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.

References

1. United Nations General Assembly. United Nations millennium declaration. 55th Session of the General Assembly, New York, 2000 Sept. 18 (A/Res/55/2). Available from: http://www.un.org/millennium/declaration/ares552e.pdf.

2. United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development. 70th Session of the General Assembly, New York, 2015 Oct. 21 (A/Res/70/1). Available from: http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E.

3. Pan American Health Organization. Preparing the Region of the Americas to achieve the Sustainable Development Goal on health . Washington, D.C.: PAHO; 2015. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/10016/9789275118634_eng.pdf?sequence=1&isAllowed=y/.

4. World Health Organization. Health in 2015: from MDGs (Millennium Development Goals) to SDGs (Sustainable Development Goals) . Geneva: WHO; 2015. Available from: http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf?ua=1.

5. Pan American Health Organization. Millennium Development Goals and health targets: final report. 55th Directing Council, 68th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2016 Sept. 26–30 (CD55/INF/5). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=36108&Itemid=270.

6. World Health Organization. The WHO framework convention on tobacco control: an overview. Geneva: WHO; 2015. Available from: http://www.who.int/fctc/WHO_FCTC_summary_January2015_EN.pdf?ua=1.

7. Pan American Health Organization. Technical reference document on non-communicable disease prevention and control. Washington, D.C.: PAHO; 2011. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=14816&Itemid=270.

8. The Lancet. Global burden of disease [Internet]; 2017. Available from: http://www.thelancet.com/gbd.

9. World Health Organization. Health in All Policies (HiAP) framework for country action [Internet]; 2014. Available from: http://www.who.int/cardiovascular_diseases/140120HPRHiAPFramework.pdf.

10. Córdova JA. El Acuerdo Nacional para la Salud Alimentaria como una estrategia contra el sobrepeso y la obesidad. Cirugía y Cirujanos 2010;78(2):105–107.

11. Pan American Health Organization. Summary of experiences from the Americas: the 8th Global Conference on Health Promotion 2013, Helsinki, Finland, 10 to 14 June 2013 . Washington, D.C.: PAHO; 2013. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=24430&lang=en.

12. Pan American Health Organization. Chapter 2: Technical cooperation and achievements. In: PAHO. Annual Report of the Director 2013: building on the past and moving into the future with confidence. Washington, D.C.: PAHO; 2013. Available from: https://www.paho.org/annual-report-d-2013/Chapter2.html.

13. Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, Kruk ME, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN sustainable development goal for health. The Lancet 2015;385(9964):239–252.

14. Thornicroft G, Patel V. Including mental health among the new sustainable development goals. BMJ 2014;349:g5189.

15. Izutsu T, Tsutsumi A, Minas H, Thornicroft G, Patel V, Ito A. Mental health and wellbeing in the Sustainable Development Goals. The Lancet Psychiatry 2015;2(12):1052–1054.

16. Dmytraczenko T, Almeida G, editors. Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries. Washington, D.C.: World Bank; 2015. Available from: https://openknowledge.worldbank.org/bitstream/handle/10986/22026/9781464804540.pdf?sequence=.

17. Liaropoulos L, Gorantis I. Health care financing and the sustainability of health systems. International Journal for Equity in Health 2015;14:80.

18. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: http://apps.who.int/iris/bitstream/10665/250368/1/9789241511131-eng.pdf?ua=1.

19. World Health Organization. World health statistics 2016: monitoring health for the SDGs (Sustainable Development Goals). Geneva: WHO; 2016. Available from: http://apps.who.int/iris/bitstream/10665/206498/1/9789241565264_eng.pdf?ua=1.

20. United Nations. Addis Ababa Action Agenda of the Third International Conference on Financing for Development. Final text of the outcome document adopted at the Third International Conference on Financing for Development (Addis Ababa, Ethiopia, 13–16 July 2015) and endorsed by the General Assembly in its resolution 69/313 of 27 July 2015. New York: UN; 2015. Available from: http://www.un.org/esa/ffd/wp-content/uploads/2015/08/AAAA_Outcome.pdf.

21. Economic Commission for Latin America and the Caribbean. Committee of High-level Government Experts (CEGAN) Twentieth Session. Regional Consultation on Financing for Development in Latin America and the Caribbean, Santiago, 12–13 March 2015. Draft report. Santiago: ECLAC; 2015. Available from: http://www.regionalcommissions.org/ECLACffdreport.pdf.

22. Economic Commission for Latin America and the Caribbean. Ten key messages of the Latin American and Caribbean Regional Consultation on Financing for Development. Economic Commission for Latin America and the Caribbean (ECLAC), Santiago, 12–13 March 2015. Santiago: ECLAC; 2015. Available from: http://www.regionalcommissions.org/ECLACffd10key.pdf.

23. United Nations Development Group. Delivering the post-2015 Development Agenda: opportunities at the national and local levels. New York: UNDP; 2014. Available from: https://sustainabledevelopment.un.org/content/documents/1909UNDP-MDG-Delivering-Post-2015-Report-2014.pdf.

24. Sebrié EM, Schoj V, Travers MJ, McGaw B, Glantz SA. Smokefree policies in Latin America and the Caribbean: making progress. International Journal of Environmental Research and Public Health 2012;9(5):1954–1970.

25. Jha A, Kickbusch I, Taylor P, Abbasi K, SDGs Working Group. Accelerating achievement of the Sustainable Development Goals. BMJ 2016;352:i409.

26. United Nations Conference on Trade and Development. World investment report 2014. Investing in the SDGs: an action plan for promoting private sector contributions. New York: UN; 2014. Available from: http://www.oecd-ilibrary.org/docserver/download/ca95f7ed-en.pdf?expires=1479243906&id=id&accname=ocid41017807&checksum=A432F265201322B98366E90BBCCC5D77.

27. Pan American Health Organization, Task Force and Working Group on Health in All Policies and the Sustainable Development Goals. Health in All Policies and the Sustainable Development Goals: reference note. Washington, D.C.: PAHO; 2015.

28. Buss PM, Fonseca LE, Galvão LA, Fortune K, Cook C. Health in All Policies in the partnership for sustainable development. Revista Panamericana de Salud Publica 2016;40(3):186–191.

29. Galvão LA, Haby MM, Chapman E, Clark R, Câmara VM, Luiz RR, et al. The new United Nations approach to sustainable development post-2015: findings from four overviews of systematic reviews on interventions for sustainable development and health. Revista Panamericana de Salud Publica 2016;39(3):157–165.

30. Pan American Health Organization. Trends and achievements in promoting health and equity in the Americas: developments from 2003–2011. Washington, D.C.: PAHO; 2011. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=270&gid=20369&lang=en.

31. de la Torre A, Levy Yeyati E, Beylis G, Didier T, Rodriguez Castelán C, Schmukler S. Inequality in a lower growth Latin America. LAC semi-annual report. Washington, D.C.: World Bank; 2014. Available from: https://openknowledge.worldbank.org/handle/10986/20413.

32. Economic Commission for Latin America and the Caribbean. Horizons 2030: equality at the centre of sustainable development. Summary. Santiago: ECLAC; 2016. Available from: http://repositorio.cepal.org/bitstream/handle/11362/40117/4/S1600688_en.pdf.

33. Economic Commission for Latin America and the Caribbean. Preliminary reflections on Latin America and the Caribbean in the post-2015 development agenda based on the trilogy of equality. Santiago: ECLAC; 2014. Available from: https://sustainabledevelopment.un.org/content/documents/4304Preliminary%20reflections.pdf.

34. International Monetary Fund. Regional economic outlook: Western Hemisphere. Washington, D.C.: IMF; 2016. Available from: http://www.imf.org/external/pubs/ft/reo/2016/whd/eng/pdf/wreo0416.pdf.

35. Pan American Health Organization. High-level Regional consultation of the Americas against NCDs and obesity. Discussion document. Washington, D.C.: PAHO; 2011. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=13836&Itemid=270.

36. Pan American Health Organization. Non-communicable diseases in the Americas: all sectors of society can help solve the problem. Issue brief on non-communicable diseases. Washington, D.C.: PAHO; 2011. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=16221&Itemid=270.

37. United Nations. Paris agreement. New York: UN; 2015. Available from: http://unfccc.int/files/essential_background/convention/application/pdf/english_paris_agreement.pdf.

38. United Nations. United Nations framework convention on climate change. New York: UN; 1992. Available from: http://unfccc.int/files/essential_background/background_publications_htmlpdf/application/pdf/conveng.pdf.

39. Prüss-Ustün A, Wolf J, Corvalán C, Bos R, Neira M. Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks . Geneva: World Health Organization; 2016. Available from: http://apps.who.int/iris/bitstream/10665/204585/1/9789241565196_eng.pdf.

40. United Nations Environment Programme. Minamata convention on mercury: text and annexes. Nairobi: UNEP; 2013. Available from: http://www.mercuryconvention.org/Portals/11/documents/Booklets/Minamata%20Convention%20on%20Mercury_booklet_English.pdf.

41. Bambra C, Fox D, Scott-Samuel A. Towards a politics of health. Health Promotion International 2005;20(2):187–193.

42. Kickbusch I. The political determinants of health—10 years on. BMJ 2015;350:h81.

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:

Emergent diseases and critical health problems undermining development

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

Summary

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

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

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

Introduction

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

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

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

Control of Transmissible Diseases

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

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

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

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

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

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

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

Foodborne diseases (infections and intoxications)

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

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

Health care–associated infections

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

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

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

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

Arboviruses

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

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

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

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

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

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

Influenza

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

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

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

Plague

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

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

Leptospirosis

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

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

Cholera

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

Conditions Targeted for Elimination

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

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

HIV

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

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

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

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

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

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

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

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

Sexually transmitted infections

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

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

Tuberculosis

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

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

Malaria

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

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

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

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

Vaccine-preventable diseases

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

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

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

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

Neglected infectious diseases

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

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

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

Political and financial challenges

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

Technical complexity of interventions

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

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

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

Viral hepatitis

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

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

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

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

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

Maternal mortality

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

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

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

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

Neonatal, child, and adolescent health

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

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

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

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

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

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

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

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

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

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

Nutritional deficiencies

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

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

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

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

Conclusions

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

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

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

References

1. De Andrade LO, Pellegrini Filho A, Solar O, Rigoli F, Malagon L, Castell-Florit Serrate P, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. The Lancet 2015;4(385):1343-1351.

2. A Promise Renewed for the Americas, United Nations Children’s Fund, Tulane University. Health equity report 2016: analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking. Summary report. Panama City: UNICEF; 2016. Available from: https://www.unicef.org/lac/20160906_UNICEF_APR_HealthEquityReport_SUMMARY.pdf.

3. Mújica OJ, Haeberer M, Teague J, Santos-Burgoa C, Galvão LAC. Health inequalities by gradients of access to water and sanitation between countries in the Americas, 1990 and 2010. Pan American Journal of Public Health 2015;38(5):347-354.

4. Restrepo-Méndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França GVA, et al. Progress in reducing inequalities in reproductive, maternal, newborn, and child health in Latin America and the Caribbean: an unfinished agenda. Pan American Journal of Public Health 2015;38(1):9-16.

5. MacDonald G, Moen AC, St Louis ME. The national inventory of core capabilities for pandemic influenza preparedness and response: an instrument for planning and evaluation. Influenza and Other Respiratory Viruses 2014;8(2):189-193.

6. Johnson LEA, Clará W, Gambhir M, Chacon Fuentes R, Marín-Correa C, Jara J, et al. Improvements in pandemic preparedness in 8 Central American countries, 2008-2012. BMC Health Services Research 2014;14:209.

7. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016;388(10053):1459-1544.

8. Ceschia A, Horton R. Maternal health: time for a radical reappraisal. The Lancet 2016;388(10056):2064-2066.

9. United Nations, General Assembly. Transforming our world: the 2030 Agenda for sustainable development, New York, 2015 Oct. 21 (70/1). Available from: http://www.ipu.org/splz-e/unga16/2030-e.pdf.

10. San Martín JL, Brathwaite-Dick O. La estrategia de gestión integrada para la prevención y el control del dengue en la Región de las Américas. Revista Panamericana de Salud Pública 2007;21(1):55-63.

11. Dick OB, San Martin JL, Montoya RH, del Diego J, Zambrano B, Dayan GH. The history of dengue outbreaks. American Journal of Tropical Medicine and Hygiene 2012;87(4):584-593.

12. Patz JA, Epstein PR, Burke TA, Balbus JM. Global climate change and emerging infectious diseases. Journal of the American Medical Association 1996;275(3):217-223.

13. Khasnis AA, Nettleman MD. Global warming and infectious disease. Archives of Medical Research 2005;36(6):689-696.

14. Taylor LH, Latham SM, Woolhouse ME. Risk factors for human disease emergence. Philosophical Transactions of the Royal Society of London Series B 2001;356(1411):983-989.

15. Schneider MC, Aguilera XP, Smith RM, Moynihan MJ, Barbosa da Silva Jr. J, Aldighieri S, et al. Importance of animal/human health interface in potential Public Health Emergencies of International Concern in the Americas. Pan American Journal of Public Health 2011;29(5):371-379.

16. Schneider MC, Jancloes M, Buss DF, Aldighieri S, Bertherat E, Najera P, et al. Leptospirosis: a silent epidemic disease. International Journal of Environmental Research and Public Health 2013;10(12):7229-7234.

17. Schneider MC, Najera P, Aldighieri S, Galan DI, Bertherat E, Ruiz A, et al. Where does human plague still persist in Latin America? PLoS Neglected Tropical Diseases 2014;8(2):e2680.

18. World Health Organization. International health regulations. 2nd ed. Geneva: WHO; 2008.

19. World Bank. Drug-resistant infections. A threat to our economic future. Washington, D.C.: International Bank for Reconstruction and Development/World Bank; 2016.

20. Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: final report and recommendations. London: AMR; 2016.

21. Etienne CF. Foreword: Caribbean burden of illness study. Journal of Health, Population and Nutrition 2013;31(4):S1-S2.

22. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al. Foodborne illness acquired in the United States-major pathogens. Emerging Infectious Diseases 2011;17(1):7-15.

23. World Health Organization. World health statistics 2016. Monitoring health for SDGs. Geneva: WHO; 2016. Available at: http://apps.who.int/iris/bitstream/10665/44289/1/9789241563970_eng.pdf.

24. Jouve JL, Aagaard-Hansen J, Aidara-Kane A. Food safety: equity and social determinants. In: Blas E, Kurup AS, eds. Equity, social determinants and public health programmes. Geneva: WHO; 2010:96-109. Available from: http://apps.who.int/iris/bitstream/10665/44289/1/9789241563970_eng.pdf.

25. Ministerio de Salud de Uruguay. Datos de incidencia de infecciones hospitalarias en medicina critica de adultos y neonatal [Internet]; 2013. Available from: http://www.msp.gub.uy/comunicado/datos-de-incidencia-de-infecciones-hospitalarias-en-medicina-cr%C3%ADtica-de-adultos-y.

26. Ministerio de Salud de Chile. Informe de vigilancia de infecciones asociadas a la atención en salud. Santiago: Ministerio de Salud en Chile; 2013. Available from: http://web.minsal.cl/sites/default/files/files2/Informe_Vigilancia_Epidemiologica_IAAS_2013.pdf.

27. Centro de Vigilancia Epidemiológica. Professor Vranjac. Sistema de Vigilância das Infecções Hospitalares do Estado de São Paulo. São Paulo: Secretaria de Estado da Saúde; 2016. Available from: http://www.saude.sp.gov.br/cve-centro-de-vigilancia-epidemiologica-prof.-alexandre-vranjac/areas-de-vigilancia/infeccao-hospitalar/sistema-de-vigilancia-epidemiologica.

28. Instituto Nacional de Salud de Colombia. Informe final infecciones asociadas a dispositivos. Bogotá: Ministerio de Salud de Colombia; 2013. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/IA/INS/infecciones-asociadas-dispositivos-2013.pdf.

29. Ministerio de Salud de Peru. Boletin Epidemiologico numero 23(17). Lima: Ministerio de Salud de Peru; 2014. Available from: http://www.dge.gob.pe/portal/docs/vigilancia/boletines/2014/17.pdf.

30. Centers for Disease Control and Prevention. National and state healthcare associated infections progress report. Atlanta: CDC; 2016. Available from: https://www.cdc.gov/hai/surveillance/progress-report/index.html.

31. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine 2013;173(22):2039-2046.

32. Gordillo A, Mejia C, Mogdazi C, Guerrero F, Schmunis GA, Falconí G, et al. Costo de la infección nosocomial en unidades de cuidados intensivos de cinco países de América Latina: llamada de atención para el personal de salud. Revista Panamericana de Infectología 2008;10(4):70-77.

33. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control & Hospital Epidemiology 2011;32(2):101-114.

34. Campos AC, Albiero J, Ecker AB, Kuroda CM, Meirelles LEF, Polato A, et al. Outbreak of Klebsiella pneumoniae carbapenemase-producing K pneumoniae: a systematic review. American Journal of Infection Control 2016;44(11):1374-1380.

35. World Health Organization. Ten years of clean care is safer care 2005-2015. Geneva: WHO; 2015.

36. Nantasit Luangasanatip N, Hongsuwan M, Limmathurotsakul D, Lubell Y, Lee AS, Harbarth S, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ 2015;351:h3728.

37. Weaver SC, Reisen WK. Present and future arboviral threats. Antiviral Research 2010;85(2):328-345.

38. Pan American Health Organization. Epidemiological alert. Chikungunya and dengue fever in the Americas [Internet]; 2014. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=270&gid=27049&lang=en.

39. Pan American Health Organization. Epidemiological update. Zika virus infection [Internet]; 2015. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=32021&lang=en.

40. Pan American Health Organization. Yellow fever outbreaks in the Americas. Disasters: preparedness and mitigation in the Americas [Internet]; 2008. Available from: https://www.paho.org/disasters/newsletter/index.php?option=com_content&view=ar ticle&id=139:yellow-fever-outbreaks-in-the-americas&catid=74:issue-109-march- 2008-member-countries&Itemid=119&lang=en.

41. World Health Organization. WHO statement on the first meeting of the International Health Regulations (2005) (IHR 2005) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations. Geneva: WHO; 2016. Available from: http://www.who.int/mediacentre/news/statements/2016/1st-emergency-committee-zika/en/.

42. Pan American Health Organization. Number of reported cases of dengue and severe dengue (SD) in the Americas, by country: figures for 2016 (to week noted by each country). Epidemiological Week / EW 24. Washington, D.C.: PAHO; 2016. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=&gid=35277&lang=en.

43. Pan American Health Organization. Epidemiological alert. Zika virus infection [Internet]; 2015. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=30078&lang=en.

44. Pan American Health Organization. Epidemiological alert. Zika [Internet]; 2015. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=35262&lang=en.

45. Pan American Health Organization. Zika suspected and confirmed cases reported by countries and territories in the Americas. Cumulative cases, 2015-2016 [Internet]; 2016. Available from: https://www.paho.org/hq/index.php?option=com_content&view=article&id=12390&Itemid=42090&lang=en.

46. Pan American Health Organization. Dengue: guías para la atención de enfermos en la Región de las Américas. Washington, D.C.: PAHO; 2015. Available from: http://iris.paho.org/xmlui/handle/123456789/28232?locale-attribute=es.

47. Shepard DS, Undurraga EA, Halasa YA, Stanaway JD. The global economic burden of dengue: a systematic analysis. The Lancet Infectious Diseases 2016;16(8):935-941.

48. Tiga D, Undurraga E, Ramos-Castaneda J, Martinez-Vega R, Tschampl C, Shepard D. Persistent symptoms of dengue: estimates of the incremental disease and economic burden in Mexico. American Journal of Tropical Medicine and Hygiene 2016;94(5):1085-1089.

49. Cheng P, Palekar R, Azziz-Baumgartner E, Luliano D, Alencar AP, Bresee J, et al. Burden of influenza-associated deaths in the Americas, 2002-2008. Influenza and Other Respiratory Viruses 2015;9(S1):13-21.

50. World Health Organization. Prevention and control of influenza pandemics and annual epidemics. Fifty-sixth World Health Assembly, Geneva, 2003 Jan. 23 (Resolution WHA56.19.28). Available from: http://www.who.int/immunization/sage/1_WHA56_19_Prevention_and_control_of_influenza_pandemics.pdf.

51. Ropero AM, El Omeiri N, Kurtis HJ, Danovaro C, Ruiz Matus C. Influenza vaccination in the Americas: progress and challenges after the 2009 A(H1N1) influenza pandemic. Human Vaccines & Immunotherapeutics 2016;12(8):2206-2214.

52. El Omeiri N, Azziz-Baumgartner E, Clará W, Guzmán-Saborío G, Elas M, Mejía H, et al. Pilot to evaluate the feasibility of measuring seasonal influenza vaccine effectiveness using surveillance platforms in Central-America, 2012. BMC Public Health 2015;15:673.

53. Costa FE, Hagan JC, Kane M, Torgerson P, Martinez-Silveira M, Stein C, et al. Global morbidity and mortality of leptospirosis: a systematic review. PLoS Neglected Tropical Diseases 2015;9(9):e0003898.

54. World Health Organization. Report of the second meeting of the Leptospirosis Burden Epidemiology Reference Group. Geneva: WHO; 2011:1-37.

55. Felzemburgh RDM, Ribeiro GS, Costa F, Reis RB, Hagan JE, Melendez AXTO, et al. Prospective study of leptospirosis transmission in an urban slum community: role of poor environment in repeated exposures to the Leptospira agent. PLoS Neglected Tropical Diseases 2014;8(5):e2927.

56. Liverpool J, Francis S, Liverpool CE, Dean GT, Mendez DD. Leptospirosis: case reports of an outbreak in Guyana. Annals of Tropical Medicine & Parasitology 2008;102(3):239-245.

57. Schneider MC, Nájera P, Aldighieri S, Bacallao J, Soto A, Marquiño W, et al. Leptospirosis outbreaks in Nicaragua: identifying critical areas and exploring drivers for evidence-based planning. International Journal of Environmental Research and Public Health 2012;9(11):3883-3910.

58. Schneider MC, Nájera P, Pereira MM, Machado G, dos Anjos CB, Rodrigues R, et al. Leptospirosis in Rio Grande do Sul, Brazil: an ecosystem approach in the animal-human interface. PLoS Neglected Tropical Diseases 2015;9(11):e0004095.

59. Maciel EAP, de Carvalho ALF, Nascimento SF, de Matos RB, Gouveia EL, et al. Household transmission of Leptospira infection in urban slum communities. PLoS Neglected Tropical Diseases 2008;2(1):e154.

60. Bacallao J, Schneider MC, Najera P, Aldighieri S, Soto A, Marquiño W, et al. Socioeconomic factors and vulnerability to outbreaks of leptospirosis in Nicaragua. International Journal of Environmental Research and Public Health 2014;11(8):8301-8318.

61. World Health Organization. Human leptospirosis: guidance for diagnosis, surveillance and control. Geneva: WHO; 2003.

62. United Nations International Children’s Emergency Fund. Call for action for WASH investment. New York: UNICEF; 2012.

63. World Health Organization. Global Health Observatory data repository. Cholera. Number of reported cases. Data by country [Internet]. Available from: http://apps.who.int/gho/data/node.main.175/.

64. Sicuri E, Evans DB, Tediosi F. Can economic analysis contribute to disease elimination and eradication? A systematic review. PLoS ONE 2015;10(6):e0130603.

65. Aylward RB, Hull HF, Coche SL, Sutter RW, Olivé JM, Melgaard B. Disease eradication as a public health strategy: a case study of poliomyelitis eradication. Bulletin of the World Health Organization 2000;78(3):285-297.

66. UNAIDS. Fast-track: ending the AIDS epidemic by 2030. Geneva: UNAIDS; 2014.

67. UNAIDS/WHO. Global AIDS response progress reporting. Geneva: WHO; 2015.

68. UNAIDS. The gap report. Geneva: WHO; 2014.

69. Pan American Health Organization. Improving access of key populations to comprehensive HIV health services towards a Caribbean consensus. Washington, D.C.: PAHO; 2011.

70. Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. The Lancet 2015;385(9962):55-71.

71. Pan American Health Organization. Addressing the causes of disparities in health service access and utilization for lesbian, gay, bisexual and trans (LGBT) persons. 52nd Directing Council of PAHO, 65th Session of the Regional Committee of WHO for the Americas; Washington, D.C., 2013 Sept. 30-Oct. 4 (CD52/18). Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/4411/CD52_18eng.pdf?sequence=1&isAllowed=y.

72. Luciano D. Human rights of women living with HIV in the Americas. Washington, D.C.: UNAIDS and CIM/OAS; 2015. Available from: http://www.oas.org/es/cim/docs/VIH-DDHH-ENG.pdf.

73. Pan American Health Organization. Elimination of mother to child transmission of HIV and syphilis in the Americas. Washington, D.C.: PAHO; 2015.

74. Luu M, Ham C, Kamb ML, Caffe S, Hoover KW, Perez F. Syphilis testing in antenatal care: Policies and practices among laboratories in the Americas. International Journal of Gynaecology and Obstetrics 2015;130(S1):S37-S42.

75. Fenton K. Sexual health: expanding our frame for action. In: Kumar B, Gupta S, eds. Sexually transmitted infections. 2nd ed. New Delhi: Elsevier; 2012:3-9.

76. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global estimates of the prevalence and incidence of four curable sexually transmitted infections in 2012 based on systematic review and global reporting. PLoS ONE 2015;10(12):e0143304.

77. Zoni AC, González MA, Sjögren HW. Syphilis in the most at-risk populations in Latin America and the Caribbean: a systematic review. International Journal of Infectious Disease 2013;17(2):e84-e92.

78. U.S. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.

79. Ministério da Saúde – Secretaria de Vigilância em Saúde. Boletim epidemiológico – sífilis 2015. Brasilia: Departamento de DST, Aids e Hepatites Virais; 2015.

80. Morris JL, Lippman S, Philip S, Bernstein K, Neilands TB, Lightfoot M. Sexually transmitted infection related stigma and shame among African American male youth: implications for testing practices, partner notification, and treatment. AIDS Patient Care STDS 2014;28(9):499-506.

81. Anicp+Vida. Estudio índice de estigma y discriminación en personas con VIH- Nicaragua [Internet]. Available from: http://www.stigmaindex.org/sites/default/files/reports/NicaraguaEstudio%20Final_ED_.pdf.

82. U.S. Centers for Disease Control and Prevention. Addressing social determinants of health: accelerating the prevention and control of HIV/AIDS, viral hepatitis, STD and TB. External consultation meeting report. Atlanta: CDC; 2009.

83. World Health Organization. Global health sector strategy on sexually transmitted infections 2016-2021. Toward ending STIs. Geneva: WHO; 2016.

84. Kalamar AM, Bayer AM, Hindin MJ. Interventions to prevent sexually transmitted infections, including HIV, among young people in low- and middle-income countries: a systematic review of the published and gray literature. Journal of Adolescent Health 2016(S3):S22-S31.

85. Dillon JA, Trecker MA, Thakur SD, Fiorito S, Galarza P, Carvallo ME, et al. Two decades of the gonococcal antimicrobial surveillance program in South America and the Caribbean: challenges and opportunities. Sexually Transmitted Infections 2013;89(S4):36-41.

86. Herbst de Cortina S, Bristow CC, Joseph Davey D, Klausner JD. A systematic review of point of care testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Infectious Diseases in Obstetrics and Gynecology 2016;2016:4386127.

87. Bychkovsky BL, Ferreyra ME, Strasser-Weippl K, Herold CI, de Lima Lopes Jr. G, Dizon DS, et al. Cervical cancer control in Latin America: a call to action. Cancer 2016;122(4):502-514.

88. World Health Organization. Global tuberculosis report 2015. Geneva: WHO; 2016. Available from: http://who.int/tb/publications/global_report/en/.

89. Dye C, Lonnroth K, Jaramillo E, Williams BG, Raviglione M. Trends in tuberculosis incidence and their determinants in 134 countries. Bulletin of the World Health Organization 2009;87(9):683-691.

90. Pan American Health Organization. Tuberculosis in the Region of the Americas. Regional report 2014 epidemiology, control and financing. Washington, D.C.: PAHO; 2014.

91. Munayco CV, Mújica OJ, León FX, del Granado M, Espinal MA. Social determinants and inequalities in tuberculosis incidence in Latin America and the Caribbean. Revista Panamericana de Salud Pública 2015;38(3):177-185.

92. Pan American Health Organization. Plan of action for prevention and control of tuberculosis. 54th Directing Council of PAHO, 67th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 Sept. 28 to Oct. 2 (CD54/11).

93. World Health Organization. Global strategy and targets for tuberculosis prevention, care and control after 2015. 67th World Health Assembly, Geneva, 2014 May 21 (WHA67.1). Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R1-en.pdf.

94. Rasanathan K, Sivasankara Kurup A, Jaramillo E, Lönnroth K. The social determinants of health: key to global tuberculosis control. International Journal of Tuberculosis and Lung Disease 2011;15(S2):S30-S36.

95. Andrews JR, Basu S, Dowdy DW, Murray MB. The epidemiological advantage of preferential targeting of tuberculosis control at the poor. International Journal of Tuberculosis and Lung Disease 2014;19(4):375-380.

96. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science & Medicine 2009;68(12):2240-2246.

97. United Nations Population Division. World urbanization prospects: the 2014 revision. New York: UNDP; 2015. Available from: https://esa.un.org/unpd/wup/Publications/Files/WUP2014-Highlights.pdf.

98. Creswell J, Raviglione M, Ottmani S, Migiliori GB, Uplekar M, Blanc L, Sotgiu G, Lonnorth K. Tuberculosis and noncommunicable diseases: neglected links and missed opportunities. European Respiratory Journal 2011;37(5):1269-1282.

99. Pan American Health Organization. Framework for tuberculosis control in large cities of Latin America and the Caribbean. Washington, D.C.: PAHO; 2016. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=35441&lang=en.

100. Pan American Health Organization. Plan of action for malaria elimination 2016-2010. 55th Directing Council of PAHO, 68th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2016 Sept. 26-30 (CD55.R7). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=35670&Itemid=270&lang=en.

101. World Health Organization. World malaria report 2015. Geneva: WHO; 2016. Available from: http://www.who.int/malaria/publications/world-malaria-report-2015/report/en/.

102. Pan American Health Organization. Report on the situation of malaria in the Americas 2014. Washington, D.C.: PAHO; 2016.

103. World Health Organization. Malaria elimination: a field manual for low and moderate endemic countries. Geneva: WHO; 2007. Available from: http://apps.who.int/iris/bitstream/10665/43796/1/9789241596084_eng.pdf.

104. Andrus JK, Crouch AA, Fitzsimmons J, Vicari A, Tambini G. Immunization and the Millennium Development Goals: progress and challenges in Latin America and the Caribbean. Health Affairs 2008;27(2):487-493.

105. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker D. Return on investment from childhood immunization in LMIC, 2011-2020. Health Affairs 2016;35(2):199-207.

106. Becerra F, Mujica O. Equidad en salud para el desarrollo sostenible. Revista de Salud Pública y Nutrición 2016;15(1):16-26.

107. World Health Organization. Investing to overcome the global impact of neglected tropical diseases: third WHO report on neglected diseases 2015. Geneva: WHO; 2015. Available from: http://apps.who.int/iris/bitstream/10665/152781/1/9789241564861_eng.pdf?ua=1.

108. Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Roses Periago M. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Neglected Tropical Diseases 2008;2(9):e300.

109. Oberhelman RA, Guerrero ES, Fernández ML, Silio M, Mercado D, Comiskey N, et al. Correlations between intestinal parasitosis, physical growth, and psychomotor development among infants and children from rural Nicaragua. American Journal of Tropical Medicine & Hygiene 1998;58(4):470-475.

110. Guyatt H. Do intestinal nematodes affect productivity in adulthood? Parasitology Today 2000;16(4):153-158.

111. Ault SK, Roses Periago M. Regional approaches to neglected tropical diseases control in Latin America and the Caribbean. In: Institute of Medicine (US) Forum on Microbial Threats. The causes and impacts of neglected tropical and zoonotic diseases: opportunities for integrated intervention strategies. Washington, D.C.: National Academies Press; 2011:115-131.

112. DNDI. Enfermedad de Chagas [Internet]; 2010. Available from: http://www.dndial.org/es/doencas-negligenciadas/enfermedad-de-chagas.html.

113. Pan American Health Organization. Leishmaniases: epidemiological report of the Americas. Washington, D.C.: PAHO; 2015. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=&gid=31145&lang=es.

114. Stanaway JD, Flaxman AD, Naghavi M, Fitzmaurice C, Vos T, Abubakar I, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study. The Lancet 2016;388(10049):1081-1088.

115. Pan American Health Organization. Hepatitis B and C under the spotlight: a public health response in the Americas, 2016. Washington, D.C.: PAHO; 2016.

116. Restrepo-Méndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França GVA, et al. Progress in reducing inequalities in reproductive, maternal, newborn, and child health in Latin America and the Caribbean: an unfinished agenda. Revista Panamericana de Salud Pública 2015;38(1):9-16.

117. United Nations. Millennium Declaration. Fifty-fifth session General Assembly of the United Nations, New York, 2000 Sept. 18 (A/RES/55/2). Available from: http://www.un.org/millennium/declaration/ares552e.pdf.

118. World Health Organization, UNICEF, UNFPA, World Bank. Trends in maternal mortality: 1990 to 2015. Geneva: WHO; 2015. Available from: http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/.

119. Economic Commission for Latin America and the Caribbean. Review of the implementation of the Beijing Declaration and platform for action and the outcome of the Twenty-Third Special Session of the General Assembly in Latin American and Caribbean countries, Santiago, 2009 (LC/L 3175). Available from: http://www.cepal.org/mujer/noticias/paginas/8/36338/eclacbeijing15.pdf.

120. Ronsmans C, Graham W. Maternal mortality: who, when, where, and why. The Lancet 2006;30;368(9542):1189-1200.

121. Economic Commission for Latin America and the Caribbean. Salud materno-infantil de pueblos indígenas y afrodescendientes de América Latina: aportes para una relectura desde el derecho a la integridad cultural. Santiago de Chile: ECLAC; 2010. Available from: http://repositorio.cepal.org/bitstream/handle/11362/3797/1/lcw347.pdf.

122. MSPAS. Estudio nacional de mortalidad materna 2007. Guatemala: Serviprensa; 2011.

123. United Nations. Global strategy for women’s, children’s and adolescent’s health 2016-2030 [Internet]; 2016. Available from: http://www.who.int/life-course/partners/global-strategy/en/#.

124. World Health Organization. Strategies toward ending preventable maternal mortality (EPMM) [Internet]; 2015. Available from:
http://who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/.

125. United Nations Office of the High Commissioner. Convention on the rights of the child. New York, 1990 Sept. 2. Available from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx.

126. United Nations Inter-agency Group for Child Mortality Estimation. Levels and trends in child mortality report 2015. New York: UN; 2015.

127. Liu L, Hill K, Oza S, Hogan D, Chu Y, Cousens S, et al. Levels and causes of mortality under age five years. In: International Bank for Reconstruction and Development, World Bank. Reproductive, maternal, newborn, and child health: disease control priorities. 3rd ed. Vol. 2. Washington, D.C.: World Bank; 2016:71-83.

128. GBD 2013 Collaboration. Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the Global Burden of Disease 2013 Study. JAMA Pediatrics 2016;170(3):267-287.

129. UN Data. Statistics: adolescent fertility rate (births per 1,000 women ages 15-19) [Internet]. Available from: http://data.un.org/Data.aspx?q=adolescent+fertility+rate+america&d=WDI&f=Indicator_Code%3aSP.ADO.TFRT%3bCountry_Code%3aLAC%2cLCN%2cNAC.

130. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129(1):e232-e246.

131. Lawn JE, Blencowe H, Oza S, You D, Lee ACC, Waiswa P, et al. Every newborn: progress, priorities, and potential beyond survival. The Lancet 2014;384(9938):189-205.

132. Lu C, Black M, Richter L. Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level. The Lancet Global Health 2016;4(12):e916-e922.

133. Fink G, Peet E, Danaei G, Andrews K, McCoy DC, Sudfeld CR, et al. Schooling and wage income losses due to early-childhood growth faltering in developing countries: national, regional, and global estimates. American Journal of Clinical Nutrition 2016;104(1):104-112.

134. World Health Organization. Early child development: a powerful equalizer. Geneva: WHO; 2007. Available from: http://apps.who.int/iris/bitstream/10665/69729/1/a91213.pdf.

135. Grantham-McGregor S, Cheung Y, Cueto S, Glewwe P, Richter L, Strupp B, et al. Developmental potential in the first 5 years for children in developing countries. The Lancet 2007;369(9555):60-70.

136. Inter-American Development Bank. The early years: child well-being and the role of public policy. Washington, D.C.: IADB; 2015.

137. Lancet Series. Advancing Early Childhood Development: from Science to Scale. October 2016. The Lancet.

138. Galicia L, Grajeda R, López de Romaña D. Nutrition situation in Latin America and the Caribbean: current scenario, past trends, and data gaps. Revista Panamericana de Salud Pública 2016;40(2):104-113.

139. Tzioumis E, Adair LS. Childhood dual burden of under- and over nutrition in low- and middle-income countries: a critical review. Food and Nutrition Bulletin 2014;35(2):230-243.

140. Uauy R, Garmendia ML, Corvalán C. Addressing the double burden of malnutrition with a common agenda. Nestle Nutrition Instructional Workshop Series 2014;78:39-52.

141. World Health Organization. Guideline: sodium intake for adults and children. Geneva: WHO; 2012. Available from: http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf?ua=1&ua=1.

142. World Health Organization. Guideline: sugars intake for adults and children. Geneva: WHO; 2015. Available from: http://apps.who.int/iris/bitstream/10665/149782/1/9789241549028_eng.pdf?ua=1.

143. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington, D.C.: PAHO; 2014. Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=28890&lang=pt.

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Reference/Note:

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

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

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

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

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

6 Persons under the age of 18 years.

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

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

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