Towards developing WHO's agenda on well-being

well-being well-being health sustainable development equitypeople peoplehealth equity sustainable development sustainable health policy agenda agenda individual commercial determinants commercial determinants community action community action investment empowerment empowerment empowerment life course life course life course social determinants communication literacy health in all policies health in all policies health in all policies advocacy advocacy advocacy advocacy COVID-19 COVID-19 economy of well-being economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy Towards Developing and Sustaining the WHO Well-Being Agenda DISCUSSION PAPER d WHO's agenda on well-being Towards developing WHO's agenda on well-being Towards developing WHO's agenda on well-being well-being well-being health sustainable development equitypeople peoplehealth equity sustainable development sustainable health policy agenda agenda individual commercial determinants commercial determinants community action community action investment empowerment empowerment empowerment life course life course life course social determinants communication literacy health in all policies health in all policies health in all policies advocacy advocacy advocacy advocacy COVID-19 COVID-19 economy of well-being economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy D and Sustaining the WHO Well-Being Agenda DISCUSSION PAPER Towards developing WHO's agenda on well-being ISBN 978-92-4-003938-4 (electronic version) ISBN 978-92-4-003939-1 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/ mediation/rules/). Suggested citation. Towards developing WHO's agenda on well-being. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/ copyright. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Editing and design by Inis Communication iii DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Contents Acknowledgements iv Abbreviations and acronyms v Executive summary vi Scope and aim viii Background: Well-being on the WHO agenda 1 Health and well-being are inextricably linked 5 Methods 6 The concept of well-being 7 Policy examples 9 National cases 9 Bhutan 9 Buen Vivir: Bolivia and Ecuador 9 Finland 10 Iceland 10 India 10 New Zealand 11 Scotland 11 Thailand 11 United Arab Emirates 12 International case 13 OECD’s Economy of well-being 13 Discussion 14 Ways forward 16 References 17 iv DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Acknowledgements The development of this document was led by Dr Ruediger Krech, Dr Faten Ben Abdelaziz and Ms Yasmine Anwar, WHO headquarters (Geneva) and by Prof. Hope Corbin, Dr Mihály Kökény and Dr Kristine Sørensen. vDEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Abbreviations and acronyms COVID-19 coronavirus disease 2019 EU European Union FAO Food and Agriculture Organization of the United Nations GDP gross domestic product GNH Gross National Happiness GPW13 WHO 13th General Programme of Work NCDs noncommunicable diseases OECD Organisation for Economic Co-operation and Development OIE World Organisation for Animal Health SDG Sustainable Development Goal SDH social determinants of health SEP Sufficiency Economy Philosophy SWB subjective well-being UHC universal health coverage UN United Nations WHO World Health Organization vi I envision a world in which everyone can live healthy, productive lives, regardless of who they are or where they live. I believe the global commitment to sustainable development – enshrined in the Sustainable Development Goals – offers a unique opportunity to address the social, economic, and political determinants of health and improve the health and well-being of people everywhere. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization Geneva 2021 vii DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Executive summary The COVID-19 pandemic and the crises it has triggered highlight that for most people there is more to life than money. Real wealth is the enduri g well-being of people – particularly those who are most vulnerable, ofte due to circumstances that lie beyond their control. An international movement to retreat from economic measures of human development toward measures that focus on the well-being of people and the planet is gaining momentum. This discussion paper gathers promising examples of where this has been implemented successfully. It seeks to amplify and elevate the well-being agenda globally in support of better policy-making: to contribute to the attainment of health – as defined in the Constitution of the World Health Organization – support implementation of the organization’s Healthier Population Framework, and to accelerate the achievement of the Sustainable Development Goals (SDGs); all of which are essential to overcoming the urgency of the pandemic and adapting to a post-COVID world. The notion of well-being has been a subject of scholarly attention for millennia. Moving beyond individual perceptions of well-being or simple behavioural wellness practices, well-being is a concept applied at a societal level to describe the overall conditions experienced by the population according to multi-dimensional measures. As a policy concept, well-being centres the health and quality of life of people and communities (including access to education and employment, participation in society, and other relevant indicators), equity and planetary sustainability. The sustainable development agenda outlines 17 goals and 169 targets that together embody an ambitious attempt to identify, articulate and address diverse and interrelated global development challenges. While Goal 3 seeks to “ensure healthy lives and well-being for all at all ages”, the targets associated with the goal are primarily focused on “healthy lives”. The concept of well-being, and the conditions that create it, require further clarification and specific guidance on how the international community, nations and other relevant actors can support and promote well-being through policy and inter-sectoral collaboration. With this goal in mind, WHO initiated discussions among 12 international organizations to develop the Global Action Plan for Healthy Lives and Wellbeing for Alla that applies the strategies of engaging, accelerating, aligning and accounting to facilitate the inter-agency collaboration needed to foster better health. The WHO 13th General Programme of Work (GPW13)b sets interconnected strategic priorities (including the 3 billion targets) to ensure healthy lives and promote well-being for all at all ages (SDG 3), and also operationalizes the tasks. The GPW13 aims to extend universal health coverage to one billion additional people, prepare one billion people to better handle health emergencies, and improve health and well-being for a further one billion people by 2023. The WHO Healthier Populations Framework focuses on the latter of these goals, providing guidance for diverse social, economic, environmental, political and programmatic initiatives as well as approaches for working at country, regional and global levels. a https://www.who.int/publications/i/item/9789241516433 b https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf viii The COVID-19 pandemic has highlighted the fragility of health systems throughout the world, as well as the vulnerability of marginalized groups within society, and the vital importance of social trust in the face of crises.c There is a need to examine how the global community can further enhance economic growth and prosperity, equity, quality of life and sustainability to boost resilience across society. The country-level applications of well-being and related concepts, and the diverse policy approaches currently being pursued, offer a range of strategic options for achieving these aims. Efforts to promote well-being as a cross cutting governance approach may include: • Deciding on a collective consensus on how the concept of well-being can serve to transform societies to be more resilient. This should be founded on common values and with specific commitments for societal transformation to support a whole-of-government, action-based approach. • Identifying relevant regional, national or local goals and objectives, and means of achieving them. • Adopting design processes that ensure open collaboration and accountability. • Linking funding to achievement of clearly defined well-being objectives. • Monitoring and measuring a broad range of locally relevant well-being outcomes. International agencies have also advocated for the uptake of wellbeing at national level. The OECD’s Economy of Wellbeing helps to situate the value of wellbeing in economic resilience and individual contribution. The move toward a wellbeing agenda would require a major paradigm shift from a focus on measures such as GDP to a broader view of wellbeing as the goal of development. The application of wellbeing concepts can bring policy coherence across sectors and galvanize action. Building societal wellbeing can help create resilient and sustainable communities that are better able to respond to current and emerging health threats like COVID-19 and ecological disasters. Wellbeing – as a policy concept-- unites the health, economic, social, and environmental aspects of the sustainable development agenda. c Abel, T., & McQueen, D. (2020). Critical health literacy and the COVID-19 crisis. Health Promotion International, daaa040. https://doi.org/10.1093/heapro/daaa040 1Scope and aim The notion of well-being holds relevance to each 17 of the Sustainable Development Goals (SDGs). Well-being is a major underlying driver of policy coherence across sectors and encourages galvanized action. Advancing societal well-being helps create active, resilient and sustainable communities at local, national and global levels – enabling them to respond to current and emerging health threats, such as coronavirus disease 2019 (COVID-19) and environmental disasters. By its comprehensive nature, well-being unites the health, economic, social and environmental dimensions of the sustainable development agenda, forming a political construct that blends the health and quality of life of people and communities, with concepts of equity and planetary sustainability. Recognizing the call for action the idea implies, the aim of this discussion paper is to illuminate well-being as a policy framework and describe its application in practice to inform the strategic work of the World Health Organization (WHO) as a central component of the Healthier Populations Framework and the sustainable development agenda. DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community act on investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda 2DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Background: Well-being on the WHO agenda The Constitution of the World Health Organization defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1948) (1). This goes beyond the previously dominant biomedical model, to reflect a comprehensive understanding and holistic approach to health, influenced by biological, social and environmental determinants. Today, well-being is framed within this broad definition and as a positive aspirational aim. The Alma-Ata Declaration (1978) (2) was also a major milestone of public health in the twentieth century. Not only did it identified primary health care as key to the attainment of the goal of ‘Health for All’ but it also placed the WHO health concept in a broader context. Health and well-being were further expanded by the Ottawa Charter for Health Promotion, situating it as not only a state experienced by an individual but also “as a resource for everyday life”. In overcoming the individualistic understanding of lifestyle and highlighting the importance of social environments and policy, the orientation shifted from focusing on the modification of individual risk factors (or behaviours) to addressing the “context and meaning” of actions and the determinants that impact people (3). The landmark Report of the Commission on Social Determinants of Health set up a pathway model to explain factors affecting the inequitable distribution of health and well-being (4). “Structural determinants” including all social and political mechanisms (e.g. governance, macroeconomic policy, social policy, public policy as well as social and cultural values) that generate, configure and maintain socioeconomic positions in a society (i.e. social class, gender or ethnicity) and “intermediary determinants” such as working and living conditions, behavioural, psychosocial and biological factors and the health care system itself. Interactions between structural and intermediary determinants were recognized to determine differentiations (or inequities) in health and well-being. The 62nd World Health Assembly in 2009 endorsed the report and called on Member States to make political commitments taking into account “health equity in all national policies that address social determinants of health, and to consider developing and strengthening universal comprehensive social protection policies, including health promotion, disease prevention and health care, and promoting availability of and access to goods and services essential to health and well-being (5).” Furthering these efforts, the 2011 World Conference on Social Determinants of Health produced the Rio Declaration (6), which stated: “Our common values and responsibilities towards humanity move us to fulfil our pledge to act on social determinants of health. We firmly believe that doing so is not only a moral and a human right imperative but also indispensable to promote human well-being, peace, prosperity and sustainable development.” The value-based, action-oriented policy framework entitled Health 2020 (7), adopted by the WHO Regional Committee for Europe in 2012, envisions a WHO European Region “in which all people are enabled and supported in achieving their full health potential and well-being, and in which countries, individually and jointly, work towards reducing inequities in health within the Region and beyond.” In this light, the document returned to the concept of the WHO founders and the Commission on Social Determinants of Health (SDH) to determine that there is no well-being without equal access to health and health services, and to achieve this, it is essential to reduce unjust social, income and educational 3differences that lead to health inequities. Health 2020 brought together some important but previously less highlighted concepts – such as well-being, the life- course approach, resilience, empowerment and health literacy) – so the combined attention shifted to focus on people-centeredness and rights-based approaches. In retrospect, Health 2020 can be viewed as a forerunner of two comprehensive strategies it helped to facilitate: the health-related Sustainable Development Goals and the WHO 13th General Programme of Work (GPW13). The SDGs plot the course for health and development work through 2030. They were formulated through a large-scale participatory process, including input from 194 member states, civil society organizations and United Nations (UN) bodies, such as the Group of Least Developed Countries, the Sustainable Solutions Network and the UN Development Group (UN Development Group, 2013) (8). The 17 goals and 169 targets comprising the SDGs represent an ambitious attempt to identify, articulate and address diverse and interrelated global development issues. While all of the SDGs have relevance to health via social determinants, the core focus of WHO’s work on achievement of the SDGs involves making progress toward Goal 3 and its targets of reducing global maternal and neonatal mortality, ending communicable disease epidemics, addressing noncommunicable diseases (NCDs), preventing traffic injury and death, achieving universal health care coverage (including reproductive and sexual health care), minimizing deaths and illnesses resulting from pollution and extending the WHO Framework Convention on Tobacco Control (9). To that end, the WHO initiated collaboration among 12 international organizations, the Global Action Plan for Healthy Lives and Well-being for All (10) applies the strategies of engaging, accelerating, aligning and accounting to facilitate the collaboration needed to achieve better health. The debate and the adoption of SDGs created favourable conditions for putting global health issues on the agenda of UN governing bodies. The UN recognized that in an interconnected world, infectious diseases can spread across continents in a matter of days; the lifestyle factors driven by media and advertising can influence global populations within months, and knowledge can be shared instantly. This approach has made more high-level meetings on the margins of the UN General Assembly (UNGA) on specific health matters possible, representing new types of political fora for health. Outcome documents adopted by such conferences were consequently endorsed by the UNGA, providing strategic guidance to international cooperation in the area concerned. The political declaration of the high-level meeting on universal health coverage, Universal health coverage (UHC): moving together to build a healthier world (11), the Global Plan of Action on noncommunicable diseases (12) and the Astana Declaration (13) all contain a wide range of political commitments, with a view to bringing together all government sectors and stakeholders of societies in the Member States, as well as the international community. These landmark strategies are even more relevant in the post-pandemic period, as public health and economic crises have multiplied and partly reshaped criteria for achieving well-being. In addition, the WHO 13th General Programme of Work (GPW13) (14) sets interconnected strategic priorities (the ‘3 billion targets’) to ensure healthy lives and promote well-being for all at all ages (SDG 3) and also operationalizes the tasks. It aims to extend universal health coverage (UHC) to one billion, prepare one billion people to better handle health emergencies, and improve health and well-being for one billion people by 2023. The WHO Promoting healthier populations framework focuses on the third goal of improving health and well-being, and provides guidance for diverse social, economic and environmental political and programmatic initiatives as well as approaches for working at country, regional and global levels within the context of multiple transitions (see Fig. 1). 4Fig. 1: Promoting healthier populations framework While SDG 3 seeks to “ensure healthy lives and well-being for all at all ages”, and the goal’s targets focus clearly on healthy lives, the concept ‘well-being’” is not well defined. Furthermore, and given the accepted broad significance of social determinants, Goal 3 is not the only goal relevant to ensuring well-being. For example, if all people were free from poverty and hunger, had access to quality education, equity, clean water, clean energy and decent work, their health and well-being would also be improved. If societies and their institutions adopted specific plans for responsible consumption and production, positive climate action, protecting life below water and on land, and for peace and justice, individual and societal well-being Would be significantly impacted Achievement of any of the SDGs – particularly all of them in unison – would do much to ensure people’s healthy lives and well-being. WHO has been engaged for decades in developing guidance for this kind of cross-cutting, intersectoral governance that supports unified action across the whole of society. Part of this work incorporates planetary health (15) and the and the One Health (16) approach promoted by WHO, the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO). Rooted in recognition of the interdependence of human and natural systems, and fostering interdisciplinary collaboration, the One Health framework works to address the interface between human–animal–environmental health by addressing environmental contamination, habitat use conflicts, biodiversity loss, emerging infectious diseases, antimicrobial resistance and ecosystem function degradation. In addition, SDHs reinforce a strong social and environmental justice aspect to One Health and its link with well-being. The relevance of the One Health approach to population well-being is particularly highlighted by the emergence of the COVID-19 pandemic. Smart pandemic prevention and management strategies are not possible unless centred on interdisciplinary, intersectoral approaches (17).  Demographic transition Fo od sy st em a nd n ut rit io n tra ns iti on Climate change and energy transition Epidemiological transition Technology transition Rapid urbanization Supportive societies Safe societies Healthy environments Measure progress and results to improve public health and guide actions towards the SDGs Engage with multiple actors and create a social movement Enhance evidence, define and prioritize research agenda Strengthen and empower health sector Act on determinants of health in all policies beyond the health sector Scale up primary prevention and health promotion A world where all people enjoy healthy lives and well-being, living in a healthy, safe and supportive environment as members of an inclusive society 5As outlined, he progression of initiatives and towards specific targets or milestones mirrors the evolution of approaches in the work of WHO as it has turned from a focus on individuals and disease prevention and treatment towards one addressing the upstream factors that collectively create health and well-being in the first place. These upstream determinants – represented by the SDGs – are interdependent and indivisible, and contribute synergistically to not only human health and well-being but also to ensuring that the limits of our planetary boundaries are respected and protected. 6DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Health and well-being are inextricably linked The WHO definition of health reflects a complex experience that is influenced by biological, societal and environmental determinants. Over the past 15 years, much work has been done to identify and research recognized social and environmental determinants of health. One illustrative example of how such determinants influence people’s health has been the COVID-19 pandemic (18). Within weeks of its emergence, the virus – SARS-CoV-2 – had spread globally, threatening population health on every continent to varying degrees. Without a good pre-existing health status, individual risks associated with COVID-19 infection are significantly elevated compared to healthy people (19). There is also a strong imperative to invest in governance and communication strategies that promote well-being at the societal level (e.g. measures to promote physical distancing measures, adherence to quarantine rules, contact tracing, mask mandates). These decisions require sometimes complex trade-offs, as although lockdowns protect citizens from infection, they also have mental health and economic consequences. The linkages between the physical, mental, social and economic impacts of COVID-19 demonstrate the close coupling between health and well-being of both individuals and societies. The global community has learned that pandemic control is more effective in countries (and communities) where crisis management is not overly politicized, where there is a significant level of health literacy and where trust-building communication and transparent data sharing can positively influence cooperation and joint action among the population. A proactive approach to coordinating the different sectors of society around the SDG agenda can help mitigate some of the ecological risks that contribute to the emergence and severity of pandemics on human populations. For instance, the increased risk of exposure to zoonotic diseases due to habitat fragmentation, the impacts of natural disasters on public health infrastructure, or how air pollution complicates the experience of respiratory illnesses, all point to overlapping and intersecting relationships of human, animal and environmental health. Reviewing the sustainable development agenda in the wake of COVID-19, understanding of well-being must be expanded to explore ways to unite visions for building more resilient, responsive and sustainable societies through governance models that centre on human well-being. 7DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Methods As already described, health is defined broadly as a positive state involving mental, physical and social well-being. While this definition is widely accepted, the precise interpretation of well-being is unclear. WHO has conducted a rapid scoping review of literature to provide an overview of the various concepts and definitions used in relation to well-being, as published in peer-reviewed journals, and to identify examples of policy initiatives by national governments and international agencies aimed at improving national or societal well-being. The examples identified are not an exhaustive list of well-being policy initiatives, and were selected to reflect regional variations and to highlight different policy approaches. In each instance, key policy documents were identified and analysed. The final stage of the review process involved a consultation in which a draft of this discussion paper was shared, enabling relevant stakeholders implementing the policy cases, well-being scholars and practitioner colleagues to provide feedback and input (20). 8DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda The concept of well-being Well-being as a stand-alone concept has been a subject of philosophical and scholarly attention for millennia. Well-being applies naturally to both individuals and societies. Individual well-being There are two distinct philosophical notions of individual well-being in Western scholarship:d a hedonic view – seen as feel-good subjective experience – and a eudemonic view – involving a person’s ability to live in alignment with and act upon their own sense of meaning and purpose (21). Theories of individual well-being, and attempts to measure it, involve numerous dimensions of the human experience that variously incorporate either/both dimensions (22), and may include overlapping concepts of happiness, positive emotion/affect, engagement, meaning and purpose, life satisfaction and social support (23, 24, 25). An individual’s perception of their own well-being, referred to as subjective well- being (SWB) (26), is experienced dynamically, is impacted by life events, and typically returns to a consistent equilibrium state for each person (27). Dodge and colleagues (28) define well-being as “the balance point between an individual’s resource pool and the challenges faced” (see also Fig. 1). This perspective highlights how supporting a person’s well-being can promote resilience by ensuring that they have the resources (including social conditions) needed to cope with challenges as they arise. Societal well-being Societal well-being is measured at the population level (29). Standard of living surveys (30) have attempted to capture this conception of well-being. While individual SWB is a critical component, societal well-being is not the mere sum of individual well-being. The orientation that draws these initiatives and concepts together is a holistic notion of human progress that considers psychological, physical, social, economic and environmental dimensions of well-being (27). While Western philosophy offers insight into the experience of individual well-being, other knowledge traditions offer elaborations of societal well-being, which is known by many names. For instance, Eduardo Gudynas elaborates the modern notion of “Buen Vivir”, based on indigenous Latin American philosophies: “The richness of the term, [Buen Vivir] is difficult to translate into English. It includes the classical ideas of quality of life, but with the specific idea that well-being is only possible within a community. Furthermore, in most approaches, the community concept is understood in an expanded sense, to include nature. Buen Vivir therefore embraces the broad notion of well-being and cohabitation with others and nature (31).” These ideas echo elaborations of well-being among the Maori of New Zealand (32), Bhutan’s Gross National Happiness, and Thailand’s Sufficiency Philosophy, among others. d Not to be confused with “wellness” – an individual behavioural concept – which is not covered in this discussion of well-being. 9In a 2020 Lancet article, the Healthier Societies for Healthier Populations Group described the process of creating healthy populations as “a collective endeavour that requires navigating competing interests, institutions and ideas.” The group further suggested that “…policy-makers and governments have a crucial leadership role in managing contestation between the public good, private sector demands, and competing political interests. A more strategic and intersectional consideration of history and political economy would help improve future efforts (33).” 10 DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Policy examples This section presents examples of how national and international policy- makers are working towards enabling societal well-being, by considering history and pursuing creative solutions to find harmony between sectors. The list is not exhaustive but seeks to present unique approaches. National cases Bhutan One of the most mature examples of a national policy strategy aimed to enhance well-being is Bhutan’s Gross National Happiness (GNH) initiative (34). GNH was introduced by the fourth King of Bhutan, Jigme Singye Wangchuck, in 1972. GNH was borne from the recognition that human development cannot be measured by GDP alone and an underlying motivation to counteract climate change. GNH centres on nine domains: health, education, living standards, ecological diversity and resilience, cultural diversity and resilience, good governance, community vitality, time use, and psychological well-being (35). Over the years, GNH has unified actors both within Bhutan and in the global community to pursue more encompassing development goals. In 2011, the United Nation’s General assembly unanimously adopted Happiness: towards a holistic approach to development (Resolution 56/309) and enlisted Bhutan to convene a high-level meeting to design a development strategy on happiness-focused development, which resulted in a publication outlining a variety of approaches to measuring happiness alongside economic development (36). Bhutan’s leadership through these efforts helped inform the sustainable development agenda (37). Buen Vivir: Bolivia and Ecuador In Latin America the concept of Buen Vivir (or Vivir Bien) has been proposed as an organizing principle to replace traditional GDP-centred development metrics. The concept is based on indigenous ideas and acknowledges the importance of local relevance and pluralism: “Buen Vivir… embraces the broad notion of well-being and cohabitation with others and nature… the concept is also plural, as there are many different interpretation depending on the cultural, historical and ecological settings (31).” The notion of Buen Vivir was incorporated into the Ecuadorian constitution in 2008 and in Bolivia in 2009. The approaches in the two countries differ, reflecting the plural nature of how the concept can be conceived and implemented. In Bolivia, “Vivir Bien” is situated in the constitution as an ethical and moral principal that frames the vision for the country. In contrast, Ecuador frames Buen Vivir as a set of rights, some of which mirror Western ideas of human rights, but expands to include the rights of nature. 11 Finland Finland utilized its European Union (EU) presidency in 2019 to further develop and support the development of knowledge around an Economy of well-being. They have supported the work of the Organisation for Economic Co-operation and Development (OECD) and created a framework that has elevated related discourse in important ways. The Economy of well-being is a pre-emptive approach based on three key principles: restoring harmony between human societies and the natural world; addressing inequity by ensuring a fairer distribution of resources; and supporting the health and resilience of individuals and communities (37). Nationally, Finland has implemented a government programme: Inclusive and competent Finland – a socially and ecologically sustainable society (38).” Through this initiative, the government takes a preventative approach by investing in measures that improve people’s health and well-being and by considering the long-term impacts of policies. Indicators that reflect economic, social and ecological well-being are applied concurrently with the traditional economic indicators. As Finland seeks to move toward a socially, economically and ecologically sustainable society by 2030, the government’s key economic policy objectives include: (a) decreasing inequity and reducing the income gaps; (b) achieving carbon neutrality by 2035; and (c) centring the target of economic policy on increasing well-being and prosperity. Iceland Iceland has been unique in its approach to examining well-being in that they began by focusing on measurement. The country started collecting baseline data in 2007. When the economic collapse happened in 2008 – they had baseline data that enabled assessment of the impact of the crisis on people and communities. As Iceland experienced the collapse of its banking system – and had unique data describing the impact of an overreliance on economic metrics – they were able to see the human cost of the established approach, and took the opportunity to reprioritize. Iceland’s 39 indicators for well-being (39) guide government decision- making, and are divided into three main categories: Society (including health, education, social capital, security and work–life balance indicators); environment (including air quality and climate, land use, energy, waste and recycling indicators); and economy (including economic conditions, employment, housing and income indicators). All the indicators are explicitly linked to the SDGs. As a small country, Iceland can conduct monthly surveys to collect well-being data representative of the full population, by segmenting the population into three age groups and randomly sampling 800 people each month. This enables the government to respond in near-real time to emerging conditions, which was especially crucial during the COVID-19 pandemic. India Building on indigenous understandings of health and well-being and long-standing traditional practices, the Government of India created the Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy (known as the Ministry of Ayush) in 2014. The Ministry of Ayush is dedicated to promoting health and well-being through education and the provision of services in the ancient traditions. Building on 5000 years of indigenous knowledge systems, the ministry collaborates through states, provinces and rural communities to provide education and clinical services. Through partnerships engaging young children to universities, the promotion of yoga and other ancient practices are embedded in daily routines and in related curricula. These practices – based heavily on respect of the planet, the seasons, as well as monthly and daily rhythms – provide a holistic approach to wellness that touches on spiritual, physical, mental, and social well-being, not only of individuals but of whole communities and the larger nation. 12 New Zealand New Zealand’s Wellbeing Budget (40), introduced in May 2019, firmly grounds the well-being agenda in the resource allocation and budgeting processes. The initiative intentionally moves away from GDP as a measure of progress, to introduce a holistic framework centred on the well-being of people, communities and the environment. Building on the New Zealand Treasury framework for measuring living standards, the Wellbeing budget prioritizes five objectives: supporting mental well-being; reducing child poverty; lifting Maori and Pacific incomes; transitioning to a low-carbon emissions economy; and boosting productivity. A unique feature of the New Zealand approach is that they are focused on micro-level implementation, rather than the macro-level. Through the budget-based approach all sectors are forced to ask the question: “Who is impacted and how?” and “What is the health impact of this initiative?” in addition to other questions such as “Can we afford it?” This involves transformative change in assessing budget initiatives, providing a filter through which the costs and benefits can be examined, and enabling prioritization. While the frameworks that form the basis of the New Zealand well-being approach are based on the OECD work and other Western philosophies, the government is also in dialogue with Maori groups and seeks to understand well-being from indigenous perspectives. Scotland The National Performance Framework (41) – first introduced in 2007 and refreshed in 2018 – was inspired by the “beyond GDP” movement and serves as the overall vision for well-being in Scotland. Considered together, the 11 component outcomes contribute to societal well-being that is more than the sum of subjective well-being. A particular innovation is the Inclusive growth diagnostic tool that is implemented at a local level using a series of indicators and a step-by-step process for identifying and addressing local problems. The framework created a common lexicon around well-being, and has helped sectors think outside of their conventional areas, to ask the question “Who is helping us reach our goals?” Each these aspects foster intersectoral collaboration and reduce the tendency to operate within silos. Partnerships have been key for Scotland, from the policy metric provided by the OECD (see below), to local authorities, to national SDG networks with over 400 members. Legislation has been a core element that has also ensured accountability. The Community Empowerment Act ensures that outcomes are reported every five years. The 11 outcomes are quite broad and command a high degree of consensus across political parties. The act serves as a lever to embed the approach and the outcomes require regular review and reporting. This mechanism for accountability drives good policy-making. Thailand In 1997, the late King Bhumibol Adulyadej of the Kingdom of Thailand introduced the concept of Sufficiency Economy Philosophy (SEP), which he defined as “a state of being that enables individuals, families, Organisations and nations to enjoy, at a minimum, a comfortable existence and, if conditions permit, a reasonable degree of luxury that balances economic, social, environmental, and cultural conditions (42).” SEP is guided by the Buddhist notion of following the middle path and consists of three principles: moderation (avoiding extremes and excess), reasonableness (being mindful of consequences) and self-immunity (basic 13 protection to withstand internal and external challenges). Two preconditions are identified for pursuing the principles: morality (the pro-social values of individuals or positive norms of groups); and knowledge (that which is known or empirical evidence) (43). This theory, and principles behind it, aim to promote physical, mental, social and spiritual well-being with concrete actions that address basic needs of diverse groups of population. These ideas build on the basic premise King Bhumibol articulated in the 1970s, when Thailand struggled against communism: democracy cannot be obtained if people are still hungry and their well-being is not achieved.    Since 2002, Thailand has integrated SEP into its National Economic and Social Development Plan and the current constitution. For instance, the Government of Thailand has applied SEP in designing policies to address poverty and encourage community self-reliance through: “(a) Schemes to reduce expenses through more home production, use of local new materials, energy savings, elimination of costly local entertainment and promotion of local markets; (b) schemes to increase income by encouraging community enterprises, producer groups and local tourism; (c) schemes for local savings; (d) promotion of local leadership and use of community plans; (e) activities to preserve and protect the environment; (f) schemes to promote social capital, including local welfare schemes, community rice mills, and other cooperative schemes (44).” The SEP became a foundation for Thailand’s health volunteers, promoting communities’ sense of belonging, empowerment, social cohesion and voluntarism by doing good deeds for the well- being of others. These village health volunteers are a major force for universal health coverage (UHC) in Thailand. SEP is aligned with the SDG agenda and in 2016 the Thai cabinet began actively promotion the application of SEP to meet the SDGs in all areas and at all levels. Thailand has also been promoting SEP as a development philosophy with the international community, particularly through the G-77 chairmanship in 2016 (45). United Arab Emirates In 2019, the United Arab Emirates adopted the National Strategy for Wellbeing 2031, which is based on a national framework consisting of three levels – individuals, society and the country. The framework includes 14 components and nine strategic objectives, which include enhancing people’s well-being by promoting healthy and active lifestyles, promoting good mental health, and adopting positive thinking. The strategy includes 90 supporting initiatives focused on over 40 priority areas. A key strategy, overseen by the National Wellbeing Observatory, with the intention of supporting the policy decisions, monitors well-being indicators and submits regular reports to the United Arab Emirates Cabinet. The United Arab Emirates strategy takes a whole-of-government approach and looks at individual well- being, strong community relations and the economy. It seeks to pay particular attention to cities, infrastructure, preserve culture, and ensure sustainability of natural resources. The United Arab Emirates builds on key health promotion principles: the federal entity does not work alone, the ministry of health works with all the other ministries, and there are guidelines for how to work with other stakeholders. Having identified the national priority areas, the targets have their own indicator cards and are evaluated on a yearly basis and reported back to the Prime Minister’s office to ensure progress in accordance with the national strategy. 14 International case OECD’s Economy of well-being The OECD provides an example of policy efforts that clearly link individual well- being with societal-level economic well-being. Building on their previous work in furthering understanding and measurement of a multi-dimensional concept of well-being, the OECD introduced the notion of an Economy of well-being (46). The intention is to support policy-makers in decision-making by providing specific guidance for political action. The OECD defines the Economy of well-being as an economy that (40): 1. expands the opportunities available to people for upward mobility and for improving their lives along dimensions that matter most to them; 2. ensures that these opportunities translate into well-being outcomes for all segments of the population, including those at the bottom of the distribution; 3. reduces inequalities; and 4. fosters environmental and social sustainability. The OECD sees the work as both an end in itself and a means to other goals. By identifying goals for individual well-being and supporting people in the attainment of those goals, policy-makers are promoting well-being as an intrinsic good, while also recognizing that supporting people’s ability to realize opportunities will lead to long-term economic growth, stability and resilience over time. The assumption is that individual and societal well-being will have a synergistic effect, strengthening and reinforcing one another in a virtuous circle. The agenda specifically identifies four policy areas that have an outsized impact on economic growth and well-being: a) education and skills; b) health care; c) social protection and redistribution; and d) gender inequality. 15 DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Discussion The COVID-19 pandemic and the ensuing crises have caused widespread devastation across the globe. Now ore than ever it is clear that there is a moral obligation to strengthen community resilience and solidarity, which governments can promote through comprehensive well-being strategies.  The well-being agenda strives to create social, economic and environmental conditions that support individual and collective health, quality of life, ability to thrive, the equitable distribution of resources, and planetary sustainability. Societies that centre on this idea of well-being intentionally create resilient, empowered communities, prepared to transcend challenges. Through good governance and the achievement of the SDGs, societies can contribute the essential resources needed for people and communities to overcome their challenges, realize their unique contributions and, in turn, contribute back to the health, well-being and sustainability of society at large. The notion of ‘contribution’ is relevant at the individual, community, as well as at national and international levels. A country that is able to balance its resources to meet its challenges will have much to contribute to the regional and global community. Focusing on sustainable societal well-being creates a virtuous cycle that adds synergy to the WHO Healthier Population’s Framework and the larger SDG agenda. To move toward a virtuous cycle of resiliency, a paradigm shift is needed. GDP has dominated human development thinking since the 1980s. Siloed sectors attempt to meet needs, but because of the profit-driven nature of societies’ organizing principle: that a privileged few enjoy most of society’s benefits, while a majority of people and the planet fall are overlooked. Fig. 2 depicts the transitions that are needed to move from this inequitable and reactive model, driven by GDP to one that achieves the following: 1. Addresses upstream determinants of health and well-being. 2. Considers individuals within the context of their communities. 3. Considers long-term health and well-being impact across generations. 4. Looks at the co-creation of health beyond care and disease prevention. 5. Prioritizes human rights. 6. Works to ensure peace. 7. Is guided by the principles of sustainable economy and prosperity that are equitable and create no harm. 8. Creates equitable and social conditions for all, moving away from victim blaming and individual responsibility. 9. Promotes a relational, holistic approach through partnership and breaking silos. 10. Appreciates the interconnection of humans, animals and the environment (One Health). 16 Fig. 2 places well-being at the centre of the sustainable development agenda, acknowledging that attainment of the SDGs will occur through collective efforts that are aimed at achieving a united vision of well-being for all. In turn, this approach can help to create resilient societies, and more resilient societies are better able to meet the goals: once again creating and reinforcing a virtuous circle of well-being that strengthens over time. Fig. 2: Paradigm shifts towards peaceful, healthy and resilient societies Powerful forces currently influence actions that run counter to this agenda. The economic paradigm is solidly entrenched and marbled with vested interest. Politicians are often pressured by economic interests that may not be in line with public health interests. Rates of tobacco use, excessive alcohol consumption and unhealthy diets are driven by aggressive marketing campaigns by transnational companies that have the economic power to subsidize election campaigns of influential politicians and/or parties. A well-being agenda requires longer- term thinking than the typical political election cycle allows. Many public health investments have ultimate impacts in relation to life expectancy, much longer than the duration of most political cycles. Parliamentarians should not be overlooked, however, as they represent important constituencies and may control or influence government decision-making in some countries.  Building a political agenda focused on well-being will require a fundamental shift from current public health models and preliminary work to creating more conducive conditions by: • Deciding on a collective consensus on how the concept of well-being can serve to transform societies to be more resilient. This should be founded on common values and with specific commitments for societal transformation to support a whole-of-government, action-based approach. • Identifying relevant regional, national or local goals and objectives, and means of achieving them. • Adopting design processes that ensure open collaboration and accountability. • Linking funding to achievement of clearly defined well-being objectives. • Monitoring and measuring a broad range of locally relevant well-being outcomes. Paradigm shift Pe ac efu l resilient societie s healthy Well-beingEducation Health Security Schools Hospitals Industry Military Economic driven GDP Downstream Individualistic Disjointed Disease prevention or treatment Inequitable Reactive Fragile Upstream Unified goals Common vision and values Integrated Universal Resilient Relational 17 DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda Ways forward The well-being agenda calls for a paradigm shift from narrow measures such as GDP or disease prevalence to a broader view of health and well-being. A focus on well-being can bring policy coherence across sectors and galvanizes action towards improved quality of life for all. Building societal well-being helps create resilient and sustainable communities that are able to respond to current and emerging health threats, such as the COVID-19 pandemic. Well-being policy brings into focus the health, economic, social and environmental aspects of the sustainable development agenda, and can guide governance objectives and budgetary allocations in support of healthy populations, equity and sustainability. The COVID-19 pandemic and the crises it has triggered highlight that for most people there is more to life than money. This should be the basis for the governments to reset their vision for a post-COVID world and revisit the SDGs on behalf of the global community. What would this mean in terms of practical policy changes?  • Mental health has deteriorated markedly in many settings as a result of widespread measures and behaviour changes aimed at controlling the spread of the SARS-CoV-2 virus. Reversing this is essential. There is a risk that the diversion of resources to COVID diagnosis, vaccines and care will inadvertently re-prioritize tackling of physical, visible problems, effectively relegating mental health to be a matter of secondary importance. Physical and mental health conditions must be tackled in unison.  • It has become increasingly clear that children gain much from school that is not directly related to passing examinations. Parents and teachers aim for children to be kind, resilient and enterprising, strengths that support them in many ways and throughout life, including academically. Various pilot schemes are being set up to assess how approaches that help to enhance children’s well-being might become a more explicit focus of all schools.  • Economically, a focus on well-being means making specific efforts to keep people engaged in the labour market. Being out of a job not only means a loss of income: it reduces self-esteem and may lead to loss of skills. There may be a need to increase spending on infrastructure to help less prosperous regions, acknowledging that social capital matters as well as physical capital.  • Encouraging community organizations and helping the civic sector to reach its full potential also contributes to enhanced well-being. During the COVID-19 crisis, the demands on many non-profit organizations have increased and yet their funding has decreased. At the same time, communities have discovered how much organizations and individuals can help each other. This sense of social togetherness should not be lost.  • Governments around the world are realizing that a well-being framework helps them to deliver what people really want, also making such initiatives good politics. Experience shows that incumbent governments tend to be rejected in subsequent elections when overall well-being of the population has declined during their term. Prime ministers from New Zealand to Iceland, and many countries, in between have successfully integrated the well-being agenda and have been met with increasing popularity as a result.   18 DEVELOPMENT WELL-BEING HEALTH SUSTAINABLE EQUITY EQUITY PEOPLE Health Policy HEALTH POLICY Health Policy AGENDA AGENDA INDIVIDUAL Commercial Determinants community action investment empowerment life course social determinants COMMUNICATION Literacy HEALTH IN ALL POLICIES advocacy COVID-19 COVID-19 economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy agenda References 1. WHO. Constitution of the World Health Organization. 1948. https://www.who. int/governance/eb/who_constitution_en.pdf 2. WHO. Declaration of Alma-Ata. 1978. Available from: https://www.who.int/ publications/almaata_declaration_en.pdf 3. WHO. Ottawa Charter. 1986. Available from: https://www.who.int/ healthpromotion/conferences/previous/ottawa/en/ 4. Commission on the determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health – Final report of the commission on social determinants of health. 2008. Available from: https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1 5. WHO. Reducing health inequities through action on the social determinants of health. In 2009. (WHA62.14). Available from: https://apps.who.int/gb/ebwha/ pdf_files/A62/A62_R14-en.pdf 6. WHO. Rio Political Declaration on the Social Determinants of Health. 2011. Available from: https://www.who.int/sdhconference/declaration/en/ 7. WHO Regional office for Europe. Health 2020: A European policy and strategy framework for the 21st Century . 2013. Available from: https://www.euro.who. int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf 8. UNDG. A Million Voices: The World We Want. 2013. Available from: https:// www.undp.org/content/dam/undp/library/MDG/english/UNDG_A-Million- Voices.pdf 9. WHO. WHO Framework Convention on Tobacco Control. 2003. Available from: https://apps.who.int/iris/bitstream/handle/10665/42811/9241591013. pdf?sequence=1 10. WHO. Stronger Collaboration, Better Health Global Action Plan for Healthy Lives and Well-being for All. 2019. Available from: https://www.who.int/ publications/i/item/9789241516433 11. UN. Political Declaration of the High-level Meeting on Universal Health Coverage “Universal health coverage: moving together to build a healthier world”. 2019. Available from: https://www.un.org/pga/73/wp-content/ uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf 12. Durie, M. (11999). Te Pae Mahutonga: A model for Māori health promotion. Health Promotion Forum of New Zealand Newsletter, 49, 2–5. 13. WHO. Declaration of Astana. 2018. Available from: https://www.who.int/docs/ default-source/primary-health/declaration/gcphc-declaration.pdf 14. WHO. Thirteenth General Programme of Work 2019–2023. 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP- 18.1-eng.pdf 15. Whitmee, S., Haines, A., Beyrer, C., Boltz, F., Capon, A. G., Dias, B. F. de S., Ezeh, A., Frumkin, H., Gong, P., Head, P., Horton, R., Mace, G. M., Marten, R., Myers, S. S., Nishtar, S., Osofsky, S. A., Pattanayak, S. K., Pongsiri, M. J., Romanelli, C., … Yach, D. (2015). Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet, 386(10007), 1973–2028. https://doi.org/10.1016/ S0140–6736(15)60901–1 19 16. WHO. One Health . 2017. Available from: https://www.who.int/news-room/ q-a-detail/one-health 17. Garine-Wichatitsky M de, Binot A, Morand S, Kock R, Roger F, Wilcox BA, et al. Will the COVID-19 crisis trigger a One Health coming-of-age? Lancet Planet Health. 2020 Sep 1;4(9):e377–8. 18. Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants of health. Lancet Respir Med. 2020 Jul 1;8(7):659–61. 19. Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect. 2020 Aug 1;81(2):e16–25. 20. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010 Sep 20;5(1):69. 21. Huta V, Waterman A. Eudaimonia and Its Distinction from Hedonia: Developing a Classification and Terminology for Understanding Conceptual and Operational Definitions. J Happiness Stud. 2014 Dec;15(6):1425–56. 22. Ryff CD, Singer BH. Know Thyself and Become What You Are: A Eudaimonic Approach to Psychological Well-Being. J Happiness Stud. 2008 Jan 1;9(1):13–39. 23. Olsen JA, Misajon R. A conceptual map of health-related quality of life dimensions: key lessons for a new instrument. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2020 Mar;29(3):733–43. 24. Delle Fave A, Brdar I, Wissing MP, Araujo U, Castro Solano A, Freire T, et al. Lay Definitions of Happiness across Nations: The Primacy of Inner Harmony and Relational Connectedness. Front Psychol . 2016 [cited 2020 Nov 2];7. Available from: https://www.frontiersin.org/articles/10.3389/fpsyg.2016.00030/full 25. Barcaccia, B., Esposito, G., Matarese, M., Bertolaso, M., Elvira, M., & De Marinis, M. G. (2013). Defining Quality of Life: A Wild-Goose Chase? Europe’s Journal of Psychology, 9(1), 185–203. https://doi.org/10.5964/ejop.v9i1.484 26. Camfield L, Skevington SM. On Subjective Well-being and Quality of Life. J Health Psychol. 2008 Sep 1;13(6):764–75. 27. Headey B. Happiness: Revising Set Point Theory and Dynamic Equilibrium Theory to Account for Long Term Change. German Institute for Economic Research; 2006. Report No.: 607. Available from: https://ideas.repec.org/p/ diw/diwwpp/dp6 2–5. 28. Dodge R, Daly AP, Huyton J, Sanders LD. The challenge of defining wellbeing. Int J Wellbeing . 2012 Aug 29 [cited 2020 Aug 27];2(3). Available from: https:// www.internationaljournalofwellbeing.org/index.php/ijow/article/view/89 29. Diener E. Guidelines for national indicators of subjective well-being and ill- being. J Happiness Stud Interdiscip Forum Subj Well-Being. 2006;7(4):397–404. 30. Rao ND, Min J. Decent Living Standards: Material Prerequisites for Human Wellbeing. Soc Indic Res. 2018 Jul 1;138(1):225–44. 31. Gudynas, E. (2011). Buen Vivir: Today’s tomorrow. Development, 54(4), 441–447. https://doi.org/10.1057/dev.2011.86 (p. 441) 32. Durie, M. (1999). Te Pae Mahutonga: A model for Māori health promotion. Health Promotion Forum of New Zealand Newsletter, 49, 2–5. 33. Healthier Societies for Healthy Populations Group. (2020). Healthier societies for healthy populations. Lancet (London, England), 395(10239), 1747–1749. https://doi.org/10.1016/S0140–6736(20)31039–4, (p. 1748) 20 34. Centre for Bhutan Studies and GNH. Gross National Happiness and Development. 2004. Available from: http://www.grossnationalhappiness. com/books/gross-national-happiness-and-development/ 35. Schroeder K. Politics of Gross National Happiness: Governance and Development in Bhutan. 1st ed. 2018 Edition. New York, NY: Palgrave Macmillan; 2017. 159 p. 36. UN. Resolution 56/309 Happiness: towards a holistic approach to development https://www.un.org/esa/socdev/ageing/documents/ NOTEONHAPPINESSFINALCLEAN.pdf. 37. Finland Government. https://ssir.org/articles/entry/the_vision_of_a_ well_being_economy 38. Finland Government. https://valtioneuvosto.fi/en/marin/government- programme 39. Iceland Government. https://www.government.is/lisalib/getfile.aspx? itemid=fc981010-da09–11e9–944d-005056bc4d74 40. New Zealand Government. The Wellbeing Budget. 2019. Available from: https://www.treasury.govt.nz/sites/default/files/2019–05/b19-wellbeing- budget.pdf 41. Scotland Government. https://nationalperformance.gov.scot/ 42. Bergsteiner, H., & Dharmapiya, P. (2016). Sufficiency economy philosophy process. In G. C. Avery & H. Bergsteiner (Eds.), Sufficiency Thinking: Thailand’s gift to an unsustainable world (pp. 1023–1343). Sydney: Allen & Unwin. P. 1101 43. Mongsawad, P. (2012). The philosophy of the sufficiency economy: A contribution to the theory of development. https://doi.org/10.18356/02BD5FB3-EN 44. United Nations Development Programme (2007). Thailand Human Development Report 2007: Sufficiency Economy and Human Development. Bangkok: UNDP, p. 48 45. Barua, P., & Tejativaddhana, P. (2019). Impact of Application of Sufficiency Economy Philosophy on the Well-Being of Thai Population: A Systematic Review and Meta-Analysis of Relevant Studies. Journal of Population and Social Studies [JPSS], 27(3), 195–219. 46. OECD. The Economy of Wellbeing. 2019. Available from: https://www.oecd- ilibrary.org/economics/the-economy-of-well-being_498e9bc7-en

For more information, please contact: healthpromotion@who.int well-being well-being health sustainable development equitypeople peoplehealth equity sustainable development sustainable health policy agenda agenda individual commercial determinants commercial determinants community action community action investment empowerment empowerment empowerment life course life course life course social determinants communication literacy health in all policies health in all policies health in all policies advocacy advocacy advocacy advocacy COVID-19 COVID-19 economy of well-being economy of well-being quality of life health promotion environment economic determinants population healthy life expectancy Towards Developing and Sustaining the WHO Well-Being Agenda DISCUSSION PAPER