This concept note is drafted by the International Union for Health Promotion & Education (IUHPE) Student and Early Career Network (ISECN) as a discussion paper on the position of health in the post-2015 development agenda.
As health is central to development, both as a precondition, an indicator and an outcome of progress in sustainable development, the position of health in the post-2015 global agenda is of critical importance. On the one hand, health has been an important direct and indirect goal of the existing MDGs, and major gains have been made in terms of health progress in many low and middle-income countries. In order to safeguard the gains in terms of health progress it is crucial to sustain the investments in health and to ensure continued global commitment to achieving the MDGs, as well as to ensure more equitable achievements in health gains across countries, populations and programs.
On the other hand, the agenda for global health is rapidly changing, based on socio-political, economic, demographic and epidemiological transitions, such as increasing urbanization and globalization, climate change, ill health and food security, which require new and innovative approaches for framing future health related development goals. Political recognition of the societal and economic impact of non-communicable diseases (NCDs), as well as increasing awareness of the social, economic and political determinants of health, both for vulnerable and poor, as well as entire populations, have resulted in a call for action aimed at addressing the broader determinants of health (1).
The growing and ageing population has led to a broad shift from communicable, maternal, neonatal and nutritional causes of death towards non-communicable diseases (2). Tobacco smoking, alcohol consumption, unhealthy diet, physical inactivity and obesity are pervasive risk factors globally, requiring concerted efforts to reduce the global burden of disease and ensure the health of future generations. In addition, the new health agenda draws attention to the importance of the provision of equitable coverage, health security and social protection, which could be achieved by introducing universal health coverage (UHC) as overall health development goal in the post-2015 agenda.
This paper argues that, although the use of a health systems approach in itself is commendable because of the shift from previous emphases on vertical programs to a systems wide approach, UHC focuses only on a single aspect of health systems, namely health care organization and delivery, and ignores the health generating potential of other actors and institutions within the health system. The selection of UHC as overall health development goal could hence produce the risk of introducing a technocratic fix without leverage at local level, and it is hence argued that health promotion could offer a complementary strategy in this regard, through its explicit focus on the upstream distal determinants of health, and its use of bottom-up empowerment strategies such as community engagement and participation (3).
Health promotion in the post-2015 agenda
The role of health promotion in the post-2015 development agenda can be outlined according to the five action areas of the Ottawa Charter for Health Promotion (4): “build healthy public policy, create supportive environments, strengthen community action, develop personal skills, and reorient health services.” These areas are discussed below in line with the issues outlined in the WHO discussion paper ‘Positioning Health in the Post-2015 Development Agenda’(5), namely sustaining the MDGs, the changing agenda for global health, and health in the context of sustainable development.
a) Sustaining the MDGs
In order to ensure sustained progress in achieving the current MDGs, continued advocacy is required to not only maintain global awareness and support for international donor funding, but also political commitment and resources for monitoring and evaluation of results. Useful lessons in this regard can be learnt from social movements, which keep a close eye on donor and political accountability. In order to back national efforts with the advocacy work needed to sustain the political and financial support, current programs could also benefit from health promotion interventions aimed at raising awareness and advocacy at local and regional level.
In addition, in the face of increasing resource constraints and global austerity measures, there are concerns that the dramatic health gains viewed during the last decade cannot be sustained. Innovative approaches are hence needed to sustain current programmatic efforts, which could benefit from strategies commonly used by civil society organizations, for example community engagement, as advocated by the International HIV/AIDS Alliance and used in the scaling up of comprehensive prevention of mother-to-child transmission (6). Community engagement is a crucial strategy for health promotion (7) and a convenient driver for bottom-up enablement, which may be cost-effective when implemented as part of a multifaceted approach (8).
Community engagement is closely related to the concept of both community mobilization and empowerment and can be implemented using conceptual frameworks developed in the field of health promotion and social development. While these models usually serve to increase local ownership and sustainability of program interventions, the concept has also been endorsed by UNAIDS to strengthen Global Fund proposals to fight AIDS, tuberculosis and malaria, using a community systems strengthening approach aimed at achieving improved health outcomes of interventions (9). Communities can be confined within geographical boundaries or within groups of people with common interests, whereas empowerment embodies both social change processes and outcomes of transformed conditions (10).
In addition, the current intensification of neoliberal policy is likely to undermine health equity (11) and risks eroding social responsibility; this requires renewal of community responsibility through refocusing on the social determinants of health and healthy public policies, which can be achieved by community engagement and creating healthy public policies, in particular with regard to equity, in the roadmap to achieving sustainable and equitable development goals. This, in return, can help avoid creating the illusion of a one-size-fits-all technocratic approach to achieve development based on a single set of user guidelines.
Finally, the MDG framework provides little guidance as to the means to achieve its goals, and this may have constituted a lost opportunity to provide guidance on how to address the causes of poverty and unmet basic needs. Without providing any blueprints the post-2015 framework could hence offer general guidelines for policy orientation and coherence, as well as highlight some of the key success factors of effective development processes. Since health promotion is concerned with empowerment of individuals and communities, valuable lessons may be learnt in this regard.
b) The changing global health agenda
The new global health agenda is characterized by the growing burden of NCDs (2), including mental health, but also focuses on injuries and disability, which require strong actions across sectors. In addition, attention is drawn to the importance of equitable coverage, health security and social protection, while the impact of increasing costs of new health technologies, ageing populations and rising public expectations may threaten the financial sustainability of health systems. To address this global health agenda, innovative approaches are required that are not amenable to the linear process traditionally adopted in policy development (12).
The common feature of this new global health agenda is a change in focus from dealing with a number of diseases and conditions through aid development mechanisms to a broader concept of accessibility and health security, founded on the values of social justice and equity, and to a wider focus on the social, economic, and environmental health determinants. As UHC aims to provide equitable access for quality health services, attention to the broader determinants of health and the increasing burden of NCDs will require a more holistic, multisectoral approach which is germane to contemporary health promotion practice and can be achieved through, for example, implementation of a healthy settings or Health in All Policies (HiAP) approach (13).
Healthy settings, such as the Healthy Cities (Healthy Municipalities or Healthy Communities in the Americas) and Healthy Schools movements, are flagship programs in which WHO and its regional offices have taken a leadership role (13). The concept is based on the recognition that place and context are important and modifiable determinants of health and wellbeing, whereby the focus is shifted from the deficit model of disease to the health potentials inherent in social and institutional settings of everyday life (14). The concept has also been developed in health care settings through the creation of the Health Promoting Hospitals (HPH) network, based on a series of standards developed under the auspices of the WHO-EURO office (15).
The HiAP approach considers the impacts of policies on health outcomes and determinants as well as on health systems, with a special emphasis on its relative distribution, with the aim of facilitating evidence-informed healthy policymaking. Public policy indeed plays a crucial role in improving population health and disease control, including NCDs, and although evidence-based approaches to formulate healthy public policies have been difficult to implement, some strategies are increasingly proposed to narrow the gap between evidence and policymaking, including implementing a health impact assessment (HIA) (16), using frameworks to generate evidence-based health policy (17), and improved outcomes monitoring (18). More investment is, however, needed to close the implementation gap between evidence and practice.
In addition, as stated above, the need to include civil society and communities remains key to achieving local health gains, since healthy policymaking is not only influenced by evidence-based decision making, but also by power relations and by forces emanating from civil society (19). These forces can be used to monitor and enforce accountability for health at the political level, in particular with regard to health inequity. As the 2008 World Health Report 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’(20).
Likewise, health promotion may also challenge corporate accountability strategies at different levels. The latter has indeed become increasingly important given the rapid globalization of the market economy, which has led to profound changes in the conditions that shape health (21). Regulating the activities of transnational corporations has become a central objective for health promoting advocacy, which needs to be addressed simultaneously at local, national and supranational level (22). Implementing HiAP and action at the global level in order to regulate the health-harming effects of trade, in particular with regard to unhealthy foods, alcohol and tobacco, are urgently needed in order to address the growing threat of NCDs (23).
Again, the process could include a form of HIA and health equity impact assessment done by WHO, supported by civil society and followed by the introduction of regulatory frameworks to restrict the health threatening activities of global trade mechanisms, in line with the WHO Framework Convention on Tobacco Control (22). Such regulation could be rooted in a human rights approach and result in a Framework Convention on Global Health, as advocated by the Joint Action & Learning Initiative on National and Global Responsibilities for Health (JALI) (24). Global health governance would thence be firmly on the agenda, guided by the fact that health is critical not only for poverty reduction, but also for human security as a whole (21).
c) Health promotion and sustainable development
The relationship between health and sustainable development is well established (25), and as stated in the Rio+20 outcome report (26), the importance of UHC for enhancing health, social cohesion, and sustainable human and economic development is fully recognized. The report also calls for the involvement of all relevant actors to coordinate multisectoral action in order to address global health needs, and commits to establish and strengthen multisectoral national policies for the prevention and control of NCDs. The report, however, falls short of agreeing on legally binding institutional agreements, and the task at hand consists of bridging the new sustainable development and global health agenda.
As stated before, health promotion is ideally positioned to provide input in this process, given its strong focus on multisectoral action and its advocacy efforts with regard to implementing healthy public policies. With its emphasis on social determinants, health promotion posits that nine prerequisites are needed for populations to experience health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity (4). Health promotion also offers strategies, traditions, tools and methods that have been developed over the last three decades, thereby providing a strong evidence-based foundation for sustainable development programs.
For example, healthy settings determine the formation of healthy habits and environmental stewardship, both at individual and at population level, and the development of public policies that transcend governmental administrations is key to the sustainability of decisions aimed at strengthening national public health actions. Since public health and sustainable development are linked by interactions between the physical environment (e.g. pollution, climate change), and the social environment, health promoting strategies perfectly suit the objectives set out in the Global Conference on Sustainable Development, as they provide a useful platform and set of tools for guiding the necessary actions.
Besides the more traditional health promoting strategies, the application of new information and communication technologies, including mobile platforms and social media, can moreover facilitate the achievement of the stated goals, for example through increased collaboration and networking, crowd-sourcing, and global problem-solving (27). New information platforms, for example open-source solutions, could also broker knowledge exchange and assist with the monitoring of policymaking and accountability mechanisms. Communication has always been an important tool for health promotion, and the advent of new technologies has expanded the range of possibilities for conducting health promotion, both at individual and population level.
Discussion and recommendations
Health promotion could play a viable role in the formulation of post-2015 health development goals, either as a separate target in terms of achievement, or as a transversal modus operandi, which could be embedded in strategic approaches towards achieving healthy public policies. Based on a human rights approach and strongly rooted in the core values of equity and social justice, health promotion could be the overall umbrella for health related development goals, by pointing out policy directions at global, regional and national level, and by complementing the overall objective of achieving UHC. In addition, health promotion could be meaningfully integrated within a Framework Convention on Global Health and/or global health governance.
In addition, health promotion should be positioned as a central policy issue, both at national and supranational government levels, by requiring assessments of the health equity impact of corporate and other sector transactions and steering healthy public policies. In addition, health promotion could be integrated in the health system itself, either as a standalone objective or as a way of reshaping services delivery towards health promotion and population health, which in turn would then serve a complementary function to the introduction of universal coverage.
The issue of measurement should go beyond assessing measures of economic growth, such as GDP, and include measures of wellbeing and human development (28). In addition, goals and targets need to be identified that adequately capture the attainment of health promotion related objectives, bearing in mind that the selected indicators should be simple, concise and reliable. Health should be at the heart of any sustainable development goals, and in view of the above, ISECN would strongly recommend the following issues to be considered for the positioning of health in the post-2015 agenda:
- While acknowledging the value of implementing UHC, health promotion methods and approaches should be incorporated in the health related development goals, either as a complementary strategy or cross-cutting theme, or as a single or standalone objective;
- Attention should be drawn to the growing burden of NCDs, including mental health, injuries and disability, and framed within a social determinants and equity approach;
- The principles of social justice, equity, and human rights need to be fully integrated in the health related framework of sustainable development goals;
- Healthy policy (e.g. regulatory frameworks, HIA, HiAP) and empowerment strategies (e.g. inclusion of civil society, community engagement) are required to promote health at individual and population level;
- Strong governance and accountability is needed at local, national, and global level, to promote healthy policymaking and decisions in both the public and private sector;
- New metrics should be introduced to capture human health and wellbeing (e.g. quality of life, life satisfaction, empowerment, participation) within and across populations.
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