Closing the gap: Action agenda for healthier lives in the Americas

PAHO's Health in the Americas reports have long advocated for improved health through more equitable and resilient health systems. The past three editions have focused on reducing potentially avoidable premature mortality; navigating the impact and challenges associated with the COVID-19 pandemic; and eliminating high-burden diseases using existing tools and technologies. This edition advances that work by emphasizing health system efficiency and the critical role of effective leadership in translating evidence into sustained health impact.

In this report, Chapter 1 showed that health gains are uneven, financially fragile, and under pressure from population aging, migration, slower economic growth, and social inequities. Chapter 2 demonstrated that health loss is increasingly concentrated in chronic and disabling conditions and that countries in lower-SHIx clusters with poorer health outcomes and service coverage, greater income inequality, and weaker socioeconomic and environmental conditions face larger shares of potentially avertable burden than countries in higher-SHIx clusters. Approximately 40% of total DALYs in the Region were estimated to be potentially avertable in 2023. Chapter 3 argued that priority-setting is unavoidable and must be translated into financed and implementable service platforms. Chapter 4 advocated for effective stewardship and governance to turn priorities into sustained impact.

The report's overall conclusions are as follows:

• The Region's health needs are evolving more rapidly than many health systems are adapting.
• Much of the remaining burden of disease may be potentially avertable through effective delivery of proven interventions.
• The Region's health priorities are becoming increasingly clear; translating these priorities into impact requires explicit, transparent, and implementable strategies.
• PHC-centered delivery platforms provide the main route for translating priority service bundles into measurable health gains.
• Effective stewardship and governance are required to mobilize and align resources, coordinate implementation, and sustain progress toward better health outcomes.

This chapter presents five opportunities for country action, relates them to the PAHO Strategic Plan 2026–⁠2031, and outlines how PAHO can support Member States in moving from evidence to implementation at scale. Implementing these opportunities will depend on countries' institutional and managerial capacity, an available and appropriately skilled health workforce, sustainable financing, service delivery readiness, and sustained capacity-building for monitoring, adaptation, and scale-up.

Five opportunities for country action

PAHO Member States encompass a broad diversity of health system contexts, with strengths and challenges varying across subregions, countries, and communities. Paths to greater health gains and system efficiency will therefore differ and require country-specific implementation planning. The regional and cluster-specific priorities identified in this report are analytical starting points, not uniform prescriptions. Countries should validate and adapt them using granular national and subnational data on disease burden and equity. Before selecting and designing priority service bundles, countries should also consider feasibility, existing domestic and external financing arrangements, legal entitlements, institutional commitments, and delivery capacity. Despite this diversity, the Region shares five opportunities for action.

1. Identify and close the avertable burden gap.

Countries should use measures of total and potentially avertable DALYs, YLLs, YLDs, and risk attribution, together with granular national and subnational burden analysis, equity stratifiers, service coverage gaps, and financial protection data, to identify priority populations and the interventions that can produce the greatest feasible and equitable health gains. Priority conditions are those that combine high burden and improvement potential with large inequities in risk, access, or outcomes. Feasibility and cost-effectiveness of available interventions and readiness for delivery should also be considered.

2. Build and assure the quality of PHC-centered service bundles for high-impact priorities.

Countries should move from long lists of interventions to integrated and implementable priority service bundles based on community health needs and cost-effective interventions. Grouping prioritized interventions by shared delivery platforms, common workforce and commodities requirements, and overlapping management functions connects priority-setting to feasible implementation and incremental scale-up. Countries should assess and strengthen workforce availability, distribution, and competencies as part of service-bundle design, since workforce shortages and competency gaps can constrain the expansion and sustained delivery of priority services. Service planning should also anticipate the implications of aging populations, multimorbidity, and the growing burden of disability. Countries should align infrastructure, delivery platforms, and referral arrangements with increasing needs for integrated chronic care, mental health services, rehabilitation, palliative care, and long-term care.

3. Align financing, purchasing, regulation, and other stewardship instruments with priority service bundles.

Priority-setting should be translated into financed and operational implementation arrangements, including budget lines, purchasing and provider payment rules and contracts, essential medicines and diagnostics lists, workforce management and training, quality standards, referral pathways, interoperable information systems, and public reporting. These arrangements should ensure that priority service bundles are adequately financed and designed to reduce reliance on OOP spending, especially among populations facing the greatest unmet need and financial hardship.

4. Engage in intersectoral action and community engagement on shared risk factors and social determinants.

Countries should prioritize intersectoral policies and action on shared commercial, behavioral, and environmental risk factors, as well as the social determinants of health. Priority areas include tobacco and alcohol use, unhealthy diets, obesity, physical inactivity, air pollution, road safety, violence, climate-sensitive risks, WASH, social protection, and healthy aging. Risk exposures and determinants are not distributed randomly across populations: they are shaped by broader social and economic conditions, including income, education, employment, housing, food environments, transport systems, environmental exposures, and other conditions of daily life. Evidence from large multicohort and meta-analytic studies shows that socioeconomic position and educational attainment are strongly associated with adult mortality, independently of conventional behavioral and metabolic risks (25, 89). Reducing avertable burden therefore requires not only clinical prevention and treatment but also fiscal, regulatory, urban, environmental, labor, education, and social protection policies that reduce exposure to shared risks and improve the conditions that sustain health. Implementing such policies can involve economic, social, and political challenges and competing interests, requiring effective stewardship and governance as well as sustained intersectoral coordination.

Social participation is also a key catalyst for addressing social determinants and health inequities. Engaging communities, civil society, and affected populations in priority-setting and accountability processes strengthens the legitimacy and sustainability of upstream policy responses. It also ensures those most affected by health inequities have a voice in the decisions that shape their living conditions.

5. Strengthen accountability and leverage regional cooperation for implementation and learning.

Countries should continuously track whether priorities are funded and implemented, reach the intended populations, and improve access, quality, equity, financial risk protection, and health outcomes. Monitoring should be disaggregated using locally relevant equity stratifiers – such as income, geography, race or ethnicity, migration status, sex, age, disability, and/or employment status – to assess whether populations experiencing exclusion or disadvantage are being reached and whether implementation is concentrated in better-resourced areas in ways that widen disparities. Relevant indicators, disaggregated where feasible, could include DALYs, the share of potentially avertable DALYs, coverage of priority service bundles, budget execution, service utilization, treatment completion, medicine availability, OOP spending, and financial hardship. These findings should inform regular implementation-review cycles and course correction. Regional cooperation can accelerate progress through comparable measures, peer-learning, shared implementation experience, and faster adaptation of successful approaches.

Taken together, these five opportunities provide a flexible, nonprescriptive pathway from diagnosis and priority selection to implementation, monitoring, and adaptation. Countries should tailor their sequence and pace to implementation readiness and national context, including fiscal space, workforce and supply chain capacity, digital maturity, governance arrangements, and the degree of decentralization. They should also anticipate financial, political, operational, workforce, and equity risks – including unfunded priorities, implementation bottlenecks, and uneven territorial rollout. These risks can be mitigated through realistic costing and sustained financing, consistent leadership, phased implementation, delivery system strengthening, and disaggregated equity monitoring.

Moving along this pathway requires more than evidence itself, or even the evidence-to-decision frameworks that translate evidence into recommendations and policy actions. Both are necessary but insufficient: an evidence-to-decision framework structures how a recommendation is reached but cannot secure the political and institutional conditions needed to adopt and implement it. Political will is the practical force that authorizes explicit choices, sustains financing, coordinates actors, and protects implementation amid competing demands and political transitions. Evidence alone does not produce reform, and even well-designed programs will not reach excluded populations without sustained governmental and administrative commitment, involvement of key stakeholders and community leaders, adaptive problem-solving, and continued attention to implementation barriers (90–⁠92). Recent developments in Belize and Jamaica illustrate how political commitment can translate health priorities into concrete reforms. Jamaica advanced comprehensive legislation to strengthen regulation of the tobacco industry through new taxes and advertising restrictions, while Belize removed service fees in public hospitals to facilitate more equitable access to health care (93, 94).

Aligning country action with the PAHO Strategic Plan

The PAHO Strategic Plan 2026–⁠2031 sets out five strategic objectives under the overarching goal of improving health and well-being for all throughout the Region (95). The five opportunities for action identified in this chapter closely align with the Plan's strategic objectives, results framework, and approaches to effective implementation, as summarized in Table 6.