FROM THE DIRECTOR
Social determinants of health in the Americas
Carissa F. Etienne
Director, Pan American Sanitary Bureau, Washington, D.C., United States of America
When all 189 United Nations Member States signed the Millennium Declaration in 2000, they set an ambitious goal for their countries and the world. With the global target date of 2015 right around the corner, the Region of the Americas has made significant progress toward achieving the eight Millennium Development Goals approved at the historic Millennium Summit. It is very encouraging, indeed, to observe the sustained economic growth, increased life expectancy, and improved governance within the Region. As the Director of the Pan American Health Organization, I am truly humbled when I reflect on the dedication and commitment of the ministries of health, the governmental and international agencies, the nongovernmental organizations, and the community groups whose efforts have reduced infant mortality rates, increased immunization coverage, tackled communicable and noncommunicable diseases, improved maternal health, and addressed important public health concerns.
Yet, while there are many accomplishments to celebrate, we must remember that the health gains have not been shared equally between and within countries, and that inequity remains the greatest challenge for health and sustainable development in the Americas. Overall income inequality has consistently outpaced income growth in the Region as illustrated by recent regional evidence showing that while income has increased significantly over a period of 30 years, the gap between those 'who have' and those 'who have not' have increased by almost three times. Moreover, women are overrepresented in the informal employment sector in which workers face more occupational hazards and are insufficiently protected by social protection mechanisms. Increased migration, the aging of the population, and the related increase in noncommunicable diseases are the most important trends shaping health in the Americas. Indeed, these and many other determinants of health are further exacerbating the health inequities between and within countries.
Since 2008, when the World Health Organization Commission on Social Determinants of Health produced the landmark report, Closing the Gap in a Generation, that helped to identify and define the underlying causes of health inequities, a global movement has emerged to address these social determinants of health (SDH). Building on the recommendations from the Commission, in 2009 the World Health Assembly called upon Member States and the international community to reduce health inequities by implementing the Health in All Policies approach. Health in All Policies provides new vigor to national and international milestones in health policy development and commitments to ensure access to comprehensive health care. These milestones include the Alma-Ata Declaration of 1978 that recognized the importance of intersectoral action in achieving Health for All. The spirit of Alma-Ata was carried forward in the Ottawa Charter for Health Promotion of 1986, which addressed "healthy public policies" as a key area for health promotion. Most recently, the Rio Political Declaration on Social Determinants of Health, adopted in 2011, expressed worldwide political commitment to implement an approach geared toward SDH. The Rio Declaration acts as a reminder that we need to work in tandem with other sectors to successfully address the stark health inequities that exist between and within countries in the Region of the Americas. As evidenced by the establishment of National Commissions on SDH and integration of SDH in national and regional plans, the Region is committed to acting on SDH and supporting the Health in All Policies movement, specifically through intersectoral collaboration towards universal health coverage.
Universal health coverage is a critical component of sustainable development, human security, and poverty reduction, and a key element of any effort to reduce social inequities. As we approach the post-2015 era, I am confident that with the commitment of our Member States and our partners, both within and beyond the health sector, we can ensure that all people, even the most vulnera- ble populations, have access to needed services (prevention, promotion, cura tive, rehabilitation, and palliative care) with sufficient quality to be effective and without exposing individuals to financial hardship. It is encouraging to see that global support for universal health coverage is gathering momentum. Recently, during the 66th World Health Assembly, delegates from countries of the Americas expressed strong support for the goal of universal health coverage and the inclusion of health as a central component of the post-2015 development agenda. Orchestrating a coherent response across governments and society still remains one of our most prominent challenges in global health. As we move forward into post-2015, the international development agenda must address the interconnectedness of social policies and health in the five areas outlined in the Rio Declaration: improving governance, promoting participation, reorienting the health sector, encouraging global action on social determinants, and monitoring progress.
As countries move towards universal health coverage, an intersectoral approach addressing the social determinants of health and going beyond the work of the health sector, will be required. We now have a great opportunity to shape the policies and practices that reinforce the importance of building partnerships and developing networks among society's various sectors. As PAHO begins to implement its Strategic Plan 2014-2019, I look forward to promoting strategic collaborative efforts among Member States and other partners to promote equity in health, to combat disease, and to improve the quality and length of life of the peoples of the Americas.
As we near the post-2015 mark, we must continue to maintain health as a priority and influence the global dialogue on strategies that effectively address SDH in order to reduce health inequities, while drawing on all the practical initiatives that have been successful. In pursuit of the highest possible level of health for all, we must strengthen our networks and institute mechanisms to facilitate the exchange of skills and experience, not only within our Region, but with other WHO Regions. The former director of the U.S. Centers for Disease Control and Prevention and a well-respected leader in global health, Dr. William Foege, summed-up health in the twentieth century in four words: "spectacular progress, spectacular inequities." Indeed, we have made much progress in the Region of the Americas in addressing the social determinants of health, however, we have much more work to do closing the health inequity gap.
Nevertheless, we must celebrate and draw inspiration from the advances, moving forward together and continuously reminding ourselves that our best work reflects our institutional values namely equity, integrity, and solidarity. The Region of the Americas has made concrete progress in reducing health inequities through action on SDH: this special issue of the Pan American Journal of Public Health speaks of numerous successes upon which we can build.