Series www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61494-X 1 Universal health coverage in Latin America 3 Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Luiz Odorico Monteiro de Andrade, Alberto Pellegrini Filho, Orielle Solar, Félix Rígoli, Lígia Malagon de Salazar, Pastor Castell-Florit Serrate, Kelen Gomes Ribeiro, Theadora Swift Koller, Fernanda Natasha Bravo Cruz, Rifat Atun 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 oppor- tunity 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 Health 5 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 Published Online October 16, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61494-X This is the third in a Series of four papers about universal health coverage in Latin America Oswaldo Cruz Foundation and School of Medicine (Prof L O Monteiro de Andrade PhD), Federal University of Ceará (K Gomes Ribeiro MSc), Fortaleza, Brazil; Center for Studies, Policies, and Information on Social Determinants of Health (CEPI-DSS), Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil (Prof A Pellegrini Filho PhD); Latin American Faculty of Social Sciences (FLACSO), Chile (Prof O Solar PhD); Health Systems Division, Pan American Health Organization, Brasília, Brazil (F Rígoli MD); Foundation 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.