Regional Strategy for Health Promotion for South-East Asia
SEA/HE/194
Regional Strategy for Health Promotion for South-East Asia This Regional Strategy for Health Promotion for South-East Asia was discussed at the Inter-country Consultation Workshop, 26 to 29 June 2006 at Chiang Mai, Thailand; and during the Regional Committee Meeting (RC59), Dhaka, Bangladesh, 22 - 25 August, 2006. The visual on the cover is derived from the 6th Global Conference on Health Promotion held in Bangkok in August 2005 which resulted in the Bangkok Charter for the health promotion.
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Contents
Foreword ................................................................................ iv Executive summary ................................................................. vii Introduction ............................................................................ 1 Health promotion practice ........................................................ 4 Bangkok Charter for Health Promotion in a Globalized World ....... 6 Regional Strategy for Health Promotion for South-East Asia .......... 7 Objectives .............................................................................. 8 Conceptual framework .............................................................. 9 Strategic directions ................................................................ 11 z z z z z z z z
Infrastructure for coordination and management ........... 11 Capacity building ...................................................... 12 Regulations and legislation ......................................... 12 Partnership, alliances and networks ............................. 13 Evidence for health promotion .................................... 14 Social mobilization and advocacy ................................ 15 Financing health promotion ........................................ 16 Management of change .............................................. 17
Role of Member States ........................................................... 19 Role of WHO ........................................................................ 20 Conclusion ........................................................................... 21
Anne xes Annex 1. SEA/RC59/R4: Regional Strategy for Health Promotion........ 22 2. WHA60.24/12.11: Health promotion in a globalized world . 24 3. The Bangkok Charter for Health Promotion in a Globalized World .......................................................... 27
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Forewor d oreword The Regional Strategy for Health Promotion for the South-East Asia (SEA) Region has evolved from commitments and actions contained in the Bangkok Charter for Health Promotion, which calls for Member countries to make the promotion of health: (a) central to the global development agenda; (b) a core responsibility for all of governments; (c) a key focus of communities and civil society; and (d) a requirement for good corporate practice. It calls for a multidisciplinary and multisectoral integration of health promotion into (a) disease or issuespecific interventions; (b) population-based interventions; or (c) settingsbased interventions. The strategy also aims to ensure that health promotion activities are addressed within the existing social, economic, environmental, political and cultural contexts. Health promotion consists of an array of strategies and techniques that draw on a body of knowledge emanating from disciplines such as social sciences, arts, education, marketing and communication, among others. Information dissemination in order to increase public knowledge and awareness remains a pivotal function of health promotion. Its expanded strategies and techniques now include advocacy, social mobilization, regulation and legislation, evidence-gathering, innovative financing and enhanced partnership among communities, civil society and government ministries other than the Ministry of Health. Increasingly, health promotion finds itself requiring these strategies and techniques to address health inequities and the negative impact of social determinants of health associated with globalization, urbanization, trade liberalization, population trends, social and political transitions and climate change. These social determinants influence the lifestyles and health outcomes for individuals and communities negatively. In order to develop and sustain health promotion interventions effectively across sectors, it is prudent that the public health workforce comprising both health and non-health professionals possesses the content and skills necessary to deliver health promotion adequately. In this regard, building the capacity of both health and non-health professionals remains a top priority. In addition, there is need to strengthen curriculum and faculty development at all training institutions as well as civil society. The need to establish a mechanism to gather
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evidence on the effectiveness of health promotion across sectors is equally important. Finally, the Regional Strategy offers countries of the SEA Region the vision to develop and sustain healthy public policies and programmes to address the causes of ill-health and premature deaths, and thereby contribute to the achievement of the Millennium Development Goals within the context of revitalizing primary health care. The Regional Strategy is a tool to make the goal of "All for Health Promotion" a reality among countries of the WHO SEA Region.
Samlee Plianbangchang, M.D., Dr.P.H. Regional Director
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Promoting, supporting and protecting health accross issues, populations and settings.
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Ex ecutive summar y Executive summary (1) The main cause of high disease burden and premature death among countries of the WHO South-East Asia Region (SEAR) is due to communicable and non-communicable diseases as well as new threats to heath. HIV/AIDS, tuberculosis and malaria remain a major public health concern, while non-communicble diseases, namely cancer, diabetes, hypertension and heart diseases are increasing even among the poor. SEAR countries also face new threats to health from natural disasters (floods, earthquakes and volcanoes) and avian influenza. Finally, due to globalization and trade, SEAR countries are experiencing drastic changes in consumption patterns of food, tobacco, alcohol and unsafe sex as well as huge disparities between and within countries. Health promotion advocates for integration of activities across sectors and also encourages multi-sectoral collaboration. It mitigates the impact of risk factors associated with broad determinants of health that contribute to premature deaths and illness using various approaches at multiple levels. The three common approaches often applied are (a) the issues-based approach, (b) population– based and (c) the setting-based approach. While the first two remain indispensable approaches to address specific diseases and population groups, the setting-based approach has the greatest potential to produce desired health outcomes because it tackles risk factors in places where individuals live, work and play. The Strategic Directions meant to give guidance to Member countries are all-encompassing of decisions reached at Regional Committee Meeting, Executive Board and World Health Assembly Meeting as well as commitments and actions reflected from the Ottawa Charter (1986) to the Bangkok Charter for Health promotion (2005). The Regional Strategy for Health Promotion propose the following priority inter ventions: infrastructure for coordination and management, capacity building, regulation and legislation, partnership, evidence for health promotion, policy and advocacy and social mobilization, financing health promotion, and management of change.
(2)
(3)
(4)
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(5)
To effectively manage change, the transition from “Health education” to “Health promotion require concerted effort in advocacy and involvement of multiple stakeholders including those outside the health field. The Regional Strategy for Health promotion calls upon Member countries to make Health promotion a core responsibility for the entire government, key focus of communities and civil society, and a requirement for good corporate practice. In terms of responsiveness to policy and programme issues, the Regional Strategy calls for Member countries to review the existing Health promotion organizational structure including leadership and management capability. It also calls for countries to review existing financing with a view to increasing budget allocation for Health promotion including considering the use of dedicated tax. WHO is requested to strengthen the capacity for Health promotion across the Organization in the Region and to support Member countries build capacity for developing policies, programmes, plans of action and guidelines, innovative and sustainable financing, and documentation of evidence.
(6)
(7)
Promoting nutrition, hygiene and sanitation through schools.
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Intr oduction Introduction (1) Health promotion is a core function of public health and is effective in reducing the burden of both communicable and noncommunicable diseases, including mitigating the social and economic impact of such diseases. The goal in promoting health is to mitigate the impact of risk factors associated with broad determinants of health leading to premature death and illness, and ultimately, to improve the quality of lives of individuals and communities. It is therefore a good public investment. To effectively address the identifiable determinants of health, health promotion requires that strategic directions and policies be formulated in addition to political commitment. Health promotion activities need to be planned, monitored, and evaluated. Similarly, the outcomes and the process have to be documented and disseminated widely in order to guide programming and resource allocation. Therefore, a sound strategy remains an essential pre-requisite for implementing effective health promotion interventions. Countries of WHO’s South-East Asia (SEA) Region recognize the need for addressing the growing burden of noncommunicable and communicable diseases as well as the new and emerging threats to health, such as earthquakes, emerging diseases like avian influenza (bird flu), SARS and HIV/AIDS, and the re-emerging diseases like dengue, TB and malaria. Furthermore, they face inequalities within and between the countries, resulting in limited resources chasing unlimited social needs. All this is due in part to a growing marginalized population that continues to place a huge burden on social services and the environmental system. Health promotion holds the key to halting or reversing the existing situation particularly in addressing primary risk factors as well as the social and economic determinants of health. Member States in the SEA Region have advocated for strengthening health promotion as part of their efforts for health systems development in a series of global meetings beginning with the Alma-Ata Primary Health Care
(2)
(3)
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Conference (1978), Global Health Promotion Conferences, as well as at the various sessions of the World Health Assembly. The resolutions WHA42.44, WHA51.12 and WHA57.16 called for Member States and WHO to give priority to strengthening health promotion. Beginning with the first Conference on Health Promotion held at Ottawa, Canada in 1986, Member States from the Region were represented at a series of conferences on health promotion, organized by WHO in collaboration with national, regional and global players, in Adelaide, Australia (1988), Sundsvall, Sweden (1991), Jakarta, Indonesia (1997), Mexico City, Mexico (2000), and Bangkok, Thailand (2005). The Region hosted two global conferences, in Jakarta and Bangkok, which demonstrated the Region’s active involvement and commitment to health promotion. (4) Globally, there is a disproportionately high number of premature deaths and illness, which are preventable. Among the global challenges that have a direct impact on the health and social well-being of people including those in the SEA Region, include, but are not limited to: • • • Addressing the sociallydetermined health outcomes associated with urbanization, climate change, food consumption patterns, communication, transportation and population ageing, among others.
Increasing inequities within and between countries due to socio-political and economic changes; Changing patterns of consumption, particularly associated with food and information; Demographic changes that affect working conditions, learning environments, family patterns, and the culture and social fabric of societies; Socio-political and economic changes, including commercialization and trade, and Global environmental change.
• • (5)
The efficacy and cost-effectiveness of health promotion in mitigating the impact of social and economic determinants of health at individual and community levels is widely recognized and acknowledged. However, major challenges still remain, especially in the countries, where both rural and urban populations are most vulnerable to the changing social and economic situations that influence health and
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social outcomes. Therefore, the specific health promotion challenges that require innovative approaches include: • Resource mobilization and allocation, including the establishment and adoption of alternative sources of financing for promoting health; Addressing complex socioeconomic and cultural changes at family and community levels; Involving the whole of government (not only the Ministry of Health) to address the social determinants of health throughout the life cycle; Actively engaging civil society, the private sector and nongovernmental organizations in health promotion; Strengthening the capacity for health promotion across sectors and at multiple levels; and Evidence gathering regarding the efficacy of health promotion and the utilization of such evidence in policy decisions and programming.
• •
• • •
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Health pr omotion practice promotion (6) The Ottawa Charter for Health Promotion, adopted at the Global Conference on Health Promotion held at Ottawa, Canada in 1986 is credited for ushering the concept and principles of health promotion. Health promotion now has an established inventory of proven effective strategies and techniques to promote health since the Ottawa Conference (1986). Health promotion takes a more comprehensive approach to promoting health by involving various players and focusing on multi-sectoral approaches compared to health education. Health education focuses on communicating health information and knowledge, and providing skills in order to support the individual to adopt desired (positive) healthy behaviours voluntarily. It uses communication processes, namely individual discussions, mass and group media to reach target groups through a strategy known as information, education and communication (IEC). Health education incorporates various social marketing techniques for advocacy and social mobilization, but it uses them predominantly for issue-specific interventions, e.g. reproductive health, condom promotion, immunization or specific disease control. Health education practices are usually the sole responsibility of health professionals from the ministries of health, with support in some cases from the Ministry of Information in the form of graphic artists and technicians from newspapers, radio and television. Health promotion practices, on the other hand, are critical elements of primary health care and essential media in the delivery of public health particularly tackling communicable and noncommunicable diseases, and other threats to health. It is proven to be effective in terms of both cost and efficacy in mitigating the social and economic impact of diseases. It recognizes health as a human right and seeks to promote the highest attainable standard of health of every human being without any form of discrimination. Health promotion seeks to respond to global developments that contribute to increasing inequality, changes in the
(7)
Investing in the future through promotion of healthy lifestyles among young people.
(8)
(9)
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patterns of consumption, the environment, cultural values and traditions, communication and changes in family and social fabric among others. These major global changes have a major impact particularly among vulnerable groups such as women, children and the elderly as well as among minority and indigenous groups. (10) Health promotion practices require support and action by all sectors and stakeholders to make concerted efforts in advocacy, investment, capacity building, regulation and legislation, and partnership and alliance building to promote health. Furthermore, health promotion encourages various players to contribute to promoting health including civil society groups, communities, the private sector and all other ministries. In addition, the leadership and authority for providing technical guidance in promoting health remain the role and responsibility of the Ministry of Health. (11) To achieve desired results, health promotion activities should use the settings-based, population-based or issues–based approaches. Healthy settings such as schools, markets, cities, townships, villages, islands or various workplaces provide an opportunity to address complex health and social needs or concerns of individuals and communities in places where daily decisions are made and where behaviours are manifested. The settings approach also allows for integrating activities into existing social activities that take into consideration cultural values, communication patterns and local leadership issues in a given socio-political environment.
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Bangk ok Charter for Health Pr omotion in Bangkok Promotion a Globalized W orld World (12) In August 2005, the Global Conference on Health Promotion held in Bangkok, Thailand, adopted the Bangkok Charter for Health Promotion. The WHO Executive Board at its 117th session held in January 2006, also reviewed the progress of work on health promotion including work related to the Bangkok Charter, and submitted a resolution to the 59th WHA (Resolution EB117.R9). (13) The Bangkok Charter confirms the need to focus on health promotion actions to address the determinants of health. It also expands the five action areas identified in the Ottawa Charter, and encourages stakeholders in all sectors and settings to: (a) advocate for health based on human rights and solidarity; (b) invest in sustainable policies, actions and infrastructure to address the determinants of health; (c) build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy; (d) regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people; and (e) partner and build alliances with public, private, nongovernmental and international organizations and civil society to create sustainable actions. Promoting active and healthy ageing through physical activities.
(14) The Bangkok Charter also identifies four commitments essential for implementing health promotion by Member States and other partners, to make health promotion: (a) central to the global development agenda; (b) a core responsibility for all of government; (c) a key focus of communities and civil society; and (d) a requirement for good corporate practice. The policy actions and commitments contained in the Bangkok Charter form the nucleus of the strategic directions for this Regional Strategy.
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Regional Strategy for Health Pr omotion Promotion for South-East Asia (15) In order for the countries of SEAR to translate the gains in life expectancy seen over the past decades into improved quality of life for the general population, concerted efforts are needed in addressing the determinants of health, particularly those contributing to premature death and illness due to communicable and noncommunicable diseases, and new threats to health. (16) The Regional Strategy for Health Promotion for South-East Asia identifies the strategic directions that should address multisectoral and interdisciplinary needs of countries as well as being applicable throughout the health systems, namely, at the preventive, curative, promotive and rehabilitation levels. Ultimately, implementation of the strategic directions should invest available financial and technical resources in interventions that utilize the settings-based approach as these are likely to address comprehensively, the needs of individuals and communities in places were individuals live, play and work. The strategy also requires technical and financial support of WHO and other partners, in addition to the active involvement and commitment of Member States to implement the strategic directions identified. (17) The Regional Strategy would provide a framework for countries of the Region to build a critical mass of human resources for health promotion, drawn from health and non-health disciplines, public/private sector, civil society groups and communities to implement multi-sectoral and multi-disciplinary interventions at all levels of society, support planning and implementation of healthy lifestyle activities and health-supportive environments to address the determinants of health and other threats to health across sectors and settings. It seeks to provide direction to Member States and partners for addressing determinants of health including new threats to health in order to reduce morbidity and premature mortality, and ultimately, to improve the quality of life of individuals and communities in the Region. It supports all efforts to implement commitments and actions recommended in the Bangkok Charter, adopted at the Sixth Global Conference on Health Promotion, as well as the attainment of targets set under the Millennium Development Goals (MDGs).
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Objectives (18) The objectives of the Regional Strategy for Health Promotion for South-East Asia Region are to: • Guide Member countries of the SEA Region in establishing, implementing and maintaining adequate infrastructure, policies, plans of action, legislations and regulations, and alternative financing and evidence-gathering measures to mitigate the impact of identifiable determinants of health including new threats to health across population groups; Provide mechanisms for supporting the fostering and sustaining of local, regional and global partnerships, alliances and networks towards harnessing new technical and financial resources in order to expand multisectoral collaboration to promote health, and Strengthen the capacity to gather evidence, and to design and implement policies on health promotion efficacy, and to support the utilization of such evidence in making decisions related to policy, advocacy and/ or programmes of intervention.
•
•
Enhancing the competencies for health promotion practices of programme managers to plan, deliver, monitor and gather evidence through workshops, seminars and conferences.
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Conceptual framework (19) Health promotion practice is cross-cutting. As a function public health intervention, Health promotion makes use of three interrelated approaches, namely: (a) issues-based approach;1 (b) population-based approach2; and (c) the settings-based approach3. (20) The Regional Strategy for Health Promotion for South-East Asia is aligned to policy actions and commitments contained in the Bangkok Charter for Health promotion. It takes into consideration decisions taken at the SEA/RC, EB and WHA as well as being responsive to the Medium-Term Strategic Plan (MTSP) 2008-2013 in order to attain and/or sustain desired health outcomes among individuals and communities. Finally, the Regional Strategy for Health Promotion for South-East Asia advocate specific actions, namely: • Integration of existing health promotion activities into health programmes across sectors in order to address communicable and non-communicable diseases and new threats to health such as avian influenza; Inter-sectoral collaboration involving communities, civil society groups, government ministries and development partners in order to address health disparities whose solutions are beyond the influence of the Ministry of Health; Imparting health content and skills using information, education and communication (IEC) techniques and information, technology and communication (ITC) tools in places where individuals live, work, and play in order to increase awareness and achieve desired actions;
•
•
1 2 3
Issues - HIV/AIDS, TB, diabètes, hypertension, cancer, etc., Population - Women, children, elderly or the poor, etc., Settings - Cities, schools, work place, villages, etc.,
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•
Generating evidence related to the effectiveness of Health promotion interventions through research, and monitoring and evaluation of ongoing and new interventions; and Strengthening the capacity for health promotion across the Organization to develop policies, programmes, plans of action, guidelines, gathering of evidence, and establishing innovative and sustainable financing mechanisms for health promotion activities.
•
Building the health promotion competencies for both the health and non-health professionals through strengthening of training and curriculum pertaining to pre-service, in-service and continuing education.
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Strategic directions Infrastructure for coor dination and management coordination (21) There should be an established and sustained infrastructure in each country to coordinate and manage health promotion activities across sectors and administrative levels in the country. The technical and managerial capacity for health promotion should be composed of an interdisciplinary staff. Most ministries of health have a unit, a section or a centre for health education, sometimes at the level of a Directorate. A few countries have changed such unit/section/centre to health promotion, but almost all of them are functioning as the IEC arm of the Ministry. There should be clearly delineated roles and responsibilities for the coordination and management team and also an adequate budget and other technical resources in order to effectively support health promotion in the country. (22) Selected specific roles and responsibilities should include but not be limited to: ¾
Pr oviding guidance regarding policy and Providing programmatic issues across sectors and settings, in order to manage the changing environment related to implementing of the regional and global strategies for health promotion; Responding to emer gencies in a timely manner and emergencies also with adequately planned health promotion inter ventions, e.g., risk communication and community mobilization; Creating and sustaining a supportive envir onment environment conducive to planning, implementation and evaluation of health promotion activities; and, Ensuring coor dination and management of health coordination pr omotion activities supported by sound policies, promotion legislation and financial resources in order to respond to the multi-sectoral health promotion demands and expectations.
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Capacity building (23) Health promotion is an emerging discipline that requires leadership for policy development, health promotion practice, content and skill base, research and documentation, knowledge transfer and health literacy. Building national capacity for health promotion is critical if countries are to realize the expected outputs. Till date, not many countries in the Region have undergraduate and graduate training in health education, less on health promotion. Even where they exist, many cater only to a handful of people. Except for a few institutions in India, Sri Lanka and Thailand, the training in health education has not been revised to incorporate skillbased health promotion modules. (24) In this context, the Regional Strategy should encourage Member States to (a) ensure that a critical mass of trained and qualified health promotion professionals exist in the country to address the multiple socio-cultural and behavioural issues across sectors and population groups; (b) ensure that both health and non-health practitioners receive under-graduate, graduate, and pre-and in-service training in health promotion from competent trainers/ teaching institutions in the country or outside the country; (c) allocate adequate financial and technical support to institutions of learning that are offering health promotion, in order to be able to allow these institutions to meet national demands for health promotion workforce; and (d) avail fellowships and/or scholarships for qualified nationals to undertake training in health promotion including those seeking advanced training outside the country.
Responding to the threats of avian influenza through behaviour change interventions.
Regulations and legislation (25) In order to ensure reduction of tobacco use and to have a high level of protection from harm through consumable products, and to guarantee equal access to health and social services for all people, there must be legislation, regulations and mechanisms for enforcement in the country. Nine of the 11 countries of the Region are the contracting Parties to the WHO Framework Convention for Tobacco control (FCTC). Many countries have also adopted legislative
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measures to reduce harm from use of alcohol. A few countries have drawn up a framework to implement the WHO Global Strategy on Diet, Physical Activity and Health. (26) The role of government in promoting health through legislation and regulations should be to (a) introduce public legislation, policies and regulations that promote, support and protect health of all citizens as well as establish mechanisms for enforcement with special attention on protecting vulnerable groups such as women, children and the elderly; and (b) ensure that existing strategies, legislation and policies regarding economic and social development are revised and re-aligned in order to promote, protect and support health, as well as remove ambiguity in interpretation and enforcement.
Partnership, alliances and networks (27) Partnership for health promotion plays an essential part in resource mobilization and advocacy. The Ministry of Health stands to benefit significantly in terms of other partners joining to support its work in the form of financial support or human resource support or other forms of support. Parliamentarians of India were sensitized through a health promotion workshop and health checkup. Employees of the ministry of health were screened for diabetes and a healthy lifestyle centre was established in the premises of the health ministry. These advocacy efforts helped to raise the level of awareness and commitment for health promotion in India. In Sri Lanka, the Sri Lanka Medical Association is working with the Ministry of Health through the Diabetes Taskforce to develop capacity building for health professionals in prevention and control of diabetes at the community level. (28) In that regard, the regional strategy should seek to: (a) encourage Member States to create and sustain a political and economic environment conducive to initiating and maintaining partnership, alliances or networks with nongovernmental organizations, private and public stakeholders, local and international development partners for purposes of mobilizing financial and technical resources for promoting health; (b) designate the coordinating role for establishing partnership, alliances and networks to the
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Ministry of Health in order to avoid duplication and conflict which could result in wasting limited resources; (c) encourage the participation of various players in forming partnerships and networks for promoting health at different levels including institutions of public health, private organizations, nongovernmental organizations, civil society groups and community-based groups. (29) The private sector and civil society groups should work closely together in promoting health in order to reward good business practices and keep in check bad business practices. The private sector should return to the community some of its profits in the form of support to grassroots initiatives to promote health. Community projects that target young people or women are popular with communities and politicians and are likely to yield positive community relations.
Evidence for health pr omotion promotion (30) While the utility of health promotion is widely acknowledged, there is still a need to continue to demonstrate and document the evidence in order to close the gap between practice and evidence and to justify the allocation of resources. It is essential that a mechanism for gathering evidence as well as analysis, documentation and dissemination is established and sustained to assess the performance of various aspects of the Regional Strategy e.g., health promotion policies, programmes, infrastructure, investments or capacity building. Creating awareness and advocating for policies and legislations in order to reduce the risk factors associated with noncommunicable diseases.
(31) The Strategy should recommend to: (a) monitor systematically health promotion policies, programmes, infrastructure and investments related to health promotion; (b) establish indicators and expected products based on health promotion objectives for planned activities including technical and financial support; (c) document all evidence and disseminate it among local, regional and global stakeholders; and promote the utilization of the evidence by practitioners and policy makers in making informed programmatic and policy decisions including allocation of resources or future programme direction.
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Social mobilization and advocacy (32) In order for health promotion to remain high on the global and national agenda, there is a need to involve various stakeholders to demand health. Social mobilization and advocacy uses multiple approaches to increase public awareness and interest in health. In order to ensure effective communication, the actions being advocated for are often conveyed through the use of mass media and group media channels of communication in the language preferred by the target audience. (33) The Strategy encourages: (a) the participation of intended beneficiaries and other stakeholders in advocating for health; (b) advocating for the integration of health promotion across sectors and settings; (c) the involvement of high profile citizens and international celebrities to become health promotion ambassadors for purposes of lobbying government officials and private corporations. (34) The consumers and beneficiaries of public health services, that is, individuals, families and communities and civil society groups, should be involved throughout all phases of health promotion activities, in order for them to gain greater control over decisions and actions affecting their health. In that regard, it is essential that individuals, communities and civil society groups participate in the setting of standards and norms of production and distribution of consumable products as well as policies, strategies, legislation and regulations and information aimed at promoting health. It is essential to ensure the participation of all people in all aspects of promoting health irrespective of age, gender, ethnicity, religious or cultural beliefs and values, among others. (35) Civil society groups and other community-based groups should empower individuals, families and communities to demand for and have access to information and services that promote health in various sectors and settings. The formation of a functional partnership and alliance between Member States and the private sector, health promotion professional associations, and civil society and consumer groups, should be facilitated for the purpose of building capacity for additional financial and technical resources to promote, support and protect health.
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(36) The strategy should promote grassroots community initiatives by civil society groups and local and international nongovernmental organizations in health settings e.g. schools, “wet” and food markets, hospitals, clinics, villages, workplaces or youth centres, and to use these as “Best Practice Models” to demonstrate evidence for health promotion.
Financing health pr omotion promotion (37) Health promotion activities are not spared from competing for the limited budget of national or regional health administrations. Despite the fact that health promotion is an essential public health function, and any expenditure on health promotion is considered a justifiable investment, these activities often receive inadequate financial support compared to the demand placed upon it. (38) Thailand adopted the “Health Promotion Act” in 2000 in order to have sustainable financing for health promotion, through the use of dedicated taxation from sales of tobacco and alcohol, managed by an autonomous body called, the Thailand Health Promotion Foundation or ThaiHealth. Nepal adopted a similar legislation a few years ago but the dedicated taxation on cigarettes has to be used for the national Cancer Hospital. In Sri Lanka, new legislation for the establishment of a National Tobacco and Alcohol Authority has been discussed in Parliament since 1994. Involving both health and non-health professionals, as well as the civil society and communities to promote health across sectors.
(39) The Regional Strategy, therefore, encourages Member States to: (a) request each sector or ministry to allocate adequate financial resources for supporting health promotion activities; (b) create and maintain a functional partnership with the private sector and donors including UN agencies in order to mobilize extra-budgetary resources; (c) consider exploring the possibility of establishing a Health Promotion Foundation along the lines of ThaiHealth or a similar arrangement. Member States need to allocate adequate financial and technical resources to support and sustain the various health promotion strategy activities across sectors and settings. Where the national budget is not adequate to support health promotion activities, there is a need for Member States to consider alternative funding sources e.g., the setting up of a Health Promotion Fund using special taxes.
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Management of change (40) The Regional Strategy also calls upon Member countries to make Health promotion a core responsibility for the entire government, key focus of communities and civil society, and a requirement for good corporate practice. This transition from “Health education” to “Health promotion” approaches require concerted effort to re-orient both health and nonhealth professionals to adopt multi-sectoral policies and strategies to promote health. (41) In the SEA Region, new threats to health such as earthquakes or avian influenza, and neglected diseases such as dengue compete for limited financial and technical resources. In order to manage this demand, it is critical that alternative sources of funding be identified at country and regional levels including considering the use of dedicated tax on tobacco and alcohol. (42) Health outcome among individuals and communities is directly related to socio-cultural, behavioral and economic determinants associated with a wide range of risk factors. In order to halt or reverse the negative impact of identifiable determinants and risk factors, the Regional Strategy support using three approaches that cut across all levels of the health system. The three distinct approaches that should be incorporated are: ¾
oach , which is associated with The settings appr approach promoting healthy settings, e.g. healthy cities, villages, islands, districts, workplaces, markets, schools and hospitals, among others, The population-based appr approach oach , which seeks to promote healthy populations, e.g. children, adolescents, women, the elderly and workers, etc., and
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oach, which promotes healthy The issues-based appr approach practices on specific issues to address major, common risk factors in the areas of diet and nutrition, tobacco, physical activity, injury prevention, safe sex, patient safety and food safety, among others.
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(43) It is therefore essential that both Member States and other partners including WHO should: (a) Formulate plans to respond and manage new challenges in health promotion including capacity building in order to re-orient health and non-health professionals, financial and technical resources, controversial issues and organized resistance or opposition to health promotion; Establish mechanisms for evidence gathering, documentation and dissemination for use in policy development, advocacy and programme direction; Provide technical support to establish norms, standards, guidelines and competencies for Health promotion professionals including those affiliated with civil society groups, NGOs, the private sector or international organizations.
(b)
(c)
Promoting recreational and voluntary community services among the elderly as part of healthy lifestyles.
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Role of Member States (44) Promoting health should not be left to the Ministry of Health alone. Member States are encouraged to embrace a “wholeof-government approach” in order to promote health through multi-sectoral and multi-disciplinary collaboration. Existing national planning and economic development policies and strategies should be reviewed to ensure that health promotion is integrated into national development plans in order to tackle the determinants of health associated with premature deaths and morbidity. Ultimately, it is critical that Member States make adjustments to current health and economic policies, strategies, approaches and resource mobilization in order to align them to health promotion. (45) Governments need to ensure that policies and strategies that seek to promote, support and protect health of the general population reflect national aspirations and priorities including views from civil society groups, communities, the private sector and development partners.
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Role of WHO (46) In order for Member States of the South-East Asia Region to successfully implement the Regional Strategy, WHO should: • Continue to advocate for renewed and sustained political commitment at the highest level to health promotion. Strengthen the capacity for health promotion across the Organization in the Region to provide better support to Member States. Facilitate the establishment of innovative and sustainable financing mechanisms for health promotion at country and regional levels. There should be adequate human and financial resources to build capability for policy development, programmes, plans of action, guidelines, and evidence gathering and documentation. Support and sustain the establishment of partnerships, networks and alliances for harnessing additional technical and financial resources for health promotion among international development partners, including other UN agencies. Facilitate and support the establishment and functioning of health promotion knowledge networks in the Region such as WHO Collaborating Centres or a Regional Network for Health Promotion in order to create a regional forum for dialogue on regional and global health promotion issues.
•
•
•
• Placing health promotion high on the national and regional agenda by convening highlevel meetings involving government ministeries other than health.
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Conclusion (47) The Regional Strategy takes into consideration historical developments from Alma-Ata (1978), Ottawa Charter (1986) and Bangkok Charter for Health promotion (2005). It also incorporates Health promotion Resolutions from the Regional Committee Meetings, Executive Board, the World Health Assembly. In addition, the strategic directions are derived from required actions and recommended commitments identified in Bangkok Charter for Health Promotion. (48) The aim of the Regional Strategy is to address social determinants of health and risk factors associated with premature death and ill-health. To achieve this, the Strategy advocates for the involvement of other players outside the health profession including the private sector, civil society groups and community-based groups. (49) Ultimately, political will and commitment of the Member States to integrate health promotion across sectors, provide adequate resources and to provide an environment conducive for various players to contribute remain a pre-requisite for success. (50) A report on the implementation status of the Regional Strategy for Health Promotion will in presented at the sixtyfirst session of the Regional Committee in 2008 and during the 7th Global Conference for Health Promotion to be held in Nairobi, Kenya (2009). (51) If and when deemed necessary, the strategic directions could be modified.
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Anne xures Annexures Anne x 1: SEA/RC59/R4: Regional Strategy for Health Annex Pr omotion Promotion The Regional Committee, Recalling World Health Assembly and Executive Board resolutions WHA57.16 and EB117.R9 respectively, and its own resolutions SEA/ RC32/R6 and SEA/RC40/R3, as well as the outcomes of the five international conferences on health promotion, all of which called for strengthening of health promotion through policies, strategies, legislation, partnership and allocation of resources, and by engaging communities. Noting with satisfaction the active involvement of Member States of the Region durinig the Sixth Global Conference on Health Promotion held in Bangkok in August 2005, and having considered the follow-up on policy actions and commitments agreed to in the Bangkok Charter for Health Promotion in Globalized World, and Confirming the priority need to address social and other determinants of health and the major common risk factors associated with preventable causes of premature death and illness due to communicable and noncommunicable diseases among the people of the Region through health promotion. Strengthening the capacity of programme managers to coordinate and manage health promotion activities across sectors.
(1)
URGES Member States: (a) to consider health promotion as a core responsibility, central to the national and global development agendas; recognize the need for increasing investments in health promotion; establish mechanisms for concerted efforts and foster active engagement of civil society, professional bodies, the private sector and non-governmental organizations; to strengthen capability for planning, coordination, management and implementation of comprehensive and multisectoral health promotion policies and programmes and to document evidence of effective
(b)
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health promotion interventions at national and local levels, in order to facilitate development of effective policies, and (c) to adopt alternative, innovative and sustainable sources of financing for health promotion activities, with a firm institutional base for management, and to strengthen the capacity for health promotion across the Organization in the Region to provide better support to Member States; to facilitate the establishment of innovative and sustainable financing mechanisms with a firm institutional base for systematic and effective health promotion efforts; to support Member States with adequate human and financial resources to build capacity for developing policies, programmes, plans of action, guidelines and documentation of evidence, and to report on the progress of the implementation of the Regional Strategy to the sixty-first session of the Regional Committee in 2008.
(2)
REQUESTS the Regional Director: (a)
(b)
(c)
(d)
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Anne x 2: WHA60.24/12.11: Health pr omotion in a Annex promotion globalized world The Sixtieth World Health Assembly, Recalling resolutions WHA42.44 on health promotion, public information and education for health, WHA51.12 on health promotion, WHA57.16 on health promotion and healthy lifestyles, and the outcomes of the six international conferences on health promotion (Ottawa, 1986; Adelaide, Australia, 1988; Sundsvall, Sweden, 1991; Jakarta, 1997; Mexico City, 2000; Bangkok, 2005); Having considered the report on follow-up to the 6th Global Conference on Health Promotion (Bangkok in 2005), which confirms the need to focus on health promotion actions to address the determinants of health; Drawing on the Declaration of Alma-Ata, the Ottawa Charter for Health Promotion, and the Bangkok Charter for Health Promotion in a Globalized World which sets out strategic directions for equitable health improvement in the first decades of the twenty-first century; Considering the actions and recommendations set out in the Bangkok Charter for Health Promotion in a Globalized World to make the promotion of health central to the global development agenda, a core responsibility for all governments and a key focus of communities, civil society, and the private sector; Creating public awareness on and advocating for protecting human health from climate change.
Noting that health promotion is essential for meeting the targets of the internationally agreed health-related development goals, including those contained in the Millennium Declaration, is intimately related to the work of WHO’s Commission on Social Determinants of Health, and makes an important contribution to realizing the objectives of the Eleventh General Programme of Work; Recognizing that the dramatic changes of the global burden of disease, notably due to noncommunicable diseases, require greater attention, and call for adjustments in society at large and in resource allocation in order to tackle the immediate and underlying determinants of health;
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Recognizing that health promotion contributes to the achievement of health for all; Confirming the importance of addressing also the wider determinants of health, and of implementing recommendations on, and undertaking action for, health for all, 1. URGES all Member States: (1) to increase, as appropriate, investments in, and to frame sound policies for, health promotion as an essential component of equitable social and economic development; to establish, as appropriate, effective mechanisms for a multisectoral, including interministerial, approach in order to address effectively the social, economic, political and environmental determinants of health throughout the lifecourse; to support and foster the active engagement in health promotion of communities, civil society, especially people or groups making positive contributions, the public including professional and labour unions, businesses and associations, bodies, especially those involved in public health and health promotion, while avoiding any possible conflict of interest and promoting constructive engagement for mutual benefit; systematically to monitor, evaluate and improve healthpromotion policies, programmes, infrastructure and investment, on a regular basis, including consideration of the use of health-impact assessments, to report results in solving problems related to health promotion and to publicize and use those results in the planning process; to reorient national public health systems towards the promotion and adoption of healthier lifestyles by individuals, families and communities; to introduce into current practices effective, evidence-based health promotion interventions; that have successfully implemented a national public health policy, within which health promotion is the key to modifying the determinants of health, effectively to transfer their expertise to those countries that are still in the implementation phase;
(2)
(3)
(4)
(5)
(6) (7)
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2.
REQUESTS the Director-General: (1) to strengthen the capacity for health promotion across the Organization in order to provide better support to Member States by advancing knowledge and the active engagement of other appropriate organizations of the United Nations system and international organizations; to provide support to Member States in their continuous efforts to strengthen national health systems with a special focus on the primary health sector, in order to enhance the ability to tackle serious threats to health; to optimize use of existing forums of Member States for multisectoral, including interministerial stakeholders, interested organizations and other bodies, while avoiding any possible conflict of interest, in order to support the development and implementation of health promotion; to encourage the convening of national, subregional, regional and global multisectoral conferences on health promotion on a regular basis; to monitor and evaluate progress, to identify major shortcomings in health promotion globally, and to report on a regular basis and make the reports accessible to the public; to facilitate exchange of information with international nonhealth forums on key aspects of health promotion; to advocate political and socioeconomic policies that impact positively on health; to report to the Sixty-first World Health Assembly, through the Executive Board, on progress in implementing this resolution. Eleventh plenary meeting, 23 May 2007 A60/VR/11
(2)
(3)
(4)
(5)
(6) (7) (8)
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Anne x 3: The Bangk ok Charter for Health Pr omotion in Annex Bangkok Promotion a Globalized W orld World Intr oduction Introduction Scope The Bangkok Charter identifies actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion. The Bangkok Charter affirms that policies and partnerships to empower communities, and to improve health and health equality, should be at the centre of global and national development. The Bangkok Charter complements and builds upon the values, principles and action strategies of health promotion established by the Ottawa Charter for Health Promotion and the recommendations of the subsequent global health promotion conferences which have been confirmed by Member States through the World Health Assembly. Audience The Bangkok Charter reaches out to people, groups and organizations that are critical to the achievement of health, including: • governments and politicians at all levels • civil society • the private sector, and • international organizations. • Public health community Health pr omotion promotion The United Nations recognize that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without discrimination. Health promotion is based on this critical human right and offers a positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual well-being. Health promotion is the process of enabling people to increase control over their health and its determinants,
Purpose
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and thereby improve their health. It is a core function of public health and contributes to the work of tackling communicable and noncommunicable diseases and other threats to health.
Addressing the determinants of health Changing conte xt context Critical factors The global context for health promotion has changed markedly since the development of the Ottawa Charter. Some of the critical factors that now influence health include: • Increasing inequalities within and between countries • New patterns of consumption and communication • Commercialization • Global environmental change, and • Urbanization Further challenges Other factors that influence health include rapid and often adverse social, economic and demographic changes that affect working conditions, learning environments, family patterns, and the culture and social fabric of communities. Women and men are affected differently and the vulnerability of children and exclusion of marginalized, disabled and indigenous peoples have increased. New Globalization opens up new opportunities for opportunities cooperation to improve health and reduce transnational health risks; these opportunities include: • enhanced information and communications technology, and • improved mechanisms for global governance and the sharing of experiences Policy coherence To manage the challenges of globalization, policy must be coherent across all: • Levels of governments • United Nations bodies, and
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• Other organizations, including the private sector. This coherence will strengthen compliance, transparency and accountability with international agreements and treaties that affect health. Pr ogress made Progress has been made in placing health at the centre Progress of development, for example through the Millennium Development Goals, but much more remains to be achieved; the active participation of civil society is crucial in this process.
Strategies for health pr omotion in a globalized world promotion Effective Progress towards a healthier world requires strong inter ventions political action, broad participation and sustained interventions advocacy. Health promotion has an established repertoire of proven effective strategies which need to be fully utilized. Required actions To make further advances in implementing these strategies, all sectors andsettings must act to: • advocate for health based on human rights and solidarity • invest in sustainable policies, actions and infrastructure to address the determinants of health • build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy • regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people • partner and build alliances with public, private, nongovernmental and international organizations and civil society to create sustainable actions.
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Commitments to Health for All Rationale The health sector has a key role to provide leadership in building policies and partnerships for health promotion. An integrated policy approach within government and international organizations, and a commitment to working with civil society and the private sector and across settings, are essential to make progress in addressing the determinants of health. Key The four key commitments are to make the promotion commitments of health: • central to the global development agenda • a core responsibility for all of government • a key focus of communities and civil society • a requirement for good corporate practice 1. Mak e the Make pr omotion of promotion health central to the global development Strong intergovernmental agreements that increase health and collective health security are needed. Government and international bodies must act to close the health gap between rich and poor. Effective mechanisms for global governance for health are required to address all the harmful effects of: • Trade • Products • Services, and • Marketing strategies. Health promotion must become an integral part of domestic and foreign policy and international relations, including in situations of war and conflict. This requires actions to promote dialogue and cooperation among nation states, civil society, and the private sector. These efforts can build on the example of existing treaties such as the World Health Organization Framework Convention for Tobacco Control.
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2. Mak e the Make pr omotion of promotion health a core responsibility for all of government
All governments at all levels must tackle poor health and inequalities as a matter of urgency because health determines socio-economic and political development. Local, regional and national governments must: • give priority to investments in health, within and outside the health sector • provide sustainable financing for health promotion. To ensure this, all levels of government should make the health consequences of policies and legislation explicit, using tools such as equity focussed health impact assessment.
3. Mak e the Make pr omotion of promotion health a k ey key focus of communities and civil society
Communities and civil society often lead in initiating, shaping and undertaking health promotion. They need to have the rights, resources and opportunities so that their contributions are amplified and sustained. In less developed communities, support for capacity building is particularly important. Well organized and empowered communities are highly effective in determining their own health, and are capable of making governments and the private sector accountable for the health consequences of their policies and practices. Civil society needs to exercise its power in the marketplace by giving preference to the goods, services and shares of companies that exemplify corporate social responsibility. Grass-roots community projects, civil society groups, and women’s organizations have demonstrated their effectiveness in health promotion, and provide models of practice for others to follow. Health professional associations have a special contribution to make.
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4. Mak e the Make pr omotion of promotion health a requirement for good corporate practice
The corporate sector has a direct impact on the health of people and on the determinants of health through its influence on: • local settings • national cultures • environments, and • wealth distribution. The private sector, like other employers and the informal sector, has a responsibility to ensure health and safety in the workplace, and to promote the health and wellbeing of their employees, their families and communities. The private sector can also contribute to lessening wider global health impacts, such as those associated with global environmental change by complying with local national and international regulations and agreements that promote and protect health. Ethical and responsible business practices and fair trade exemplify the type of business practice that should be supported by consumers and civil society, and by government incentives and regulations.
A Global Pledge to Mak e it Happen Make All for health Meeting these commitments requires better application of proven strategies, as well as the use of new entry points and innovative responses. Partnerships, alliances, networks and collaborations provide exciting and rewarding ways of bringing people and organizations together around common goals and joint actions to improve the health of populations. Each sector – intergovernmental, government, civil society and private – has a unique role and responsibility.
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Closing the Since the adoption of the Ottawa Charter, a significant implementation number of resolutions at national and global level have gap been signed in support of health promotion, but these have not always been followed by action. The participants of this Bangkok Conference forcefully call on Member States of the World Health Organization to close this implementation gap and move to policies and partnerships for action. Call for action Conference participants request the World Health Organization, in collaboration with others, and its Member States, to allocate resources for health promotion, initiate plans of action and monitor performance through appropriate indicators and targets, and to report on progress at regular intervals. United Nations organizations are asked to explore the benefits of developing a Global Treaty for Health. This Bangkok Charter urges all stakeholders to join in a worldwide partnership to promote health, with both global and local engagement and action.
Worldwide partnership
Commitment to We, the participants of the 6th Global Conference impr ove health on Health Promotion in Bangkok, Thailand, pledge to improve
advance these actions and commitments to improve health. 11 August 2005
Note:
This charter contains the collective views of an international group of experts, participants to the 6th Global Conference on Health Promotion, Bangkok, Thailand, August, 2005, and does not necessarily represent the decisions or the stated policy of the World Health Organization.
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The Regional Strategy for Health Promotion for South-East Asia features strategic directions for strengthening health promotion across sectors, arising from commitments and actions arrived at during regional and global conferences and high-level meetings on health promotion. The regional strategy delineates the mechanisms for promoting, supporting and protecting the desired health outcomes using interdisciplinary and multisectoral approaches that involve individuals, communities, civil society, private sector and all government ministries. It endeavours to tackle the broad social, economic, environmental and political determinants of health that lie outside the health sector and are associated with ill-health and premature deaths. The need for strengthening the capacity of health and non-health sectors to plan, implement and evaluate health promotion activities, including gathering and dissemination of evidence; establishing partnerships and alliances; setting up innovative financing mechanisms; and the management and coordination of health promotion activities, remains the nucleus for effective implementation and sustainability.