Pan American Health Organization

Mortality in the Americas

Mortality in the Americas

  • Introduction
  • Quality of Mortality Data
  • Mortality by GBD Causes of Death
  • Mortality by Leading Causes of Death
  • Maternal Mortality by Time Period and Cause of Death
  • Infant Mortality by Time Period
  • Neonatal Mortality by Time Period
  • Conclusion
  • References
  • Full Article
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Introduction

Mortality trends and profiles in the Region of the Americas have undergone substantial changes in recent decades (). In Latin America and the Caribbean (LAC), demographic changes coupled with evolving lifestyle, environmental, behavioral, and economic factors have led to noncommunicable diseases (NCDs) replacing or, in some settings, co-existing with the burden of communicable diseases (CDs) (). This epidemiological transition helps explain the particularly heterogeneous mortality trends in LAC countries (), where the double burden of CDs and NCDs is common and takes a tremendous toll on the health system (). However, improvements in primary health care () and disease control and surveillance have reduced the risk of death from vaccine-preventable diseases () and complications during pregnancy and childbirth ().

In the Americas overall, the past decade has been characterized by an increase in deaths resulting from external causes such as road traffic injuries and suicides, which have contributed to changes in the Region’s mortality profile (). These changes have not occurred uniformly across different subregions, countries, populations, age groups, and genders (). For example, declines in mortality rates among indigenous populations in LAC countries have generally lagged compared to those in other groups ().

The analysis of mortality trends is crucial for developing effective health, social security, and other types of policies (). This chapter describes the trend and magnitude of mortality in the Americas between 2002 and 2013, by main causes of death, time period, and age group, and the heterogeneous patterns of mortality across subregions of the Americas in different stages of the epidemiological transition.

The LAC region has been recognized as having the highest socioeconomic disparities in the Americas, a status that has inevitably translated into high mortality due to NCDs, including cardiovascular diseases, diabetes, and cancer (). Reversing mortality trends due to NCDs in these subregions may be the Region’s biggest challenge as well as its greatest opportunity to meet the Sustainable Development Goals (SDGs) ().

Aging, globalization, urbanization, and the rise in obesity and physical inactivity in the Region have made cardiovascular diseases the leading cause of death and disability in the Americas (), accounting for almost one-third of all Regional mortality, with the risk generally higher in men compared to women.

The Region of the Americas also suffers from a high burden of diabetes mellitus, which is known to increase the risk of cardiovascular diseases two- to fourfold, and is among the top five causes of death in the LAC region, according to the 2010 Global Burden of Disease Study (GBD) (). Based on current trends, mortality from diabetes in the LAC region is projected to be 1.6 times higher than the SDG target (). In addition, cancer contributes to one-third of the NCD burden in the Region, according to the World Health Organization (WHO), with demographic, social, economic, and environmental factors, as well as changes in reproductive patterns, as the main drivers of the patterns of cancer mortality ().

Over the last decade, the Americas has experienced a decline in mortality from CDs resulting from improvements in access to water and sanitation services, micronutrient supplementation, primary care, and vaccination, among other areas (). Between 2007 and 2009, 12.5% of all deaths in the Region were attributed to CDs, with the highest mortality rates observed in Guatemala and Peru (). Despite favorable trends in CD mortality overall, challenges such as antibiotic resistance and emerging and reemerging infectious diseases will require continued and constant surveillance (). A better understanding of the link between climate change and infectious diseases will also be crucial given the predicted climatic effects on vector-borne and zoonotic diseases ().

Maternal mortality reduction remains an unfinished agenda in the Americas. No country in the Region achieved Millennium Development Goal 5 (MDG 5) (“Reduce maternal mortality”). In fact, from 1999 to 2013, an increase in maternal mortality was reported in the Americas (). This increase may be at least partially attributable to the enhanced identification of direct and indirect maternal deaths; the addition of a pregnancy checkbox in U.S. death certificates in 2003 (); the inclusion of late maternal deaths in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10); active surveillance of maternal deaths in Brazil and Mexico since 2002 (); and an increasing prevalence of chronic conditions and risk factors such as obesity, hypertension, diabetes mellitus, and heart disease among pregnant women, along with the obstetric transition ().

The lowest rate of decline in maternal mortality during the 1990–2015 period was observed in the Caribbean, which reported a 1.8% reduction (). Maternal mortality reporting in the Region continues to be challenged by misclassification and under-reporting ().

Despite an overall decline in complications during pregnancy and childbirth across the Region (), direct obstetric causes still accounted for 75.0% of Regional maternal deaths in 2007 (). Improvements in fighting CDs and perinatal complications in children over the last few decades have led to marked reductions in deaths in neonates and children under 5 years old, which enabled the LAC region to meet MDG 4 (“Reduce child mortality”) (). Nevertheless, striking disparities remain within LAC countries. For example, despite major improvements in preventing maternal, newborn, and child mortality, Mexico’s neonatal mortality rate is still twice as high as the United States’ (8.2 compared to 3.6 deaths per 1,000 live births) ().

Youth and adolescents, representing about 26% of the total population of the Region, comprise the largest cohort in the Americas (). This population is also the most affected by external causes of mortality, which accounted for 64.7% of deaths in the 10–24 year age group and 11.1% of all deaths in the Region between 2007 and 2009 (). The largest contributors to external causes of death include road traffic injuries, which are among the leading causes of death in the 5–14 and 15–44 year age groups (), followed by accidental injuries, assaults, and suicides. Global estimates predict that by 2020 road traffic injuries will rank third in the causes of disability-adjusted life years (DALYs) lost (). External causes of death thus remain a major concern given the increasing proportional mortality they represent in the Region of the Americas.

The differences in mortality due to external causes by sex are striking, disproportionately affecting men more compared to women (). For example, deaths from assaults account for up to 30.0% of total deaths from external causes among males but only 10–12% of total deaths among females, and the risk of death from road traffic injuries was 3–4 times higher in men than in women in 2007 ().

To assess mortality in the Americas, an ecological study was conducted using data from () the Pan American Health Organization (PAHO) mortality database for 2002–2013 and () estimated maternal and infant mortality indicators obtained from interagency groups. This chapter describes the magnitude, distribution, and trends of mortality data across the Americas and its subregions over three time periods (2002–2005, 2006–2009, and 2010–2013). The countries are grouped according to PAHO’s Regional Core Health Data Initiative (RCHDI), with Mexico and Brazil listed separately as subregions due to their population size. Age-adjusted mortality rates were calculated for comparison across subregions, using the WHO world population age structure constructed for the period 2000–2025 as the standard population. Relative risk (RR) of mortality was calculated by sex and each of the 3-year time periods, along with the percentage of change in mortality between the time periods, using the latest interval as the reference variable.

Quality of Mortality Data: Under-registration, Ill-defined Causes of Death, and Garbage Codes

Data quality was assessed for proportions of under-registration, ill-defined causes of death, and garbage codes. For under-registration, the analysis indicated that the Region of the Americas mortality data for 2010–2013 had 5.9% under-registration, compared to 7.2% for 2002–2005 and 2006–2009. A total of 3.4% of the data for 2010–2013 were considered ill-defined causes of death, compared to 4.7% of the data in 2002–2005 and 3.6% in 2006–2009. On the other hand, the proportion of garbage codes increased to 15.2% for 2010–2013, compared to 14.8% for 2002–2005 and 15.0% for 2006–2009. Therefore, the quality of mortality data for the Region improved in terms of under-registration and ill-defined causes of death but dropped in terms of the proportion of garbage codes.

There was wide variability in the quality of mortality data by subregion (Figure 1). For example, in 2010–2013, the Andean Area had 24.9% under-registration, 2.2% ill-defined causes of death, and 17.2% garbage codes, whereas the Southern Cone reported 2.5%, 7%, and 24.7% for the same respective categories. In 2010–2013, the highest and lowest proportions of under-registration were observed in the Andean Area (24.9%) and in Mexico (near 0%), respectively. During the same period, the highest and lowest proportions of ill-defined causes of death were in the Southern Cone (7.0%) and North America (1.5%), respectively, whereas the highest and lowest proportions of garbage codes were in the Southern Cone (24.7%) and in Mexico and the Latin Caribbean (13.5%).

Figure 1. Mortality data quality by subregion and time period, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

Analysis of data quality across subregions over time (Figure 1) shows that Brazil and Mexico had the largest decline in under-registration between 2002–2005 and 2010–2013. During the same period, in Mexico the proportion declined from 4.5% to near 0%, whereas in Brazil it declined from 7.6% to 3.1%. Brazil also had the largest reduction in ill-defined causes of death (from 12.4% in 2002–2005 to 6.5% in 2010–2013), whereas North America experienced a slight increase for that category (from 1.3% in 2002–2005 to 1.5% in 2010–2013). The LAC region experienced a decrease in garbage codes followed by an increase (from 14.3% in 2002–2005 to 12.9% in 2006–2009 and 13.5% in 2010–2013), whereas in Mexico, this category increased from 12.6% (2002–2005) to 13.5% (2010–2013).

Mortality by GBD Causes of Death: CD, NCD, and External

Mortality by main causes of death according to the GBD 2010 categories (CDs, NCDs, and external) is shown in Table 1. The results show that in the Region of the Americas in 2010–2013, NCDs were the largest contributor to mortality. The age-adjusted mortality rate due to CDs was 59.7 deaths per 100,000 population compared to 441.3 deaths per 100,000 due to NCDs and 62.7 deaths per 100,000 due to external causes.

Table 1. Age-adjusted mortality rate by Global Burden of Disease (GBD)a cause of death, time period, and sex, Region of the Americas, 2002–2013

GBD cause of death Period Rate Variation
(%)b
Relative
riskc
Male Female Total
Communicable disease 2002–2005 74.8 58.1 66.2 –9.9 1.3
2006–2009 71.9 56.6 64.1 –6.9 1.3
2010–2013 66.7 53.0 59.7 1.3
Noncommunicable disease 2002–2005 539.3 436.0 483.4 -8.7 1.2
2006–2009 521.9 422.7 468.7 –5.8 1.2
2010–2013 490.7 398.1 441.3 1.2
External 2002–2005 98.8 27.2 62.4 0.5 3.6
2006–2009 101.2 27.9 64.0 –2.0 3.6
2010–2013 98.9 27.5 62.7 3.6
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Global Burden of Disease Study 2010 ().
b) Reference variable: period 2010–2013.
c) Reference variable: female.

Over the three time periods, CD age-adjusted mortality rates dropped from 66.2 per 100,000 (in 2002–2005) to 59.7 deaths per 100,000 (in 2010–2013), a 9.9% reduction. Similarly, the NCD age-adjusted mortality rates fell steadily from 483.4 per 100,000 in 2002–2005 to 441.3 deaths per 100,000 in 2010–2013. External causes of mortality rates rose from 62.4 to 64.0 per 100,000 between 2002–2005 and 2006–2009 and dropped to 62.7 deaths per 100,000 for 2010–2013.

An analysis of GBD causes of death in the Americas (stratified by sex) was carried out to assess the disparities between men and women regarding the risk of CD, NCD, and external causes of death over time (Table 1). The results indicated a constant RR for CD deaths of 1.3 over time, with a 30% higher risk for men, throughout the three time periods. Similarly, men had a 20% higher risk of NCD deaths throughout the study period (RR = 1.2). For external causes of death, disparity by sex was much larger: men had a 3.6-fold higher risk of death compared to women, and the disparity remained constant between 2002–2005 and 2010–2013. There were disparities in risk of death due to CDs, NCDs, and external causes for all subregions of the Americas, with the RR for the first two causes ranging from 1.2 to 1.4 for men compared to women for 2010–2013 and the RR for external causes ranging from 2.3 to 5.2 for men compared to women for the same period of time.

Within the Region of the Americas, there was variability in the patterns and trends of mortality rates for CDs, NCDs, and external causes (Figure 2). In the most recent time period (2010–2013), the subregions with the highest and lowest mortality rates due to CDs were Central America (111.8 deaths per 100,000) and North America (32.8 deaths per 100,000), respectively. NCD mortality rates were highest in Central America (454.2 deaths per 100,000) and lowest in the Non-Latin Caribbean (297.3 deaths per 100,000). Mortality rates for deaths due to external causes within the same period were the highest in Central America (90.2 deaths per 100,000) and lowest in the Non-Latin Caribbean (38.7 deaths per 100,000). Hence, the analysis by subregions suggests that Central America had the highest mortality rates for CDs, NCDs, and external causes in 2010–2013.

Analysis of the trend across the three time periods (Figure 2) shows that all subregions experienced a continuous decline in CD mortality rates with the exception of Brazil and Central America. In Central America, a steep rise was reported between 2002–2005 and 2006–2009 (from 80.7 to 131.9 deaths per 100,000), followed by a steady decline in 2010–2013 to 111.8 deaths per 100,000. Similarly, all subregions except Brazil, Central America, and Mexico experienced a continuous decline in NCD mortality rates. In Central America, a pattern resembling that for CDs was observed, with a sharp increase in the NCD death rate (from 351.0 to 454.8 deaths per 100,000) between 2002–2005 and 2006–2009, followed by a steady drop in magnitude to 454.2 deaths per 100,000 in 2010–2013. The Non-Latin Caribbean had the largest decline in NCD mortality rates, with 475.7 deaths per 100,000 in 2002–2005 and 297.3 deaths per 100,000 in 2010–2013 (a 37.5% reduction).

Figure 2. Trends in mortality rates for Global Burden of Disease (GBD)a causes of death by time period and subregion, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Global Burden of Disease Study 2010 ().

Different trends were observed across the subregions for deaths by external causes: North America, the Latin Caribbean, and the Non-Latin Caribbean had a similar pattern, with a slight increase between 2002–2005 and 2006–2010, followed by a decline in 2010–2013. In Mexico, mortality due to external causes continued to increase in 2010–2013, whereas in Brazil it declined between 2002–2005 and 2006–2009 and then increased in 2010–2013. The Andean Area was the only subregion with a steady and continuous decline in mortality due to external causes throughout the study period (from 98.6 deaths per 100,000 in 2002–2005 to 89.1 deaths per 100,000 in 2010–2013). Central America had the largest increase in mortality from external causes (from 65.0 in 2002–2005 to 98.5 deaths per 100,000 in 2006–2009), followed by a decline to 90.2 in 2010–2013.

Mortality by Leading Causes of Death

Leading causes of death were analyzed by age group (10–24, 25–64, and 65+ years) and the three designated time periods. Figure 3 shows the five leading causes of death and associated mortality rates for the Region by age group and time period. Results for the Region overall for 2010–2013 indicated homicide was the leading cause of death among the 10–24 year age group, with a death rate of 20.4 per 100,000, followed by land transport accidents, with a rate of 13.4 per 100,000, and suicide, with a rate of 5.7 deaths per 100,000. In the 25–64 year age group, for the same period, ischemic heart diseases were the leading cause of death (35.9 deaths per 100,000), followed by diabetes mellitus (19.1 deaths per 100,000); homicides were on par with cirrhosis and other liver diseases, with a rate of 18.3 deaths per 100,000. Land transport accidents had a rate of 17.0 per 100,000. Homicide and land transport accidents were among the top five leading causes of death in both the 10–24 and 25–65 year age groups for both the 2002–2005 and 2002–2005 time periods (and for the 2006–2009 time period as well, for the younger age group). Among people 65 years old and older, ischemic heart diseases remained the leading contributor to mortality for 2010–2013, with a rate of 620.6 deaths per 100,000, followed by cerebrovascular disease deaths, dementia and Alzheimer’s disease deaths, chronic lower respiratory disease deaths, and diabetes mellitus.

Figure 3. Leading causes of death by age group and time period, Region of the Americas, 2002–2013 FMaterna;

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

There was little heterogeneity in the leading causes of death over time in the Americas among the 10–24 year age group: homicide, land transport accidents, and suicide remained the top three causes of death between 2002–2005 and 2010–2013. For the 25–64 year age group, throughout all three time periods, ischemic heart disease remained the top cause of death and land transport accidents remained in the top five leading causes of death. Conversely, diabetes mellitus was not among the five leading causes of death in 2002–2005 but was the second leading cause of death for the periods 2006–2009 and 2010–2013. Also, cerebrovascular diseases, which were a leading cause of death in 2002–2005, were no longer a cause of death in the last two study periods, when cirrhosis and other liver diseases became a leading cause of death for the first time in the study period.

Among people 65 years old and older, a similar homogenous trend across subregions was observed for the leading causes of death over time. Ischemic heart diseases, cerebrovascular diseases, chronic lower respiratory diseases, and diabetes mellitus remained among the top five contributors to mortality in this age group. The category of dementia and Alzheimer’s disease was not one of the five leading causes in the first time period but increased from the fourth leading cause in 2006–2009 to the third leading cause in 2010–2013.

The data for the Americas overall suggest variability between subregions and countries in the leading causes of death by age group. Subregional and country data can be accessed from the mortality database of PAHO’s Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA).

Maternal Mortality by Time Period and Cause of Death

For the period 2010–2013, the maternal mortality ratio (MMR) Region-wide was 58.2 deaths per 100,000 live births, a decline from MMRs of 68.4 for 2002–2005 and 64.6 for 2006–2009 (a reduction of 14.9% and 9.9%, respectively) (Table 2). The highest subregional MMR recorded for 2010–2013 was in the Latin Caribbean, which experienced 192.2 deaths per 100,000 live births. Haiti had the highest MMR (375.0) in the Latin Caribbean for that period. The subregion with the lowest MMR for 2010–2013 was North America, which reported 13.5 deaths per 100,000 live births; at the country level in North America, for the same period, Canada had the lowest reported MMR (7.7).

Table 2. Maternal mortality ratio (MMR) by region/subregion and time period, Region of the Americas, 2002–2013

Region/subregion Period MMR Variation
(%)a
Americas 2002–2005 68.4 -14.9
2006-2009 64.6 -9.9
2010–2013 58.2
Andean Area 2002-2005 118.4 -19.2
2006–2009 104.8 -8.7
2010–2013 95.7
Brazil 2002–2005 64.5 -10.1
2006–2009 66.5 -12.8
2010–2013 58.0
Central America 2002-2005 126.9 -15.8
2006–2009 115.8 -7.7
2010–2013 106.9
Latin Caribbean 2002–2005 219.1 -12.3
2006–2009 214.8 -10.5
2010–2013 192.2
Mexico 2002–2005 56.5 -24.8
2006–2009 51.0 -16.7
2010–2013 42.5
Non-Latin Caribbean 2002–2005 114.1 -5.7
2006–2009 107.3 0.3
2010–2013 107.6
North America 2002–2005 12.7 6.3
2006–2009 13.8 -2.2
2010–2013 13.5
Southern Cone 2002–2005 64.2 -10.0
2006–2009 62.1 -6.9
2010–2013 57.5
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Reference variable: period 2010–2013.

Between 2002–2005 and 2010–2013, there was an overall trend of decline in maternal mortality in all subregions except North America, where there was a 5.7% increase in the MMR. The United States was the largest contributor to the rise in MMR in North America. Despite having the lowest MMR in the Region of the Americas, North America was the only subregion with an increase in MMR over the past decade (Table 2). In the other subregions, the largest decline over time was recorded in Mexico, where there was a 24.8% drop between 2002–2005 (MMR = 56.5) and 2010–2013 (MMR = 42.5).

Causes

Causes of maternal death were divided into four categories: (1) direct obstetric causes; (2) indirect obstetric causes; (3) obstetric deaths of unspecified causes; and (4) late maternal deaths and deaths from sequelae of obstetric causes. The distribution of maternal mortality causes for the Americas over time, by subregion, is shown in Figure 4. In 2010–2013, 66.4% of maternal deaths in the Americas were direct obstetric deaths, 23.5% were indirect obstetric deaths, 7.4% were late and obstetric sequelae deaths, and 2.8% were obstetric deaths of unspecified causes. When mortality was analyzed by these categories, within the overall declining trend, the largest contributor over all three time periods was direct obstetric causes, which accounted for 77.2%, 71.3%, and 66.4% of maternal deaths in 2002–2005, 2006–2009, and 2010–2013, respectively, followed by the rising proportion of indirect obstetric causes, which led to 16.3%, 20.4%, and 23.5% of maternal deaths, respectively. Late and sequelae maternal deaths also increased over the study period, representing 4.0%, 6.0%, and 7.4% of maternal deaths across the three time periods. Obstetric deaths from unspecified causes made up the smallest proportion of maternal deaths in the Americas (2.6%, 2.4%, and 2.8%, respectively, of total maternal deaths).

Figure 4. Causes of maternal mortality by region/subregion and time period, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

In the subregions, the proportional distribution of causes of maternal deaths varied. The Andean Area and Latin Caribbean followed a pattern similar to that of the Region in 2010–2013, with the largest contributor being direct obstetric deaths (68.1% and 63.5%, respectively) compared to indirect obstetric deaths (26.6% and 27.4%, respectively) and late and obstetric sequelae deaths (1.7% and 5.1%, respectively). Central America and the Non-Latin Caribbean had a similar distribution but with a much larger contribution from direct obstetric deaths (87.5% and 87.2%, respectively). North America had a more even distribution of maternal death causes, with 52.2% direct obstetric deaths, 24.2% indirect obstetric deaths, and 20.3% late and obstetric sequelae deaths in 2010–2013.

These data suggest an overall increase in the proportion of both indirect obstetric deaths and late and obstetric sequelae deaths, and a decline in the proportion of direct obstetric deaths. In the North American subregion, the proportion of direct obstetric maternal deaths declined from 62.5% in 2002–2005 to 53.7% and 52.2% in 2006–2009 and 2010–2013, respectively, and the proportion of obstetric deaths from unspecified causes declined from 4.1% in 2002–2005 to 3.2% in 2010–2013. Conversely, in the same subregion, indirect obstetric causes increased (from 18.6% in 2002–2005 to 24.3% in 2010–2013), and there was a sharp increase in late and obstetric sequelae maternal deaths (from 15.0% to 24.3%) between 2002–2005 and 2006–2009, which then declined slightly in 2010–2013 (to 20.3% of maternal deaths). Since 2002–2005, North America has had the highest subregional proportion of late maternal deaths and deaths from sequelae of obstetric causes in the Americas. In Mexico, there was an increase in indirect obstetric maternal deaths (from 15.3% in 2002–2005 to 23.5% in 2010–2013) and in late obstetric sequelae causes deaths (from 2.3% in 2002–2005 to 8.0% in 2010–2013) simultaneous with a decline in the proportion of direct obstetric causes (from 82.1% in 2002–2005 to 68.3% in 2010–2013). This pattern was also observed in both the Andean Area and the Latin Caribbean. In the Latin Caribbean, between 2002–2005 and 2010–2013, the proportion of direct obstetric causes declined from 74.5% to 63.5%, while the proportion for indirect obstetric causes rose from 19.2% to 27.4%. The proportional mortality for that subregion from late and sequelae maternal deaths remained relatively constant (approximately 5% over time), while obstetric deaths from unspecified causes rose from 1.7% in 2006–2009 to 4.0% in 2010–2013.

In both the Southern Cone and Brazil, the rise in proportional mortality from late and obstetric sequelae causes was not as striking as what was reported for North America and Mexico. For example, in Brazil, this value only increased from 4.1% in 2002–2005 to 6.4% in 2010–2013. However, both the Southern Cone and Brazil followed the same pattern as the rest of the Americas with regard to the interchanging contributions of direct and indirect obstetric causes of maternal death over time. In Central America and the Non–Latin Caribbean, a somewhat different scenario was observed in which the proportion of direct obstetric deaths rose between 2002–2005 and 2006–2009 while indirect obstetric deaths declined, followed by a reverse trend in 2010–2013. For example, in Central America, the contribution of direct obstetric causes increased from 86.0% to 89.1% from 2002–2005 to 2006–2009, and then declined to 87.5% in 2010–2013. This trend was reversed for indirect obstetric causes, whose contribution to maternal deaths declined from 10.9% to 7.5% between the first two time periods and then rose again to 10.2% in 2010–2013.

Infant Mortality by Time Period

Infant mortality rates (IMRs), defined as deaths in children under 1 year old per 1,000 live births, are presented in Table 3. In 2010–2013, the IMR in the Americas was 13.6 deaths per 1,000 live births, a decline from 17.9 and 15.2 deaths per 1,000 live births in 2002–2005 and 2006–2009 (a 24.0% and 10.5% reduction), respectively. Within the region, the IMR ranged between 6.0 and 38.7 deaths per 1,000 live births in North America and the Latin Caribbean, respectively, in 2010–2013.

Table 3. Infant mortality rate (IMR) by region/subregion and time period, Region of the Americas, 2002–2013

Region/subregion Period IMR Variation
(%)a
Relative
riska
Americas 2002–2005 17.9 –24.0 1.3
2006–2009 15.2 –10.5 1.1
2010–2013 13.6
Andean Area 2002–2005 23.4 –25.2 1.3
2006–2009 20.0 –12.5 1.1
2010–2013 17.5
Brazil 2002–2005 21.9 –33.8 1.5
2006–2009 16.7 –13.2 1.2
2010–2013 14.5
Central America 2002–2005 28.1 –23.1 1.3
2006–2009 24.4 –11.5 1.1
2010–2013 21.6
Latin Caribbean 2002–2005 41.2 –6.1 1.1
2006–2009 38.3 1.0 1.0
2010–2013 38.7
Mexico 2002–2005 17.9 -24.6 1.3
2006–2009 15.6 –13.5 1.2
2010–2013 13.5
Non-Latin Caribbean 2002–2005 21.4 –14.0 1.2
2006–2009 19.9 –7.5 1.1
2010-2013 18.4
North America 2002–2005 6.7 –10.4 1.1
2006–2009 6.4 –6.3 1.1
2010–2013 6.0
Southern Cone 2002–2005 15.4 –20.8 1.3
2006–2009 13.5 –9.6 1.1
2010–2013 12.2
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Reference variable: period 2010–2013.

Analyses of the IMRs over time suggest all subregions had a declining trend in infant mortality since 2002–2005. Within the overall decreasing trend Region-wide, the Latin Caribbean subregion had the highest IMR, with 41.2, 38.3, and 38.7 deaths per 1,000 live births for the three time periods. In both the Latin Caribbean subregion and the Region of the Americas as a whole, Haiti’s IMR was consistently the highest, ranging from 68.0 to 63.5 deaths per 1,000 live births between 2002–2005 and 2010–2013. At the subregional level, North America had the lowest IMR throughout the respective time periods (6.7, 6.4, and 6.0 infant deaths per 1,000 live births). At the country level, for 2010–2013, Cuba’s IMR was lowest (4.7 deaths per 1,000 live births). The Latin Caribbean subregion had the greatest disparity in infant mortality, with both the highest and lowest IMRs at the country level. The largest decline in infant mortality over time was in Brazil (followed by the Andean Area), with a 33.8% reduction (RR = 1.5) between 2002–2005 and 2010–2013 and a 13.2% reduction (RR = 1.2) between 2006–2009 and 2010–2013.

Neonatal Mortality by Time Period

Neonatal mortality, defined as deaths occurring during the first 28 days of life per 1,000 live births, was analyzed by principal causes and time period. The principal cause was “certain conditions originating from the perinatal period,” and consistently accounted for more than 70.0% of all neonatal deaths in the Americas during all time periods. Therefore, the analysis reported here focused on this cause of death among neonates. Within this category, the leading specific causes of neonatal mortality in the Americas were respiratory distress of newborns, which accounted for 18.2–20.4% of neonatal deaths between 2002–2005 and 2010–2013, followed by disorders related to length of gestation and fetal growth (14.3–15.8%); bacterial sepsis in newborns (13.5–14.9%); and fetus and newborn affected by maternal factors and complications of pregnancy and labor and delivery (11.5–12.8%). In North America and the Southern Cone, disorders related to the length of gestation and fetal growth remained the leading cause of neonatal deaths throughout the three time periods, whereas in the Andean Area, Brazil, Central America, the Latin Caribbean, Mexico, and the Non-Latin Caribbean, respiratory distress of the newborn was the leading cause. In addition to “certain conditions originating from the perinatal period,” intrauterine hypoxia and birth asphyxia, hemorrhagic and hematological disorders of the fetus and newborn, and congenital pneumonia were the top causes of neonatal mortality in certain subregions.

Conclusion

Despite major improvements since 2002–2005 for the Americas in both the overall health indicators and the quality of mortality data (i.e., the proportion of under-registration, ill-defined causes, and garbage codes), important challenges remain to sustain progress and further improve quality (e.g., continued reduction of the proportion of garbage codes). Suggested changes include a reduction in the disparities among health indicators across regions and countries.

Trends for the GBD causes of death were mixed. Between 2002–2005 and 2010–2013, risk decreased by 10.0% and 9.0% for CDs and NCDs, respectively, but risk of death from external causes remained relatively constant.

Based on the analysis of leading causes of death in the Region by age group, mortality trends across the Americas subregions were heterogeneous. However, there were some similarities Region-wide. For example, across all countries, homicide and land transport accidents were among the leading causes of death in the 10–24 year age group; ischemic heart diseases, cerebrovascular diseases, and diabetes were common leading causes of death in the 25–64 year age group; and chronic lower respiratory diseases and dementia and Alzheimer’s disease were common leading causes of death in people 65 years old and older.

Despite general declines in the risk of maternal mortality across subregions of the Americas, a rising trend was observed in North America. Regarding the causes of death, a declining proportion of direct obstetric causes and a rising proportion of indirect obstetric causes, late maternal deaths, and deaths from sequelae of obstetric causes were recorded throughout the Region. Infant mortality data indicate a declining trend in infant deaths across the Region, with the largest decline reported in Brazil since the period 2002–2005. The majority of deaths among neonates across the Americas were uniformly attributed to conditions originating from the perinatal period, including (1) newborn respiratory distress; (2) disorders related to length of gestation and fetal growth; (3) bacterial sepsis in newborns and fetus and newborn affected by maternal factors and by complications of pregnancy, labor, and delivery; and (4) other newborn respiratory conditions.

Technical notes

Mortality in the Americas was assessed through an ecological study using two sources: PAHO mortality data for the period 2002–2013 and estimated maternal and infant mortality indicators obtained from interagency groups (). The 2002–2013 study period was selected to capture at least a decade of data and because that period included the most complete information from PAHO’s mortality database.

PAHO data are collected on an annual basis from the national statistics institutes and ministries of health of all PAHO Member States. Each Member State documents deaths by year with ICD-10 coding. The data in the PAHO mortality database include at least five variables consistently reported by all countries: country name, year of death, age, sex, and underlying cause of death—all of which are used in the analyses reported here. Variability in the accuracy of the data across countries is measured by comparing the percentages of unregistered deaths (under-registration), the percentage of deaths attributed to ill-defined causes of death (from Chapter XVIII of the ICD-10), and the percentage of garbage codes (proportion of deaths assigned to causes that are not considered useful for public health purposes). For countries that do not have good-quality mortality data (data ≥10.0% of under-registration or ≥10% of ill-defined causes of death), a corrected mortality rate is calculated by applying a correction algorithm for under-registration and ill-defined causes of death that distributes both types of deaths into the registered mortality data. For countries with high-quality data (and those with low-quality data that lack inputs for correction), the original death registration data were used for the analyses.

References

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2. Rivera-Andrade A, Luna MA. Trends and heterogeneity of cardiovascular disease and risk factors across Latin American and Caribbean countries. Progress in Cardiovascular Diseases 2014;57(3):276–285.

3. Economic Commission for Latin America and the Caribbean. Mortality in Latin America: a favourable but heterogeneous trend. Santiago: UN ECLAC; 2007:27–43. Available from: http://www.cepal.org/publicaciones/xml/9/33269/od-4-mortalityinla.pdf.

4. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Quarterly 2005;83(4):731–757.

5. Pan American Health Organization. Chapter 4: Health conditions and trends. Mortality in the Americas. In: Health in the Americas: 2012 edition. Volume I–Regional. Washington, D.C.: PAHO; 2012:111–124. Available from: https://www.paho.org/salud-en-las-americas-2012/dmdocuments/hia-2012-chapter-4.pdf.

6. Rodrigues EM, Villaveces A, Sanhueza A, Escamilla-Cejudo JA. Trends in fatal motorcycle injuries in the Americas, 1998–2010. International Journal of Injury Control and Safety Promotion 2014;21(2):170–280.

7. Gawryszewski VP, Souza Mde F. Mortality due to cardiovascular diseases in the Americas by region, 2000–2009. Sao Paulo Medical Journal 2014;132(2):105–110.

8. Ordunez P, Prieto-Lara E, Pinheiro Gawryszewski V, Hennis AJ, Cooper RS. Premature mortality from cardiovascular disease in the Americas – Will the goal of a decline of “25% by 2025” be met? PLoS ONE 2015;10(10):e0141685.

9. Institute for Health Metrics and Evaluation; Human Development Network, World Bank. The global burden of disease: generating evidence, guiding policy. Latin America & Caribbean regional edition. Seattle: IHME; 2013. Available from: http://www.healthdata.org/sites/default/files/files/policy_report/2013/WB_LatinAmericaCaribbean/IHME_GBD_WorldBank_LatinAmericaCaribbean_FullReport.pdf.

10. Luciani S, Cabanes A, Prieto-Lara E, Gawryszewski V. Cervical and female breast cancers in the Americas: current situation and opportunities for action. Bulletin of the World Health Organization 2013;91(9):640–649.

11. Medone P, Ceccarelli S, Parham PE, Rabinovich JE. The impact of climate change on the geographical distribution of two vectors of Chagas disease: implications for the force of infection. Philosophical Transactions of the Royal Society of London B Biological Sciences 2015;370(1665):20130560.

12. de Cosio FG, Jiwani SS, Sanhueza A, Soliz PN, Becerra-Posada F, Espinal MA. Late maternal deaths and deaths from sequelae of obstetric causes in the Americas from 1999 to 2013: a trend analysis. PLoS ONE 2016;46:e0160642.

13. Edwards JE, Hanke JC. An update on maternal mortality and morbidity in the United States. Nursing for Women’s Health 2013;17(5):376–388.

14. Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet 2016;387(10017):462–474.

15. Callaghan WM. Overview of maternal mortality in the United States. Seminars in Perinatology 2012;36(1):2–6.

16. United Nations Inter-agency Group for Child Mortality Estimation. Levels and trends in child mortality, 2015. New York: UN; 2015. Available from: http://www.childmortality.org/files_v20/download/igme%20report%202015%20child%20mortality%20final.pdf.

17. González-Pier E, Barraza-Lloréns M, Beyeler N, Jamison D, Knaul F, Lozano R, et al. Mexico’s path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030. The Lancet Global Health 2016;4(10):e714–e725.

18. Quinlan-Davidson M, Sanhueza A, Espinosa I, Escamilla-Cejudo JA, Maddaleno M. Suicide among young people in the Americas. Journal of Adolescent Health 2014;54(3):262–268.

19. Ubeda C, Espitia-Hardeman V, Bhalla K, Borse NN, Abraham JP, Dellinger A, et al. National burden of road traffic injuries in Argentina. International Journal of Injury Control and Safety Promotion 2012;19(1):9–18.

20. de Souza ER, de Melo AN, Silva SG, Franco SA, Alazraqui M, González-Pérez GJ. [Multicentric study of deaths by homicide in Latin American countries]. Ciência & Saúde Coletiva 2012;17(12):3183–3193.

21. World Health Organization. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO; 2015. Available from: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf.

×

Reference/Note:

1. Theory of Abdel Omran (1971) connecting displacement of infectious diseases (CDs) by degenerative diseases (NCDs) as main causes of morbidity and mortality to economic development and demographic changes over time as countries’ level of development increases ().

2. Subregions as defined according to PAHO’s Regional Core Health Data Initiative (RCHDI), which lists Brazil and Mexico as subregions due to their population size.

3. Obstetric transition describes the gradual shift from high to low maternal mortality and an aging maternal population, from direct obstetric deaths to indirect obstetric deaths, and from pregnancy and childbirth to institutionalized maternity care.

4. Causes listed in Chapter XVIII of the ICD-10.

5. Deaths assigned to causes that are not considered useful for public health purposes.

6. https://www.paho.org/plisa.

7. From the mortality database of PAHO’s Health Information Platform for the Americas (https://www.paho.org/plisa).

The Americas keep an eye on malaria

Malaria control in Petén Suroccidental, Guatemala

    Week against mosquitoes, Argentina

    Kids participate in the activities

      Pathway to sustainable health

      • Introduction
      • Equity: a renewed focus for sustainable development
      • Transitioning to the era of the SDGs
      • Redefinition of global priorities
      • Regional priorities
      • Health across the SDGs
      • Identifying common ground
      • Looking forward
      • Conclusions
      • References
      • Full Article
      Page 1 of 10

      Introduction

      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.

      Sustainable Development

      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 ().

      2030 SDG Breakdown 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.

      Transitioning to the era of the SDGs

      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.

      2030 SDG Breakdown 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 Outcome
      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 ().

      Redefinition of global priorities

      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.

      Regional priorities

      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.

      Noncommunicable diseases

      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.

      Health across the SDGs

      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
      3.2 Child mortality
      3.3 HIV, tuberculosis, malaria, hepatitis, neglected tropical diseases
      3.4 Noncommunicable diseases and suicide
      3.5 Substance abuse
      3.6 Road traffic injuries
      3.7 Sexual and reproductive health
      3.8 Universal health coverage
      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
      6.2 Sanitation
      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.

      Finance

      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  
      Regional organizations 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)
      Civil society Nongovernmental organizations, neighborhood associations, media, unions
      Think tanks and academic institutions Universities, research institutes
      Private sector Industries, businesses

      Identifying common ground

      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 eradication

      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.

      Governance

      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.

      Urban development

      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.

      Environmental sustainability

      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.

      Looking forward

      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.

      Conclusions

      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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      Healthy Municipalities and Communities Network: A strategy that integrates actions across public health, popular education and community development to address the economic, social, and political determinants of health. More information can be found at https://www.paho.org/hq/index.php?option=com_content&view=article&id=10706&Itemid=41981&lang=en; http://www.who.int/healthy_settings/types/hmc/en/.

      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/.

      ×

      Reference/Note:

      Socioeconomic inequalities in health

      • Social Inequalities in Health
      • Two inseparable notions: equity in health and the social determinants of health
      • A regional look at health through the window of the Millennium Development Goals: focusing on equity
      • The persistence of inequities and inequalities in the Region
      • No one left behind…? How to make good on our promise
      • References
      • Full Article
      Page 1 of 6

      Social Inequalities in Health

      Equity in health is a cardinal expression of social justice, attained when every individual has the opportunity to reach his full health potential and no one is excluded or hindered from reaching that potential because of his social status or other socially determined circumstances. This ethical imperative is accompanied by a political imperative, since today it is recognized that social equity is a prerequisite for good governance. Thus, equity is a political objective that consists of creating equal opportunities for health and well-being. Indeed, without social equity, sustainable human development cannot be guaranteed (). In recognition of this, “Transforming our world: the 2030 Agenda for Sustainable Development,” embraced by every country in the world in 2015, has explicitly promised that no one will be left behind ().

      Two inseparable notions: equity in health and the social determinants of health

      Aspiring to equity in health, including universal access to health and universal health coverage, implies altering the underlying distribution and role of the social determinants of health—that is, the circumstances in which individuals are born, grow, live, work, and age and the broader array of forces and systems that affect those circumstances, such as the global, national, and local distribution of wealth, power, and resources. Transformational action that addresses the social determinants of health and promotes equity in health requires, on the one hand, abandoning public health practices based on the risk-factor paradigm, in which the individual and behavior are the focus, while, on the other hand, adopting a more comprehensive approach to public policy that empowers individuals and communities to exercise control over their circumstances—a multidisciplinary and essentially intersectoral approach under the principle of Health in All Policies.

      The Americas: a vibrant region plagued by persistent inequities

      Guaranteeing the universal right to health will remain simply an aspiration if the profound social inequalities behind the health gaps in the Region are not addressed. Empirical studies offer clear proof that the population groups with the worst health outcomes in the countries of our Region also are those that demonstrate the tangible expressions of socioeconomic inequality, including low income and consumption levels, poor housing, job insecurity, limited access to quality health services, fewer educational opportunities, inadequate access to water and sanitation services, marginalization, exclusion, and discrimination, among other adverse social and health situations ().

      Evidence of the stubborn persistence of profound social inequalities, exclusion, and discrimination—and, thus, profound inequalities in population health and the burden of disease—is present even in Latin American countries where “post-neoliberal” political, economic and social reforms have been implemented to counteract the neoliberal model that emerged in the 1980s (). One possible explanation for this could be a certain myopia in the policies designed and implemented, even in those consistent with the universal right to health.

      According to Garcia-Subirats et al., 20 years after the introduction of reforms to increase equity in access to health care, inequities (defined in terms of unequal use for equal need) are still present in both Brazil and Colombia (). According to these authors, the inequalities in the two countries illustrate the close connection between use of the health services and the design of each health system ().

      For example, and delving a bit further into the matter, bridging gender gaps in health implies unmasking and addressing explicit and, especially, implicit, discrimination or bias in their various forms, which make public policies ineffective for women. The combination of gender based discrimination and the material constraints imposed by poverty and the consequences of other social discrimination (such as living in a neglected geographical area or belonging to an ethnic group subject to social discrimination), will lead to significant health service access barriers (even to services in the public sector) for certain women. In other words, the different forms of discrimination, which tend to fuel each other (intersectionality ) and, in practice, affect certain women, become real obstacles to taking advantage of public policies that, in theory, could benefit them. As a result, if the aspiration is to make the health system an effective equalizer that intervenes to improve the health of disadvantaged groups and, consequently, bridge the gaps in health, its design and implementation should be based on a paradigm that involves an analysis of the target populations’ most pertinent problem stemming from the array of inequalities, exclusion, and discrimination to which they are subject.

      The causality between socioeconomic and health inequalities runs in both directions: on the one hand, conditions associated with poverty (such as economic insecurity, stress, and malnutrition) and different types of social discrimination directly affect people’s health and at the same time limit their access to health services; and on the other hand, poor health limits the potential for income generation and upward mobility by lowering school and work performance, thus reinforcing the patterns of social exclusion and discrimination.

      A regional look at health through the window of the Millennium Development Goals: focusing on equity

      Notwithstanding the historical structural impact of harmful colonial legacies, tremendous social injustice, and profound socioeconomic inequities (), the Region of the Americas, and Latin America in particular, enjoyed macroeconomic growth for much of the period 1990–2015, characterized by a reduction in poverty, extreme poverty, and inequality in income distribution—a period that has come to be known as the temporary window of the Millennium Development Goals (MDGs). As documented in this publication and its preceding edition (), the Region consolidated undeniable gains in health, meeting several of the targets set for MDG 4 (child mortality), MDG 6 (incidence of infection with the human immunodeficiency virus [HIV], tuberculosis), and MDG 7 (access to safe drinking water).

      Despite the impressive overall improvements, a regional look at health through the window of the MDGs paints a different and more troubling picture when examined through the lens of equity. Achievement of––or progress toward––the health-related MDGs has not generally been accompanied by a systematic reduction in social inequalities in health, especially relative inequality, which tends to be the most sensitive indicator for determining the impact of policies targeting population segments at greatest social disadvantage to ensure that no one is left behind. An eloquent—and dramatic—example is illustrated for MDG 5 (maternal mortality) in Figure 1, which looks at the maternal mortality situation through the lens of equity.

      Figure 1. Inequalities in maternal mortality in the Americas, by human development quartiles in the MDG period (1990–2015)

      Source: SDE/PAHO, 2016. Prepared by the authors using WHO data in the public domain.

      On average, the Region succeeded in halving the maternal mortality ratio between 1990 (101.8 per 100,000 live births) and 2015 (51.7 per 100,000 live births)—information that, in principle, is necessary and sufficient to determine whether or not MDG 5 (which established a 75% reduction) has been achieved. However, the histograms of human development quartiles among countries (Figure 1, left side) show that while the absolute gaps in maternal survival have been reduced—especially at the expense of a reduction in maternal mortality in the countries in the quartile with the lowest human development levels—gradients of inequality in maternal mortality persist. Both the regression curves (lower left-hand corner) and the concentration curves (lower right-hand corner) of social inequality (i.e., according to human development) for maternal mortality among countries in the Americas, which yield more sophisticated and detailed metrics of the inequality gradient (i.e., the slope index of inequality and the health concentration index, respectively), confirm this undesirable effect. In fact, 50% of maternal deaths in the Region continue to be concentrated in the 20% of countries with lower human development levels—a situation that did not change in the period 1990–2015. These women represent the people we have left behind.

      There is documented evidence of health inequalities between countries—analogous to those illustrated here with maternal mortality—involving other health outcome indicators and other stages of the life course (). For example, a regional study of the burden of tuberculosis incidence in the Americas between 2000 and 2013 found that the absolute inequality gradient (measured as the slope index of inequality) was virtually constant throughout the period: around 54 excess new cases per 100,000 population in the countries with the lowest human development versus those with the highest human development; the relative inequality gradient (measured as the health inequality concentration index) grew even more steeply (shifting from –0.20 to –0.24 between 2000 and 2013): 40% of the regional tuberculosis incidence burden in 2013 was concentrated in the quintile of countries with the lowest human development (). Similarly, recent studies using double stratification have documented the presence of profound educational and gender inequalities in the risk of death () and the burden of blindness () in the countries of the Region.

      More eloquent still is the available evidence on health inequalities within countries, based on microdata from population surveys. The distinguished International Center for Equity in Health of the Federal University of Pelotas in Brazil—a new PAHO/WHO Collaborating Center on Equity in Health—has produced a detailed study that, using data from demographic and health surveys (DHS) and multiple indicator cluster surveys (MICS), systematically documents the magnitude and extent of social inequalities in reproductive, maternal, newborn, infant, child, and adolescent health in many of the countries in the Region that have these surveys for the MDG window. These unjust inequalities in health outcomes, health coverage, and access to health services and programs, are reproduced in inequality gradients in income and wealth, access to education, and the urban-rural, male-female, and geographic dichotomies (). On a more positive note, this study also notes the gradual progress toward universal maternal and child health care observed in some countries, which have managed to reduce extreme absolute inequalities among social groups. Another study, conducted in 14 Latin American countries, documented the presence of profound sociogeographic inequalities in the distribution of ophthalmologists and underscored the critical implications of redistributing human resources for the gradual achievement of universal health ().

      The persistence of inequities and inequalities in the Region

      The Region of the Americas—and Latin America and the Caribbean in particular—continues to have the dubious distinction of being one of the regions of the world with the greatest social and health inequities (), especially in terms of inequality in income distribution (the starting point for the construction of the imaginary group on regional inequality). The social, economic, and health inequalities observed and felt in the streets and among the peoples of our Region tend to be the product of something more deeply rooted and, therefore, less evident: policies, laws, and regulations whose design and implementation reflect the persistent inequality of access to power in our countries.

      In an article published in 2006, Navarro et al. () noted the scarcity of scientific research on the connection between political power, health policy, and people’s health. In order to bridge this knowledge gap to some extent, these authors developed and tested a model that linked political and power resources with two types of public policies (labor market policies and government welfare policies) and their effects on income inequality and mortality levels in the majority of the Organisation for Economic Co-operation and Development (OECD) countries from 1950 to 1998. The countries studied were grouped by the political tradition that had governed them for the longest time during the period in question.

      Some of the conclusions of this study reinforce the idea of the connection between political contexts and certain health outcomes: the duration of governments headed by pro redistribution parties in the period 1950–1998 played an important role in reducing income inequality and infant mortality in the OECD countries analyzed ().

      The Navarro et al. findings serve as a frame of reference for the Region’s experience in from 2000 to 2010 and the fight against poverty and its relation to the political context at that time. Contrary to the situation in the 1990s, the 2000s were characterized by economic growth, coupled with a reduction in poverty and inequality in the vast majority of countries in the Region (). While the causes of the decline in poverty and inequality in the 2000s following their increase in the 1990s are still a matter of debate, the majority of these causes can be linked to high levels of economic growth, accompanied by the growth of employment and job earnings, or with a change in the political paradigm (expressed in a greater proclivity for public policies with a redistributive impact) or both. (). In any case, there is recognition of the significant role of public interventions in social and labor policy, which need further strengthening, and the reversal of certain pro-market reforms in some countries of the Region. The recent experience in Brazil exemplifies this: some estimates indicate that around 17% of the direct decline in income inequality in that country between 2001 and 2011 was due to conditional transfer programs— specifically the Bolsa Familia and Beneficio da Prestação Continuada programs; 19% to contribution- and non-contribution-based pensions; and 58% to the growth of job earnings ().

      In fact, “politics are important in designing, creating, and guaranteeing the sustainability of legitimate institutions and adopting public policies that work to the benefit of all citizens” (). However, the extreme inequality that characterizes the Region can alter the policy-making process, even in democratic contexts in countries where pro-redistribution parties are in power, for it often translates into in imbalances in the way in which the power to influence the political process is distributed in a society. As a result, the real potential of those who lack that power to overcome poverty and exclusion and thus enjoy decent and satisfactory living conditions, including robust health, will be diminished. A study that explores access to justice and the right to health in Brazil from the standpoint of equity in health is useful for exemplifying how the aforementioned asymmetry works in practice. At the time of publication (2009), the author of this study warned about the potentially negative impact of Brazil’s litigation model on equity in health:

      The model is characterized by the prevalence of individual lawsuits requesting curative care (often medicines) and a high success rate for litigants. These two elements are largely the consequence of the way in which Brazilian judges have interpreted the enjoyment of the right to health recognized in Articles 6 and 196 of Brazil’s Constitution—that is, as the right of individuals to meet all their health needs with the most advanced treatments available, regardless of cost. Since resources are always scarce in relation to the health needs of the population as a whole, this interpretation can only be sustained at the expense of universality (…). Individuals and (less often) groups that can resort to the courts and exercise this right are therefore privileged over the rest of the population. This is potentially prejudicial to equity in health, because privileging litigants over the rest of the population is not based on any concept of need or justice, but rather, on their ability to resort to the courts, which only a minority of citizens can do ().

      Policy-making involves the discussion, approval, and implementation of public policies. It can be understood as a negotiating or transactional process among stakeholders that unfolds in both formal and informal settings. When this process occurs in contexts of profound inequalities, the circumstances, realities, and agendas of the elites—the privileged stakeholders who hold all the power to influence the political process—tend to be reflected in the resulting policies that govern our societies, which reinforces the culture of privilege that prevails in our Region (). As the Economic Commission for Latin America and the Caribbean (ECLAC) points out, reducing the entrenched social inequalities in the Region urgently requires a “shift from a culture of privilege to a culture of equality” ().

      The elites use various means to influence the political process in their favor. These range from practices that are not illegal but are a topic of growing concern and debate, such as the lack of transparency in lobbying, the private funding of electoral campaigns or political advertising, to mechanisms that are undesirable, such as “revolving doors” and the concentration of media ownership (which facilitates the dissemination of certain ideas or beliefs and stifles others that oppose the agendas of the elites), or are frankly illegal, such as threats and assaults against journalists, patronage (where public employment and the delivery of public services are considered an exchange of favors), political cronyism, or corruption ().

      In any case, the Gordian knot of the issue lies in the fact that the elites and their networks, with their ideas and resources, can be synonymous with forces having great potential to shape the conditions for generating and appropriating the economic surplus in their favor and slanting the workings of government institutions against the public interest. In extreme cases, the elites can come to have a permanent influence on the different branches of government, even when there is a change in the head of the executive branch and political party represented. For example, the elites can exacerbate or take advantage of imbalances in the customary systems of checks and balances among branches of government, which exist to maintain the health of democracy, or of regulatory deficiencies or omissions in key areas. In this regard, Schneider () states that while judicial systems in the Region have become more independent and powerful with democratization, the elites have also been quick to exploit for their own benefit the prerogatives granted to these systems ().

      Thus, the influence of the elites and their consequent co-opting of policies (for example, progressive taxation or policies that apply the principles of social justice to health policies) are not simply structural obstacles to combatting inequities but a violation of the basic precepts of democracy, debilitating its institutions and corrupting policy-making in general.

      Today, given the sustainable development scenario promoted in the 2030 Agenda, PAHO has identified a key role in rendering policy-making more equitable in furtherance of the universal right to health at all stages of life. First, it must continue producing and disseminating specific analyses and evidence related to the social determinants of health—that is, on the close correlation between certain characteristics of the broader political, economic, and social context (structural determinants) and the social conditions of various population groups (intermediate determinants), the interaction between these groups and their physical and mental health status, and the distributive inequality imposed by the social determinants on the rest of society. These studies should reflect the magnitude of the changes in the paradigms of analysis and practical intervention, which are key to reducing health inequities.

      It will also be essential to ensure that that evidence is reflected in the recommendations on public health policies (including those related to health service access, which is one of the channels for translating socioeconomic conditions into health conditions) and on social and economic policies, broadly speaking. Moreover, guaranteeing that health is not just the privilege of the few in the Region also implies the need to facilitate technical cooperation for generating political advocacy to further social equity in health and the search for the common good.

      No one left behind…? How to make good on our promise

      Notwithstanding its undeniable and timely emphasis on equity, the 2030 Agenda and its Sustainable Development Goals (SDGs) do not have explicit targets or specific indicators for the reduction of social inequities in health or progress toward equity in health, beyond recommending greater availability of data disaggregated by the variables that produce social stratification. We must build institutional capacity to measure, analyze, monitor, and communicate social inequalities in health; to manage statistics, data, and evidence honestly and responsibly; to inform policy-making; and to engender political advocacy to further equity in health throughout the life course. All of this is essential for creating and strengthening national capacity to make good on the promise that no one will be left behind on the road to sustainable development by the year 2030.

      A recent and still unresolved debate on target setting for maternal mortality in the SDGs, published in The Lancet (), offers an eloquent example of the need for serious reflection on how to report on the impact of the 2030 Agenda on equity in health. SDG target 3.1 calls for reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Although it has yet to be determined how this target can be incorporated at the national level, one proposal (Jolivet et al.) is to convert the global target to a relative national target equivalent to a two-thirds reduction in maternal mortality between 2015 and 2030. The other proposal (Kassebaum et al.) is to convert the global target to an analogous absolute national target—that is, to reduce maternal mortality to less than 70 per 100,000 live births by 2030. Figure 2 illustrates the potential distributive impact of maternal mortality between 2015 and 2030 on the social gradient, defined by income per capita quintiles among all the countries in the world, under these two proposals.

      Figure 2. Maternal mortality worldwide by 2015 and 2030 income quintiles, according to two types of SDG target

      At the conclusion of the MDG period (2015), the risk of maternal death was distributed very unequally among the countries of the world, according to the distribution of their income per capita (deflated and adjusted by purchasing power): there were 610 excess maternal deaths (slope index of inequality) along the length of the income gradient among the countries and an absolute gap of 436 excess maternal deaths in the poorest quintile of countries with respect to the wealthiest quintile (in other words, the maternal mortality ratio in the poorest quintile was 46 times higher than that of the wealthiest quintile: the relative gap). And this was in 2015 (top histogram). Again, these women are the people we have left behind. Under the figure is the distribution of maternal deaths established for the year 2030 at the end of the SDG period, according to the two types of target 3.1 proposals: Jolivet’s relative target (middle histogram) and the Kassebaum’s absolute target (bottom histogram), as well as the magnitude of the reduction in absolute and relative inequality, the gap, and the gradient associated with each scenario—that is, the intensity of potential fulfillment of the promise that no one will be left behind.

      This exploratory prospective analysis yields a message of the greatest importance for the success of the 2030 Agenda: only through a systematic analysis of unjust and avoidable social inequalities in health will it be possible to visualize who we are leaving behind; this implies building institutional capacity to study the distributive equity of health gains (in terms of access and outcomes) in socially determined population groups, as well as quantifying the magnitude of social inequality in health through standardized composite metrics over time and throughout the life course. Moreover, only by monitoring inequalities will it be possible to verify the impact of pro equity policies and progress toward keeping the promise that no one will be left behind. This requirement of reporting on the progress toward equity in health was clearly anticipated in 2008 in the final report of the WHO Commission on the Social Determinants of Health, whose third general recommendation invokes the need for evidence: without it, the call for equity and social justice will be reduced to mere rhetoric. Despite the complexity of a regional scenario historically marked by profound inequities, the peoples of the Americas have been taking firm and determined steps toward reducing poverty and social exclusion at the dawn of the new millennium; the primacy of the principle of equity, expressed in the commitment to ensuring that no one is left behind on the road to sustainable development by 2030, should provide reasons to build, with optimism and determination, the fairer, more inclusive, equitable, and cohesive societies that the Region needs for sustainability and health.

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      18. Telles P. Brazil: poverty and inequality. Where to next? Brasília: OXFAM; 2013. Available from:http://csnbricsam.org/wp-content/uploads/2014/05/FULL-REPORT-Brazil-Poverty-and-Inequality.pdf..

      19. Payne Zovatto G, Mateo Díaz M. La política importa: democracia y desarrollo en América Latina.Washington, D.C.: Inter-American Development Bank; 2005.

      20. Motta Ferraz OL. The right to health in the courts of Brazil: worsening health inequities? Health and Human Rights Journal 2009;11:2.

      21. Itriago D. Wielding influence, building inequality: capture of tax policies in Latin America and the Caribbean. Development 2016;59(1–2):151–157.

      22. Comisión Económica para América Latina y el Caribe. La matriz de la desigualdad social en América Latina. I Reunión de la Mesa Directiva de la Conferencia Regional sobre Desarrollo Social de América Latina y el Caribe. Santo Domingo, 1 November 2016.

      23. Schneider BR. Hierarchical capitalism in Latin America: business, labor, and the challenges of equitable development. New York: Cambridge University Press; 2013.

      24. Boldosser-Boesch A, Brun M, Carvajal L, Chou D, de Bernis L, Fogg K, et al. Setting maternal mortality targets for the SDGs [letter]. The Lancet 2017;18(389):696–697; also Kassebaum NJ, Lozano R, Lim SS, Murray CJ. Setting maternal mortality targets for the SDGs [authors’ reply]. The Lancet 2017;18(389):697–698.

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      Reference/Note:

      National and international migration

      • Introduction
      • Context
      • Areas of Concern for Migrant Health
      • Policy Response
      • The Future of Migrant Health in the Americas
      • References
      • Full Article
      Page 1 of 6

      Introduction

      According to the International Organization for Migration (IOM), a migrant is a “person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (a) the person’s legal status; (b) whether the movement is voluntary or involuntary; (c) what the causes for the movement are; or (d) what the length of the stay is” (). The term encompasses a wide array of categories. This chapter is oriented to present the health challenges faced by migrants and their host communities, emphasizing the special challenges faced by irregular and forced migrants who, because of their situation, are in conditions of high vulnerability ().

      Migrations are often prompted by, and in turn can lead to, many situations of insecurity. Economic deprivation, disease outbreaks, food insecurity, environmental hazards, political and religious persecution, family separation, and gender, sex, and ethnic discrimination constitute several of the factors that may give rise to massive migration flows and affect the health of migrants during their migration path. These factors often place migrants at higher risk for occupational injuries, violence (including sexual violence), drug abuse, mental health disorders, tuberculosis, HIV/AIDS, and other infectious diseases (). In addition, there may be barriers to accessing health services, including restrictive policies and laws, high costs, language and cultural differences, stigma, and discrimination.

      The social, economic, environmental, and political context within which migration takes place in the Americas is dynamic, presenting new challenges and opportunities in the health field that can help facilitate a dignified and safe migration process. This section examines health determinants and conditions of migration and health matters associated with migration in the Americas. It also examines global, regional, and national policy responses and proposes a path for the future to ensure the health of migrants and their host communities in the Americas.

      Context

      Migration trends in the Americas

      Migration is not a new phenomenon, despite its seemingly sudden rise to global attention. The movement of people, whether within country borders or across international borders, has been occurring for centuries and has recently become a major feature of globalization.

      Figure 1. Total male and female international migrant stock in Latin America and the Caribbean (LAC) and Northern America in 2015 ()

      In the Americas, the number of people who migrated across international borders surged by 36% in the last 15 years, to reach 63.7 million in 2015; of those, 808,000 were defined as refugees (see Figure 1). About 15.2% of the population of Northern America (Canada and the United States) and 1.5% of the population of Latin America and the Caribbean (LAC) are international migrants. Approximately 39% of this population in LAC and 26% in Northern America are 29 years old or younger and about 51% are females (see population pyramids in Figure 2). Forced migrants within country borders account for an estimated 7.1 million people, of whom 6.9 million are in Colombia (). Most LAC members are primary sources of emigration to northern high-income countries in America and Europe. Table 1 lists the top 10 emigration countries in LAC. Despite these flows from lower- to higher-income countries, migration between low- and medium-income countries and from higher- to lower-income countries has increased recently (). In addition, LAC has been experiencing a significant increase in extraregional irregular migrants. For example, according to IOM, Costa Rica experienced an inflow of over 5,600 irregular migrants between April and August 2016, primarily from Haiti and African and Asian countries ().

      Table 1. Top 10 LAC countries for emigration in 2015 ()

      Home country Number of people that emigrated Proportion of people that emigrated from the total home country population
      Mexico 12,339,062 9.7%
      Colombia 2,638,852 5.5%
      Puerto Rico 1,768,384 48.0%
      Brazil 1,544,024 7.4%
      El Salvador 1,436,158 23.4%
      Cuba 1,426,380 12.5%
      Peru 1,409,676 4.5%
      Dominican Republic 1,304,493 12.4%
      Haiti 1,195,240 11.2%
      Ecuador 1,101,923 6.8%

      According to IOM (), the Americas are characterized by four migration-related trends: a steady flow of returnees due to economic crises and inhospitable social settings in high-income countries; the receipt of remittances from migrants in high-income countries as an important source of income for several LAC countries; the trafficking in persons and smuggling of migrants; and the contribution of LAC communities in the United States, Canada, and Europe to the development of cultural, economic, and social ties with their countries and communities of origin.

      Figure 2. International migrant stock by age and sex in LAC and Northern America in 2015 ()

      The right to health of migrants and other related human rights in the Americas

      The Universal Declaration of Human Rights proclaims that “all human beings are born free and equal in dignity and rights,” that every person is entitled to all human rights and fundamental freedoms, and that all persons “have the right to freedom of movement and residence within the borders of each State [and] the right to leave any country, including his own, and to return to his country” (). The Constitution of the World Health Organization (WHO) also clearly supports the right to health: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (). This right applies to all persons, wherever they are and regardless of their migration status.

      According to the Office of the United Nations High Commissioner for Human Rights, there are 27 international legal instruments relevant to migration and human rights (). In particular, the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families of 1990 () has been increasingly recognized and prominently reflected in the international agenda. As States Parties of the Convention, 18 governments of the Americas have acknowledged the need to integrate health needs and the vulnerability of migrant workers into their national plans, policies, and strategies. Accordingly, these governments have demonstrated a heightened appreciation for the development of health programs and policies that address health inequities and improve access to health facilities, goods, and services. It is important to note that migrant destination countries such as Brazil, Canada, the Dominican Republic, and the United States have yet to take action on the Convention.

      In the Americas, the 59th Session of the Executive Committee of PAHO in 1968 began to discuss the relationship between health and international human rights instruments in the context of the technical cooperation that PAHO provides to its Member States (). In 2007, ministers and secretaries of health of the Americas underscored their commitment to the aforementioned international principle in the Health Agenda for the Americas (2008–2017). In doing so, they placed human rights among this instrument’s principles and values and reconfirmed the importance of ensuring the highest attainable standard of health by stating, “In order to make this right a reality, the countries should work toward achieving universality, access, integrity, quality and inclusion in health systems that are available for individuals, families, and communities” (). In 2010, the 50th Directing Council of PAHO agreed to work to improve access to health care for groups in conditions of vulnerability, including migrants, by promoting and monitoring compliance with international human rights treaties and standards ().

      Social determinants of health of migrants in the Americas

      Migration is regarded as a social determinant of health since the health of migrants is determined primarily by the conditions along the migration path. As illustrated in Figure 3, the health of migrants can vary according to personal characteristics, individual and relational factors, social and community influences, living conditions, and general socioeconomic, cultural, and environmental conditions (). In particular, irregular and forced migrants may travel to destination communities in precarious conditions. For example, many irregular migrants from Central America ride atop moving cargo trains colloquially known as La Bestia, or the beast, on their journey across Mexico to the United States. Along the trip they face physical dangers including amputation and death. In addition, they are subject to extortion and violence at the hands of gangs and organized-crime groups ().

      Figure 3. Risk factors associated with migration at the individual, relational, community, and social levels of the ecological model ()

      Migrants work in some of the riskiest industries in their destination communities, including agriculture, forestry, fishing, and construction. These types of work have higher rates of injury and fatality compared with other sectors. Migrant farmworkers are also more exposed to pesticides and their associated health risks. Moreover, their housing is associated with unsafe drinking water; crowding; substandard and unsafe heating, cooking, and electrical systems; inadequate sanitation; dilapidated structures; and food insecurity. For example, it is estimated that more than half of the migrant farmworker households in the United States suffer from food insecurity due to their limited access to transportation, food storage, and cooking facilities ().

      Migration can also affect the health and well-being of family members who stay in the communities of origin by impacting on remittances and “brain drain” (i.e., the migration of educated workers to higher paying countries). On the one hand, remittances can improve the economic conditions of remittance-receiving households in communities of origin and can have a positive effect on their health and well-being. Households receiving remittances have improved human development outcomes including better access to health services, less crime, and better education. For example, a study in Nicaragua showed that about 48% of remittances are used to pay for health services, 27% for home improvement, 15% for education, and 10% for savings (). In 2014, there was an inward remittance flow of US$ 63.6 billion into LAC countries, with the top remittance recipients being Haiti (22.7% of gross domestic product, or GDP), Honduras (17.4% of GDP), EI Salvador (16.8% of GDP), and Jamaica (16.3% of GDP). On the other hand, family separation may lead to negative effects regarding health and well-being, including psychological trauma, material hardship, residential instability, and family dissolution. Moreover, remittances may generate tensions and inequalities between remittance-receiving households and households that do not receive them (). In addition, communities of origin can find themselves at risk of a “brain drain” of talent, depriving them of trained workers in key sectors of their economy ().

      Migrants’ access to health services

      Migrants, and in particular irregular and forced migrants, often have limited access to appropriate health services and financial protection for health. WHO reports that globally, migrant health needs are not addressed consistently and access to health services in recipient countries remains highly variable ().

      Factors associated with health policies and the organization of health systems can constitute formal barriers to accessing health services. These include legal restrictions on entitlements to health services and financial barriers to irregular and forced migrants. In several countries in the Americas, only emergency and limited private charity health services are available to these migrants. For example, exclusionary policies and treatment resulted in limited health care service accessibility for male Latino migrant workers in North Carolina, U.S.A. (). User fees can also be seen as a formal barrier, creating inequality in access due to migrants’ limited financial means.

      Inadequate health literacy, language differences, sociocultural factors, stigma, and perceptions of the health system may constitute informal barriers to access to health services (). Health beliefs and health-seeking behavior of migrant groups may be different from the host communities because of their needs and differences in social norms, culture, and organization of health systems in communities of origin. For example, a study of a shelter in Monterrey, Mexico, with migrants primarily from Central America, shows that migrants avoided public health services due to the need to work in order to survive and the constant fear of being traced (). In these situations, health education is often regarded as a solution that can improve health literacy and help migrants acquire the skills they need to maneuver in their new health system. Health education programs for migrant groups need to be appropriately targeted to reach them more effectively (). Limited proficiency in the host community language can also present a significant obstacle to accessing health services. For example, an analysis of U.S. Behavioral Risk Factor Surveillance System data from 2003 and 2005 showed that Spanish-speaking Hispanics reported far worse access to care than English-speaking Hispanics (). To the extent possible, patient information on health issues should be provided in whatever languages are necessary to reach potential users of health care services. In addition, health service providers should be trained on cultural sensitivity and appropriateness. Furthermore, limited understanding of the patient’s social norms and culture may also present an obstacle. For this reason, the role of the translator should include cultural mediation. Migrants may also be reluctant to make use of services because of stigma or anxieties about reactions within their own community. Mental health, for instance, is often stigmatized in migrant communities. For example, the perceived discrimination and the experience of humiliation have contributed to poor mental health and limited access to health services among Haitian migrants in the Dominican Republic (). Reproductive health, sexuality, pregnancy, and childbirth are sensitive topics that people may find difficult to discuss with a stranger. Often, one of the elements that helps overcome informal barriers to accessing health services is trust. Clients need to be confident that they will be treated with respect and receive appropriate and relevant services.

      Areas of concern for migrant health

      Health along international borders

      International border areas are geographical spaces in which residents, regardless of which country they live in, share risks and protective factors that generate a health profile that is often different from that of populations in the rest of their country’s national territory (). Border communities can also be impacted by forced migratory movements including people displaced by war, sudden environmental events, violence, and political or financial crises (). Border population groups in conditions of vulnerability may also include indigenous groups whose conception of the land may give them a different recognition of country borders from that of the dominant population (). In other cases, border areas are poles of economic development that generate disorganized urban growth where basic services are limited (). Moreover, border communities tend to be distant from the national political center of the country and therefore have little influence on decision-making and the allocation of resources ().

      The nature of cross-border political cooperation that exists can influence the health situation of the border population, and at the same time, it can determine how the countries and their respective border populations organize themselves to respond jointly to their health needs. For border areas in which the relationship is one of merely coexistence or even confrontation between countries, looking after health issues may foster understanding between them. For example, in 2012 Paraguay was politically suspended from regional country integration systems but continued participating in health projects. This shows that joint work on health activities can overcome political barriers, serving to tie neighboring nations together (). For border areas in which the relationship is one of interdependence between countries, there is a mutual interest in improving health conditions. However, in several cases, such interdependence may be asymmetrical. For example, there has been a financial asymmetry in environmental health collaboration between the United States and Mexico along the border. Most funds available for border programs have been provided by the U.S. Environmental Protection Agency, enabling this agency to have more control over the program agenda (). For borders where relationships are more integrated, the countries and their border communities make maximum use of existing resources (); examples include portable health insurance for border communities between Uruguay and Brazil (), health services shared between Ecuador and Peru (), and joint delivery of emergency health services between Chile and Argentina ().

      Health interventions in border areas may create tensions between the national government and its border communities. On the one hand, border communities feel a need to resolve concrete issues in a space that is influenced by—and to some degree shared with—another country (). On the other hand, national governments have a constitutional mandate to safeguard national sovereignty (). Therefore, striking a balance between national and local interests is crucial when designing and implementing health interventions in border communities ().

      Defining health priorities is one of the greatest challenges of cross-border cooperation since it must respond to the needs and assets of two or more countries. One criterion may be tackling health issues that are causing or may cause conflict between neighboring countries, such as the origin of an infectious disease in one country that could affect people, productivity, or trade in a neighboring country, or the use of the health services by residents of one country in a neighboring country, incurring additional costs to the latter’s health system (). Another criterion may be managing health issues that cannot be resolved without a binational approach. This frequently applies to vector-borne diseases and environmental contamination. A third criterion may be the interest of academic researchers, since border populations can become unique public health laboratories ().

      Structures and mechanisms to address border health issues may be official or unofficial. For the former, the predominant actors are national and subnational governments including local governments in the countries that share the border (). Generally, the higher the public institutional level of participation, the better organized the structures or mechanisms, and the more long-term oriented their objectives are (, , ). However, they may also be more political, be slower to act, be less sensitive to the perceived needs and assets of border communities, and have more problems addressing issues on which the countries do not agree (). The opposite is seen when unofficial structures and mechanisms such as academic, private, or community-based institutions play the central role (, ). They often are more technical and have a more limited sphere of work and a shorter-term vision. They also tend to be transient or with limited sustainability. Many border areas address health issues through both mechanisms. For example, health issues in the United States—Mexico border area are addressed through formal national and state-level structures through the United States—Mexico Border Health Commission or more informal structures through binational health councils that are part of sister city arrangements ().

      Depending on their objectives, the structures and mechanisms can be temporary or permanent. Countries in the Americas have developed structures and mechanisms to attend to border health issues that encompass the types mentioned, from short-term specific projects, to medium-scope programs, to permanent binational commissions (). The latter have been developed primarily for cases in which the needs of border communities have been made a national priority and placed at the highest level of the political agenda.

      Humanitarian health assistance

      Globally, about 201 million people were affected by disasters and conflicts in 2014, of which 141 million endured sudden environmental events and 60 million were forcibly displaced by violence (). In the Americas, the Inter-Agency Standing Committee (IASC) () estimates indicate that Haiti, Colombia, and Guatemala have the highest risks for humanitarian crises and disasters. According to the Office of the United Nations High Commissioner for Refugees (UNHCR) (), there was a five-fold increase in asylum-seekers from El Salvador, Guatemala, and Honduras, primarily of unaccompanied children, from 2012 through 2015. In addition, even as it strives to resolve decades of conflict, Colombia reported about 6.9 million internally displaced people.

      In 2016, PAHO reported giving critical support to several Member States that have faced unexpected migrant flows, including 171,000 Venezuelan migrants in Colombia between October 2015 and May 2016; over 5,000 Cuban nationals who traveled through Ecuador, apparently intending to continue northward towards the United States but instead found themselves stranded in Central America in late 2015; and approximately 100,000 Haitians who were repatriated in 2015 from the Dominican Republic ().

      A special concern during humanitarian crises is the need for adequate basic health services and sanitation in shelters and settlements. For example, in Colombia, even though 75% of the internally displaced people were affiliated with the national social security program in 2014, only 32% had access to health services. (Of those, 38% were males and 62% were females.) Barriers to health services include limited infrastructure, technology, and human resources in rural areas (). The low vaccination rate among Venezuelan migrants in Colombia also caused concern about a potential change in the host population’s health profile. Another major health concern was the increased risk of cholera outbreaks among deported migrants in the Haiti–Dominican Republic border area ().

      Finally, the impacts of climate change—primarily on Small Island Developing States such as the ones in the Caribbean, and on indigenous communities–have led to discussions about decision-making regarding the potential need to migrate (). Climate-induced migration may cause forced displacement from rural to urban areas and from one country to another. The range and extent of health risks associated with future climate­related population movements cannot be clearly foreseen. However, the evidence of movements of people due to similar situations indicates that health risks will predominate over health benefits ().

      Migrant workers’ health

      Current levels of human mobility have created serious challenges for migrant workers, becoming a political priority at national and supranational levels. Despite several migrant-specific instruments adopted by the International Labour Organization (ILO) during the past seven decades (Conventions No. 97, 86, and 143, and Recommendation No. 151) (), the dignity and rights of migrant workers are threatened because of limited national labor protection regulations and enforcement.

      In 2014, the Fair Migration Agenda was adopted after the UN General Assembly High-Level Dialogue on International Migration and Development (). The Agenda seeks to make migration a choice and not a need by pursuing decent work opportunities in the countries of origin. It also aims to ensure fair recruitment and equal treatment of migrant workers by promoting bilateral agreements for well-regulated and fair migration between countries, countering unacceptable situations, and contributing to a strengthening of the multilateral rights-based agenda on migration.

      According to the ILO (), in 2013 there were 150.3 million migrant workers worldwide (55.7% males and 44.3% females). They represented 4.4% of the global work force. The majority of international migrant workers were in high-income countries, about 24.7% in North America and only 2.9% in LAC, accounting for 20.2% and 1.4% of the work force in North America and LAC, respectively. They were concentrated in certain economic sectors, primarily in services (71.1%), industries including manufacturing and construction (17.8%), and agriculture (11.1%). Domestic service migrant workers represented 7.7% of all international migrant workers (with 73.4% of domestic service migrant workers being females) and were concentrated in high-income countries.

      ILO estimates that in 2015 migrant workers sent US$ 601 billion in remittances to their home countries, evidence that their work is a driver for economic development in the countries of origin. At the same time, migrant workers fill labor gaps in countries of destination. Nonetheless, the unequal distribution of types of work, income, benefits, and job opportunities has raised questions of social justice, sustainable development, and health equity ().

      Based on the impetus created by the adoption of the 2030 Agenda for Sustainable Development, ILO has developed several instruments for addressing migrant workers’ health rights and equity. For example, the gender equality in labor migration law, policy, and management tool kit () was created to support fair immigration and respect for fundamental rights of women migrant workers, seeking to offer them real opportunities for decent and healthy work.

      It is vital that the international community acknowledges the shared global responsibility of developing collective and inclusive action, particularly in the context of the 2030 Agenda for Sustainable Development. Effective actions may include creating more productive and decent work in countries of origin; establishing more dignified, regular, and safer migration processes that meet real labor market needs and facilitate preservation of family units; and placing human rights, including health and labor rights, at the core of all interventions.

      Communicable diseases

      Communicable diseases can significantly affect the health and well-being of migrants, and have public health implications due to the potential importation of transmissible pathogens. In the Americas, the spectrum of communicable diseases in migrants may range from diseases that require acute recognition and management (such as malaria) to chronic illnesses with significant public health concerns (such as tuberculosis and HIV/AIDS). The recognition and timely management of infectious diseases in migrants requires knowledge of the geographic context, modes of transmission, and clinical presentation of a wide variety of infectious agents. Many of these infections may be unfamiliar to health care providers in destination communities.

      Malaria

      In South America, small-scale gold mining draws people to the Guiana Shield from different countries, known in Brazil as garimpeiros. The Guiana Shield comprises Guyana, Suriname, French Guiana, and parts of Colombia, Brazil, and Venezuela. In 2014, miners in this region represented at least 13% of all malaria cases in the Americas. It is highly likely that the number is even higher due to underreporting, since many miners live solitary lives and try to avoid health facilities. Mining also prompts related movements within country borders, leading to malaria outbreaks. For example, malaria increased from around 21,000 cases in 2010 to over 52,000 in 2014 in the Sifontes municipality of Bolivar State in Venezuela due to an increase in the mining population coming from other parts of the country ().

      The importation of cases is a major factor that can inhibit progress being made in the control of outbreaks and can defer elimination of the disease. For example, the district of Candelaria in Campeche State, Mexico, near the Guatemalan border, reported an outbreak of malaria in 2014 although it had had no cases in previous years. A change in migratory patterns was suggested as a possible reason for this outbreak. Malaria in Dajabon in the northwest corner of the Dominican Republic has also been attributed to mobility across the international border between the Dominican Republic and Haiti. This location is known for its binational market that attracts residents from both countries. Since 2005, approximately 2,000 Haitians have entered the Dominican Republic twice weekly to buy and sell their goods. The number of malaria cases reported subsequently increased from approximately 100 in 2005 to about 1,000 in 2007. This number has decreased in recent years (17 cases in 2014) due to focused interventions ().

      While the preceding examples highlight how migration has increased the risk of malaria in the Americas, success stories are also present in the region. For example, Suriname’s Ministry of Health has succeeded in reducing the number of malaria cases by improving diagnosis and treatment to miners through trained individuals working in mining areas. Another example is the success story of Costa Rica. Since 2000, the Ministry of Health, in coordination with the private sector and the national health services network, has prevented the introduction of imported cases of malaria in Huetar Atlantica and Huetar Norte despite agricultural developments in these areas that led to an increased risk of malaria due to vector habitat changes and an inflow of migrants seeking work.

      Tuberculosis

      Migrants’ risk for becoming infected with or developing active tuberculosis (TB) depends on the TB incidence in their community of origin; living and working conditions in their communities of destination, including their access to health services; whether they have been in contact with an infectious case (including the level of infectiousness and how long they breathed the same air); and the way they travel to the destination countries (with the risk of infection being higher in poorly ventilated spaces). People who live in communities characterized by low levels of education, poor nutrition, inadequate or overcrowded housing, and with poor access to preventive and curative medical services are the most vulnerable to infection. Specifically, recently arrived migrants from endemic countries who often congregate in deprived communities within wealthy cities constitute high-risk groups. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once in treatment, family support and migrant-sensitive health providers can become key factors facilitating adherence ().

      In the Americas, migrant groups are associated with an increase in TB prevalence in low-risk countries. For example, the increase in TB incidence in Costa Rica between 2009 and 2011 was associated, among other factors, with the influx of Nicaraguan migrants. The increase in TB incidence in Chile was also associated with migrants from endemic countries ().

      At the national level, migration has also influenced the incidence of TB in destination countries outside of the Americas. For example, Spain has one of the highest incidence rates of TB in Europe with approximately 20 cases annually per 100,000 persons, primarily international migrants. In particular, in Barcelona, the percentage of foreigners with TB increased from 5% to 32% with an incidence rate greater than 100 cases per 100,000 persons per year between 1999 and 2000 (). Studies conducted between 1998 and 2013 revealed that multidrug- resistant TB was 2.5 to 4.0 times more frequent in immigrant populations from Latin America, Eastern Europe, Africa, and Asia than in the native Spanish population. Multidrug resistant TB was diagnosed in 7.8% of immigrant population cases but in only 3.8% of native cases (). Moreover, studies using Spanish national surveillance data between 2004 and 2009 reported that TB was often diagnosed in later stages in migrant populations due to their limited access to quality, migrant-sensitive health services (). About 60% of TB cases in migrants were diagnosed in hospitals and not in primary health care facilities.

      HIV/AIDS

      Migration can disrupt migrants’ access to HIV services. Barriers include lower and late access to testing and care and fear of discrimination and deportation (). For example, there are documented cases of Central American migrants having their HIV services disrupted when they travel through Mexico to the United States (). According to a cross-sectional study by Leyva-Flores et al. (), the prevalence of HIV among Central American migrants traveling through Mexico was 0.71% between 2009 and 2013 and peaked at 3.45% in the transvestite, transgender, and transsexual community, reflecting the concentrated epidemic in their countries of origin. In addition, it appears that there is a modest positive association between population mobility, measured by the net migration rate, and HIV prevalence in Central America and Mexico when socioeconomic cofactors are included by country (education, health, and income) (). Moreover, male migrants who stayed in border areas were more likely to engage in sex, and have unprotected sex, with female sex workers during their recent stay on the border compared with those in other contexts ().

      Mental health

      The mental health of migrants is frequently affected by changes in their lives that result from the process of migration itself, and varies according to how their experience in the new situation and cultural context evolves (). In particular, uncertainty about the future and the process of moving from one cultural setting to another can be stressful, with potentially negative impacts on mental health outcomes ().

      The conditions that create forced migration increase psychosocial stress on the individuals and families affected (). Migrants may be exposed to various stress factors in each phase of the migration path, and they experience different challenges during and after migration. These challenges could become risk factors for mental illness. For example, the reasons that cause or promote migration, such as a difficult economic and employment situation in the country of origin, the breakdown of social support, or possible trauma, as well as uncertainty about whether one will be accepted by the new host community or not and about the process of migration itself all have an impact on one’s mental health (). In the post-migration phase, other risk factors have been associated with mental disorders, such as the uncertainty about legal status, employment opportunities or lack thereof, loss of any preexisting social role, uncertainties about family and social support, and the difficulties of learning a new language and culture and adapting to these new norms ().

      Many studies have reported that the process of migration can lead to a whole spectrum of mental health disorders, for example, psychoses (), posttraumatic stress disorders (), depression (), and suicidal acts (). Multiple factors and complex interactions will determine post-migration adjustment and the outcome of migration. The evidence of mental health disorders among populations who migrate between or within LAC countries is limited. Only a few studies report an association between natural disasters and mental disorders in the subregion (). Other studies show an increase in psychological issues in migrant children and adults due to political repression in their countries of origin (). On the other hand, there is significant evidence of mental health disorders in people who migrated from LAC to North America ().

      While the aforementioned elements can have an impact on all migrants, some social groups may be exposed to additional risk factors that must be taken into account when considering possible psychosocial or mental disorders, in particular for women; children and adolescents; the elderly; lesbian, gay, bisexual, and transsexual (LGBT) people seeking asylum; indigenous populations; and people with mental disorders prior to migrating (). Preexisting mental health conditions can be intensified due to the same requirements of adaptation in short periods of time that many migrants without preexisting conditions experience ().

      The assessment of risk for mental health problems includes consideration of pre-migration exposures, stresses, and uncertainty during migration, and post-migration resettlement experiences that influence adaptation and health outcomes. It is important that cultural elements are taken into consideration when assessing physical health and more clearly when dealing with mental health issues by the health system in the host community (). Furthermore, the right to receive pharmacological or psychotherapeutic treatments has to be preserved. Some evidence has been reported of satisfaction of the mental health services among immigrants (), but more research on the effectiveness of these services in immigrant populations is needed. Clinicians need to be aware of the mental health needs of immigrants and the challenges of delivering appropriate care to them ().

      Violence

      Violence is an increasingly important driver of migration in LAC (). According to 2012 estimates (the most recent available), 18 of the 20 countries with the highest homicide rates in the world were located in LAC (see Figure 4 for the top 10). Also, the rate of 23 homicides per 100,000 population for the Region of the Americas was nearly four times the world average (6.2 per 100,000)—higher than the average for the “fragile and conflict-affected” countries as defined by the UN (). Preliminary 2015 data suggest that after the end of a gang truce in 2012, El Salvador may have surpassed Honduras as the most dangerous peacetime country in the world ().

      Figure 4. Countries with the highest homicide rates per 100,000 population, 2012 ()

      Violence associated with transnational organized crime and gang activity in the Central American “Northern Triangle” (El Salvador, Guatemala, and Honduras) and Mexico has created what the UNHCR calls a “protection crisis,” forcing thousands of women, men, and children to leave their home (). Asylum applications by Northern Triangle migrants in Belize, Costa Rica, Mexico, Nicaragua, and Panama rose by almost 1,200% between 2008 and 2014, and the number of families and unaccompanied minors migrating north from Central America through Mexico towards the United States has risen sharply (). Meanwhile, civil war in Colombia has created the largest internal forced migration in the world (an estimated 6.9 million) (), as well as a large diaspora of refugees in surrounding countries such as Ecuador ().

      Violence plays a particularly important role in female migration. A 2015 UNHCR study found that a majority of women interviewed after migrating north out of Central America and Mexico cited violence, including rape, assault, extortion, and death threats, as a primary motivation for leaving their communities; much of this violence was perpetrated by intimate partners, many of whom were involved in gang activity (). Often, women left after local authorities refused or were unable to provide protection. Conflict-related sexual violence has been a persistent feature of the armed conflict in Colombia, and an important reason why many women have been forced to leave their communities ().

      While many migrants leave home to escape violence, they often face heightened risk of physical and sexual violence during the journey itself and within destination communities. Women and families migrating north from Central America and Mexico report high levels of extortion, kidnapping, rape, death threats, and abandonment in life-threatening situations along the migratory travel route (). Research in Colombia has documented “pervasive exposure to violence” and vulnerability to physical harm in forced migrant settlements (). In the United States, migrant populations report high levels of certain types of violence, including sexual harassment and assault among women migrant farm workers (). In sum, violence not only drives much migration in the Region but is an important human rights and public health problem during all stages of migration and displacement, including within communities where migrants and displaced populations settle.

      Maternal and child health

      The Americas is home to 6.3 million migrant children, about one-fifth of the global total. Approximately 80% of them reside in three countries: the United States, Mexico, and Canada, with the United States hosting the largest number in the world, an estimated 3.7 million. An alarming concern is the percentage of children who migrated from Central America, where almost half of all migrants are younger than 18 years of age, compared with an estimated 8%, 15%, and 15% from North America, South America, and the Caribbean, respectively ().

      A distinct pattern in the Region is the number of children who have migrated on their own, many of them fleeing violence in their homes and communities, primarily from Colombia, El Salvador, Guatemala, Mexico, and Honduras (), and wanting to reunite with their families, many of whom are located in the United States ().

      Migrating children and adolescents face barriers to accessing adequate health services during the migration path (). Studies have shown that children residing in households with noncitizen parents have trouble accessing health care and thus experience worse health outcomes (). A study in Argentina reported that migrant women had poor prenatal care and newborns required more medical care compared with newborns born to native-born mothers (). Similar challenges have been cited for children of internal migrants. In a study examining child mortality associated with maternal migration in Haiti, researchers reported that children born to migrants moving from rural to urban areas or vice versa experienced higher mortality (). Other situations faced by child migrants include being detained at borders, being left behind by migrating parents, and being forcibly returned to their countries of origin ().

      Several countries are trying to improve access to health services for migrant children. For example, Guatemala is working with IOM on capacity- building for government officials to assist child migrants in transit, especially those who are unaccompanied or have been separated from their families (). In Brazil, policies have recently been adopted to assure equal access to coverage for all migrants including irregular migrants (). The increase in the number of unaccompanied and separated children who have been detained at the southern border of the United States () has led to increased cooperation between the United States and several Central American countries—led by El Salvador, Guatemala, and Honduras—in programs to reduce extreme violence and increase economic opportunities in countries of origin (). In order to make further improvements to health services for migrant children, it is necessary to better understand their specific health needs by collecting data disaggregated by socioeconomic status, geographic location, and migration status during the entire migration path ().

      Adolescent health

      Adolescents face unique challenges during their migration path because adolescence is a time of rapid physical, mental, emotional, and social development, during which the influence of parents, peers, the media, and school plays an important role in their life. This is also when they first develop the capacity to reproduce and when they begin to take progressive responsibility for their own health and development. Adolescents may be forced to move with their families, forced to migrate without their families to seek a better future somewhere else, or left behind by migrating parents to take care of younger siblings.

      On the one hand, migration can have positive results for adolescents, including increased opportunities for education and income. On the other hand, the potential increased health risks associated with separation from family, peers, school, and community requires careful consideration and response. There is growing evidence that the health and development of adolescents are profoundly affected by their relationships with these social settings. For example, studies in the English Caribbean countries and territories have documented associations between low levels of connectedness or emotional attachment with parents, peers, school, and community and increased risk of negative health outcomes and behaviors such as anxiety, depression, suicide ideation and attempts, unsafe sex, unplanned pregnancy, and substance use (). Studies also document the protective effect of high levels of connectedness on the emotional and physical well-being of adolescents (). With the interruption and separation from these social settings that comes with migration, it is critical that programs and services attempt to fill the gap and offer opportunities for adolescents to build meaningful relationships with peers, adults, and social institutions along their migration path.

      Noncommunicable diseases

      A number of studies have shown differences in the risk for noncommunicable diseases among different population groups of recent LAC migrants to the United States and between recent international migrants and populations born in the United States. For example, recent migrants from South America to the United States have a lower prevalence of diabetes and being overweight than the average United States–born population and a lower prevalence than recent migrants from Mexico, Central America, and the Caribbean, too. Moreover, there appears to be an increased morbidity and mortality burden among Latinos born in the United States compared with Latinos born elsewhere. The decline in health status of subsequent generations of Latinos can be attributed to negative acculturation and to adopting unhealthy behaviors (poor diet, smoking, alcohol consumption, substance abuse, and physical inactivity) that are more prevalent in the receiving communities to which the migrants moved (). Furthermore, conditions related to communities of origin appear to have a protective effect on cancers but not on obesity and diabetes. However, over time, the rates of most cancers tend to converge towards the rates seen in locally born residents ().

      Rural to urban mobility in low- and middle-income countries, such as the Andean countries, can also be detrimental to the health of migrants due to changes in dietary and physical activity patterns, enhancing the risks for cardiovascular diseases such as hypertension and obesity (). However, it appears that the impact of rural-to-urban migration on the cardiovascular risk profile is not uniform across different risk factors and can be further influenced by the age at which migration occurs (). Moreover, rural-to-urban migrants may have better access to health services than the populations who stay in rural areas ().

      Policy response

      The situation of migrants has gained recognition in and prominence on global agendas. In October 2013, the UN General Assembly adopted the Declaration of the High-Level Dialogue on International Migration and Development, which recognizes that human mobility is a key contributor to sustainable development. In September 2015, the UN General Assembly adopted the 2030 Agenda for Sustainable Development, recognizing “the positive contribution of migrants for inclusive growth and sustainable development.” A central reference to migration is made under Goal 10 (reduce inequality within and among countries), under which target 10.7 is a commitment to “facilitate orderly, safe, regular, and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies” (). Finally, in May 2016, the UN Secretary General presented his report, “In Safety and Dignity: Addressing Large Movements of Refugees and Migrants” (). The report focuses on ensuring at all times the human rights, safety, and dignity of refugees and migrants. It calls for the development of national inclusive policies (including health policies), seeking to bring migrants into the receiving society and to provide access to basic services, including health services. As a follow-up to the UN Secretary General’s report, the General Assembly held a high-level plenary meeting in September 2016 to address the topic of large movements of refugees and migrants. At the meeting, Member States adopted the New York Declaration for Refugees and Migrants (). The Declaration endorsed a set of commitments related to refugees and migrants including women at risk; children, especially those who are unaccompanied or separated from their families; members of ethnic and religious minorities; victims of violence; older persons; persons with disabilities; persons who are discriminated against on any basis; indigenous peoples; victims of human trafficking; and victims of exploitation and abuse in the context of the smuggling of migrants. Specifically, the Declaration endorsed among other commitments, the need to address the vulnerability to HIV and specific health care needs experienced by migrant populations.

      Specifically in health, the new WHO’s International Health Regulations of 2005 () were adopted “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” As of 2016, the status of all core capacities established in the International Health Regulations across PAHO Member States continues to be heterogeneous, with the lowest scores consistently registered in the Caribbean (). In 2008, the 61st World Health Assembly endorsed the WHO Resolution on the “Health of Migrants” (), and in 2016, the 69th World Health Assembly endorsed a report promoting the health of migrants () in support of migrant-sensitive health policies, information programs, and services.

      Heads of State in the Americas agreed to establish an inter-American program within the Organization of American States (OAS) at the Third Summit of the Americas held in April 2001 (), for promoting and protecting the human rights of all migrants, regardless of their immigration status. The OAS recognizes that, given the scope, prevalence, and significance of the current migratory phenomenon, virtually every state in the Americas has become a country of origin, transit, destination, or return for migrants, and as a direct result of this, migration has become a priority in the Region (). Specifically regarding the health of migrants, the 55th Directing Council of PAHO in 2016 () adopted the Regional Strategy for Universal Access to Health and Universal Health Coverage () as the overarching framework for health system actions to protect the health and well-being of migrants.

      At the national level, there are wide differences in the extent to which countries in the Americas have considered and implemented national migrant policies that include the health dimension. They range from free access to health services in the formal public system for all people in precarious economic conditions, including migrants, like in Argentina (), Brazil (), and El Salvador (), to ensuring health insurance coverage or health services in the public system only to migrants with legal residential status, like in the United States () and Canada (). The overall political climate in a country is an important factor that can help or hinder health systems in becoming more responsive to the needs of migrants (). The range of areas that need to be addressed by migrant-sensitive health policies should go beyond improving health services to encompass actions addressing the social exclusion of migrants and their employment, education, and housing conditions (see Figure 5).

      Figure 5. Policy measures tackling the social determinants of health for migrants ()

      The future of migrant health in the Americas

      By adopting a resolution on health and human rights in 2010 (), agreeing on a Regional Strategy for Universal Access to Health and Universal Health Coverage () and Plan of Action for the Coordination of Humanitarian Assistance () in 2014, and adopting the global 2030 Agenda for Sustainable Development in 2015, the countries of the Americas have shown their commitment to protecting the rights of all people, including migrants. Thus, everyone can achieve the highest attainable standards of physical and mental health and commit to the development of health policies and programs to address health inequities and improve access to health services.

      At the national and supranational levels, the strategic lines of action defined within WHO Resolution WHA61.17 of 2008 and PAHO Resolution CD55.R13 of 2016 on the health of migrants constitute the overarching framework for the health system’s actions to protect the health and well-being of all migrants. The agreed strategic lines of action on these resolutions are well aligned with the 2030 Agenda for Sustainable Development, and comprise the following:

      1. Ensuring inclusive health services responsive to the needs of migrants and readily accessible to migrants by eliminating geographical, economic, and cultural barriers;
      2. Improving mechanisms to provide financial protection in health for migrants with equity and efficiency;
      3. Adopting inclusive policy and legal frameworks that provide access to comprehensive, high-quality, and people-centered health services to migrants that are consistent with international human rights legal instruments;
      4. Ensuring the standardization and comparability of data among countries on migrant health; supporting appropriate aggregation and assembling of migrant health information and mapping of good practices; and
      5. Strengthening intersectoral action and development of partnerships, networks, and multicountry frameworks to address the social determinants of health of migrants; these should aim at shaping individual and community resilience and advocating for migrant-sensitive social policies and programs.
      6. Furthermore, the countries of the Americas, in coordination with international entities, have shown a continuous commitment to ensuring that all people, including migrants, are able to access life-saving and essential health care during health emergencies such as internal and international massive force displacement due to sudden environmental events, violence, or other reasons. This includes HIV prevention, protection, and treatment; reproductive health services; food security and nutrition; and water, sanitation, and hygiene services. Key to the success of humanitarian health assistance is coordination with existing national disaster risk management authorities, promotion of mechanisms for coordination with other sectors, participation in regional and global health networks for emergencies, and implementation of a flexible mechanism for registry of qualified foreign medical teams and multidisciplinary health teams and for emergency response procedures (). In addition, the countries of the Americas should continue working toward attaining and strengthening core capacities required by the International Health Regulations, including migrant-sensitive surveillance, response, preparedness, risk communication, human resources, and points of entry ().

        At the local and community levels, there is a need for a sustainable, equity-driven process that can bridge short-term humanitarian assistance during health emergencies with long-term universal access to health and universal health coverage for all migrants. Mainstreaming human security in country health plans can play this bridging role. In the Americas, PAHO’s Member States have demonstrated a heightened appreciation for considering the incorporation of human security into their country health plans by adopting the 2010 Resolution “Health, Human Security, and Well-being” (). A human security approach can help overcome challenges of national health systems with regards to the health care of marginalized communities such as migrants and their families. It would seek to address health threats in communities of origin, transit, destination, and return following a balance of individual and community-based interventions that are people-centered, context-specific, prevention- and promotion-oriented, comprehensive, and multisectoral within an integrated protection-empowerment framework. Human security can effectively guide health systems to be better prepared and to promote resilience in communities with migrants so that they move beyond a focus on survival to a focus on livelihood and dignity (). For example, the integration of the human security approach in health emergency plans would prevent, monitor, and anticipate acute migrant health-related threats by developing early warning and response mechanisms, as well as strengthen community ownership, resilience, and preparedness to identify and control these threats. Incorporating the human security approach in local health service models would provide migrant-sensitive services, as well as strengthen the health knowledge, mobilization, and decision-making power of migrants and of communities of origin, transit, destination, and return. Mainstreaming human security in country health plans requires a substantial capacity-enhancement program that is focused on research, training, and consolidation of multidisciplinary expertise. It calls for a multisectoral, multistakeholder strategy that articulates collective interests, establishes rights and obligations, and mediates differences using good governance principles such as promotion of equity, participation, pluralism, transparency, co-responsibility, and the rule of law ().

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      Reference/Note:

      Emergent diseases and critical health problems undermining development

      • Summary
      • Introduction
      • Control of Transmissible Diseases
      • Conditions Targeted for Elimination
      • Challenges for Women, Children, and Adolescent Health, including Nutritional Deficiencies
      • Conclusions
      • References
      • Full Article
      Page 1 of 7

      Summary

      The Region of the Americas has made substantial progress over the past decade in achieving health-specific goals related to maternal and child mortality, reproductive health, infectious diseases, and undernutrition. Socioeconomic development, environmental factors, the relative strength and resilience of health systems, and improved access to health services have been instrumental in these achievements (). However, advances at the national level continue to obscure disparities among certain subpopulations. The slow progress in closing gaps resulting from avoidable inequalities continues to negatively affect the balanced distribution of those advances (). For example, scaling up evidence-based interventions to fight communicable diseases (CDs) and improving maternal and child health is necessary but not sufficient to resolve health disparities across different populations. Progress, while ongoing, has been nonlinear, and potential social, economic, environmental, and public health crises threaten to reverse the fragile gains.

      The Region also faces new challenges from emerging and reemerging infectious diseases that adversely affect communities, families, economies, and health systems and services. Lessons learned from past emergencies (i.e., the 2009 influenza pandemic) have resulted in greater preparedness and increased awareness of the need to strengthen surveillance (). Yet, in other cases, such as the dengue, Zika, and chikungunya epidemics, important challenges remain that will require a coordinated, multisectoral, integrated response.

      Achieving the goals of the 2030 Sustainable Development Agenda requires more integrated and collaborative approaches to address inequities in the Region across the social, environmental, and economic dimensions of development, including a clear intergenerational vision. Health systems must adopt a more decisive role in efforts to increase equity and sustainable development, ensuring effective coverage and quality of health services and interventions, and, most importantly, contributing to build coherence and synergy of actions across different sectors, both nationally and locally.

      Introduction

      In recent decades, the patterns of disease in the Region of the Americas have shifted, with an overall decrease in both the communicable disease (CD) burden and maternal and child deaths linked mainly to disease control, an aging population, increased political will, and improvements in socioeconomic conditions (). Over the past two decades, in all countries in the Region, CDs and maternal, neonatal, and nutritional diseases have dropped below noncommunicable diseases (NCDs) and injuries as causes of years of healthy life lost (disability-adjusted life years). Progress in decreasing mortality over the past decade has been greatest in Latin America and the Caribbean (LAC), with reductions of more than 30% in the Dominican Republic, Guatemala, Haiti, Honduras, Mexico, and Nicaragua (). However, significant disease burdens persist in some countries, such as Bolivia, Haiti, Guatemala, Guyana, and Peru, where more than 20% of deaths are estimated to be related to CDs and maternal, neonatal, and nutritional diseases ().

      Sustained long-term economic development with improvements in public sanitation, housing, nutrition, and health care over the past decade has driven a transition in health outcomes (). Despite this progress, the persistence of specific CDs as well as preventable maternal and child illnesses hinders the well-being, social cohesion, and development of some populations in the Region. These conditions are markers of inequities related to gaps in socioeconomic development.

      The Millennium Development Goals (MDGs) for 2000–2015 helped mobilize political will and address health development and equity challenges, and the Sustainable Development Goals (SDGs) (2016–2030) are building on that momentum (). This section covers health-related goals of the MDG agenda—maternal and child mortality, reproductive health, infectious diseases, and undernutrition—focusing on current challenges in public health policy and action, including control and/or elimination of CDs within the context of changing health outcomes, persisting inequities, and a re-strategized approach to sustaining gains while leaving no one behind.

      Control of Transmissible Diseases

      Diseases are not limited by geopolitical boundaries and thus can spread quickly across borders through international travel and trade, with a single health crisis in one country potentially affecting the economies and livelihoods of the entire international community. In the Americas, there are a wide variety of settings and unique scenarios that may contribute to the emergence of infectious hazards events such as populated urban centers affected by multiple natural disasters, and remote rural areas lacking access to drinking water and sanitation, where close contact between humans and animals is common. Risk of CDs in the Region is also affected by environmental pressures associated with, among other events, rapid urbanization and climate change. For example, the emergence and spread of arboviruses depends on the presence and abundance of vectors, which is in turn related to various social, economic, and environmental factors (). The macrodeterminants that influence the onset of these diseases are compounded by climate change effects, which impact the intensity and duration of rainy seasons and hurricanes, give rise to intense droughts, and alter biodiversity (). Persisting poverty and social inequities also impede sustainable, equitable progress in the control of CDs.

      Of all human pathogens worldwide, 61% are classified as zoonoses and account for 75% of all emerging pathogens in the past decade (). A study analyzing the importance of zoonoses and CDs common to man and animals as potential public health emergencies of international concern (PHEIC) reported that 70% of recorded PHEIC in the Region were within the animal/human health interface. Of these, 25% were food safety events (). These results underscore the importance of the animal/human health interface and intersectoral collaboration. Several zoonotic diseases, such as influenza and leptospirosis, are listed as top 10 infectious hazards in the Americas in the WHO Event Management System (EMS) (). Plague, another zoonotic disease, is one of the few diseases requiring notification under IHR 2005, even though there are no current plague outbreaks in the Region ().

      Other challenges in controlling CDs in the Region are related to changes in demographics and lifestyle and issues such as availability of treatments and drug resistance. For example, multiple chronic infectious diseases have increased with aging populations. Antimicrobial, antifungal, antiparasitic, and antiviral drug resistance has emerged as a factor with high economic impact in the annual global gross domestic product (GDP), which could fall between 1.1% to 3.8% in 2050 (depending on estimated levels of antimicrobial resistance), according to a World Bank report (). Drug resistance may jeopardize efforts to eliminate malaria, tuberculosis (TB), and HIV and would thus have a direct impact on the lethality of these diseases (). Preventing the spread of resistant infections and slowing the emergence of resistance overall is critical in the Region.

      Among the groups at highest risk of contracting infectious diseases are people with inadequate access to water and sanitation and those who live below the global poverty line (), particularly pregnant women, children, and immunosuppressed patients. Some populations may also face barriers in access to prevention and control services due to stigma and discrimination based on their behaviors, sexual orientation, or ethnicity that can be compounded by legal frameworks and cultural and religious beliefs.

      While the circulation of many established pathogens in the Americas has decreased, both new and traditional infectious diseases, such as Zika virus (ZIKV), chikungunya virus (CHIKV), dengue virus (DENV), plague, cholera, yellow fever virus (YFV), and leptospirosis, periodically emerge or reemerge. This poses challenges to health systems that lead, in some cases, to competing political, social, and technical perspectives, the absence of an organized and efficient public health strategy.

      Disease emergence or reemergence is related to social, political, and economic factors that have resulted in increased movement among the population, increased pressure on the environment, and environmental changes, as well as disparities across different social groups related to a lack of health service capacity in disease detection, prevention, and control (). Prevention and management of emerging diseases is a major health concern in the Region. Acute outbreaks of DENV, CHIKV, and ZIKV have increased the pressure on health systems, highlighting their structural weaknesses and the shortcomings of fragmented approaches to public health emergencies. In addition, the Region faces outbreaks of reemerging diseases such as yellow fever, cholera, and plague, which can cause devastating epidemics. These outbreaks pose a threat to public health security and can undermine socioeconomic progress.

      Some of the more important Regional challenges in communicable disease control—foodborne diseases (FBDs), health care–associated infections (HAIs), arboviruses, influenza, plague, leptospirosis, and cholera—are described below.

      Foodborne diseases (infections and intoxications)

      Foodborne diseases can be defined as conditions commonly transmitted through ingested food and comprise a broad group of illnesses caused by enteric pathogens, parasites, chemical contaminants, and biotoxins. FBDs reduce societal productivity, impose substantial stress on the health care system, and reduce economic output by adversely affecting tourism, food production, and access to domestic and export markets. In the Caribbean, acute gastrointestinal illness associated with contaminated food (which has an annual incidence of 0.65–1.4 cases/person) has an estimated cost of US$ 700,000–US$ 19 million per year (). The U.S. Centers for Disease Control and Prevention (CDC) estimates that each year about 1 in 6 people in the United States gets sick, 128,000 are hospitalized, and 3,000 die of FBDs, at a total cost of US$ 77.7 billion ().

      Socioeconomic determinants lead to different levels of exposure and vulnerability to FBDs (). Poverty, education, ethnicity, gender, demographic factors, living and working conditions, and trade are structural determinants of food safety and different modes of food production, handling, and consumption. For example, ethnicity is often structurally linked to inequity, leading to conditions prejudicial to food security and safety. Brucellosis due to the consumption of raw milk or raw milk products such as cheese occurs more frequently among indigenous populations (). Female literacy rates and education are also important factors in access to food and food safety ().

      Health care–associated infections

      Health care–associated infections (HAIs) are linked to significant morbidity and mortality and pose a major problem for hospitals and other health care delivery settings throughout the world. Estimating HAI incidence Region-wide is challenging, but some countries have national surveillance systems that include hospital-acquired infections (). In 2014, the United States reported more than 700,000 HAIs and 75,000 deaths in patients with HAIs ().

      The economic impact of HAIs is substantial. The costs of treating a bloodstream infection in the United States can be high as US$ 45,000 (). Data from Latin American countries indicate that treatment of HAIs accounts for 15%–35% of operational costs for critical care units ().

      Implementing infection prevention and control programs, which include surveillance and targeted strategies at the hospital level, can prevent 55%–70% of HAIs (). Although the main prevention strategies are not resource-intensive, many countries do not have HAI control programs at the national and hospital level (), and implementation of the programs in countries where they do exist remains a challenge. For example, hand-hygiene campaigns at health care facilities showed implementation rates of about 50% ().

      In the Americas, the changing population demographics, increasing number of patients with comorbidities and chronic treatments, development of antimicrobial resistance, and more complex medical care aggravate the challenge posed by HAIs.

      Arboviruses

      Despite vector control efforts, in recent years the prevalence of viral infections transmitted by arthropods has increased worldwide (). Emerging epidemics in the Americas from new arboviruses such as CHIKV and ZIKV and already endemic viruses such as DENV and the reemergence of YFV reflect important changes in patterns of disease (, ). A recent example was the PHEIC declared in February 2016 in response to the increasing numbers of ZIKV-associated neurological syndromes ().

      The characteristics that make these epidemics complex issues for prevention and control include the following: (1) vectors’ adaptation to new habitats, use of unusual breeding sites (e.g., sewers and septic tanks), and expansion to new geographic areas or areas where they had been eliminated (e.g., the reinfestation of Aedes aegypti in continental Chile); (2) virus spread in densely populated areas in the Region; and (3) the simultaneous circulation of closely related pathogens and new clinical manifestations. All of these factors contribute to the increase in virulence and pathogenicity of arboviruses in the Americas.

      The association between congenital ZIKV infection and birth defects, including microcephaly, has prompted concern among health officials and the public, highlighting the need to address the issue from both a human rights and reproductive health perspective. The report of congenital syndromes has demonstrated gaps in the proportion and number of cases reported by each country, mostly due to differences in surveillance systems. Therefore, standardized methodologies should be implemented.

      The epidemiologic status of arboviruses in the Region is complex. DENV control efforts have decreased fatality rates, but incidence and morbidity are on the rise. For example, in 2015, DENV case fatality decreased by 23% compared to 2012, but incidence increased by 44% over the same period (). In December 2013, after autochthonous transmission of CHIKV in Saint Martin (French territory) was confirmed, the virus spread rapidly from that focal point to the northern coast of South and Central America. In 2015, transmission of CHIKV was documented in 44 countries and territories in the Region. Similarly, the dissemination of ZIKV has rapidly disseminated following the first detection of the virus in northeast Brazil in May 2015 (). By 2016, the virus had been confirmed in 40 countries and territories in the Region (). The new patterns of arboviral disease, including the emergence of ZIKV and its cocirculation with other arboviruses in areas where only DENV had been documented, highlight the need for more research on the pathogenesis and clinical and epidemiological behavior of these viruses in new habitats.

      Emerging and reemerging epidemics are causing an overload on health systems, affecting families and communities. Challenges include difficulties in clinical and laboratory diagnosis as well as surveillance (). These epidemics also increase the pressure on social infrastructures in affected countries and territories. Chronic disease manifestations or sequels can affect the productivity of the population as well as individual and national incomes. Congenital health problems in newborns related to virus infections can result in the need for long-term care and family and community support. Although some research has been conducted (, ), the economic and social impact of arbovirus infections has not been fully estimated.

      The response to arbovirus epidemics requires a multisectoral approach. Responses limited to the health sector increase the risk of higher-cost outcomes with less social impact and more inequity. The promotion of an integrated approach for arboviral disease surveillance, prevention, and control should therefore be a priority.

      Influenza

      Influenza is estimated to cause about 80,000 deaths annually in the Americas (). In 2013–2015, there were tremendous gains in the Region related to the surveillance of influenza. There are currently more than 100 hospitals in the Americas conducting influenza surveillance according to global standards and 28 national laboratories carrying out virologic surveillance. These hospitals and laboratories, working with their ministries of health, international partners, and PAHO/WHO, developed a Regional influenza network, SARInet, which was formally established in 2014. This type of Regional collaboration allows for the sharing of experiences, lessons learned, and resources and has created a structure to respond to questions of public health importance, such as the burden of influenza-associated hospitalizations.

      Groups at higher risk for adverse outcomes from influenza infection include children, the elderly, pregnant women, and persons with specific coexisting conditions. It is recommended that these groups receive the influenza vaccine and early antiviral therapy (e.g., oseltamivir) in order to decrease their risk of prolonged hospitalization and death (). Trends in the early use of antiviral therapy are difficult to monitor due to untraceable purchases of antiviral products without a prescription, but increased use of the influenza vaccine in the last 5 years has been reported. In 2014, 40 countries and territories in the Americas used the vaccine, and 12 of them (29%) targeted pregnant women in their coverage (compared to seven countries/territories in 2008). Among the 23 countries reporting coverage data, on average, 75% of adults ≥60 years, 45% of children aged 6–23 months, 32% of children aged 2–5 years, 59% of pregnant women, 78% of health care workers, and 90% of individuals with chronic conditions were vaccinated during the 2013–2014 vaccination campaigns (). Estimates based on 2013 surveillance data from LAC suggest that the vaccine was 52% effective in preventing medically attended severe influenza infection ().

      There is much more to be done, especially in strengthening influenza surveillance at the human-animal interface, developing estimates of the burden of influenza-associated hospitalizations, strengthening the rapid response capacity, and gaining a better understanding of the barriers to access to vaccination among various population groups. Targeting these aspects of the work plan requires a multisectoral approach and open communication and data sharing among partners.

      Plague

      Plague persists in the Americas, with endemic foci in Bolivia, Brazil, Ecuador, Peru, and the United States (). Since 2009, small outbreaks and occasional human deaths have occurred, including in hospital settings. Notification of pneumonic plague is mandatory under the IHR (). Plague’s epidemiology is highly entangled with the ecology of its vectors and reservoirs, which are influenced by climatic, ecological, and social changes that have contributed to its resurgence.

      The Andean region population has the highest risk of ecological and climatic changes derived from the El Niño Southern Oscillation (ENSO). The effects of ENSO have been associated with plague reemergence in the past (1992 and 1998). High-risk populations include those living in semiarid areas surrounded by a rural agricultural (intensive or extensive/traditional) landscape, where interface with the sylvatic cycle of the plague reservoir may be ubiquitous. Local housing conditions can also increase the risk of plague; isolated households in maize or sugarcane production areas, with adobe homes that have soil floors, high intrahousehold human density, and store agricultural products inadequately, are most at risk.

      Leptospirosis

      Estimates suggest that in the Americas, over the last decade there have been more than 100,000 cases of leptospirosis, causing 5,000 deaths annually. Consequently, leptospirosis has garnered more attention, mostly during outbreaks (). However, the disease remains under-reported due to nonspecific symptoms that mimic those of DENV, malaria, and influenza, and because it requires laboratory confirmation (). The diversity of leptospirosis’ animal carriers creates additional challenges for prevention and control.

      Studies have identified environmental drivers of leptospirosis, such as heavy rains or floods, frequently related to outbreaks with a higher number of cases (). Alkaline and neutral soil types facilitate the survival and persistence of the bacteria (). Socioeconomic drivers include living in dense urban or peri-urban areas with inadequate waste collection and sanitation, lack of potable water, and poor housing conditions (). As an occupational disease, leptospirosis affects rice workers, animal handlers, sewer workers, and gold miners (). Rural workers who acquire leptospirosis in areas with limited access to health services may not be able to return to their jobs and some may even die. Severe leptospirosis cases may lead to renal failure that requires hemodialysis (). If this complex and costly procedure is not available, the chances of patient recovery are low.

      Cholera

      Cholera is still present in the Americas. In 2010–2016, cholera was reported in Cuba, the Dominican Republic, Haiti, and Mexico. In Haiti, Vibrio cholerae O1 has persisted since 2010 and epidemiological peaks have been observed during rainy periods due to the increased water runoff feeding the endemic transmission, which is maintained through movement of the population and inadequate hygiene practices. The oral cholera vaccine was introduced in Haiti in 2015, and approximately 373,000 persons were vaccinated. However, on 4 October 2016, Hurricane Matthew struck the departments of Grand Anse and Sud, generating more cases than normally expected for the season. Water and sanitation infrastructure is limited in the country and was destroyed in the southern peninsula by the hurricane. Total sanitation coverage in Haiti remains low (28% in 2015); in 2012, in the poorest population quintile, 90% were still practicing open-air defecation (). Drinking water coverage in Haiti declined in urban settings over the period 1990–2015, despite a national increase of 2%; in 2012, in the poorest population quintile, only 1% had access to improved water sources. Water treatment centers in urban settings in Haiti need to improve their performance in water chlorination and routinely measure fecal coliforms and residual chlorine in drinking water. In rural settings, sustainable local water chlorination strategies still need to be devised. Without adequate investment in sewage discharge infrastructure, improvements in the current endemic cholera situation in Haiti will be slow. The Dominican Republic and Cuba reported cholera cases related to Haiti’s outbreaks. Differences in health service infrastructure, sanitation conditions, and access to safe water help explain patterns in cholera spread across the three countries. Mexico also suffered a cholera outbreak related to the Haitian strain between 2012 and 2014 ().

      Conditions Targeted for Elimination

      Disease elimination and eradication are the ultimate goals of public health. The successful eradication and/or elimination of diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) and significant progress in the control of many infectious diseases have prompted global and Regional target-setting, collective decision-making, and action towards elimination of goals with regard to many diseases.

      Nevertheless, the costly up-front investments required to eliminate diseases and the risk of failure are cause for concern. The benefits of disease elimination include the positive return on the investment in most cases, ending important causes of disability and death, improved results in health service delivery, and closing the equity gap (). Lessons learned from previous elimination successes show that the societal and political commitment of countries is key to maintaining efforts to achieve elimination (). To support the elimination agenda, countries need to move beyond a perspective based solely on cost-effectiveness. Disease elimination requires political commitment, a human-rights- and gender-based approach, and a strategy that addresses structural and social determinants, focusing on the most excluded and vulnerable populations.

      HIV

      With regard to HIV, 2016 was a turning point. The Americas, which has an estimated 3.4 million people living with HIV, is moving toward ending the AIDS epidemic by 2030, as marked by the 2016 United Nations General Assembly (UNGA) High-Level Meeting on Ending AIDS, held in New York, where heads of state from member countries endorsed the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track strategy to end the AIDS epidemic by 2030 (). This is an important challenge given that an estimated 25% of people with HIV in LAC do not know their serostatus and a 55% were receiving antiretroviral treatment (ART) in 2015 ().

      LAC countries have the highest level of ART coverage of all low- and middle-income countries (LMICs) and have achieved a remarkable reduction in new infections in children (a 55% decrease since 2010). However, challenges remain in curtailing new infections, and an effective response is complex given the nature of the epidemic. In 2015, LAC experienced a decreasing trend in HIV deaths and new infections compared to 2005 (a 32% versus 10% decrease respectively). However, the rate of reduction in new infections slowed after 2010, and has begun to increase in the past 2 years. The burden of HIV is not equally distributed and key populations in the Americas, such as gay men and other men who have sex with men (MSM), transgender women, and sex workers, are disproportionately affected compared to the general population. Key populations also include prison inmates, certain ethnic groups (e.g., the Honduran Garifuna population and Canadian Aboriginal people), the homeless, non-injecting drug users, and young women in the Caribbean. These high-risk groups are increasingly vulnerable and often driven underground due to various factors including stigma and discrimination in their communities and at health service facilities (). Stigma and discrimination can lead to delayed care-seeking. In 2015, almost one-third of newly diagnosed HIV cases accessed care with a highly compromised immune system ().

      The HIV epidemic uncovers social inequities, stigma and discrimination and poses challenges to health systems. Stigmatization of same-sex relationships and sex work hinders access to HIV prevention services and leads to an increase in risky behaviors (). Homophobia drives MSM away from HIV testing and prevention activities and is associated with lower adherence to treatment. Women in key populations face stigma and discrimination in various forms, including violence and violations of their human rights ().

      Ending AIDS by 2030, to meet the goals of the Sustainable Development Agenda, will require increased financial investment to expand services and improve the prevention response. UNAIDS has estimated that US$ 3.05 billion was allocated to finance the response to HIV in 2014 in LMICs in the Region, with 87% of that amount coming from domestic (in-country) resources. The Americas region is a global leader in terms of supporting the HIV response with domestic funds, although one-third of countries depend on external donors for much (more than 40%) of their response (particularly Haiti, Bolivia, and the Dominican Republic). Other requirements for meeting Agenda goals include (1) the decentralization of services, to support the expansion of HIV testing and treatment for all; (2) the implementation of models for delivery of prevention services, with a focus on the most vulnerable populations, and those at highest risk; and (3) the elimination of stigma and discrimination, including the elimination of punitive laws and policies that create barriers to the receipt of health care and the protection of human rights.

      Box 1. Elimination of mother-to-child transmission (MTCT) of HIV and congenital syphilis (CS) in LAC

      In 2015, Cuba became the first country credited by WHO for eliminating MTCT of HIV and syphilis. Other countries and territories, such as the United Kingdom Overseas Territories (OKOTs) and Eastern Caribbean countries, have applied to WHO for accreditation for HIV elimination. As of 2015, 19 countries and territories in the Region had reached CS rates compatible with the elimination of MTCT of syphilis ().

      Data suggest that testing for HIV and syphilis has been integrated into antenatal care (ANC) services, and the goals of eliminating MTCT of HIV and syphilis are seen as indicators of good quality in maternal and child health services. Despite the high rates of testing and treatment coverage (in 2014, 75% and 79% for HIV and syphilis testing, respectively, and 81% and 85% for treatment of pregnant women for HIV and syphilis, respectively), the neediest and most vulnerable populations are underserved ().

      Health service barriers for the elimination of CS in LAC countries include late access to ANC; the need to attend health centers multiple times (for diagnosis and treatment of syphilis), often resulting in a lack of follow-up care for syphilis-positive pregnant women; penicillin shortages and stock-outs; uncommitted budgets; and lack of partner treatment, resulting in syphilis reinfection in pregnant women (). To eliminate CS, it is necessary to address sexual health and syphilis prevention as well as diagnosis and treatment among women of reproductive age and the general population. Therefore, effective responses must address HIV and sexually transmitted infection (STI) prevention in the community, satisfy the need for family planning, and rapidly identify and treat early infections, including in sexual partners ().

      Sexually transmitted infections

      STIs have often been neglected in favor of the HIV response, but the socioeconomic costs of these infections and their complications are substantial. For example, they rank among the top 10 reasons for health care visits in most developing countries (). Annually, 64 million new cases of four curable STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and Trichomonas vaginalis) are reported among people 15–49 years old in the Americas (2012 data) (). High levels of STIs among key populations such as gay men and other MSM, sex workers, transgender populations, and specific indigenous and ethnic groups in LAC have been reported (). Reported data for 2008 and 2012 show a small decrease or stagnation in the incidence and prevalence of the four curable STIs among men and women 15–49 years old (). However, in recent years, some countries, such as Brazil and the United States, are reporting increases in rates of curable STIs (). Stigma regarding STIs is prevalent in the Region () and community attributes such as poverty, substance abuse, sex roles, gender-based violence, and norms for sexual behavior affect the risks associated with individual behaviors and impede the adoption of preventive behaviors ().

      The decision to move toward the elimination of STIs was agreed upon by WHO Member States in 2016 (). Most STI prevention tools and interventions have been available for years (STI case management, counseling and behavioral interventions, diagnostic tests, treatment and vaccines, etc.). However, the extent of their use varies and the adoption of innovations such as point-of-care tests, multipurpose technologies, and HPV vaccine is slow (). These interventions require targeted approaches for vulnerable populations, including youth (). The time has come to address the broader framework for sexual health to end STI epidemics. This will require interventions at not only the individual level but also the community and public infrastructure levels to address the root causes and social contexts.

      Tuberculosis

      In 2015, an estimated 268,500 people in the Region contracted TB, and 25,000 died (). Between 1996 and 2015, with the implementation of Directly Observed Treatment Short Course (DOTS) and the WHO Stop TB Strategy, and improved socioeconomic conditions in the countries of the Region, TB incidence dropped from 46 to 27 cases per 100,000 population (), thus meeting the TB-related MDG indicators for 2015 for the Region and the majority of its countries. This rate of decline has slowed since 2007 due to the persistence of factors linked to poverty, social inequity and exclusion, and rising urbanization, which generate living conditions and circumstances favorable to TB transmission. These difficult conditions also influence adherence to treatment among groups with poor socioeconomic status and education, regardless of disease control measures ().

      Countries are committed to ending the TB epidemic (<10 cases per 100,000 population) by 2030 and eliminating TB as a public health problem (<1 case per 1,000,000 population) by 2050 (). Challenges to achieving elimination include social inequalities; demographic changes such as rapid urbanization, migration, and aging of the population; the epidemiological transition, with an increase in NCDs; and the persistence of multidrug TB and HIV transmission (), all of which increase the risk of falling ill with TB (, ). TB is concentrated in the most disadvantaged populations within the social gradient (, ), including those living in city slums, where poor housing and limited access to basic health services generate greater transmission and vulnerability (, ); ethnic minorities; migrants, prisoners; people with HIV; and those affected by NCDs (). Countries are applying different prevention and control initiatives adapted to the needs of each population. One example is the initiative for TB control in large cities () using a cross-sectoral and inter-programmatic approach, incorporating community participation and health care services adapted to the needs of the poorest.

      Malaria

      Eighteen of the 21 countries in the Americas endemic for malaria have committed to eliminating the disease in the next 5 to 15 years (). Argentina and Paraguay have formally requested certification of malaria-free status from WHO. Costa Rica reported zero autochthonous cases since 2013 and El Salvador and Belize reported, respectively, 6 and 19 autochthonous cases in 2014. The Dominican Republic, Ecuador, and Mexico are also considered close to malaria elimination ().

      As the Anopheles vector exists in almost all of the 30 non-endemic countries in the Americas, it is imperative to have surveillance and emergency response systems in place Region-wide to prevent the reestablishment of malaria transmission. Between 2000 and 2014, non-endemic countries reported an annual average of about 2,000 imported cases, mostly originating among travelers from endemic countries. Control measures in the non-endemic countries are based on travel and include preparedness for outbreaks.

      In the 21 endemic countries, malaria risk depends on interactions with the epidemiologic factors (host, vector, parasite, and environment). The most important drivers of the disease in these countries are related to social determinants, occupation, geography, and the environment. Social determinants stemming from race, ethnicity, and cultural distinctions are major issues to consider in malaria elimination in key malaria-endemic areas. Many ethnic groups live in poverty, lack access to health care, and face cultural barriers inhibiting proper diagnosis and treatment. Cases from ethnic/indigenous populations were only reported by 8 of the 21 endemic countries in 2014. In Guyana, Amerindians have a fivefold higher risk of malaria than the rest of the population. Unfortunately, most other countries do not report similar types of information, making it difficult to measure risks by ethnicity, track disease trends, implement proper interventions, and make sound cases for policy change. Additional risks are related to specific occupational exposures, particularly in mining, logging, and agriculture. Miners in all countries making up the Guiana Shield are at risk of malaria with limited intervention or control methods available to them (). The approach to malaria elimination needs to be tailored to the local situation and needs to consider the social determinants in contexts where available interventions may be highly effective if implemented appropriately ().

      An increasing trend of domestic funds remains the primary source of support for malaria efforts in the Region (approximately US$ 189 million in 2013) (). There are also a number of ongoing malaria initiatives in the Americas focusing on malaria elimination, including the U.S. Agency for International Development (USAID) investment to support technical cooperation on malaria control and elimination throughout the Region; the Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE) initiative, funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Geneva); and Malaria Zero (Atlanta, Georgia, United States), funded by the Bill & Melinda Gates Foundation (Seattle, Washington, United States). These and other initiatives, along with in-country resources, financial support from key partners, and technical collaboration from international agencies, provide a platform for eliminating malaria in the short to medium term.

      Vaccine-preventable diseases

      The Americas was the first Region in the world to eradicate smallpox, poliomyelitis, rubella, congenital rubella syndrome (CRS), and measles. With the technical support from the Pan American Sanitary Bureau and its associated Revolving Fund for Vaccine Procurement, the Region has been at the forefront of sustainable and equitable introduction of new vaccines ().

      An analysis of return on investment associated with achieving projected coverage levels for vaccinations to prevent diseases related to 10 antigens in 94 LMICs during 2011–2020, based on the costs of illnesses averted, and using costs of vaccines, supply chains, and service delivery and their associated economic benefits, estimated that immunizations will yield a net return about 16 times greater than costs over the decade. Using a full-income approach, which quantifies the value that people place on living longer and healthier lives, net returns amounted to 44 times the costs. Across all antigens, net returns were greater than costs ().

      As with other indicators, high national vaccine coverage levels often mask inequalities within a country. There is a clear gradient in the proportion of the population under 1 year old living in municipalities of the Americas with suboptimal coverage of DTP3 (i.e., less than 80%) along the social hierarchy defined by per capita income. Countries in the lower income quartile have an excess of almost 20% of the population under 1 year living in municipalities with suboptimal DPT3 coverage compared to countries in the highest quartile. Such excess risk of exposure is attributable to the prevailing economic inequality among countries ().

      The main priorities for the Americas are (1) to ensure universal access to vaccines with emphasis on the most disadvantaged, (2) to manage the risk of reintroduction of diseases that could be brought into the Region by people traveling from other regions where the disease circulates, (3) to respond to increasing pressure from “antivaccine” groups, (4) to manage the high cost of new vaccines, and (5) to maintain immunization as a political priority, as reflected in the sustained allocation of national resources.

      Neglected infectious diseases

      The neglected infectious diseases (NIDs) rank with HIV/AIDS, malaria, and tuberculosis among the most common serious infections globally and in the Americas (). They are associated with poverty and marginality and have failed to receive attention, nor sufficient resources to address them, and have not historically been a priority on the public health or research agendas. They disproportionately affect populations that have been historically neglected including certain indigenous populations, Afro-descendants, and poor populations in rural and peri-urban areas. Their social determinants of health include poor housing conditions; lack of access to proper drinking water, basic sanitation, and hygiene; low income; poor education; and other barriers to access health services.

      NIDs create a significant social and financial burden on poor and marginalized groups because they contribute to the cycle of poverty (). The adverse effects on the individuals include growth retardation, stunting, and impairment of cognitive development caused by soil-transmitted helminths in children, leading to decreased productivity and income in adulthood; chronic, disabling morbidity, such as chronic heart failure due to Chagas disease; disability and disfigurement caused by leprosy, lymphatic filariasis, and leishmaniasis; and visual impairment and blindness resulting from trachoma and onchocerciasis. In many cases, the chronic sequelae caused by NIDs lead to additional stigmatization and discrimination.

      Many NIDs are on the path toward elimination (lymphatic filariasis, onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma). Others can be prevented or controlled with the appropriate tools and resources from health systems as well as government commitment and support from partners, and donors. The main challenges for elimination and control of NIDs can be grouped into two areas: (1) political and financial and (2) technical.

      Political and financial challenges

      NIDs are usually given a low priority in the national public health agendas due to competition with other public health-related problems, including public health emergencies, and because they affect mostly groups of people with a low political voice and their chronic nature. This diminishes the resources needed to tackle this group of diseases. This is particularly concerning because only with sustained interventions across several years can the elimination goals be reached.

      Technical complexity of interventions

      NIDs can be prevented, controlled, and in some cases even eliminated when health services use the proper tools and resources and have both commitment from their governments and support from partners and donors. While in some cases adequate implementation, monitoring, and evaluation of public health interventions have contributed to the successful elimination of some NIDs (e.g., preventive chemotherapy for onchocerciasis, lymphatic filariasis, and trachoma), intersectoral action in tackling the social determinants of NIDs is essential for achieving a faster, greater, and longer-lasting impact. The effective implementation of intersectoral coordination and collaboration poses a great challenge. The most cost-effective public health intervention for the control of schistosomiasis is the large-scale distribution of praziquantel, but access to healthy water, improved basic sanitation, snail control, and environmental enhancements are key to moving towards elimination. Transmission of soil-transmitted helminths and of trachoma is also closely linked to lack of access to proper sanitation, hygiene, safe water, and to lack of education on good hygiene practices such as hand and face washing and personal cleanliness. The use of proper shoes is also vital to keep children from being infected with soil-transmitted helminths.

      The weakness of health systems affects the care and treatment of many persons affected by NID. Only an estimated 1% of persons with Chagas disease annually receive appropriate and timely diagnosis and treatment (). Young and middle-aged women are most likely to develop irreversible visual disabilities from ocular trachoma because of their limited access to health services, and weak health systems also contribute to delayed diagnosis of leprosy cases, with a higher risk of developing disabilities and deformities.

      Changes in the environment also affect the distribution and incidence of some NIDs as occurs with visceral leishmaniasis in the Southern Cone, which is expanding due to population displacement, environmental changes, and adaptation of vectors to different environments ().

      Viral hepatitis

      A major shift worldwide has occurred in the significance given to viral hepatitis as a public health concern. Considered “silent” epidemics, they are now on the global health agenda with a goal of elimination as a public health threat by 2030. Of the different hepatitis virus types, the greatest burden of disease in the Americas is caused by hepatitis B and C, which contribute to more than 95% of the Regional mortality from viral hepatitis (). While the burden of other CDs has declined in the past decade, the burden of viral hepatitis has increased. National strategies for the prevention, care, and control of viral hepatitis are in place in fewer than half of countries in the Americas. The greatest strides in the Region have been in vaccination for HBV: Every country and territory has included HB vaccine in its immunization schedule for children and 69% of countries/territories have included an HB birth dose in their immunization policies. While the Region of the Americas is making gains in reducing chronic HBV prevalence, particularly from decades-long universal HBV vaccination and catch-up campaigns (), the time has come to accelerate access to care and treatment for people living with chronic viral hepatitis, particularly from HCV.

      With a focus on health systems strengthening, strategies based on integrating packages of services in primary health care, including maternal and child health services, and strengthening infection control policies and practices in healthcare institutions, are key components of a sustainable and efficient public health response to viral hepatitis. Major challenges for countries include the financial investment related to prices of viral hepatitis treatment, and improving the planning, organization and delivery of services for viral hepatitis prevention, diagnosis and treatment. Price negotiation, use of generics and joint procurement strategies are solutions underway to address these issues.

      Challenges for Women, Children, and Adolescent Health, including Nutritional Deficiencies

      Sexual and reproductive health, newborn and child health, and nutrition in the Americas progressed in the last decade, with improvements in the national indicators and reduced inequalities among economic and educational subgroups (). Increased contraceptive use, ANC coverage and births attended by skilled personnel, decreased unmet need for family planning, decreased stunting, and decreased maternal mortality (despite not meeting the MDGs for maternal health) show a pattern of slow national improvements and a small reduction in absolute inequities in most indicators. Nevertheless, inequalities in reproductive, maternal, and child health continue and the most disadvantaged populations groups present values that the advantaged groups presented 5 to 10 years ago ().

      The lessons learned from these efforts and progress are (1) the effort to assure child survival needs to be accompanied with a focus in child development; (2) achieving goals for maternal, child, and adolescent health requires addressing health sector issues, for example, those related directly to safe blood and obstetric services, and also a wider array of strategies addressing sexual health for women and adolescents, nutrition, gender, human rights, poverty and exclusion; (3) further gains will require specific approaches toward the needs of most vulnerable populations; and (4) greater attention needs to be focused on adolescent health.

      Maternal mortality

      Maternal health, measured by maternal mortality, remains a crucial indicator for measuring human and social development. In LAC, countries have made tremendous efforts to improve outcomes in maternal health. Between 1990 and 2015, the maternal mortality ratio (MMR) decreased by 52% in Latin America (from 124 to 69 per 100,000 live births) and by 37% in the Caribbean (from 276 to 175 per 100,000 live births) (). This decrease in MMR, however, was not enough to achieve MDG 5 (75% reduction compared to the 1990 baseline) ().

      In 2015, an estimated 7,800 women died of maternal causes throughout the Region (). Most of these maternal deaths were due to complications of pregnancy and childbirth, such as bleeding, sepsis, unsafe abortions and hypertension, and the majority were preventable with quality obstetric care during pregnancy, delivery, and postpartum (). These deaths are concentrated within certain disadvantaged populations of women who face inequity in access to adequate reproductive and maternal health care services (). The link between social determinants, such as place of residence, race, occupation, gender, religion, education, and socioeconomic status, and maternal mortality is clear. In Peru, the estimate for the poorest group presented a sixfold excess maternal deaths per 100,000 live births compared with the richest quintile (). In Guatemala, the maternal mortality rate among indigenous women was more than double that of nonindigenous women (163 versus 77 deaths per 100,000 live births) ().

      By looking closely at the causes of maternal mortality and morbidity, it is evident that there are economic, social and gender health inequalities that persist throughout LAC (). Women with lower socioeconomic status are less likely to have contact with the health system during pregnancy and childbirth, which are known to be periods of extreme vulnerability. On average, 90% of women in LAC have at least four ANC visits. Yet, large inequalities exist, for example, in Haiti and Nicaragua, where there is a gap of more than 30 percentage points between the poorest and wealthiest women having at least four ANC visits; for Bolivia and Panama, the gap is about 20 percentage points (2).

      Some of the main barriers affecting maternal health in LAC countries in obtaining skilled birth attendance (SBA) include the lack of medical personnel in rural and low-income areas, difficult and long distances to the nearest health facilities, cost of care, and the low quality of medical treatment. As a result, a significant number of women in rural areas are less likely to deliver with SBA. In Haiti, there is a 35% gap between women living in rural and urban areas, while in Guatemala and Bolivia there are gaps of 41% and 26%, respectively (). The SDGs present a renewed opportunity to meet the challenges of maternal health and reduce the maternal health inequalities (), offering a new scenario aligning the strategy to end preventable maternal deaths ().

      Neonatal, child, and adolescent health

      The traditional way of describing the health situation of children () has been to present the mortality trends and the disease prevalence of the main causes of deaths for three age groups: under 5 years old, under 1 year old, and 10–19 years old. While the MDGs promoted a more integrated approach to health, the emphasis remained on mortality and on a limited set of diseases. Neonates and adolescents were barely visible, and equity was a missing component.

      The region achieved MDG 4 due to the 67% decline in the under-5 mortality rate between 1990 and 2015 (). Diarrhea, pneumonia, undernutrition, and vaccine-preventable diseases as causes of mortality have decreased significantly (). However, the risk of dying shows a clear gradient: the lower in the social position the higher the risk of dying. This is the case for newborns, children, and adolescents. Most child deaths in the Region are currently either neonatal or stillbirths.

      A more detailed analysis shows that the speed of mortality reduction varied by age. The annual rate of reduction was largest in the post-neonatal group, followed by the 1–5 year age group, and lower in the neonates and stillbirth (). The mortality rate of adolescents for all causes has remained stable, but the mortality rates are consistently three to four times higher among male adolescents compared with females ().

      Despite international calls to address the health and social needs of adolescents, adolescent health has been overlooked. Sexual and reproductive health among adolescents is an area of political sensitivity and tension. Latin America and the Caribbean shows some decline in adolescent fertility (from 70 in 2008 to 65 births per 1,000 women 15-19 in 2014), but remains significantly higher than the global average of 45 (). Adolescent pregnancy is recognized as having profound effects on the health and well-being of young women and their children, especially for those living in disadvantage. Access to contraceptives in LAC is limited due to various legal and religious restrictions and the increasing influence of conservative groups. Child marriage is still a concern in various countries in the Region. Finally, groups such as ethnic minorities, LGBT (lesbian, gay, bisexual, or transgender) youth, those with disabilities, or who are homeless or in juvenile detention have the greatest health needs that remain invisible and unmet.

      Ensuring the survival of children, their mothers, and adolescents is crucial when aiming for zero preventable deaths. Even so, country efforts to save lives are incomplete if the life prospects of those who survive remain constrained by factors that could be effectively addressed (). The process of growth and development are by nature inter-related, interdependent, and mutually reinforcing. Therefore, efforts and resources must simultaneously promote survival and development (intellectual, emotional, and social).

      Globally, an estimated 7.1% of preterm babies who survive have some level of long-term neurodevelopmental impairment (). In the LAC region, an estimated 4.1 million children 3–4 years old (18.7% of the population for that cohort) experienced low cognitive and/or socio-emotional development (). The economic consequences of these and other delays are significant. Developing countries lose an estimated US$ 616.5 billion per cohort due to early life growth faltering, which is just one factor affecting child development. The losses for Latin America are estimated at US$ 44.7 billion ().

      The foundations of brain architecture are laid down early in life (). Social inequities in early life contribute to inequities in health later in life (). Gender inequalities have roots in early childhood through gender socialization, gender biases, and the day-to-day experiences of a child’s early years, especially among girls.

      The emphasis on early child development (ECD) is growing in the Region. The main factors driving the expansion of ECD programs are recognition of the importance of ECD and the need to increase female participation in the labor market, especially among women living in poverty. The programs vary widely in terms of their organizational structure, governance, and level of financing ().

      The investment of countries in ECD services is significant. Countries such as Brazil and Chile spend annually US$ 882 and US$ 641 per child 0–5 years old, respectively (). While public spending on children 0–5 years old is estimated at 0.4% of GDP, it is two or three times higher for children 6–12 years old, in countries in Latin America and the Caribbean. In addition to lower levels of investment for younger children, it is necessary to improve the overall quality of these services. The few available studies show that full-time day care services in the Region are generally of low quality.

      The health care system has an important role to play in ensuring that children and adolescents have the opportunities to thrive (). Mothers and young children seek health care more frequently than in any other period of their lives. For them, health services can serve as a platform for information, as well as a source of support and linkages with other social resources. Adolescents have the poorest level of health coverage of any age group. This fact makes the visit of an adolescent to a healthcare service a unique opportunity to address the nutritional, sexual, mental health and social changes of this age period. More than in the case of maternal and child health, progress in adolescent health will only be possible if a whole of society approach is at the center of country efforts.

      Nutritional deficiencies

      The nutrition landscape in the Americas is undergoing change in all countries and in most population groups as a result of changes in the food environment that affect diet and eating practices. The Americas met the MDG 1 target related to underweight prevalence in children under 5, but undernutrition in the form of stunting in young children continues to be highly prevalent in many countries, particularly in Central America and the Andes (). There are large differences within and among countries, with indigenous and Afro-descendant children and those living in rural areas especially affected. Stunting is a predictor of lower educational outcomes and adult productivity and a risk factor for subsequent overweight and associated metabolic disorders. Wasting is far less prevalent and focused in specific high-poverty communities. Overweight and obesity are similar in women and adolescents and among all income and ethnic groups. In some households, child stunting and maternal overweight coexist ().

      Between 1990 and 2014, the prevalence of stunting among children less than 5 years of age in the Region decreased from 14.9% to 7.1%. However, it remains above 25% in two countries and above 15% in six more. A traditional approach to reduce stunting has been to provide complementary foods, which has met with limited success. A more innovative approach is to provide conditional cash transfers/or comprehensive and integrated programs to address its root causes of poverty and other social determinants. Brazil and Mexico have been particularly successful with this approach and have significantly reduced not only the prevalence of stunting but also inequities among the affected population subgroups. At the same time, such programs have led to increases in overweight in women and need to be carefully monitored and adjusted to not reduce one nutrition problem while exacerbating another ().

      Micronutrient deficiencies, particularly iron deficiency, continue to be a problem among women, children, and adolescents, and rates are especially high among children under 2 years of age and pregnant women. Staple food fortification, such as salt iodization and fortification of sugar with Vitamin A has proven effective in reducing deficiencies of these micronutrients. However, the reduction of iron deficiency and deficiency of other key micronutrients through supplements and food-based approaches is challenging. As the reduction in the consumption of salt and sugar to prevent obesity and/or NCDs becomes increasingly important, adjustments to staple food fortification programs will be needed ().

      Given the rapid changes in the nutrition landscape in which undernutrition coexists with overweight and obesity, the increases in child, adolescent, and maternal overweight and obesity, and persistent micronutrient deficiencies, efforts to improve food and nutrition security must be addressed through comprehensive multisectoral actions that simultaneously address malnutrition in all its forms. While alleviating poverty and other social determinants, actions are also needed in the agricultural sector to improve access to nutritious foods. Regulatory actions are necessary to improve the food environment to promote the consumption of minimally processed foods such as fiscal policies, regulation of food marketing and front-of-package labeling ().

      Conclusions

      In all countries of the Americas, maternal and child mortality and the burden of CDs have decreased in the past 5 years. Nevertheless, inequities persist in the Region, and LMICs experience worse health outcomes, including higher mortality and morbidity related to CDs and other diseases and conditions that affect mothers and children. Re-strategizing the approach to sustain the gains in MDGs 4, 5, and 6 and address complex issues of this unfinished agenda will be part of the transition to the 2030 Agenda. Countries and development partners need to acknowledge that while chronic diseases are increasing, the burden of CDs and maternal and child deaths including those related to nutritional deficiencies is still considerable.

      The Region of the Americas has moved into a period of emergent infectious diseases due to changes in environment, lifestyle, and travel. These conditions can lead to the evolution of new pathogenic arboviruses and others, meaning that timely notification of public health events with potential international impact and future disease control strategies must recognize this context and plan accordingly. Vaccine development, innovative technologies, new drugs, and research programs are some of the areas recommended for collaboration among different sectors, including public sector partners such government health, education, agriculture, and urban development departments and private sector partners such as industry, academia, and civil society.

      A focus on health, education, and socioeconomic disparities is needed in order to close the gaps and leave no one behind in working to achieve the SDGs—particularly in the elimination of HIV, malaria, NIDs, STIs, TB, and viral hepatitis and the improvement of maternal, child, and adolescent health.

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      ×

      Reference/Note:

      1 Health events that endanger international public health, as defined by the International Health Regulations (IHR) (2005), an agreement between 196 countries including all WHO Member States.

      2 An online WHO application tool designed to provide timely information for event monitoring and iterative risk assessment and support decisions about response operations during outbreaks and other acute public health events in accordance with the IHR [http://apps.who.int/iris/handle/10665/206496?locale=zh&null].

      3 While elimination is based on interruption of transmission to zero or very low levels, the specific definitions of elimination vary depending on each disease and its control measures.

      4 Key populations refer to both vulnerable and most-at-risk populations for HIV infection. They are important to the dynamics of HIV transmission in a given setting and are essential partners in an effective response to the epidemic (WHO. 2013. HIV/AIDS: definition of key terms. Available from: http://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/).

      5 See http://www.who.int/neglected_diseases/Social_determinants_NTD.pdf.

      6 Persons under the age of 18 years.

      7 MDG 4: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.

      8 Defined by WHO as people between 10 and 19 years old.

      Social determinants of health in the Americas

      • Introduction
      • Conceptual Foundation of the Social Determinants of Health
      • Setting the Scene
      • Core Regional Challenges
      • The Social Determinants of Health Approach to Core Regional Challenges
      • Advances Achieved in the Key Action Areas Identified by the Rio Declaration (2011)
      • Towards Sustainable Development
      • Conclusion
      • References
      • Full Article
      Page 1 of 9

      Introduction

      The social determinants of health (SDH) are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (). These forces and systems include economic policies and systems, development agendas, social norms and policies, and political systems. These conditions can be highly inequitable and lead to differences in health outcomes. The experience of such conditions may simply be unavoidably different, in which case they are considered inequalities, or they may in fact be unnecessary and avoidable, in which case they are considered inequities and therefore appropriate targets for policies designed to increase equity.

      In the Region of the Americas, evidence exists on how the SDH influence a wide range of health outcomes and efforts towards universal health, as reflected in both the development of the Millennium Development Goals (MDGs) and the ways in which they were pursued by countries. Analyzing these determinants is particularly relevant in the Americas, given that health inequity and health inequality continue to constitute the principle barriers to sustained development in the Region. Those living in the Region tend to be disproportionately affected by the poor conditions of daily life, which are shaped by structural and social factors (macroeconomics, ethnicity, cultural norms, income, education, occupation). These conditions and factors are responsible for pervasive and persistent health inequalities and inequities throughout the Americas.

      The Pan American Health Organization’s Strategy for Universal Access to Health and Universal Health Coverage notes that recent improvements achieved in health throughout the Americas were due in part to advances in economic and social development of the countries, the consolidation of democratic processes, the strengthening of health systems, and the political commitment of countries to address the health needs of their populations (). The strategy recognizes that policies and interventions addressing the SDH and fostering the commitment of society as a whole to promote health and well-being, with an emphasis on groups in conditions of poverty and vulnerability, are essential requirements to advance toward universal access to health and universal health coverage. There is a clear need to continue efforts to overcome exclusion, inequity, and barriers to access and the timely use of comprehensive health services. Improved intersectoral action is required to impact policies, plans, legislation, regulations, and joint action beyond the health sector that address the SDH.

      Conceptual foundation of the social determinants of health

      The concept of the SDH incorporates a broad set of determinants extending beyond those that are only social in nature. The basic components of the SDH conceptual framework include (a) the socioeconomic and political context, (b) structural determinants, and (c) intermediary determinants (). Figure 1 outlines some of the key social, economic, cultural, and environmental aspects influencing health outcomes. Combined with individual behavior, genetic factors, and access to quality health care, these factors are thought to account for all, or virtually all, health outcomes (). It is critical to both distinguish between factors that mitigate risk concerning the extent to which they are modifiable–in other words, whether the differences in health outcomes they cause represent inequities or inequalities–and to consider the probable relationship between these factors and policies designed to influence them (). In considering the value, effectiveness, and appropriateness of policies in this regard, the SDHs offer the opportunity to position health as a public good, that is to say, having benefits for all of society that are not reduced by the marginal health gains of one individual but may in fact have exponentially positive effects on the health of other individuals ().

      Figure 1.The social determinants of health conceptual framework

      Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Geneva: World Health Organization; 2007. ().

      The SDH approach is widely regarded as a highly effective means of addressing health inequities that promotes action across a range of factors that affect individual and population health outcomes, many of which are beyond the reach of the health sector. The approach has developed substantially over the past number of years, punctuated by two core calls to action. In 2005, the World Health Organization launched a Commission on the Social Determinants of Health (CSDH) and charged it with the responsibility of gathering evidence on inequities, as a way to understand the SDH and their impact on health equity, and issue recommendations for action (). The CSDH’s final report (2008) issued three recommendations for action: to improve daily living conditions; to tackle the inequitable distribution of money, power, and resources; and to measure and understand the problem and assess the impact of action (). The Rio Political Declaration on Social Determinants of Health (2011) also had substantial implications for this agenda in the Region. The Declaration emphasizes the need for an SDH approach and served as a call to action on interrelated principles addressing the SDH approach as well as broader, related concepts including equity and human development.

      Clear emphasis has been placed on the importance of multisectoral action in addressing the SDH, the unacceptability of stark health inequities, and health as a human right. Grounded in equity, action on the SDH in the Region of the Americas requires recognition of the complex and often long-term causes of ill health and health inequity, through research in both social science and epidemiological disciplines. A growing body of evidence has led to intensified action across the global health spectrum with notable national-level engagement in the Region of the Americas. By addressing the fundamental “causes of the causes” of good and ill health, the SDH approach has the potential to remove some of the fundamental barriers that impact health and address some of most intractable health issues in the Region that are closely associated with dimensions of inequity, supporting the progressive transition towards universal health.

      Setting the scene

      The Region of the Americas has much to celebrate in terms of the progress in health over the past 5 years. As we reach the end of the era of the Millennium Development Goals (MDGs), it is valuable to briefly review progress made during this period in order to contextualize the current health landscape in the Region and address key areas where there is still much work to be done. Significant progress has been recorded in terms of reaching the health-related MDG, particularly in terms of overall levels of nutrition, life expectancy, poverty, under-5 mortality, HIV, malaria, and tuberculosis. Targeted efforts at the local, national, and regional levels in each of these areas have been facilitated by economic development, resulting, for example, in improved levels of nutrition and lower levels of associated child stunting.

      At the same time, the review of progress made during this period combined with the assessment of the current health landscape in the Region highlights key areas where there is still much work to be done. Pursuit of the MDG contributed to improved outcomes in health for the Region; however, it also highlighted challenges with regard to equity of outcomes. While the achievements made during this time period can be lauded, other challenges have appeared in their place. In some areas, progress has stagnated. For example, despite reaching the MDG target of halving the rate of extreme poverty (), the reduction in rates in the Americas has slowed to a near halt in recent years (). This has severe implications for the Region as poverty has a direct impact on access to decent housing, services, education, transport, and other vital factors for overall health and well-being (). In fact, poverty is arguably the single largest determinant of health (). A recent publication from the World Bank Group on chronic poverty estimated that one in four people in Latin America and the Caribbean (LAC) are still living below the poverty line (). Compounding concerns over mobility, the United Nations Development Program (UNDP) estimates that over 200 million people in the Region subsist just above the poverty line of US$ 4 a day, outside of the middle classes not yet included in income classifications as poor (). These individuals are considered to be at high risk of falling into poverty should a financial crisis or natural disaster strike. This type of transient poverty (that is, poverty experienced as the result of a temporary fall in income or expenditure) generates variability and thus inequality in the poverty status of individuals ().

      Additionally, the favorable trends that have been reflected in national and regional averages mask the gaps in progress that remain both within and between countries. A more nuanced look at the regional and national averages disaggregated by income and social strata reveals substantial gaps in equity between and within countries in the Region (). Most notably, in 2015, while the Region of the Americas had one of the highest reported average for life expectancy at birth (76.9) (), a closer look at country-specific data reveals that the difference in life expectancy at birth between countries was as great as 18 years (). The Region’s apparent success with regard to eradicating poverty also demonstrates the MDGs focus on national averages rather than on progress at subnational levels and across different population groups (). The Economic Commission for Latin America and the Caribbean (ECLAC) 2014 edition of Social Panorama of Latin America confirmed that not everyone in the Region has reaped the same benefits on this front as the downward trend in poverty over the last 15 years was greater among the wealthiest groups than among the most disadvantaged (). Many individuals categorized as chronically poor were unable to escape poverty during this time period. Labor income was a powerful driver behind the immense reduction in poverty over the last decade. The chronically poor face greater barriers to entering the labor force, reducing their opportunity for employment and exacerbating the cycle of chronic poverty. Poverty also continues to be concentrated within certain ethnic groups. In the Region of the Americas, indigenous peoples remain among the poorest and, in some areas, the income gap between them and other population groups has grown even wider ().

      These findings highlight the concerns that programming to achieve the MDGs did not go far enough in terms of reaching less advantaged populations. Regional successes relate disproportionately to the “low-hanging fruit” of those already better served by public services. This paradox highlights the genuine limitations of the MDG-era achievements. While true success has been achieved in terms of global health indicators, many of these successes fall short when viewed through the equity lens.

      Core regional challenges

      Monitoring inequities and the factors that determine them is a challenge for existing information systems, requiring changes in the types of data the health sector collects. Information gathering entails choosing basic health indicators, stratifying criteria, and applying indices to measure both inequities and inequalities (). Conversely, it also offers the opportunity to measure multiple facets of health outcomes: who we are, how we live and die, and which events and circumstances play deciding or influential factors in determining these outcomes, at both the individual and population levels. Though numerous MDG targets were achieved, it must be noted that, almost universally, progress by wealthier, more privileged members of society exceeded that of the more disadvantaged. Furthermore, MDG targets that were not achieved indicate continuing Regional challenges in addressing health outcomes related to gender, sexual and reproductive health, communicable diseases, noncommunicable diseases, mental health, and access to care. This section examines the inequities and inequalities related to a sample of Region-specific issues in reproductive and maternal health, communicable and noncommunicable diseases, and mental health that will require more concerted action on the social determinants of health to improve health outcomes in these areas.

      Reproductive and maternal health

      The health of mothers can directly affect the health of their children. The cycle that is created from this dynamic potentially allows health inequalities to remain concentrated in certain populations for generations. While progress was made in terms of reducing the under-5 mortality rate during the MDGs era, on a global scale, maternal mortality remains incredibly high, reflecting the presence of inequities in access to health services, such as routine reproductive health care. A lack of access to basic services results in many unmet health care needs, such as contraceptive needs, unintended pregnancies, undiagnosed sexually transmitted infections, and undiagnosed cancers.

      In order for barriers to be addressed and for progress to be made, it is imperative that social policies recognize the role of gender as a strong structural determinant of health. For example, women have higher health care costs than men due to their greater use of health care services. At the same time, women are more likely than men to be poor, unemployed, or engaged in work that does not provide health care benefits (). That said, gender alone does not account for all of the barriers women face in accessing care. Access to the necessary resources for health attainment is further restricted by the intersections between gender inequality and other important determinants of health such as income, education, age, ethnicity, and sexual orientation, leaving vulnerable populations at an especially high risk. For example, in Latin America and the Caribbean, women from the poorest quintile have greater unmet health needs, such as the need for contraception, compared to women from the wealthiest quintile (). Lower levels of income and ethnic background have been associated with early sexual initiation. Early sexual initiation is often associated with risks of both adolescent pregnancy among young women and adverse sexual health outcomes, such as sexually transmitted infections, thereby exposing less-advantaged populations to a double burden of infectious disease and barriers to women’s socioeconomic mobility (). Additionally, women in rural communities do not have equal access to convenient, affordable, or culturally appropriate reproductive health services and education. Women from racial/ethnic minorities frequently experience social and economic exclusion—yet another example of an unequal situation that produces health inequities at numerous moments throughout the life course, particularly during pregnancy and childbirth.

      Within the Region of the Americas, reducing maternal mortality also remains a persistent challenge despite the fact that numerous Member States reported having adopted policies, programs, or plans for gender and health. This has troubling implications for the Region’s ability to meet the needs of women, despite the avowed political commitment. National and subnational inequalities in the maternal mortality rate are prominent (). Data from 2015 revealed stark differences between countries in the maternal mortality rate per 100,000 live births, with numerous countries reporting rates far below or far above the Regional average of 81 per 100,000 live births (Figure 2) (). These findings echo the point that has been made from a variety of Regional stakeholders, that the focus must remain on gaps in achievement of the MDGs, recognizing that however challenging the achievement of MDG targets was, there is still considerable work to be done to ensure that these targets are met on an equitable basis ().

      Figure 2. Maternal mortality rate (per 100,000 live births), 2015

      Source: World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Population Division.Trends in maternal mortality: 1990 to 2015. Geneva: WHO; 2015.
      Available from: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1.

      Communicable diseases

      The incidence of major infectious diseases has declined globally since 2000. Regardless, communicable diseases remain a prominent global challenge. For many years, the “big three” of HIV, tuberculosis, and malaria have overshadowed others, leading to the emergence of the “neglected diseases” category, also referred to as “neglected tropical diseases” (NTD). The SDG recognize NTD as a major global threat, with an estimated 1.7 billion people across 185 countries requiring treatment for NTD in 2014 (). The pressing concern of NTD, as well as other vector- and water-borne diseases, led to the adoption of the target 3.3 within the SDG, “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”

      NTD encompass a group of pathologies that disproportionally impact resource-constrained areas of the world, subject to inadequate response systems, resources, and the ability to mitigate harm, in addition to the level of harmful environmental exposures. Numerous determinants affect the spread of communicable diseases. These determinants include, but are not limited to, water and sanitation, housing and population clustering, climate change, gender inequity, sociocultural factors, and poverty. The relationship between these determinants and health and equity is rather complex given that these determinants are often overlapping. For example, housing and population clustering can be viewed as an intermediary social determinant for NTD as it has direct links with poverty as a structural social determinant. It must be recognized that the spread of these diseases is often perpetuated by multiple environmental and social determinants coupled with a lack of resources for prevention and care, and due attention afforded to the issue by policymakers.

      Noncommunicable diseases and mental health

      Noncommunicable diseases (NCD) have been identified as a major challenge to sustainable development in the 21st century and are therefore central to the post-2015 development agenda (). The rise of NCD has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets. Efforts to address these risk factors have been met with numerous challenges, many of which are attributed to the prioritization of wealth over health by other sectors. There has been substantial growth in the provision of processed foods and products that are linked to higher levels of obesity, diabetes, and other diet-related chronic diseases ().

      NCD represent a substantial disease burden in the Americas in terms of both mortality share and impact upon disability-adjusted life year (DALY) rates (). Looking at the proportional mortality in the Americas, the burden of NCD appears staggering, with the overall proportion of deaths attributed to NCD ranging from 60% to 89% (Figure 3) (). Moreover, not all social groups are affected by NCD in the same way. NCD risk factors are much higher among poor populations. In fact, substantial differences in DALYs across income levels exist in the Americas (). There is also a strong correlation between low education levels and high rates of NCD in low-, middle-, and high-income countries. Given this, there has been a shift towards interventions focused on risk factors and their related environmental, economic, social, and behavioral determinants. Additionally, differing characteristics of inequity and inequality within and between countries require country-specific contexts to be taken into consideration when addressing NCD. Changing demographics give cause for concern, as does the impact of increasing economic prosperity on individual health once a particular threshold is passed. For example, a 2016 study on socioeconomic status and health in adolescents found a positive correlation between socioeconomic status and sedentary behavior, which is associated with risk of NCD, suggesting that this group may respond to interventions that target this behavior (). In these cases, health does not always follow wealth, highlighting the complex nature of inequalities and the social determinants of health ().

      Figure 3. Proportional mortality in the Americas by subregion, 2012

      Source: Escamilla-Cejudo JA, Sanhueza A, Legetic B. The burden of noncommunicable diseases in the Americas and the social determinants of health. In: DCP3 Disease Control Priorities. Section 2: socioeconomic dimensions of the impact of NCD. 3rd ed. Seattle: Disease Control Priorities Network; 2013:13–22. ().

      Mental health also has been inextricably linked to NCD and their outcomes. The prevalence and social distribution of mental health disorders has been well documented in high-income countries, but there is a growing recognition of the issue in low- and middle-income countries. Evidence suggests that social risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the risk (). Accordingly, mental health disorders can be shaped by various social, economic, and physical environments () operating at different stages of life—not only in early life when there is a higher predisposition to develop a mental health disorder, but also at older ages, and during working and family-building years (). The impact of these social determinants on mental health can be accumulated over the life course (hence the importance of employing the “life course perspective” in considering fundamental causes of health and morbidity), increasing the severity of mental health disorders and/or the incidence of new ones.

      Studies have shown that the more relevant SDH associated with mental health disorders include income, education level, gender, age, ethnicity, and geographic area of residence. For example, increased rates of depression and substance use are systematically associated with lower income levels (). The poor and disadvantaged suffer disproportionately from common mental disorders (depression, anxiety, suicide, etc.) and their adverse consequences (). In addition to household income, low educational attainment, material disadvantage, and unemployment are other factors leading to common mental disorders (). Gender is another important social determinant: certain mental health disorders are more prevalent in women than in men (), and, in fact, women frequently experience the impact of social, economic, and environmental determinants in different ways than men (). For example, women report more suicide attempts while men commit more fatal suicides (). Regarding substance abuse, though men are more likely to engage in risky behavior and develop drug-related problems, women suffering from addiction are less likely to seek treatment for substance abuse due to societal barriers in place ().

      In the Region of the Americas, there is increasing interest in the relationship between working conditions and mental disorders, particularly depression and anxiety. Mental health disorders affect many employees in the Region, a fact that in the past has been overlooked because these disorders have tended to be hidden in the workplace. As a consequence, mental health disorders often go unrecognized and untreated, not only damaging an individual’s health and career but also reducing productivity at work ().

      The social determinants of health approach to core Regional challenges

      Given the close links between health equity and the underlying determinants of health, an integrated and systematic approach to address the underlying determinants of health is essential for reducing health inequities. The idea that health is created in the context of everyday life as opposed to being limited to health service-oriented settings was articulated in the 1986 Ottawa Charter for Health Promotion (). The Ottawa Charter drew strong links between the principles of health promotion and the SDH, both of which consider health to be an ecological phenomenon, created and modified by the wider system of factors that influence how individuals, as well as population groups, experience daily life and long-term trends throughout the life course. Taking into account the contextual determinants of health and health behaviors, a vigorous health promotion response is another essential component to addressing health challenges ().

      Recently, health promotion in the Region has focused on the creation of healthy and supportive municipalities, workplaces, housing, schools, and universities. As part of this strategy, there has been a reactivation of the various health-promoting networks at the Regional level, namely Healthy Cities, Municipalities and Communities; Health-Promoting Universities; and Health-Promoting Schools. For example, while both Mexico and Cuba have maintained full coverage of Healthy Cities for over 20 years, numerous cities in the Region of the Americans have joined this movement in recent years. Prominent cities include Medellín, Cali, and Bogotá in Colombia; Curitiba, Guarulhos, and São Paulo in Brazil; La Granja, Chile; Cienfuegos, Cuba; and Buenos Aires, Argentina.

      Building on the Declaration of Alma-Ata, the Ottawa Charter also highlighted the need for all sectors to invest in health and the need for the expansion of the concept of health determinants in order to “build healthy public policies.” Currently, a strategic approach to harness action across all sectors, known as Health in All Policies (HiAP), is being implemented in countries. The Helsinki Statement on Health in All Policies (2013), articulated HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve populations health and health equity” (). HiAP emerged from the increasing recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors. HiAP is known as the “operational arm” of the SDH approach precisely because many of the health inequities outlined have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health. In order to truly achieve equity in health, the “one size fits all” approach must be avoided. The various policy interests involved in the conditions that produce healthy (or unhealthy) outcomes require coordination, stewardship at the highest level of government, mutual appreciation for distinct priorities and capacities of different sectors, and skills in communication and negotiation that have not traditionally been part of the public health sphere. HiAP establishes a strategic approach that provides advocates and policy makers with guidance to address the “causes of the causes” of ill health and to develop intersectoral effective action.

      In line with the Helsinki Statement, the HiAP approach promotes sustained collaboration among sectors whose policies and practices have significant influence on health outcomes such as those discussed (). It sets out concrete priorities and practices to support positive action on the SDH (). The approach has been well received in the Region of the Americas, the first WHO Region to establish a Regional Plan of Action on Health in All Policies (2014) (). The Regional Plan of Action on HiAP marks a significant milestone in the global acceptance of the HiAP approach to encourage collective and coordinated action for health. Progress since then in the Americas includes a series of guiding documentation and activity designed to support Member States in implementation, largely under the rubric of the aforementioned HiAP initiative and including the Road Map for the Plan of Action on Health in All Policies (), the creation of a Health in All Policies in the Sustainable Development Goals Task Force and Working Group, and the Commission on Equity and Health Inequalities in the Region of the Americas. Additionally, countries including Brazil, Chile, Mexico, and Suriname (see Box), have recently embarked on consolidating actions in this area through capacity building and planning that will ensure that health is firmly placed at the crux of national policy development and planning. Such action is being complemented by PAHO through the work of Commission on Equity and Health Inequalities in the Region of the Americas.

      The Suriname experience—implementing health in all policies to address the social determinants of health

      After hosting the subregion’s first HiAP training in Paramaribo, the government of Suriname began immediately moving towards implementation of the HiAP approach to address the social determinants of health. Under the leadership of the Ministry of Health and with support from PAHO, the Government of Suriname implemented a Quick Assessment of the Social Determinants of Health to understand the underlying causes of major health problems and associated health inequities. Results from the assessment of available data found that, in Suriname, the social determinants that are predominately related to the major diseases contributing to DALYS are geographical location, socioeconomic status, population group, and gender. These findings were used to establish eight country-specific areas of action for the implementation of HiAP. Suriname’s experience demonstrates the success of taking on a multisectoral approach to health and highlights the strong links between the social determinants of health and HiAP.

      Source: Pan American Health Organization. Health in All Policies in the Americas. Health in All Policies approach: quick assessment of health inequities. [Internet]; 2015. Available from: http://saludentodaslaspoliticas.org/en/experiencia-amp.php?id=29.

      Given the strong overlap of the goals, means, and priorities associated with the SDH approach, health promotion, and HiAP, progress made on one front has great potential to simultaneously advance the others. Additionally, the successful implementation of HiAP and health promotion throughout the Region demonstrates that the factors that affect health and well-being can be addressed through the establishment of sustainable public policies, the creation of intersectoral partnerships, the development of supportive environments, the active participation of local governments and communities, and the strengthening and sustainability of new and existing networks (). The focus on an inclusive and participatory approach and collaboration across sectors is echoed by the global community’s recent commitment to implement the 2030 Agenda and the Sustainable Development Goals (SDG).

      Advances achieved in the key action areas identified by the Rio Declaration

      Within the Americas, individual countries and Regional bodies have made considerable progress in implementing the SDH agenda. Practitioners, policymakers, and the public alike have been receptive to this equity-oriented approach, advancing a range of initiatives to address some of the gross health inequalities that feature nationally and regionally using SDH tools. The Rio Political Declaration on Social Determinants of Health continues to serve as a guiding principle for the successful implementation of the SDH approach. In line with the recommendations of the Commission on Social Determinants of Health (), the Rio Declaration established five key action areas on SDH at the global, national, and local levels (). These key areas optimize the potential of the approach to reduce inequities and achieve targets set by the Region and help build momentum within countries for the development of dedicated national action plans and strategies. Accordingly, a review of the advances and progress in addressing the SDH over the last 5 years, within the context of the Rio Declaration, is merited.

      1. Key area: improve governance for health and development

      Improving health means improving governance in health and development. The three main arguments supporting this assertion are as follows: (1) health is unevenly distributed, (2) many health determinants are dependent on political action, and (3) health is a critical dimension of human rights and citizenship (). Improved governance is therefore essential to advance human health and development. In this context, the term governance refers to the interaction between governments (including their different constituent sectors) and other social organizations, how governments and organizations relate to civil society, and how decisions are taken in a complex and globalized world ().

      Improving governance for health and development and addressing the social determinants involves transparent and inclusive decision-making processes that give voice to all groups and sectors involved (). Actions within this area pertain to government structures and the development of social and environmental policies and programs that aim to reduce inequity in health. In order to provide guidance to countries, the following five principles of good governance have been identified to better address the SDH ():

      1. Legitimacy: Processes focused on the implementation of policies that impact the SDH must ensure legitimacy by providing a voice to all stakeholders involved, including those affected by the decisions.
      2. Direction: Work on the SDH requires a clear, strategic vision for promoting the SDH agenda.
      3. Performance: The mechanisms for decision-making on the SDH must be responsive to all stakeholders and encourage participation.
      4. Accountability: All actors must be held accountable for the decisions made in respect to the shared goals.
      5. Fairness: Decision-making should be fair and aim to reduce inequalities in health.

      These principles demonstrate that effective governance requires a range of conditions, including the creation of conducive policy frameworks; accountability and ongoing participation of civil society and nontraditional partners; and emphasis on shared values, interests, and objectives among partners. Successful implementation of an SDH approach to improve health and well-being requires the establishment of governance mechanisms that delineate the individual and joint responsibilities of different actors and sectors in the pursuit of health and well-being.

      A lack of coordination among different actors and conflicting interests can constitute a significant barrier to advancing development. This touches on another important concept, namely the commercial determinants of health, defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (). Historically, there has been criticism from the public health sector regarding the influence of the corporate sector on health and well-being. There are four main channels through which corporate influence is exerted: (1) marketing, (2) lobbying, (3) corporate social responsibility strategies, and (4) extensive supply chains. The focus on lifestyle choices has been extensively analyzed, particularly in regards to tobacco marketing and the marketing of unhealthy commodities towards children (). There is now a growing body of evidence to suggest that the tobacco, food, drink, and alcohol industries have on occasion employed tactics and strategies to undermine public health, and policymakers have faced difficulties to effectively mitigate against the impact of such strategies.

      Action across all sectors—Regional approach to reducing traffic-related injuries and deaths

      The Region’s progress in reducing traffic-related injuries and deaths is an example of collaboration and intersectoral action in practice. Intersectoral strategies include improving road infrastructure, updating transportation legislation, and promoting vehicle inspections and safety standards. Numerous countries within the Region have created national policies promoting sustainable and safe public transportation. Specific countries implementing safe transportation practices include Argentina, Cuba, Guatemala, Jamaica, Panama, Peru, and Uruguay. Additionally, 27 countries created road safety agencies between October 2011 and December 2014. Fifteen countries passed laws setting the blood alcohol limit for drivers, 32 countries approved laws making seatbelt use compulsory for all passengers in vehicles, and 30 countries passed laws on compulsory helmet use for all motorcycle passengers.

      Source: Pan American Health Organization. Progress report on plan of action on road safety. 54th Directing Council of PAHO; 67th
      Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 September 28-October 2 (CD54/INF/5)

      An example of intersectoral action for health at work is Mexico’s National Agreement for Healthy Food (). This agreement is an intersectoral initiative to address the determinants of obesity, by regulating access to food and beverages and providing supportive environments for healthy lifestyles. The agreement received political support from the highest levels of the federal government, and has been implemented through several federal government agencies including finance, social development, education, economics, agriculture, rural development, workplace safety, and health. The program focuses on reducing inequity by giving particular attention to the prevalence of overweight and obesity in children, low-income populations, and indigenous communities. Under the agreement, the food and beverage industries were held accountable for their role in health outcomes, particularly those of children. The objective here was to work with the food and beverage industries to contribute to health more positively by incorporating health-promoting principles into their campaigns while at the same time limiting the marketing of unhealthy foods and beverages towards children. Since the program was first implemented, much progress has been made, particularly in terms of the regulation of media advertisements and the sale and distribution of unhealthy foods and beverages in schools ().

      2. Key area: promote participation in policy-making and implementation

      Successful action on the SDH requires the participation of communities and civil society groups in the creation of policies, and the monitoring and evaluation of their implementation. Civil society has a critical role to play in identifying priority areas for action, generating evidence for work on the SDH, and by holding policymakers and program implementers accountable for the actions they undertake and the commitments they make. Governments can play an active role in promoting participation by offering incentives, subsidizing costs, and ensuring legitimacy and transparency. Improving transparency in policy-making on the determinants of health is critical for the adoption and implementation of successful and inclusive policies.

      A recent report from the World Bank and PAHO, Toward universal health coverage and equity in Latin America and the Caribbean evidence from selected countries, noted that governments have made progress in supporting and promoting the participation of civil society in the policy-making process (). Bolivia, Ecuador, and Venezuela, among other countries, have have inscribed social participation in their constitutions as a means of reducing social and economic inequality (). Additionally, as of 2014, nine countries and territories reported having specific mechanisms in place to engage communities and civil society in the policy development process across sectors.

      Case Study: Ecuador’s National Plan of Good Living

      Ecuador’s Plan nacional para el buen vivir (National Plan for Good Living, or NPGL) is an example of the successful involvement of civil society in policy-making and implementation. Ecuador’s countrywide action plan incorporates an SDH approach to health and policy and is committed to developing and implementing social policies. The plan was developed through consultation with diverse actors and recognizes citizen participation as a basic right. In order to identify specific needs within the policy, forums for dialogue were created to enable the participation of different groups, including women and men from different social-cultural backgrounds, of different ages and sexual orientation, to provide their opinion on the achievements of the previous National Development Plan. The feedback given was incorporated into the new plan. The NPGL consists of specific sectoral work plans consistent with national strategy and priorities, with one specific work plan being dedicated to health. The health sector work plan adopts the SDH approach and its goals are set through multiple sectors including health, education, and housing, among others. Ecuador’s NPGL serves as a concrete example of the successful use of the SDH approach in the development of new policies with the input and participation of citizens and different social groups.

      Sources: National Secretariat of Planning and Development. Good living: a better life for everyone 2013–2017 [Internet]; 2013.
      Available from:http://www.plani6cacion.gob.ec/wpcontent/
      uploads/downloads/2013/12/Buen-Vivir-ingles-web-6nalcompleto.pdf.
      .

      Throughout the Region, efforts have also been made to engage previously excluded populations. As of 2014, 10 countries and territories reported having specific strategies in place to involve marginalized groups in policy discussions at the local, subnational, and national levels (). Actions are ongoing to promote mental health and well-being in indigenous populations. Indigenous populations are disproportionately affected by an array of common mental disorders. These groups have different ways of conceptualizing their health issues and of organizing care, as determined by historical, geographic, and cultural factors. Argentina, Brazil, Canada, and Chile, among others, have promoted fora for dialogue with the participation of indigenous practitioners, clinical health, public health, anthropology, and mental health specialists, where each of the actors share their knowledge and best practices spanning different indigenous communities.

      3. Key area: further guide the health sector towards reducing health inequalities

      Reducing health inequities and inequalities through transformation of the health system is core to PAHO’s Strategy for Universal Access to Health and Universal Health Coverage, adopted in 2014 (). The strategy expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the SDH and health inequities. It argues that “universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and provide a society-wide commitment to fostering health and well-being” (). The strategy makes the case that gender, ethnicity, age, and economic and social status are social determinants that have a positive or negative impact on health inequities, the reduction of which is a core objective of universal health.

      In the Region, Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, Jamaica, Mexico, Peru, and Uruguay have implemented an array of policies to increase the scope and equity of health programs (). There has also been Regional progress in expanding health care services and resources to persons with disabilities. In October 2014, ministers of health throughout the Americas pledged to improve access to health and rehabilitation for people with disabilities and to safeguard their rights. To demonstrate this commitment, the Regional Plan of Action on Disabilities and Rehabilitation was approved by PAHO Member States in 2014. This plan calls for a stronger, more integrated health sector response in supporting persons with disabilities, their families, and caregivers. Countries that have demonstrated notable efforts towards a more integrated health sector response in supporting persons with disabilities, their families, and caregivers include Chile, Guyana, and Mexico ().

      The strategies adopted by countries to transform the health system moving towards universal health are presented elsewhere in this chapter, specifically in the discussions relating to access to health services, improved health governance and stewardship, and health financing. Here, however, it is important to note that efforts to address health inequities, as they relate to the SDH, must vary depending on the context of the country, existing health inequities, and the structure of social and health systems. For example, in examining the health situation of women in La Paz, Bolivia, critical variations were found in several conditions: cancer (especially cervical-uterine cancer), maternal mortality, sexual and reproductive health, the impact of HIV/AIDS, and domestic and intrafamily violence. Women reported significantly lower health care coverage and minimal participation in the promotion and care of their own health. Evidence suggests that this was due to discrimination, mistreatment, and the lack of available services that address needs specific to women. The STAR Health Services initiative was developed by the health department in La Paz from 2004 to 2006 later focusing on the Pampahasi Bajo health services (). The initiative aimed to improve health conditions by strengthening the management of services, ensuring “quality with a focus on gender” and the development of processes that empower women in their community (primarily migrant Aymarans and those living in poor areas).

      During the first phase of the initiative, gender considerations were successfully integrated into the primary health care framework. These adjustments included improvements in signs posted, the use of native language and curtains for privacy, easier scheduling,, more accessible and informative literature, the organization of health service teams, better treatment of patients, the monitoring of user satisfaction, and the development of a community education program that raised awareness and strengthened the respect for women’s health care rights. The initiative served to reestablish the role of the health team as an “agent of change” responsible for confronting gender-based issues and promoting gender sensitivity within the existing healthcare delivery system. It demonstrated the need for collaborative planning among health staff and community organizations to address differentiated needs and to respond appropriately to the inequities at hand.

      4. Key area: strengthen global governance and collaboration

      Ensuring political coherence requires action on the SDH both within countries and internationally. International collaboration towards the adoption of coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health is an important component in advancing an SDH approach. Reforming global governance for health is a necessary component for achieving global health with justice, as this goal requires international and domestic responsibilities that are centered on human rights (). For example, the Framework, was developed in response to the globalization of the tobacco epidemic to demonstrate the commitment of all countries to combating this health crisis. Thirty countries in the Region of the Americas are State Parties to the Convention (). Brazil was one of the first signatories of the WHO Framework Convention on Tobacco Control, and created an intersectoral commission called the National Commission for the Implementation of the Framework Convention on Tobacco Control and its Protocols. Tasked with developing and implementing policies to reduce tobacco consumption, 18 different governmental sectors collaborated to produce the National Policy for Tobacco Control (). They also passed other legislative changes to regulate tobacco product costs and marketing, and even to provide technical and financial support for small-scale tobacco farmers to diversify their crop production.

      Some more recent prominent international conferences that address health and development include the Third International Conference on Financing for Development, the 2015 UN Summit (during which the Sustainable Development Goals were adopted), the 2015 UN Climate Change Conference, and the Seventh World Urban Forum, to name a few. These conferences have considered including commitments for advancing global health and its determinants (). For example, the Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects of climate change on health.

      <

      The Paris Agreement for Climate Action: a global commitment

      The Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects climate change has on health. The Paris Agreement is a global initiative to protect population health from harmful and unhealthy products and environments. In 2016, 31 PAHO Member States signed the Paris Agreement, including Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Canada, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, Granada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, the United States of America, Uruguay, and Venezuela.

      Sources: UN Climate Change Newsroom. Paris Agreement signature ceremony [Internet]; 2015. Available from: http://newsroom.unfccc.int/media/632121/list-of-representatives-to-high-level-signature-ceremony.pdf. United Nations. Paris Agreement-status of ratification [Internet]; 2016. Available from: http://unfccc.int/paris_agreement/items/9444.php.

      5. Key area: monitor progress and increase accountability

      It is imperative that the implementation of policies that address the SDH be informed by evidence. The availability of data, or lack thereof, adversely impacts decision-making in policy development and public health action, and in shaping what research can or will be done. Building the evidence base for intersectoral action that addresses the SDH will be necessary to improve our understanding of populations that experience the greatest levels of inequality, and the interventions that are required to address inequities and disparities. This is particularly relevant for many low- and middle-income countries where there are significant limitations in the available data, namely, disaggregated data for socioeconomic status, ethnicity, and education levels as well as other important health determinants ().

      As a result of the priorities established in the MDG agenda, there is a greater preponderance of data related to reproductive, maternal, and child health, allowing for a more detailed analysis of socioeconomic inequalities in these areas. However, countries are now being tasked with meeting SDG 17, which specifically calls for the “availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts.” The need to address this challenge is of particular relevance when developing monitoring mechanisms for SDG 3, to ensure healthy lives and promote well-being for all at all ages. The limited data associated with NCD as well as measures for universal health coverage means that countries will need to build capacity in assessing health inequalities as they relate to the SDH and these health priority areas. The Health Inequality Monitoring Framework developed by the WHO along with the Health Equity Monitor, as part of the Global Health Observatory, provides a guide and resource to countries when building monitoring capacity. Ensuring the comparability of data is essential for sharing successes and challenges when addressing health inequalities at the national level. The Region of the Americas has already taken action on this front through the inclusion of indicators measuring inequality in the 2014–2019 Strategic Plan of the Pan American Health Organization. Countries are responding to the challenge of generating disaggregated data by establishing observatories for the measurement of inequalities and health inequities. Already, Uruguay and Colombia have established national observatories that use the WHO Framework for monitoring inequalities, and Mexico is in the process of establishing its own health inequity monitoring system.

      Monitoring the progress made during the MDG era has played an important role in identifying key areas for future action as well as core health issues that still remain to be addressed. The Region of the Americas has shown a strong commitment to identifying these key areas. Throughout the Region, countries have begun establishing national/regional networks of multisectoral working groups and stakeholders to evaluate the impact of government policies on health and health equity. As of 2014, six countries reported having these networks in place. Additionally, in May 2016, ECLAC presented a document, Horizons 2030: equality at the centre of sustainable development, which takes an in-depth look at the key challenges and opportunities for implementation of this approach in the Region (). The Member States of ECLAC also recently adopted resolution 700(XXXVI) establishing the Forum of the Countries of Latin America and the Caribbean on Sustainable Development, a body responsible for monitoring and reporting on implementation of the wider 2030 Agenda. A series of priorities has been articulated by ECLAC to support this approach, which both strengthens and reinforces the connections between the SDH, equality, and sustainable development, namely, strengthening the regional institutional architecture, enhancing analysis of the means of implementation of the 2030 Agenda at the Regional level, supporting the integration of the SDG into national development plans and budgets, and promoting the integration of the measurement processes to build SDG indicators into national and regional strategies for the development of statistics and statistics capacity (). Several of these components—particularly strengthening statistics capacity at the country level, which facilitates examination of the population groups benefiting most and least from certain policies and interventions—have profound implications for achieving equity and improving health.

      Additionally, monitoring and surveillance systems have been identified as key to guiding the adoption of new programs and policies. Given the varying national contexts within the Region, programming must be sensitive to the landscape of social determinants within each country. Therefore, country-specific programming is required as opposed to a broad-brush Regional approach. A number of new surveillance initiatives have been developed in order to better understand the arising health needs that vary within and between countries. In 2013, UN-Habitat introduced a measure for prosperity, the City Prosperity Index, with the intention of helping decision-makers design appropriate policy interventions (). Since its creation, the City Prosperity Index has been applied in numerous cities in the Region, including Buenos Aires, Ciudad Obregón, Fortaleza, Guadalajara, Guayaquil, Guatemala City, Lima, Medellín, Mexico City, Montreal, New York, Panama City, Quito, São Paulo, and Toronto. Moving forward, the relationships between health outcomes and social stratification variables must be clearly established, and developing accountability mechanisms in policy-making will be essential.

      Towards sustainable development

      The 2030 Agenda for Sustainable Development named eradicating poverty, in all forms and dimensions, as one of the greatest challenges facing humanity as well as a core component to achieving sustainable development (). The 2030 Agenda and the 17 SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the population. Poverty is explicitly highlighted in Goal 1 of the SDGs, which calls for an end to poverty by 2030 (). Achieving this goal entails targeting the most vulnerable populations through poverty-reduction strategies. These strategies involve the development and use of cross-sectoral development frameworks that tackle the cause and effect of poverty in a country (). Based on the broad consensus of leading development agencies, successful poverty-reduction strategies must be results oriented, comprehensive, country specific, participatory, collaborative, and long term (). In the Region, a large number of countries have expanded coverage and noncontributory benefits to specific populations through poverty reduction strategies in the form of special plans and programs. In several countries, these programs have contributed to reducing poverty and extreme poverty, particularly in rural areas.

      Conditional cash transfers (CCT), which are programs through which cash can be transferred to families in extreme poverty, have been recognized as evidence-based mechanisms for both reducing poverty and improving health. These programs also serve as important contributors to human development and social protection. CCT programs have a long-standing history throughout the Region. From the earliest transfer programs in the mid- to late 1990s in Mexico to the Federal District in Brazil, practically every country within the Region has deployed these types of programs. Positive outcomes are evident in significant, albeit modest, improvements in school enrollment, education outcomes, and overall early childhood development. Progress in health has been demonstrated across several indicators including infant mortality, maternal health, immunization, access to nutritious food, and quality of services accessed. As poverty often manifests itself in the form of hunger and malnutrition, the success of these interventions in regards to food and nutrition are particularly relevant for vulnerable groups and those living in extreme poverty. That said, contextual goals and benchmarks that respond appropriately to domestic priorities are critical to this process (). It is worth noting that the greatest advances in these trends have occurred in countries with modest welfare gaps such as Argentina, Brazil, Chile, Uruguay, and, to a lesser extent, Panama. However, Ecuador, Bolivia, El Salvador, and, to a lesser extent, Mexico, have positively escaped this generalization as these countries have enacted successful initiatives despite having very low fiscal commitment. As both poverty and growing inequality are detrimental to economic growth and undermine social cohesion, practical solutions such as these that pertain to the common challenges of human development will be crucial moving forward.

      Conditional cash transfers: improving outcomes for the most vulnerable

      The effects of poverty are particularly harmful in vulnerable populations such as infants and children. Many CCTs have therefore set their focus on maternal and child health. For example, Juntos (“Together”), a cash-transfer program in Peru, aims to lift children out of poverty and improve their education, health, and nutrition. While the program appeared to lead to modest improvements in school enrollment (a 4% increase), a recent evaluation found that Juntos has mitigated the problem of extreme chronic malnutrition among its child participants. The program has also successfully enhanced access to resources and services. Since 2012, Juntos has been managed by the Ministry of Social Development and Inclusion, in coordination with various ministries in charge of social affairs. This cooperation across sectors opened access to the variety of public services offered by each individual ministry.

      The Uruguay Grows with You program outlines another platform for success, which runs highly focused activities targeting the most vulnerable citizens. The impact on those enrolled has been substantial thus far, reducing the level of depression in mothers and pregnant women from 31% to 16% since 2012. Other actions include the inclusion in social safety nets, such as family allowances and housing programs, and the construction of inclusive policies. The latter is especially important as the development of inclusive policies helps promote economic opportunities for the poor.

      Both in Uruguay and Peru, contextual implementation was key, yet in each case, and elsewhere in the Region, integrating different institutional sectors into an overall strategy has allowed policymakers to create all-encompassing strategies to combat poverty in novel and effective manners.

      Conclusion

      As the Region transitions from the MDGs into the new 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs), addressing health inequities must be seen as priority. It is important to benefit from the lessons learned and address unfinished business through the new development agenda (). This new Agenda is the product of an unprecedented inclusive and collaborative process and is unique in that it integrates all three dimensions of sustainable development (economic, social, and environmental) around people, the planet, prosperity, peace, and partnership. The targets set by the SDGs seek to go beyond the scope of MDGs while addressing the most important social, economic, environmental, and governance challenges of our time. The SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the world’s population (). The implementation of the SDGs provides a unique opportunity to address the “causes of the causes” and shape health outcomes through a stronger focus on the differential distribution in access to health services. Whereas traditional approaches to public health and health promotion addressing risk factors centered around individual “risky” behavior remain relevant, increasingly (regionally and globally) attention is shifting to examine macroscale processes involving trade, global markets, and geopolitical relationships as determinants of health (). Surveillance systems will need to be enhanced for the wider social monitoring of the goals of SDH, the SDGs, and HiAP.

      The Strategy for Universal Access to Health and Universal Health Coverage constitutes a call for action, for the health sector to progressively expand integrated quality health services, and beyond the health sector, in the implementation of health policies, plans, and programs that are equitable and efficient and that respect the differentiated needs of the population. Health is a key component of sustainable human development, and universal access to health and universal health coverage are essential for the achievement of better health outcomes in order to ensure healthy life and promote the well-being of all.

      As countries continue to develop people-centered, robust, and resilient health systems, efforts must continue to intensify intersectoral action focusing on areas outside of the health sector to improve equity, health, and well-being, in accordance with the 2030 Agenda, for Sustainable Development and the Sustainable Development Goals and the SDGs. The breadth and ambition of the 2030 Agenda for Sustainable Development, and the interlinked nature of the 17 SDGs, require a national, regional, and global response that harnesses cooperative action across sectors. From the education of women and girls to taxation of nonnutritious foods, from healthy living spaces to health financing, universal health will only be achieved through a concerted effort to address the social determinants of health, and the development of key strategic partnerships involving actors well outside of the health sector.

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