Health and disease are established by many factors including environmental exposures, housing, education, and social and economic status.1 Thus, improvement of population health and health equity needs intersectoral action and social participation, which have been introduced by many Latin American countries.2
Health is an important dimension and a sensitive tracer of sustainable development. Health represents the collective effect of social, economic, and physical life conditions. A healthy population enables increased labour productivity and economic returns to households from labour market participation, which creates opportunity for more inclusive and sustainable growth.3
The Declaration of Alma-Ata,4 the Commission on Social Determinants of Health,1 and the Rio Political Declaration on Social Determinants of Health5 have underlined the crucial importance of policies and actions on social determinants of health in the promotion of health equity. In 2012, the United Nations General Assembly Resolution “The future we want” affirmed that “Universal Health Coverage is a key instrument to enhancing health, social cohesion and sustainable human and economic development”.6 Universal health coverage contributes to the social, economic, and environmental dimensions of sustainable development, and its pursuit should not be restricted to health care, and should include promotion of population health.6
Equity is inherent as a goal of universal health coverage because it implies universal access for all people to needed health services, of sufficient quality across the continuum of care without the risk of financial hardship as a result of using those services. Similarly, following sustainable development, the universal health coverage notion has been enlarged to cover the continuum of care, including health promotion that addresses social determinants of health.7
Key messages
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The broad context of health, including social determinants, democratic progress, and sustainable development, are intrinsically related. Because change in one domain affects others, integrated health, social, and economic actions are needed in the design of public policies and health systems to achieve equitable health and welfare.
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Latin American countries have substantial experience in intersectoral action of varying scope, intensity, and management approaches to improve population health outcomes. As well as time-limited government actions, investment in managerial and political capacity, strong political and managerial commitment, and state programmes have been crucial in underpinning success.
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Latin American countries have effectively used social participation with institutionalised deliberative mechanisms of participation (Brazil) and intersectoral action (Cuba), to enhance equity. However, achievements in population health and social outcomes expressed as country averages hide the unacceptably wide and persistent social and health inequities.
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The health challenges from chronic non-communicable diseases, violence, road traffic accidents, and illicit drug use can only be met in Latin America by simultaneous investments in health systems and actions to address social determinants of health. Hence, broad conception, design, and implementation of universal health coverage need to incorporate actions aimed at addressing social determinants of health if equitable health is to be achieved for present and future generations.
Structural inequities, which define social hierarchy in countries, also establish different health needs, resources, and capabilities to navigate health systems.8 Health sector interventions alone are not enough to improve population health and social wellbeing. Policies and actions from economic, education, transport, housing, agriculture, and other sectors are needed to improve social determinants of health. Therefore, the health sector needs to act as a leader to catalyse intersectoral actions aimed at addressing disparities in social determinants of health, improving health, and reducing health inequities.
Social injustice, health and economic inequities, and disparities in social determinants of health have long been a distinguishing feature of Latin America (panel 1) motivating actions that have sought to address them. Therefore, the lessons from Latin American countries are especially relevant for the global agenda on universal health coverage and sustainable development. Here, with case studies in four Latin American countries, we assess the experiences in the design and implementation at national scale social programmes underpinned by intersectoral action and social participation aimed at addressing social determinants of health, improving health, and reducing health inequities. Atun and others9 provide a detailed analysis of health systems and universal health coverage and Cotlear and others12 address the historical antecedents of health reforms.