocates.
As countries move from the MDGs to the 2030 Agenda, it is important to review progress made through 2015. As a whole, the Region achieved health-specific targets related to child mortality, the spread of HIV/AIDS, the incidence of tuberculosis and malaria, drinking water, and sanitation (Table 1). Much progress was made on several targets that were not strictly identified as part of the “health” MDGs, but have substantial implications for health, such as reducing the proportion of people living in poverty. However, some of this progress is under threat by political instability and the ongoing effects of the financial crisis of 2008. Moreover, progress achieved has tended to mask persistent inequalities while gains remain unequally distributed within and between countries.
Table 1. Outcomes for selected Millennium Development Goal (MDG) targets, 2000–2015
MDG and targets
MDG 1: Eradicate extreme poverty and hunger
1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger
This target was achieved
MDG 4: Reduce child mortality
4.A: Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate
This target was achieved
MDG 5: Improve maternal health
5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
This target was not achieved
5.B: Achieve, by 2015, universal access to reproductive health
This target was not achieved
MDG 6: Combat HIV/AIDS, malaria and other diseases
6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
This target was achieved
6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
This target was not achieved
6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
This target was achieved for TB and malaria
MDG 7: Ensure environmental sustainability
7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation
This target was achieved in terms of safe drinking water, and virtually achieved in terms of sanitation (the proportion was reduced by 48.5%)
Source: Adapted from PAHO, Millennium Development Goals and health targets: final report().
While the progress during the MDG era should be celebrated, the underlying inequalities driving poor health and limiting sustainable development remain. Furthermore, not all health-related targets were achieved by 2015, specifically those related to maternal mortality, access to reproductive health, and access to antiretroviral treatment for eligible persons who are HIV-positive. Persistent inequalities and the unmet health targets of the MDG agenda are key challenges to achieving health for all in the Americas, and will need to form the basis of action within the post-2015 development agenda.
As the most inequitable region in the world, the Region of the Americas is faced with unique challenges as it works toward promoting health for all and achieving sustainable development. Building on the achievements of the past 15 years, the 2030 Agenda encourages governments and societies to collaborate in new and innovative ways, while acknowledging that equity is central to sustainable global progress. It also presents a challenge to the global public health community’s responsiveness to policy action, given that the 2030 Agenda should be implemented in full alignment with national priorities, national action plans, and existing global agreements, such as the World Health Organization (WHO) Framework Convention on Tobacco Control (). To do so, identifying areas where the various agendas are harmonized will be of utmost importance so that countries are equipped to tackle these challenges efficiently and coherently.
SDG 3: “Ensure healthy lives and promote well-being for all at all ages”
Health, as a key input to sustainable development and healthy populations, is fundamental to the spirit and pursuit of the 2030 Agenda. In addition to traditional health development priorities targeted by the MDGs, particularly HIV/AIDS and maternal, newborn, and child health, the new agenda identifies a broader range of health objectives. Although SDG 3 is the only explicitly health-based goal, it calls for ambitious progress by 2030 (“Ensure healthy lives and promote well-being for all at all ages”). The first three targets for SDG 3 reflect the recognition of unfinished business under MDGs 4, 5, and 6, including commitments to reduce premature mortality due to maternal complications and to end preventable deaths due to the epidemics of AIDS, tuberculosis, malaria, and other communicable diseases (Table 2). The remaining targets address issues that were not addressed in the MDGs, including NCDs; mental health; alcohol, and other substance abuse; road traffic injuries; reproductive health services; UHC; and access to safe and effective medicines and vaccines for all.
Table 2. Sustainable Development Goal (SDG) 3: targets and means of implementation, 2016–2030
SDG 3 targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 By 2030, reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programs
3.8 Achieve universal health coverage, 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
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination
SDG 3 Means of implementation
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
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
Source: Adapted from United Nations, Transforming our world: the 2030 Agenda for Sustainable Development ().
By widening and diversifying the global health agenda, a shift that reflects a greater understanding of the breadth and complexity of global health challenges, SDG 3 targets have the potential to significantly improve global health outcomes. The redefinition of global priorities has profound implications for health governance. The 2030 Agenda and health-related SDGs not only lay out new principles, targets, and measurements for combating global health challenges; they also reinforce the role of the state as the primary actor in global health governance, while promoting partnership with non-State partners. Along with the emphasis on engaging civil society and mobilizing domestic political leadership and financial resources, there is an overall recognition of the state’s responsibility for setting public health agendas and implementing health-related interventions.
To achieve the nine technical targets and operationalize the four key means of their implementation under SDG 3, the health sector will need to assume a leadership role at the national level. The health sector’s pivotal position will be important in promoting actions, often implemented across sectors, which target the determinants of health and support overall well-being. At the same time, SDG 3 reflects the need for an integrated approach to addressing the cross-cutting elements of the SDG framework. Thus, the health sector will need to provide support to other sectors and institutions outside their purview to ensure progress and avoid inequitable health outcomes. While this approach will need to be adapted to differing country contexts, examining successful approaches employed at the national level can facilitate interventions that other countries in the Region may find useful.
While each of the SDG 3 targets and indicators are applicable to all signatories, countries have the flexibility to decide which ones to specifically pursue as part of their commitment to the wider Agenda, according to their own priorities and sovereign interests. Nonetheless, much of the Region of the Americas shares common priorities, particularly with regard to NCDs, UHC, and the elimination agenda for infectious diseases, which are discussed in further detail below. In fact, PAHO/WHO Member States had adopted several resolutions concerning these topics, and other SDG 3 targets, before the 2030 Agenda. Moving forward, these areas will serve as opportunities to not only produce further success at the national level but also generate shared achievements through joint collaborations at the Regional level.
NCDs represent a large and growing burden in the Region of the Americas, posing a threat to both regional and national development. Driven by the negative effects of unhealthy and unsustainable patterns of consumption, rapid unplanned urbanization, and longer life expectancy, these diseases have a direct impact on well-being, productivity, income, and health system costs (). The negative effects of chronic disease are exacerbated by an unequal distribution of the burden of disease predicated on socioeconomic inequality and unequal access to education, health services, and healthy living conditions. Knowledge about the impact of these diseases and the factors that lead to their development is limited by underreporting and underdeveloped monitoring systems.
Whereas the MDGs did not address NCDs, the inclusion of Target 3.4 in the 2030 Agenda clearly acknowledges the growing health burden of NCDs, a category that comprises 7 of the 10 leading causes of death in the world (). The explicit delineation of two separate targets to address communicable and noncommunicable diseases, both equally integral to the sustainability of human health and development, signifies that resources may need to be reallocated. Interventions that can most efficiently and effectively reduce the burden of diseases that pose the greatest threat to national and Regional well-being should be prioritized.
NCDs represent a whole-of-government issue, accompanied by a shift in discourse from the problem of individuals to a collective challenge requiring political action. These complex health challenges will require multisectoral collaborations and innovative solutions from heads of state. Approaches like the one used in the WHO Health in All Policies Framework for Country Action () that promote integrated, multilevel, and participatory health interventions have been identified as key to decreasing NCD prevalence in the Americas by acting on the relevant social and environmental determinants of health. Much can be learned from Mexico’s strategy to reduce obesity through its National Agreement for Healthy Eating (), Suriname’s enactment of antitobacco legislation aligned with the Framework Convention on Tobacco Control (), and Costa Rica’s executive order mandating schools to sell only fresh produce and foods and beverages that meet specific nutritional criteria ().
Target 3.4 goes further than just NCDs, however. Mental, neurological, and substance use disorders, including alcohol, are among the leading causes of the global burden of disease, and are the leading cause of global disability across all disorders worldwide and in the Americas. Like NCDs, mental health and well-being are precursors to family and community wellness, as well as the broader goals of the 2030 Agenda, which foresees “a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” ().
Mental health can be linked with 8 of the 17 SDGs, including those related to health, poverty, hunger, gender equality, sanitation, employment, inequality, and inclusiveness. Given the important role of mental health, countries may consider measuring key markers of mental health and availability of mental health services, namely, avoidance of premature deaths, including those from suicide (), and achievement of parity in access to mental and physical health services (). In addition, Goals 4, 8, 10, and 11 highlight the inclusion of people with disabilities, essential for the promotion and protection of the rights of people with mental, neurological, and substance abuse disorders, a population that has historically comprised the most marginalized, vulnerable, and neglected in society (). Despite the significant overlap between mental health and substance abuse, each issue presents unique challenges. As such, a different target is dedicated to the prevention and treatment of substance abuse, though action on either will likely have implications for both.
Universal health coverage
In a Region that has historically maintained a public-private health system, UHC is considered an essential pillar for development. It is key to achieving health-related SDGs and critical to minimizing health system fragmentation, preventing disease, achieving better health outcomes, and, ultimately, promoting well-being for all. UHC also signifies a shift from disease-specific interventions to ensuring that communities have access to well-resourced health systems that offer comprehensive health services. Although the socioeconomic and political context of each country requires flexibility when developing strategies to achieve UHC, the need for health coverage for all is truly universal. Ensuring access to comprehensive, timely, and good-quality health care without discrimination requires a society-wide commitment to expand equitable access to health services and supplies, strengthen governance, increase financing, improve information systems, invest in human resources, and support multisectoral coordination.
To make meaningful progress toward fulfilling the promise of UHC, a human rights framework must be used to support the progressive and equitable implementation of the right to health as an obligation of the state. Doing so opens the door to an array of policies to increase the scope and equity of health programs. For example, national health systems have grown increasingly more responsive in delivering affordable care for all without causing financial hardship. Public spending, population coverage, and access to health services are increasing in the Region, while out-of-pocket payments are declining ().
A long-term challenge to UHC is the development of fiscally sustainable approaches to improve revenue generation. For any health system to become sustainable, countries must balance actual revenue generation and current expenditures. Increasing revenues through taxes is only one means of doing so and can be more or less equitable depending on which taxes are raised and in what ways they are raised (). Other ways to increase revenue include anchoring inputs or expenditures, such as limiting waste, reducing administrative inefficiencies, and reducing the adoption, intensity, and volume of services that are not cost-effective. The resulting level and quality of available health care resources is a trade-off between service coverage, the public service portfolio, and costs. Middle-income countries might struggle to adapt to steep health expenditures outpacing economic growth, whereas low-income countries often face other, unique, and possibly more limiting, obstacles. In addition to sustained investments in health, an evidence base, informed by continuous progress assessments and formal mechanisms for dialogue, should be prioritized to inform policies at the national level.
The call for UHC by the 2030 Agenda also leads to increased demand for qualified health workers, which must be matched with redoubled government efforts to produce and retain the health workforce. Strategies include coping mechanisms and self-sufficiency policies to address gaps in distribution of health workers. Countries can also offer higher salary levels and financial incentives to health providers, or introduce health worker safety policies to reduce occupational diseases and work-related accidents. Though ensuring a sufficient health workforce accounts for a significant portion of health service costs in low- and middle-income countries, strategic planning and management will better prepare countries to meet international health regulations and promote global health security (). It will also trigger broader socioeconomic development in line with SDG attainment, such as gender equality and decent employment opportunities.
The explicit inclusion of UHC and the promotion of both physical and mental health is evidence that the 2030 Agenda considers access to health and overall well-being as essential not only to human health but also to sustainable development.
Elimination agenda for infectious diseases
Countries in the Americas are increasingly aware that the control and elimination of infectious diseases have far-reaching implications for health and well-being, social and economic outcomes, and the achievement of SDG 3 and broader development goals. Over the last decades, the Region has undergone a changing environment marked by an increasingly aging population (demographic transition) and socioeconomic development including successful vaccination and vector control efforts, leading to a decrease in the overall burden of communicable diseases (epidemiologic transition). For example, there has been a 30% decrease in disability-adjusted life years (DALYs) due to communicable diseases since the year 2000. This significant progress in the control of many infectious diseases has prompted the next steps in infectious disease control, namely disease elimination.
The Region set targets for the elimination of many infectious diseases, and has already achieved many of these goals. Historically, the Americas has been a global pioneer in elimination efforts. Many endemic diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) were eliminated through the widespread use of vaccines. Regional elimination of mother-to-child transmission of HIV, malaria, tuberculosis, viral hepatitis B and C, syphilis (including congenital syphilis), and neglected tropical diseases (onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma) represents a more ambitious step forward.
Disease elimination has evolved from being based on interventions relying on effective vaccines to include those cases where no vaccine or cure (in the case of HIV) exists. In this regard, the WHO has coined the term “elimination as a public health problem,” wherein the elimination threshold is a minimum value that is achievable using all current evidence-based interventions, and where continued actions will be necessary (Box 1). Strategies for the elimination of communicable diseases now comprise a wide spectrum of interventions focusing on vaccination, use of vector control strategies, diagnostics, and medications, acknowledging the need for broad multisectoral interventions for success. Currently, there is no absolute common definition of elimination for all diseases. The various criteria used for disease elimination make having one single conceptual framework and definition a pending task that experts are working to build.
Box 1. Basic definitions related to the control and elimination of infectious diseases.
Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts. Continued intervention measures are required to maintain the reduction.
Elimination as a public health problem: A term related to both infection and disease. It is defined by achievement of measurable global targets set by WHO in relation to a specific disease. When reached, continued actions are required to maintain the targets and/or to advance to the interruptions of transmission. The process of documenting elimination as a public health problem is called “validation.”
Elimination of transmission: Reduction to zero of the incidence of infection caused by a specific pathogen in a defined geographic area, with minimal risk of reintroduction, as a result of deliberate efforts; continued actions to prevent reestablishment of transmission are required. The process of documenting elimination of transmission is called “verification.”
Eradication: Permanent reduction to zero of a specific pathogen as a result of deliberate efforts with no risk of reintroduction. Intervention measures are no longer needed. The process of documenting eradication is called “certification.”
Sources: Dowdle WR. The principles of disease elimination and eradication. Bulleting of the World Health Organization 1998;76(S2):23-25.
Pan American Health Organization. Report on the Regional consultation on disease elimination in the Americas. Washington, D.C.: PAHO; 2015.
The current major components of the elimination agenda include the vaccine-preventable disease agenda, including HBV infection; the neglected tropical diseases; the big epidemics of tuberculosis, HIV, and malaria; and lastly, sexually transmitted diseases and chronic HCV infection. The decreasing burden of disease and efficacy of technology will dictate new possibilities for elimination defining the thresholds for elimination from a public health perspective. As new drugs and new technologies develop, the elimination agenda will surely broaden to include other infectious disease and may expand into NCDs, such as for cervical cancer in relation to vaccine-preventable HPV.
Past experience shows that continuing current prevention and control efforts alone are not sufficient for elimination. In addition to strong political will, adapting strategies to local contexts, capitalizing on new technologies, and accelerating translation of science into policy and implementation are required. Combining intensified traditional approaches with innovative approaches can generate new synergies and enhance the effectiveness of elimination efforts.
Current threats to the elimination agenda include the emerging drug resistance, an increasingly aging population, antivaccination movements, and shifting political priorities. High initial costs in the path towards elimination might also be deterrents, but as the health system becomes more effective, unit costs will decrease. There are also high costs to monitor its success.
The Region is moving towards a comprehensive elimination agenda that ranges from disease control to eradication, with quantifiable goals for each step along the way. Countries are striving towards greater integration of disease elimination efforts and capitalizing on synergies. This agenda symbolizes how the Region continues to work on health, human rights, and tackling inequities. To achieve these ambitious targets, along with the other targets of SDG 3, countries must exercise strong leadership to collaborate and create synergies with other sectors and ministries.
Unlike the disease-specific focus of health sector priorities outlined by the MDGs, the 2030 Agenda establishes numerous health-related targets that would traditionally fall under the coordination of other sectors. The interdependent framing of the SDGs creates opportunities for health programming and activities across the entire 2030 Agenda, allowing countries to tailor their national plans and policies to their own needs. While all SDGs create opportunities for the health sector, or have some effect on them, WHO has identified specific SDG targets and indicators that countries should prioritize in policy-making and resource allocation for the best return on health. These include Target 2.2 (child stunting, and child wasting and overweight); Target 6.1 (drinking water); Target 6.2 (sanitation); Target 7.1 (clean household energy); Target 11.6 (ambient air pollution); Target 13.1 (natural disaster); and Target 16.1 (homicide and conflicts) (Table 3).
Table 3. Sustainable Development Goal (SDG) targets identified by the World Health Organization for policy-making/resource allocation prioritization, 2016&ndash2030
SDG health targets
3.1 Maternal mortality and births attended by skilled health personnel
3.9 Mortality due to air pollution; unsafe water, unsafe sanitation and lack of hygiene; and unintentional poisoning
3.a Tobacco use
3.b Essential medicines and vaccines
3.c Health workforce
3.d National and global health risks
SDG health-related targets
2.2 Child stunting, and child wasting and overweight
6.1 Drinking water
7.1 Clean household energy
11.6 Ambient air pollution
13.1 Natural disaster
16.1 Homicide and conflicts
Source: Adapted from World health statistics 2016: monitoring health for the SDGs().
Like the SDG 3 targets, the quantity and breadth of these health concerns have far-reaching implications for funding and policy implementation, particularly in low- and middle-income countries. The systemic and multifactorial interventions needed to achieve these targets have the potential to strain the human, financial, and technological resources of health sectors and health systems. For example, “achieving universal and equitable access to safe and affordable drinking water for all” and “significantly reducing all forms of violence and related death rates everywhere” pose more complex challenges than the disease-specific MDGs.
Historically, policymakers and political leaders tend to prioritize the most feasible goals and activities with the potential to produce rapid results. As countries move forward with the 2030 Agenda, the criteria for prioritizing targets should instead focus on selecting those that utilize the most appropriate principles, assumptions, and methods to maximize health outcomes per unit of resources available.
While SDG 3 offers four essential means of implementation, they must be complemented by other actions to fully achieve the 2030 Agenda’s health and health-related targets. SDG 16 and 17 fill many of those gaps. SDG 16 articulates the importance of effective and equitable governance as an essential and enabling feature of the 2030 Agenda, and sets the stage for international cooperative action and partnerships among governments, civil society, and the private sector. SDG 17 supplements each of the goal-specific approaches with cross-cutting means of implementation for the entire agenda. Framed as a revised global partnership for sustainable development, SDG 17 covers a wide range of targets for finance, technology, capacity building, trade, policy, and institutional coherence.
National budgetary constraints demand a thorough analysis to strategically select which targets will be emphasized and how they will be financed. Public-private partnerships and investments in other sectors should be considered to ensure that all are viable and can operate efficiently. Internally, countries can mobilize domestic resources by improving tax collection, reducing external debt, and tackling tax evasion. A financially feasible development agenda will require domestic public resources and traditional sources of financing for development, such as official development assistance, as well as private investment, innovative mechanisms for funding to address structural threats to health, and the use of regulations to ensure compliance with national priorities and legislation.
The UN Addis Ababa Action Agenda, adopted in July 2015, was the first step toward developing a new and innovative financing framework (). It proposes an array of mechanisms for countries and stakeholders to effectively mobilize financial resources for the achievement of the SDGs, taking into particular consideration the challenges of middle-income countries like many of those in the Americas. The first Regional consultation on financing for development took place in Santiago, Chile, in March 2015, allowing the Region’s perspective and priorities to be fully reflected in the process ().
Measurement, monitoring, and evaluation
The importance of highlighting and tackling inequalities between subpopulations is central to the 2030 Agenda and requires indicators that incorporate data disaggregated for drivers of inequality. As the most inequitable region in the world, average improvements may mask growing inequalities between population groups, particularly the most vulnerable, disadvantaged, and marginalized. As such, there is a need to refine, adapt, and scale up the measurement, monitoring, and evaluation capacity of countries, especially those with less developed or poorly equipped health information systems. The explicit goal to develop indicators that are disaggregated by income level, education, gender, and ethnicity, as well as other important determinants of health and social inclusion within the SDG agenda, represents an important shift from the MDG agenda and reflects a growing appreciation for the negative impact of inequalities on health and development.
Mobilization of stakeholders
Achieving the health-related targets will require contributions, engagement, and leadership from beyond the health sector and greater coordination between public and private stakeholders. The term “stakeholder” should be considered broadly and adapted at the country level to expand the participation of relevant actors, including sectors such as finance, trade, environment, and labor, along with government institutions, local authorities, international organizations, civil society organizations, and the private sector. The negotiation process of the 2030 Agenda is a key example of how Regional leadership is both evolving and redefining traditional approaches to health and development. There is no doubt that the changing landscape of these players will continue to have important implications for the Region through 2030.
Because the most marginalized populations often suffer most from the negative effects of unsustainable growth and development, locally led civil society organizations are an essential element to fulfill the 2030 Agenda. A people-centered, inclusive, participatory approach will strengthen mechanisms designed to advance the 2030 Agenda. Moreover, as the front line of engaging with citizens to achieve the SDGs, civil society plays a critical role in widening access to different populations, fostering advocacy, identifying development priorities, proposing practical solutions, and even providing feedback on problematic or unrealistic policies (). Often, governments and civil societies share common goals; a good example of this is the Region’s adoption and implementation of tobacco control policies, a process in which civil society has actively promoted and monitored the enforcement of new policies ().
Although Regional bodies and organizations have long been involved in health issues in differing roles and to varying degrees, their increasing influence on global health policy-making will make them key players in the implementation of the SDGs. Because of their familiarity with Regional challenges, barriers, and opportunities, these organizations have the ability to mediate between the global and national levels. They also have the unique capability to unite specific countries and harmonize specific goals and data at the regional or subregional level. Ultimately, Regional organizations can generate new opportunities for information exchange at the global level.
Think tanks and academic institutions can also help accelerate the SDG process through their engagement in policy development, identification of determinants of success, measurement of policy outcomes, and role in ensuring that the knowledge that is generated, translated, and disseminated reaches marginalized populations more quickly (). In turn, these institutions can provide direct input to high-level processes and support more effective implementation of the overall 2030 Agenda as well as specific actions, thereby ensuring greater political accountability.
Finally, business has a critical role to play in achieving the SDGs. The private sector has traditionally been the driver of scientific and technological development and strategies. Involving the private sector has immense potential to tap into that innovative capacity and deliver solutions to the barriers outlined in the 2030 Agenda (). Mobilization of the private sector will be critical to provide capital, jobs, technology, and infrastructure. Governments should coordinate with the private sector from the earliest stages of planning and implementation to ensure that businesses contribute to, and do not undermine, inclusive and sustainable development.
Table 4. Examples of Regional stakeholders in the 2030 Agenda for Sustainable Development
Type of stakeholder
Southern Common Market (Mercosur), Economic Commission for Latin America and the Caribbean (ECLAC), Central American Integration System (SICA), Council of Ministers of Health of Central America (COMISCA), Organization of American States (OAS), Pan American Health Organization (PAHO), Community of Latin American and Caribbean States (CELAC), Union of South American Nations (UNASUR), Andean Health Organization (ORAS-CONHU)
The 2030 Agenda is a timely reminder of the complexity of human health and the systems designed to protect it. It is also an opportune moment to strategize, coordinate, and plan for a future in which many of the Region’s greatest health concerns will originate outside the health sector. In light of this, health experts will be required to strengthen health systems and break down artificial boundaries across sectors to address key trends in the Americas that have direct and indirect implications on the Region’s health and well-being.
Health in All Policies (HiAP) is a useful framework for policymakers and government officials to address the SDGs at the national level (). Before the Health in All Policies approach was explicitly defined, it had already been adopted and applied throughout the Region of the Americas to place health at the center of development. Specifically, the HiAP framework is designed to identify and develop common ground between the health sector and other sectors in order to build shared agendas and strong partnerships, ultimately leading to mechanisms for participation, accountability, collaboration, and dialogue among various social actors ().
HiAP is frequently seen as a country approach to tackle NCDs and the social determinants of health, including tobacco use, obesity, housing, and transportation. Focused action and alliances between the health sector and sectors involved in clean energy, chemical safety, standards for employment opportunities in the health industry, and safe food production and distribution have also proven to be win-win situations (). While the HiAP framework has been successful in these areas, it can also be effective in “hard” politics (the use of traditional political systems and mechanisms), bringing together various stakeholders in health security, foreign policy, and finance to negotiate for health among competing interests. Given that the HiAP approach requires firm, long-term political commitments from national authorities responsible for formulating policies within and beyond the health sector, the 2030 Agenda provides an effective platform for building intersectoral health-oriented policies.
Likewise, innovative health promotion strategies can result in greater capacity and empowerment to both prevent and respond to public health concerns. A robust Healthy Municipalities and Communities Network() (Red de Municipios y Comunidades Saludables) is already in place throughout much of the Region (). In line with the 2030 Agenda, health promotion and the Healthy Settings approach() provide practical models of integrated, multilevel interventions based on enabling healthy environments, engaging local governments, reorienting health services, and promoting well-being and healthy choices through political commitment, public policies, community involvement, and strengthened individual capacity to improve health.
Both of these approaches complement the biomedical services already in place, but they also foment a Regional shift from response to preparation and prevention of negative health outcomes, and from a medicalization of society to a true public health approach to solve complex challenges. In addition, they emphasize the fact that all people and all levels of government bear responsibility for controlling diseases and managing health. The approaches and principles of the health promotion and HiAP strategies mirror those of the SDGs, thus ensuring synergy with the 2030 Agenda. More specifically, the Agenda’s call for an inclusive and participatory approach, expanded resources and participation, and collaboration across sectors presents a historic opportunity to mobilize relevant sectors, local and national governments, civil society organizations, and communities in an effort to promote health and achieve HiAP goals. Both strategies will be increasingly important at the global level, for achieving the goals of the 2030 Agenda, and at the Regional level, with regard to managing the effects of mega-trends and addressing inequalities that have become so large that they contribute to instability and poor health outcomes.
Poverty reduction is inextricably linked to health and sustainable development. It is a multifaceted phenomenon that threatens the health outcomes of affected individuals and communities, denying them full enjoyment of their human rights, including the right to health. As shown in Table 1, poverty and extreme poverty rates have decreased in the Americas since 1990, culminating in the Region’s achievement of the first target of the MDGs. Thanks to improvements in employment opportunities and income levels, income inequality also fell during this period ().
Nonetheless, since the start of the economic slowdown in 2008, the downward trends for poverty and extreme poverty have slowed; in fact, the rates are projected to increase slightly in coming years, which will affect the creation of jobs and the quality and level of the available work (). Moreover, the Region remains the most unequal in the world, leaving a high proportion of the population in a highly vulnerable position defined by volatile incomes near the poverty line (). In this way, poverty eradication signifies more than the elimination of extreme poverty; it also involves efforts to close these gaps and minimize individuals’ and communities’ vulnerability to poverty.
Approaches that prioritize concerted efforts toward poverty reduction will benefit from potential synergies with other priority areas of sustainable development, including sustainable cities, employment, energy, water, and education. Previous Regional experience has demonstrated that progress toward poverty reduction will remain fragile and reversible until countries embrace the multisectoral approach presented by the 2030 Agenda. Cross-sectoral collaboration must be accompanied by concrete commitments to ensure UHC, universal access to health, and social protection mechanisms that sustainably mitigate vulnerability and eradicate poverty in all its forms.
Sustainable consumption and production
Controlling production and consumption patterns are prerequisites for achieving the 2030 Agenda objectives of true equity, inclusion, and sustainability. As the Region’s population continues to grow, so does the importance of maintaining the productivity and capacity of the planet to meet human needs and sustain economic activities. At the same time, Regional patterns of consumption are being altered by lower fertility rates and an aging population ().
In order to reduce the risks to health and the environment associated with overarching demographic dynamics, this two-pronged issue depends on the sustainable, clean, and efficient production of goods and services, as well as more efficient and responsible consumption. Natural resources key to human survival, such as water, food, energy, and habitable land, must be protected; pollution associated with human and economic activity, including greenhouse gases, toxic chemicals, emissions, and excess nutrient release, must be reduced; and current consumption patterns, as drivers of unsustainable development, poor health outcomes, and resource degradation, must be significantly altered.
Food loss, waste, and overconsumption represent part of the unsustainability of the Region’s production and consumption patterns. The overconsumption of food has led to sharp increases in obesity and detrimental effects on the environment, primarily through greenhouse gas production, overuse of arable land, and deforestation. In spite of this, growing consensus in recent years shows that the Region has not only an adequate food supply but also a network of economic and social policies that could eradicate hunger, combat malnutrition, and address obesity in the short to medium term ().
To achieve the goals of the 2030 Agenda, the Region will need to promote a combination of multisectoral policies and economic and social activities. These should serve as enablers, empowering countries, producers, and consumers to become owners and successful users of technologies and processes that will ensure resource efficiency, sustainable consumption, and, ultimately, healthier livelihoods and lifestyles.
Since the start of the global financial crisis, the Region has been undergoing an economic slowdown. The Americas will confront the challenges of the 2030 Agenda in the midst of persistent external vulnerability, long-run low growth rates, smaller financial inflows, weaker external demand, and declines in investment growth rates. The slowdown has led to consistently increasing urban unemployment rates and poor employment quality, factors that partially explain why Regional inequality reduction has slowed. These patterns of economic activity represent one of the most significant challenges for the Region in building the capacity, infrastructure, and innovation necessary to achieve the 2030 Agenda ().
Moreover, these economic trends have the potential to reverse development progress achieved over the last decade, particularly with regard to shared prosperity and poverty reduction (). Sustaining these advances and realizing the SDGs, despite the deceleration of activity and sometimes contracting economy, means the Region must change its way of doing business under conditions less favorable than those experienced during the MDG era. This will require a stronger Regional commitment to governance and regulation of the ways institutions are shaped, legitimized, and equipped. Governance structures affect growth, equity, and well-being, each of which is pivotal for realizing sustainable development.
Accountability and responsiveness are two key pillars underlying the effectiveness of government institutions and their ability to deliver on the SDGs. Neglect of these pillars can lead to social and political instability, reduced investment, poor economic performance, and direct and indirect effects on the well-being of citizens. They can be overcome by reforms that prioritize transformative leadership, citizen participation, transparency, and innovative interventions. In order to manage this transition and mitigate the associated risks, it is vital that the Region continue to bring together high-level decision-makers, researchers, experts, and civil society to engage in strategic policy discussions, build alliances, and explore innovative approaches and mechanisms for use by governments and citizens to effect positive, sustainable change.
The Region of the Americas is the most urbanized region in the world, with nearly 80% of the population living in urban centers, a proportion expected to increase to an estimated 85% by 2030 (). These urban areas are often hubs of innovation and economic production, with populations that tend to have greater access to social and health services than their rural counterparts. While opportunities, jobs, and services are concentrated in these areas, so are health risks and hazards. The adverse effects of these conditions are increasingly concentrated among the urban poor, generating notable health inequities between the richest and poorest urban populations. Aggravated by poor strategic planning, the ability of urban centers to meet the needs of their entire population has become a persistent challenge that will inhibit truly sustainable development.
For example, unhealthy lifestyles resulting from diets that prioritize cost savings and convenience over health; sedentary behaviors; and the harmful use of alcohol, tobacco, and drugs could heighten risks related to obesity and the increase in chronic NCDs, including diabetes, heart disease, and cancer (). In addition, the potential for communicable disease outbreaks is amplified due to large numbers of people living in close proximity, oftentimes in conditions with compromised standards for sanitation and water provision. Substance abuse, poor housing conditions, road safety concerns, and a plethora of environmental hazards associated with urban centers can also have a harmful effect on the ways in which people grow, work, live, and age.
If the 2030 Agenda is to effectively foster health and well-being in a way that advances equity, the importance of urban centers to human lives and livelihoods must be fully considered. Although an increasingly urbanized world has the potential for a multitude of adverse consequences for health and well-being, it also creates opportunities. Because the trends of urbanization are highly interdependent and multilevel, a greater focus on the ways in which cities are planned, designed, developed, and managed can help policymakers recognize systemic relationships and opportunities for strategies that will generate co-benefits and long-term synergies for health. Strategies from multiple sectors must be applied to reduce inequities and influence the determinants of health associated with rapid urbanization.
Widespread urbanization, population growth, and industrial development continue to directly affect human health and broader development goals in the Americas. The effects of these trends include increased exposure to both traditional environmental hazards, like indoor air pollution and drinking-water contamination, and newer hazards, such as toxic chemicals, pesticides, electronic waste, and phenomena related to climate change, including natural disasters and irreversible changes to ecosystems. In terms of climate change, shifting temperatures alter disease patterns and vector distributions, ambient air quality has negative effects on respiratory health, and extreme climate events increase the vulnerability of populations to morbidity and mortality. At the same time, higher population concentrations require increased reliable access to resources that are already in high demand, namely water, sanitation, infrastructure, and energy.
While the assortment of risks varies across and within countries, they all reflect potential effects of environmental shifts on the Region’s vulnerability. Moreover, they are evidence that sustainable development, environmental health, and climate change are deeply intertwined, and that improving environmental conditions is a prerequisite for achieving SDG 3. This interconnectedness is apparent in both SDG 13 of the 2030 Agenda and the Paris Agreement of the United Nations Framework Convention on Climate Change (). In the Paris Agreement, several Regional signatories have committed to strengthening responses to the threat of climate change and developing plans to urgently reduce greenhouse gases to help meet part of the Framework’s broader goals to “allow ecosystems to adapt naturally to climate change, to ensure that food production is not threatened, and to enable economic development to proceed in a sustainable manner” (). In other words, the planet and the people that inhabit it are intrinsically interdependent. Because they cannot be separated, the harms inflicted on the planet are a threat to peoples’ health and ability to thrive.
The Region’s unequal distribution of income and the fact that those in the highest income brackets make a disproportionate contribution to emissions will require considerable improvements in the diversification of renewable energies; preservation measures in agriculture; and coverage of public services, such as mass transit and waste management (). In this way, multisectoral approaches to protecting the environment and protecting people from the consequences of its degradation are increasingly accepted as key aspects of strategies for overcoming health inequities and achieving the broader 2030 Agenda.
The health and well-being of the Region, as well at its ability to achieve these global agendas, is dependent on scaled-up actions, both immediate and long-term, to address the rapidly changing nature and scope of challenges related to the environment and climate change. Those actions are also needed to ensure that all national development plans consider environmental concerns and include rigorous safeguards and sustainability measures that also benefit and synchronize with the aims of the health sector, such as actions related to chemical safety (). Throughout this process, the greatest challenge will be to reconcile the demands of growth with the need to protect and manage natural habitats and resources and the importance of ensuring that environmental policies do not generate additional burdens for the poor. Nonetheless, the Region has many opportunities to address the topic of health and many facets of environmental sustainability in national and regional policies, which can subsequently contribute to an enabling environment for achieving many of the SDGs.
Building resilience and improving adaptive capacity is critical to continued development and achievement of the 2030 Agenda across the Americas. Adaptive efforts include increasing engagement with other sectors to improve environmental consciousness; reducing carbon footprints; and developing innovative solutions in renewable energy, transportation, water supply, forestry, agriculture, and urban development. In addition, countries must improve the reliable production of environmental statistics, promote research, build regional capacity, and develop platforms for dialogue and shared learning among relevant stakeholders. This will support the development of evidence-based prevention policies; generate income opportunities; mainstream environmental health and climate change in broader development initiatives; and ultimately strengthen the Region’s capacity to adapt to an ever-changing world.
The world has entered a new era of sustainable development, building on the successes of the MDGs. To continue advancing on social, economic, and environmental fronts, the Region must advocate, implement, and practice innovative public policies that close persistent inequities and address the increasing complexity and interconnectedness of health and development. Although only one of the 17 SDGs explicitly names health as a priority, many SDGs and their targets are related to health and thus highlight the health sector as one that not only is inherent to achieving the overall 2030 Agenda but also provides many opportunities for cooperation. In this way, health is central to the development of an equitable and sustainable future.
In the midst of rapid urbanization, threats to the climate and environment, and the emergence of new challenges, such as the growing burden of NCDs, it is crucial to adopt the 2030 Agenda core principles of equity and multesectoriality to harness complementary efforts and deliver shared gains. National plans and global agreements that are already in place, such as the WHO Framework Convention on Tobacco Control, the Minamata Convention, and the Paris Agreement, are prime examples of how the 2030 Agenda can be used to integrate priorities, innovations, and inputs from a variety of partners and stakeholders (). The public, private, and civil society sectors all have a role to play in strengthening the implementation of these policies and ensuring that new policies and interventions are not only equitable but also efficient.
Health is politicized at all levels of governance—locally, regionally, and globally—in governments, international institutions, the private sector, and civil society organizations. In addition, health itself is inherently political, because it is unevenly distributed, with many determinants that are dependent on political action, and inherently related to human rights (). Thus, only when the political nature of health is explicitly acknowledged will countries be enabled to develop more realistic, evidence-based public health strategy and policy.
Given the central importance of equity to the 2030 Agenda, it is clear that persistent inequities are not likely to dissipate unless health-related issues are discussed and addressed at the highest political levels. Because health affects economic and social conditions, and thus also has an impact on political legitimacy, the consequences of not embracing this strategic shift may be significant. At the same time, the effective use of politics in public health is already generating positive outcomes in areas such as NCDs and climate change. In order to gain political influence, countries and public health organizations must be equipped to analyze political contexts and complexities, frame arguments, and act effectively in the political arena ().
The 2030 Agenda has redefined public health in a fundamental way by demonstrating that public health challenges can no longer be addressed merely through technical actions but must be accompanied by political action within and beyond the health sector. The implementation of such an ambitious agenda simultaneously () creates opportunities to apply an ecological perspective, and systems thinking, and () requires that health be considered in government policies. Regional bodies, civil society groups, and global health institutions will be essential in accelerating the 2030 Agenda at all levels of governance, and the Region of the Americas must be prepared to embrace a more political approach to health in the context of sustainable human development and the SDGs.
The 2030 Agenda represents a fascinating point in public health history in which health is a driving force for a new quality of life and well-being, and challenges in the health sector extend beyond traditional health boundaries. The health sector thus becomes intertwined not only with development but also with politics and political processes. Health challenges require complex solutions and should thus have policy potential to take advantage of windows of opportunity and produce mutual gain across different sectors. Moreover, the co-production and co-benefits of health must be shared across society as a whole. The 2030 Agenda establishes a framework in which successful outcomes in health can have a positive impact on other aspects of development-advances that will in turn reciprocally benefit health.
Despite the complex interplay of the SDGs, the 2030 Agenda’s call is straightforward: in order to create a more equitable world for future generations, countries must identify their most vulnerable populations, develop innovative strategies to reach those populations, and monitor progress toward that end. Achieving these objectives should not be solely the responsibility of government, however. The aspirational goals and targets of the 2030 Agenda must be translated into relatable, practical, and implementable actions that individuals, families, and communities can take. These everyday actions will make sustainable development tangible, enhance effectiveness, involve new actors, and foster ownership of the Agenda across and within borders. Now, more than ever, it is of paramount importance to collectively transform the 2030 Agenda into a reality for the benefit of all.
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The settings-based approach to health promotion involves holistic and multidisciplinary action across risk factors to maximize disease prevention via a “whole system” approach. More information is available at http://www.who.int/healthy_settings/en/.