Global Health Promotion

This article links 10 regional field reports to the statement Shaping the future of health promotion: Priorities for action, which are both outcomes of the global IUHPE and CCHPR project, Renewing our Commitment to the Ottawa Charter: The Way Forward. The Shaping the future statement has emerged from the regional field reports and will act as the driving force behind the future articulation of health promotion policy at an international level. Connections are made between the key areas of the regional field reports, which include health promotion policy, health-promoting services, health promotion funding and availability of resources, community participation in health, research and information, and the recommendations made in the Shaping the future of health promotion: Priorities for action statement. The coverage includes putting healthy policies in to practice; strengthening structures and processes for health promotion; moving towards knowledge based practice; building a competent health promotion workforce and empowering communities. There are a number of significant issues arising across all the regional field reports that have been drawn on to make the recommendations in the statement. For example, the political environment has strongly influenced the evolution of health promotion. There is a clear message from the reports that political will is essential and that political advocacy needs to continue to ensure that policy goals represent the principles of Ottawa in an appropriate manner. Examples drawn from the reports demonstrate the many and varied challenges for health promotion in addressing 21st century global health determinants. There is also a clear indication that the principles established in Ottawa, and developed in subsequent WHO declarations and charters, have been embedded in the framework of health promotion practice. Shaping the future articulates the key message from the regional field reports, and therefore ensures that the lessons learnt from implementing Ottawa over the past two decades are harnessed and will shape health promotion in the future. (Promotion & Education, 2007, XIV (4): pp 194-198)

Australia has a longstanding history of promoting health through programs that reflect the principles of the Ottawa Charter and recognising the importance of social determinants of health. Health promotion programs are delivered by a wide range of organisations, in a wide range of settings and sectors for, or with, multiple groups. Since the mid-1980s aspects of infrastructure and capacity for health promotion, such as human and financial resources, have been put in place including the establishment of health promotion foundations via tobacco hypothecation. Following neo-liberal reforms in the 1990s, however, government policies have increasingly focused more narrowly on specific diseases and risk factors. Chronic disease has become the new banner under which health promotion, social determinants and efforts to address health inequalities fit. While the importance of social determinants is often recognised within and outside the health sector, health promotion practitioners are seldom at the centre of policy development. (Promotion & Education, 2007, XIV (4): pp 203-208)

The evolution of health promotion within the Brazilian health system is examined, including an assessment of the intersectoral and development policies that have influenced the process. Particular attention is paid to the legal characteristics of the Unified Health System. Human resources formation and research initiatives in health promotion are outlined, with a summary of the obstacles that need to be overcome in order to ensure the effective implementation of health promotion in the future. Up to the end of the 20th Century health promotion was not used as a term in the Brazilian public heath context. Health promoting activities were concentrated in the area of health education, although targeting the social determinants of health and the principle of intersectoral action were part of the rhetoric. The situation has changed during the last decade, with the publication of a national policy of health promotion, issued by the Ministry of Health and jointly implemented with the States and Municipals Health Secretaries. More recently there has been a re-emergence of the discourse on the social determinants of health and the formation of intersectoral public policies as the basis of a comprehensive health promotion. Health promotion infrastructure, particularly around human resources and financing, requires strengthening in order to ensure capacity and sustainability in health promotion practice. (Promotion & Education, 2007, XIV (4): pp 209-213).

The evolution of health promotion in Canada between 1986 and 2006 is characterized by three major eras: Health Promotion in the Limelight, 1986-1992, Health Promotion Behind the Scenes, 1993-2003, and Health Promotion Restaged, 2003-2006. These eras are illustrated using the Canadian Heart Health Initiative as an example. The first era, backed by strong federal government leadership and support, was a progressive time of developing concepts, collaborations and infrastructure for health promotion across the country. Despite significant progress, by the end of this era, health promotion was neither sufficiently developed nor funded to make it a cornerstone of the health system. In addition, the emphasis was heavily biased towards changing individual behaviour. In the second era, health promotion continued to develop in pockets across the country and debates within the field intensified. However, these events went largely unnoticed and massive overall cuts at federal and provincial levels of government made acute care a much higher priority than health promotion. The third era, mostly shaped by fears linked to public health threats, saw a restaging of health promotion through efforts to strengthen public health infrastructure. Nevertheless, at the end of this era, the necessary intersectoral partnerships (such as in health, housing, education, food, income) remained scarce, and little progress was made to decrease health inequalities. The Canadian Heart Health Initiative was implemented over the same time period as the three eras. Its legacy includes collegial relationships across various levels of government and with non-government organizations, a culture that values pan-Canadian initiatives, and support for integration of research, evaluation, surveillance, policy and practice. It remains to be seen how quickly it will be possible to advance the vision of health promotion conceived during the Limelight Era in Canada. (Promotion & Education, 2007, XIV (4): pp 214-218)

China has the world's largest population. In the past, the public health system in mainland China has been strongly influenced by the former Soviet Union. Hong Kong and Macao, the Special Administrative Regions (SAR), have been under colonial administration adopting a laisser-faire approach to health policy. Over the most recent decades, mainland China and the two SARs have adopted the Ottawa Charter principles and re-orientated the healthcare systems towards greater community participation, built a healthy environment in different settings and developed capacity in health promotion. Positive results have resulted from efforts to move towards a bottom-up approach to health promotion, using the overarching framework of Healthy Settings. Adequate resources will be needed to build up the infrastructure for sustainable development of health promotion initiatives. This report is selective, rather than comprehensive and will highlight specific health promotion activities in different parts of China, reflecting how the approach to health promotion has evolved since Ottawa. An analysis will be made of the potentials of these initiatives to take forward the spirit of the Ottawa Charter in paving the way for the Bangkok Charter. (Promotion & Education, 2007, XIV (4): pp 219-223)

Mexico, with a 92 percent literacy, 62 native languages and 12.7 million indigenous people, has entered a new era of macroeconomic stability. Nevertheless 40 percent of the population live below the poverty line. The burden of disease includes malnutrition, infectious diseases, reproductive health problems, as well as chronic diseases. Addressing the social determinants of health has been a priority. This can be seen in two of the most successful Mexican programs. The National Healthy Communities Program that uses a setting approach to establish a link between socioeconomic development and health levels and the Opportunities Program that has become an international model and which is a comprehensive, poverty alleviation program that uses education, fiscal measures and health education to improve population health. Both have been implemented throughout all the states in an intersectorial manner, since 1997 and 2000 respectively. Health promotion in Mexico has evolved in many positive ways during the past 20 years. Development of healthy environments and community actions are the strongest components. Evidence and evaluation, health services reorientation, and building personal skills and empowerment are the weakest. The paradox between low empowerment and high community action results in a superficial community participation that lacks a real commitment towards health. The newest Mexican health promotion policy is named National Alliance for Health and it aims to involve all members of society. Its value is to be independent of any international recommendation; its weakness is that it lacks a deep analysis of the health issues that it is supposed to solve. Consequently valid evaluations are not feasible, and without real evidence the impact of these kinds of policies will remain unknown. (Promotion & Education, 2007, XIV (4): pp 224-227)

Scotland has recently embarked on a new phase of policy and infrastructure development for improving population health and reducing health inequalities that broadly conforms to the Ottawa Charter and WHO's strategic framework for the prevention and control of non-communicable diseases. The new phase is characterised by an integrated, cross-government approach to improving health with strengthened political and Scottish Executive leadership and investment since devolution. A comprehensive policy framework for improving young people's health and reducing inequalities has been developed across education, health, environment and social justice. It builds on an earlier phase of relative stability and continuity in the health promotion infrastructure with policy focused on CVD and cancer prevention and tackling the behavioural risk factors (smoking, alcohol, diet, physical activity) as well as sexual health and mental health and wellbeing. These national strategies are currently being implemented across Scotland. They combine promotion, prevention, treatment and protection goals and target both population-level and high-risk groups. Crosscutting government objectives and headline targets for addressing poverty, disadvantage and health inequalities now supplement the NHS health improvement targets on smoking, alcohol, physical activity, teenage pregnancy and child immunization. Within the health service, prevention efforts are largely concerned with primary care development (anticipatory care) and health system reform to maximize their impact on reducing health inequalities. Efforts to tackle the social determinants of health and reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government with Community Planning Partnerships as the main vehicle. National level mechanisms for integrated funding, planning and performance reporting to deliver shared priority outcomes have yet to be developed. The development of health improvement strategies has been founded upon a rich source of population health data to monitor changes and improvements, epidemiological studies and evaluation work. The key issues have been to find ways of intervening to accelerate the rate of improvement and to stem the growing health inequalities. A further challenge is to ensure that the lessons from reviews and evaluations of past programmes and strategies are not lost, but help to guide improvements in the complex delivery system and to inform future policy direction. Within the health service, prevention efforts are largely concerned with primary care development and health system reform. Efforts to reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government. (Promotion & Education, 2007, XIV (4): pp 228-232)

Health promotion first entered the South African health system in 1990. Today, Health Promotion is a Directorate located within the Social Sector Cluster (SSC) within Primary Health Care (PHC), District and Development operations which falls under the Deputy Director General for Health Service Delivery in the National Department of Health (DoH). The first significant piece of new policy for health promotion in South Africa appeared in the African National Congress (ANC) health policy document, health care services including reproductive health care. At the moment, health promotion service delivery is the responsibility of the national, provincial and local governments with provincial and local governments mainly implementing and the National Health Promotion Directorate offering support. Funding for health promotion activities comes from the Department of Health budget allocation by the National Treasury. One major problem for Health Promotion development is infrastructure. There is significant community participation in South Africa including health promotion policy and strategy document development. Health Promotion research and evaluation is limited. The National Department of Health considers the settings approach to be crucial in driving the progress of health promotion. There are very few trained health promotion specialists either capable or in the position to inform politicians and opinion leaders about the relationship between health and social determinants, and the evidence of effectiveness of health promotion action. Mechanisms for demonstrating evidence of health promotion effectiveness in terms of health, social, economic and political impact are lacking and occupational standards for health promotion education and training are needed. (Promotion & Education, 2007, XIV (4): pp 233-237)

South Asia has 22 percent of the world's population but only 1.3 percent of the global income. Consequently 40 percent of the population is living in absolute poverty. However the health transition in some of its countries including India and Sri Lanka is a testimony to the fact that there are proven solutions to the problems of health and development within the region. The countries of the region have much in common, including a democratic political system, four major religions, a vibrant and living tradition of voluntarism and an extensive health infrastructure which is operating well below par. Despite the underlying unity, South Asia enjoys enormous cultural, linguistic and ethnic diversity. In this large, complex and vibrant region, health promotion is a challenging task, but it also holds the key to a dramatic change in the global health situation. Many of these solutions lie in wider areas of socio-political action. There are much needed shifts in the health promotion and development efforts, particularly in the area of poverty and social justice; gender inequity; population stabilisation; health and environment; control of communicable and non-communicable diseases; and urban health strategies. The principle of cooperation, partnership and intersectoral collaboration for health will be explored. Developing an appropriate, sustainable and people centred health and development strategy in the coming decades is an enormous challenge. There has been an attempt to focus on the emerging needs of the region, which call for health promotion, and involvement of civil society, private sector and the governments bestowed with the increased responsibility of ensuring health security for people. Strengthening the existing health systems, allocating adequate resources for health development and ensuring community participation are all prerequisites to the success of health promotion in the region. ( Promotion & Education, 2007, XIV (4): pp 238-243)

Swedish public health policy clearly illustrates how the concept of the Ottawa Charter for health promotion can be utilized at a national level. The impact has been more implicit than explicit. Public health has a long history in Sweden and much of the present and future is, and will be, linked to traditional values and structures. International input, however, has been essential to prompt new approaches and change. Health inequalities remain the major shortcoming. The Swedish system offers universal access to healthcare in a decentralized system. Still, primary healthcare, and the health services as a whole have not yet sufficiently embraced the idea of health promotion. Political attention to modern public health at the Prime Minister level was established in late 1980s. Since, continuous initiatives in terms of organization, infrastructure and funding have taken place. With regard to funding, a vast majority of the resources allocated to health promotion will be found outside the health sector. An interesting observation is that the Swedish public health policy with its 11 objective domains remains the same, also after a change of government. Future challenges include maintaining and developing an intersectoral mechanism for implementation, allocating more resources for intervention research to strengthen knowledge-based health promotion, and developing tools for coping better with the challenges of globalisation identified in the Bangkok Charter. (Promotion & Education, 2007, XIV (4): pp 244-249)

A landmark in health promotion in Thailand came in 2001 with the launching of the Universal Health Coverage Scheme at the cost of approximately USD 2 billion a year. Another important event was the establishment of the Thai Health Promotion Foundation (ThaiHealth) as a health promotion funding mechanism that draws upon a 2 percent surcharge levied on alcohol and tobacco excise tax, approximately USD 50-60 million a year. The most significant institutional development is the promulgation of the National Health Act in 2007. The Act embraces the principle of human rights and key principles of the Ottawa Charter in 2005. It is a result of five years of extensive public dialogues on important health issues that enhanced public awareness and nation wide networking on health promotion. ThaiHealth regards itself as a catalyst for health promotion. The organisation collaborates with all sectors of the society, from the national to the grassroots level, and is the most notable organisation for health promotion in Thailand. ThaiHealth funds programs on health risks/issues such as alcohol, tobacco, accidents, exercise, as well as area or setting based programs, for example, school, work place, community, and programs that target specific population groups such as the youth, the elderly, Muslim community. The open grants program invites proposals from all kinds of organizations/groups interested in launching health promotion initiatives. The endeavour has started to bear fruit. Smoking and alcohol consumption rates have dropped and more people have become health conscious and do more exercise. However, much remains to be done as some population groups especially the youth have become susceptible to various kinds of health risks. This remarkable start must be sustained and reinforced by the continuation and expansion of knowledge generation and dissemination, relentless policy advocacy and creative public campaign, with a strong health promotion network as the most critical success factor. ( Promotion & Education, 2007, XIV (4): pp 250-253)

Cet article fait le lien entre le document Déterminer l'avenir de la promotion de la santé : priorités d'action et les dix rapports de terrain régionaux à partir desquels il a été conçu. Ces éléments sont tous deux issus du projet mondial de l'UIPES et du CCRPS destiné à réaffirmer l'engagement des professionnels de la promotion de la santé envers la Charte d'Ottawa (Renewing our commitment to the Ottawa Charter “The Way Forward”). La déclaration Déterminer l'avenir de la promotion de la santé est née de ces rapports de terrain régionaux et servira de force motrice pour l'articulation future des politiques de promotion de la santé à l'échelle internationale. Il existe des liens entre les domaines clés abordés par les divers rapports mentionnés notamment en termes de politiques de promotion de la santé, de services promoteurs de santé, de financement de la promotion de la santé ainsi que de disponibilité des ressources, de participation communautaire en matière de santé, de recherche et d'information, et de recommandations telles qu'énoncées dans le document Déterminer l'avenir de la promotion de la santé : priorités d'action. Sont couverts la mise en pratique de politiques publiques favorables à la santé, le renforcement des structures et des processus pour la promotion de la santé, la recherche d'une pratique basée sur les connaissances, le développement de ressources humaines compétentes pour la promotion de la santé et l'empowerment des communautés. Plusieurs questions significatives ressortent de l'ensemble de ces rapports de terrain régionaux, et c'est à partir de celles-ci que l'on a énoncé les recommandations présentées dans la déclaration. Par exemple, l'environnement politique a fortement influencé l'évolution de la promotion de la santé. Les différents rapports délivrent un message clair selon lequel la volonté politique est un élément essentiel. Le plaidoyer au niveau politique doit donc continuer pour garantir que les objectifs politiques reflètent effectivement les principes d'Ottawa d'une manière appropriée. Des exemples tirés des rapports démontrent la quantité et la diversité des défis à relever pour la promotion de la santé pour aborder les déterminants mondiaux de la santé au 21^e siècle. Il ressort également très nettement que les principes établis à Ottawa, et développés ensuite dans les différentes déclarations et chartes de l'OMS, sont fortement ancrés dans le cadre de référence des pratiques de promotion de la santé. Le document Déterminer l'avenir formule le message clé qui se dégage des rapports de terrain régionaux, et garantit ainsi que les enseignements tirés de la mise en œuvre d'Ottawa ces vingt dernières années vont être exploités et déterminer l'avenir de la promotion de la santé. (Promotion & Education, 2007, XIV (4) : pp 255-259)

El presente artículo relaciona 10 informes de campo regionales con el documento Determinar el futuro de la promoción de la salud: Acciones prioritarias, siendo ambos fruto del proyecto mundial de la UIPES y del CCIPS, Renovar nuestro compromiso con la Carta de Ottawa: visión para el futuro. La declaración Determinar el futuro ha surgido de los informes de campo regionales y actuará como motor de la futura articulación de las políticas de promoción de la salud a escala internacional. En este artículo, se establecen relaciones entre las principales áreas que cubren dichos informes (políticas, servicios y financiación de la promoción de la salud y disponibilidad de los recursos, participación de la comunidad en el ámbito de la salud, investigación e información) y las recomendaciones formuladas en la declaración Determinar el futuro de la promoción de la salud: Acciones prioritarias. Los temas tratados son los siguientes: cómo llevar a la práctica políticas públicas favorables a la salud; el fortalecimiento de las estructuras y procesos de la promoción de la salud; fomentar prácticas basadas en los conocimientos; generar una mano de obra competente y potenciar la autonomía y la responsabilidad de las comunidades. En todos los informes de campo aparecen una serie de cuestiones importantes a partir de las cuales hemos formulado las recomendaciones de la declaración. Por ejemplo, el entorno político ha influido enormemente en la evolución de la promoción de la salud. De los informes se desprende el mensaje claro de que la voluntad política es esencial y que habrá que seguir luchando para que los objetivos de las políticas materialicen de modo apropiado los principios de Ottawa. Los ejemplos tomados de los informes demuestran los muchos y variados retos que tiene ante sí la promoción de la salud si pretende abordar los determinantes de la salud del siglo XXI a nivel mundial. También se indica claramente que los principios establecidos en Ottaway desarrollados en posteriores declaraciones y documentos de la OMS han sido integrados en el marco de la práctica de la promoción de la salud. Determinar el futuro expresa el mensaje clave de los informes regionales mencionados y asegura por lo tanto el aprovechamiento de las lecciones aprendidas de la aplicación de la Carta de Ottawa a lo largo de estos últimos veinte años lo cual modelará la promoción de la salud del futuro. (Promotion & Education, 2007, XIV (4):pp 269-273).