PaclIIc islandS ...... be plam ......
Children are nllrtured in botfy and mind; Environments invite learning and leisllre; People work and age with dignity; E&ologi&al balan&e is a sOllru of pride; The o&ean whi&h slistains liS is protuted.
WROIWPROtm
MANILA, PIULI'MICS ·
20 NOV
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CONTENTS PI.lcw and Adiuowl.d.' ••b ........................... ......................................,............... ......... .iii hlb dudlan 1.1 1.2 1.3 1.4 Wh y prod uce guid elines? .......... .... ............ .... ....... ... ... ........ ..... ..... ... ... . 7 What is meant by H ealthy Island s? .... .. ................. .. .... ........ ...... ........... 7 What prompted this development? ... .... .... .. ....... ....... ................ .... .. ... . 8 Who wo uld use these Guidelines? ... ... ..... .. ..... .. ..... .. ...... .... ....... ..... .. .. .. 8
Hilda. unci ID the Cdd ..... 2.1 2.2 What are the special characteristics of Pacific island cou l1tries? .......... .. . 9 What health approaches have been used in the P acific? ..... ..... ........... ... 9
2.3 A framework for operationa lizing the Healthy Island s vision .............. 10 2.4 What common lessons were learned from early rrials?............ ............. 12 2.5 What would characterize realization of the Vision ' ........... .. ................ 14
MavhllllD AdIan 3.1 Steps fo r initiating actiol1 .. .... .. .. ...... .. .. ....... .. .. .. .. .. .. .. .. ...... ............ .. .... . 16 3.2 Checkpoints for ini tiating action .. .. .. ............ ................ .... .. ....... .. .. ...... 22 3.3 Steps for implementing ac tion ......... .. ................. ... .. .. ........ ..... .. .... ... .... 23 3.4 Ch eckpoints for implementing actio n ... .. ........ ......... .. ...... ............... .. .. . 24
Ann".sl Annext Glossary .. ...... ..... .. ............. ..... .. .... .... ... .......... ... ..... .... ... .... ...... ............... ... 25
Annex 2 Possible attributes and indicato rs fo r the core elements .... .. .... ........ .. ...... .... 27
G lobalization of the world's economy has resulted in the accelerated movement of goods, people and information, affecting the livelihoods of people in the Western Pacific Region. The effect is particularly great in small island nations in the Pacific, most of which have limited natural, industrial, human, and flnancial resources and are thus morc vulnerable to external influences. The importation
of food items, for example, influences the dietary patterns of people, hence affecting their health. Similarly, changing cultural and social Dorms in these Pacific island countries influence the nature of the community and the bebaviour of individuals, thus affecting their health. The global climate variability and change also impact tbe safety and health of people in the Pacific. Since 1995 when the first Pacific Health l'vlinisters' Meeting was held on Yanuca Island in Hji, the World Health Organization Regional Office for the Western Pacific has worked closely with its member countries to develop the concept and v1sion of Healthy Islands and put them intO practice. Further development in Ilcalthy Islands was reviewed, and leadershjp support confirmed, at the subsequent
Pacific Health linisters' Meetings in Raratonga, Cook Islands in 1997 and in Korar, Palau in 1999. At the fOllrth Pacific Health J\'finisters' Meeting in ladang, Papua New Guinea in 2001 it was reaffirmed that Healthy Islands provides an overarching framework for health protection and health promotion in the Pacific, and the l\1inlsters committed to making the vision of Healthy "I slands a
reality. The meeting participants also confirmed that the core elements of Healthy Islands were community action, environmental management and policy/ infrastructure development.
The development of regional guidelines on llealthy Islands was first discussed at the WHO workshop on Healthy Islands in Suva, Fiji in February 1999. Two years later, draft regional guidelines were reviewed and discussed at another \VHO technical workshop on Healthy ISlands initiatives in Nadi,
Fiji, in January 2001 . Comments from participants and other relevant practitioners of Healthy Islands on the draft guidelines were incorporated into this publication. The publication is a compilation of views, practices and experiences in developing and implementing Healthy Islands initiatives garn ered over the last six years. It should be regarded as a progressive, working document, and will be revised as morc experiences are accumulated in the future. In the meantime, we hope that these gujdelines wiU serve as a useful reference document for more innovative local and national initiatives of Healthy Islands.
Shlgeru Region al Director
l:!:!:
ACKNOWLEDGMENTS
M
any people contributed their valued time and effort to the development of these regional
guidelines for converting the Vision of Healthy lslands
[Q action. 'To begin with. the Vision was framed, confirmed, and further developed during the regular reb~onal meetings of Pacific island
leaders which took place in Yanuca Island, Fiji (1995), Raroto nga, Cook Islands (1997), Koror, Palau (1999) and Madaag, Papua New G uinea (2001 ). Issues leading to the need for such guidelines were raised at a regional workshop in Suva, Fiji in February 1999. The firSt draft was subsequently compiled by J an Ritchie, Michael Sparks and Atie Rotem from the School of Medical Education, University of New South Wales, Sydney, Australia. I'urther development preceded another regional workshop, convened in adi, Fiji in January 2001. Based on the input provided during this workshop, another draft was prepared. final review and comments were sought from the workshop participants and
other relevant policymakers and practitioners of Healthy Islands in the Pacific before finalization of
the document. Thanks for these contributions arc extended to Tetupu Araiti, Rosmarie Erbcn,Joscphine Gagliardi-Gregiore, Karen Heckert, Robert Hughes, Dennie 1niakwala, Vivian lin, Heather MacDonald, Caleb Otto, Harry Paka, Brent Powis, Yogendra Ptadhananga, Lindsay Piliwas, Tiliga Pulusi, Don Sharp, Barbara Spalding, and Puka Temu. This most recent draft of the work in progress was compiled by J an Ritchie, Hisashi Ogawa and Gauden Galea.
1.1 ~ praduce guidelines? These guidelines are designed to take the Vision of Healthy Islands forward and support Pacific Island countries who have, as a group, expressed a wish to convert this V isio n to action. A common framework is slowly emerging from the various experiences of the different countries in the Western Pacific Region over the last six years. The g uidelines are the outcome of these experiences, compiled here in a form that countries can choose to use in whichever way th ey find best, in order to implement
national Healthy Islands action plans effectively.
1.2 What Is mIGht b!I' HeaRt., Islands? T h e Vision of H ealthy I slands refers to that set by Pacific Health leaders at their meeting on Yanuca Island, Fiji in 1995 and stated in the opening words of the ensuing declaration. The Vision has been recently enhanced by the addition of a fifth component, as agreed when the Pacific Health leaders met again this year,in 2001, in Madang, Papua New Guinea. The Vision appears on the title
page of this document, but is worthy of bears repeating:
H ealthy I slands are p laces IVhere: Children are nurtured in body and mind; E n viroIll11enfS in vite learning and leisure;
People work and age with dignity; Ecological balance is a source of p ride; The ocean which sus tains us is protected . ~fadang
Commitment 200t, building on the
Yanuca Island Declaration, 1995)
The concept of H ealthy Islands was defmed during the Yanuca Meeting as 'the unifying theme for health protection and health promotion for the Pacific in the 21st Century'. The concept involves enhancing exis ting heal th services health as well as res to ring it.
by a broadenjng the focus
to include creating and maintaining
The concept was strengthened at ti,e Pacific Health Leaders' Meeting of 1997 in Rarotonga. The Rarotonga Agreement stated: Tbe Healll!} Islands concept illvolves (Ollti""OIlS!J identifying alld resolt.illg pnon"ty isSllU related
10 btallh, det.lopllltol and Ivell-being 0' admcating, facililating and enablillg tbese iSSIIU 10 be addressed ill paltlferships alJJo11g (Ollllllllllih" u, orgo11izoh"olls and agmdu at lo(a~ 11ational and "gional levels.
I. IntroductIon
3
1.1 What promplied this ..." lIapme.. t? As is eyident from the above, Pacific health leaders have convened regular regional meetings in the last several years to discuss issues of concern that are relevant to countries across the Pacific, and to share ways of addressing these concerns. From their meeting in 1995 arose the Yanuca lsland
Declaration on Health in the Pacific in the 21 st Century, where they proclaimed the commitment of their countties to act to enhance the quality of life and the continued well-being of their people. The Vision was conceived, and documented in
the declaration. In addition, the declaration stated the aim
of placing this Vision within national plans: COlJsenSIIS ]I1OS reached 011 a course islanders al Ibe (mire
of actioN to place Ibe begllb ol1d well-bei"g oj Pllcifle
oJ lJalional del'elopfJIenl plans.
The leaders met again at Rarotonga in 1997, to reviewing progress towards realizing the Vision and reaffirming the importance of partnerships among communities, gO\'ernment departments and other sectors in resolving priority health issues. The outcome of the meeting was the Rarotonga Agreement which reiterated the consensus and commitment declared at the Yanuca Island rvfeeting. Countries agreed to develop plans of action, and to put in place coordinating mechanisms at the
national b·el to suppOrt these plans. 1\ further Ministerial Meering was held in Koror, at Palau in 1999. The leaders signed the Palau Action Sratcment agreeing to review progress made and endorsing the importance of each country \vorking within their own priorities.
The most recent i\linisterial i\ leeting in Healthy Islands for 2001-2003.
~[adang,
Papua New Guinea in March 2001, reaffumed
the good progress made in implementing Healthy Islands and adopted the regional action plan on
The de"elopment of the Vision of l icalth)" Islands O\·er these four meetings has demonstrated the leaders' continuous commitment co it, and further, to the conversion of the Vision to its realization. Local ownership of the Vision is clearly a reality, and countries express a genuine desire to take action.
u Who
would
we these gu.....lnes?
The guidelines have been developed for those who are responsible in all these Pacific Island countries for converting the health leaders' Vision of Hea1thy Islands intO practice. The document is
targeted primarily at policy make rs and poticy implementers at the nationallcvcl, but it is intended that it can also be used by health workers at the locallevcls.
TO 'l1li
The Vision of Health), Islands has arisen within the unique Pacific setting and developed as a way of improying upon pteyious approaches to
address ing the health of Pacific island people. As an
e\rolving process, it takes into account earlier experiences and the resulting lessons learned. Backgrou nd factors that have influenced this evolution include the unique characteristics of these island nations, current and previous approaches that these cou ntries have used to advance the health of their people, the global infl uences of the "settings" approach and earlier experiences of implementation in this
locality.
2.1 What are the special characterlstla of PadRe Island CIOUilb ...7 The Pacific island countries have particular characteristics which create a unique backdrop to the Vision of I lealth)' Islands. To begin with, island countries have their own local geographic and meteorological influences which must be taken in account. ~Lany
are very small and most arc remote from industrialized countries, with
their islands widely scattered within a vast ocean. This has led to transport and communication difficulties leading to constraints on such health-related activities as procurement of technical resources or difficulty in waSte recycling. Assigning human and material resources to outer islands to pro\~de appropriate health services is costly, time-consuming, and frequently limited by lack of an adeguatcly trained workforce. i\ [ost countries express a need to upgrade resources and training to cope with this deficiency. The climate of these Pacific island countries is tropical, leading to the potential hazards of'lphoons and cyclones) and to risks of diseases carried by \vater, food and mosquitoes. Some countries are also at risk of volcanic upheavals and others fear global warming. Dealing "ith health crises which result from these extreme conditions can use the entire health budget and more, leading to great disruption in regular semces.. Sharing mechanisms across countries that deal with these crises in \vays that result in morc fruitful outcomes is a regional imperative. Another imponant characteristic is that island countries with small populations have modest economic bases with consequently limited natural, human and financial resources. Tiny domestic marketS, weak taxation sysrems, limited industrial development and marked trade imbalances are typical. Tourism is increasing but brings tensions when economical benefits are sought ~u the risk of environmcmal damage. In these instances the health of the environmem and therefo re of the people may take second place to economic development and provision of tourist facilities. Overall, the economy of the Pacific has for decades been characterized by dependence on foreign aid. The health systems are equall), as dependent as other sectors. Innovative ways of addressing issues within these low-level economic bases need to be funher explored. The fragile narute of these small islands means that increases in their population size puts their physical environment at risk. Difficulties in waste disposal, water contamination, and toxic chemical use are making waste management o ne of the major environmental health issues in the Pacific. AgaJn. sharing experiences about what has worked is essential.
2 £Jocbground
to the Cuidelinln
5
The strong cu.ltural traditions of the "Pacific war" are being slowly but surely eroded b}' \Vestern influences, weakening the values of long- held customs. Furthermore, other industrial society trends such as the shrinking of the extended famil y, urbani zation, and the ageing o f the population arc also impacting Pacific societies. All countries are expressing a wish allow retention of traditional values. These shared characteristics of Pacific island countries have led to these countries recognizi ng the benefits of cooperating with each other in addressing their unique needs. Pacific islanders are becoming increasingly vocal in their demands ro have a direct role in decisions about their future rather than taking direction from foreign experts. Carrying the shared Vision of Healthy Islands forward to actio n is one such instance of them taking these concerns into their own hands. to
deal with these issues in ways that
2.2 What hulth appi DacMs have ........... In the PuclRe7 Based on this unique Pacific setting, health care patterns evolved initially within their own local context, with later strong influences from wider global forces. Traditionally, Pacific peoples' pcrceptions of health have been more to do with well-being and quality of life, as judged by the people themselves, rather than their clinical state of health as defined in a medical sense. Each cultural group originally developed its own way of promoting health and dealing with diseases and conditions which arose. As medical care has become the dominant approach in recent decades, developments have focused on diagnosis and treatment of disease. \x/ith sparse human and fmancial resources, this emphasis has been to thc detriment of health promotion and health protcction in many instances. To assist countries ro rcfocus on a broader perspective embracing promotion, protcction and preycntion, \VIIO in 1978 called on them to embrace primary health care, and Pacific island countries were qukk to respond. Pri mary health care refers to a particu lar approach to health care whereby essential services include public health components such as clean water and good sanitation, preycntive measures such as immunization and antenatal care, and clinical scn;ces are offered in a way that is mOSt appropriate to
each country and its resources. This new global approach appeared to be consistent with the original
concepts of health held by people of the Pacific and was heralded as havin,\ the potemial to be improved on the pro\.ision of clinical services. I r was proclaimed that primary health care would address essential services in a way that would be accessible, affordable and appropriate. But despite these hopes, primary health care has not lived up to its expectations in many countries. On the whole, prevention and health promotion have attractcd less artention lhan acute care, conununhy participation has been minimally enb:raged, intersecrorai collaboration has rarely taken place and the very suong focus on clinical care has remained. Seeing rhe need for another entry point to refocus) c( agrun, WHO g,,·e health promotion a boost globally in the mid 1980s. 11 ealth promotion, as defined in the Ottawa Charter of 1986, "i s the process of enabling people to take control of and improve their health" . Although health education had been listed as an essential
element of primary health care, provision of information on the "right" war
(0
prevent and control
6
2. IkKkground to the CuideNneJ
diseases has not necessarily brought about changes in inctiddual's desired beha\rl.ours. In dlC experiences of many islanders, health education has been based on scientific "facts", often presented in a way which has ignored cultural traditions. Based on the recognition that this way of influencing individuals to
change their behaviour has so often proved to be ineffecth-e, the charter endorsed much wider to
social and structural change through the building of healthy public polic)" the creation of supportive
environments and the strengthen ing of community action, as well as continuing
suppOrt the
deyelopment of personal skills. In addition, ir proposed that reorientation of healrh sen·iccs, which began with primary healrh care, should be continued and reinforced. The expanded definition of health promotion has been a major step forward in promoting people's health through a multifaceted framework for action. Rather than focusing only on individual willpower, the chartcr suggested changing
social and physical environments to tlmake the healthier choice the easier choice". Health protection refers ro strategies adopted by authorities to address the preservation of the health of the community through legi slative and regulatory measures. E.nvironmental health is a wider term which encompasses the protection of people from environmental risks as well as embraces the
maintenance and sustainabiliry of rhe physical conditions for healthy life and the management of environmental resources for the benefit of human health. It is clear in island countries that the health ,.
of people is gready influenced by the srate of the island environment. Human beings need to be protected from unhealthy environments; simila.rly, the env'ironment needs to be protected from
becoming unhealthy through inappropriate human action in the first place. Environmental healrh activities in the Pacific evolved in parallel to the development of medical care \virh the \vork of such key personnel as sanitary engineers and health inspectors. Once primary health care was embraced, it was envisaged that environmental health would take its rightful place since, for instance, the maintenance of clean water supplies and the establishment of appropriate sanitation were essential elements of this
approach. The Vision of Ilealthy Islands includes a strong thrust by Pacific islanders to maintain and sustain d,e healrh of their island environments in order to promote the health of their people and has given new impetus to integ ration. As the Yanuca Island Declaration states:
E nvironmental health musr be inregrared with other health programmes and linked to the activities of other sectors.
:z.s. A .lalLS_a.... for apllatlonal""" the Healthy Islands VIsion :z.J.1. SettIngs approach Healthy settings o r a sertings approach refers ro an approach to promoting the health of whole communities where the primary focus is on creating and maintaining healthy living conditions and associated lifestyles across whole settings, directing attention to structural and organizational change
and (b;eiopment, rather than to the health-related behaviours of individuals. Jusr as health promotion has embraced aspects of health protection in recognizing the importance of the creation of a supportive environment for health as a key action area, environmental health has similarly recognized that health
2. Background to the Culdelines
7
protection is strengthened when accompanied by community ownership. Recognizing the synergy between these two approaches, a new combined approach to health promotion and health protection has evolved with this settings approach, where these two ways of addressing the health of communities are together implemented in the settings where people live, work, learn and play. The earliest of these settings approaches has been the Healthy Cities movement which evolved in Europe and has spread globally to become a network of thousands of cities in both developed and developing countries alike. The same principles evident in the HealdlYCities approach can be applied to any serting where people gather. This has led to the developme nt of health-promoting schools and hospitals, healthy workplaces and marketplaces, healthy villages and communities, and others, with Healthy l slands being one of the most recent developments. The Rarotonga Agreement outlined an emerging Healthy Islands framework which was schematically presented in an annex co the agreement and is reproduced below. The participants at Rarotonga agreed that Healthy Islands was an overarching setting where health promotion and health protection strategies could be harnessed both across the whole setting of the island country, and also in smaller, more defined settings. The framework shows how these smaller settings, including healthy villages, towns, schools, homes, workplaces and markets, fit into the overall Healthy Islands context.
Emerging Healthy Islands framework
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2 Background to the Cuidellnes
2.3.2. Core
elements
The other component of the Rarotonga Agreement of 1997 that is important in tracing the background to Healthy Islands is the list of items that participants called core elements, which th ey determined should be addressed in these identified settings. The document pointed o ut that the list is no t exclusive or in priority order, bur that these sixteen elements should be considered. The sixteen are: adequate water supply and sanitation facilities; nutrition, food safety and food security; waste management; housing; human resou rces development; communicable and non-communicable disease prevention and control; lifestyle and quality oflife issues; reproductive and famil y health; promotion of primary health care; social and emotional well-being; population issues; ecological sustainability; information manageme nt; tobacco or health; alcohol and substance abuse; and environmental and occupational health. They covered almost all fields of public health, and country experiences indicated that they were not particularly useful in initiating Healthy Islands activities. The participants at the Nadi, Piji workshop in 2001 discussed the Rarotonga core clements and the experiences of countries in using th em, and came up with a simpler set of three corc clements. They Dominated the following: • Environmental management (where the environment includes th e socia-cultural and eco-nom ic as weU as the ph ysical); • Community action; and • Policy and infrastrucrure development. All three are key in all settings, however, environmental management and community action are particularly evident as local action and are most relevant to the smaller, more localized, settings whereas policy and infrastructure development are essential at the national level so that o nce in place, they can support local action.
2A What
comlllMl lessolls were ...." .d from
~
trials?
In the light of these historical developments in global health movements and in regional policy, some earl y attempts have been made in Pacific island countries to explore how the Vision of H ealthy ight be translated intO practice. Islands m, The \'VHO-hostcd meeting in Suva, Fiji, in February 1999 reviewed progress and implementation experiences. Participants at th e meeting drew on their own experiences to identify lessons learned. Following this meeting, the W HO Westero Pacific Regional Office produced a set of case studies of some early trials (see WP RO Healthy Cities-Health y Islands documents series no 10). In synthesizing the major iss ues arising from both the meeting and the case studies, the fo llowing factors were noted by participants as positive contributions:
Z Bocbground
to the Guidelk1eJ
9
• Commhment. Progress was noticeable when a clear commitment to the Vision was made by all
levels of Pacific island society, especially government leaders. • Leadership. A major feature contributing to the success of these early implementation trials was
the presence of a strong, motivated and influential leader. It appeared essential that the project have sufficient financial and political support to retain this leadership. • Local vision. Although some countries implemented their Healthy Islands action to
address
identified health problems, others followed the Healthy Cities' pattern of starting with a local vision of their island country in an envisaged furore ideal state, and set up strategies to work towards this
vision. Although both approaches were likely to end up with similar actions, it was noted that Pacific islanders in general preferred to focus on aiming for positive well-being rather then dealing with existing negative problems. • Diversity. It was clear that a wide range of interventions could quire appropriately fit under the
Vision of Healthy Islands and be implemented successfu lly. lndicators of success could be health outcomes (e.g. reduction in disease incidence) o r process monitoring (e.g. introduction of new
health policy). • Capacity building. Participants believed that implemenL1tion of the Vision of Healthy Islands would require the capacity of all levels of personnel - from ministry heads to
technical officers to
community leaders - to be built through both training and systems strengthening. • CoUaboration and partnership. The need for sharing and alliance-building between stakeholders was identified. Participants expressed a strong belief in participation and ownership. In particular,
they recognized the value of working across sectors other than hcalth, and they acknowledged the leadership skills required to
work inte"ectorally.
• Empowerment. A further lesson was the importance of alJowing communit}· participation to occur in a \Va}' that encouraged empowerment and self-determination. Often it was necessary to "kick-start" cOinmunity involvement by the leader or coordinator, and then to slowly step aside as the community rook more control. Results were more promising where political suppOrt for empowerment was backed by resources. • Evaluation. It was clear from the case studies that guidance was being sought for developing appropriate methods for evaluating Healthy Islands activities. Participants were interested in receiving assistance with using both process and outcome indicators effectively. It was clear that activities needed to be country-relevant with appropriate monitoring towards continuous improvement. • Sustainability. In all instances, the activities explored in these case studies retained community
interest after the dedicated funding ceased. Sustainability seemed possible with the essential ingredients of well-trained personnel, enthusias tic communities and appropriate resources.
10
2 Background to the Guidelines
2.5. What would chaiCX_be realization of
the Vision?
Building on the abm'e foundations and with the benefit of the lessons learned, some ke), characteristics of working towards the Vis io n of Healthy Islands at a national levd have been assembled. After reviewing the actions taken in the documented case studies that complement these guidelines, it
was felt that an ideal implementation experience would:
• Start in a small way from a wide range of entry po ints. Due to a consideration of local context, each country in the early stages may choose very different entry points from which to commence implementation. Being part of the national health plan is a potencial long-term goal butJ in the meantime, cotry points may address smaU, manageable health problems or risk factors, the
health issues of populations Ot groups, or smaller sub-settings within the Pacific island country such as a health promoting ,'illage project. • Adap' and be flexible. Healthy Islands is a dynamic, developing approach which should be able to grow, adapt and remain flexible. Particularly at this early srage, it must be characterized by openness to change.
• Be part and parcel of national heal'h plans. At rhe Yanuca Island Meeting, it was determined that the health and well being of Pacific peoples should be central to national de"elopment plans. The Vision of Healthy Islands has the potential to be incorporated into the national health plan so that the focus of the plan addresses health promotion and health protection as well as health care services in a systematic, integrated, planned and incremental approach.
• E ncompass all. I t is particularly significant that implementation of the Vision of Healthy Islands is being seen by Pacific island countries not as a replacement for projects focusing on specific health problems or particular population issues, but, instead, providing a mechanism to embrace
them all. • B e c ontext-s pecific. Putting the Vision of Healthy Islands into practice must be country-specific.
The particular social, political, economic and cultural factors of each is land context must be considered, along with taking account of the natural and built environment. • Include influe ntial partne rships. i\lechanisms art! put in place to achieve results nOt by the health secror alone, but through forging intersectoral collaboration and strategic partnerships. [t is likely, but not necessary, that the health sector wi U act as initiator or lead agency.
• Address equity. T he Vision for Healthy Islands envisages all community members achieving optimal health. Implementation of the Vision works best on the basis that greatest gains in health starns can be achieved through a fair and just approach, putting the primaty focus on promoting the health of those with least opportunities. • Integrate monitoring and evaluation. An integral part of implementing the Vision is document-
ing the steps taken, and indicating health-related Outcomes. Mechanisms to collect and document baseline data should be strengthened and processes to mo ni tor and evalu ate changes undertaken continuously.
2. Background to the Guidelines
11
• Include training and systems s trengthening. In order to undertake this implementation, commitment and resources will be required for building the capacity of those taking this Vision forward. • Incorporate general principles of settings approaches. The Pacific Vision of Healthy Islands is unique to the region, but countries can benefit by learning from other settings approaches - the Healthy Cities movement, healthy villages and healthy communities, health-promoting schools, workplaces and marketplaces. • Address action regarding the core elements. The three core clements identified at the Nadi, Fiji meeting - environmental management, commu nity ac tion and policy and in frastructure development - provide a basis for action. They can be broken down intO many smaller areas of actio n within these cores. • Foster ownership. Early trials indicated that the above characteristics must be incorporated in a way that fosters local ownership of any activities towards the Vision of Healthy Islands, such that change will be welcomed and sustained.
laMOV
TOACIIOI.
\Vith these characteristics in mind, the guidelines set out an approach that is generic and therefore
available for each Pacific island country to determine which are the key issues they want to take for their country-specific development. Contributo rs to this document have made very clear that there is a need for the guidelines to take the form of a framework or outer shell, within which countries can
build their own inner components. Although providing a common pattern available to all across the region, the guidelines are offered to be used in a way that is specific to each country's own needs and
resources. No single approach is the right onc and diversity is valued.
101 Steps for initiating action Regardless of which of the core elements are chosen as priority areas for each country, nine steps
are to be considered during the initial process of converting the Vision of Healthy Islands to action. These are: (1) Confirm political commitment. I t is essential that political commitment be obtained to develop
action plans in whichever form the country decides suits them. Although the health ministers of all countries attending the regional meetings indicated their commitment by being signatories to the agreements, confirmation on the ground by appropriate budget allocation would be a clear indicator of initial commitment. Eventually institutionalizing the way the Vision of Healthy Islands
is converted into action would be the soundest indkator of all.
Niue initiated a Healthy Islands project in 1995, aided by the Australian Government, putting in place a designated coordinator, a national committee, and a local name and logo. The approach progressed with strong political commitment. Upon completion of the three year project, New Zealand saw it valuable enough to allocate part of their recurrent health funds to support continuation for another three years, to mid 2002. Nuie now views Healthy Islands actions as essential, and intends to allocate further funds from that date.
3. Moving to Adion
13
(2) Collect baseli ne da ta. Since it is important
[0
monitor developments towards the Vi~ion of
Healthy Islands, much can be gained by identifying some key measures before commencing implementation, especially those that could indicate positive movement. Such data could include com'entional health Statistics like incidence and prevalence data, but from the point of vicw of health promotion and protection, could also comprisc documentation of existing relevant policies, health worker roles and responsibilities, identification of applicable environmental factors and commuruty perceptions and experiences. (3) P ublicize and promote the Vision of Healthy Islands. As with aU innovations, helping spread understanding is essential for eventual acceptance. Awareness of the meaning of the Vision and what it will do for the health of the people of the country must become widespread. Ideally, promotion of the concepts and related acti\'ities should occur very actively at the start and should continue as the action plans are implemented. Communication should occur throughout the health "ector, with key personnel of other sectors and with the community.
Samoa spread understanding of its initial Healthy Islands activities at all levels. Primary responsibility for Healthy Islands activities was initially in the hands of the Health Education and Promotion Service, but staff of this unit realized from the start the importance of harnessing energies across the country. The Director-General of Health became a faithful convert to health promotion, directing his attention away from disease-centred care, which encouraged strong partiCipation from the Nursing and Dental Health Divisions of the Clinical Services. Other sectors such as the Departments of Education, Women's Affairs, Treasury, Environment, Youth and Agriculture were drawn into the project. Partnerships developed with non-governmental organizations such as the Samoa Rugby Football Union, the Red Cross, the YMCA and various religious groups, in order to facilitate achievement of the project's goals. Social marketing campaigns were launched to raise awareness 01 Healthy Islands activities within communities across the island nation.
14
3. !.fov;ng to Acttcn
(4) Establish effec tive leaders hip. Since effective leadership was identified as a key element in all rhe early trials of Health), Islands, it is imperative thar a person with leadership qualities heads the action. Such qualities include among others, clarity of vision, ability to inspire confidence, deftness
in pulling together insights from different sources, confidence to act, and ability to mobilize others to act.
(5) N o minate team, Tn many instances, an existing team structure may be more appropriate than
the formation of a new onc. Key personnel inducting those from the health sector, orner government sectOrs, non-goycrnmenr organizations, community representath'cs and others, need ro work with the leader. A process for allocating the Healthy Islands' role to an existing council or commircce or nomination of new team members needs to be determined. Checkpoints would likely be identification of the range of represcntatives on rhe team.
fiji's National Centre for Health Promotion was responsible for initiating Healthy Islands activities on a national scale. The National Health Promotion Council was formed with key representatives holding various health sector responsibilities. In addition, other key players on the Council included representatives from the Ministry of Education and Technology, the Ministry for Regional Development and Multl-Ethnic Affairs, the Ministry of Fijian Affairs, the Ministry of Labour and Industrial Relations, the Fiji Council of Women, the Fiji Council of Churches, the Ministry of youth Employment Opportunities and Sports and the Ministry of Trade and Commerce.
3. Moving to Adion
lS
(6) Draw upon outside knowled ge. One of the lessons learned that had a positi"e influence on earlier trials was ha\-ing the opportunity provided to to
draw upon expert knowledge or external experiences.
The "kick-start" that either other countries with similar experiences or outsider expertise has countries newly developing their plans has been found to be invaluable.
The Solomon Islands used a Healthy Islands approach to address the serious problem of malaria in the capital, Honiara. The "kick-start" for this project came from WHO through the enthusiasm of the Regional Environmental Health Adviser and advice from consulting experts. However, rather than taking the lead, the experts supported the Solomon Islander Initiative to setting up their own mechanisms to get the project underway, and In making their own decisions about the way it should proceed. A multifaceted strategy was adopted which resulted in a marked drop in malaria incidence following this intervention. Activities include a community-wide campaign on World Health Day, case detection, surveillance activities, environmental management and householder involvement. A wide range of citizens of Honiara were thus responsible for the success of this project
16
3. Moving to Action
(7) Confirm resources. Once the leader and team are in place and the mechanism for operating decided, it is cssentiaJ to confirm that resources, in the form of personne~ equipment and fmances are readily available. (8) Set goals a nd objectives. The process may take the form of logical decision-making, following standard guidelines for serting health programme goals and objectives. On the od,er hand, this is the opportuniry for each country to modify the Vision of H ealthy Islands ro suit their own unique siruacion. Once the local Vision is explicit as a country-specific image, development of goals and objectives to convert the local Vision into action then follo\\~
Following the Palau Agreement of 1999, the people of Palau set to work to develop their own Vision of Healthy Islands. They determined that the vision statement issued from the Yanuca Island Meeting was most suitable as a basis for their own country vision, but they decided to expand upon it in relation to the issues especially important to Palau. The Pacific Health Ministers Meeting of 2001 at Madang, Papua New Guinea determined that one of the additional phrases included by Palau was relevant to all Pacific island countries. In this way the fifth line of the Vision statement, "The ocean which sustains us is protected ", was added to these guidelines.
(9) Develop action plans or integrate action into national health plan. The final Step in initiation is determining the actions (hat will aUow the set goals and objecti,~cs
to be achieved. To do
this, planners should consider the priority issues jdentificd above and suggest actions ro address these issues. These actions willlikeir fit into the core element cacegories of policy/ infrastructure development, environmental management, or community action. Indicators should then be dC\'elopcd for cyaluating and monitoring the progress of implcmenL~tion of the chosen action plan. Since more than o ne action plnn will usually be required to attain the Vision of Healthy
Islands, additional indicators would be very useful in gauging overall the degree to which the country has acbieved its Vision. Annex 2 suggests possible attributes and indicators for this purpose.
3. Moving
to Adion
17
In addition to being a signatory of the Yanuca Declaration of 1995, Papua New Guinea has confirmed its political commitment to Healthy Islands by its National Executive Council endorsing The Papua New Guinea Healthy Islands Plan of Action: A Vision for 21 st Century in November, 2000. The Council also directed the Department of Health and all agencies and local authorities involved in the various Healthy Islands settings to implement the plan of action (Step 1). As a part of dissemination of the Vision of Healthy Islands, Papua New Guinea named 1998 a year of Healthy Islands and organized a Health Expo to raise awareness of the Vision across the country. Videotapes were used in health worker training, and radio talk programmes and public speeches by government authorities also facilitated publicity (Step 3). The senior managers, including the Secretary of the Department of Health, with clear vision, confidence, and willingness to mobilize partners are leading the Healthy Island actions (Step 4). A multisectoral and multidisciplinary team (The Healthy Islands National Coordinating Committee) has been conceptualized to coordinate the overall activities. Establishment of provincial teams is underway. The Healthy Islands Unit at the Health Promotion Branch of the Department is facilitating implementation of various healthy settings (Step 5). National financial resources seconded by WHO technical support have been mobilized to carry out some healthy settings as the "kick-start" (Steps 6 and 7). The Healthy Islands Framework for a Plan of Action, approved by the National Executive Council, is a blue print for Healthy Islands initiatives in the country. The goal is to empower communities and individuals to be responsible for healthy living and healthy lifestyles in the context of community participation through a multisectoral and multidisciplinary approach (Step 8). The activity plan included in the National Health Plan 2001-2010 is geared towards realization of the Vision of Healthy Islands for 21st Century. The plan alms to establish provincial networks, develop local guidelines, train health workers and negotiate with partners for the implementation of healthy marketplaces, villages, schools, and health facilities. It is expected that the successful implementation of these activities would help realize the Vision of Healthy Islands for Papua New Guinea "to be a nation of healthy individuals, families and communities where self-reliance prepares all for healthy living in a healthy island environment" (Step 9).
18
3- MovIng
to Action
3.2. Chechpoints for initiating action As each step is rcached and passed, countries may want to audit progress through dOCUlllcntatio n o f the following checkpoints:
1. Confirm political commilment
i the Vision of Heatthy Islands 2. Collect baseline data
experiences documented 3. Publicize and promote Healthy Islands Campaign for dissemination of the Vision throughout initiated i put in place
4. Establish effective leadership country leaders documented 5. Nominate team
6. Draw upon outside knowledge created Input from outside experts providedgained 7. Confirm resources
8. Set goals and objectives
Sequences of goals and objectives documented, and/or country-specific Vision conceived Overall action plans specified; indicators to mon~or and evaluale progress determined
9. Develop overall action plans or integrate action into national heatth plan
3. Moving to Action
19
J.J Steps far ImpIIIiNiitl... action plans Once initiated, action plans need to be implemented. The following implementation issues need to
be considered: 10. De,ermine roles and responsibilities. With the leader and 'eam members in place, and goals and objectives set, a sharing of roles and rcsponsibilities to achieve them will need to occur.
11. Mobilize resource allocation. Similarly, the resources alIoca,ed will now need ro be available for usc.
12. Draw upon expert adYice. It is at this stage of clarifying what has to be done that the "kicksrar," from experts is probably mosr needed. This may be available within-country, or may need to be drawn from neighbouring countries with similar experiences.
13. Develop organizational capacity. Once implementation commences, organizational capacity to deliver the action must be developed. Capacity is required for overall management of the
action and within th is, for networking, collaborating intersectorall y, resource sharing, information e.'\changmg, reporting, decision-making. coordinatingacrion, and continuing to monitor and evaluate.
Fiji has established divisional and subdivisional Health-Promoting Communities Project Management Teams and set up a training scheme for team members. These management teams consist not only of health workers, but also of local people who have an interest in promoting health. The training takes the teams through a live-stage process which has formed a sound foundation for developing organizationai capacity for health-promoting communities.
20
3. MovIng to Action
14. Evaluate the implementation of the action plan. It will be important here to evaluate, monitor and report regularly the implementarion of the action plan, using the indicatOrs developed.
u ChecIIs for hnplllMiitllll action As above, as each step is reached. countries may want to continue to audit progress through documentation of the following checkpoints: _ <0
..
, c . ,
....'
l
~
,,..,, ,-
.'
10. Determine roles and responsibilities 11 . Mobilize reSOlJrce allocation 12. Draw upon expert advice 13. Develop organizational capacity
Clearty delineated roles and responsibilities documented
Resources mobilized 'Kick-start' provided by outside experts Capacity buin for overall management of converting the Vision of Healthy Islands into action Capacity buin for networking Capacity buin for collaborating intersectoralty Capacity buin for resource sharing Capacity buin for infonnation sharing and reporting Overall action plans specified; indicators to mon~or and evaluate progress determined Overall action plans specified; indicators to mon~or and evaluate progress determined Capacity buin for deciSion making and coordinating action Capacity built for appropriate mon~oring and ongoing evaluation Action and outcomes documented using the indicators developed
J
I
14. Evaluate and monitor
1-
'-
21
Glossary • The Vision of Healthy Islands refers to that set by Pacific health leaders during their meeting on Yanuca Island, Fiji in 1995 and stated in the opening words of the ensuing declaration. The Vision has been receml), enhanced by the addition of a fifth component, as agreed when the Pacific health leaders met again in 2001. The Vision appears on the title page of this documem, but is wonh)' of repeating:
/-IeallilY Islallds are places ]Vhere: Childrm are m"tllred ill body and IIlind; t:.miro/JIIJef/ls illLite !eoming and ItiSllrt;
People /J~l'k alld age .'ilh diglliry; ceologiral balallce is a sOflrce ofpride; 'l'he orcall JJibicb IlIS/aillS liS is protected. (~ lad 1ng
Commitment 2001 , building on the
Yanuca Island Dedar.Ulon 1995)
• The concept of Healthy Islands was defined at the Yanuca Island l\ [eeting as 'the unifying theme for health protection and health promotion for the Pacific in the 21 St Cenrury'. The concept suggests enhancing existing health services by broadening the focus to include creating and maintaining health as well as restoring it. The concept was strengrhened at the Pacific Health Leaders' Meeting of 1997 in Rarotonga. The Raroronga Agreement stated: 'The ileallhy Islallds (olIc",1 illvok.s (oIlIiIllIOflS/y idettlif),illg alld moltillgprioriry issues ,.laltd 10 bealth, developlllellt aNd JJltJ/-beil1J!.
I!J
advocating,larililo/jng and enabling !hue issNes to be ad-
drnsetl ill pm1ncnhips olllOllg COIIII/Jllllities, organizatiolls al/d agendes at loca~ lIatiOllal and regional lei oeM. n
• The Healthy Islands approach has evolved through country experiences and has generally taken shape in the form of a councry-wide settings approach, where the island country is the setting for action, and the approach is d1rough three core elements: environmental management for health, community actio n, and policy and infrastructure deve lopment.
• Healthy Islands projects, programmes and initiatives are those defined activities on the ground which reflect the principles and characteristics of action towards the Vision o f Healthy Islands, but
are merely component of the larger approach. Most address particular risk factors o r health issues and many are concerned with the health of sub-populations within an island country. Small projects, programmes and initiatives wc.::re especially prominent early in the development of th e Vision of Healthy l slands as countries wresded with attempts to trial va rious means of attaining the Visio n.
22
Annex I
• Primary health care refers to a particular approach to health care whereby essential services include public health components such as clean water and good sani tation, preventive measures
such as immunization and antenatal care, and clinical services are offered in a way that is most appropriate to each country and its resources.
• Health promotion, as defmed in the Ortawa Charter of 1986, is the process of enabling people to take control of and imptove their health framework for action. The Charter suggested changing social and physical environments to "make the healthier choice the easier choicel!. • Health education comprises consciously constructed opportunities for learning, involving some form of communication designed to improve health literacy, including improving knowledge, and
developing ~fe skills which are conducive to individual and community health. • Health protection refers to srrategies adopted by authorities to address the preservation of the health of the community through legislative and regulatory measures. • Environmental health encompasses the protection of people from environmental risks, the
maintenance and susrainability of the physical conditions for healthy life and the management of environmemal resources for the benefit of human health.
• A seuings approach or healthy settings refers to an approach to promoting the health of whole communities where the primary focus is on creating and maintaining healthy living conditions and associated lifestyles across the whole setting, directing attention to structural and organizational
change and development, rather than to the health related behaviours of individuals. • Core elements refers to the list of items that participants at the Ratotonga Meeting determined
should be addressed in identified health y setti ngs, including: adequate water supply and sanitation facilities; nutrition, food safety and food security; waste management; housing; human resources development; communicable and non -communicable disease prevention and control; lifestyle and
quility of ~fe issues; reproductive and family health; promotion of primary health care; social and emotional well-being; population issues; ecological sustainability; information management; tobacco
or health; alcohol and substance abuse; and environmental and occupational health. Based on the experiences of islanders, the term has recently been modified to encompass only three elements: environmental management (where the environment includes the socia-cultural and economic as
well as the physical); community action, and po~cy and infrastructure development.
23
Possible attributes and indicators for core elements This li st is a source of possible attributes of the three corc clements. In each instance where an attribute is a component of an action plan, appropriate ind icators need to be developed. Attribu tes
might include the following: 1. Policy ancllnfraltnlcture - . elapment At a nacionallcvcl, each country will determine the policies and infrastrucrurc development rC'1uired
that take priority at that given time. \Vitlun this core element, provisions would need to be made for
the following: • policies to create safe and clean environments, encou rage community action, and to provide effec tive
social suppOrt for healthy lifestyle/ behavioural choices by individuals; • policies for th e health sector to work effectively with other sectors; • policies o n importati o n of food items, industrial development, etc; • human resources trained to make and support health-protecting/ promo ting decisions;
• research to produce information that can support health-protecting! promoting policy making; • a national coordinating strucrure for Healthy Islands; and
• a national plan to facilitate the implementation of the Healthy Islands approach. Indicators can be established to demonstrate the degree to which each of these attributes is put in place.
The core element of environment management for health requires that ho mes, schools, workplaces, villages and urban communities be provided with: • safe potable water; • adequate sanitation and wastewater management; • proper management of solid and hazardous waste; • dean air; • safe, nutritious food;
• safe playgrounds, sports and recreational facilities for physical activity; • non-po U uting and safe industries fo r sources of employment and inco me; • productive, life-sustaining natural resources within the ocean, coast, land and forest;
24
Annex 2
• social suppOrt to individuals to avoid unsafe and unhealthy lifestyles/behaviours; • respect to the elderly and care to the disadvantaged/disabled; and • effective health services. Indicators can be established to demonstrate
me extent to which each of these attributes is put in
place.
The corc element of community action requires that community members be provided with: • a mechanism that could coorclinate community efforts in identifying priorities and solutions; • information through effective communication to suppOrt individuals to make healthy decisions;
and • programmes to facilitate community-wide participation in planning and implementing activities, including willing non-governmental organizations and the private sector, Indicators can he established to demonstrate the extent to which each of these attributes is put in
place. In addition to these indicators for Healthy Islands' atttibutes, others could be developed a100gside them to help measure progress towards achieving shore and longer term improvements towards
health.