Pan American Health Organization

Pathway to sustainable health

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

In 2000, the United Nations (UN) General Assembly laid out the Millennium Development Goals (MDGs), an ambitious vision for global development with a groundbreaking approach to collaborative international action (). In the Americas, an unprecedented regional response allowed many countries to reach or surpass health-related goals to reduce child mortality, control infectious diseases, reduce poverty, and increase access to improved water and sanitation.

Sustainable Development

Figure 1. The “five Ps” (people, planet, prosperity, peace, and partnership) representing the broad scope of the 2030 Agenda for Sustainable Development, 2016-2030
Source: United Nations.

Nonetheless, persistent challenges present during the MDG era remain unresolved, and new challenges in the health landscape have since emerged. As a result, in September 2015, the UN General Assembly adopted Resolution A/RES/70/1, “Transforming our world: the 2030 Agenda for Sustainable Development” (). The product of numerous consultations and deliberations, the 2030 Agenda is an aspirational plan of action for people, planet, prosperity, peace, and partnership—the “five Ps” (Figure 1)—that shifts the world onto a sustainable and resilient path for global development over the next 15 years.Through an equity-based approach that emphasizes the needs and experiences of traditionally disadvantaged groups, the Agenda has the potential to transform the public health landscape in the Region of the Americas. By recognizing the interconnectedness of factors and interventions that influence human development outcomes, the 2030 Agenda and its Sustainable Development Goals (SDGs) outline a paradigm shift in policy-making, prioritizing actions that target the complex and intersecting structural determinants of social and economic development.

The SDGs contain just one explicitly health-oriented goal—SDG 3—out of a total of 17 (Figure 2), in contrast to the MDGs, which have three out of eight. However, many, if not all, of the SDGs include targets related to health, such as poverty, hunger, education, access to sanitation, and exposure to physical violence. While not explicitly included in SDG 3, these themes are among the most immediate determinants of health and well-being. The shift in focus between the two sets of global development goals represents a more nuanced understanding of the factors that affect health, and lays the groundwork for action across different sectors whose activities have significant effects on health but fall outside the purview of the health sector. Governments, the private sector, and civil society will need to innovate and adapt to meet the challenges laid out in the 2030 Agenda, which incorporates a broader and more multifaceted vision for health and development than ever before. A strong evidence base already exists to support this approach, and this chapter topic will extend the effort by highlighting useful strategies, mechanisms, and major global agreements to ensure that countries are prepared to achieve these global goals ().

2030 SDG Breakdown Figure 2. Breakdown of the 2030 Agenda for Sustainable Development by goal (1–17), 2016–2030
Source: United Nations.

Equity: a renewed focus for sustainable development

The MDGs galvanized broad government action to achieve national targets related to specific diseases, maternal health, and child health, but in doing so frequently focused on the “low-hanging fruit” of populations already well served by services, leaving many behind. Despite many successes in reducing population averages of disease-specific incidence and maternal and child mortality, progress was not achieved equally within or between countries. As discussed extensively in “Social determinants of health in the Americas,” health outcomes in the Region are heavily influenced by income, gender, ethnicity, cultural identification, geographic location, and education, as well as access to services and infrastructure. The 2030 Agenda has the potential to address these gaps through the promotion of multisectoral programming that seeks to address the inequalities that persistently produce poor health outcomes, with particular attention paid to the social, economic, and environmental conditions in which people are born, live, work, learn, and age. This approach has profound implications for equity, a core principle of the 2030 Agenda.

In addition to the need to develop programs and interventions that promote health for vulnerable populations, monitoring their impact through data collection and analysis is crucial to ensure that the 2030 Agenda will achieve its promise of reducing health inequalities. Country capacity to measure Regional and national progress toward the SDG targets should be developed in the earliest phases of engagement with the 2030 Agenda in order for governments and policymakers to gain greater insight into which SDG-oriented activities are realizing their goal of reducing health inequalities. It will be especially important to establish equity-sensitive monitoring tools that show which populations are experiencing improvements and increased access to services while highlighting gaps that impede progress in addressing the needs of the most vulnerable and marginalized communities.

Transitioning to the era of the SDGs

While the 2030 Agenda builds on the successes of the MDGs, it also articulates a critical political and conceptual shift in the development paradigm. The 2030 Agenda recognizes many of the lessons learned from the MDGs, which includes the need to explicitly address inequalities, requiring interventions designed to address the unequal distribution of health, disease, and resources. While the MDGs provided both a focal point and framework for government policy-making, a growing evidence base developed over the past 15 years has shown the need for a broader and more holistic understanding of health and human development (). Therefore, the 2030 Agenda encourages innovative multisectoral initiatives in which the health sector partners with actors from other areas of governance to address the key determinants of health affected by actions from systems and institutions outside the traditional scope of the health sector.

2030 SDG Breakdown Figure 3. Breakdown of the Millennium Development Goal (MDG) agenda by goal (1–8), 2000&ndash2015
Source: United Nations.

The MDGs were focused on improving the health and living conditions of those in low-income countries (Figure 3 and Table 1), whereas the SDGs recognize that inequity and gaps in services, opportunities, and outcomes are present at all levels of economic development. Recognizing the limitations of the relationship between the traditional donor (high-income country) and recipient (low- or middle-income country), particularly in today’s globalized “market” of expertise, commerce, skills, and resources, the 2030 Agenda promotes innovative models for development governance, collaboration, and financing that encourage countries to engage creatively with the process of sustainable development. In this way, the SDGs are truly global in that they represent a shared commitment to address mutual challenges across the spectrum of economic development.

Beyond these key shifts, the 2030 Agenda places the 193 signatory countries at the center of SDG implementation. From the earliest stages of consultation, national and regional input has been key to defining goals, targets, and indicators. A case in point is the inclusion of noncommunicable diseases (NCDs) and universal health coverage (UHC) in the 2030 Agenda. Neither was included in the MDGs, but both were identified as major challenges for sustainable development, and ultimately became targets with associated indicators, in the final Agenda. This was an important achievement, particularly for the Region of the Americas, where UHC has long been a priority of policymakers and public health advocates.

As countries move from the MDGs to the 2030 Agenda, it is important to review progress made through 2015. As a whole, the Region achieved health-specific targets related to child mortality, the spread of HIV/AIDS, the incidence of tuberculosis and malaria, drinking water, and sanitation (Table 1). Much progress was made on several targets that were not strictly identified as part of the “health” MDGs, but have substantial implications for health, such as reducing the proportion of people living in poverty. However, some of this progress is under threat by political instability and the ongoing effects of the financial crisis of 2008. Moreover, progress achieved has tended to mask persistent inequalities while gains remain unequally distributed within and between countries.

Table 1. Outcomes for selected Millennium Development Goal (MDG) targets, 2000–2015

MDG and targets Outcome
MDG 1: Eradicate extreme poverty and hunger
1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger
This target was achieved
MDG 4: Reduce child mortality
4.A: Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate
This target was achieved
MDG 5: Improve maternal health
5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
This target was not achieved
5.B: Achieve, by 2015, universal access to reproductive health This target was not achieved
MDG 6: Combat HIV/AIDS, malaria and other diseases
6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
This target was achieved
6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it This target was not achieved
6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases This target was achieved for TB and malaria
MDG 7: Ensure environmental sustainability
7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation
This target was achieved in terms of safe drinking water, and virtually achieved in terms of sanitation (the proportion was reduced by 48.5%)

Source: Adapted from PAHO, Millennium Development Goals and health targets: final report().

While the progress during the MDG era should be celebrated, the underlying inequalities driving poor health and limiting sustainable development remain. Furthermore, not all health-related targets were achieved by 2015, specifically those related to maternal mortality, access to reproductive health, and access to antiretroviral treatment for eligible persons who are HIV-positive. Persistent inequalities and the unmet health targets of the MDG agenda are key challenges to achieving health for all in the Americas, and will need to form the basis of action within the post-2015 development agenda.

As the most inequitable region in the world, the Region of the Americas is faced with unique challenges as it works toward promoting health for all and achieving sustainable development. Building on the achievements of the past 15 years, the 2030 Agenda encourages governments and societies to collaborate in new and innovative ways, while acknowledging that equity is central to sustainable global progress. It also presents a challenge to the global public health community’s responsiveness to policy action, given that the 2030 Agenda should be implemented in full alignment with national priorities, national action plans, and existing global agreements, such as the World Health Organization (WHO) Framework Convention on Tobacco Control (). To do so, identifying areas where the various agendas are harmonized will be of utmost importance so that countries are equipped to tackle these challenges efficiently and coherently.

SDG 3: “Ensure healthy lives and promote well-being for all at all ages”

Health, as a key input to sustainable development and healthy populations, is fundamental to the spirit and pursuit of the 2030 Agenda. In addition to traditional health development priorities targeted by the MDGs, particularly HIV/AIDS and maternal, newborn, and child health, the new agenda identifies a broader range of health objectives. Although SDG 3 is the only explicitly health-based goal, it calls for ambitious progress by 2030 (“Ensure healthy lives and promote well-being for all at all ages”). The first three targets for SDG 3 reflect the recognition of unfinished business under MDGs 4, 5, and 6, including commitments to reduce premature mortality due to maternal complications and to end preventable deaths due to the epidemics of AIDS, tuberculosis, malaria, and other communicable diseases (Table 2). The remaining targets address issues that were not addressed in the MDGs, including NCDs; mental health; alcohol, and other substance abuse; road traffic injuries; reproductive health services; UHC; and access to safe and effective medicines and vaccines for all.

Table 2. Sustainable Development Goal (SDG) 3: targets and means of implementation, 2016–2030

SDG 3 targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 By 2030, reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programs
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination
SDG 3 Means of implementation
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

Source: Adapted from United Nations, Transforming our world: the 2030 Agenda for Sustainable Development ().

Redefinition of global priorities

By widening and diversifying the global health agenda, a shift that reflects a greater understanding of the breadth and complexity of global health challenges, SDG 3 targets have the potential to significantly improve global health outcomes. The redefinition of global priorities has profound implications for health governance. The 2030 Agenda and health-related SDGs not only lay out new principles, targets, and measurements for combating global health challenges; they also reinforce the role of the state as the primary actor in global health governance, while promoting partnership with non-State partners. Along with the emphasis on engaging civil society and mobilizing domestic political leadership and financial resources, there is an overall recognition of the state’s responsibility for setting public health agendas and implementing health-related interventions.

To achieve the nine technical targets and operationalize the four key means of their implementation under SDG 3, the health sector will need to assume a leadership role at the national level. The health sector’s pivotal position will be important in promoting actions, often implemented across sectors, which target the determinants of health and support overall well-being. At the same time, SDG 3 reflects the need for an integrated approach to addressing the cross-cutting elements of the SDG framework. Thus, the health sector will need to provide support to other sectors and institutions outside their purview to ensure progress and avoid inequitable health outcomes. While this approach will need to be adapted to differing country contexts, examining successful approaches employed at the national level can facilitate interventions that other countries in the Region may find useful.

Regional priorities

While each of the SDG 3 targets and indicators are applicable to all signatories, countries have the flexibility to decide which ones to specifically pursue as part of their commitment to the wider Agenda, according to their own priorities and sovereign interests. Nonetheless, much of the Region of the Americas shares common priorities, particularly with regard to NCDs, UHC, and the elimination agenda for infectious diseases, which are discussed in further detail below. In fact, PAHO/WHO Member States had adopted several resolutions concerning these topics, and other SDG 3 targets, before the 2030 Agenda. Moving forward, these areas will serve as opportunities to not only produce further success at the national level but also generate shared achievements through joint collaborations at the Regional level.

Noncommunicable diseases

NCDs represent a large and growing burden in the Region of the Americas, posing a threat to both regional and national development. Driven by the negative effects of unhealthy and unsustainable patterns of consumption, rapid unplanned urbanization, and longer life expectancy, these diseases have a direct impact on well-being, productivity, income, and health system costs (). The negative effects of chronic disease are exacerbated by an unequal distribution of the burden of disease predicated on socioeconomic inequality and unequal access to education, health services, and healthy living conditions. Knowledge about the impact of these diseases and the factors that lead to their development is limited by underreporting and underdeveloped monitoring systems.

Whereas the MDGs did not address NCDs, the inclusion of Target 3.4 in the 2030 Agenda clearly acknowledges the growing health burden of NCDs, a category that comprises 7 of the 10 leading causes of death in the world (). The explicit delineation of two separate targets to address communicable and noncommunicable diseases, both equally integral to the sustainability of human health and development, signifies that resources may need to be reallocated. Interventions that can most efficiently and effectively reduce the burden of diseases that pose the greatest threat to national and Regional well-being should be prioritized.

NCDs represent a whole-of-government issue, accompanied by a shift in discourse from the problem of individuals to a collective challenge requiring political action. These complex health challenges will require multisectoral collaborations and innovative solutions from heads of state. Approaches like the one used in the WHO Health in All Policies Framework for Country Action () that promote integrated, multilevel, and participatory health interventions have been identified as key to decreasing NCD prevalence in the Americas by acting on the relevant social and environmental determinants of health. Much can be learned from Mexico’s strategy to reduce obesity through its National Agreement for Healthy Eating (), Suriname’s enactment of antitobacco legislation aligned with the Framework Convention on Tobacco Control (), and Costa Rica’s executive order mandating schools to sell only fresh produce and foods and beverages that meet specific nutritional criteria ().

Target 3.4 goes further than just NCDs, however. Mental, neurological, and substance use disorders, including alcohol, are among the leading causes of the global burden of disease, and are the leading cause of global disability across all disorders worldwide and in the Americas. Like NCDs, mental health and well-being are precursors to family and community wellness, as well as the broader goals of the 2030 Agenda, which foresees “a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” ().

Mental health can be linked with 8 of the 17 SDGs, including those related to health, poverty, hunger, gender equality, sanitation, employment, inequality, and inclusiveness. Given the important role of mental health, countries may consider measuring key markers of mental health and availability of mental health services, namely, avoidance of premature deaths, including those from suicide (), and achievement of parity in access to mental and physical health services (). In addition, Goals 4, 8, 10, and 11 highlight the inclusion of people with disabilities, essential for the promotion and protection of the rights of people with mental, neurological, and substance abuse disorders, a population that has historically comprised the most marginalized, vulnerable, and neglected in society (). Despite the significant overlap between mental health and substance abuse, each issue presents unique challenges. As such, a different target is dedicated to the prevention and treatment of substance abuse, though action on either will likely have implications for both.

Universal health coverage

In a Region that has historically maintained a public-private health system, UHC is considered an essential pillar for development. It is key to achieving health-related SDGs and critical to minimizing health system fragmentation, preventing disease, achieving better health outcomes, and, ultimately, promoting well-being for all. UHC also signifies a shift from disease-specific interventions to ensuring that communities have access to well-resourced health systems that offer comprehensive health services. Although the socioeconomic and political context of each country requires flexibility when developing strategies to achieve UHC, the need for health coverage for all is truly universal. Ensuring access to comprehensive, timely, and good-quality health care without discrimination requires a society-wide commitment to expand equitable access to health services and supplies, strengthen governance, increase financing, improve information systems, invest in human resources, and support multisectoral coordination.

To make meaningful progress toward fulfilling the promise of UHC, a human rights framework must be used to support the progressive and equitable implementation of the right to health as an obligation of the state. Doing so opens the door to an array of policies to increase the scope and equity of health programs. For example, national health systems have grown increasingly more responsive in delivering affordable care for all without causing financial hardship. Public spending, population coverage, and access to health services are increasing in the Region, while out-of-pocket payments are declining ().

A long-term challenge to UHC is the development of fiscally sustainable approaches to improve revenue generation. For any health system to become sustainable, countries must balance actual revenue generation and current expenditures. Increasing revenues through taxes is only one means of doing so and can be more or less equitable depending on which taxes are raised and in what ways they are raised (). Other ways to increase revenue include anchoring inputs or expenditures, such as limiting waste, reducing administrative inefficiencies, and reducing the adoption, intensity, and volume of services that are not cost-effective. The resulting level and quality of available health care resources is a trade-off between service coverage, the public service portfolio, and costs. Middle-income countries might struggle to adapt to steep health expenditures outpacing economic growth, whereas low-income countries often face other, unique, and possibly more limiting, obstacles. In addition to sustained investments in health, an evidence base, informed by continuous progress assessments and formal mechanisms for dialogue, should be prioritized to inform policies at the national level.

The call for UHC by the 2030 Agenda also leads to increased demand for qualified health workers, which must be matched with redoubled government efforts to produce and retain the health workforce. Strategies include coping mechanisms and self-sufficiency policies to address gaps in distribution of health workers. Countries can also offer higher salary levels and financial incentives to health providers, or introduce health worker safety policies to reduce occupational diseases and work-related accidents. Though ensuring a sufficient health workforce accounts for a significant portion of health service costs in low- and middle-income countries, strategic planning and management will better prepare countries to meet international health regulations and promote global health security (). It will also trigger broader socioeconomic development in line with SDG attainment, such as gender equality and decent employment opportunities.

The explicit inclusion of UHC and the promotion of both physical and mental health is evidence that the 2030 Agenda considers access to health and overall well-being as essential not only to human health but also to sustainable development.

Elimination agenda for infectious diseases

Countries in the Americas are increasingly aware that the control and elimination of infectious diseases have far-reaching implications for health and well-being, social and economic outcomes, and the achievement of SDG 3 and broader development goals. Over the last decades, the Region has undergone a changing environment marked by an increasingly aging population (demographic transition) and socioeconomic development including successful vaccination and vector control efforts, leading to a decrease in the overall burden of communicable diseases (epidemiologic transition). For example, there has been a 30% decrease in disability-adjusted life years (DALYs) due to communicable diseases since the year 2000. This significant progress in the control of many infectious diseases has prompted the next steps in infectious disease control, namely disease elimination.

The Region set targets for the elimination of many infectious diseases, and has already achieved many of these goals. Historically, the Americas has been a global pioneer in elimination efforts. Many endemic diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) were eliminated through the widespread use of vaccines. Regional elimination of mother-to-child transmission of HIV, malaria, tuberculosis, viral hepatitis B and C, syphilis (including congenital syphilis), and neglected tropical diseases (onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma) represents a more ambitious step forward.

Disease elimination has evolved from being based on interventions relying on effective vaccines to include those cases where no vaccine or cure (in the case of HIV) exists. In this regard, the WHO has coined the term “elimination as a public health problem,” wherein the elimination threshold is a minimum value that is achievable using all current evidence-based interventions, and where continued actions will be necessary (Box 1). Strategies for the elimination of communicable diseases now comprise a wide spectrum of interventions focusing on vaccination, use of vector control strategies, diagnostics, and medications, acknowledging the need for broad multisectoral interventions for success. Currently, there is no absolute common definition of elimination for all diseases. The various criteria used for disease elimination make having one single conceptual framework and definition a pending task that experts are working to build.

Box 1. Basic definitions related to the control and elimination of infectious diseases.

Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts. Continued intervention measures are required to maintain the reduction.

Elimination as a public health problem: A term related to both infection and disease. It is defined by achievement of measurable global targets set by WHO in relation to a specific disease. When reached, continued actions are required to maintain the targets and/or to advance to the interruptions of transmission. The process of documenting elimination as a public health problem is called “validation.”

Elimination of transmission: Reduction to zero of the incidence of infection caused by a specific pathogen in a defined geographic area, with minimal risk of reintroduction, as a result of deliberate efforts; continued actions to prevent reestablishment of transmission are required. The process of documenting elimination of transmission is called “verification.”

Eradication: Permanent reduction to zero of a specific pathogen as a result of deliberate efforts with no risk of reintroduction. Intervention measures are no longer needed. The process of documenting eradication is called “certification.”

Sources: Dowdle WR. The principles of disease elimination and eradication. Bulleting of the World Health Organization 1998;76(S2):23-25.
Pan American Health Organization. Report on the Regional consultation on disease elimination in the Americas. Washington, D.C.: PAHO; 2015.

The current major components of the elimination agenda include the vaccine-preventable disease agenda, including HBV infection; the neglected tropical diseases; the big epidemics of tuberculosis, HIV, and malaria; and lastly, sexually transmitted diseases and chronic HCV infection. The decreasing burden of disease and efficacy of technology will dictate new possibilities for elimination defining the thresholds for elimination from a public health perspective. As new drugs and new technologies develop, the elimination agenda will surely broaden to include other infectious disease and may expand into NCDs, such as for cervical cancer in relation to vaccine-preventable HPV.

Past experience shows that continuing current prevention and control efforts alone are not sufficient for elimination. In addition to strong political will, adapting strategies to local contexts, capitalizing on new technologies, and accelerating translation of science into policy and implementation are required. Combining intensified traditional approaches with innovative approaches can generate new synergies and enhance the effectiveness of elimination efforts.

Current threats to the elimination agenda include the emerging drug resistance, an increasingly aging population, antivaccination movements, and shifting political priorities. High initial costs in the path towards elimination might also be deterrents, but as the health system becomes more effective, unit costs will decrease. There are also high costs to monitor its success.

The Region is moving towards a comprehensive elimination agenda that ranges from disease control to eradication, with quantifiable goals for each step along the way. Countries are striving towards greater integration of disease elimination efforts and capitalizing on synergies. This agenda symbolizes how the Region continues to work on health, human rights, and tackling inequities. To achieve these ambitious targets, along with the other targets of SDG 3, countries must exercise strong leadership to collaborate and create synergies with other sectors and ministries.

Health across the SDGs

Unlike the disease-specific focus of health sector priorities outlined by the MDGs, the 2030 Agenda establishes numerous health-related targets that would traditionally fall under the coordination of other sectors. The interdependent framing of the SDGs creates opportunities for health programming and activities across the entire 2030 Agenda, allowing countries to tailor their national plans and policies to their own needs. While all SDGs create opportunities for the health sector, or have some effect on them, WHO has identified specific SDG targets and indicators that countries should prioritize in policy-making and resource allocation for the best return on health. These include Target 2.2 (child stunting, and child wasting and overweight); Target 6.1 (drinking water); Target 6.2 (sanitation); Target 7.1 (clean household energy); Target 11.6 (ambient air pollution); Target 13.1 (natural disaster); and Target 16.1 (homicide and conflicts) (Table 3).

Table 3. Sustainable Development Goal (SDG) targets identified by the World Health Organization for policy-making/resource allocation prioritization, 2016&ndash2030

SDG health targets
3.1 Maternal mortality and births attended by skilled health personnel
3.2 Child mortality
3.3 HIV, tuberculosis, malaria, hepatitis, neglected tropical diseases
3.4 Noncommunicable diseases and suicide
3.5 Substance abuse
3.6 Road traffic injuries
3.7 Sexual and reproductive health
3.8 Universal health coverage
3.9 Mortality due to air pollution; unsafe water, unsafe sanitation and lack of hygiene; and unintentional poisoning
3.a Tobacco use
3.b Essential medicines and vaccines
3.c Health workforce
3.d National and global health risks
SDG health-related targets
2.2 Child stunting, and child wasting and overweight
6.1 Drinking water
6.2 Sanitation
7.1 Clean household energy
11.6 Ambient air pollution
13.1 Natural disaster
16.1 Homicide and conflicts

Source: Adapted from World health statistics 2016: monitoring health for the SDGs ().

Like the SDG 3 targets, the quantity and breadth of these health concerns have far-reaching implications for funding and policy implementation, particularly in low- and middle-income countries. The systemic and multifactorial interventions needed to achieve these targets have the potential to strain the human, financial, and technological resources of health sectors and health systems. For example, “achieving universal and equitable access to safe and affordable drinking water for all” and “significantly reducing all forms of violence and related death rates everywhere” pose more complex challenges than the disease-specific MDGs.

Historically, policymakers and political leaders tend to prioritize the most feasible goals and activities with the potential to produce rapid results. As countries move forward with the 2030 Agenda, the criteria for prioritizing targets should instead focus on selecting those that utilize the most appropriate principles, assumptions, and methods to maximize health outcomes per unit of resources available.

While SDG 3 offers four essential means of implementation, they must be complemented by other actions to fully achieve the 2030 Agenda’s health and health-related targets. SDG 16 and 17 fill many of those gaps. SDG 16 articulates the importance of effective and equitable governance as an essential and enabling feature of the 2030 Agenda, and sets the stage for international cooperative action and partnerships among governments, civil society, and the private sector. SDG 17 supplements each of the goal-specific approaches with cross-cutting means of implementation for the entire agenda. Framed as a revised global partnership for sustainable development, SDG 17 covers a wide range of targets for finance, technology, capacity building, trade, policy, and institutional coherence.

Finance

National budgetary constraints demand a thorough analysis to strategically select which targets will be emphasized and how they will be financed. Public-private partnerships and investments in other sectors should be considered to ensure that all are viable and can operate efficiently. Internally, countries can mobilize domestic resources by improving tax collection, reducing external debt, and tackling tax evasion. A financially feasible development agenda will require domestic public resources and traditional sources of financing for development, such as official development assistance, as well as private investment, innovative mechanisms for funding to address structural threats to health, and the use of regulations to ensure compliance with national priorities and legislation.

The UN Addis Ababa Action Agenda, adopted in July 2015, was the first step toward developing a new and innovative financing framework (). It proposes an array of mechanisms for countries and stakeholders to effectively mobilize financial resources for the achievement of the SDGs, taking into particular consideration the challenges of middle-income countries like many of those in the Americas. The first Regional consultation on financing for development took place in Santiago, Chile, in March 2015, allowing the Region’s perspective and priorities to be fully reflected in the process ().

Measurement, monitoring, and evaluation

The importance of highlighting and tackling inequalities between subpopulations is central to the 2030 Agenda and requires indicators that incorporate data disaggregated for drivers of inequality. As the most inequitable region in the world, average improvements may mask growing inequalities between population groups, particularly the most vulnerable, disadvantaged, and marginalized. As such, there is a need to refine, adapt, and scale up the measurement, monitoring, and evaluation capacity of countries, especially those with less developed or poorly equipped health information systems. The explicit goal to develop indicators that are disaggregated by income level, education, gender, and ethnicity, as well as other important determinants of health and social inclusion within the SDG agenda, represents an important shift from the MDG agenda and reflects a growing appreciation for the negative impact of inequalities on health and development.

Mobilization of stakeholders

Achieving the health-related targets will require contributions, engagement, and leadership from beyond the health sector and greater coordination between public and private stakeholders. The term “stakeholder” should be considered broadly and adapted at the country level to expand the participation of relevant actors, including sectors such as finance, trade, environment, and labor, along with government institutions, local authorities, international organizations, civil society organizations, and the private sector. The negotiation process of the 2030 Agenda is a key example of how Regional leadership is both evolving and redefining traditional approaches to health and development. There is no doubt that the changing landscape of these players will continue to have important implications for the Region through 2030.

Because the most marginalized populations often suffer most from the negative effects of unsustainable growth and development, locally led civil society organizations are an essential element to fulfill the 2030 Agenda. A people-centered, inclusive, participatory approach will strengthen mechanisms designed to advance the 2030 Agenda. Moreover, as the front line of engaging with citizens to achieve the SDGs, civil society plays a critical role in widening access to different populations, fostering advocacy, identifying development priorities, proposing practical solutions, and even providing feedback on problematic or unrealistic policies (). Often, governments and civil societies share common goals; a good example of this is the Region’s adoption and implementation of tobacco control policies, a process in which civil society has actively promoted and monitored the enforcement of new policies ().

Although Regional bodies and organizations have long been involved in health issues in differing roles and to varying degrees, their increasing influence on global health policy-making will make them key players in the implementation of the SDGs. Because of their familiarity with Regional challenges, barriers, and opportunities, these organizations have the ability to mediate between the global and national levels. They also have the unique capability to unite specific countries and harmonize specific goals and data at the regional or subregional level. Ultimately, Regional organizations can generate new opportunities for information exchange at the global level.

Think tanks and academic institutions can also help accelerate the SDG process through their engagement in policy development, identification of determinants of success, measurement of policy outcomes, and role in ensuring that the knowledge that is generated, translated, and disseminated reaches marginalized populations more quickly (). In turn, these institutions can provide direct input to high-level processes and support more effective implementation of the overall 2030 Agenda as well as specific actions, thereby ensuring greater political accountability.

Finally, business has a critical role to play in achieving the SDGs. The private sector has traditionally been the driver of scientific and technological development and strategies. Involving the private sector has immense potential to tap into that innovative capacity and deliver solutions to the barriers outlined in the 2030 Agenda (). Mobilization of the private sector will be critical to provide capital, jobs, technology, and infrastructure. Governments should coordinate with the private sector from the earliest stages of planning and implementation to ensure that businesses contribute to, and do not undermine, inclusive and sustainable development.

Table 4. Examples of Regional stakeholders in the 2030 Agenda for Sustainable Development

Type of stakeholder  
Regional organizations Southern Common Market (Mercosur), Economic Commission for Latin America and the Caribbean (ECLAC), Central American Integration System (SICA), Council of Ministers of Health of Central America (COMISCA), Organization of American States (OAS), Pan American Health Organization (PAHO), Community of Latin American and Caribbean States (CELAC), Union of South American Nations (UNASUR), Andean Health Organization (ORAS-CONHU)
Civil society Nongovernmental organizations, neighborhood associations, media, unions
Think tanks and academic institutions Universities, research institutes
Private sector Industries, businesses

Identifying common ground

The 2030 Agenda is a timely reminder of the complexity of human health and the systems designed to protect it. It is also an opportune moment to strategize, coordinate, and plan for a future in which many of the Region’s greatest health concerns will originate outside the health sector. In light of this, health experts will be required to strengthen health systems and break down artificial boundaries across sectors to address key trends in the Americas that have direct and indirect implications on the Region’s health and well-being.

Health in All Policies (HiAP) is a useful framework for policymakers and government officials to address the SDGs at the national level (). Before the Health in All Policies approach was explicitly defined, it had already been adopted and applied throughout the Region of the Americas to place health at the center of development. Specifically, the HiAP framework is designed to identify and develop common ground between the health sector and other sectors in order to build shared agendas and strong partnerships, ultimately leading to mechanisms for participation, accountability, collaboration, and dialogue among various social actors ().

HiAP is frequently seen as a country approach to tackle NCDs and the social determinants of health, including tobacco use, obesity, housing, and transportation. Focused action and alliances between the health sector and sectors involved in clean energy, chemical safety, standards for employment opportunities in the health industry, and safe food production and distribution have also proven to be win-win situations (). While the HiAP framework has been successful in these areas, it can also be effective in “hard” politics (the use of traditional political systems and mechanisms), bringing together various stakeholders in health security, foreign policy, and finance to negotiate for health among competing interests. Given that the HiAP approach requires firm, long-term political commitments from national authorities responsible for formulating policies within and beyond the health sector, the 2030 Agenda provides an effective platform for building intersectoral health-oriented policies.

Likewise, innovative health promotion strategies can result in greater capacity and empowerment to both prevent and respond to public health concerns. A robust Healthy Municipalities and Communities Network() (Red de Municipios y Comunidades Saludables) is already in place throughout much of the Region (). In line with the 2030 Agenda, health promotion and the Healthy Settings approach() provide practical models of integrated, multilevel interventions based on enabling healthy environments, engaging local governments, reorienting health services, and promoting well-being and healthy choices through political commitment, public policies, community involvement, and strengthened individual capacity to improve health.

Both of these approaches complement the biomedical services already in place, but they also foment a Regional shift from response to preparation and prevention of negative health outcomes, and from a medicalization of society to a true public health approach to solve complex challenges. In addition, they emphasize the fact that all people and all levels of government bear responsibility for controlling diseases and managing health. The approaches and principles of the health promotion and HiAP strategies mirror those of the SDGs, thus ensuring synergy with the 2030 Agenda. More specifically, the Agenda’s call for an inclusive and participatory approach, expanded resources and participation, and collaboration across sectors presents a historic opportunity to mobilize relevant sectors, local and national governments, civil society organizations, and communities in an effort to promote health and achieve HiAP goals. Both strategies will be increasingly important at the global level, for achieving the goals of the 2030 Agenda, and at the Regional level, with regard to managing the effects of mega-trends and addressing inequalities that have become so large that they contribute to instability and poor health outcomes.

Poverty eradication

Poverty reduction is inextricably linked to health and sustainable development. It is a multifaceted phenomenon that threatens the health outcomes of affected individuals and communities, denying them full enjoyment of their human rights, including the right to health. As shown in Table 1, poverty and extreme poverty rates have decreased in the Americas since 1990, culminating in the Region’s achievement of the first target of the MDGs. Thanks to improvements in employment opportunities and income levels, income inequality also fell during this period ().

Nonetheless, since the start of the economic slowdown in 2008, the downward trends for poverty and extreme poverty have slowed; in fact, the rates are projected to increase slightly in coming years, which will affect the creation of jobs and the quality and level of the available work (). Moreover, the Region remains the most unequal in the world, leaving a high proportion of the population in a highly vulnerable position defined by volatile incomes near the poverty line (). In this way, poverty eradication signifies more than the elimination of extreme poverty; it also involves efforts to close these gaps and minimize individuals’ and communities’ vulnerability to poverty.

Approaches that prioritize concerted efforts toward poverty reduction will benefit from potential synergies with other priority areas of sustainable development, including sustainable cities, employment, energy, water, and education. Previous Regional experience has demonstrated that progress toward poverty reduction will remain fragile and reversible until countries embrace the multisectoral approach presented by the 2030 Agenda. Cross-sectoral collaboration must be accompanied by concrete commitments to ensure UHC, universal access to health, and social protection mechanisms that sustainably mitigate vulnerability and eradicate poverty in all its forms.

Sustainable consumption and production

Controlling production and consumption patterns are prerequisites for achieving the 2030 Agenda objectives of true equity, inclusion, and sustainability. As the Region’s population continues to grow, so does the importance of maintaining the productivity and capacity of the planet to meet human needs and sustain economic activities. At the same time, Regional patterns of consumption are being altered by lower fertility rates and an aging population ().

In order to reduce the risks to health and the environment associated with overarching demographic dynamics, this two-pronged issue depends on the sustainable, clean, and efficient production of goods and services, as well as more efficient and responsible consumption. Natural resources key to human survival, such as water, food, energy, and habitable land, must be protected; pollution associated with human and economic activity, including greenhouse gases, toxic chemicals, emissions, and excess nutrient release, must be reduced; and current consumption patterns, as drivers of unsustainable development, poor health outcomes, and resource degradation, must be significantly altered.

Food loss, waste, and overconsumption represent part of the unsustainability of the Region’s production and consumption patterns. The overconsumption of food has led to sharp increases in obesity and detrimental effects on the environment, primarily through greenhouse gas production, overuse of arable land, and deforestation. In spite of this, growing consensus in recent years shows that the Region has not only an adequate food supply but also a network of economic and social policies that could eradicate hunger, combat malnutrition, and address obesity in the short to medium term ().

To achieve the goals of the 2030 Agenda, the Region will need to promote a combination of multisectoral policies and economic and social activities. These should serve as enablers, empowering countries, producers, and consumers to become owners and successful users of technologies and processes that will ensure resource efficiency, sustainable consumption, and, ultimately, healthier livelihoods and lifestyles.

Governance

Since the start of the global financial crisis, the Region has been undergoing an economic slowdown. The Americas will confront the challenges of the 2030 Agenda in the midst of persistent external vulnerability, long-run low growth rates, smaller financial inflows, weaker external demand, and declines in investment growth rates. The slowdown has led to consistently increasing urban unemployment rates and poor employment quality, factors that partially explain why Regional inequality reduction has slowed. These patterns of economic activity represent one of the most significant challenges for the Region in building the capacity, infrastructure, and innovation necessary to achieve the 2030 Agenda ().

Moreover, these economic trends have the potential to reverse development progress achieved over the last decade, particularly with regard to shared prosperity and poverty reduction (). Sustaining these advances and realizing the SDGs, despite the deceleration of activity and sometimes contracting economy, means the Region must change its way of doing business under conditions less favorable than those experienced during the MDG era. This will require a stronger Regional commitment to governance and regulation of the ways institutions are shaped, legitimized, and equipped. Governance structures affect growth, equity, and well-being, each of which is pivotal for realizing sustainable development.

Accountability and responsiveness are two key pillars underlying the effectiveness of government institutions and their ability to deliver on the SDGs. Neglect of these pillars can lead to social and political instability, reduced investment, poor economic performance, and direct and indirect effects on the well-being of citizens. They can be overcome by reforms that prioritize transformative leadership, citizen participation, transparency, and innovative interventions. In order to manage this transition and mitigate the associated risks, it is vital that the Region continue to bring together high-level decision-makers, researchers, experts, and civil society to engage in strategic policy discussions, build alliances, and explore innovative approaches and mechanisms for use by governments and citizens to effect positive, sustainable change.

Urban development

The Region of the Americas is the most urbanized region in the world, with nearly 80% of the population living in urban centers, a proportion expected to increase to an estimated 85% by 2030 (). These urban areas are often hubs of innovation and economic production, with populations that tend to have greater access to social and health services than their rural counterparts. While opportunities, jobs, and services are concentrated in these areas, so are health risks and hazards. The adverse effects of these conditions are increasingly concentrated among the urban poor, generating notable health inequities between the richest and poorest urban populations. Aggravated by poor strategic planning, the ability of urban centers to meet the needs of their entire population has become a persistent challenge that will inhibit truly sustainable development.

For example, unhealthy lifestyles resulting from diets that prioritize cost savings and convenience over health; sedentary behaviors; and the harmful use of alcohol, tobacco, and drugs could heighten risks related to obesity and the increase in chronic NCDs, including diabetes, heart disease, and cancer (). In addition, the potential for communicable disease outbreaks is amplified due to large numbers of people living in close proximity, oftentimes in conditions with compromised standards for sanitation and water provision. Substance abuse, poor housing conditions, road safety concerns, and a plethora of environmental hazards associated with urban centers can also have a harmful effect on the ways in which people grow, work, live, and age.

If the 2030 Agenda is to effectively foster health and well-being in a way that advances equity, the importance of urban centers to human lives and livelihoods must be fully considered. Although an increasingly urbanized world has the potential for a multitude of adverse consequences for health and well-being, it also creates opportunities. Because the trends of urbanization are highly interdependent and multilevel, a greater focus on the ways in which cities are planned, designed, developed, and managed can help policymakers recognize systemic relationships and opportunities for strategies that will generate co-benefits and long-term synergies for health. Strategies from multiple sectors must be applied to reduce inequities and influence the determinants of health associated with rapid urbanization.

Environmental sustainability

Widespread urbanization, population growth, and industrial development continue to directly affect human health and broader development goals in the Americas. The effects of these trends include increased exposure to both traditional environmental hazards, like indoor air pollution and drinking-water contamination, and newer hazards, such as toxic chemicals, pesticides, electronic waste, and phenomena related to climate change, including natural disasters and irreversible changes to ecosystems. In terms of climate change, shifting temperatures alter disease patterns and vector distributions, ambient air quality has negative effects on respiratory health, and extreme climate events increase the vulnerability of populations to morbidity and mortality. At the same time, higher population concentrations require increased reliable access to resources that are already in high demand, namely water, sanitation, infrastructure, and energy.

While the assortment of risks varies across and within countries, they all reflect potential effects of environmental shifts on the Region’s vulnerability. Moreover, they are evidence that sustainable development, environmental health, and climate change are deeply intertwined, and that improving environmental conditions is a prerequisite for achieving SDG 3. This interconnectedness is apparent in both SDG 13 of the 2030 Agenda and the Paris Agreement of the United Nations Framework Convention on Climate Change (). In the Paris Agreement, several Regional signatories have committed to strengthening responses to the threat of climate change and developing plans to urgently reduce greenhouse gases to help meet part of the Framework’s broader goals to “allow ecosystems to adapt naturally to climate change, to ensure that food production is not threatened, and to enable economic development to proceed in a sustainable manner” (). In other words, the planet and the people that inhabit it are intrinsically interdependent. Because they cannot be separated, the harms inflicted on the planet are a threat to peoples’ health and ability to thrive.

The Region’s unequal distribution of income and the fact that those in the highest income brackets make a disproportionate contribution to emissions will require considerable improvements in the diversification of renewable energies; preservation measures in agriculture; and coverage of public services, such as mass transit and waste management (). In this way, multisectoral approaches to protecting the environment and protecting people from the consequences of its degradation are increasingly accepted as key aspects of strategies for overcoming health inequities and achieving the broader 2030 Agenda.

The health and well-being of the Region, as well at its ability to achieve these global agendas, is dependent on scaled-up actions, both immediate and long-term, to address the rapidly changing nature and scope of challenges related to the environment and climate change. Those actions are also needed to ensure that all national development plans consider environmental concerns and include rigorous safeguards and sustainability measures that also benefit and synchronize with the aims of the health sector, such as actions related to chemical safety (). Throughout this process, the greatest challenge will be to reconcile the demands of growth with the need to protect and manage natural habitats and resources and the importance of ensuring that environmental policies do not generate additional burdens for the poor. Nonetheless, the Region has many opportunities to address the topic of health and many facets of environmental sustainability in national and regional policies, which can subsequently contribute to an enabling environment for achieving many of the SDGs.

Building resilience and improving adaptive capacity is critical to continued development and achievement of the 2030 Agenda across the Americas. Adaptive efforts include increasing engagement with other sectors to improve environmental consciousness; reducing carbon footprints; and developing innovative solutions in renewable energy, transportation, water supply, forestry, agriculture, and urban development. In addition, countries must improve the reliable production of environmental statistics, promote research, build regional capacity, and develop platforms for dialogue and shared learning among relevant stakeholders. This will support the development of evidence-based prevention policies; generate income opportunities; mainstream environmental health and climate change in broader development initiatives; and ultimately strengthen the Region’s capacity to adapt to an ever-changing world.

Looking forward

The world has entered a new era of sustainable development, building on the successes of the MDGs. To continue advancing on social, economic, and environmental fronts, the Region must advocate, implement, and practice innovative public policies that close persistent inequities and address the increasing complexity and interconnectedness of health and development. Although only one of the 17 SDGs explicitly names health as a priority, many SDGs and their targets are related to health and thus highlight the health sector as one that not only is inherent to achieving the overall 2030 Agenda but also provides many opportunities for cooperation. In this way, health is central to the development of an equitable and sustainable future.

In the midst of rapid urbanization, threats to the climate and environment, and the emergence of new challenges, such as the growing burden of NCDs, it is crucial to adopt the 2030 Agenda core principles of equity and multesectoriality to harness complementary efforts and deliver shared gains. National plans and global agreements that are already in place, such as the WHO Framework Convention on Tobacco Control, the Minamata Convention, and the Paris Agreement, are prime examples of how the 2030 Agenda can be used to integrate priorities, innovations, and inputs from a variety of partners and stakeholders (). The public, private, and civil society sectors all have a role to play in strengthening the implementation of these policies and ensuring that new policies and interventions are not only equitable but also efficient.

Health is politicized at all levels of governance—locally, regionally, and globally—in governments, international institutions, the private sector, and civil society organizations. In addition, health itself is inherently political, because it is unevenly distributed, with many determinants that are dependent on political action, and inherently related to human rights (). Thus, only when the political nature of health is explicitly acknowledged will countries be enabled to develop more realistic, evidence-based public health strategy and policy.

Given the central importance of equity to the 2030 Agenda, it is clear that persistent inequities are not likely to dissipate unless health-related issues are discussed and addressed at the highest political levels. Because health affects economic and social conditions, and thus also has an impact on political legitimacy, the consequences of not embracing this strategic shift may be significant. At the same time, the effective use of politics in public health is already generating positive outcomes in areas such as NCDs and climate change. In order to gain political influence, countries and public health organizations must be equipped to analyze political contexts and complexities, frame arguments, and act effectively in the political arena ().

The 2030 Agenda has redefined public health in a fundamental way by demonstrating that public health challenges can no longer be addressed merely through technical actions but must be accompanied by political action within and beyond the health sector. The implementation of such an ambitious agenda simultaneously () creates opportunities to apply an ecological perspective, and systems thinking, and () requires that health be considered in government policies. Regional bodies, civil society groups, and global health institutions will be essential in accelerating the 2030 Agenda at all levels of governance, and the Region of the Americas must be prepared to embrace a more political approach to health in the context of sustainable human development and the SDGs.

Conclusions

The 2030 Agenda represents a fascinating point in public health history in which health is a driving force for a new quality of life and well-being, and challenges in the health sector extend beyond traditional health boundaries. The health sector thus becomes intertwined not only with development but also with politics and political processes. Health challenges require complex solutions and should thus have policy potential to take advantage of windows of opportunity and produce mutual gain across different sectors. Moreover, the co-production and co-benefits of health must be shared across society as a whole. The 2030 Agenda establishes a framework in which successful outcomes in health can have a positive impact on other aspects of development-advances that will in turn reciprocally benefit health.

Despite the complex interplay of the SDGs, the 2030 Agenda’s call is straightforward: in order to create a more equitable world for future generations, countries must identify their most vulnerable populations, develop innovative strategies to reach those populations, and monitor progress toward that end. Achieving these objectives should not be solely the responsibility of government, however. The aspirational goals and targets of the 2030 Agenda must be translated into relatable, practical, and implementable actions that individuals, families, and communities can take. These everyday actions will make sustainable development tangible, enhance effectiveness, involve new actors, and foster ownership of the Agenda across and within borders. Now, more than ever, it is of paramount importance to collectively transform the 2030 Agenda into a reality for the benefit of all.

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

The settings-based approach to health promotion involves holistic and multidisciplinary action across risk factors to maximize disease prevention via a “whole system” approach. More information is available at http://www.who.int/healthy_settings/en/.

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Reference/Note:

Chronic conditions and diseases due to external causes

  • Summary
  • Introduction
  • Discussion
  • Tackling the Major NCD Risk Factors
  • Management of Noncommunicable Diseases
  • Mental Health
  • Road Traffic Injuries
  • Interpersonal Violence Prevention
  • Disabilities
  • Chronic Conditions, Life Course, and Social Stratification
  • Conclusions
  • References
  • Full Article
Page 1 of 12

Summary

Noncommunicable diseases (NCDs), which comprise cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases, are the leading causes of ill health, death, and disability in the Americas. Because of their high cost of care and economic impact, NCDs have a significant impact on development. Thus, tackling the common risk factors of NCDs (tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet) is an urgent priority. In addition, mental and substance use disorders are highly prevalent, and together with road traffic injuries and interpersonal violence, are also major causes of disability.

These conditions are driven by demographic changes, economic growth, negative effects of globalization, rapid and unplanned urbanization, and the epidemiological transition from infectious diseases to chronic conditions. Populations living in vulnerable conditions are more affected by these changes, and together with structural factors such as education, occupation, income, gender, and ethnicity, lead to a disproportionate impact of underlying social determinants on this population.

Prevention is the cornerstone of a response to these chronic conditions. Policy, regulatory, and health promotion interventions are recommended to reduce NCD risk factors, and all policies should be centered on public health interests. For mental health, the first steps are early prevention, correct identification, and treatment of emotional or behavioral problems. Prevention practices for road traffic injuries and disabilities include laws that prohibit speeding and drunk driving and that require the use of motorcycle helmets and seat belts.

Universal health coverage for equitable access to quality care for persons living with chronic conditions, and in many cases multiple chronic conditions, is necessary to improve health outcomes. For those at risk for or living with one or more NCDs, a chronic care approach is recommended. This includes organizing services for continuous and quality care, evidence-based guidelines, support for self-management, clinical information systems, coordinating care among providers, and community resources to support patients. People living with disabilities require special attention as they often seek more health care but have greater unmet needs. Barriers to care include physical barriers, financial barriers, and lack of appropriate services. The treatment gap for mental health and other conditions is significant and is expected to worsen with an aging population. Service delivery tends to be fragmented, with poor coordination between the primary, secondary, and tertiary levels, and there is a heavy emphasis on mental institutions. The Mental Health Gap Action
Program (mhGAP) of the World Health Organization (WHO) offers a model of care, with psychosocial assistance and medication, to improve mental health.

As the Region continues to develop, the focus shifts to the Sustainable Development Goals (SDGs); they include specific targets for NCDs, mental health, and road safety, among other issues. Achieving these goals will require governments to intensify their response to chronic conditions, as well as increased technical assistance from the global health community.

Throughout the text, the terminology of chronic conditions is used to encompass conditions that are recurrent or that manifest throughout the life course, and not necessarily related to disease or illness. From the perspective of a socially organized response, chronic conditions are expressed in more expanded time trajectories and in cycles of critical periods that trap health systems in ongoing health interventions. This perspective is aligned with the life-course approach and with the social determinants approach, both of which are discussed in separate chapters.

Introduction

Noncommunicable diseases (NCDs)—including cardiovascular diseases, cancer, diabetes, chronic respiratory diseases—are the leading cause of morbidity, mortality, and premature death in the Americas, accounting for 79% of all deaths in 2012 (). A significant proportion of these deaths is preventable by tackling the four common risk factors: tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity (). In addition, mental, neurological, and substance use (MNS) disorders are among the leading causes of the global burden of disease, responsible for 19% of the overall loss in disability-adjusted life years (DALYs) in the Region (). Recurrent depression, anxiety disorders, schizophrenia, bipolar affective disorder, suicide, dementia, and alcohol-use disorders are among the most common MNS disorders, for which significant treatment gaps exist in the Region ().

The number of people with disabilities in the Americas, estimated at 140 million people, is increasing due to the population aging, increasing prevalence rates of NCDs, and changes in lifestyles (). People with disabilities generally have poorer health, fewer economic opportunities, and higher rates of poverty, owing to the barriers of everyday living ().

Road traffic injuries continue to be a significant public health problem in the Americas, with a death rate of 15.9 per 100,000 population (). The situation is worsening with greater population growth, urbanization, economic development, and weak public transportation systems (). The Americas is also one of the regions with the highest levels of violence of all types (). This situation is strongly associated with the poor rule of law; weakening governance; cultural, social, and gender norms; increasing unemployment and income inequality; and limited educational opportunities.

In this section, we describe the situation for this group of NCDs and health issues, while highlighting effective public health interventions to address these conditions.

Discussion

Overview of noncommunicable diseases

NCDs are the leading causes of death in the Americas, causing an estimated 4.8 million deaths in 2012 (). Premature mortality is a major concern, given that 35% of NCD deaths occur in persons under 70 years of age. Cardiovascular diseases (CVDs) account for 37% of all NCD deaths, while cancer accounts for 25%, diabetes for 8%, and chronic respiratory diseases for 6% (). CVD mortality rates have declined steadily in most countries in the Americas, with an overall reduction of 19% from 2000 to 2010 (20% in women and 18% in men) (), while cancer mortality rates have remained relatively stable for both men and women over the past 15 years ().

NCDs are impeding economic growth and development in the Region, as countries face important lost output due to early deaths, disability, and costs of ill health (). The economic burden of NCDs (including mental health) in low- and middle-income countries has been estimated at US$ 21.3 trillion for 2011-2030 (). This is in contrast to the estimated cost of US$ 2 billion annually, equivalent to less than US$ 0.20 per person, to implement a set of cost-effective interventions to address NCD risk factors in low- and middle-income countries ().

NCDs disproportionately affect people living in vulnerable situations because of the complex interplay between social, behavioral, biological, and environmental factors, along with the accumulation of positive and negative influences over the life course (). For example, NCD mortality tends to be higher in populations with less education, lower income, less social support, and racial discrimination ().

NCDs and their risk factors manifest differently among men and women. For example, insufficient physical activity is more common among women than men (37.8% vs. 26.7%), and more women are obese compared to men (27.4% vs. 21.7%) (). More men smoke than women (24.1% vs. 14.2%) and also drink alcohol heavily (21.0% vs. 7.2% among women) (). Hypertension affects men and women equally; however, women show greater awareness of their hypertensive status and have higher rates of treatment and control than men (). As a result, CVD mortality rates are higher in men in all countries of the Americas, and premature mortality from CVD during 2000–2010 dropped more in women (average annual rate of 2.7%, vs. 2.3% among men) ().

Underlying NCD risk factors

NCDs are driven largely by forces that include demographic changes, epidemiological transition, economic development, rapid and unplanned urbanization, and negative effects of globalization, among other factors. These dynamics have had an impact on the four key risk factors that account for the majority of preventable deaths and disability from NCDs: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use ().

Most of these are associated with the consumption of commodities, such as tobacco, alcohol, and ultra-processed products (UPPs) including sugar-sweetened beverages (SSBs). UPPs are a result of modern industrial food science; their nutritional quality is very low although they may be palatable and quasi-addictive (). Alcohol and tobacco are psychoactive substances with reinforcing and known addictive properties. As a consequence of globalization and market changes, alcohol, tobacco, UPPs, and SSBs are widely available, inexpensive, and heavily promoted through advertising, promotions, and corporate sponsorships. In the case of alcohol, the negative impact goes beyond NCDs and includes mental and neurological disorders, injuries, and associated diseases.

The consumption of these commodities is influenced by industries that massively produce, distribute, sell, and promote their products without adequate regulatory frameworks. In addition, favorable trends in economic development that increase people’s income can also increase the affordability of these products, but only if not combined with sound regulatory measures, including trade, fiscal, and investment policies that limit their consumption. This is shown in the relationship between foreign investment and the increase in tobacco consumption (); market deregulation and fiscal incentives and the increase in sales and consumption of UPPs (); and trade liberalization and harmful use of alcohol (). In addition, physical inactivity is reinforced by rapid urbanization, automation of many activities, an increase in violence and insecurity, and inadequate or expensive public transportation.

Overweight/obesity, physical inactivity, and unhealthy diet are strongly associated with type 2 diabetes, and more than half of these cases can be prevented by reducing these risk factors (). Furthermore, an estimated 30% to 40% of cancers can be prevented by reducing the main NCD risk factors. Tobacco control can significantly reduce chronic respiratory diseases, notably chronic obstructive pulmonary disease. Tobacco control and minimizing salt consumption can reduce population-level CVD risk. Control of elevated blood pressure (hypertension) is also a cost-effective intervention () to reduce cardiovascular risk, and secondary prevention can prevent and delay up to 75% of new cardiovascular events ().

More information on individual NCD risk factors is provided below.

Unhealthy diet and obesity. Hunger and nutritional deficits coexist with an increase in overweight and obesity; they share common determinants of poverty, inequities, and lack of healthy, nutritious food (). Changes in dietary patterns have emerged from globalization, urbanization, the incorporation of more women into the work force, and increased consumption of food outside the home concomitantly with the increase in marketing and availability of SSBs and UPPs (). The fastest increase in UPP sales, and in overweight and obesity, are found in Latin America and the Caribbean (). This is the result of food industry mass-marketing campaigns, foreign investments, and the takeover of domestic food companies (). Global producers are driving the “nutrition transition” from traditional, simple diets to highly processed foods, and the pace is accelerating ().

To address obesity in the Region and as part of the Plan of Action for Prevention of Obesity in Children and Adolescents (), PAHO commissioned an expert consultation group to develop a nutrient profile model (). The model has been used as a basis for legislation of front-of-package labeling in countries such as Chile and Ecuador.

Tobacco. Tobacco continues to be one of the main causes of preventable death (). In the Region, tobacco-related deaths account for 14% of all deaths in adults 30 to 70 years old. The average prevalence of tobacco smoking in the Region is decreasing, but this is not the case in all countries (). Research has shown that achieving the target of 30% reduction in tobacco use is fundamental to reaching the overall goal of 25% reduction in premature mortality from NCDs (). Despite the progress made in several countries by implementing the WHO Framework Convention on Tobacco Control (FCTC) and the growing engagement of civil society and Member States, a large proportion of the Region’s population is still not covered by even a single FCTC measure at the highest level of achievement (). Finally, the influence and interference of the tobacco industry has been, and continues to be, a severe obstacle to progress in tobacco control in the Region, as it is in the rest of the world ().

Harmful use of alcohol. Alcohol consumption is responsible for a host of often devastating consequences for the drinker, the family, and the community, including but not limited to death and disability (). Alcohol is the most common underlying risk factor associated with death in people 15–49 years of age and can cause significant disability throughout the life course. Alcohol use can lead to alcohol dependence, liver cirrhosis, traffic injuries, and over 200 illnesses, including cancers, cardiovascular disease, infectious diseases, and fetal alcohol spectrum disorders ().

The average per capita consumption among those aged 15 years and older in the Region of the Americas is higher than the global average (). The prevalence of heavy episodic drinking in adults and adolescents is also high (see Chapter 3) and appears to be increasing, consistent with initiation of drinking before the age of 14 (). The prevalence of alcohol-use disorders in women in the Region is the highest in the world, at 3.9% ().

Globally, alcohol consumption is responsible for 10% of DALYs lost due to NCDs (). Alcohol-attributable health conditions strike more men than women in every country, although, for the same amount of alcohol consumed, the risk for negative consequences is higher among women (). For some of these conditions, there is no known safe level of drinking (). Acute heavy episodic drinking is related to violence, injuries, and poisoning, while chronic disease is primarily associated with patterns of chronic or repeated episodic heavy consumption ().

Physical inactivity. The recommended physical activity levels are at least 60 minutes of moderate or vigorous physical activity every day for children and adolescents, and at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity every week for adults of all ages (). Yet in the Americas, 50% of people do not meet this recommendation, raising the mortality risk by 20% to 30% ().

Physical inactivity leads to excess weight and obesity. Physical activity improves muscular and cardiovascular functions, improves bone health, and reduces depression and the overall risk of developing an NCD. Greater physical fitness also improves academic performance in children ().

The design of communities and cities and the ability of people to move about safely on foot, by bicycle, or using public transportation (all called “active transportation”) appear to have a major influence on levels of physical activity and obesity ().

Tackling the Major NCD Risk Factors

The global health community has adopted a set of nine targets to tackle major NCD risk factors and reduce NCDs (). This effort is reinforced by the Sustainable Development Goals, which include NCDs as a target within the health goal (Goal 3), with the aim of reducing premature mortality from NCDs 30% by 2030 ().

There is global consensus on the achievable, cost-effective measures to reduce NCD risk factors as described in Table 1 (). For tobacco, the interventions are defined by the WHO FCTC, the first international treaty negotiated under the auspices of WHO. The demand-side measures are summarized in the WHO MPOWER tool and include tax policies, health warnings, smoke-free environments, and a ban on advertisement, promotions, and sponsorship. Even though the Region has advanced in the implementation of smoke-free environments and health warnings, tax measures and marketing bans are well behind ().

Table 1. WHO Cost-effective interventions for NCD risk factors*

NCD risk factor Intervention
Tobacco use
  • Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products.
  • Implement comprehensive ban of tobacco advertising, promotion, and sponsorship, including cross-border advertising and on modern means of communication.
  • Implement plain/standard packaging and/or large graphic and legislated health warnings on all tobacco packages.
  • Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and all places of outdoor mass gatherings.

Other interventions:

  • Provide cost-covered, effective, and population-wide support (including brief advice, national toll-free quit line services, and mCessation) to everyone who wants to quit smoking tobacco.
  • Implement measures to minimize illicit trade in tobacco products.
Harmful use of alcohol
  • Increase excise taxes on alcoholic beverages.
  • Enforce bans or comprehensive restrictions on alcohol advertising (across multiple types of media).
  • Enforce restrictions on the physical availability of retail alcohol (by reducing the density of retail outlets and limiting hours of sale).

Other interventions:

  • Enforce drunk-driving laws and blood-alcohol concentration limits via sobriety checkpoints.
  • Provide brief psychosocial intervention for persons with hazardous and harmful alcohol use.
Unhealthy diet
  • Reduce salt intake by engaging the industry in a voluntary reformulation process.
  • Reduce salt intake by establishing a supportive environment in public institutions, such as hospitals, schools, and nursing homes, that encourages low-sodium meals to be provided.
  • Reduce salt intake through a mass-media, behavioral-change communication campaign.
  • Reduce salt intake through implementing front-of-package labeling.

Other interventions:

  • Completely eliminate industrial trans fats by developing legislation that bans their use in foods.
  • Promote breast-feeding and support exclusive breast-feeding for the first six months of life.
  • Implement subsidies to encourage people to eat more fruits and vegetables.
  • Replace trans-fats and saturated fats with unsaturated fats through reformulation, labeling, and fiscal and agricultural policies.
  • Reduce sugar consumption by taxing sugar-sweetened beverages.
  • Encourage limits on portion size to reduce energy intake and the risk of childhood overweight/obesity.
  • Implement nutrition education and counseling in different settings (e.g., schools, workplaces, hospitals, etc.) to increase the intake of fruits and vegetables.
  • Implement nutrition labeling to show better macronutrient information and total energy of foods (kcal).
  • Institute nutrition labeling in educational settings to improve dietary intake.
  • Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, fiber, and salt, and to promote the consumption of more fruits and vegetables.
Physical activity
  • Make counseling about physical activity a routine part of primary health care services.

Other interventions:

  • Ensure macro-level urban design that incorporates the core elements of residential density, connected street networks, and easy access to public transportation and to a variety of destinations.
  • Implement public awareness and motivational programs for physical activity, including mass media campaigns to encourage a change in levels of physical activity.
  • Ensure that adequate facilities are available on school premises to encourage recreational physical activity for all children.
  • Provide safe and adequate infrastructure to enable walking and cycling.
  • Implement multicomponent physical activity programs at workplaces.

For alcohol, the most cost-effective interventions are an increase in alcohol taxes, legislative measures to control alcohol marketing, and restrictions on the physical availability of alcohol. However, only four countries (Colombia, Costa Rica, Panama, and Venezuela) have tax policies that can limit alcohol consumption, only two have comprehensive marketing bans, and no country has comprehensive controls on the physical availability of alcoholic beverages (). Despite adopting the WHO Global Strategy for Reducing Harmful Use of Alcohol in 2010, then adopting a Regional Plan of Action in 2011, the Region has not made progress on any of the alcohol indicators of the PAHO Strategic Plan 2014-2019 ().

A “Health in All Policies” approach, as illustrated in Box 1, is needed to reduce NCD risk factors. Such an approach calls for all relevant sectors to consider the impact of their policies on NCDs and to utilize policy, legislative, regulatory, and fiscal measures to better prevent and control NCDs. The sectors include economic, trade, education, and agriculture, among others. Promising interventions for NCD prevention that can also address broader social determinants of health are urban planning, taxation (incentives or disincentives), pricing and subsidies (incentives or disincentives), production and marketing of goods, health-promotion financing, and legislative mandates ().

Box 1. Examples of multisectoral policies for NCD prevention and control

  1. Agriculture: subsidize healthy food production, substitute other crops for tobacco, maintain adequate land for agriculture and local food system development, encourage farmers markets, promote local food availability and sales.
  2. Environment: improve mass public transportation systems; design and plan roads to facilitate walking and cycling; develop green spaces, facilities, and spaces for physical activity; enforce environmental pollution standards.
  3. Education: develop school-based nutritious meal programs, curriculum on healthy lifestyles, and policies on sales of healthy foods and beverages; restrict marketing of foods and beverages to children in schools; increase time for physical education.
  4. Trade: increase import taxes on unhealthy products such as tobacco, alcohol, sugar-sweetened beverages, and ultra-processed foods; reduce import taxes on health-promoting products.
  5. Social-protection policies: consider a single-payer system that equitably funds treatment and care for persons with NCDs, mental health conditions, and disabilities.
  6. Law enforcement: promote crime reduction and safe communities to encourage physical activity; establish and enforce penalties for violating smoke-free environment laws and for excessive drinking and occupational and environmental pollution.
  7. Labor: provide incentives for worksite health-promotion programs.
  8. Media: ban smoking and alcohol use in TV and films; enforce bans on advertising tobacco and alcohol in the media, and on marketing foods and beverages to children.
Source: Lin V, Jones C, Shiyong W, Baris N. Health in All Policies as a strategic policy response to NCDs. Health, Nutrition, and Population (HNP) discussion paper [Internet]. Washington, D.C.: World Bank; 2014. Available from: The World Bank.

Role of the private sector in tackling NCD risk factors

Given that many of the products associated with NCD risk factors are produced by the private sector, that sector has the potential to play a significant role in preventing NCDs. The private sector has acknowledged the need to create healthier products for consumers, as well as to create healthier workplaces. Moreover, the international community has called on the private sector to contribute to NCD prevention, as described in Box 2 ().

However, the interests of some private entities may be opposed to the interests of health protection/promotion, particularly when there may be a negative impact on profits. For example, in tobacco there is a long history of deceptive strategies to undermine regulatory action; much of it was confirmed by the industry’s own internal documents that were made public and clearly exposed as a consequence of tobacco litigation in the state of Minnesota (United States). Article 5.3 of the FCTC states that “in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law” (). The guidelines for implementing this article detail how countries should interact with the tobacco industry (). Similar strategies are observed with food and alcohol industries, as well ().

Box 2. How the private sector can contribute to NCD prevention

  1. Take measures to implement the WHO recommendations to reduce the impact of marketing unhealthy foods and nonalcoholic beverages to children, while taking into account existing national legislation and policies.
  2. Consider producing and promoting more food products consistent with a healthy diet, including reformulating products to provide healthier options that are affordable and accessible and that follow relevant nutritional facts and labeling standards (information on sugars, salt, fats and, where appropriate, trans fat content).
  3. Promote and create an environment for healthy behaviors among workers by establishing tobacco-free workplaces and safe and healthy working environments that adhere to occupational safety and health measures, including good corporate practices, workplace wellness programs, and health insurance plans.
  4. Work towards reducing the use of salt in the food industry, to lower sodium consumption.
  5. Contribute to efforts to improve access to and affordability of medicines and technologies that help prevent and control noncommunicable diseases.
Source: United Nations. Political declaration of the high-level meeting on the prevention and control of noncommunicable diseases. New York: UN; 2011.

Strengthening regulatory capacity and the use of health law

Regulatory processes refer broadly to both legislative and executive action. Many of these measures require the correction of market failures or the modification of widespread social practices—changes that can only be achieved through the effective use of legislation or regulation, often in areas outside the traditional scope of health systems. These measures require the health authority to effectively work with other sectors of government to ensure that all policies take into account the impact on health. PAHO launched the REGULA initiative in 2014 to strengthen the regulatory capacity of the Region’s health authorities to reduce NCD risk factors (). Laws related to each risk factor in every Latin American country have been collected, and in selected countries an in-depth analysis of the regulatory capacity has been conducted. In addition, Member States adopted a Strategy on Health-related Law in 2015 to strengthen legal and regulatory frameworks that promote health based on the perspective of the right to health. It aims to protect health by strengthening coordination between health authorities and legislative branches ().

Management of Noncommunicable Diseases

The challenge for managing NCDs is to implement universal, financially and physically accessible, high-quality primary care services while also enhancing early diagnosis, timely treatment, and improvements in the quality of care, particularly in disadvantaged communities (). Box 3 summarizes why a focus on NCD management is such an important aspect of the response to the NCD problem.

Box 3. Why focus on NCD management?

It has been estimated that:

  1. Out of 100% of people who have an NCD, only 50% are diagnosed;
  2. Of those diagnosed, only 50% are treated;
  3. Of those treated, only 50% have their NCD under control;
  4. Of those under control, only 50% are successfully controlled;
  5. Therefore, among those who live with an NCD, fewer than 10% have it successfully controlled.

    Poor NCD control leads to poor health outcomes.

Source: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice 1998;1(1):2-4.

Cardiovascular disease (CVD), the leading cause of death, requires intensified and specific health system interventions to reduce risk, control hypertension, manage acute episodic events, and prevent premature death (Table 2). Type 2 diabetes, a common comorbidity of hypertension, is a chronic metabolic disease that also requires specific primary care interventions (Table 2). However, a chronic care approach for integrated management of diabetes, CVD, and other NCDs has been proposed by PAHO (). This approach includes organizing health services to reduce barriers and promote prevention; self-management support to empower people to effectively manage their conditions; evidence-based guidelines and support for decision-making; coordinated care among the health team; a clinical information system to monitor patients; and community resources to support patient care.

Table 2. NCD management interventions

NCD Disease management objectives
Primary health care interventions
Counseling, patient education, and prevention Screening and early detection Treatment
Cardiovascular diseases (CVDs)
  • Assess risk and reduce risks for developing CVD
  • Diagnose CVD early and accurately
  • Control high blood pressure
  • Prevent acute events and complications
  • Improve self-care for CVD
  • Assess risk for CVD
  • Educate about risk factor reduction
  • Educate about healthy lifestyle
  • Measure and monitor blood pressure, body mass index (BMI), and blood lipid profile
  • Drug therapy for those who have had or are at risk for heart attack and stroke
  • Hypertension medication
  • Treatment of new cases of acute myocardial infarction with either:
    acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or
    thrombolysis, or primary percutaneous coronary interventions
    • Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker, and diuretic
    Diabetes type 2
    • Prevent diabetes, including gestational diabetes
    • Assess risk for developing diabetes
    • Improve quality of care and outcome in people with type 2 diabetes
    • Reduce and maintain a healthy body weight
    • Control blood sugar levels
    • Reduce complications from poor diabetes management
    • Improve self-care for diabetes
    • Lifestyle education to prevent type 2 diabetes
    • Prenatal care and intensive glucose management among pregnant women to prevent gestational diabetes
    • Advice to overweight people to reduce weight by reducing food intake and increasing physical activity
    • Education on diabetes self-management, including foot care and eye care
    • Measure blood sugar
    • Screen for diabetic retinopathy
    • Drug therapy to control blood sugar
    • Drug therapy to prevent progression of renal disease
    Cancer
    • Prevent cancer
    • Detect cancer at early stages
    • Screen men and women for cancers amenable to early detection (cervix, breast, colorectal cancers)
    • Ensure prompt diagnosis, treatment, and supportive and palliative care
    • Health education on cancer prevention and healthy lifestyles
    • Hepatitis B vaccination for the prevention of liver cancer
    • HPV vaccination for the prevention of cervical cancer
    • Examinations for early signs and symptoms of common cancers (lung, prostate, colorectal, breast, cervix, stomach, leukemia, etc.)
    • Breast cancer clinical breast exam and/or mammogram, according to national guidelines
    • Cervical cancer – pap test, HPV, DNA test, visual inspection with acetic acid (VIA), cryotherapy for treatment of precancerous lesions, according to national guidelines
    • Oral cancer – screen in high-risk groups such as tobacco smokers
    • Colorectal cancer – fecal occult blood test or colonoscopy, according to national guidelines
    • Refer to secondary level care for diagnosis and treatment, including surgery, chemotherapy, and radiotherapy.
    • Provide post treatment follow up care
    • Offer supportive care and palliative care
    Chronic respiratory diseases
    • Control asthma and COPD
    • Improve quality of care for persons living with asthma and COPD
    • Health education on self- management for persons with asthma and COPD
    • Assess asthma control using severity and frequency of symptoms
    • Drug therapy to manage stable asthma and COPD, as well as exacerbated asthma and COPD.

    PAHO has disseminated this approach through the Evidence-Based Chronic Illness Care (EBCIC) course attended by over 1,000 primary health care providers. As a result, a total of 81 chronic care projects in 27 countries have been implemented, some of which have shown impact. For example, in Argentina, the REDES program increased the proportion of people with hypertension who were taking medication and decreased mortality due to stroke (personal communication, Sebastian Laspiur, Argentina Ministry of Health). In Cuba, after applying a chronic care approach, 62% of people achieved good glycemic control, according to international norms (). In Porto Alegre, Brazil, a chronic care program decreased hospitalization due to CVD and diabetes and improved hypertension control from 60% to 77% ().

    Two other examples of a chronic care approach applied to improve hypertension control include the Canadian Hypertension Education Program () and the Kaiser Permanente model in northern California (). These models include a simple, standardized, and evidence-based treatment algorithm; the availability of and access to a set of core, high-quality medications; a clinical registry for monitoring patients and evaluating performance; and teamwork, with shared responsibilities, patient empowerment, and community participation. This approach was tested in Barbados with promising results, including improvement in hypertension control, development of a clinical registry, and improvement of prescription practices (). Similar hypertension control interventions are in place in Chile, Colombia, and Cuba.

    An initiative of broader scope for CVD, the Global Hearts Initiative, has been launched that aims to reduce heart attacks and strokes by improving management of CVD in primary health care. Global Hearts is led by WHO in collaboration with the Centers for Disease Control and Prevention of the United States, PAHO, the World Heart Federation, the World Stroke Organization, the International Society of Hypertension, the World Hypertension League, and other partners ().

    While these are illustrative examples of NCD management, most countries in the Region continue to have important gaps in the implementation of clinical NCD preventive services, secondary CVD prevention, and cardiac rehabilitation management (). For example, data from Argentina, Brazil, Colombia, and Chile show that only 18% of people with hypertension had blood pressure controlled (<140/90 mmHg) (), and only 12% of those with coronary heart disease or stroke were under treatment with three or more drugs of proven efficacy in preventing recurrence ().

    Additionally, most countries report a lack of progress in health system response to managing CVD acute events. Public awareness is low, capacity and resources for early reperfusion therapy are insufficient, and infrastructure (such as stroke units) is inadequate (). Five priority interventions are recommended to improve this situation: (1) public communication and education to recognize symptoms and warning signs and seek emergency care; (2) equitable availability of emergency medical services; (3) broadened access to early reperfusion therapy, including availability of basic technologies; (4) coronary and stroke units within the health system that give priority to patients at highest risk of complications and death; and (5) rehabilitation programs for social reintegration of patients ().

    Cancer includes a group of diseases with multiple causes that require specific health system interventions at all levels of care (Table 2). To effectively control cancer, PAHO/WHO promotes the development and implementation of national cancer control plans (Table 3), with public health and health service interventions that provide primary and secondary prevention, accurate and timely diagnosis and treatment, and palliative care (). More than half the countries in the Region (23 of 34 countries, 67%) report having a national cancer control plan, strategy, or policy in place (). Peru’s national cancer plan, Plan Esperanza, is an example of how a cancer plan can have an impact. Since it was launched in 2013, over 16 million Peruvians have received free cancer prevention services; 2.5 million have been screened for cervical, breast, stomach, colon, or prostate cancer; and the proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 58% to 7% ().

    Table 3.National cancer control plan

    Primary prevention Screening and early detection Diagnosis and treatment Palliative care
    • Policies for tobacco, alcohol, healthy diets, physical activity
    • Vaccination for hepatitis B and HPV
    • Policies to reduce exposure to carcinogens in the workplace and the environment
    Organized screening program, with quality assurance, for:

    • Cervical cancer (HPV test, Pap test, or VIA test)
    • Breast cancer (mammography)
    • Colorectal cancer (fecal occult blood test or colonoscopy)

    Knowledge of early signs and symptoms of cancer, with prompt referral for diagnosis

    • Pathology services
    • Chemotherapy, surgery, radiotherapy
    • Palliative care
    • Regulations and education for access to opioids

    Notable progress is being made in cervical cancer prevention, in which mortality has declined in 11 countries: Brazil, Canada, Chile, Colombia, Costa Rica, El Salvador, Mexico, Nicaragua, Panama, Venezuela, and the United States (). To date, 23 countries in the Region (58%) report introducing human papillomavirus (HPV) vaccines and 33 countries (87%) report available cervical cancer screening services, although only 5 of those countries report having adequate screening coverage of 70% or higher. Despite that breast cancer is the most common cancer in women, only 16 countries (42%) report that mammography is available, and only 3 countries report a screening coverage likely to have an impact (70% coverage or greater) ().

    Prostate cancer continues to be the leading cause of cancer in men and is increasing in some countries in the Region (). Black men of African descent, specifically Jamaican men, are at greater risk of prostate cancer; the explanations for this are inconclusive (). Prostate cancer screening has not decreased mortality, and harm (impotence and incontinence) associated with prostate-specific antigen (PSA)-based screenings is frequent (). The current approach is, therefore, to strengthen cancer diagnosis and treatment ().

    Cancer treatment in the form of radiotherapy and chemotherapy is generally available in the public sector in the majority of countries in the Americas (), but most cancer cases are diagnosed at an advanced stage, when treatment is less effective (). Palliative care is necessary to improve the quality of life of patients and their families by managing pain and providing physical, psychosocial, and spiritual support. Yet access to opioid medications, such as oral morphine for pain management, continues to be a challenge; availability is reported in only 50% of the countries ().

    A set of cancer-control priorities, suitable for all resource levels, have been recommended as follows:
    – primary prevention through tobacco control, alcohol reduction, healthy diet, and physical activity
    – prevention of liver cancer through hepatitis B vaccination
    – prevention of cervical cancer through HPV vaccination (two doses) for girls 9–13 years old; and through screening for women aged 30–49, either through visual inspection with acetic acid (VIA), Pap smear (cervical cytology) every three to five years, or HPV test every five years; linked with timely treatment of precancerous lesions
    – early detection of breast cancer through screening with mammography (once every 2 years for women aged 50–69 years), linked with timely diagnosis and treatment
    – population-based colorectal cancer screening through a fecal occult blood test starting at age 50 years, linked with timely treatment
    – home-based and hospital-based palliative care with a multidisciplinary team and access to opiates and essential supportive medicine;

    However, implementing these interventions will require strengthening health care systems, as follows:
    – increase financial resources for cancer control, including access to high-cost drugs and procedures
    – develop social protection policies against catastrophic health expenditure for poor individuals towards equitable services and coverage
    – reduce long waiting times for diagnosis and treatment, especially in rural and remote regions and
    – address the shortages of cancer specialists through use of telemedicine, and retraining of specialists ();

    While they share the main cancer risk factors associated with other NCDs, cancers attributable to occupational exposures and environmental pollution have additional important sources of risk. The most common types of occupational cancer are lung, bladder, mesothelioma, leukemia, and skin. In general, the most common agents in the Region include solar radiation, environmental tobacco smoke, crystalline silica, pesticides, and asbestos (). The WHO global plan of action on workers’ health calls on governments to strengthen legislation and regulations to eliminate carcinogenic exposures in the workplace, to protect and safeguard workers’ health ().

    A population-based cancer registry (PBCR) is recommended by WHO to inform cancer programs (). However, this requires significant resources, and in the Americas only 11 countries have high-quality PBCRs: Argentina, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Ecuador, Puerto Rico, Uruguay, and the United States (). Convened by the International Agency for Research on Cancer, the Global Initiative for Cancer Registry Development (GICR) is using regional expertise to establish hubs in Latin America and in the Caribbean in order to expand the coverage and quality of data from PBCRs.

    Chronic respiratory disease (CRD)—principally chronic obstructive pulmonary disease, asthma, and occupational lung diseases—is responsible for approximately 372,000 deaths annually in the Americas (). Tobacco use, air pollution, and occupational chemicals and dusts are the most important risk factors for these diseases, which cannot be cured but for which effective treatment is available. Treatment is reported as generally available in the primary care facilities of the public health sector in the Region: 28 countries (74%) report availability of steroid inhalers and 33 countries (87%) report availability of bronchodilators. Guidelines on the management of CRD, however, are only implemented in 9 countries (24%), and only 8 countries (21%) indicate that they have an operational policy, strategy, or action plan specific for CRD. Better surveillance to establish the magnitude of CRD, and primary prevention to reduce risk factors and improve health care for people with CRD, are urgently needed to improve quality of life for those affected by CRD.

    Mental Health

    No health without mental health

    It is widely acknowledged that mental health is a fundamental component of health (). Member States adopted the Plan of Action on Mental Health 2015–2020 (), committing to “a region in which mental health is valued, promoted, and protected, mental and substance-related disorders are prevented, and persons with these disorders are able to exercise their human rights and to access both health and social care.” The plan includes four strategic lines of action on mental health policies: community-based services, promotion and prevention, information systems, and evidence and research. Mental, neurological, and substance-use (MNS) disorders were recognized in the global scenario as health priorities and ratified in the international development agenda ().

    Burden of MNS disorders

    Mental disorders represent an alarming public health concern. Ten percent of the world’s population and 20% of children and adolescents suffer from some mental or neuropsychiatric disorder, and this doubles among populations facing humanitarian emergencies (). MNS disorders are responsible for 12.35% of disability-adjusted life years (DALYs) and 35.9% of years lived with disability (YLDs), making them the leading cause of global disability. In the Americas, MNS disorders are the leading cause of disease burden, accounting for 19% of DALYs, and they are the largest source of disability, responsible for 34% of YLDs. Depression is the leading factor, or 8% of YLDs, while anxiety and substance use disorders (including alcohol) are responsible for 5% and 3% of YLDs, respectively ().

    Socioeconomic impact

    The global cost of MNS disorders has increased to US$ 8.5 trillion and is projected to double by 2030 (). Although scaling-up services for depression and anxiety might cost only US$ 1.50 annually per person, the resources gap is significant due to the existing low coverage levels. The disparity between burden of disease and available resources results in treatment gaps of 73.5% among adults with severe/moderate disorders, 82.2% among children and adolescents (), and bigger gaps among indigenous and African-American descendants (). Nevertheless, such investment could represent a return value of US$ 709 billion and benefit-to-cost ratios of up to 3:1 (). For the Region, not taking action represents a gross domestic product (GDP) annual loss of 0.82% in Costa Rica, 0.58% in Jamaica, and 1.42% in Peru (). Costs are higher if also considering mid- to long-term effects of maternal depression and poor care practices on early child development, burden of substance use disorders (), and dementia as growing Regional concerns ().

    Emergencies

    Mental health preparedness and response are critical components of any emergency (); the relationship between mental and physical health becomes closer and bidirectional following emergencies (), and exposure to extreme stressors is a main risk factor for mental illness (). Community-based services constitute an important intervention level during emergencies, with communities engaging in nonspecialized activities across sectors aiming for a return to normal living conditions (). Indeed, emergency settings became opportunities to improve regular sustainable mental health systems ().

    Human rights

    Multiple treaties and conventions () require countries to adopt a paradigm shift to an approach firmly rooted in the promotion and protection of human rights (). People with mental disorders experience a wide range of violations of human rights (). Children with psychosocial disabilities are neglected in particular when living in institutional settings, a harmful but still a common practice; mental institutions are associated with human rights infringements (); and in low-income countries, people with severe mental illness die up to 30 years younger than their peers ().

    Main MNS conditions

    Most common mental disorders

    Depression results from a complex interaction of social, psychological, and biological factors; it can develop after exposure to adverse life events that become chronic stressors, and at moderate or severe intensity it can lead to suicide (). Anxiety disorders include acute problems and chronic conditions involving significant stress-related symptoms; recurrent, excessive, sudden, or progressive displays of anxiety or worry; and impaired daily functioning (). Depression and anxiety account for 13% of YLDs and 5.5% of DALYs in the Americas.

    Severe mental disorders

    Schizophrenia results from an interaction of genetic, environmental, and psychosocial factors. People with schizophrenia are 2.5 times more likely to die early; they also experience stigma and neglect when treated in traditional psychiatric hospitals (). Bipolar affective disorder is a severe type of depression consisting of manic and depressive episodes separated by periods of normal mood (). Schizophrenia and bipolar disorder account for 3.4% of YLDs and 1.5% of DALYs in the Americas ().

    Children and adolescents

    Developmental and behavioral disorders are specific conditions affecting children and adolescents; they usually have an early onset and a regular sustained development, and they can persist into adulthood. These disorders are characterized by impairment or delay in functions related to maturation of the central nervous system, diminished ability to adapt to the daily demands of life, and increased vulnerability to physical illness and to other mental and neurological conditions (). Developmental and behavioral disorders account for 2.2% of YLDs and 0.9% of DALYs in the Americas ().

    Suicide

    Suicide is determined by the interaction between psychosocial, biological, and psychiatric factors. A systematic review from 2003 showed that up to 90% of suicidal victims have a diagnosable mental disorder (). Attempted suicide is 10-20 times more common than completed suicide (), and while suicidal ideation is a predictor of suicidal acts (), the strongest risk factor is a previous suicide attempt. In the Americas, according to estimates from 2005–2009, suicide has a mortality rate of 7.3 per 100,000 and is responsible for 1.6% of total DALYs. Chile, Uruguay, and Trinidad and Tobago have rates of more than 10 per 100,000. Suriname and Guyana have the highest rates of the Region, with 23.3 and 26.2 per 100,000 population, respectively (). Significant efforts in suicide prevention are being conducted. Guyana, for instance, has launched a National Mental Action Plan for 2015–2020 and a National Suicide Prevention Plan.

    Dementia

    Dementia is a syndrome in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities beyond what might be expected from normal aging. With more people reaching an advanced age, dementia constitutes a big concern for Latin America and the Caribbean (LAC), with a projected increase of 47% by 2030 in the prevalence of severe disabilities affecting people aged 60 and older (). Dementia accounts for 1.2% of YLDs and 2% of DALYs in the Americas ().

    Epilepsy

    Epilepsy can be caused by genetic and congenital abnormalities, brain damage, tumors, and infections such as meningitis, encephalitis, neurocysticercosis, and cerebral malaria (). In the Americas, epilepsy is one of the most frequent chronic neurological disorders; it affects 5 million people and accounts for an annual death rate of 1.04 per 100,000 population. Although epilepsy responds to treatment 70% of the time and the cost of medication is as low as US$ 5 per patient per year, more than 50% of persons in LAC with epilepsy do not receive treatment (). Epilepsy accounts for 0.8% of YLDs and 0.5% of DALYs in the Americas ().

    Substance use disorders

    Some 85 million people use illicit substances each year in the Americas; their use is associated with adverse health and social consequences, particularly for young people (). A public health approach to reduce substance use includes prevention, treatment services, monitoring, and surveillance. Substance-use disorders account for 1.8% of YLDs and 1.5% of DALYs in the Americas ().

    Conditions of disability

    In the Americas, 140 million people live with some form of disability, and rates are increasing due to the aging population and their chronic conditions. Those living in psychiatric institutions experience higher levels of disability. Among persons with disabilities, only 3% have access to rehabilitation. MNS disorders are the biggest contributors to the burden of disabilities. Their treatment cannot be limited to the physical domain, but should also include the psychosocial axis, addressing the needs of, and impact on, relatives and communities ().

    Strategies and interventions

    Insufficient treatment coverage and inadequate and outdated models of care need to be addressed. The service structure is fragmented and there is insufficient coordination between primary, secondary, and tertiary levels. There exists a heavy emphasis on mental institutions at the expense of delivering mental health care in primary- and secondary-care settings and at the expense of developing community-based models (). Allocated resources are scarce and are distributed inequitably and inefficiently. While LAC countries assign 1%-5% of the total public health budget to mental health, 88% of funds are allocated to psychiatric hospitals that serve 10% of those requiring mental health services. Psychiatric hospitals persist as a result of tradition and the absence of comprehensive models of care. People living in mental institutions do not receive individualized care based on their needs and rights (). Mental health should be integrated into existing care delivery channels as a key strategy to close the treatment gap in the Region. That effort targeted prevention and promotion programs; services through primary health care; rational cost-effective roles for secondary and tertiary levels of care; comprehensive community-based services; and synergetic interactions with key areas, stakeholders, and actors within and beyond the health sector ().

    Prevention and promotion

    The first step in reducing the burden of mental illness is tackling its onset with evidence-based interventions to help prevent MNS disorders and protect mental well-being, particularly in the early stages of life. Because up to 50% of adult mental disorders begin before the age of 14, fundamental action lines include early prevention, identification, and treatment of emotional or behavioral problems in childhood and adolescence. Powerful models of mental health promotion and prevention provide strong evidence about their effectiveness and represent promising starting points in reducing mental health illness and its consequences. Because suicide is a potential outcome of MNS disorders, suicide prevention is an essential component of any strategy ().

    Care levels and community-based services

    To integrate basic mental health services into primary health care (PHC), it is extremely important to adopt task-sharing approaches (also known as task shifting), especially in countries with limited specialized human resources (). With proper care from PHC professionals, psychosocial assistance, and medication, tens of millions could be treated for MNS disorders, prevented from suicide, and begin to live normal lives even where resources are scarce ().

    Developing a community-based model with new services and alternatives is a key element in offering comprehensive, specialized, and continuous mental health services (). The recommended strategy is to shift resources allocated to mental hospitals into development of service networks that cover persons with MNS disorders and other potential users. This model allows progressive replacement of mental institutions and offers a higher quality of secondary-level care to people who need acute, mid- and long-term specialized care. The objective is recovery rather than cure; the services include psychosocial rehabilitation and they combine psychosocial and pharmacological interventions. Recommended services to develop include: (a) community mental health centers with specialized professionals in charge of the mental health needs in specific catchment areas; (b) coordination with facilities that provide acute care and support from health workers at the PHC level; (c) community-based residential facilities that provide overnight residence for people with relatively stable and long-term mental disorders; (d) psychiatric services in general hospitals to take care of patients’ needs during acute phases and the needs of nonpsychiatric patients in the hospital (interconsultation); and (d) day hospitals that provide more intense treatment and structured support for users who have failed to respond to outpatient care or have been discharged from inpatient care ().

    Opportunities for integration and challenges

    Community-based interventions are an opportunity for integrating referrals and coordinating interventions between sectors, sharing material and human resources, and innovation and sustainability. Key areas for collaboration include maternal and child health and nutrition; children and adolescents; gender, aging, and disability; noncommunicable diseases such as cancer, diabetes, and cardiovascular disease; and communicable diseases such as HIV/AIDS and tuberculosis; and substance-use problems and disorders ().

    Barriers to introducing this model and implementing the required reforms include the complexity of decentralizing mental health services; resistance from authorities and health professionals; the low number of workers trained and supervised in mental health care; and a scarcity of public health perspectives in mental health leadership (). Although 81% of countries in the Region have a stand-alone mental health policy/plan, 50% do not have laws or regulation frameworks. Just 34% have mental health legislation that is partially or fully implemented and in satisfactory compliance with human rights standards ().

    In addition to national authorities, civil society also typically tries to create conditions that encourage successful community integration and participation (). Together, government institutions and civil society share responsibilities to build tools and promote and monitor effective implementation. The Region is making serious efforts to overcome the challenge of shifting from services at traditional psychiatric hospitals to a community-based model that results in better care and rehabilitation of people with MNS disorders and other types of disabilities ().

    Road Traffic Injuries

    Road transportation is considered the most complex and dangerous essential human activity (). In the Americas, road crashes kill 154,089 people each year, or 12% of road traffic deaths worldwide (). The regional death rate is 15.9 per 100,000 people, marginally lower than the global rate of 17.4 per 100,000 (). However, there are variations between countries, with national rates ranging from a low of 6.0 per 100,000 population in Canada to a high of 29.3 per 100,000 population in the Dominican Republic (). Nearly half the world’s road traffic deaths occur among pedestrians (22%), motorcyclists (20%), and cyclists (3%), all of whom are considered vulnerable road users ().

    A combination of economic changes, unmet need for public transportation, traffic congestion, and a number of other factors associated with motorcycle use (their comfort, low cost, readily available financing, ease of maintenance, and the appeal of urban mobility) have resulted in motorcycle sales outpacing economic development. The results is that the number of motorcycles on the roads has increased by more than six-fold ().

    In the Americas, 73% of road traffic deaths occur in middle-income countries, whereas 26% take place in high-income countries. The motorcycle fleet in the Region has increased by 45%, while the automobile fleet has grown by 11%. The rapid and massive introduction of motorcycles in countries of the Americas—used for activities varying from urban delivery services to cattle driving in rural regions—is a relatively recent phenomenon, and has not yet been absorbed into the culture of local road traffic.

    Although motorcycles have provided unprecedented mobility for many, the rapid rise in their use has led to large increases in motorcycle injuries and death. Mortality among motorcyclists increased from 15% to 20% in 2013, and in some countries of the Americas, the proportion of motorcycle users involved in road fatalities has exceeded pedestrian fatalities. Furthermore, poorer countries in the Region have higher motorcycle fatality rates than richer countries ().

    In the early 2000s, after the United Nations requested that WHO coordinate global efforts to tackle road traffic injuries (RTIs), PAHO/WHO emphasized their importance as a public health concern. This launched a multisector response involving the health sector, law enforcement, traffic/transport engineering, and road safety education. The effort has faced challenges, particularly in defining the role the health sector can play and what impact it can have in improving road safety.

    PAHO has provided direct technical support to ministries of health, with plans, programs, projects, legislative improvements, publications, and road safety policies. It has monitored road safety indicators through regular reports, encouraged the collection and analysis of national data, and built local capacity for integration and technical cooperation between countries. Also, it has advocated designating road safety as a public health issue in national policies, and for strengthening the health sector’s response on road safety initiatives.

    The Vida no Trânsito (“Life in Traffic”) project, implemented in Brazil in 2010, is illustrative of the health sector’s approach to road safety. The project, led by PAHO and Brazil’s Ministry of Health, was based on the need for good data and multisectoral coordination. It was initially implemented in five state capitals and was later extended to other cities. The strategy consists of national and local multisectoral road safety commissions that are firmly backed by program directors and authorities such as mayors.

    Local commissions gather data from multiple sources (health, police, and traffic/transport) and generate information on the crashes (type, nature, time, days, places, etc.), victims’ profiles, and the risk factors involved. This resulted in focused interventions with measurable goals to build capacity, raise awareness, and implement best practices for road safety. The initiative’s visible results include increased speed control and alcohol checkpoints and sobriety tests (with fewer drivers testing positive). As a result, the mortality rate declined in most of the cities that enacted the project.

    In 2011, PAHO adopted the Plan of Action for Road Safety (), which was approved during the 51st Directing Council. This plan is consistent with the UN Decade of Action for Road Safety 2011&ndash2020, which acts as a call to action for Member States to adopt road safety policies. More recently, the 2nd Global High-Level Conference on Road Safety, held in Brazil in 2015, provided further opportunities for countries to strengthen their road safety response. There, Member States adopted the Brazilian Declaration on Road Safety (), developed through a long intergovernmental process involving consultation with different stakeholders. The Brazilian Declaration highlights road safety measures coupled with equity/inclusion issues that are highly relevant in the Region. Furthermore, it extends the health sector’s role beyond RTI prevention and addresses issues such as mobility and active, sustainable modes of transportation—walking, cycling, and public transportation.

    The Brazilian Declaration, endorsed by the 58th United Nations General Assembly (), reinforces the Sustainable Development Goals (SDGs), to reduce road traffic deaths and injuries by 50% by 2020, and it consolidates the linkage of road traffic safety and sustainable mobility policies. This is reflected in the SDG 11.2 target, which aims to provide access to safe, affordable, accessible, and sustainable transport systems for all. Its objective is to improve road safety, notably by expanding public transportation, with special attention to the needs of those in vulnerable situations, e.g., women, children, persons with disabilities, and older persons.

    Interpersonal Violence Prevention

    Interpersonal violence takes many forms, including multiple manifestations of violence against children, youth, and women, as well as the elderly. All forms of interpersonal violence lead to negative health outcomes, threaten development, undermine quality of life, and erode communities’ social fabric. Recognizing the impact that violence has on development, the 2030 Agenda for Sustainable Development includes multiple targets relating directly to violence under Goal 5 for achieving gender equality and empowering women and girls (targets 5.2 and 5.3) and under Goal 16 for promoting just, peaceful, and inclusive societies (targets 16.1 and 16.2).

    The Americas is one of the regions with the highest levels of violence, a phenomenon that has had a significant negative impact, particularly in the countries where it is most common. The 2014 Global Status Report on Violence Prevention (GSRVP) () shows that there were an estimated 185,235 deaths from homicide in the Region in 2012 (the last year for which data are available). The average homicide rate was 19.4 per 100,000 (35.1 for males and 4.1 for females). Young male adults (aged 15–44 years) bear much of this burden, accounting for about 72% of the deaths. Over the period 2000–2012, homicide rates were estimated to have increased by about 20% in the Americas as a whole; nearly all of the increase was in low- and middle-income countries, while high-income countries reported negligible changes ().

    Women, children, and older persons bear the brunt of nonfatal physical, sexual, and psychological abuse. Such violence can contribute to lifelong ill health—particularly for women and children—and early death. For example, one in three women in the Americas has experienced violence from an intimate partner or sexual violence by a nonpartner during her lifetime () and over 99 million children report experiencing some form of child maltreatment in the last 12 months ().

    Interpersonal violence can be effectively prevented and its far-reaching consequences can be mitigated, although different types of violence may require different strategies. According to the GSRVP (), several countries in the Americas have begun to implement prevention programs and victim services and to develop national action plans, policies, and laws to prevent and respond to violence. However, planning efforts have been undermined by severe lack of data to guide actions, and by lack of funding for national plans and policies on violence prevention. As for the lack of data, most instances of nonfatal violence against women, children, and older persons do not even come to the attention of authorities or service providers. In addition, while countries are investing in violence prevention programs that include the seven WHO strategies for violence prevention (Box 4 (159)), their investment is not on a level commensurate with the scale and severity of the problem. Moreover, since evidence regarding “best buy” violence prevention strategies is limited and biased in favor of high-income countries, it may be challenging for governments in low- and middle-income countries to decide where to invest.

    Box 4. “Best buy” violence prevention strategies

    1. Develop safe, stable, and nurturing relationships between children and their parents and caregivers.
    2. Develop life skills in children and adolescents.
    3. Reduce the availability and harmful use of alcohol.
    4. Reduce access to guns and knives.
    5. Promote gender equality to reduce violence against women.
    6. Change cultural and social norms that encourage violence.
    7. Identify victims and provide them with care and support programs.
    Source: Pan American Health Organization. Status report on violence prevention in the Region of the Americas. Washington, D.C.: PAHO; 2014.

    The GSRVP also shows that countries of the Americas have addressed key risk factors for violence through policy and other measures, such as ones on the harmful use of alcohol or the accessibility to firearms. However, fewer than half of the 22 countries surveyed have implemented social and educational policies that would help mitigate these risk factors—such as incentives for youth who are at risk of violence to complete secondary schooling, or housing policies explicitly aimed at reducing violence by reducing the concentration of poverty in urban areas.

    Moreover, the GSRVP reported that although laws to prevent violence are largely in place, enforcement is often inadequate. The biggest gaps between the existence of laws and their enforcement were laws pertaining to rape, to sexual violence involving contact but without rape, and to noncontact sexual violence. Finally, the report indicated that the availability of high-quality care and support services to identify, refer, protect, and support victims of violence is highly variable. For example, the medical-legal services most widely reported to exist on a large scale are services pertaining to sexual violence and child protection; services least likely to exist are those pertaining to elder abuse. (The quality of these services and their accessibility were not ascertained.)

    To realize the full potential of violence prevention, policies, plans, and programs should be adequately funded; data collection and management should be strengthened; research regarding effective violence prevention strategies should be promoted; national violence prevention action plans should be developed and should be people-centered, context-specific, comprehensive, evidence-informed, and integrated into other health and nonhealth platforms; laws should be enforced; and care services for victims should be comprehensive and informed by evidence ().

    In 2016, PAHO joined efforts with numerous UN and national government agencies to launch the INSPIRE project (), an initiative to help countries and communities achieve the SDGs 5 and 16. INSPIRE includes seven strategies (Table 4) that together provide a framework for ending violence against children and that may also prevent violence against women. These agencies stand together and urge countries and communities to intensify their efforts to prevent and respond to violence against children by implementing the strategies in this package.

    Table 4. INSPIRE package for preventing and responding to violence against children aged 0–18 years ()

    Strategy Approach
    Implementation and enforcement of laws
    • Laws banning violent punishment of children by parents, teachers, or other caregivers
    • Laws criminalizing sexual abuse and exploitation of children
    • Laws that prevent alcohol misuse
    • Laws limiting youth access to firearms and other weapons
    Norms and values
    • Changing adherence to restrictive and harmful gender and social norms
    • Developing community mobilization programs
    • Promoting bystander interventions
    Safe environments
    • Reducing violence by addressing “hot spots”
    • Interrupting the spread of violence
    • Improving the built environment
    Parent and caregiver support
    • Via home visits
    • Via groups in community settings
    • Via comprehensive programs
    Income and economics
    • Cash transfers
    • Group saving and loans combined with gender-equity training
    • Microfinance combined with gender-norm training
    Response and support services
    • Counseling and therapeutic approaches
    • Screenings combined with interventions
    • Treatment programs for juvenile offenders in the criminal justice system
    • Foster care interventions involving social welfare services
    Education and life skills
    • Increasing enrollment in preschool, primary, and secondary schools
    • Establishing a safe and enabling school environment
    • Improving children’s knowledge about sexual abuse and how to protect themselves from it
    • Providing training in life skills/social skills
    • Offering programs for adolescents focused on preventing violence between intimate partners

     

    Disabilities

    The number of people with disabilities in the Region of the Americas is growing due to the aging population, an increase in NCDs, and changes in lifestyles (). It is estimated that these disabilities represent 66.5% of DALYs in low- and middle-income countries (). Occupational injuries and those caused by traffic accidents, violence, and humanitarian crises are most common, with 1.7% of DALYs attributed to injuries caused by traffic accidents and another 1.4% to violence and conflict ().

    The World Report on Disabilities shows that about 15% of the world population lives with some type of disability (). In the Region of the Americas, approximately 140 million people are living with disabilities; 2% to 3%, or 2.8 to 4.2 million people, have disabilities serious enough that they affect functioning. Only 3% of those with some type of disability have access to rehabilitation services, and 3% have a high level of dependency on another person to perform their vital activities ().

    Disabilities disproportionately affect vulnerable populations: the highest prevalence is among the poorest quintile, as well as women and the elderly. People with low incomes, without work, or with little academic training have an increased risk of disability, as do ethnic minorities and indigenous groups. Compared to those without disabilities, people with disabilities have worse health outcomes, less education, higher poverty rates, and participate less in economic activity. This is due in part to the obstacles they face in accessing health services, education, employment, transport, and information ().

    Estimating the prevalence of disabilities in the Region continues to present major challenges primarily because there is little consistency in the criteria for measuring them. However, the 2010 round of censuses provides an accurate estimate of the prevalence of disabilities and of country-to-country comparisons (Figure 1). Women have a higher rate of disability than men, especially women over 60, who are more likely to have health problems and often become disabled; this population also often lacks resources and access to affordable support services. They are among those who devote more time to caring for a family member with a disability, and are at greater risk for acquiring a disability themselves. Also, people living in rural areas are at greater risk of living with a disability compared to those in urban areas. Finally, the censuses show that compared to other groups, people of African heritage in Brazil, Colombia, Costa Rica, Ecuador, El Salvador, Panama, and Uruguay are more likely to be disabled, particularly men and children under the age of 18.

    Visual impairments, hearing problems, and limitations in mobility associated with increasing age, as well as mental and neurological disorders and intellectual disabilities, are all very common in Latin America and the Caribbean ().

    Although significant, the direct and indirect economic and social costs of disability are difficult to quantify. It is important to know the cost of disability in order to determine the investments that are needed and to design good public policies and implement services. However, even in the developed countries, information on the cost is scarce and fragmented, partly because neither definitions nor methods of measurement are standardized. Standardized definitions and methodologies are needed.

    For people with disabilities, the greatest challenge is improving aspects that affect the quality of life—accessibility, social acceptability, educational opportunities, job opportunities, and the right to exercise citizenship. The WHO World Report on Disability () and ECLAC report on the Social Panorama of Latin America () found that people with disabilities have the poorest health outcomes and highest rates of poverty. They also have poorer educational performance, lower rates of participation in economic activity, more restricted opportunities, and are more likely to be dependent.

    To meet the needs of people with disabilities, it is necessary to overcome social, environmental, and physical challenges—developing appropriate policies, addressing negative social views, improving accessibility and delivery of services, making reliable data more available, and involving people with disabilities in decision-making. To address these issues, PAHO/WHO is working with Member States to develop programs, strengthen rehabilitation services (including health and social services and access to devices for technical assistance), and improve data.

    Figure 1. Prevalence of disabilities in the Americas (based on 2010 census data)


    Source: PAHO/WHO elaboration according to publically available census data from 2010

    Chronic Conditions, Life Course, and Social Stratification

    Health disparities are closely linked to social, economic, and/or environmental disadvantage. Subgroups that have historically faced discrimination and exclusion encounter greater obstacles to health, and the disparities they face are caused by factors beyond any individual’s behavior or choices (). Individual behavior accounts for only approximately 30% to 50% of deaths and other health outcomes.

    Over the course of a life, social stratification and social and economic conditions have a strong modifying effect on health of the population (). Even small initial differences in the conditions at birth and in early childhood widen with passing years and can lead to large health differences among adults (). Improvements in living conditions and health during the last decades of life invalidate the assumption that the elderly are more vulnerable simply because of their age. Due to increased life expectancies, growing proportions of people with limited resources are now reaching the age of retirement and a very old age. However, because of the social determinants of health, there are larger gaps in health outcomes in the older population, which are reflected mainly in indicators of morbidity and mortality associated to chronic diseases and conditions (). Also, social stratification and a life course perspective are closely interconnected. Family and social support can be significant resources, but they can also be sources of stress when responses are nonadaptive.

    Conclusions

    Unprecedented socioeconomic, demographic, and epidemiological changes in recent decades in the Americas have led to significant changes in the population’s health status. NCDs, mental disorders, disabilities, road traffic injuries, and interpersonal violence are, cumulatively, the leading health problems and urgently require strengthening of multisectoral policies and health systems.

    NCDs are largely preventable by tackling their common risk factors; they can be better managed by improving health systems to provide chronic care for people at risk of or living with an NCD. There are global commitments and targets for reducing the burden of NCDs, as well as consensus on cost-effective and feasible health policies and health service interventions; it is now a matter of making greater investments, strengthening multisector collaboration, and building country capacity to implement the interventions. The treatment gap for mental disorders can be reduced by integrating mental health care in primary- and secondary-care settings and moving away from providing treatment in mental institutions. Road safety measures should be addressed through legislation and regulations, which are urgently needed to reduce speed, enforce the wearing of seat belts, and increase the use of motorcycle helmets. People with disabilities, both physical and mental, need better access to community-based rehabilitation services, health services, and more support services. Violence of all types, a significant problem in the Americas, is strongly associated with weakened governance; poor rule of law; cultural, social, and gender norms; increasing unemployment; income inequality; and limited educational opportunities. Stronger violence prevention measures are needed, with legislation and regulations that limit access to firearms and other weapons, reduce excessive alcohol use, and offer enhanced services for victims of violence.

    Advances in science, technology, and knowledge, together with the Sustainable Development Goals and numerous public health commitments to tackle health issues, offer a promising future for improved health and well-being for the people of the Americas.

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    Reference/Note:

    1. Information and reference on the Vida no Trânsito project is located on the PAHO website: https://www.paho.org/bra/index.php?option=com_content&view=category&id=1249&layout=blog&Itemid=787.

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