Regional Framework for Health Promotion 2002-2005
making healthy choices easy, early and exciting...everywhere
World Health Organization Regional Office for the Western Pacific
making healthy choices easy, early and exciting...everywhere
message Health promotion is fundamental to all of our work in the health sector. The Regional Framework for Health Promotion is proposed as a guide for Member States and strategic partners in health. It is a work in progress and is presented for general circulation to stimulate discussion towards rallying various sectors to work with Ministries of Health on a shared vision for healthier lifestyles and supportive environments for health. Much has been achieved in health promotion, and yet much more needs to be done. This document seeks to explore the changing role of the health sector in promoting health and to seize opportunities that could pave the way for stronger partnerships and shared social accountability for health promotion. Through this first version of the Regional Framework for Health Promotion, it is hoped that a consensus will be reached in due course on how best WHO's Regional Office for the Western Pacific can be more responsive to the demand for scaling-up health promotion and maximizing its potential as a cost-effective approach for reaching national health goals, objectives and targets. Ultimately, health promotion should not just be a priority, but can and must be our mission.
Shigeru Omi, M.D., Ph.D. Regional Director WHO Regional Office for the Western Pacific
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Health Promotion
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contents Introduction………………………………………………………………………....…… 3 Section 1. Section 2. Overview of Health Promotion in the Western Pacific Region ….. 6
Health Status and Broad Determinants of Health in the Western Pacific Region…………………………..……………..…...… 9 Health Promotion Actions and Outcomes…………………………... 13 Global and Regional Commitments to Health Promotion……....… Regional Framework for Health Promotion 2002-2005….......…… 17 19
Section 3. Section 4. Section 5. Section 6. Section 7. Section 8.
Approaches in the Western Pacific Region……………………….… 22 Insights and Lessons Learned: The Need for Strategic Action... Strategic Analysis and Action for Implementing the Regional Framework For Health Promotion………...…….....… 28
32
Section 9.
Recommended Strategies for Member States at the Regional Level…………………………………………………... 39
Section 10. Areas for Action for WHO and International Partners at the Country Level…………………………………………….......… 43 Conclusion: Making healthy choices early, easy, and....everywhere…............. 45
References……………………………………………………………………............… 48
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introduction
Regional Framework for Health Promotion introduction 2002-2005
Health Promotion
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STRENGTHEN COMMUNITY ACTION
DEVELOP PERSONAL SKILLS
ENABLE MEDIATE ADVOCATE CREATE SUPPORTIVE ENVIRONMENT
Health promotion is the process of enabling people to increase control over and improve their health. To reach a state of complete physical, mental and social well being, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not as the objective of living. Health is a positive concept emphasizing social and personal resources as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well being.
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ILD BU A HE
Y
REORIENT HEALTH SERVICES
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BL IC
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The Ottawa Charter, 1986 World Health Organization
Health Promotion
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introduction Health promotion as a process, a strategy and an approach to enable individuals and communities to take charge of conditions and circumstances that contribute to ill health, has emerged as a powerful public health philosophy in recent decades. Evolving from the Ottawa Charter of 1986, five core strategies continue to guide the direction of health promotion practice in the Western Pacific Region: • • • • • building healthy public policies; creating supportive environments; strengthening community action; developing personal skills; and reorienting health services. This document also presents a framework that identifies how health promotion can be positioned as a national priority and as a mission of Ministries of Health. It re-states basic concepts of health promotion and proposes alternative parameters for evaluating the effectiveness of programmes. It frames issues on health promotion programme development and leadership . It proposes social mobilization and advocacy as key actions to scale up health promotion, but underscores the importance of ultimately integrating health promotion into health systems development, specifically health sector reform. More importantly, this document challenges the health sector to break barriers to personal and social accountability for health. The power of health promotion will only be unleashed when capacity is built within the health sector to take on new roles and responsibilities that require creativity, boldness and political commitment in moving beyond the realm of health education to the broader arenas of advocacy and social mobilization. While it is the individual that ultimately chooses a healthy lifestyle, the state and society as a whole have a responsibility to make those choices easy, to present the options early enough and to ensure that supportive environments are available in various settings. The greater challenge is to engage in strategic partnerships with sectors that can infuse new ideas and know how to cross over from archaic and boring ways of promoting health to fresh approaches. Such new directions will make healthy lifestyles compelling, exciting and socially desirable.
However, the changing disease and demographic profile of the Region as well as rapid social change ushered in by a globalized environment necessitate a review of the role of health promotion in helping countries achieve health goals and objectives. This document seeks to reaffirm the commitment of the WHO Western Pacific Region to the core values and principles of health promotion as articulated in the Ottawa Charter. It should also stimulate critical thinking on how health promotion can be made more relevant to the complex and dynamic environment of the 21st Century.
The power of health promotion will only be unleashed when capacity is built within the health sector to take on new roles and responsibilities that require creativity, boldness and political commitment in moving beyond the realm of health education to the broader arenas of advocacy and social mobilization.
The document takes a closer look at the transformation of traditional lifestyles and cultures against the backdrop of globalization and revisits current approaches to health promotion. It emphasizes the need to build on the successes of the past. It also challenges stakeholders to work with other sectors to influence individual and collective actions that will create an environment supportive of healthy choices in all places, at all stages of the life course.
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Health Promotion
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Overview of Health Promotion in the Western Pacific Region: Building on the Successes of Healthy Settings
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Health Promotion
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Overview of Health Promotion in the Western Pacific Region: Building on the Successes of Healthy Settings In the Western Pacific Region, health promotion has contributed to improvements in health status and quality of life in specific localities. Through the settings approach, health promotion in cities, islands, schools, workplaces and communities has been demonstrated to be an effective entry point for disease control and the promotion of healthy lifestyles and healthy environments. More importantly, health promotion activities through the settings approach have shown how to generate trust, goodwill and cooperation among individuals and groups. bonds, the more likely members of a community will cooperate for mutual benefit. In this way social capital creates health and may enhance the benefits of investments for health.3 People promote health. When people invest time and energy to overcome barriers to better health, social capital is spent. But as social capital is spent, it expands. Often, what seem to be small attempts to mobilize local leaders can cascade into an enabling environment for the empowerment As social capital of entire communities. Social capital has been an important factor for improving health even where economic capital is is spent, it expands. low. This has many implications for poverty-stricken areas in the Region where a high value is placed on interpersonal relationships, family ties and community identity. When a community is energized to work towards health goals despite economic limitations, a potent social force is unleashed. This force shapes healthy behaviour, attitudes and lifestyles of individuals, and the cycle of empowerment goes on. At the same time, it is recognized that social capital alone cannot be the basis of sustained improvements in health.4 Ultimately, the energies unleashed through empowering individuals to take responsibility for their own health must be linked to responsive health care delivery systems that are equally committed to the principles of health promotion. It must, therefore, be argued that social capital generated through experiences in Healthy Settings can break barriers, but to sustain changes, reforms in health care systems are in order. The Regional Framework for Health Promotion seeks to reposition health promotion in national health plans by building on the experiences of Healthy 1
Social capital is created from a myriad of everyday interactions between people, and is embodied in such structures as civic and religious groups, family membership, informal community networks, and in norms of volunteerism, altruism and trust.
Education, social mobilization and advocacy for health results in intersectoral action and builds social capital.1 Social capital, as a relational term that connotes interaction among people through systems that enhance and support that interaction, can be a compelling force for change.2 Social capital is created from a myriad of everyday interactions between people and is embodied in such structures as civic and religious groups, family membership, informal community networks, and in norms of volunteerism, altruism and trust. The stronger these networks and
2
3 4
Putnam, R.D. Making Democracy Work: Civic Traditions in Modern Italy. (Princeton, Princeton University Press, 1993) Kreuter, et.al. Social capital: evaluation implications for community health promotion Evaluation in Health Promotion (WHO Regional Publications, European Series, No. 92) World Health Organization, Health Promotion Glossary WHO/HPR/HEP/98.1 pp 19 Kunitz, Stephen "Accounts of social capital: the mixed health effects of personal communities and voluntary groups," Poverty, Inequality and Health: An international perspective (Oxford University Press, Great Britain, 2001)
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Settings. There are many other reasons why the settings approach is an effective take-off point for scaling up health promotion. The settings approach for health promotion in the Region has strengthened technical areas related to different stages throughout the life course. Healthpromoting schools, for example, are effective mechanisms for addressing issues during childhood and adolescence, such as malnutrition, helminthiasis, tobacco use, substance abuse and sexual and reproductive health problems. The settings approach has also created opportunities for new initiatives for lifestyle change. Healthy Cities, for example, have taken up "smoke-free" policies or have identified open spaces for physical activity. Local officials have shown how the goals of health promotion can be achieved through intersectoral planning, more responsive local government services and local laws, ordinances and regulations. Healthy marketplaces stimulate interest in consumer education on food safety, nutrition and hygiene. Over the past decade, while Healthy Settings have been the predominant model for implementing health promotion activities in the Region, two more tracks have evolved: healthy populations, addressing risks related to stages in life; and healthy lifestyles, addressing risks related to individual behaviour and choices. Demonstration sites and pilot projects in many parts of the Region provide ample insight into the effectiveness of health promotion in localities. It has been shown that health promotion can be a cost effective strategy to achieve disease control targets and to modify the immediate social and physical environment. The way forward is for health promotion to be perceived not only as a national priority but also as a mission of Ministries of Health. The WHO Office for the Western Pacific Region is committed to collaborating with Member States to strengthen national capacity for health promotion planning, implementation and evaluation to create health promoting public policy, strengthen community action, create supportive environments,
enhance personal skills and reorient health services. Three approaches are proposed through this framework: Healthy Settings, Healthy Populations and Healthy Lifestyles. These approaches are not vertical approaches, but form part of a continuum for action with areas of integration and overlap that foster a dynamic process of change. This process of change seeks to influence the way people behave in the places where they live, work, play and learn at all stages of their lives and at every opportunity to make a healthy choice.
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Health Promotion
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Health Status and Broad Determinants of Health in the Western Pacific Region
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Health Status and Broad Determinants of Health in the Western Pacific Region "These global transitions in demography and epidemiology are not happening in isolation, but in the context of important changes in the environment. I refer not just to the physical environment but also to the social, cultural and economic conditions under which people live. These living conditions determine the risks to which populations are exposed." Dr Shigeru Omi Regional Director WHO, Western Pacific Regional Office Modernization, urbanization, industrialization, environmental degradation, disasters, migration, the globalization of markets and telecommunications, and a changing demographic profile have had a profound influence on the social, political and cultural milieu of the Region in recent years. Correspondingly, these changes have had a significant impact on health. Demographic patterns in the developing countries of the Region show that measures to improve maternal, child and adolescent health must be undertaken immediately and aggressively. Population growth should be addressed in these countries as well. Simultaneously, the health of the growing number of older persons must be addressed. Currently, noncommunicable diseases such as cancer, cardiovascular disease and diabetes are dominant public health problems in practically all countries in the Region. And yet, communicable diseases such as tuberculosis, malaria, measles, helminthiasis, dengue hemorrhagic fever and other infections continue to be leading causes of mortality and morbidity. Food and waterborne illness such as campylobacteriosis, salmonellosis, cholera, shigellosis, typhoid, paratyphoid and trematode infections are leading causes of morbidity and have high economic costs. High rates of maternal deaths, unwanted pregnancies and the spread of sexually transmitted infections (STI) and HIV-AIDS are major concerns. Rates of injury, disability and mental illness are steadily increasing. Lifestyles have changed. Smoking, physical inactivity, unsafe sexual practices and unhealthy diets are key risk factors that underlie the high prevalence rates of noncommunicable disease. Dramatic increases in smoking rates among young people and women have been noted in the Region. Tobacco use is the most important preventable cause of death.
Young people as well as older persons experience isolation and alienation from a social environment that continues to undergo dramatic and unpredictable change.
Family life has changed. Long-held traditions, beliefs and values are now being challenged by new ideas and information transmitted through global media. The family, once the basic social unit that served as an anchor for order and normative behaviour, is threatened by increased mobility and migration. Mechanization, technology and a faster pace of life have resulted in a host of social problems with serious health consequences: violence, conflict, substance abuse, illicit sex and alcohol use. Young people as well as older persons experience isolation and alienation from a social environment that continues to undergo dramatic and unpredictable change. Communities have changed. Unplanned urbanization and weak regulatory control over industrialization have resulted in overcrowding, congestion, environmental degradation and pollution. The importance of water as an essential requirement for life, development, economic growth and poverty alleviation cannot be overemphasized. There is increasing concern about the presence of naturally occurring arsenic and fluoride in water as well as nitrates and other chemical residues from pesticides, fertilizers and toxic waste products from other human activities. In many parts of the Region, contamination of water sources and supplies is a major threat to health and development. Economic and trade environments have undergone radical change. Trade liberalization has resulted in the free flow of goods between developed and
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developing countries. In some instances, this has resulted in more and cheaper food products, which may have both positive and negative impacts on diet and nutrition. At the same time, illicit trade, smuggling and trafficking of tobacco and drugs, and the transport and dumping of hazardous materials and chemical waste continue. The international economy is based on global trade law, but not a global labour market. The model of the free market, as reflected by the unrestricted movement of labour and goods, has generated a number of inconsistencies.5 In some instances, the expansion of markets through globalized trade and business has created new jobs and new opportunities for work. In others, it has encouraged the growth of pockets of industrialized zones where jobs are created, but wages are so low that the benefits of the added income are often outweighed by the medical costs that must be borne by the state or the family. As a result, even in situations where cheaper products are more readily available and new wealth has been created, the gap between rich and poor continues to widen. About 1.3 billion people (20% of the world's population) live in absolute poverty, with an income of less than US$1 per day. Many are in developing countries in the Region. Wide economic disparities remain among and within different countries. Pockets of poverty may exist in urban and rural areas that seem to benefit from economic growth. The poorest of the poor may remain invisible and excluded from the benefits of economic development or advances in human health. The poverty issue is also linked to gender and age. It is estimated that 70% of the world's poor are women and children. Women's ill health is too often the result of gender-based discrimination and their lack of power to make decisions, to claim their rights and to influence others. Political systems have changed as well. The growing interdependence of economies within regions have marked the 21st century. Power vacuums have resulted in multiple power centres above, below and across national levels. Stronger forms of multilateral cooperation and solutions It is estimated that are called for in addressing transborder issues where 70% of the world's unilateral approaches have had limited success. These poor are women and issues include disease control, terrorism, immigration children and environmental destruction.6 The private sector
continues to emerge as an important player in the political and economic life of countries. Yet, its role in health and development is often unclear and remains untapped. Global media has become the vehicle for a homogenized global culture, but this development has been accompanied by a heightened awareness of ethnic and religious differences within and among countries. These tensions have sometimes resulted in the escalation of conflict at local levels.
Access to the Internet has resulted in a greater connections among many parts of the Region. But in many developing countries, the cost of utilizing the Internet for an hour could be beyond the daily minimum wage of a skilled worker.
The growing interdependence of economies within regions have marked the 21st century. Power vacuums have resulted in multiple power centres above, below and across national levels.
Much has been written about the impact of globalization on society. In contrast to what Marshall McLuhan elegantly described as the global village,
5
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Green Cross International Globalization and Sustainable Development: Is Ethics the Missing Link? (Earth Dialogues Forum: Lyon, February 21-23, 2002) Green Cross International Op.cit. pp 4
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some sectors envision that the next century will bring the "local globe" or the localization of globalization.7 This phenomenon is expected to result in the flourishing of local democracies with themes of identity, distinctiveness and multilayered governance. Connections of public and private sectors of the economy to various scales of responsibility, accountability and evaluation are predicted. For example, a community could be run locally, receive funding from multinational sources, implement a global environmental agreement and be regulated by a national organization In contrast to what responsive to local needs. The importance of locality, Marshall McLuhan therefore, is expected to increase in a world where global elegantly described as outcomes would be the result of countless local actions.8 the global village, the And yet in areas where globalization will not localize, traditional culture and ways of life may prevail and result in the increasing exclusion and marginalization of vulnerable groups.
next century will bring the "local globe" or the localization of globalization.
The long-term implications of these developments remain to be seen. In most of the developing countries, these profound changes have and continue to result in a struggle among social, political and even religious institutions to control and command policy and resources. It is hoped that societies will uphold processes to ensure that these struggles will be resolved in peaceful ways. In places where that struggle is prolonged and unresolved, however, political turmoil, weakening of institutions and social polarizations result in health inequities that are more pronounced across gender, age, ethnicity and economic status.
7
8
O'Riordan, Tim Globalism, Localism and Identify: Fresh Perspectives on the Transition to Sustainability Earthscan Publications, United Kingdom and USA, 2001 Ibid. pp ix
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Health Promotion Actions and Outcomes
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Health Promotion
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Health Promotion Actions and Outcomes Health Promotion represents a comprehensive social and political process. It not only embraces actions directed at strengthening the skills and capabilities of individuals, but also actions directed towards changing social, environmental and economic conditions to alleviate their impact on public and individual health. Health promotion is the process of enabling people to On one end, there are increase control over the determinants of health and sectors that claim that thereby improve their health. Participation is essential to health promotion is sustain health promotion action.9 concerning the underlying social, economic and environmental conditions impacting on health, as well as individual risk factors and risk behaviours, and use of the health care system. Thus, health education may involve the communication of information, and development of skills that demonstrates the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health. In the past, health education was used as a term to encompass a wider range of actions including social mobilization and advocacy. These methods are now encompassed in the term health promotion and a more narrow definition of health education is proposed here to emphasize the distinction.10
everything, and consequently nothing. There are also those who would argue that health promotion is just as linear, quantitative and vertical as a communicable disease control programme and that "legitimate" health promotion activities can only be undertaken with clear isolated variables that can be "measured" in the same way that one measures blood chemistry.
Over the years, there have been changing views about what health promotion really is and what would be the tangible outcomes of health promotion activities. On one end, there are sectors that claim that health promotion is everything, and consequently nothing. There are also those who would argue that health promotion is just as linear, quantitative and vertical as a communicable disease control programme and that "legitimate" health promotion activities can only be undertaken with clear isolated variables that can be "measured" in the same way that one measures blood chemistry. Health Education is not equal to Health Promotion
In the past, health education was used as a term to encompass a wider range of actions including social mobilization and advocacy. These methods are now encompassed in the term health promotion and a more narrow definition of health education is proposed here to emphasize the distinction.
What are health promotion actions? What are health promotion outcomes? In 1999, the International Union for Health Promotion and Education (IUHPE prepared a report for the European Commission entitled "The Evidence of Health Promotion Effectiveness". This document assessed 20 years of evidence of the health, social, economic and political impacts of health promotion in Europe and presented a framework for health promotion actions and outcomes.11
One of the obstacles to advancing health promotion within Ministries of Health is the traditional perception that health promotion is equal to health education. Within the Regional Framework for Health Promotion, it is necessary to address this issue by restating the definition of health education in relation to what is currently accepted as the definition of health promotion: Health education comprises conspicuously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health. Health education is not only concerned with communication of information, but also with fostering the motivation, skills and confidence (self-efficacy) necessary to take action to improve health. Health education involves the communication of information
9 10 11
World Health Organization, Health Promotion Glossary WHO/HPR/HEP/98.1 pp 2 World Health Organization, Health Promotion Glossary ( Geneva, 1998) pp 4 Nutbeam, Donald "Measuring the Effectiveness of Health Promotion" The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe IUHPE and the European Commission BrusselsLuxembourg 1999
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AN OUTCOME MODEL FOR HEALTH PROMOTION* Health and Social Outcomes Intermediate Health Outcomes (modifiable determinants of health)
Social Outcomes – measures include: quality of life, functional independence, equity Health Outcomes – measures include: reduced morbidity, disability, avoidable mortality Healthy Lifestyles Measures include: tobacco use, food choices, physical activity, alcohol and illicit drug use Effective Health Services Measures include: provision of preventive services, access to and appropriateness of health services Healthy Environments Measures include: Safe physical environment, supportive economic and social conditions, good food supply, restricted access to tobacco, alcohol
Health Promotion Outcomes (intervention impact measures)
Health Literacy Measures include: healthrelated knowledge, attitudes, motivation, behavioural intentions, personal skills, selfefficacy
Social Action and Influence Measures include: community participation, community empowerment, social norms, public opinion
Healthy Public Policy and Organizational Practice Measures include: policy statements, legislation, regulation, resource allocation, organizational practices
Health Promotion Actions
Education Examples include: Patient education, school education, broadcast media and print media communication
Social Mobilization Examples include: Community development, group facilitation, technical advice
Advocacy Examples include: lobbying, political organization and activism, overcoming bureaucratic inertia
* Nutbeam, Donald "Measuring the Effectiveness of Health Promotion" The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe IUHPE and the European Commission Brussels-Luxembourg 1999
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Within the Regional Framework for Health Promotion, three health promotion actions are identified: health education, social mobilization and advocacy.
Within the Regional Framework for Health Promotion three health promotion actions are identified: health education, social mobilization and advocacy.
"In this model, Health and Social Outcomes represent the end point of health and medical interventions. These are usually expressed as personal or social outcomes, such as quality of life, functional independence and equity, or more often, in terms of health outcomes, expressed as mortality, morbidity, disability or dysfunction.
Intermediate Health Outcomes represent the determinants of these health and social outcomes. Changing these health determinants is a fundamental goal of health promotion. Personal behaviours, such as smoking or physical activity, may increase or decrease the risk of ill health, and are summarized as Healthy lifestyles. Healthy environments consist of the physical, economic and social conditions that can both impact directly on health as well as support healthy lifestyles --for example by making it more or less easy for an individual to smoke or adopt a healthier diet. Access to appropriate provision and appropriate use of health services acknowledged as important determinants of health status are represented as effective health services in this model . Health Promotion Outcomes represent those personal, social, and structural factors that can be modified in order to change the determinants of health. These outcomes also represent the most immediate impact of planned health promotion activities. Health literacy refers to the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand and use information to promote and maintain good health, typically the outcome of health education activities. Social action and influence describe the results of efforts to enhance the actions and control of social groups over the determinants of health. For example, efforts to mobilize older people towards the achievement of common health goals. Healthy public policy and organizational practices are the result of efforts to overcome structural barriers to health, typically the outcome of internal government policy development processes, and/or external advocacy and lobbying which may lead to legislative change."12 While it is apparent that this model could be subjected to further testing for relevance in regions outside of Europe, it presents concepts that are appropriate
not only for evaluating effectiveness, but also for analysing situations that could benefit from health promotion actions and planning for health promotion interventions. For purposes of the Regional Framework on Health Promotion, this model is hereby put forth as the theoretical basis for research, agenda setting and programme development.
12
Nutbeam, Donald op.cit. pp5-7
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Global and Regional Commitments to Health Promotion
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Global and Regional Commitments to Health Promotion Against a complex and dynamic environment, health systems in developing countries of the Region struggle to reform and make the most efficient use of severely limited resources to meet old and emerging health problems within internationally accepted principles and agreements. It is apparent that the key to overcoming some of the major obstacles to improved health may be found in actions that address the broader determinants of health that lie outside of the hands of the health sector. Health promotion as an approach facilitates inter-sectoral action to improve basic services, protect human rights and create enabling environments for individuals and communities. Health promotion forms part of a continuum of empowerment for achieving not only health outcomes, but also social outcomes. Several important international instruments attest to this. Building on the Ottawa Charter, global and regional action has been supported through subsequent meetings on health promotion. The Adelaide Recommendations (Australia, 1988) focused on building healthy public policy. The Sundsvall Statement (Sweden ,1991) expanded the concept of creating supportive environments. The Jakarta Declaration (Indonesia, 1997) reiterated the importance of partnerships for health. The Fifth Global Conference on Health Promotion (Mexico, 2000) zeroed in on the issue of equity. The Regional Framework for Health Promotion also draws from recent international meetings that emphasized the need to address health problems from a broader health promotion perspective: • The Global Consultation on Child and Adolescent Health (Sweden, March 2002) cited specific health promotion interventions as conclusions of the consultation including: 1) expansion of coverage of effective interventions through new alliances among those working in health and others in the public and private sectors in order to scale up existing strategies to reach more children in need and to monitor the effectiveness of efforts; 2) mobilization and empowerment of children, adolescents and their families to make substantial improvements in their own health through opportunities for greater participation in the life of their communities; and 3) addressing poverty and inequity through comprehensive strategies for multiple sectors -- health and, for example, education, environmental sanitation, safety, transportation and economic development.13 • The Second World Assembly on Ageing (Madrid, April 2002) adopted three themes: 1) older persons and development; 2) advancing health and well-being into old age; and 3) ensuring enabling and supportive environments.14 • The WHO Conference on Health and Disability (Italy, April 2002), which endorsed the International Classification of Functioning Disability and Health emphasized the shift from traditional health indicators that emphasize "mortality" to focusing on "life", how people live with their health conditions and how these can be improved to achieve a productive, meaningful and fulfilling existence.15 • The World Summit on Sustainable Development (Johannesburg, South Africa 2002) declared a renewed commitment to sustainable development and emphasized the need for action and results in addressing poverty, environmental degradation, globalisation and speedily increasing access to basic requirements such as clean water, sanitation, adequate shelter, energy, health care, food security and the protection of biodiversity. The Johannesburg Declaration also cited the need to give priority attention to the fight against the worldwide conditions that pose severe threats to sustainable development: chronic hunger, malnutrition, foreign occupation, armed conflicts; illicit drugs problems, organized crime; corruption, natural disasters, illicit arms trafficking; trafficking in persons; terrorism; intolerance and incitement to racial, ethnic, religious and other hatreds, xenophobia; and endemic communicable and chronic disease, in particular HIV-AIDS, malaria and tuberculosis.
13
14 15
UNICEF/WHO A Healthy Start in Life: Global Consultation on Child and Adolescent Health and Development, 12-13 March 2002 Stockholm, Sweden. Second World Assembly on Ageing, Madrid April 2002 WHO Conference on Health and Disability, Italy March 2002
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Regional Framework for Health Promotion 2002-2005
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Regional Framework for Health Promotion 2002-2005
vision Healthy places, healthy stages and healthy choices.
strategies 1. To support countries in identifying and prioritizing major risk factors based on leading causes of morbidity, mortality and burden of illness and developing relevant and appropriate health promotion interventions to reduce risks related to settings, populations and lifestyles. 2. To strengthen the infrastructure for health promotion at regional and country levels in relation to settings, populations and lifestyles through: a) b) health promotion leadership training; developing effective "external" campaigns to communicate and reduce risks; developing an "internal" marketing strategy for health promotion within the health sector; and building capacity to determine effectiveness of health promotion (ensuring accountability for health promotion at the national level)
mission To make healthy choices easy, early and exciting, everywhere.
goal To promote health and well-being among individuals, communities and populations, enabling them to address the broad determinants of health in order to reduce the vulnerability and risks to ill health and disability throughout the life cycle, especially among poor and marginalized groups.
objectives 1. To promote health in the settings where people live, work, learn and play. 2. To prevent risks associated with age-specific developmental stages throughout the life course. 3. To enable individuals and communities to modify risks caused by unhealthy lifestyle, behaviour and the environment. 4. To reduce vulnerability of groups that are marginalized due to gender, ethnicity, age and socio-economic status.
c)
d)
3. To undertake or support research and generate evidence for policy on effective health promotion interventions, specifically in relation to health sector reform and health systems development, with an emphasis on groups that are marginalized due to gender, ethnicity, age and socio-economic status. 4. To collaborate with other technical areas in planning, implementation and evaluation of health education, social mobilization and advocacy initiatives in relation to disease control, health systems development and health sector reform. 5. To explore new parameters for evaluating health promotion in relation to social and cultural goals and outcomes within countries.
approaches 1. Healthy Settings 2. Healthy Populations 3. Healthy Lifestyles
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APPROACHES TO HEALTH PROMOTION IN THE WESTERN PACIFIC REGION Health promotion actions are integrated into various technical areas within the Division of Building Healthy Communities and Populations, World Health Organization, Western Pacific Region, as the broad determinants of health are addressed in the different places, stages and choices that people make. These technical areas include:
healthy settings • • • • • • • Healthy Cities Healthy Islands Healthy Villages Healthy Workplaces Healthy Marketplaces Health-Promoting Schools Health-Promoting Hospitals
healthy populations • • • • child and adolescent health adolescent health and development reproductive health ageing and health
healthy lifestyles • • • • • • • • • nutrition tobacco-free initiative food safety family planning physical activity substance abuse prevention domestic violence prevention injury prevention mental health promotion
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Health Promotion Approaches in the Western Pacific Region
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Health Promotion
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Health Promotion Approaches in the Western Pacific Region The response of the WHO Regional Office for the Western Pacific has been to enhance its work in health promotion by mainstreaming health promotion across the Organization. At the same time, WHO has developed a framework with specific strategies to enable Member States to adopt and undertake health promotion. The Regional Framework for Health Promotion seeks to build on what has been done in the past and re-position health promotion from being a locally successful initiative to becoming a national strategy for achieving national health goals and objectives. protection through settings approaches; b) to develop mechanisms for advocacy, communication and networking in support of Healthy Settings; and c) to set up systems that ensure the sustainability of projects and programmes for Healthy Cities and Healthy Islands. At this meeting, the idea of identifying The and sustaining idea of support for health promotion identifying and "champions" (i.e. committed mayors, local leaders, representatives of nongovernmental organizations (NGOs) and sustaining support for health promotion members of media) was agreed upon as a major factor that would contribute to the continuing success of Healthy Settings. "champions" i.e.
healthy settings Over the past Over the past decade, Healthy Settings has become decade, Healthy well established in the Western Pacific Region as an Settings has integrated approach to health protection and health promotion. Pilot projects in settings (Healthy Cities, become well Healthy Islands, Health-Promoting Schools, Healthy established in Marketplaces, Healthy Tourism, Healthy Workplaces and the Western Health-Promoting Hospitals) have been linked and are Pacific Region as mutually reinforcing.16 Generic processes have been an integrated identified for developing and implementing projects that approach to have served as demonstration sites and models for health protection learning. Key strategies and core principles for and health implementing projects have been encapsulated in promotion. Regional guidelines for Healthy Cities, Healthy Islands, Health-Promoting Schools and Healthy Workplaces. Social mobilization and community action have characterized the implementation of Healthy Settings throughout the Region. In 1999, the Regional Meeting on Health Protection and Health Promotion: Harmonizing Our Responses to the Challenges of the 21st Century adopted a Regional Action Plan on Healthy Settings, which encouraged Member States to develop national plans of action with emphasis on three areas: a) to strengthen capacity for health promotion and health
committed mayors,
Among the different settings, Healthy Cities has local leaders, progressed to the stage of having an active regional network of representatives of partners involved in capacity-building, training and technical nongovernmental collaboration. In 2001, the Regional Workshop on Healthy Organizations, Cities: Evaluation and Future Directions was held in Johor members of media Bahru, Malaysia. Nine countries reported on progress and was agreed upon as identified specific targets for 2002-2003 in relation to evaluation a major factor that of Healthy Cities. Evaluation and monitoring were recognized would contribute to as enabling mechanisms for sustaining and strengthening the the continuing success gains of the Healthy Cities Movement in the future. ofdesigns Healthy Settings. Recommendations of this meeting included: the need for evaluation that would adopt ecological, qualitative and quasi-experimental methods; the need to reflect quality of life indicators; and the need to use evaluation through a continuous feedback mechanism for designing and implementing local projects.
Social mobilization and community action have characterized the implementation of Healthy Settings throughout the Region.
healthy populations 16
Lin, Vivian "Regional Overview on Healthy Settings" presented at the WHO Meeting on Health Protection and Health Promotion: Harmonizing Our Responses to the Challenges of the 21st Century" (WPRO, 1999)
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In recent years, renewed interest in development stages throughout the life course created new opportunities to promote health as a complement to the settings approach. Social mobilization, advocacy for Social mobilization, policy, education and awareness raising have all been advocacy for policy, cited as essential activities within these units. Reorientation education and of health services also emerges as a common priority area awareness raising for healthy populations.
actively pursued creating a supportive environment for adolescent health and development through advocacy for policy. In 2000, The Adolescent Health and Development Regional Framework and the Regional Advocacy and Communications Strategy (2001-2004) were developed and disseminated. A Media Kit for Adolescent Health and Development is being finalized for regional use. As a result, Member States have also developed national strategies for ADH. In order to strategically position the WHO ADH programme in relation to other international agency efforts, health promotion through reorientation of health services has been identified as the "niche" for the ADH working group. Currently, several projects have been directed towards the development of "adolescent friendly" health facilities. Capacity-building at the national level has been initiated in Cambodia, China, Mongolia and Viet Nam. Collaborative projects on technical areas have been developed to address concerns of adolescents such as reproductive health, violence, substance abuse, tobacco use and nutrition. Pilot projects linking ADH to Health-Promoting Schools are ongoing in Mongolia and Viet Nam. In the area of adolescent reproductive health, several initiatives have been undertaken to promote health and prevent teenage pregnancy and unsafe abortions. Community outreach programmes in the Pacific Islands have been undertaken in collaboration with the United Nations Population Fund (UNFPA). In
have all been cited as essential activities within these units. Reorientation of health services also emerges as a common priority area for healthy populations.
Child Health and Development (CHD)
The main vehicle for improving child health in the Region is the Integrated Management of Childhood Illness Strategy (IMCI). The strategy reorients health services towards treating the "whole child," not specific illnesses. It actively promotes the health of children through a community component where information, education and communication (IEC) strategies are put into place, accessibility to basic child health services is improved and active participation of the family is encouraged. Within this community component, partnerships are encouraged between the different stakeholders that intervene at the community level. These include government institutions, bilateral partners, NGOs, the private sector and organized community groups. This strategy is being implemented in Cambodia, China, Kiribati, Lao People's Democratic Republic, Malaysia, Papua New Guinea, the Philippines, Solomon Islands, Vanuatu and Viet Nam. Advocacy for policy, awareness raising, social mobilization and health education are also key activities for nutrition programmes. These include: a) the Infant and Young Child Feeding (IYFP) Programme; and b) the micronutrient deficiency control programme. On another front, a pilot project has been developed in relation to healthpromoting hospitals through an extended day care centre in a tertiary hospital in the Philippines. Adolescent Health and Development (ADH) Since 1999, the Adolescent Health and Development Working Group has
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the Marshall Islands, WHO supported the provision of contraceptives and counselling to high-school students in a Youth-to-Youth-in-Health programme. Ageing and Health (AHE) To promote the health of older persons in the Region, steps have been taken to support the development of national policy in Member States. Communitybased programmes and reorientation of health services have been identified as priority areas for policy and action. In 1998, Country Profiles and Regional Guidelines for National Policies and Programme Development for Health of Older Persons were developed. Subsequently, China, Mongolia, Papua New Guinea and Viet Nam have started collecting data and developing models to promote the health of older persons. Pilot projects linking the health of older persons to health-promoting hospitals have been initiated. A demonstration site for a multi-purpose community centre for older persons linked to health-promoting hospitals through a referral system with screening programmes for risk factors among older persons is being implemented under the Healthy Cities project in Marikina City, the Philippines. Currently, two books, Ageing and Health: A Health Promotion Approach for Developing Countries and Healthy Ageing: Practical Pointers on Keeping Well in the Third Age, are being finalized for use of countries in the Region. Reproductive Health (RPH) Efforts to address high maternal mortality rates, low contraceptive prevalence rates, women's health and other issues related to the child-bearing and reproductive stage of life of women and men are being undertaken in several countries. Activities specifically related to health promotion include the development of standards for mother-friendly care facilities in Mongolia and Papua New Guinea; advocacy for
policy in family planning policy in China; programmes for strengthening community involvement in reducing maternal mortality in Cambodia, Lao People's Democratic Republic, Mongolia, Papua New Guinea and Viet Nam.
healthy lifestyles Over the past few years, there has also been a renewed interest in reducing risk factors among the general population by promoting healthy lifestyles. Policy advocacy, behaviour change communication and health education have all been cited as Policy advocacy, key interventions of these units and focuses.
Awareness raising about iron-deficiency anaemia, specifically for the use of weekly iron/folate in Cambodia, the Philippines and Viet Nam, and other interventions to address micronutrient deficiencies have been a priority among the developing countries of the Region. Health education and health campaigns characterize much of the work in this area. Important steps have been taken to establish food fortification strategies in Cambodia, China, Fiji, the Philippines and Viet Nam to create an enabling environment for preventing micronutrient malnutrition in the general population. Advocacy for policy and social mobilization are used as tools to achieve these goals. Behavioural change communication is an important strategy for the pilot projects on obesity prevention and control that have been initiated in Fiji and Tonga. This includes the development of tools for quick self-assessment of risk for obesity. Tobacco-Free Initiative (TFI)
behavioural change communication and health education have all been cited as key interventions of these units and focuses.
Nutrition
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The Tobacco-Free Initiative seeks to reduce the burden of disease and death due to tobacco by reducing smoking prevalence rates. The key strategies for achieving this are: National Plans of Action for Tobacco Control, policy development, advocacy, monitoring and evaluation. In 1999, the Regional Action Plan and Country Profiles for Tobacco or Health was updated. Consistent with the goals of building healthy public policy, a Regional Strategy for Media, Advocacy and Communication was developed and disseminated. Consequently, advocacy and communications for policy in relation to the development of national legislation to ratify the Framework Convention on Tobacco Control (FCTC) as a treaty is being supported in Cambodia, China, Malaysia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. The FCTC has been identified as a rallying point for achieving awareness and generating political support to regulate tobacco at the national level. Other activities that help create supportive environments include pilot projects for smoke-free settings and capacity-building for smoking cessation programmes. Food Safety The Regional Food Safety Strategy was developed and endorsed by the Regional Committee in September 2001. The ten-point strategy includes several health promotion interventions such as strengthening partnerships, integration
with Healthy Settings, consumer participation and education in food safety, and development of effective communication systems for disasters and emergencies. Local action for food safety has already been demonstrated through settings such as Healthy Marketplaces and Health-Promoting Schools. Activities have included mass media campaigns in Mongolia and Viet Nam and the development of advocacy materials in Cambodia and Papua New Guinea. Family Planning Awareness raising, advocacy for policy, strengthened community involvement and education of women are key strategies to achieve higher contraceptive prevalence rates and reduce unwanted pregnancies, unsafe abortions and maternal mortalities in the Region. Current challenges include the lack of information about family planning as well as cultural, social and behavioural obstacles to contraceptive use among women and health providers. Reorientation of health services has been identified as a core strategy to address these problems. "Mother-friendly services" have been piloted in Mongolia and Papua New Guinea. Capacity-building for improving services for women's health, including family planning, have been undertaken in China, Mongolia and Papua New Guinea. Physical Activity Awareness raising, advocacy and local action to promote health through physical activity have been demonstrated through several activities. Two brochures from the WHO Western Pacific Regional Office 2002 Health Promotion Series TIME FOR HEALTH! have been developed and disseminated. They are: A Guide to Physical Activity and Fitness and A Guide to Stretching Exercises in the Office. A CD-ROM entitled Office Exercise Routine has also been developed and disseminated.
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postpartum women. Another study was undertaken to determine risk factors in relation to suicides among women of childbearing age. In Korea, training on gender and strengthening of capacity to manage survivors of domestic violence was undertaken. Mental Health The Regional Strategy for Mental Health was developed and was endorsed by the Regional Committee in September 2001. The strategy places mental health in the context of public health and incorporates approaches to mental health promotion as well as the prevention and treatment of mental disorders. A "journalists' encounter" was organized in September 2002. A CD-ROM on mental health resources was developed and is being finalized. Training and capacitybuilding on mental health has been conducted in Cambodia, China and Viet Nam. Development of policies and legislation are being supported in Cambodia, China, Lao People's Democratic Republic, Samoa and Tonga. Raising awareness, providing information, defining community mental health models, developing family and consumer support groups and supporting legislation have been identified as future actions to support the Regional strategy.
In celebration of World Health Day 2002, key messages about physical activity were communicated through the mass media as Member States mobilized communities to "Move for Health". A Ministerial Round Table Discussion on Diet, Physical Activity and Health was held during the 53rd session of the Regional Committee in Kyoto, Japan, in September 2002. The results of this Ministerial Round Table constitute part of the Regional input on the Global Strategy on Diet and Physical Activity. Substance Abuse Prevention Several activities have been undertaken to promote health by addressing the problem of substance abuse at national levels. In Fiji, educational materials and activities for school children and the community were supported. Capacitybuilding activities for Cambodia, China, Palau and Viet Nam were also supported. Domestic Violence Prevention Initiatives have been undertaken to create an enabling environment and pave the way for action by studying the extent of the problem of domestic violence in selected countries. In China, a survey technique was developed to increase the awareness of health workers about domestic violence against pregnant and
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Insights and Lessons Learned: The need for strategic action
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Insights and Lessons Learned: The need for strategic action Strategic action for the Western Pacific Region is needed in order to scale up health promotion at the country level and contribute to achieving national goals, objectives and targets for health. Ministries of Health and health promotion programme managers to define their roles in relation to: a) informing and educating the public; or b) instituting policies that make information more accessible. Health promotion programme managers within Ministries of Health must make an extra effort in advocacy and social mobilization to emphasize the relationship between individual lifestyle and the environment.
It is, therefore, not enough to intervene at the level of the individual through health education strategies. . .
Specifically, scaling up should be done with the intention of providing a wider range of choices for vulnerable groups and for addressing broad determinants as underlying causes of increased risk factors and ill health. Where choices for a healthier lifestyle do not exist, social mobilization and advocacy can contribute to empowering individuals and groups to influence policy and decision-makers to expand the range of healthy choices for all individuals.
two levels for strategic action Strategic action to influence lifestyle and environment must be based on two operational levels for health promotion: a) health promotion as a set of public health actions that contribute to the spectrum of health care and disease prevention; and b) health promotion as a social enterprise to ensure protection of the right to health and well-being of all individuals regardless of gender, race, political affinity or religious belief. These two levels for operations are directed at two distinct but interrelated "audiences" for social mobilization, advocacy and education. Both are important and complement any strategic plan of action for health promotion. They reflect world views of two different sectors, the health sector and the non-health sector, which must be equally engaged and committed to working with each other in the grey area where health is both an outcome and a social goal.
The roles and responsibilities of Ministries of Health, and health promotion programme managers may need to be re-examined in order to develop strategies that can result in changes both at the individual level as well as in the environment. At the individual level, the voluntary adoption of healthy behaviours may be seen as fine-tuning within the limits set by the environment. For example, individuals may choose to eat healthy food only if it is available in their community at a price they can afford. Cultural norms determine the choice of food items and quantities of food consumed. Trade and agricultural policies determine what foods appear at the sources where consumers make purchases. These environmental factors set the menu within which an individual's food preferences and attitude to health can operate. In the case of many people, the scope for making healthy choices is small. Healthy choices are often difficult choices."17 It would not be enough, therefore, for
Health Promotion in the Spectrum of Health Care 17
...the health sector and the non-health sector must be equally engaged and committed to working with each other in the grey area where health is both an outcome and a social goal.
World Health Organization, Western Pacific Regional Office Ministerial Round Table: Diet, Physical Activity and Health WPR/RC53/12 ( Kyoto, Japan, September 2002)
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...health promotion can be seen as part of a spectrum spanning from promotion, to protection, to general prevention, to specific prevention, to curative and palliative treatment and lastly to rehabilitation.
Healthy Population
Systems Within health care systems, for example, health promotion can be seen as part of a spectrum spanning from promotion, to protection, to general prevention, to specific prevention, to curative and palliative treatment and lastly to rehabilitation. In most instances, the weight of actions undertaken by health care service is placed to the right of the spectrum.18
Population at risk
Population with disease
Population with disease needing hospitalization Population Hospitalized
Based on the above, it is apparent that efforts to make health promotion a priority within health care systems is the first challenge that must be addressed by a comprehensive strategy. Secondary Prevention Treatment Rehabilitation Health Promotion as a Social Enterprise Moving from the boundaries of health care systems that must operationalize health promotion in relation to disease control and prevention, it is necessary to articulate another perspective for health ...health promotion promotion within the domain of social and cultural systems, can be seen as a where health promotion can be seen as a social enterprise to social enterprise to ensure protection of the right to health and well-being of all ensure protection of individuals.
Promotion & Primary Prevention
While there seems to be agreement that health promotion is important, in reality, very little priority is given to health promotion within health care systems. Another way of visualizing the low priority given to health promotion would be through a schematic diagram which starts with the healthy population (yellow), the population that is at risk for disease (blue), the population with disease (green), the population with disease that requires hospitalization (orange), and the population that actually has access to hospital care (red). In most instances, the majority of budgets for health would go to the smallest box, demonstrating the relative unimportance given to health promotion in most health systems.
This conceptual shift is not an academic exercise but a practical one that supports the definition of health in the WHO constitution of 1948 as:
the right to health and well-being of all individuals.
"A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity." Much of the concern about the "hard evidence" to prove the effectiveness of health promotion in relation to its ability to prevent and control disease emanates 18
World Health Organization, Pan American Health Organization, Ministry of Health of Mexico Technical Report 6: Reorienting Health Systems and Services with Health Promotion Criteria a Critical Component of Health Sector Reforms Fifth Global Conference on Health Promotion, 2000
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Health Promotion
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In another sense, therefore, promoting healthy lifestyles can be viewed as a social investment that results in improvements in quality of life. A spectrum of levels of satisfaction or well-being could be proposed ranging from meeting basic needs, such as the ability to eat, sleep, work and be engaged in productive activity and meaningful relationships, to the other end ---where individuals perceive fulfilment in their ability to exercise creativity in work or engage in social creative expression through cultural and art forms. These outcomes of health promotion would be essential components of a healthy lifestyle as perceived not by health experts, but by ordinary people. While these may not necessarily fall into the discrete and quantifiable epidemiological information that could be used to convince policy-makers to undertake changes in policy, a process must be put in place to develop parameters for a new body of evidence related to quality of life as related to the social and cultural contexts of each country. Within the discipline of political science, various methods and instruments have been developed to measure and track public perception and satisfaction on a variety of issues. In the field of advertising, client satisfaction and perception of quality are fundamental to product development and quality assurance. Both of these fields have had a profound influence on the emergence of "social marketing" for health. But these two fields are only examples of where health promotion can draw new insights into evaluating its true value and "effectiveness" in society. New initiatives are needed to broaden the perspective on the impact of health promotion as a social goal and outcome. Other avenues worth exploring include the fields of art and culture, which are equally powerful transmitters of values and social aspirations.
from a health care systems perspective, where stakeholders in health care must define and quantify how health promotion actions influence disease outcomes. While this is a valid concern that must be addressed, it is not the only parameter for evaluating the value of health promotion to society. The concept of health promotion as a social enterprise is put forth, where individuals, groups and institutions invest time, energy and resources to achieve a state that is more than just the "absence of disease". This affirms the notion of "health as a resource for everyday life, and not the object of living."19 From this perspective, a healthy lifestyle can be viewed as an end in itself, and not just as a means to prevent diseases or minimize risks. In functional terms, health must be seen as a resource that permits people to lead individually, socially and economically productive lives. These lives should not be quantified only in terms of disease-related outcomes but also in terms of perceived improvements in quality of life.
19
Ottawa Charter for Health Promotion, WHO, Geneva 1986
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Strategic Analysis and Action to Implement the Regional Framework on Health Promotion
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Strategic Analysis and Action to Implement the Regional Framework on Health Promotion
predisposing factors There are several predisposing factors that have led to the low prioritization of health promotion both within the health sector and the rest of society: 1. Lack of understanding of health promotion Within many Ministries of Health, health education and health promotion are still one and the same. In many instances, after the Ottawa Charter in 1986, the old health education unit that was in charge of publications or IEC production was renamed as the Health Promotion Unit. However, its function and capacity to undertake the new tasks of social mobilization and advocacy remained the same. 2. Limited evidence on health promotion
3. Confusion about who is in charge of health promotion The multi-sectoral nature of health promotion activities diffuses accountability over several groups or individuals. In most instances, health It is everyone's promotion is 'integrated" across various disciplines and programmes to the extent that it is everyone's business and no business and no one's responsibility. one's responsibility. 4. Isolation of health promotion from health systems development.
The old health education unit that was in charge of publications or IEC production was renamed as the Health Promotion Unit.
It is composed of activities that involve many people, draws a lot of attention but is unable to provide "hard" evidence of impact.
Health promotion, even within the health sector is seen as a "soft" public health intervention whose outcomes are nebulous and ill defined. It is composed of activities that involve many people, draw a lot of attention but are unable to provide "hard" evidence of impact. While there has been success in building evidence for health promotion in developed countries, these models for research and evaluation are too expensive for developing countries. As a result, limited resources are transferred from health promotion programmes that could have a direct benefit to the community to sophisticated evaluation projects conducted by external experts, who undertake studies that cannot be replicated by their local counterparts. On the other hand, methods for measuring improvements in quality of life have not been utilized to argue for the value and impact of health promotion in the general population.
Health promotion as discipline is seen Health promotion as a discipline is seen as distinct and separatea from hospitals, medical care and even public health programmes as distinct and when, in fact, health promotion is an integral part of health care. separate from Advocacy among policy-makers and decision-makers is weak. hospitals, medical Despite the evidence, health promotion is not appreciated even care and even public among hospital administrators, clinicians and public health health programmes officials as a relevant or efficient intervention for the "practice of when, in fact, health medicine" or improving the health of individuals or communities. promotion is an integral part of 5. Inability to use new technology to advance health health care. promotion
While other sectors have been able to maximize the use of advances in behavioural change communication to promote and market all types of products and services, the promotion of health concepts, ideas, practices and lifestyles is oftentimes archaic, anachronistic and boring.
The promotion of health concepts, ideas, practices and lifestyles is still done in archaic, anachronistic and boring ways.
Enabling factors Health Promotion
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Strategies to support the implementation of the Regional Framework for Health Promotion are proposed to scale up health promotion at the country level and contribute to achieving national goals, objectives and targets for health, as well as social goals and outcomes. Three critical steps would enable this process. They are: Step 1. Reframing the challenges; Step 2. Positioning for new roles and responsibilities; and Step 3. Setting strategic directions. Reframing the Challenges Simply stated, the challenges for health promotion are threefold: a) To scale up in order to reach a strategic mass at national levels, with an emphasis on reaching the most vulnerable and marginalized groups, especially the poorest of the poor; b) To scale out laterally, in order to engage strategic partners outside of the health sector who could break barriers to health promotion in addressing broad determinants of health within the social and cultural context of the country; and c) To scale in and sharpen the tools for effective health promotion integrating it into health systems development and making it a priority within the health sector and a mission of the Ministries of Health.
by identifying strategic partners and providing them with relevant and timely information. The role of the catalyst is to build bridges and nurture strategic partnerships with key people who can make things happen at the national level. Champions for Health Promotion Health promotion "champions", on the other hand, have emerged for Healthy Settings in almost all of the Member States. These individuals outside of the formal health sector have demonstrated a natural interest in health promotion and are able to immediately take the lead among different stakeholders by The role of the champion mobilizing communities and individuals to take action. is to break barriers These individuals are leaders in their own field and now to health promotion by serve as strategic partners for health. The role of the linking health outcomes champion is to break barriers to health promotion by to social outcomes. linking health outcomes to social outcomes. They will help create perceptions and shape public opinion to equate health promotion action with social goals actively linking health promotion to good governance, corporate responsibility, sustainable development, education for all and economic growth. They will speak out on health in relation to education, trade, economics, finance, governance and other health-related areas. In the process they will acquire ownership of health programmes and inspire others to do the same. They will take health promotion outside of the arena of the health sector and into the arena of public debate where the issue will be how to health promotion can be scaled up to achieve strategic coverage with benefits that would accrue to entire populations. Coaches for Health Promotion While catalysts and champions for health promotion must exert influence on the environment, conscious efforts must also be undertaken to strengthen health promotion as a technical discipline and incisively integrate it into broad health
The role of the catalyst is to build bridges and nurture strategic partnerships with key people who can make things happen at the national level.
Positioning for New Roles and Responsibilities Catalysts for Health Promotion The new role of the technical focal person for health promotion within Ministries of Health must now be redefined. Essentially, this individual emerges more as a "catalyst" for change rather than as an implementer of a national programme. As a change catalyst, the health promotion focal person mobilizes gatekeepers. The catalyst facilitates the health promotion process
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The role of the coach is to strengthen health promotion by integrating and linking it to other technical areas and to provide technical support for developing strategies and tactical alliances for catalysts and champions through Setting Strategic Directions international networking Developing Leaders for Health Promotion and collaboration.
initiatives such as health systems development and health sector reform. WHO Country Offices, international partners and academic institutions can contribute to this process as coaches for health promotion. The role of the coach is to strengthen health promotion by integrating and linking it to other technical areas and to provide technical support for developing strategies and tactical alliances for catalysts and champions through international networking and collaboration.
on how to scale-up health promotion by breaking social and political barriers to health promotion. In order to engage in strategic partnerships outside of the sector, catalysts need to acquire political skills for mediation, consensus building, negotiation, and managing conflict. Champions and catalysts in health promotion should work within their existing spheres of influence to create learning organizations that cascade to empowerment of the communities they serve. Networking, sharing of experiences and documentation of best practices need to be systematized. To develop relevant, dynamic and problem-based learning experiences for leaders and champions of health promotion, coaches need to link-up with institutions that build capacity for local and global governance, education, corporate responsibility, sustainable development, social development, culture and the arts. Developing Effective "External" Campaigns to Communicate and Reduce Risks Communicating, managing and reducing risks to health is highlighted in THE WORLD HEALTH REPORT, 2002 Reducing Risks, Promoting Healthy Life. One of the global expected result areas for 2004-2005 is: "Advocacy and health communications strengthened at all levels in relation to health promotion and the major risk factors, as defined in the World Health Report of 2002." In support of this global direction, the development of national campaigns to communicate and reduce risks related to lifestyle, environment and broad determinants of health should be a key strategy for addressing the new challenges to health promotion. A national campaign should involve as many potential partners as possible, drawing from leaders who have worked on Healthy Settings and forging new tactical alliances with other sectors, such as education, business and industry,
In order to achieve strategic coverage, capacities to undertake health promotion activities in a systematic and scientific manner need to be strengthened. This process cannot happen overnight. Leadership, partnerships, tactical alliances and teamwork need to be developed among catalysts, champions and coaches. For this to happen, new competencies are required. A paradigm shift in health human resource development for health promotion is necessary. While acquiring skills in the technical and management aspects of health education are still relevant at lower levels, in a scale-up mode, programme management training should be replaced by leadership development and training. Coaches for health promotion will play a critical role in providing opportunities for Leadership, leadership development. Coaches need to develop templates on core competencies for partnerships, catalysts and champions. In relation to this, new training modules tactical alliances and programmes need to be conceptualised. Training programmes and teamwork should be focused on localized problem solving and mentoring. need to be Training programmes should not take leaders out of the area of developed among work, but should instead create opportunities for them to learn from catalysts, others who are in similar situations. Champions could benefit from technical assistance, study tours and interactive sessions with champions and other political leaders in health who could provide them with insight
coaches.
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civil society, NGOs and the general public. Ministries of Health and Education could jointly spearhead this campaign with local champions. Spokespersons for national health promotion campaigns need not be from the Ministry of Health. Celebrities, entertainers, athletes, local government officials and other influential people could also be effective in delivering key messages. Champions can challenge the existing complacency about health promotion within the wider arena of politics and public debate. Coaches should provide technical support for opportunities when this process Spokespersons for occurs.
the first step in a national campaign for risk reduction. Awareness raising needs to be accompanied by local action, policy change and reorientation of health services. Developing an" Internal" Marketing Strategy for Health Promotion within the Health Sector Health promotion cannot be confined to local or inter-sectoral action. To complete the picture, the entire health sector must be actively engaged in promoting health. Unfortunately, engaging the health sector in health promotion has often been more difficult than engaging other sectors. This is especially true in health care delivery systems that are cash-strapped and overwhelmed by the need to respond to lifethreatening situations and critical care. Reorientation of health services as a recurring issue among technical areas should be addressed in a systematic manner. A conscious effort should be made to develop a separate "internal" marketing strategy for health promotion with champions inside the health sector, but outside of the health promotion sector. For example, clinicians and specialists may be credible sources of health promotion messages. A famous cardiovascular surgeon could be "recruited" to be a spokesperson for physical activity. A specialist in paediatric pulmonology could be positioned as an advocate for tobacco control. A team of health promotion champions made up of clinicians, specialists and hospital directors would facilitate the process of reorientation of health services. The process should be deliberate and
national health promotion campaigns need not be from the Ministry of Health. Celebrities, entertainers, athletes, local government officials and other influential people could also be effective in delivering key messages.
Behavioural change communication and the use of mass media should be maximized for promoting healthy lifestyles and environments. Risk communication should bridge equity gaps in information, especially among poor and marginalized groups. Coaches should explore approaches to strengthening capacity-building for health communication through partnerships with schools of mass communication. The capacity to use mass media and undertake communications design, research, implementation, assessment and evaluation should be built into Ministries of Health. Their new role would be to provide technical support, monitor and evaluate the effectiveness and efficiency of health promotion programmes as implemented by strategic partners. But, raising awareness would be only
Clinicians and specialists may be credible sources of health promotion messages. A famous cardiovascular surgeon could be "recruited" to be a spokesperson for physical activity. A specialist in paediatric pulmonology could be positioned as an advocate for tobacco control. A team of health promotion champions made up of clinicians, specialists and hospital directors would facilitate the reorientation of health services.
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consciously designed to change the current thinking that health promotion is only within the domain of public health specialists. Health economists would also be good potential spokespersons for health. They should be deliberately engaged as "champions" of health promotion in order to fast-track the articulation of the economic benefits of health promotion among economists and financing experts within the health sector. Building Capacity to Determine Effectiveness of Health Promotion: Ensuring Accountability for Health Promotion at the National Level Coaches need to help Ministries of Health develop the capacity to evaluate and assess the effectiveness of health promotion actions at the local and national level in cost-effective ways. Tools for analysis and evaluation should be appropriate and accessible. Capacity for conducting reviews of effectiveness should be built into national academic institutions and other partners.
Strengthening of the infrastructure for health promotion effectiveness would include capacitybuilding for using burden of illness as the basis for health promotion planning, monitoring and evaluation.
A building block for determining the effectiveness of health promotion would be to adopt burden of illness as the basis for health promotion planning, monitoring and evaluation .
integrate health promotion under the philosophy of "corporate responsibility." ü Cities will play an increasingly critical role as a political unit for promoting health. Local leaders of island communities play a similar role. Health promotion policy development for local officials could be actively linked to principles of good governance.
Cross-disciplinary interventions to assess perceptions of improvements in quality of life could help in advocating for greater support for health promotion. Coaches could encourage Ministries of Health to work with political scientists and tacticians to undertake "polling" exercises to understand how people perceive health education messages. Specialists in advertising could also help in determining what "excites" the public and how programmes for health promotion could be successfully packaged and marketed. Coaches should consciously identify models for effective health promotion and actively disseminate lessons learned among champions and catalysts. Examples of these would include:
ü Ministries of Education should be engaged to broaden the scope of health education through school-based interventions and link health-promoting schools to "education for all". Catalysts should identify strategic partners within the education sector and nurture these relationships. Capacity-building in health education should be relevant and tailored to local contexts. ü Health-promoting schools need to spread their influence to the communities that they serve. Strategies to reach rural communities through health-promoting schools should be considered. Strategies that empower women, adolescents and children at the community level should be expanded
Ministries of Education should be engaged to broaden the scope of health education through school-based interventions and link health-promoting schools to "education for all".
ü How the role of the private sector in health promotion needs to be explored, defined and nurtured. Given the opportunity, business and industry can
ü Local health promotion activities should be culturally sensitive and take into consideration how people perceive health and disease. NGOs and civil
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Health Promotion
making healthy choices easy, early and exciting...everywhere
Health financing for health promotion services and activities should be studied. Where it is possible and relevant, health promotion must be included in health systems development and health sector reform. Colleges of Economics should be actively engaged in projects that undertake costeffectiveness and costbenefits analysis. Health promotion should be reflected in the National Health Accounts.
society will play an important role in mobilization for change. Coaches will play an important role in capacity-building in these areas. ü Guidelines for incorporating health promotion in clinical care need to be developed and tested. ü Health promotion foundations may be explored as mechanisms for developing national infrastructure for health promotion. ü Health financing for health promotion services and activities should be studied. Where it is possible and relevant, health promotion must be included in health systems development and health sector reform. Colleges of Economics should be actively engaged in projects that undertake cost-effectiveness and cost-benefits analysis. Health promotion should be reflected in the National Health Accounts.
Guidelines for incorporating health promotion in clinical care need to be developed and tested.
Ultimately, health promotion must become part of the core values of individuals, groups, the community and society. In the WHO Regional Office for the Western Pacific, an internal advocacy initiative has started and should be sustained. As this progresses, an enabling environment for collaborative work with other technical areas is facilitated.
Regional Framework for Health Promotion page 2002-2005 38
Health Promotion
making healthy choices easy, early and exciting...everywhere
Recommended Strategies for Member States at the Country Level
Regional Framework for Health Promotion section 2002-2005 9
Health Promotion
making healthy choices easy, early and exciting...everywhere
Recommended Strategies for Member States at the Country Level Public Education and Communication for Health Promotion Providing the general public with basic information and evidence on the effectiveness of health promotion can be pursued through: • National campaigns on major risk factors and how they can be reduced; • Internal marketing strategy to communicate the benefits of health promotion within the health sector; • Scaling-up and institutionalizing health education in partnership with the education sector; • Building capacity for strategic communication to maximize utilization of mass communication technology to deliver health messages to wider audiences; • Partnerships with academic institutions specializing in mass communication and radio and television networks towards developing courses/programmes/study tours for: 4 communication specialists, on health promotion; 4 health professionals, on mass communication; 4 local officials, on health promotion and mass communication; society groups for building capacity for lifeskills training and lifestyle change in communities; and • Building capacity for patient education in health facilities. Social Mobilization and Advocacy for Health Promotion Creating an enabling environment for local action through mobilization of different stakeholders and the positioning of health promotion as a national priority through: • Strategic partnerships with other sectors (i.e. education, trade, industry, sports, beauty and fitness, fashion, entertainment, and media); • Engaging celebrities and other influentials (athletes, entertainers, mayors) to be spokespersons for health promotion; • Advocacy for incorporation of health promotion policy, programmes and interventions as parameter for good local governance; • Advocacy for sponsorship of health promotion campaigns by business and industry within the context of "corporate responsibility"; • Advocacy for integration of health promotion for in-patient and out-patient care within the context of quality improvement and quality assurance; • Advocacy for health education linked to "education for all" and the provisions of the International Convention on the Rights of the Child; • Advocacy for health promotion in relation to empowerment of women; • Advocacy for healthy environments linked to sustainable development; and • Strengthening of social mobilization and advocacy skills within the health • Partnerships with NGOs, organized community groups, foundations and civil
Regional Framework for Health Promotion page 2002-2005 40
Health Promotion
making healthy choices easy, early and exciting...everywhere
sector through strategic leadership training in health promotion. Evidence for Healthy Public Policy Development and Sustainability of Health Promotion Building capacity to generate evidence for effective health promotion at national levels and developing the national support infrastructure for sustained action in health promotion through: • Development and dissemination of models, templates and demonstration sites on effective and efficient health promotion approaches and interventions; • Collaboration with social scientists, psychologists and behaviour specialists on specific strategies for health promotion among poor and marginalized groups; • Collaboration with political scientists and the advertising sector on practical strategies and methods for appraising public perceptions on improvements in quality of life after health promotion interventions are undertaken; • Integration of health promotion in health sector reform including adoption of effective health promotion financing models and options (social health insurance, health promotion foundations); • Building capacity for the generation of knowledge on the determinants of health and vulnerabilities of populations at risk through research, monitoring and evaluation; and • Integration of health promotion theory and practice in other technical areas to support education, social mobilization and advocacy components for disease control and health systems development at national levels.
Regional Framework for Health Promotion page 2002-2005 41
Health Promotion
Expected Results: Selected countries enabled to strengthen effectiveness of health promotion programmes Regional Expected Results Capacity strengthened at national and regional levels for effective leadership, policies and programmes on health promotion. Linkage to Global Expected Results Capacity strengthened at national and regional levels for the planning and implementation of multisectoral health promotion policies and programmes across the life course, and as populations age. Activities 1. Development of a template for leadership training in health promotion with emphasis on ensuring multi-sectoral participation in health promotion programmes and policy development across the life course; 2. Capacity-building at national levels in partnership with academic institutions to undertake leadership training programs based on the template developed; 3. Leadership training programmess implemented at national level; 4. Sharing of experiences among leadership fellows within the region and with other leaders in health promotion in other regions; 5. Regional Workshop on Capacity-Building for Health Promotion (2002). Indicators 1. Template for leadership training that emphasizes mentoring, problemsolving in relation to multi-sectoral participation in national health promotion initiatives developed; 2. Number of trainers training or designated "centres of excellence" using the template for leadership training within the Western Pacific Region; 3. Number of countries with national leadership training/fellowship programmes for health promotion based on the template; 4. Number of workshops for health promotion leadership fellows from within and outside of the Western Pacific Region; 5. Report of the Regional Workshop on Capacity-Building for Health Promotion. 1. Number of countries with action in relation to health promotion financing arrangements; 2. Number of countries with policy discussions on how best to sustain and finance health promotion given a package of options.
Health promotion programmes for capacity building and financing at local and community levels, workplace and other settings, with particular focus on disadvantaged people. Systematic efforts to define opportunities and mechanisms for reorienting health services toward health promotion.
1. Review of health promotion financing arrangements especially among developing countries; 2. Packaging of options for health promotion financing (insurance, health promotion foundations and others) and disseminating these options to countries for review and adoption. 1. Projects to develop capacity to undertake burden of disease studies and use this as the basis for identifying risks and developing health promotion interventions to minimize or reduce these risks; 2. Projects to link health promotion to health sector reform; 3. Projects to integrate health promotion in health systems development; 4. Projects to integrate health promotion in clinical practice guidelines, quality improvement and quality assurance; 5. Regional Meeting on Health Promotion and Health Sector Reform (2004).
1. Number of countries that are building capacity to undertake burden of disease studies and use this for health promotion programme development; 2. Number of countries linking health promotion to health sector reform; 3. Number of countries integrating health promotion in health systems development; 4. Number of countries integrating health promotion in quality improvement and standard setting; 5. Report of the Regional Meeting on Health Promotion and Health Sector Reform. 1. Consensus on framework for reviewing effectiveness of health promotion among developing countries; 2. Number of countries with capacity-building projects on effectiveness of health promotion; 3. Number of case studies on effective health promotion models; 4. Number of meetings at national and regional levels on disseminating models for effective health promotion. 1. Number of countries providing accurate, timely and relevant information in relation to major risk factors and healthy lifestyles using mass media and modern communication methods; 2. Number of countries with marketing strategies to engage clinicians and specialists in advocating for health promotion. 1. Number of countries with action to monitor the major behavioural risk factors of youth, adolescents and children and to provide timely and relevant interventions to reduce these risks through strong multisectoral partnerships and networks; 2. Number of countries with health promotion projects that involve partnerships with other health-related sectors.
Evidence through global review on the effectiveness of health promotion collected and disseminated.
1. To develop a framework for reviewing effectiveness of health promotion specifically for developing countries; 2. To build capacity to undertake review of effectiveness of health promotion at national levels in partnership with academic institutions; 3. To undertake review of effectiveness of health promotion; 4. To share experiences and best practices of models of effective health promotion. 1. National campaigns for major risk factors; 2. Internal marketing and advocacy campaigns for health promotion within the health sector.
Strengthened capacity to undertake advocacy and campaigns for healthy settings, populations and lifestyles. Integration and strengthening of health promotion activities within other technical areas.
Advocacy and health communications strengthened at all levels in relation to health promotion and the major risk factors, as defined in the World Health Report 2002.
Strengthened approaches to health promotion that reach young people in and out of school.
1. Partnerships with education sector and other relevant agencies, communities and youth groups to promote the health of youth, adolescents and children; 2. Partnerships with other health-related sectors i.e. tourism, business and industry, trade and commerce, finance, media, non-governmental organizations, women's groups etc.
Regional Framework for Health Promotion page 2002-2005 43
Health Promotion
making healthy choices easy, early and exciting...everywhere
Areas for Action at the Regional Level for WHO and International Partners 2002-2005
Regional Framework for Health Promotion section 2002-2005 10
Health Promotion
making healthy choices easy, early and exciting...everywhere
Areas for Action at the Regional Level for WHO and International Partners 2002-2005 Health Promotion Leadership Training Support will be provided for developing leadership training for health promotion utilizing templates that emphasize learning by problem-solving, mentoring and facilitated study tours in partnership with academic / training institutions. Development and Dissemination of Models of Health Promotion Effectiveness Parameters for analysing and evaluating the effectiveness of health promotion actions will be encouraged specifically where cross-disciplinary paradigms can be created between the sciences, the social sciences, culture and the arts. In support of this, demonstration sites and model projects will be encouraged. At the same time, efforts will be undertaken to strengthen the role of health promotion in disease control by using burden of disease as the basis for health promotion planning, and evaluation. Risk analysis, management and communication will also be pursued in relation to health promotion programme development. Communication Campaigns for Health Promotion Support will be provided to countries in developing communication campaigns for the different approaches to health promotion. Capacity to undertake mass media campaigns for healthy lifestyles and environments will also be strengthened. Integration with Health Systems Development and Health Sector Reform Collaboration with other units/programmes/focuses will be undertaken to integrate health promotion with health systems development and health sector reform. Integration and Support for Other Technical Areas Collaboration with other technical areas will be pursued in order to develop effective and efficient interventions in social mobilization, health education and advocacy.
Regional Framework for Health Promotion page 2002-2005 42
Health Promotion
making healthy choices easy, early and exciting...everywhere
Making healthy choices easy, early and exciting…everywhere
Regional Framework for Health Promotion conclusion 2002-2005
Health Promotion
making healthy choices easy, early and exciting...everywhere
Making healthy choices easy, early and exciting…everywhere Changes in the social, political and economic environment of the 21st century pose new threats to health and well being. At the same time, these threats provide opportunities to position health promotion as a cost-effective and efficient strategy to improve the quality of lives of millions of people in the Region. Health promotion does not require expensive drugs or elaborate technology that is capital intensive. What it requires on its most basic level is a personal investment of time and energy to change our lifestyles in favour of health over convenience, comfort or monetary gain. For Ministries of Health, it requires a perspective where health promotion is a mission. For the rest of the health sector, it requires building trust and partnerships with other sectors. For society as a whole, it entails engaging in the promotion of health as a social enterprise. Health promotion requires intensive social capital, but once this has been tapped, health promotion must be linked to the development of more responsive health care systems. The way forward has been stated as "making healthy choices easy, early and exciting….everywhere." This emphasizes the importance of healthy lifestyles within the context of healthy supportive environments where healthy choices can be just as compelling as unhealthy ones. The Regional Framework for Health Promotion is not a quick fix or a recipe for success. Much of what needs to be achieved must be done by building capacity at national levels to effect changes in the way the Ministries of Health and its partners go about the business of promoting health. Health promotion creates the possibility of choice, which is perhaps the greatest weapon in protecting the right of all to health and well-being.
Regional Framework for Health Promotion page 2002-2005 44
Health Promotion
making healthy choices easy, early and exciting...everywhere
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An artistic interpretation of the Ottawa logo is presented using the bamboo plant as a metaphor for the health promotion process. Historically, bamboo is intertwined with centuries of tradition in the different cultures of the Region. Today, it can be found almost everywhere and continues to be an important medium for expressing traditional and contemporary social goals and aspirations through music, crafts, and architecture. It pervades daily life as a source of food, material for furniture, cookware, and homes and is a part of the environment. Bamboo captures the principles of unity and polarity: strength with resilience, versatility with stability, durability with dispensability. These qualities of the bamboo plant are similar to how health promotion is envisioned: pervasive, persistent and integrated into lifestyles with ease, elegance and simplicity.
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Regional Framework for Health Promotion page 2002-2005 45
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Health Promotion
making healthy choices easy, early and exciting...everywhere
references Green Cross International, Globalisation and Sustainable Development: Is Ethics the Missing Link? (Earth Dialogues Forum: Lyon, 2002) Kreuter, Marshall, Nicole Lezin, Laura Young and Adam Koplan "Social Capital: evaluation implications for community health promotion" Evaluation in Health Promotion: Principles and Perspectives (WHO Regional Publications, European Series, No. O2, 2001) Leon, David and Gill Walt Poverty, Inequality and Health: An international perspective (Oxford University Press, Great Britain, 2001) Lin, Vivian "Regional Overview on Healthy Settings" (WHO WPRO, 1999) Nutbeam Donald, "Measuring the Effectiveness of Health Promotion" The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe IUHPE and the European Commission Brussels/Luxembourg 1999) O'Riordan, Tim Globalism, Localism and Identity: Fresh Perspectives on the Transition to Sustainability (Earthscan Publications, UK/USA, 2001) Putnam, R.D. Making Democracy Work: Civic Traditions in Modern Italy (Princeton, Princeton University Press, 1993) UNICEF/WHO A Healthy Start in Life: Global Consultation on Child and Adolescent Health and Development (Stockholm, Sweden, 2002) UN, Second World Assembly on Ageing (Madrid, April 2002) World Health Organization, Health Promotion Glossary ( WHO/HPR/HEP/98) World Health Organization, Ministerial Round Table: Diet, Physical Activity and Health (WPR/RC53/12 Kyoto, Japan, September 2002) World Health Organization, Pan American Health Organization, and Ministry of Health of Mexico Technical Report 6: Reorienting Health Systems and Services with Health Promotion Criteria, A Critical Component of Health Sector Reforms (Fifth Global Conference on Health Promotion, Mexico, 2002) World Health Organization, WHO Conference on Health and Disability (Italy 2002)
Regional Framework for Health Promotion page 2002-2005 46
Health Promotion
World Health Organization Regional Office for the Western Pacific United Nations Avenue, PO Box 2932 1000 Manila, Philippines
www.wpro.who.int
World Health Organization Regional Office for the Western Pacific United Nations Avenue, PO Box 2932 1000 Manila, Philippines
www.wpro.who.int