Discussants: Hope Corbin, Peter Delobelle, Gabriel Oguda and Laura Tomm-Bonde
ISECN recently launched its first “topic” (working) group, the focus of which is “health promotion in Africa”. For our first meeting we discussed the seminal article “What is needed for health promotion in Africa: band-aid, live aid or real change?” by Sanders and colleagues . We will briefly summarize the article and the main points of our discussion.
The authors begin by presenting obstacles to health in Africa, such as poverty, urbanization, gender inequities, and conflict over natural resources, including land. The combined burden of HIV/AIDS and other communicable and non-communicable diseases have caused many countries in sub-Saharan Africa to lose as many as 10 years off their average life expectancy. These issues are exacerbated by a crisis in the health care system due to a lack of infrastructure and an ever-increasing brain-drain of health care workers leaving the region to work elsewhere.
This information sets the stage for the need for health promotion in the region, however, Sanders and colleagues go on to describe some of the issues in delivering effective programs. Drawing on examples from Mozambique, Zambia and Zimbabwe, they present three impediments to effective programming:
1. Perpetuation of hierarchal and bureaucratic structures left-over from colonialism;
2. An orientation toward technological solutions rather than political solutions to problems;
3. The proliferation of neo-liberal policies focused on trade liberalization, drawing money away from social programs.
Establishing that current efforts are lacking, the authors reiterate many of the tenets of the Ottawa Charter for Health Promotion and describe how health promotion in Africa needs to be refocused. They suggest that such initiatives must place human rights at the center, build on local cultures while challenging some traditional beliefs (like gender inequity), and address inequity and disempowerment of the most marginalized by concentrating on the social determinants of health (peace, shelter, basic sanitation, etc.). The objective of initiatives must be achieved through multisectoral action from the local level to the global level and must combine the efforts of public policy, civil society, and academia. In this respect the authors highlight the advocacy role of networks and social movements, which use a global health equity lens, for example the Zambian Equity Gauge which succeeded in mobilizing communities to work on public sector reform. The authors end by challenging readers to harness the values that inspired many of the independence struggles across Africa.
We agree with the content of the paper noting some additional issues the authors failed to present. For example, health promotion in Africa has rarely found a place within the policy domain in many African countries. For example, unlike many Northern countries where attempts have been made to create policies reflective of the Ottawa Charter for Health Promotion (such as those found in Australia and New Zealand), African countries continue to operate largely from a traditional public health perspective at a policy level. Therefore, making health promotion initiatives more visible in Africa was identified as issue in our discussion. Mapping health promotion efforts was offered as a strategy to give health promotion initiatives recognition with the aim to get health promotion on the radar of health authorities in African countries. The ultimate objective in mapping out health promotion in this region would be to get health promotion onto the policy agenda.
Another issue raised in the discussion was the fact that health promoters in Africa miss out on speaking with one voice. Rather, what frequently occurs is that trained health promoters get absorbed into the government or private sector, which results in a formal failure to advocate for health promotion in the region. A possible strategy to remedy this situation could be to create a formal body to speak out about the need for health promotion throughout the region, in order to formally embed health promotion in a structured way. A complementary strategy would be to encourage publications about health promotion, a point which Sanders and colleagues also noted.
An additional concern noted related to the persistence of turf wars which ensue between public health and health promotion, especially in the South Africa region. Consequently, public health, driven largely by an individualistic and biomedical focus continues to get the “lion’s share” of funding. This turf war prevents upstream approaches from taking root in the region, leaving band-aid solutions to persist. One strategy offered through our discussions was the need to continue pushing a world-wide movement for equity in line with the recent political declaration issued by WHO in Rio during its World Conference on Social Determinants of Health . The “health in all” policies movement supported by many European countries reflects another possible strategy to emulate within the African region, and a three-pronged strategy was hence raised to advocate effectively for getting health promotion onto the policy agenda. This three-pronged approach consists of (a) civil society involvement; (b) multidisciplinary action; and (c) policy level advocacy.
In addition, it was noted that many health promotion programs in Africa continue to be modeled after Northern programs which rarely, if ever, translate successfully in the African context. The challenge, therefore, is implementing a health promotion perspective into the health landscape that is increasingly dominated by neo-liberal market driven policies. The discussants suggested to turn to Fran Baum’s  “nutcracker” approach (see cartoon below) of applying both top-down and bottom-up pressure on policy makers to tackle this issue. This brought the discussion full-circle for the need to connect the various institutions engaged in health promotion – whether through public-private partnerships or other forms of collaborations – to maximize services, expertise or political prowess. In other words, there is a need to ‘cross boundaries’– in between public and private; researchers, practitioners and policy makers, and a commitment must be made to bridge this gap, based on continued networking, communication and advocacy.
1. Sanders D, Stern R, Struthers P et al. What is needed for health promotion in Africa: band-aid, live aid or real change? Critical Public Health 2008;18:509 – 519.
2. WHO. Rio Political Declaration on Social Determinants of Health. World Conference on Social Determinants of Health. Geneva: World Health Organization, 2011.
3. Baum F. Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health Promotion & education 2007;14:90-95.
Published: March 2012 HPC