Introduction: A prospective view to health
This chapter focuses on the future by building on the ideas and proposals from earlier chapters, which identified health drivers as well as current and anticipated challenges for health systems in the Region. The following topics are addressed in the context of the Region of the Americas: (1) pathways to the health-related Sustainable Development Goals, (2) the construction of health throughout the life course, (3) the dual role of health as an essential component and a prerequisite of development and the role of society in that development, (4) the reforms in health systems needed to overcome the drawbacks associated with fragmentation and segmentation that stand in the way toward universal health, and (5) the role of technology and research in informing public health policies.
In endorsing and advocating a life course approach to health, communities and civil society are not mere passive recipients of health services and messages. Instead, communities and civil society are crucial actors in the transformation of their physical and social environments. Beyond a defined set of evidence-based interventions (i.e., interventions targeting a particular disease or condition) that have increased life expectancy, health services should be implemented and perceived as ongoing, interlinked activities throughout the life course rather than a response to episodic demands. By considering individuals and populations within their social, economic, and political context, health actions throughout the life course become continuous and coherent. Along with the 2030 Agenda for Sustainable Development, a good example of a strategy taking this life course approach is the Global Strategy for Women’s, Children’s and Adolescents’ Health, which is based on the foundational principles of surviving (ending preventable and premature death), thriving (ensuring health and well-being), and transforming (expanding enabling environments). Each of the three principles and their associated goals is incomplete without the other two. Under this perspective, community development and accountability, health services and systems, and open information are mutually dependent.
This chapter addresses the marked aging of the population of the Region, the subsequent extension of longevity, as well as the increased commitment the elder population represent for health services. The chapter also highlights the health determinants approach as a substantive component of the life course paradigm, and underscores the need for multisector actions and a multilevel approach. Corresponding with the critical-period model, timely interventions result in optimal longitudinal effects during the course of life, and often impact more than one generation. A one-time intervention thus commonly becomes a permanent intervention.
Topic 1 addresses SDGs and Health in All policies. It sets the strategic lines along which to operate in a world that is more aware of the fact that health for all cannot be constrained to the traditional interventions of the health sector. A review of the evidence shows that the implementation of Health in All policies provides practical clues to interaction among sectors.
Topic 2 deals with the linkage among experiences during the life course. Due to the fast demographic and social transition under way in the Region, several generations with different socioeconomic, environmental, and cultural backgrounds live together at a given point in time. This mosaic of age groups and life trajectories poses serious challenges to health systems. New models of health care thus need to be found and implemented, not only to promote health but also to reduce inequities.
Topic 3 addresses public health policies that involve community health programs. It ends with a call for a more inclusive society where the voices of all are heeded, to improve the design and implementation of health policies and for more transparency in policies and information, more accountability, and more efficient financing mechanisms.
Topic 4 deals with the dynamic reform of health systems aimed towards universal health. The essential building blocks of the health systems towards universal health and equity in health include elements of governance, fiscal space and financing policies, and social dialogue as well as a pathway to reduce the human resources gap. Key strategic components of the reform are its stewardship, the institutional changes to reduce fragmentation and segmentation of health systems and services, more efficient financing of public health, and a policy of human resources more attuned to public health needs.
Topic 5 deals with knowledge in the information age. Free access to information, often dubbed the “democratization of information,” provides a unique platform for changing the way we manage health and disease, through accessing products, advice, or services. Innovation and technology are changing the way we live our lives and will invariably have a key role in our future lives.
The way forward
This chapter proposes strong multipronged approaches to health and development by addressing the stated paradigms of health, development, and life course approaches as follows:
Innovation and change. The Region of the Americas is undergoing epidemiological changes in the health and social spheres, which demand constant adaptation. With an overall mortality decrease, a population which is aging, and decreasing fertility, this Region must plan for changes in the future. Methods to control diseases and promote health are evolving, presenting new opportunities for innovation. Investing in the future, through research and development both in the field of biosciences as in the field of management and operations, is of paramount importance.
Primary health care from a community perspective. The concept and definition of a community in the 21 century needs to be revised, to move beyond traditional geographic distinctions. Communities play a key role in health and their participation will be increasingly required to lessen the strain on health facilities, especially when it comes to caring for individuals with multiple chronic conditions. Community involvement is also essential to enhance individual decision-making regarding the complex interplay of the different factors impacting health. Primary health care functions must be strengthened, for which crucial changes are needed in the health delivery model. The role of communities has to be enhanced as a prerequisite for universal health, for example, to avoid leaving people in situations of vulnerability excluded from services. One result of this underservice is the lack of real community involvement that hinders people’s acceptance of primary services as the first point of contact.
Equity and evidence. Health statistics cannot be reduced to averages. Averages tend to mask differences, which in turn are the numeric expressions of underlying inequities, probably the most important driver of poor health in the Region. Equity gaps need to be exposed and dealt with. Members of a certain gender, ethnic group, socioeconomic position, and cultural and education background may encounter large, unfair health gaps based on the aforementioned circumstances and other stratifying factors. The performance of health systems has to be measured along two axes, one represented by health indicators and the other by health gaps. This approach should enable targeting interventions to the most in need.
Multisectoral approaches. The health sector has the main responsibility of improving and promoting the health of the population. However, as has been known for centuries, many determinants of health are out of the direct control of the health sector. The 2030 Agenda and its health-related SDGs lays out principles and targets to confront global health challenges, and highlights the role of the State as a primary actor in health governance and in promoting partnership with non-State partners. The 2030 Agenda advocates multisectoral initiatives in which the health sector, in partnership with actors from other areas of governance, addresses key determinants of health under the influence of actions from systems and institutions that fall outside the traditional purview of the health sector. To make these multisectoral initiatives work in practice is a challenge.
Integration of strategies. Vertical and comprehensive approaches to primary health care are needed, and the discussion promoting one approach over the other highlighted by the launch of the Primary Health Care Movement in the 1970s is now redundant. In practical terms, comprehensive approaches are required that include not only vertical interventions but also that involve communities in promoting and improving health. Immunization programs and directly observed treatment, short-course (DOTS) programs for the control of tuberculosis are examples of highly specific, cost-effective, evidence-based interventions with recognized benefits when distributed among wide segments of the population. Vaccination programs, for example, have been extremely innovative in promoting equity and leaving no one behind, and thus should be studied as models for effective engagement in the future.
Partnering and funding. New paradigms call for new ways to interact, but there are key questions that arise. Which partnerships need to be forged to address the challenges to health? How can these partnerships be funded? While it is clear that organizations have their own missions and mandates, the complementarity of these institutions is a powerful way to deal with tomorrow’s health challenges. Partnerships are win-win solutions to complex health problems. They can be instrumental in bringing funding and innovation to fields that are lacking them. Private sector funding can link with public sector funds and merge to produce very specific outcomes. Political, legal, and financial frameworks are needed to meet future challenges. At the same time, new types of alliances, based on well-established criteria and legal regulatory frameworks, are needed to reach goals and close gaps in areas where health systems have failed so far.
This Region benefits from great experiences, which should be documented and shared widely. The lessons learned will allow the Region to push ahead, addressing new and existing health challenges. Only in this way will we be able to reach everyone, everywhere.