# ABSTRACT

This article analyzes the dynamic interaction between the Health in All Policies (HiAP) agenda and the ongoing implementation of the 2030 Agenda for Sustainable Development. At the World Conference on Social Determinants of Health, held in Rio de Janeiro in October 2011, the Rio Political Declaration pledged to use HiAP as a mechanism to address health inequities. In 2014, the Ministers of Health of the Region of the Americas approved a regional Plan of Action of the Pan American Health Organization (PAHO) that sought to call attention to the health consequences and benefits of policies and actions developed by other sectors. The HiAP approach seeks to integrate activities across the pillars of the sustainable development governance framework (economic, social, and environmental development). Advocates of the process are challenged to consider, using guiding questions outlined at the close of this article, how to pursue action at the country level and in what ways the HiAP approach can contribute to timely and effective implementation of the Sustainable Development Goals (SDGs). The authors propose that coordination between the 2030 Agenda and the regional Plan of Action on HiAP can make an important contribution to the implementation of both processes in the Region.

Key words
United Nations; Sustainable Development Goals; social determinants of health; equity in health; Latin America; Caribbean Region

# RESUMEN

En el presente artículo se examina la interacción dinámica entre el programa de Salud en Todas las Políticas (STP) y la ejecución, en curso, de la Agenda 2030 para el Desarrollo Sostenible. En la Conferencia Mundial sobre los Determinantes Sociales de la Salud, celebrada en Río de Janeiro en octubre del 2011, la Declaración Política de Río puso de manifiesto el compromiso de adoptar el enfoque de STP como mecanismo para combatir las inequidades sanitarias. En el 2014, los ministros de salud de la Región de las Américas aprobaron un plan de acción regional de la Organización Panamericana de la Salud (OPS) encaminado a hacer resaltar las consecuencias y los beneficios sanitarios de las políticas y medidas aplicadas por otros sectores. El enfoque de STP tiene por finalidad integrar las actividades de todas las áreas fundamentales del marco de gobernanza del desarrollo sostenible: el desarrollo económico, social y ambiental. A los partidarios del proceso se les insta a meditar, guiándose por las preguntas de orientación al final de este artículo, acerca de cómo emprender medidas en los países y cómo el enfoque de STP puede facilitar la puesta en práctica de los Objetivos de Desarrollo Sostenible (ODS) de manera pronta y eficaz. Los autores opinan que la coordinación de la Agenda 2030 con el plan de acción regional sobre la salud en todas las políticas puede dar un impulso importante a la aplicación de ambos procesos en la Región.

Palabras clave
Naciones Unidas; Objetivos de desarrollo sostenible; determinantes sociales de la salud; equidad en salud; América Latina; Región del Caribe

# BACKGROUND

The process initiated at the United Nations (UN) Conference on Sustainable Development in 2012 (Rio+20) (11 United Nations. The future we want. Outcome document of the United Nations Conference on Sustainable Development, Rio de Janeiro (Brazil), 20-22 June. New York: UN; 2012. Available from: https://sustainabledevelopment.un.org/futurewewant.html
https://sustainabledevelopment.un.org/fu...
), which incorporated a series of focused thematic consultations (22 World Health Organization and UNICEF. Meeting report of the High Level Dialogue on Health in the Post-2015 Development Agenda, Gaborone, Botswana, 4–6 March 2013. Available from: https://www.worldwewant2015.org/bitcache/66bf6c79eadb132e2e9f7c22f3c23a74fe58954b?vid=348522&disposition=attachment&op=download
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) and the participatory approach of the Open Working Group, has been hailed as the most inclusive process ever conducted by the UN. It established the basis for the 2030 Agenda for Sustainable Development and the associated Sustainable Development Goals (SDGs). Formally adopted in the Sustainable Development Summit at the 70th Session of the UN General Assembly (New York, September 2015), Resolution A/RES/70/1 (33 United Nations. Transforming our world: the 2030 agenda for sustainable development. Resolution A/RES/70/1. New York: UN; 2015. Available from: https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf
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) contains a declaration of the signatory Member States pledging commitment to the 17 agreed SDGs and 169 targets. The number of indicators was expected to be finalized at 230 during the first half of 2016.

Health in All Policies was advocated by the Rio Political Declaration of the World Conference on Social Determinants of Health (Rio de Janeiro, 2011) as a valuable mechanism to promote health equity and build accountability for health into policies in other sectors (44 World Health Organization. Rio political declaration on social determinants of health. World Conference on Social Determinants of Health, Rio de Janeiro (Brazil), 19-21 Oct 2011. Geneva: WHO; 2011. Available from: http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf
http://www.who.int/sdhconference/declara...
). The approach was further legitimized by the Statement of the Eighth Global Conference of Health Promotion (Helsinki, 2013), which recognized multisectoral action and health-oriented public policies as “central elements for the promotion of health, the achievement of health equity, and the realization of health as a human right” (55 World Health Organization. The Helsinki statement on health in all policies. Eighth Global Conference on Health Promotion, Helsinki, Finland, 10–14 June 2013. Geneva: WHO; 2013. Available from: http://www.who.int/healthpromotion/conferences/8gchp/statement_2013/en/
http://www.who.int/healthpromotion/confe...
). At the 53rd Directing Council of the Pan American Health Organization (PAHO) in September 2014, the Ministers of Health of the Region of the Americas approved the Plan of Action on Health in All Policies (HiAP) (66 Pan American Health Organization. Plan of action on health in all policies. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, 29 Sept – 3 Oct 2014. Washington, DC: PAHO; 2014. Document CD53/10, Rev. 1. Available from: http://www.google.com.br/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCAQFjAAahUKEwjD6afQucfIAhXDGZAKHbbgAiE&url=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid%3D26797%26Itemid%3D270%26lang%3Dfr&usg=AFQjCNFGUoS6miQ3WJs80VjptQBfUmXX5A
), calling attention to the consequences and benefits for health of policies and actions developed by other sectors. Effective coordination between the implementation of the 2030 Agenda and the regional Plan of Action on HiAP can make an important contribution to the positioning of health in the wider development agenda.

# THE 2030 AGENDA AND HEALTH

Sustainable Development Goal 3 of the 2030 Agenda (33 United Nations. Transforming our world: the 2030 agenda for sustainable development. Resolution A/RES/70/1. New York: UN; 2015. Available from: https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf
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), “ensure healthy lives and promote well-being for all at all ages,” sets out nine targets and four means of implementation. Three of the targets of SDG 3 incorporate and go beyond those of the Millennium Development Goals: reducing the maternal mortality ratio; ending preventable deaths of newborns and children under the age of 5; and ending epidemics of several communicable diseases. The other six targets refer to noncommunicable diseases and promotion of mental health and well-being (target 4); substance abuse, including narcotic drug abuse and harmful use of alcohol (target 5); traffic accidents (target 6); sexual and reproductive health (target 7); universal health coverage, including access to health-care services, medicines, and vaccines (target 8); and public health and environment (target 9).

This set of targets is not sufficient to implement the entirety of SDG 3. The majority of them refer to disease control or individual health care, but disease and health status have long been acknowledged as the manifestations and outcomes of the dynamic interaction between individual biology and social, economic, and environmental health determinants; therefore, they can be transformed only through coherent, coordinated, and equity-promoting intersectoral policies and actions. Similarly, the four specific means of implementation represent a restricted version of the framework that already exists in public health and the sciences. However, even in this limited model it is clear that contributions from sectors outside of health, such as finance, trade, the environment, and labor, will be instrumental in achieving progress.

It is the position of this article that the SDGs are an indivisible and interdependent set of goals for sustainable development, including the strengthening of health systems. This view differs from that of some other authors (77 Kieny MP, Evans DB. Universal health coverage. East Mediterr Health J. 2013;19(5):305–306. Available from: http://applications.emro.who.int/emhj/v19/04/EMHJ_2013_19_4_305_306.pdf?ua=1
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, 88 Knaul FM, González-Pier E, Gómez-Dantés O, García-Junco D, Arreola-Ornelas H, Barraza-Lloréns M, Sandoval R, et al. The quest for universal health coverage: achieving social protection for all in Mexico. The Lancet. 2012;380(9849):1259–1279. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61068-X.pdf
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), to whom development of the health sector is directly linked to the universal coverage approach to meeting people’s health needs. Furthermore, it considers that many targets of virtually all the SDGs can be conceptualized as health determinants, in accordance with the position categorically established by the Commission on the Social Determinants of Health (99 United Nations Division for Sustainable Development (UNDESA). HLPF Issue Briefs 5: From silos to integrated policy making. New York: UN; 2014. Available from: http://sustainabledevelopment.un.org/index.php?page=view&type=400&nr=1322&menu=35
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). In this view the HiAP approach provides a tool for finding common ground between economic and social development, environmental sustainability, and human health. This position is much more aligned to that of authors to whom HiAP is “an innovative strategy…in the economies and social life of 21st century societies” (1010 Kickbusch I, McCann W, Sherbon T. Adelaide revisited: from healthy public policy to Health in All Policies. Health Promot Int. 2008;23(1):1–4. Available from: http://heapro.oxfordjournals.org/content/23/1/1.full
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) that relates to “decisions in many different policy areas [which] have influence on health determinants” (1111 Puska P. Health in all policies. Eur J Public Health. 2007;17(4):328. Available from: http://eurpub.oxfordjournals.org/content/17/4/328.full
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).

The UN Statistical Commission (UNSD) is working with national statistics authorities and other agencies of the UN System to develop a global framework of indicators for monitoring progress on the 2030 Agenda, including at the country level. According to a UNSD technical report (1212 United Nations Economic and Social Council, Statistical Commission. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators. Document E/CN.3/2016/2/Rev. 1. New York: UN; 19 February 2016. Available from: http://unstats.un.org/unsd/statcom/47th-session/documents/2016-2-SDGs-Rev1-E.pdf
http://unstats.un.org/unsd/statcom/47th-...
), around 230 indicators are still under discussion. The indicators used to evaluate health will not be restricted to the indicators of SDG 3 but will also capture the impact of all SDG targets considered as determinants of health. Employing this broader approach to understanding health progress and deterioration will allow for a more flexible and effective multisectoral effort, which recognizes the wider “causes of the causes” of health, and is better able to distinguish progress.

Although all the SDGs and their targets and indicators are applicable to all signatory nations, countries can decide, according to their own priorities and sovereign interests, which goals and targets to pursue as their contribution to that universal commitment. This flexibility may create additional opportunity for employing HiAP, primarily because each SDG, along with the priorities it reflects, relates to a different set of sectors outside of health whose collaboration adds significant potential to benefit health.

# SUSTAINABLE DEVELOPMENT GOVERNANCE: INTEGRATING THE ECONOMIC, SOCIAL, AND ENVIRONMENTAL PILLARS

Identifying the most appropriate governance process for implementing the 2030 Agenda and its SDGs was a key subject raised by several leaders during the 2015 UN Summit on Sustainable Development in New York. Further consideration of governance appeared in Resolution A/RES/70/1, which advocated transparency, accountability, institutional effectiveness, and anticorruption as key principles while recognizing that, although necessary, they are not sufficient to allow global governance or to permit national and local governments to implement goals as complex as those contained in the 2030 Agenda. Fulfillment of such goals will require the deployment of appropriate political-technical and administrative-managerial mechanisms that are not yet fully developed.

One of the most important statements on this issue is the UN High-Level Political Forum (HLPF) Issue Brief 5, “From silos to integrated policy making” (99 United Nations Division for Sustainable Development (UNDESA). HLPF Issue Briefs 5: From silos to integrated policy making. New York: UN; 2014. Available from: http://sustainabledevelopment.un.org/index.php?page=view&type=400&nr=1322&menu=35
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), which states:

Achieving effective integration of the three dimensions of sustainable development goes beyond merely “aggregating” independently formulated policies across the different domains. It entails taking into account inter-linkages among different areas of policy at the formulation stage. Integration implies that policy-making in any one area takes into account the effects of (and on) policies and outcomes in other sectors and areas. This will help ensure that policy is mutually coherent across the full range of dimensions, and that the effects of policy in one area do not contradict or undermine desired outcomes in others. This also enables to incorporate in sectoral policy-making cross-cutting dimensions that are crucial to achieving sustainable development, such as sustainable consumption and production.

# HEALTH IN ALL POLICIES AS AN INTER-LINKAGE MECHANISM

HiAP is a powerful approach to link the goals, means, and priorities associated with health in the SDGs to those of other policies. This core concept was first addressed in 1978 at the Alma-Ata International Conference on Primary Health Care (1313 World Health Organization. Declaration of Alma Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. Geneva: WHO; 1978. Available from: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_...
) and again in 1986 in Ottawa at the First International Conference on Health Promotion (1414 World Health Organization. The Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa (Canada), 21 Nov 1986. Geneva: WHO; 1986. Available from: http://www.paho.org/hiap/images/stories/PDFs/1986-OttawaCharterEN2.pdf
http://www.paho.org/hiap/images/stories/...
), both of which established intersectoral action for health as an important strategy. The Second International Conference on Health Promotion (Adelaide, 1988) also focused on “healthy public policies” and advocated taking into account policies’ effects on health (1515 World Health Organization. Adelaide Recommendations on Healthy Public Policy. Second International Conference on Health Promotion, Adelaide, South Australia, 5–8 April 1988. Available from: http://www.who.int/healthpromotion/conferences/previous/adelaide/en/index1.html
http://www.who.int/healthpromotion/confe...
). The commitment to implementing a broadly conceived approach to health promotion in the Region of the Americas was reaffirmed at conferences held in Latin America (Bogotá, 1992) (1616 World Health Organization. Declaration of the International Conference on Health Promotion. Health Promotion in Latin America. International Conference on Health Promotion, Santa Fé de Bogotá (Colombia), Nov 1992. Geneva: WHO; 1992. Available from: http://www.bvsde.ops-oms.org/bvsdeps/fulltext/declarationBogota.pdf
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) and the Caribbean (Port of Spain, 1993) (1717 Healthy Caribbean Coalition. Caribbean charter for health promotion [Internet]. First Caribbean Conference of Health Promotion, Port of Spain (Trinidad and Tobago), 1-4 June 1993. St. Michael (Barbados): HCC; 1993. Available from: http://www.healthycaribbean.org/publications/documents/cchp.pdf
http://www.healthycaribbean.org/publicat...
). However, those initiatives were limited by the privatizing policies of the 1990s, which were not very conducive to addressing the social determinants of health, health promotion, and intersectoral approaches.

These important subjects were also revisited on a global level in the final document of the WHO Commission on Social Determinants of Health (1818 World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health; final report of the Commission on Social Determinants of Health. Geneva: WHO; 2008. Available from: http://www.who.int/social_determinants/thecommission/finalreport/en/
http://www.who.int/social_determinants/t...
) and in the Adelaide Statement on Health in All Policies (1919 World Health Organization. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Report from the International Meeting on Health in All Policies, Adelaide (Australia), 13–15 Apr 2010. Available from: http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf
http://www.who.int/social_determinants/h...
). Likewise, they were addressed by the WHO World Conference on Social Determinants of Health (2020 World Health Organization. World Conference on Social Determinants of Health: meeting report, Rio de Janeiro, Brazil, 19–21 Oct 2011. Available from: http://www.who.int/sdhconference/resources/Conference_Report.pdf?ua=1
http://www.who.int/sdhconference/resourc...
) (Rio de Janeiro, 2011), followed by the Eighth Global Conference on Health Promotion (55 World Health Organization. The Helsinki statement on health in all policies. Eighth Global Conference on Health Promotion, Helsinki, Finland, 10–14 June 2013. Geneva: WHO; 2013. Available from: http://www.who.int/healthpromotion/conferences/8gchp/statement_2013/en/
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) (Helsinki, 2013), where the core subject was Health in All Policies. The latter conference produced a statement and a framework for HiAP actions at the country level (2121 World Health Organization: Health in All Policies: Helsinki Statement. Framework for Country Action. Geneva: WHO; 2014. Available from: http://apps.who.int/iris/bitstream/10665/112636/1/9789241506908_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665...
). The 2013 Helsinki Statement describes the widely accepted concept of HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” (2121 World Health Organization: Health in All Policies: Helsinki Statement. Framework for Country Action. Geneva: WHO; 2014. Available from: http://apps.who.int/iris/bitstream/10665/112636/1/9789241506908_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665...
).

In September 2014, at PAHO’s 53rd Directing Council, the Ministers of Health of the Americas adopted Resolution CD53.R2 (66 Pan American Health Organization. Plan of action on health in all policies. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, 29 Sept – 3 Oct 2014. Washington, DC: PAHO; 2014. Document CD53/10, Rev. 1. Available from: http://www.google.com.br/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCAQFjAAahUKEwjD6afQucfIAhXDGZAKHbbgAiE&url=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid%3D26797%26Itemid%3D270%26lang%3Dfr&usg=AFQjCNFGUoS6miQ3WJs80VjptQBfUmXX5A
), approving the regional Plan of Action to implement the HiAP approach. The Plan includes strategic lines of action and indicators for the period 2014–2019, in compliance with the objectives defined in the PAHO Strategic Plan 2014–2019 (2222 Pan American Health Organization. Strategic plan of the Pan American Health Organization 2014–2019. 52nd Directing Council of PAHO, 65th Session of the WHO Regional Committee for the Americas, 30 Sept – 4 Oct 2013. Washington, DC: PAHO; 2013 (Official Document 345). Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=24405&Itemid=270&lang=en
http://www.paho.org/hq/index.php?option=...
), which is designed to address the social, economic, and environmental determinants of health and to promote the sustainable well-being of the population.

The regional Plan of Action on HiAP is based on six strategic lines of action, compatible with the WHO HiAP framework for country actions: 1) establish HiAP needs and priorities; 2) plan actions; 3) identify support structures and procedures; 4) facilitate evaluation and engagement; 5) ensure monitoring, evaluation, and accountability; and 6) strengthen capacities. Regarding the multi-faceted SDGs and their interdependence, the Plan of Action states that “application of HiAP involves identifying opportunities for policy development across sectors with potential implications for health and health equity, assessing potential impacts, and then advocating and negotiating for changes…. HiAP emphasizes the importance of promoting and integrating health across all sectors, including agriculture, education, labor, the environment, finance, housing, and transportation” (66 Pan American Health Organization. Plan of action on health in all policies. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas, 29 Sept – 3 Oct 2014. Washington, DC: PAHO; 2014. Document CD53/10, Rev. 1. Available from: http://www.google.com.br/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCAQFjAAahUKEwjD6afQucfIAhXDGZAKHbbgAiE&url=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid%3D26797%26Itemid%3D270%26lang%3Dfr&usg=AFQjCNFGUoS6miQ3WJs80VjptQBfUmXX5A
).

# HIAP AND THE SDGS

The 2030 Agenda and the HiAP approach are being implemented simultaneously, both globally and in each country of the Americas. It was not a coincidence that while the 2030 Agenda and the SDGs were being defined, an important discussion was taking place on HiAP and the social determinants of health. While the HiAP concept involves synergy among health promotion, the social determinants of health, and human rights, substantial synergy similarly exists between HiAP and SDG implementation.

The HiAP approach aims at the participation of the health sector in the broad process of intersectoral governance and advances the idea of development as transformation (2323 Stiglitz J. Towards a new paradigm for development. 9th Raúl Prebisch Lecture given at the United Nations Conference on Trade and Development (UNCTAD), Geneva, 19 October 1998. Available form: http://unctad.org/en/docs/prebisch9th.en.PDF
). Thus it is ideally suited for addressing the social determinants of health manifested in other SDGs. It is vital to optimize the implementation of SDGs that are relevant to achieving health and to reduce harm to health caused by other policies.

In view of the complex relationships and competencies needed to meet this challenge, PAHO has established a Task Force and Working Group on Health in All Policies and the Sustainable Development Goals (2424 Pan American Health Organization. White Paper: Health in All Policies—from the local to the global. Draft 1. Working document for the Expert Consultation on Health in All Policies. Washington, DC: PAHO; 2015. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwjX9PzGxtPNAhWGQCYKHXTQB88QFggeMAA&url=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid%3D29632%26Itemid%3D270%26lang%3Den&usg=AFQjCNGSZ_4k4Gj-iDJsfNjfERGH4mPxlg&sig2=70P4xFQSsRQFYtp6bkmDYA
). It formulated a set of guiding principles for analyzing the SDG agenda, as follows:

1. Equity is at the heart of sustainable development in the Americas, and an equity index should be developed for measuring progress in the Region.

2. In order to assess long-term life course prospects, intersectoral action is needed to support work on achieving SDGs.

3. Data sources need strengthening, with specific and concrete measures to improve data collection and the identification of information sources that can be used to measure progress toward the SDGs, to include guidance about indices used to measure universal health coverage and access.

Moreover, greater effort must be directed at pursuing and strengthening integration of the SDG and HiAP agendas. These activities include identifying priority issues that affect different sectors at different levels, developing monitoring systems that incorporate HiAP/SDG-sensitive indicators, improving the evidence base for approaches to intersectoral collaboration, mapping and developing thematic websites, training HiAP and SDG policy decision-makers, and providing activities designed to train trainers.

It is clear that achieving progress on SDG 3 calls for coordination with actions aimed at the targets of other SDGs. How can achieving health SDG targets help other sectors to achieve their own targets? In the opinion of Becerra-Posada, “the major synergies between health and other sectors can be achieved by ensuring that the fulfillment of SDG targets involves political coherence and solutions that are shared among multiple sectors. In other words, the Health in All Policies approach!” (2525 Becerra-Posada F. Health in all policies: a strategy to support the Sustainable Development Goals. The Lancet Global Health. 2015;3(7):e360. Available from: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00040-6/fulltext?rss=yes
http://www.thelancet.com/journals/langlo...
).

# FUNDING SUSTAINABLE DEVELOPMENT

The costs of universally achieving the SDGs and their targets, “leaving no one behind” as the 2030 Agenda and its associated UN Resolution urge, are significant. According to information cited in the report of the Intergovernmental Committee of Experts on Financing for Sustainable Development (2626 UN General Assembly. Report of the Intergovernmental Committee of Experts on Sustainable Development Financing. Document A69.315, 15 August 2014. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/69/315&Lang=E
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), the estimated cost of just eradicating extreme poverty in all countries would amount to around US$66 billion annually over the next 10 years. Estimates of the requirements to meet other needs include US$ 50.2 billion annually to eliminate hunger by 2025, US$37 billion to achieve universal health care, and US$ 42 billion to achieve universal primary education and expand access to lower secondary education (2626 UN General Assembly. Report of the Intergovernmental Committee of Experts on Sustainable Development Financing. Document A69.315, 15 August 2014. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/69/315&Lang=E
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).

Viewed in isolation, these individual goal-specific costs would seem difficult to meet, but intersectoral approaches have the potential to achieve objectives from multiple goals and issue areas with the same investments. Therefore, investments directed at reducing morbidity and lowering risk of mortality will need to be aligned with those aimed at expanding access to education and augmenting familial income (2727 Jukes MCH, Drake LJ, and Bundy DAP. School health, nutrition and education for all: levelling the playing field. Wallingford (UK): CAB International; 2008. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwipoJepztPNAhXDNSYKHUREATQQFggeMAA&url=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26gid%3D16874%26Itemid%3D&usg=AFQjCNEFMZ15BKcNzI8vwEseNBuYk_ImZg&sig2=J3iJ0-s7KNXWh0Ygpmos1w
, 2828 Maluccio JA, Hoddinott J, Behrman JR, Martorell R, Quisumbing AR, Stein AD. The impact of improving nutrition during early childhood among Guatemalan adults. Economic J. 2009;119(537):734–763. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0297.2009.02220.x/abstract;jsessionid=1E45FEF97A5FB571A09254DA914529FD.f01t01?userIsAuthenticated=false&deniedAccessCustomisedMessage=
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).

The Addis Ababa Action Agenda (2929 United Nations. Addis Ababa Action Agenda of the Third International Conference on Financing for Development, Addis Ababa (Ethiopia), 13–16 July 2015. New York: UN; 2015. Available from: http://www.un.org/esa/ffd/wp-content/uploads/2015/08/AAAA_Outcome.pdf
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), which emerged from the Third International Conference on Financing for Development (2015), argued that funding for SDGs in developing countries should be based on a combination of official development assistance (ODA) from developed countries and productive investments made by the global private sector, together with developing countries’ own resources generated from domestic savings reforms, increased public tax collection, and the countries’ private sector. This approach is questioned by smaller countries with limited capacity for mobilizing funds of any type, given the size of their economies in relation to the cost burden imposed by this new global agenda. As long ago as 1998, Stiglitz pointed out that focusing ODA and foreign investment on bolstering the economies of less developed countries “has confused not only means with ends, but also cause with effect” of development (2323 Stiglitz J. Towards a new paradigm for development. 9th Raúl Prebisch Lecture given at the United Nations Conference on Trade and Development (UNCTAD), Geneva, 19 October 1998. Available form: http://unctad.org/en/docs/prebisch9th.en.PDF
).

Notwithstanding the above complexities, we are confident that a State-driven process of development toward the 2030 Agenda remains important and is conducive to supporting efficient coordination of the HiAP approach. Public financing, both national and international, will be vital for supplying essential goods and public services. It will also be a key catalyst for attracting other sources of financing. In addition, different areas of the private sector, from micro-enterprises and cooperatives to multinationals, as well as civil society and philanthropic organizations, will all play fundamental but complementary roles in the implementation of the new agenda under the stewardship of the State.

# COUNTRY ACTION ON HIAP AND SDG

Although the 2030 Agenda, its SDGs, and respective targets were defined at the global level, implementation is the responsibility of each country. Major governance challenges remain regarding national implementation of the Agenda and the SDGs.

At this stage of the process, the following considerations may be helpful in identifying appropriate and practical national implementation strategies:

• Who (government entity, commission, working group, or other specific entity) will be appointed as responsible for implementing the 2030 Agenda of SDGs at the national or central level in the country?

• How can advocates ensure that health plays an active role in this body?

• If HiAP is a government policy, how can the SDG body communicate and collaborate with the organization responsible for implementing the resolution on HiAP (if they are different entities)?

• How are the 2030 Agenda and the SDGs linked to pre-existing national health and development agendas/plans?

• What proactive actions can ensure that health is a priority in the 2030 Agenda and will be taken into account in all the SDGs?

• What type of action is needed for health ministries to ensure that the resolution on HiAP adopted by the Region becomes government policy, along with the proposal that HiAP can facilitate and strengthen “integrated policies,” as recommended by the High-Level Political Forum (HLPF)?

• Since the UN Country Offices have overall responsibility for actions related to implementation of the 2030 Agenda and for monitoring SDGs in each country, how can WHO/PAHO’s active and strategic participation be ensured?

• How can partnerships be forged to ensure that civil society and parliaments also play a role consistent with HiAP proposals?

Adequate and timely responses to these and other questions in each country should contribute to improving SDG implementation in line with the recommendation on HiAP enshrined in Resolution CD53.R2 adopted by the Region’s health ministers. It follows that political cross-linkages are important for ensuring joint implementation of the SDGs and HiAP.

Many countries of the Americas already have multi-year development plans that incorporate the concept of sustainable development. Knowledge can be shared and valuable lessons learned from these experiences. When the health ministry’s commitment to the HiAP approach is included in this policy framework, it assumes three dimensions:

• an international commitment to the 2030 Agenda and its incorporation into domestic policy;

• the national government’s multi-year plan as an agent of sustainable development; and

• the health ministry’s strategic HiAP proposals.

The most effective approach at the national level will depend on the characteristics of government policies. If the command structure encourages policy coherence and coordination, the three processes will be synergistic and the common objectives will almost certainly be achieved, possibly with greater cost-effectiveness. With regard to governance of the process, institutional and managerial arrangements are equally as important as the development of appropriate technical tools and mechanisms to ensure effective policy guidance and coordination (3030 Máttar J, Perrotti DE (eds). Planificación, prospectiva y gestión pública: reflexiones para la agenda del desarrollo. Santiago de Chile: Economic Commission for Latin America and the Caribbean (CEPAL); 2014. Available from: http://repositorio.cepal.org/bitstream/handle/11362/36762/S20131070_es.pdf;jsessionid=0C9D34908126A66697AF7824CDE7DD79?sequence=1
http://repositorio.cepal.org/bitstream/h...
).

Application of the concepts and practices of situational strategic planning to intersectoral relationships can be extremely valuable in this respect. According to the concept developed by Matus (3131 Matus, C. Política, planificación y gobierno. Caracas: Fundación Altadir; 1987. Available from: http://www.trabajosocial.unlp.edu.ar/uploads/docs/2_carlos_matus_politica__planificacion_y_gobierno_.pdf
http://www.trabajosocial.unlp.edu.ar/upl...
), it is a social process aimed at producing a linked set of non-routine actions by a social actor (the government in this case) in order to produce changes from an initial situation to a target situation, given certain limitations and opposition, in accordance or compliance with a “national project” of the political group in power.

Each country of the Americas has historical structural characteristics and situational elements that need to be carefully analyzed from political and technical standpoints to determine the most relevant and effective approach to implementing these two mutually beneficial agendas. The central goal should be to define processes that will enable the success of national development plans, aligned with the 2030 Sustainable Development Agenda and facilitated by the Health in All Policies approach.

# Conflicts of interest

The authors declare no conflict of interest in terms of financial ties, academic or institutional commitments, personal relationship, political affiliation, or religious beliefs with the ideas expressed in this article.

# Disclaimer

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or PAHO.

# Publication Dates

• Publication in this collection
Sept 2016