By Peter Delobelle (ITM)
Health is key to human development, no doubt about it. Health is a precondition, an outcome, and an indicator of all three dimensions of sustainable development, and should hence be part of the post-2015 development agenda. The adoption of the UN Resolution on Global Health and Foreign Policy, which supports the implementation of universal health coverage (UHC) in the fight against health inequality and poverty, is hence commended by many institutions and organizations to be included in the post-MDG agenda. While UHC in itself is a laudable goal, however, it falls short of pursuing another, equally important goal: addressing the underlying determinants of health. Providing access to quality and affordable health care is one thing, providing a healthy social and physical environment another.
As the consortium Go4Health recalls in an editorial published in the WHO Bulletin this week, health is not only a matter of improved access and reduced healthcare spending, but also of safe water and sanitation, food security and housing, occupational and environmental safety, and gender equality. In addition, health is also influenced by the distal structural determinants of ill health that create socio-economic inequities, for example through the maldistribution of resources that influence social position like income, employment, education, knowledge, and power. In this regard, the issues of governance, empowerment and community participation are strongly advocated by rights-based movements, such as the People’s Health Movement, to advance the global health agenda.
Addressing the social determinants is required in order to deal not only with health inequality, but also with the increasing burden of non-communicable diseases (NCDs), which are often linked with the ‘causes of the causes,’ although this may quite conveniently be ignored. Since NCDs already account for 60% of all deaths globally, of which more than 80% in developing countries, the need to address these upstream determinants is apparent, in particular given the current political and economic climate that may pose significant barriers to addressing these determinants in a meaningful way. Current intensification of neoliberal policy is also likely to undermine health equity and risks eroding social responsibility, requiring increased attention towards not only the social determinants of health, but also healthy public policies.
Some strategies have been proposed in this regard, such as the application of the ‘Health-in-All Policies’ (HiAP) approach, which targets social determinants through integration of policy responses across relevant policy areas with the ultimate goal of supporting health equity; and, the use of Health Impact Assessments (HIA), to review proposed and existing social policies for their likely impact on health. The HiAP approach was adopted as a WHO Resolution after the publication of the World Health Report 2008 ‘Primary Health Care: Now more than ever’ and has become a main theme in EU policies and other regions to a varying extent.
As already noted before, however, the strategy is not new but well-known in health promotion circles. Moving towards intersectoral action for health and beyond the health sector were core recommendations of the Alma Ata Declaration (1978) and the Ottawa Charter (1986), which set the stage for a move towards the new public health by reaffirming social justice and equity as prerequisites for health and which identified five health promotion action areas: ‘to build healthy public policy, create supportive environments, develop personal skills, strengthen community action, and reorient health services.’
These action areas have guided health promotion interventions over the last three decades and resulted in a wide set of strategies, tools, and methods that could inform the post-2015 health development agenda. For example, the WHO Healthy Settings approach, which includes the Healthy Cities and Healthy Schools movement, is based on the recognition that place and context are important and modifiable determinants of health and wellbeing, shifting the focus from the deficit model of disease to the health generating potentials of social and institutional settings in everyday life. The concept has also been extended to health care settings, resulting in the creation of the Health Promoting Hospitals network under the auspices of the WHO-EURO office.
Health promotion is guided by the key principles of community participation, empowerment and equity, and hence in line with the new global health agenda. Community participation is advocated by UNAIDS in the response to HIV, tuberculosis, and malaria, and adopted by the Global Fund through their Community Systems Strengthening Framework. Communities are powerful actors that can play a significant role in shaping and monitoring public policy, as the World Health Report 2008 observed: ‘the demand from communities that bear the burden of existing inequities and other concerned groups in civil society are among the most powerful motors driving universal health coverage reforms and efforts to reach the unreached and the excluded.’
Likewise, health promotion can also challenge accountability strategies at local, national and supranational levels, for example to regulate the health-harming effects of international trade. Implementing HiAP and action at the global level are indeed urgently required given the rapid globalization of the market economy, especially with regard to the food, alcohol and tobacco industry. Regulating the activities of transnational corporations has become a central objective for health promoting advocacy that could, in turn, be rooted in a Human Rights approach and result in a Framework Convention on Global Health, such as advocated by the Joint Action & Learning Initiative on National and Global Responsibilities for Health (JALI), and in line with the WHO Framework Convention on Tobacco Control.
In summary, given the essence and tradition of health promotion, as the ‘process of enabling people to increase control over, and to improve, their health, which moves beyond a focus on individual behaviour toward a wide range of social and environmental interventions,’ it seems surprising that health promotion is not mentioned even once in the UN resolution ‘The Future We Want’, especially given the fact that ‘action on the social and environmental determinants of health… is important to create inclusive, equitable, economically productive and healthy societies,’ which leaves one wondering if the global push towards including health in the post-2015 agenda will be able to avoid the risk of introducing a technocratic fix without leverage at local level, or ultimately result in anything more than the, however well-intentioned, ‘business as usual’.