WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANISATION MONDIALE DE LA SANTE BUREAU REGIONAL DE L’AFRIQUE
ORGANIZAO MUNDIAL DE SADE ESCRITÓRIO REGIONAL AFRICANO
REGIONAL COMMITTEE FOR AFRICA Fifty-first session Brazzaville, Congo, 27 August – 1 September 2001 Provisional agenda item 8.5 HEALTH PROMOTION: A STRATEGY FOR THE AFRICAN REGION Report of the Regional Director EXECUTIVE SUMMARY
AFR/RC51/12 Rev. 1 21 June 2001 ORIGINAL: ENGLISH
1. Broad determinants of health, most of which are intertwined, underlie the double burden of communicable and non-communicable diseases in the Region. To reduce the impact of these determinants on health, it is necessary to apply integrative comprehensive approaches. 2. Health promotion facilitates increased social and community participation in health. While health education is central to health promotion, legal, fiscal, economic, environmental and organizational interventions are also essential. Health promotion contributes to programme impact through the prevention of disease, the reduction of risk factors associated with specific diseases, the fostering of lifestyles and conditions conducive to health, and increasing use of available health services. 3. Health promotion is a cost-effective approach which has great potential for accelerating the realization of health for all in the Region. It is effected through the empowerment of individuals and communities, the changing of socio-economic conditions, mediation between different interests in society (through healthy public policies), reorientation of health services and advocacy for health. 4. The strategy proposed aims at supporting Member States to foster actions that enhance physical, social and emotional well-being and contribute to the prevention of leading causes of disease, disability and death. 5. The objectives of the strategy involve strengthening national capacities for health promotion, supporting priority programmes to achieve set objectives, implementing specific initiatives in order to achieve priority health objectives, increasing the recognition of health promotion as an integral component of socio-economic development and promoting the involvement of non-health public and private sectors in health development. 6. The priority interventions proposed are: advocacy, capacity building, development of country plans, incorporation of health promotion components in non-health sectors and strengthening of priority programmes using health promotion interventions. 7. The Regional Committee is invited to examine the proposed strategy and give orientations for its implementation consistent with national health policies and available resources.
CONTENTS Paragraphs INTRODUCTION.…………………………...……………………………………………..…1-10 SITUATION ANALYSIS AND JUSTIFICATION.……………………...…………..………11-26 Situation analysis.……………......……………………………………………..….....…11-17 Justification.……………………………….…………....………………………….....…18-26 THE REGIONAL STRATEGY.……………………..…………………………...……...……27-43 Aim and objectives.……………………………………….......………………….……...27-28 Guiding principles.………………………..…………………………..….………...…….....29 Priority interventions.…………………………………………..…………………......…30-35 Implementation framework.…………………………………………………….…….....36-39 Monitoring and evaluation.………………………………………….....….…...……......40-43 CONCLUSION.………………………………………………………..…….………………..….44
AFR/RC51/12 Page 1 INTRODUCTION 1. Health promotion is a means of increasing individual and collective participation in health action and strengthening programmes through the integrative use of various methods. These methods are combined through comprehensive approaches which ensure action at all levels of society, leading to enhanced health impact. 2. Health promotion practice has been in existence for a long time though the use of the term to refer to a specific field started only in the 1980s. The development of health promotion was greatly influenced by the evolution of other broad approaches to human development such as: (a) the increased demand for social justice and for the rights of women, children and minorities; (b) the health for all concept; (c) movements to protect and improve the physical environment; and (d) the increased attention being paid to poverty as a major underlying cause of illness. 3. The development of health promotion is part of the global search for effective means of preventing disease and improving general living conditions. There has progressively been increased recognition of the need to address behavioural, lifestyle (harmful cultural practices) and other underlying socioeconomic, physical and biological factors, referred to here as the broad determinants of health, so as to improve health. 4. By the mid 20th century, the Public Health model was well established and technologies for manipulating the physical environment were regarded as the ultimate answer to critical health issues. During this period, emphasis was placed on controlling specific diseases through biomedical interventions. Non-professionals played a minimal role in these developments.1 5. During the 1960s, the role of behavioural factors in ensuring improved health became widely recognized. It was then understood that besides biomedical care and improvements in the physical environment, individual lifestyles also influence morbidity and mortality. Health education became the main method of informing people on how to positively change their behaviour so as to prevent specific diseases and improve their health. At that time, health education was applied through a topdown approach to learning, often using general, untargeted messages, within a strictly biomedical understanding of health. The participation of communities and the lay public in health was still limited. 6. In the 1970s, the health for all concept and the primary health care strategy were developed. This development gave health education and related information, education and communication approaches a prominent role in health. Health education was then viewed as an activity for supporting the other primary health care components. Application of health education and related approaches in the Region resulted in increased participation of the public in health action, though many people, including policy-makers, still regard health development as the domain of health professionals. 7. The development of health promotion with a view to increasing social and community control and participation in health started in the 1980s. It was motivated by the recognition of the impact of social, behavioural, economic and organizational factors on health status. Since most health problems have multiple causes, an integrated response to these problems became necessary.
1
Egger, G. et al (1990). Health Promotion Strategies and Methods. McGraw-Hill Book Company, Sydney, p. 5.
AFR/RC51/12 Page 2 8. Health promotion is any combination of health education with appropriate legal, fiscal, economic, environmental and organizational interventions in programmes to achieve health and prevent disease.2 Other health promotion methods include information, education and communication, social mobilization, mediation, lobbying and advocacy. These methods are especially relevant in mobilizing non-health sectors to contribute to health development. 9. Health promotion action can significantly contribute towards the achievement of the Region’s priority programme objectives which include: (a) prevention of priority communicable diseases such as HIV/AIDS, tuberculosis and malaria; (b) prevention of priority noncommunicable diseases such as mental illness, cardiovascular diseases, diabetes and cancer; (c) reduction of risk factors, such as conditions and behaviours that expose people to HIV/STI, tobacco use and other substance abuse diabetes, and other priority communicable and noncommunicable diseases; (d) fostering lifestyles and conditions that are conducive to physical, social and emotional wellbeing, such as healthy dietary practices, active living and use of life skills; and (e) increasing effective use of existing health services and stimulating demand for others. 10. Health promotion action contributes towards the achievement of priority health programme objectives by:3 (a) increasing individual knowledge and skills using health education and informationeducation-communication (IEC); (b) strengthening community action through social mobilization; (c) creating environments which are protective and supportive of health using mediation and negotiation; (d) developing healthy public policies, legislation and economic and fiscal controls which enhance health and development through lobbying and advocacy; and (e) reorienting health services by emphasizing prevention and consumer needs. SITUATION ANALYSIS AND JUSTIFICATION Situation analysis 11. Countries in the Region are experiencing a double burden of disease: communicable diseases which are highly prevalent and non-communicable diseases which are increasing rapidly. The HIV/AIDS pandemic, malaria and the re-emergence of tuberculosis, etc. have further compounded this situation. Low levels of literacy (especially among women), poor sanitation, inadequate food, civil strife and risky behaviours (e.g., smoking, increasing sedentary living and unhealthy diets) which constitute broad deteminants of health underlie many health problems in the Region. “Poverty fuels Adapted from a statement in Tones, K. et al (1990). Health Education: Effectiveness and effeciency. Chapman and Hall, London, p. 4. 3 Adapted from WHO (1998). Health Promotion Glossary (WHO/HPR/HEP/98.1), p. 2. Action at all or most of these levels is motivated by the understanding that many causes of illness and death can be addressed through simple measures directed at the individual, the community and the environment. 2
AFR/RC51/12 Page 3 the impact of these factors on health as it keeps people in poor health and poor health keeps people in poverty”.4 12. WHO recognizes the need to involve all people in addressing these broad determinants to improve health. The WHO Constitution states that informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.5 The Organization therefore encourages and supports countries to use health promotion to address the broad determinants. 13. Countries recognize the value of health education and also that to achieve its full potential, it has to be combined with other health promotion methods as proposed in this strategy. 14. A recent WHO survey in the Region reveals the existence of various health promotion aproaches and methods institutionalized in diverse structures. Of a total of 37 countries, fifteen have health education; eleven information, education and communication; five health promotion; two information, education and communication and health education; one information, education and communication and social mobilization; one other health education and social mobilization; and two have no specific approach.6 Health promotion is being increasingly incorporated into non-health sectors, especially education and agriculture. Seventeen countries are already implementing the Health Promoting Schools Initiative.7 15. A report of an expert consultation shows that the implementation of health promotion and related approaches in the Region has traditionally been spearheaded by the health sector although the participation of individuals, communities and non-health actors is gradually increasing. 16. Reports from various countries indicate innovative use of entertainment and communication media in the Region. However, the main media used continue to be print. Radio, focus groups, folk media, interactive theatre, puppetry and television are also used to some extent.8 17. The major challenges relating to the implementation of health promotion in the Region include: (a) poor definition of expected health outcomes, specific factors and conditions to be influenced through health promotion; (b) lack of health promotion policies and guidelines for coordination of different methods and approaches; (c) inadequate capacity (especially in human resources) to develop, implement and evaluate health promotion programmes and activities; 4 5
WHO Regional Office for Africa, Report of the Regional Consultation on Poverty and Health. July 2000, Harare, p. 8. Constitution of The World Health Organization, Section One, p. 1. 6 A questionnaire was sent to countries and these are the responses which had been received by September, 2000. Only two countries have full health promotion structures. Three others combine health promotion with health education or information, education and communication. 7 Health Promoting Schools Initiative is a school health focused programme introduced by AFRO in the Region with donor support. The programme encourages use of the school as a setting for health promotion. Health Promotings Schools Initiative interventions include school health policy development, service delivery, health education and environmental health activties. 9 The key reports are: The Ottawa Charter, The Adelaide Recommendations on Healthy Public Policy, The Sundsvall Statement on Supportive Enviroments for Health, The Jakarta Declaration on Leading Health Promotion into the 21st century, and the Mexico Statement for the Promotion of Health.
AFR/RC51/12 Page 4 (d) insufficient intra- and inter-sectoral collaboration at national and regional levels; (e) low investment in preventive and promotive services within the health sector; (f) limited operational research and dissemination of information on good practices in health promotion; (g) lack of appropriate linkages between health promotion and the delivery of health services; and (h) lack of full understanding of the effectiveness of health promotion by the public and policy makers; (i) Political and social instability and poor governance which impede the process of democratization and participation of civil society in health action. Justification 18. There is evidence that the application of health promotion leads to positive outcomes such as empowerment for health action, healthy public policies and increased community involvement. 19. Health promotion makes a unique contribution to health development by integrating various approaches and methods to address broad determinants of health. It is a necessary component in all health and related programmes. Health promotion plays a central role in the creation and management of enabling environments for health. 20. Health promotion has a rapidly increasing distinct body of knowledge, principles and methodology. It is important, therefore, that countries of the Region have a strategy to ensure its development and use. 21. Since 1986, five global health promotion conferences have been convened by WHO and key partners. The conferences have influenced the development and implementation of health promotion in countries. During the latest of these conferences (Mexico, June 2000), African participants called on the WHO Regional Office for Africa to develop a regional health promotion strategy. The strategy would help countries in the Region to adapt the Mexico framework for the development of health promotion within the African context. 22. Reports of five global health promotion conferences indicate, among other things, that there is a need to ensure the mobilization of new players in health by involving all sectors and cutting across sectoral, departmental and institutional boundaries. The challenge in the coming years is to unleash the potential for health promotion inherent in many sectors of society, communities and families.9 23. Various WHO resolutions prior to 1989 did not specifically deal with health promotion but emphasized the role of public information and education in health. The resolutions specifically urged Member States to develop infrastructure for health education and information, education and communication.10 24. WHO resolutions after 1989 deal specifically with health promotion.11 The resolutions call upon Member States to develop health promotion as an essential element of primary health care and take steps to train health and related professionals in health promotion. Intercountry cooperation and exchanges of experience in health promotion are encouraged. The United Nations system, international and non-governmental organizations and foundations, donors and the international 11
The resolutions are: WHA51.12 and EB101/SR/12.
WHO Regional Office for Africa. Health-for-All Policy for the 21st Century in the African Region: agenda 2020
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AFR/RC51/12 Page 5 community are called upon to mobilize and cooperate with Member States to develop and implement health promotion strategies. Countries are urged to secure infrastructure for health promotion. The WHO Director-General thus gives top priority to health promotion the development of which is supported within the Organization.12 25. A Regional Committee resolution calls on Member States to develop or strengthen information, education and communication strategies as essential elements of health promotion.13 The resolution emphasizes the role of communication strategies in health promotion but does not address health promotion specifically. 26. The Regional Office recognizes health promotion as a necessary component in its priority programmes as part of the effort to achieve health for all in the 21st century.14 The programmes include: HIV/AIDS, Malaria, Tuberculosis, Immunization, Mental Health, the Tobacco Free Initiative and Reproductive Health. Though currently these programmes have elements of health promotion, the proposed strategy should facilitate strengthening and systematization of the application of health promotion to improve programme effectiveness and sustainability. THE REGIONAL STRATEGY Aim and objectives 27. The aim of the strategy is to foster actions that enhance physical, social and emotional wellbeing and contribute to the prevention of leading causes of disease, disability and death. 28. The objectives of the strategy are to: (a) strengthen the capacity of countries to design, implement and evaluate health promotion; (b) support priority health programmes to achieve set objectives; (c) implement specific health promotion initiatives to achieve priority health objectives; (d) increase recognition of health as a necessary component of socio-economic development; and (e) promote the involvement of non-health public and private sectors in health development. Guiding principles 29. The success of health promotion interventions will depend on the following principles: (a) Existence in countries of knowledge and skills for implementation of evidence-based health promotion; (b) Integration of health promotion into all health programmes with clearly defined goals and objectives; (c) Systematization of the use of the interventions to complement priority health programmes; (d) (d) Recognition of health as a resource for development and achievement of equity incommunities and within countries; of expenditure on health as an investment in human
15
WHO (1997). Jakarta Declaration, p. 5.
AFR/RC51/12 Page 6 resources and development; of policies and practices that avoid harming individual health, protect the environment, restrict trade in or production of harmful goods and substances, and safeguard health in the workplace;15 and (e) Tapping the potential for health promotion in all sectors, creating partnerships and identifying non-health sector actors in support of peace, shelter, education, food, adequate income, a stable ecosystem, social justice, respect for human rights and equity that are conditions for health and that can reduce poverty which is the greatest threat to health. Priority interventions 30. Member States and WHO need to address the following priorities in order to develop and implement effective health promotion programmes and activities: (a) Advocacy on use of health promotion to improve health and prevent disease; (b) Capacity building for strengthening of health promotion policies, mechanisms and interventions; (c) Country plans of action for strengthening the use and institutionalization of health promotion in health systems; (d) Incorporation of health promotion components into non-health sector interventions and programmes; and (e) Strengthening of priority health programmes through the use of health promotion methods and approaches. 31. Since health promotion is still being developed in many countries of the Region, there is a need for advocacy of its use in health development. The support of community and political leaders, academic institutions, NGOs, donors, professional associations and private enterprises should be solicited in order to accelerate the development and application of health promotion. 32. National health promotion policy should facilitate the coordination of activities, the mobilization of resources and capacity building. Health promotion practitioners should be orientated or trained as necessary and training curricula should reflect health promotion components. 33. Health promotion should be integrated throughout the health system and plans of action should be developed for this purpose. 34. Collaborative mechanisms to support the implementation of health promotion in non-health sectors should be put in place. These should involve all potential players including, but not limited to, the private sector, academia, NGOs and community-based organizations. 35. The health promotion component in priority health programmes should be strengthenened. Available guidelines and examples of good health promotion practice should be used.
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Implementation framework At country level 36. The technical leadership of the health sector is crucial to the implementation of this strategy. Countries will: (a) undertake advocacy to increase awareness and support for the use of health promotion, targeting both the health and non-health sectors and mobilizing new players for health; (b) develop and adjust policy, establish institutional frameworks and mechanisms, and mobilize and allocate resources for health promotion components in programmes; (c) establish mechanisms for linking health promotion interventions in non-health sectors with the national health system; (d) formulate action plans to facilitate the development of health promotion capacity and support at various levels; the plans should be based on a framework which includes situation analysis, problem definition, objectives, mechanisms for coordination, partnership building, monitoring and evaluation; and (e) strengthen the health promotion component in priority programmes by adapting available guidelines for Health Promoting Schools Initiative, the Tobacco Free Initiative, Immunization,16 etc. 37. To plan, implement and evaluate health promotion efforts, each country will: (a) identify goals in terms of health outcomes to which the health promotion effort will contribute; (b) delineate the behaviours or conditions associated with each targeted health outcome that are to be influenced by the health promotion effort; and (c) define the specific changes that are intended to be achieved by the health promotion effort in order to influence targeted behaviours or conditions, focusing on: • • • • • increasing individual knowledge; strengthening community action; creating environments supportive of health; developing, implementing and enforcing health-related policies; and reorienting health services.
At regional level 38. WHO will continue to advocate for renewed political commitment and for the creation of environments which are supportive of health in accordance with the health-for-all policy in the African Region for the 21st Century.17 More specifically, WHO will: 16
The guidelines will be based on the use of settings, public health issues and specific population groups as the entry points for health promotion interventions.
AFR/RC51/12 Page 8 (a) Support, technically and materially, countries of the Region to implement the recommendations of this strategy; (b) provide leadership and guidance to regional counterparts, international NGOs and agencies to enable them understand, support and use health promotion to address health and development; (c) mobilize and support countries to participate in intercountry consultations and to form health promotion partnerships; (d) advocate with governments and agencies to support the implementation of health promotion and sharing of experiences; (e) facilitate the training of designated national health promotion focal persons; (f) coordinate the development of guidelines and a regional implementation framework, including clearly defined targets, for strengthening health promotion in countries; (g) use health promotion actions to carry out regional initiatives and to support country efforts. 39. Partners in health development will support the use of health promotion in countries through the provision of resources and strengthening of the health promotion component in their programmes Monitoring and evaluation 40. Countries will agree on indicators to be used for monitoring the implementation of the strategy’s objectives and country actions to increase capacity and support, and to plan, implement and evaluate health promotion. 41. Countries will monitor implementation of the strategy using agreed indicators. 42. WHO will collect information on the implementation of the strategy two years after its adoption and every three years thereafter. 43. Countries and WHO will carry out periodic intercountry evaluation of the effectiveness of health promotion. CONCLUSION 44. The major thrust of the strategy is the emphasis on health promotion as a means of integrating various methods and approaches to improve the health of the people. Integration of methods and actions at several levels results in increased health knowledge, skills and community participation, healthy public policies and environments which are supportive of health. Priority actions recommended include advocacy, capacity building, plans of action, involvement of all sectors and strengthening of health programmes. 17
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