Shaping the Future of Health Promotion: the Ottawa Charter

revisitedFlora Douglas

University of Aberdeen28th August, 2008

By: Dave OlsonLicense was: Attribution-Sharealike 2.0

Vancouver!!

Why this seminar

• 19th IUHPE conference last year Vancouver - global reflection on the relevance of Ottawa Charter (OC) for health promotion 21 years since 1st conference.

• Global IUHPE review of health promotion: Shaping the future of health promotion: Priorities for health promotion Statement 2007

• UK review of health promotion specialist practice.

• A chance for NHSG HP and PH staff to consider their own practice in light of this global and national debate.

• Raise awareness about the birth of health promotion as discipline - with it’s World Health Organisation defined set of principles and values) - ongoing debate in Scotland about health improvement versus health promotion

http://commons.wikimedia.org/wiki/User:Malene

An invitation to have a look at the ‘Health Promotion forest’ from above, and take your mind up from the twigs and branches

of the day-to-day work

Health promotion’s emergence

1. World Health Organisation (WHO) Declaration of Alma Ata (Russia) 1978

Improvements in health could not be determined by investments in the health care systems alone – prevailing view since the end of the 2nd WW.

Needed to enrol other sectors in health improvement efforts.

2. Canadian Lalonde Report (1974) 3. WHO’s Global Strategy for Health for All by the Year

2000 (1981)4. Health Promotion: Concepts and Principles (WHO, 1984)5. Ottawa Charter for Health Promotion (1986)

Other secular drivers• A general, trans-national reappraisal of health care

priorities – rising health care costs– an apparently limitless demand for healthcare – a rapid growth in the elderly proportion.

• Emerging critiques of the role and effectiveness of medicine versus social and environmental changes in population health gain (McKeown 1976, llich, 1977)

• Emergence of feminist ideas about reclaiming control over health care decisions, and in self-help groups.

• Other similar movements e.g. community development, communications and consumerism movements.

Basis of the Ottawa Charter

• Ottawa charter prioritised the social model of health.

• Targeted wider determinants – health inequalities.

• OC linked health with structural adjustment brought about through political, economic and social change –shaped public health at a global level for the past 20 years.

• Stated that health promotion must be taken into other sectors, and to and by politicians.

Overall intention Ottawa Charter

• To refocus on upstream determinants of health, where the individual was an active participant.

• Create a climate of multi-sector partnerships and for that to became the framework for health promotion.

Upstream mindset?

Courtesy of Carolyn BennetCanadian MP for St Paul’s

In order to reduce morbidity and mortality associated with increased numbers of

people getting more physical activity in and around Stonehaven, do you think we should

have a:

A) strong fence at the top of the cliff

B) state of the art fleet of ambulances and paramedics waiting at the bottom ?

Health promotion defined by the Ottawa Charter

“Health promotion is the process of enabling people to increase control over and to improve their health. …. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes

beyond healthy lifestyles to well-being.” Ottawa Charter for Health Promotion (1986)

Five health promotion action areas

• Building healthy public policy

• Creating supportive environments

• Strengthening community action

• Developing personal skills

• Reorientating health services

Five HP action areas• Building of healthy public policy - intended to

encourage coordinated action to ensure health, economic and social policies that fostered great equity through legislative, fiscal; taxation and organisational change.

• Creating supportive environments - aimed at developing a socio-ecological approach to health improvement.

• Strengthening community action -promoted participatory community development processes, aimed at encouraging communities to take ownership and control their own health and its determinants.

• Developing personal skills - focussed attention on enabling individuals to exercise control and make healthful choices

• Reorientation of the health service - challenged the health sector to move beyond curative service provision.

Health promoters roles and responsibilities - according to the

OC

• Advocates - ensuring the conditions favourable to health were in place.

• Enablers - facilitating health potential.

• Mediators - to advocate between differing interests in society in the pursuit of health.

The copyright on this image is owned by Richard Webb and is licensed for

reuse under the Creative Commons Attribution-ShareAlike 2.0 license. GNU Free Documentation License

Photograph by Stan Shebs

My personal experience of health promotion!

Sometimes a fertile field

At others, Mont Blanc surrounded by inhospitable terrain

More questions

What OC health promotion actions do you feel you doin your day-to-day work?

What OC health promotion actions do you feel you don’t do or are unable to pursue in your day-to-day work?

Main conclusions of global review

• Politics, politicians and the political environment have had a major influence on the progress of health promotion in the last 20 years.

• Across countries there have been differences in the way that health promotion has been conceived, valued and approached - strongly determined by political, cultural and economic contexts.

• Competitive culture between government departments,• Lack of national agency for health promotion • Dominance of a biomedical rationale in health

governance - - has had a negative impact on health promotion in some

countries.

Main conclusions of global review

• Intersectoral action is happening - but complacency is a risk and urges more equity between different sectors.

• Knowledge-based practice critical - but there are significant challenges about getting evidence out of practice! More resourcing of health promotion action is needed.

• Challenges in workforce capability and capacity – (related to the competencies advocacy, mediation and

enabling)– chronic shortage of resources– will take a high level of political will to resolve.

What do you believe are the key health promotion challenges in the future?

21st century health challenges• Health inequalities within and between nations are

widening.

• Rise in globalisation, trans-boundary influences on the determinants of health are beyond the direct control of individuals, communities and nations.

• Population growth, urbanisation, consumerism are stretching global resources and damaging the environment.

• Increased spread of communicable diseases.

• Burden of chronic disease falling on the most disadvantaged societies.

• Recommitment to the ideas and values of the Ottawa Charter and strengthening conditions for effective health promotion is urgent!

Health inequalities are widening within and between countries

Solutions? WHO's Commission on the Social Determinants of

Health …”The benefits of increased life expectancy to the worst off had not

been as significant as those seen among the best off.”

"The key message of our report is that the circumstances in which people are born, grow, live, work, and age are the fundamental drivers of health, and health inequity."

"We rely too much on medical interventions as a way of increasing life expectancy."

"A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity; to make health and health equity a marker for government performance."

"People need the opportunity, the possibility, to take control of their lives - but the conditions need to be right to allow them to do that."

Michael Marmot BBC Radio 4

28th August, 2008

Our mandate?

• WHO's Commission on the Social Determinants of Health, found that, in almost all countries, poor socioeconomic circumstances equated to poor health.

• The differences were so marked that genetics and biology could not begin to explain them.

• "(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible."

• The report calls for governments to consider how all their policies impact on health.

For example!‘Tories warn of obesity 'excuses‘’ Being overweight cannot be allowed to become the norm, say the Tories

People should not be offered "excuses" for being overweight, shadow health secretary Andrew Lansley has said.

He told the BBC earlier the government-commissioned Foresight report, published last year, sent a message that "it's not about you, it's about your environment".

: "Tell people that biology and the environment causes obesity and they are offered the one thing we have to avoid: an excuse.”

“The Tories are using individual responsibility as an excuse for their lack of effective policies in this area”

Ann Keen Health Minister • http://news.bbc.co.uk/1/hi/uk_politics/7583669.stm

New Approaches – Shaping the Future of Health Promotion 2007

• Putting healthy public policy into practice.

• Strengthening structures and processes in all sectors

• Towards a knowledge-based practice• Building a competent health-promotion

work-force• Empowering communities

Putting healthy public policy into practice

• Health improvement should be an objective of policies in all sectors.

• Social determinants of health can only be tackled through multi-sectoral action – coordinated across sectors.

• Little tangible evidence that this was happening is a serious way globally, but:

• Australia - one country that had legislated to ensure that a Health Impact Assessment of all policies.

• Scotland - significant new phase of health promotion policy development - whole government approach to health improvement.

We need the public to be on our side for public health policy to

happen• “There is a need for us to engage civic society to

advocate politically..”HOWEVER……Public policy usually follows public opinion….

BECAUSE…….Doing the right thing is very difficult if the people

aren’t onside…

“Father knows best” not a great media sound bite!

Strengthening structures and processes in all sectors

• “Successful health promotion is delivered through whole systems approaches. To act effectively on the determinants of health, all sectors, including healthcare, education, environment, transport, housing and commerce must take responsibility for improving health”.

• Healthy Cities movements provided successful models of the delivery of integrated coordinated healthy public policy.

Towards a knowledge-based practice

• Health promotion uses complex processes to act on complex social phenomena, not readily evaluated by traditional experimental research methodologies.

• Evaluation draws on both quantitative and qualitative methods that are the most appropriate for judging the HP actions implemented – be it policy, organisational or individual change.

• There has been some progress in convincing the health care evidence ‘industry’ to recognise the importance of evaluating of intervention processes and quality, but significant gaps remain.

• Rapid increase in research funding to evaluate complex, community-based health promotion interventions, longitudinal studies, impacts on policy and effect on health inequalities is required.

Towards a knowledge-based practice

• Need for robust information systems to monitor progress – access to good quality data remains a key challenge.

• Need to develop and use indicators that demonstrate health promotion processes, to monitor progress in promoting health, in addition to reducing mortality and morbidity.

• Health promoters need to increase their competence in formative and summative evaluation of interventions.

• Limited funding for health promotion research and evaluation - vicious cycle as this leads in turn to a debate about the relative merits of health promotion hampered by a weak evidence base.

Health promotion systems, structuresand processes weakened

Insufficient resourcesfor systematic evaluation

Lack of evidenceof effectiveness

Health promotion omitted from policy

Lack of fundingfor buildingcapacity andcompetency

Relationship between funding allocation and priorities in Shaping the Future of Health Promotion

Inadequatefunding

Building a competent health-promotion work-force

• Workforce capacity and capability for health promotion is well developed in only a few countries and under resourced and entirely lacking in many.

• Essential training for health promotion specialists should include:

– Developing the knowledge and skills for advocacy and mediation with politicians and the private sector,

– Assessing the impact of policies on health and its determinants,

– Accessing and using available information and evidence,

– Evaluating interventions.

Empowering communities

• Empowering individuals and communities is a fundamental health promotion principle, and an effective tool for health promotion and legitimate public health goal in its own right.

• The involvement of civil society was essential not only to health promotion strategy but to grass roots activity – which has often sustained health promotion when government policy interest has waned

Empowering communities

• Health promotion programmes are most successful when linked to the normal daily life of communities, building on local traditions and led by community members.

• In Scotland, community engagement is at the heart of public service tradition and community development approaches have led to a well-developed infrastructure????

• To influence future health public policy, work is required to work with civic society and communities to ensure that our communications are heard and understood by all.

WHO Commission on the Social Determinants of Health: 3 key

principles of action• Improve daily living conditions – the circumstances in

which people are born, grow, live, work and age• Tackle the inequitable distribution of power, money and

resources –the structural drivers of those conditions of daily life, globally, nationally and locally.

• Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, raise public awareness about the social determinants of health. A stronger focus on the social determinants of health in public health is required.

WHO Commission on the Social Determinants of Health, 2008

Finally, how capable do you feel individually, and organisationally, to

address these new approach challenges?

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Photograph by Frank Hurley showing Mawson in a blizzard

Commons Wikimedia

References

• International Union for Health Promotion and Education. (2007). Shaping the future of health promotion: Priorities for action. Promotion and Education, XIV(4), 199-202.

• Scriven, A., & Speller, V. (2007). Global issues and challenges beyond Ottawa: The way forward. Promotion and Education, XIV(4), 194-198.

• World Health Organisation: Commission on the Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organisation.