Pan American Health Organization

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
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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/.

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Reference/Note:

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.

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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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Reference/Note:

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