Elsevier

The Lancet

Volume 385, Issue 9975, 4–10 April 2015, Pages 1343-1351
The Lancet

Series
Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries

https://doi.org/10.1016/S0140-6736(14)61494-XGet rights and content

Summary

Many intrinsically related determinants of health and disease exist, including social and economic status, education, employment, housing, and physical and environmental exposures. These factors interact to cumulatively affect health and disease burden of individuals and populations, and to establish health inequities and disparities across and within countries. Biomedical models of health care decrease adverse consequences of disease, but are not enough to effectively improve individual and population health and advance health equity. Social determinants of health are especially important in Latin American countries, which are characterised by adverse colonial legacies, tremendous social injustice, huge socioeconomic disparities, and wide health inequities. Poverty and inequality worsened substantially in the 1980s, 1990s, and early 2000s in these countries. Many Latin American countries have introduced public policies that integrate health, social, and economic actions, and have sought to develop health systems that incorporate multisectoral interventions when introducing universal health coverage to improve health and its upstream determinants. We present case studies from four Latin American countries to show the design and implementation of health programmes underpinned by intersectoral action and social participation that have reached national scale to effectively address social determinants of health, improve health outcomes, and reduce health inequities. Investment in managerial and political capacity, strong political and managerial commitment, and state programmes, not just time-limited government actions, have been crucial in underpinning the success of these policies.

Introduction

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

  • 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.

  • 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.

  • 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.

  • 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.

Section snippets

Social and health inequities in Latin America

Latin American countries are characterised by their colonial legacies and high and persistent socioeconomic inequalities with among the highest Gini indices (a measure of income inequality in a country) in the world. Poverty and inequality worsened substantially in the 1980s and inequality increased until the late 1990s, when the average Gini index for Latin America reached more than 58.13 Between 1990 and 2004, income equality continued to deteriorate in many Latin America countries but

Intersectoral action and social participation to address social determinants of health and achieve universal health care

Intersectorality is a political, administrative, and technical process20 that involves negotiation and distribution of power, resources, and capabilities (technical and institutional) between different sectors. Intersectoral action not only demands a societal vision or a political intention of the government, but also management capability, along with new institutional arrangements and training for managers in health and other sectors to develop appropriate technical capacity.

Intersectoral

Social participation

The Commission on Social Determinants of Health22 identified participatory approaches as a crucial component of a health system to tackle health inequities underpinned by “…organisational arrangements and practices that involve population groups and civil society organisations, particularly those organisations working with socially disadvantaged and marginalised groups, in decisions and actions that identify, address and allocate resources to health needs”.

In the context of universal health

Intersectoral programmes to address social determinants of health in Latin American countries

We explore intersectoral programmes implemented in Brazil, Chile, Colombia, and Cuba across the three domains of analysis. These programmes, although diverse in terms of target populations, activities, and coverage, share the common objective of reduction of health inequities through intersectoral actions on social determinants of health. In addition to the contributions to health-system goals of improved level and distribution of health, financial protection and user satisfaction, these

Intersectoral action and social participation to address social determinants of health and advance towards universal health coverage: lessons learned from Latin America

The experiences from the four Latin American countries highlight the challenges faced when addressing health inequities and social determinants of health. These challenges are not only rooted in inherent societal inequities, but also in the institutional organisation of government sectors that encourage unisectoral action and hinder multisectorality.

The country cases and the policies we look at provide an insight into the ways in which integrated intersectoral actions are developed and

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