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date: 16 July 2018

Health in All Policies: Perspectives From the Region of the Americas

Summary and Keywords

There is a broad consensus that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. The recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors has led to the emergence of a comprehensive policy perspective known as Health in All Policies (HiAP). Building on earlier concepts and principles outlined in the Alma-Ata Declaration (1978) and the Ottawa Charter for Health Promotion (1986), HiAP is a collaborative 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. Health in All Policies has become particularly relevant in light of the adoption of the 2030 Agenda for Sustainable Development and the 17 Sustainable Development Goals (SDGs), as achieving the goals of the agenda requires policy coherence and collaboration across sectors. Given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, the implementation of HiAP at the local level is seen as a powerful approach to advancing health and achieving the SDGs through scaled-up initiatives. As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success in order to identify best practices. The Region of the Americas has made much progress in advancing the HiAP approach, and as such much can be learned from analyzing implementation at country level thus far. Specific initiatives of the Americas may highlight key examples of local action for HiAP and should be taken into consideration for future implementation. Moving forward, it will be important to consider bottom up approaches that directly address the wider determinants of health and health equity.

Keywords: health, governance, policy, social determinants of health, health in all policies, equity, sustainable development

The 21st century brings about many new, complex challenges that have been critical in shaping health outcomes. These challenges are interdependent and complementary in nature, meaning that finding solutions will require collaborative efforts across many sectors at the local, state, regional, and federal levels. It has long been recognized that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. More recently, efforts targeting the social determinants of health (SDH), or the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping them, have increasingly gained attention (World Health Organization [WHO], 2011). This renewed focus on the social, environmental, and economic dimensions of health and development has driven forward the emergence of comprehensive policy perspectives, one approach being Health in All Policies (HiAP).

The Helsinki Statement on Health in All Policies (2013), conceptualized 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 populations health and health equity” (WHO, 2013). Over the past two decades, a remarkable persistence of inequalities and inequities within and between countries have become evident (Kickbusch & Buckett, 2010). Globally, evidence exists on how equity influences a wide range of health outcomes, including both morbidity and mortality associated with mental health, accidents, violence and homicides, infectious and non-communicable diseases such as cancer, and cardiovascular diseases.

The term inequity has a moral and ethical dimension referring to unfair and unjust inequalities that are unnecessary and avoidable by reasonable means (Pan American Health Organization [PAHO], 2015). Equity refers to a state where these unjust and avoidable inequalities do not exist. For example, different forms of inequality extending beyond socio-economic position and relating to structural inequalities, such as those related to gender and ethnicity, profoundly affect the right to health but are neither necessary nor inevitable, and can therefore be mitigated through effective action on health and the determinants of health (PAHO, 2015). Inequities in health status and outcomes pose a significant threat as they have great potential to erode progress made on other margins in health and development. On the other hand, a healthy and skilled population is more likely to bring about stability, economic growth, and higher workforce participation (Bert, Scaioli, Gualano, & Siliquini, 2015). Inequities furthermore tend to result in a “vicious circle.” For example, inequities in wealth and income may affect distribution of access to health services, leading to worse health outcomes, particularly for groups who are already less advantaged. This in turn may restrict their income or access to education and social services, leading to worse health outcomes (Commission on Social Determinants of Health [CSDH], 2008).

Action on the SDH, that is the “causes of the causes,” has been widely regarded as a highly effective mechanism for addressing persistent health inequities and promoting action across a range of factors that affect individual and population health outcomes, many of which are beyond the responsibility of the health sector (WHO, 2011). Two groundbreaking documents have further developed how the SDH are conceptualized, those being the Final Report of the Commission on the Social Determinants of Health (CSDH; CSDH, 2008) and the Rio Political Declaration on the Social Determinants of Health (WHO, 2011). These two documents served as catalysts for operationalizing the SDH agenda, giving attention to the growing consensus around the concept of public policies outside of health as key requisites for improving health outcomes and health equity—and therefore an appropriate priority for the public health field.

To this end, HiAP establishes a strategic approach that provides both advocates and policymakers with guidance to address the SDH and to develop effective intersectoral action. In fact, HiAP is known as the “operational arm” of the SDH approach precisely because many health inequities have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health. Founded on health-related rights and obligations, it emphasizes the consequences of public policies on health systems, determinants of health, and well-being.

HiAP has become particularly relevant given that the 21st century determinants of health and dynamics of the health society are challenging not only the way we conceptualize health and conduct health policy, but they also redefine who should be involved in policymaking (Kickbusch, McCann, & Sherbon, 2008). Governance will play a significant role, with both global and local actors advocating for the development and implementation of public policies that take into account persistent inequities and recognize the increasing complexity and interconnectedness of health and development (United Nations Development Program & United Nations Capital Development Fund [UNDP & UNCDF], 2011). The transition from structural devolution, disaggregation, and single-purpose organizations toward a more integrated approach to public service delivery is already underway. Variously termed “one-stop government,” “joined-up government,” and “whole-of-government,” is part of the movement from isolated silos in public administration to formal and informal networks as a global trend driven by various societal forces, such as the growing complexity of problems that call for collaborative responses, and the increased demand on the part of citizens for more personalized and accessible public services, which are to be planned, implemented, and evaluated with their participation.

In order to further advance on social, economic, and environmental fronts, whole-of-government approaches that seek collaborative efforts across many sectors at the local, state, regional, and federal levels to address these current challenges and achieve common societal goals, such as HiAP, must be implemented (Harris & Harris-Roxas, 2010). Local governments in particular are uniquely positioned to take action and achieve these societal goals through a HiAP approach, given their ability to incorporate local context into the planning process. Successful cases of HiAP in practice can be found all over the globe, each one taking on a slightly different approach than the next.

The Region of the Americas shares a wealth of experience in working across sectors to promote health and has demonstrated dedication to addressing health inequities through the implementation of HiAP-related activities. This article highlights the importance of HiAP in delivering on improved outcomes for health and development, and provides examples of the on-going work on the ground within countries of the Region toward this end. In doing so, opportunities for scaling up HiAP to broaden its effectiveness can be identified. Analyzing these cases is particularly relevant in the Americas, given that health inequity and health inequality continue to constitute the principal barriers to health and sustained development in the Region. Moving forward, in order to more effectively implement the HiAP approach, more work must be done to compile these experiences and identify best practices from the local implementation of HiAP that can be scaled up and applied at a wider level.

Historical Trajectory

The complex challenges of the 21st century have caused governments at all levels to begin incorporating horizontal governance models, which in turn has created a platform for the widespread implementation of HiAP. The HiAP approach is grounded in numerous concepts surrounding health and development that have evolved over time, both at the local and global level. A report presented at the Adelaide 2010 Health in All Policies International Meeting identified three intellectual policy “waves” as the main contributors to the current 21st century model of horizontal governance (Kickbusch & Buckett, 2010). These waves have been crucial to achieving better health and development, and include: intersectoral action for health, healthy public policies, and finally, Health in All Policies (Kickbusch & Buckett, 2010).

Wave One: Intersectoral Action for Health

The importance of intersectoral action on the wider determinants of health was first made explicit in 1978 by the Declaration of Alma-Ata, which called for a “comprehensive health strategy that provided both health services and means of addressing the underlying social, economic, and political causes of negative health outcomes” (WHO, 1978). The Declaration of Alma-Ata was written with the knowledge that health improvements achieved in developed countries were largely attributed to advancements made in social, environmental, and economic living and working conditions (Kickbusch & Buckett, 2010). In working to develop win-win strategies and eliminate contradictions between policies, the intersectoral approach makes use of the different resources and skill sets brought by each sector to solve social problems more effectively than approaches in which sectors work in siloes. Additionally, intersectoral action improves the flow of good ideas and co-operation between different stakeholders in a particular policy sector, thus producing “synergy” or smarter ways of working. By recognizing the extreme value of cooperation between different sectors to improve both equity and health, the Declaration set a new direction for health policy (Kickbusch & Buckett, 2010).

Wave Two: Building Health Public Policy

The spirit of Alma-Ata was carried forward in the Ottawa Charter for Health Promotion, adopted at the First International Conference on Health Promotion held in Ottawa, Canada in 1986 (WHO, 1986). Building on the key principles of intersectoral action outlined in the Declaration, the Ottawa Charter went a step further by advocating for the expansion of the concept of health determinants in order to “build healthy public policies” (WHO, 1986). The Charter is regarded as one of the first major attempts to highlight that healthy public policies are different from health policy as they are concerned with equity, and maintain explicit focus on the impacts of all policies on the health of the population (Bacigalupe, Esnaola, Martin, & Zuazagoitia, 2010). The emphasis the Charter placed on building healthy public policies to improve health and living conditions was critical, as it helped put health on the agenda of policymakers across various sectors (Potvin & Jones, 2011).

The Ottawa Charter also played a key role in giving momentum to the SDH approach as it shifted the focus from individual risk behaviors to the SDH (Mcqueen & De Salazar, 2011). The movement to address the SDH has gained momentum in recent years, with the principles of the SDH approach having been incorporated into numerous global and regional agendas, indicating the global community’s recognition that action on social determinants of health is not only vital for health equity but has other highly desirable societal outcomes, such as enhanced social cohesion (Marmot, 2011). The Region of the Americas, for example, ensured that the SDH be an integral part in the Region’s most recent five-year of the Pan American Health Organization (PAHO) Strategic Plan (PAHO, 2013). In fact, the Region has a longstanding history of working to address the broader factors that determine the distribution of resources, and thereby health and health equity, and has made numerous efforts to translate the SDH and equity into political action through joined and coordinated action across sectors on the five priority areas outlined in the Rio Political Declaration on the SDH (Marmot, Filho, Vega, Solar, & Fortune, 2013).

Wave Three: Health in All Policies

Health in all Policies is an innovative and collaborative policy strategy that builds on the earlier concepts and approaches highlighted in the Declaration of Alma-Ata and the Ottawa Charter, taking as a starting point the crucial roles that health and equity play in development and achievement of broader societal goals (Kickbusch & Buckett, 2010). The term “Health in All Policies” was coined at the end of the 1990s and developed in depth during Finland’s second European Union presidency in 2006, during which the predominant theme was health (Leppo, Ollila, Peña, Wismar, & Cook, 2013). HiAP incorporates a concern with health impacts into the policy development process of all sectors and agencies, thereby giving public authorities and political representatives at all levels the opportunity to ensure accountability for the health and equity consequences of public policy decisions and to address the key determinants of health in a more systematic manner (Kickbusch, McCann, & Sherbon, 2008). In doing so, HiAP takes the critical first step in clarifying the role of sectors other than health that are responsible for many of the policy decisions shaping population health (Kickbusch, 2008).

By creating a more inclusive dialogue and opening up decision-making processes to a broad range of stakeholders across the spectrum, HiAP helps build consensus on the definitions and conceptual frameworks for collaborative undertakings, thereby creating shared goals and strategies across all sectors. For example, in Mexico, under the National Agreement for Nutritional Health—Strategy to Combat Overweight and Obesity, the issues of being overweight and obese have been addressed by the government of Mexico through integrated, intersectoral actions aiming to change unhealthy diets and eating patterns and enhance physical activity levels. A more specific example of one of the Agreement’s intersectoral actions is the work that has been done in school settings. In collaboration with the Ministry of Health, the Ministry of Education developed a plan of action for health promotion and education, regular physical activity promotion and availability, and access to healthy food and drinks in schools range (Latinovic & Rodriguez Cabrera, 2013). In order to increase effectiveness, guidelines on nutritional standards for food and beverages were created for both primary and secondary schools. Notably, efforts to collaborate with the food and beverage industry, a non-traditional partner of the health sector, to limit their marketing of unhealthy food and beverage items to children under a certain age were made (Latinovic & Rodriguez Cabrera, 2013). In this case, the health and education sectors were able to get the public sector to work in collaboration with the private sector to achieve their goal, acting as a successful example of collaboration between the two sectors. Moving forward, the challenge is to ensure that this can be applied on a larger scale to ensure that the entire population has access to healthy foods.

New Wave: Achieving Sustainable Development Through Health in All Policies

In September 2015, the United Nations (UN) General Assembly laid out the 2030 Agenda for Sustainable Development, signifying a historic entrance into a new era of global development (United Nations, 2015). Building on the strengths of the Millennium Development Goals (MDGs), the 2030 Agenda is the most ambitious and universal plan of action for people, planet, and prosperity to date. The product of an unprecedented inclusive and participatory process, the agenda serves as a call to action for all countries and stakeholders to form collaborative partnerships in its implementation to ensure that all people can fulfill their potential to live in good health and with dignity and equality (Sachs, 2012). At the heart of the agenda are 17 goals, known as the Sustainable Development Goals (SDGs). These goals, which reflect the scale of the agenda, address the most important social, economic, environmental, and governance challenges of our time and seek to go beyond the scope of MDGs and complete what they did finish (Sachs, 2012).

A Renewed Focus on Equity

Positioning equity as a cross-cutting goal of development can facilitate greater alignment given its relevance to all major global priorities (WHO, 2011). Analysis of the MDGs unearthed the pressing need to communicate the objective of global agendas more efficiently to all actors and at every level (United Nations Development Group [UNDG], 2014). While the MDGs contributed to many improved health outcomes, the way in which the goals were pursued resulted in numerous challenges with regard to equity. As such, equity and the equitable distribution of health are driving principles of the 2030 Agenda. By emphasizing equity and the need for action outside the purview of the health sector in their achievement, the 2030 Agenda and SDGs invite countries to take an even more visionary approach to health and human development (United Nations, 2015).

The eight MDGs were revolutionary in that they provided a common language to inspire global commitment to development. The goals were sector-driven, measurable, realistic, and easy to communicate. The 17 SDGs and their 169 targets simultaneously expand on that progress, while articulating a critical shift in the development paradigm. Building on the achievements of its precursors, the Sustainable Development Goals thus require governments and societies to collaborate in new and innovative ways, while acknowledging that equity is central to sustainable global progress. The SDGs recognize that inequity and gaps in services, opportunities, and outcomes apply to rich and poor countries alike. As such, they are truly universal in that they are shared globally.

The SDGs’ comprehensive approach to development provides a framework with which countries are to develop their agendas and political policies. The focus on equity is particularly relevant for the Region of the Americas as it remains one of the most inequitable regions in the world. During the MDGs era, many countries in the Region of the Americas reached or surpassed goals to reduce child mortality, control infectious diseases, reduce poverty, and increase access to improved water, sanitation, education, and infrastructure; however, progress varied across goals, between and within countries.

Following this revelation, the Region has demonstrated much enthusiasm in advancing the 17 Goals. The launch of the Commission on Equity and Health Inequalities in the Region of the Americas signified the first large-scale effort to gather evidence on health inequities in the Region of the Americas. The Commission will play a vital role in deepening the understandings of the main drivers of health inequalities in the Americas and examining how gender, ethnicity, and human rights norms and standards interact with these interrelated inequities by identifying evidence, examples of good practice, and opportunities and arenas for action (PAHO, 2013). The Commission will also draw on expertise, evidence, and experience from a range of stakeholders from various disciplines and sectors including civil society, academia, the private sector, and international organizations to place equity and social justice at the heart of all action in health (PAHO, 2013).

Links to Health

A first glance at the 17 SDGs suggest a seemingly diminished importance of health in terms of the overall agenda as compared to the MDGs, with just one explicitly health-oriented goal (SDG 3) out of 17, in contrast to the MDGs’ three explicitly health-oriented goals out of eight. The reality is just the opposite: while the SDGs only explicitly identify health in one of the goals, they have made the links between health and other aspects of development more strikingly clear than ever before as the aims and parameters of each of the 17 SDGs filters through every aspect of health. “Ensuring healthy lives and promoting well-being for all at all ages” is the third goal of the Sustainable Development Agenda and is much more expansive and inclusive than the pre-2015 vision for global action on health. While health issues such as HIV, malaria, and maternal health continue to be priorities for the health sector, emerging concerns, including non-communicable diseases, hazardous chemicals, and narcotic drug use, have been integrated as targets.

The Role of Health in All Policies

The 2030 Agenda is an aspirational approach to advance human development and make it more equitable through complex, comprehensive approaches such as Health in All Policies and the Social Determinants of Health approach. The shift from the Millennium Development Goals to the Sustainable Development Agenda highlights the ability of global agendas to rouse global efforts. A major determinant of the world’s ability to achieve the SDGs, especially SDG 3 and health-related targets, will be the level of intersectoral action that is carried out. Galvanizing action across multiple sectors and agencies has immense potential to tap into that innovative capacity and deliver solutions to the barriers outlined in the agenda and the SDGs. As such, the breadth and ambition of the SDGs presents a unique opportunity to achieve greater synergies between health and other sectors, and at the same time from other sectors with health. The principles of the 2030 Agenda and the SDGs greatly overlap with the goals, means, and priorities associated with other agendas, thereby linking different sectors together. Additionally, the close links between health equity and underlying determinants of health create opportunities not only for collaborative action across sectors, but also among agencies and various levels of government.

For instance, a successful example of HiAP implementation that simultaneously addresses targets laid out by the 2030 Agenda is Guatemala’s Zero Hunger Plan. The Zero Hunger Plan was created in 2012 by Guatemalan President Otto Perez Molina as part of his National Agenda for Change (Sahn, 2015). The plan was designed to reduce malnutrition, provide education, and create better opportunities for families, specifically those living in poverty (Sahn, 2015). Meeting the criteria established under HiAP, the program contributes to policies that impact health and received political commitment from the highest level of government, placed equity at the core of the program, and galvanized action from a broad, multi-sectoral group including: the Guatemalan government, the Scaling Up Nutrition (SUN) Movement, World Food Program, World Vision International, the Inter-American Development Bank, and other UN and civil society organizations (PAHO, 2012). In just 12 months after its creation, the Zero Hunger Plan achieved positive results in 166 municipalities, particularly for children under five. This program has greatly contributed to the achievement of SDG 2 to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture, and has inspired numerous other projects that build upon its work (United Nations, 2017).

In order to capitalize on the opportunities presented by the HiAP approach and facilitate the action needed, the SDGs must be framed in such a way that their attainment requires policy coherence and collaboration across sectors (Becerra-Posada, 2015). HiAP is therefore a powerful mechanism for achieving the SDGs. The approaches and principles of HiAP mirror those of the SDGs, thus ensuring harmony with the 2030 Agenda. HiAP recognizes that health inequities have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health, and advocates for health impacts to be considered in the development of policies across all sectors and agencies.

From Local to Global

Whole-of-government approaches involve multilevel governance, meaning governance must occur at the national, regional, and local levels of government (Kickbusch & Gleicher, 2012). Action at the local level in particular has garnered attention in recent years given its potential to greatly influence the success of global and national agendas (UNDP, 2011). The increased focus on country-specific contexts has prompted the evaluation of the organization and implementation of Health in All Policies at the local level. While HiAP is a global initiative, success cannot truly be achieved without participation at the local level. Localization is a critical component of the multi-level governance required for the implementation of HiAP. Additionally, as the success of Health in All Policies largely depends on the level of collaboration, implementing HiAP at the local level has great potential to achieve results given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, thereby creating ownership within the community as well as accountability.

Health in All Policies at the Local Level

The implementation of HiAP varies in different contexts reflecting local, social, and political cultures, government structures, and existing health landscapes. The importance of taking country specific context into account was made especially clear at the end of the MDGs era. Analysis of the MDGs unearthed the pressing need to communicate the objective of global agendas more efficiently to all actors, at every level (UNDG, 2014). Considering the global scenario of interdependence between levels of government and between nations, decentralized administration of public policies, and participation in the public affairs by a society that is increasingly segmented in new collective identities, a highly differentiated profile of experiences in governance and inter-sector approaches at the local level is apparent. Local government acts as a key instrument in the establishment of policies and programs that create resources for health and wellbeing.

Given the close proximity of local government to constituents, local governments are better able to gauge community health priorities, and thus have great potential to more directly address the wider determinants of health and health equity. Case in point is the implementation of a Quick Assessment of Social Determinants of Health in Suriname. After hosting the Region’s first Health in All Policies training in Paramaribo, in May 2015, the government of Suriname implemented this assessment in order to understand the underlying causes of major health problems and associated health inequities (PAHO, 2015). The findings from this assessment were used to establish eight country-specific areas of action for the implementation of HiAP, which were assessed during a National Consensus Workshop on August 2015. Following this workshop, the eight areas of action and corresponding policy options were presented and accepted at the International Conference on Health Equity, Social Determinants, and Health in All Policies in October 2015.

The use of this assessment tool to help identify and prioritize health determinants according to the local context demonstrates the ability of local governments to analyze the current health landscape, thereby maximizing potential to reduce health inequities. Interventions such as this that have been organized at the lowest level (in this case, local) and have been evaluated and demonstrated great success can subsequently be scaled up and organized at higher levels (Brandão, 2004). In this way, the relevance of repositioning the Health in All Policies approach at the local level is made clear. Engagement from local stakeholders is essential in the development and implementation of health-related policies, the analysis and comparison of which can be highly relevant for revealing the diversity of situations and for a contextualized production of inclusive public policies in different regions and places of the world.

Opportunities and Barriers to Integrating Public Policies

Efforts to integrate health into public policies will be met with many challenges, including the traditional challenges encountered when pursuing other collaborative efforts and those presented by the 21st century. Many of these challenges, such as developing new financing methods, engaging civil society and relevant stakeholders, and adopting better governance, to name a few, stem from a lack of coordination between sectors. Intersectoral action for health is one of the two key concepts upon which HiAP is built; therefore, HiAP cannot operate without collaboration from all sectors, especially those with the largest influence on health outcomes. A lack of participation from these sectors can not only halt current progress but erode progress that has already been made, whereas partnerships that build on the resources, capacity, and the influence of a range of stakeholders to tackle complex challenges can accelerate sustainable development. These partnerships are becoming increasingly important as poverty, hunger, and youth unemployment raise significant barriers to health and social development. Different actors have numerous diverging interests and often times the aims of one sector directly conflicts with those of another. This has proven a difficult challenge in the past and can have severe implications for health. Areas of common interest and opportunities, such as win-win strategies and mechanisms, must be identified as a way of maximizing co-benefits while minimizing the negative effects on health. Additionally, learning how to reconcile tensions and conflicts is critical to ensuring progress in health and development. The health sector can play a significant role in helping guide other sectors on this front. The health sector must be prepared to continuously provide other sectors with strategies, tools, guidance, and technical assistance in addressing the health dimensions of their activities and policymaking processes.

It is also imperative that the health sector itself serve as an example to other sectors by making fundamental changes in their own structures, capacities, skills, and mandates to support Health in All Policies (PAHO, 2015). This will require time, resources, capacity building, training, coordination, and accountability systems in order to establish a workforce skilled in consensus-building, facilitation, negotiation, policy analysis, and communication management (PAHO, 2015). Doing so will allow the health sector to obtain a better understanding of the political agendas and administrative imperatives of other sectors and assess the health consequences of options being considered in the policy development process. This in turn will allow the health sector to work in partnership with all sectors and jointly define policy innovations, mechanisms, instruments, and legal and regulatory frameworks in order to advance both the goals of each sector and health and well-being (PAHO, 2015).

Opportunities and Challenges of the SDGs Agenda at the Local Level

The SDGs present an opportunity to put the priorities, needs, and resources of local communities and their people at the center of sustainable development. Each of the 17 SDGs contains targets directly related to the responsibilities of local and regional governments. For example, the United Cities and Local Governments (UCGL) group from the Global Network of Cities, Local[,] and Regional Governments noted that the inclusion of Goal 11, Sustainable Cities and Communities, is, “in large part, the fruit of the fought campaign by local governments, their associations[,] and the urban community” (UCGL, 2015) as this goal marks a major step forward in the recognition of the role of city leaders in driving global change from the bottom up. The Mayors’ Forum on Health Promotion held in Santiago, Chile in 2016 is a case in point. At the 9th Global Conference on Health Promotion (9GCHP), mayors and health promotion personnel from 12 countries in the Region exchanged experiences and adopted the Declaration of Santiago, highlighting their commitment toward revitalizing the Healthy Cities, Municipalities[,] and Communities movement in the Region. The declaration went on to be presented at the conference and greatly contributed to the outcomes of the conference, including the Shanghai Declaration. Since then the Santiago Declaration has served as a guiding document for current work being done for the Healthy Cities, Municipalities[,] and Communities movement at both the regional and global levels. Additionally, the Santiago Declaration is significant in that it highlights the potential impact of the work being done by local governments as well as the central role that mayors have in the implementation of the SDGs’ agenda.

Exchanging best practices at the global level is key, given that reliable and timely data is increasingly necessary to systematically monitor progress toward the SDGs. To this end, a High Level Political Forum has been held each year since the adoption of the SDGs in order to serve as a central platform for follow-up and review of the 2030 Agenda (United Nations, 2017). In addition to gathering an evidence base and keeping track of progress toward the SDGs, the Forum also serves as a key opportunity for collaboration between both Member States and agencies. In this way, by fostering intersectoral action at the highest level, we see that HiAP is applied through the SDG agenda. This form of collaboration is crucial not only for the advancement of HiAP, but also the SDGs. In addition to the need for a strong evidence base, the successful implementation of the SDGs demands the work of numerous actors and sectors. Additionally, participation requires that public policies are not imposed from the top, but that the whole policy chain is shared. Local governments must play a role in the policy development process and should be viewed as catalysts of change and the level of government best placed to link the global goals with local communities. As such, efforts to involve all relevant actors in the decision-making process, through consultative and participative mechanisms, at the local, subnational, and national levels, are critical (Global Taskforce of Local and Regional Governments, UNDP, & UN Habitat, 2016).

Lessons Learned From the Region of the Americas

Health in All Policies has been the source of considerable enthusiasm from Member States, particularly in light of the interdependent and multisectoral framing of the SDGs. During the 8th Global Conference on Health Promotion, 26 case studies from 15 countries in the Americas were presented to showcase best practices from the Region for implementing Health in All Policies (PAHO, 2013). The Region of the Americas has also played an instrumental role in driving forward the HiAP initiative with the adoption of a Regional Plan of Action on Health in All Policies in September 2014 (PAHO, 2014).

As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success. In doing so, best practices can be identified and a better understanding can be reached for how HiAP is being implemented in different contexts, what works, and where there is room for improvement (WHO, 2013). Additionally, a common set of concepts can be identified in order to help facilitate knowledge sharing between countries and to help scale up HiAP.

Much of the work being done within the Region of the Americas illustrates this. Table 1 highlights specific examples of HiAP in practice in the Region of the Americas. The role taken on by the health sector, as well as the degree of intersectoral action that must take place, varies depending on the specific needs and priorities at hand. While the health sector is often seen as a leader in HiAP-related activities, the health sector can also serve as a negotiator or a partner in cases where it does not control the means for implementation or does not have a clear vision for how such measures should be framed (Torgersen & Stigen, 2007). The relationship between the health sector and other sectors can also vary in intensity and involve exchanging information, identifying key areas for cooperation and win-win strategies, adjusting to the policies and programs of each sector for better coordination, and working to enhance the integration of sectors through collaborating on the development of policies and programs (PAHO, 2015).

Table 1. Specific Examples of HiAP in Practice in the Region of the Americas

Country

Initiative

Aim of Initiative

Leadership

Role of the Health Sector

Main Vision of Health in the Strategy

Degree of Intersectorality

Focus

Argentina

Healthy Municipalities Strategy in Argentina

Improve the overall quality of life and health of the people, focusing on health promotion and the environment

Local community and the health sector

Leader

Health promotion, lifestyle choices, and risk factors

Information

Prosper

Brazil

Belo Horizonte Citizenship

Address the issue of social exclusion within the municipality of Belo Horizonte

Local community and the local government

Partner

Curative aspects delivery of social services

Cooperation

Prosper

Brazil

Family Exchange (Bolsa de Familia) Program

Reduce poverty and extreme poverty and combat hunger and food insecurity in vulnerable families

National and social policies

Partner

Social Determinants of Health approach

Cooperation

Transform

Chile

Chile in Solidarity System

Overcome poverty through a multidimensional perspective using a social vulnerability approach

National and social policies

Partner

Curative aspects delivery of social services

Coordination

Survive and prosper

Chile

Chile Grows With You

Develop a comprehensive system for childhood development and protection

National and social policies

Negotiator

Social Determinants of Health approach

Cooperation

Transform

Colombia

From Zero to Forever

Ensure the comprehensive development of early childhood for all children in the country as well as the eradication of poverty

National and from the presidency

Partner

Social Determinants of Health approach

Cooperation

Transform

Cuba

Intersectoral and participatory strategy for the control and prevention of dengue

Enhance the prevention and control of dengue

National and health

Leader

Health promotion, lifestyles and behavior, risk factors

Coordination

Prosper

Ecuador

Plan for Good Living 2009–2013

Implement new plan for development that seeks to improve the life of the people, territories, and communities (good living)

National and from the presidency

Negotiator

Social Determinants of Health approach

Integration

Transform

El Salvador

CISALUD

Intersectoral coordination in health within the framework of the social determinants of health

National and from the presidency

Leader

Health promotion, lifestyle and behavior, risk factors

Coordination

Prosper

Mexico

Intersectoral School Health Program

Develop healthy lifestyles and prevent risk factors within educational establishments

National and health

Leader

Health promotion, lifestyles and behavior, risk factors

Cooperation

Prosper

The initiatives described in this table are key examples of local action commitment to HiAP. Compiling and assessing these examples is a critical step in addressing the knowledge gaps in scaling up different country contexts to move beyond the local level to the global level. As such, sub-national data should be taken into consideration in the review of national progress and plans. It will be important to continue strengthening the institutions that gather this data to aid in planning processes.

Conclusion

While both the SDG agenda and the HiAP approach are global, the level at which they are implemented will depend on the ability of countries to make them both a reality at the local level. As local governments play a key role in the delivery of services and the creation of policies that directly impact health, HiAP is particularly relevant. Additionally, the 17 SDGs present an unprecedented opportunity to promote health and reduce inequities by putting health at the center of public policymaking. Action taken at the local level has great potential to achieve success in this regard, and from the successes best practices can be identified and scaled up. Despite the unique challenges countries and sub-regions of the Americas have, the Region has demonstrated that implementation of HiAP at a smaller scale is feasible through political commitment, intersectoral action, community engagement, and resource mobilization. The specific initiatives described in this article are just some examples of many efforts to translate this conceptual approach into realistic action at the local level. Not only do local initiatives such as these contribute to the overall global success of the HiAP approach, they also help combat the large disparities in health that continue to remain within and between countries. Moving forward, it will be important to not rely solely on trickle-down approaches but instead continue to assess the impact of local programs and initiatives in order to develop bottom-up approaches centering on notable achievements.

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