CHAPTER 1 Health promotion in context
Primary Health Care and the New Public Health movement
There are many factors that influence health and illness. In this chapter the determinants of health and illness will be outlined and we will review the development of the World Health Organization’s policy process to achieve Health for All. The conceptualisations of health and illness and the responses of individuals, communities and countries are socially constructed. The role that Primary Health Care, the New Public Health movement and health promotion play in achieving the goal of Health for All will be discussed and a continuum of approaches to promote health will be introduced.
There are major disparities in the health of people around the world, with serious differences in life expectancy between people living in various countries, as well as differences between groups of people within countries. Over the last 50 years, average life expectancy at birth has increased globally by almost 20 years; however, social and environmental changes in recent years have contributed to life expectancies in some of the poorest countries collapsing to half the level of the richest countries (WHO 2006). Emerging diseases affecting physical, social and emotional health are experienced differently, unequally and inequitably. Some people experience better access to health and other resources than ever before but many do not. There are sufficient resources worldwide to meet the challenges in health inequalities but ‘many national health systems are weak, unresponsive, inequitable — even unsafe’ (WHO 2006).
There are many terms used to describe the position of countries worldwide. Currently, the descriptors are tied to economic status such as ‘developed’ or ‘developing’. Similarly, ‘first world’ and ‘third world’ have been used for many years. ‘Developed’ countries are relatively rich and have a strong industrial base. The ‘developing’ countries are neither rich nor have a strong industrial base. In this book we will use the terms the Majority world and the Minority world because they provide a meaningful description of how the world is divided up now. The majority of the world’s people are not rich but there is a minority of people who are. The United States of America (USA) for example is a very rich and powerful country and part of a small minority in the world. Bangladesh is very poor and part of the large majority in the world. However, within both of these countries are people who belong to the Majority world and Minority world.
The World Health Organization (WHO) is an agency of the United Nations. It was established in 1948, as the major body to deal with international health issues. The WHO is made up of 193 member states which aim to work together to promote the health of the world’s people.
The preamble to the constitution of the WHO makes several statements about the way to achieve health worldwide. First, the WHO definition of health is that ‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO 1948). The tenets of the constitution are that:
In the late 1960s and early 1970s there was growing concern that the health status of some populations had not improved as predicted, despite the investment in and rapid growth of health care systems. Minority countries invested in high technology; however, those in Majority countries lacked access to even basic health care services. As medical technologies and medical knowledge developed, there had been the belief that these things would solve the health problems facing people around the world. It became increasingly apparent that this was not the case, and that high technology acute medical services had a limited effect on the health of populations. There was growing evidence that it was public health in its broadest sense, rather than medical care, which was responsible for most population health improvement (McKeown 1979). At the same time, there was a growing scepticism of the role and power of medicine itself and the value of medical treatment (Illich 1975). The determinants of health and illness were beginning to be acknowledged globally. Yet, few countries had acted to improve health by reducing poverty, improving housing and food availability, and stopping political oppression, despite the wide-ranging evidence that social conditions have a great impact on health. Some countries began to review their health systems and the approach to health and illness care. In Australia, for example, the Labor Government began to invest in community-controlled, community-based, multidisciplinary health services in 1973. The Lalonde Report (1974) had a significant impact in Canada and other Minority countries. In that report, health was represented as being dependent on biological, environmental and lifestyle factors and access to health systems. This was a dramatic shift away from the focus on the biological determinants of health that had dominated health sector thinking.
In 1978, the WHO and United Nations International Children’s Emergency Fund (UNICEF) held a major international conference on Primary Health Care in the former USSR. It was attended by representatives from 134 nations. The outcome of the conference was the Declaration of Alma-Ata (Appendix 1). This conference is now regarded as a critically important milestone in the promotion of world health.
Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology. Primary Health Care is made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (WHO 1978).
The prerequisites for health include peace, shelter, education, social security, social relations, food, income, empowerment of women, a stable ecosystem, sustainable resource use, social justice, respect for human rights and equity (WHO 1978).
The Declaration of Alma-Ata was seen as the key to achieving a level of health that permitted people of the world to lead a socially and economically productive life. The declaration gave rise to the slogan — ‘Health for All by the Year 2000’ (WHO 1978).
Equity means fairness and social justice implies a commitment to fairness. Empowerment is a process which enables people to participate in a way that improves their life and achieves social justice. These three key principles underpin all Primary Health Care activities; they will be discussed more fully in Chapter 2.
The Declaration of Alma-Ata provided further guidance to governments to reduce health inequalities between and within countries and achieve Health for All through a number of defining characteristics:
political action to achieve health, which includes cooperation between countries, a reduction of money spent on armaments in order to increase funds for Primary Health Care, and a commitment to world peace.
To some extent, achievement of these defining characteristics set out in the Declaration of Alma-Ata rely on nations undertaking a commitment to the first three key principles; without them other approaches will be ineffectual.
The Primary Health Care philosophy is the foundation of the Primary Health Care movement and its goal of achieving Health for All. Health for All was, and remains, fundamentally a call for social justice. It is a process that leads to progressive improvements in the health of people, and is not a single finite goal.
The Primary Health Care philosophy embodies the principles described above and enables health workers to address the root causes of ill health. It emphasises working with people to enable them to make decisions about their needs and how best to address them. These principles reflect the Primary Health Care philosophy — using approaches that emphasise participation in decision-making, health promotion activities, and providing services that are affordable and sustainable.
To be effective, Primary Health Care principles need to be applied throughout the health system and in every interaction between health workers and community members. No matter where in the health system consumers find themselves, these principles need to be evident. Indeed, given the recognition of the need for action outside the health sector to improve health and the impact of social services on health, the Primary Health Care philosophy has implications way beyond the health system.
Implementation of the Primary Health Care philosophy is clearly a massive task involving considerable political will and major changes in health systems. This is politically significant. Given the power of the medico–industrial complex, and the urgent need for basic medical services in some parts of the world, it is not surprising that those already in power in the Minority world set priorities based on the medical model of health care. Primary Health Care threatens those with vested interests in the current system; in particular, those who have power in, and who make money from, a technologically dependent health system.
Health for All by the Year 2000 was not a goal in itself, but rather a process to improve the health of the world’s population. The WHO continues to affirm the philosophy that underpins Primary Health Care. Thirty years on, the WHO recommends that health care must be built on: universal access on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas, and inter-sectoral approaches to health.
The words ‘selective’ and ‘comprehensive’ are good descriptors of the different approaches to, or ways of ‘doing’, Primary Health Care. The strengths and weaknesses of each will be discussed throughout the book. Selective Primary Health Care (Walsh & Warren 1979, cited in Baum 2008) is based on the medical model of health care while comprehensive Primary Health Care is more consistent with the Primary Health Care philosophy discussed in this book. Comprehensive Primary Health Care is a developmental process that emphasises the aforementioned principles of equity, social justice and empowerment to work for social changes that impact on health and wellbeing. In comprehensive Primary Health Care, emphasis is on addressing the determinants of health; that is, the conditions that generate health and ill health. Therefore, provision of medical care is only one aspect of Primary Health Care. Selective Primary Health Care concentrates on treating illnesses. Thus, while comprehensive Primary Health Care focuses on the process of empowerment and increasing people’s control over all those influences that impact on their health, selective Primary Health Care operates in a way that assumes that medical care alone creates health and ensures that control over health is maintained by health professionals. In discussing the two perspectives, some have likened it to ‘the individual versus the system’ (Green & Raeburn 1988, in Baum 2008: 35).
Arguing for comprehensive over selective Primary Health Care is not to argue against the importance of addressing specific diseases. Selective Primary Health Care has produced important gains, such as reducing diseases through immunisation. Clearly we must address those diseases that cause human suffering and premature death. However, by only addressing those diseases, we risk perpetually attempting to address the end result of the problem instead of addressing the root causes of the diseases themselves or the social conditions that perpetuate disease and other suffering. Comprehensive Primary Health Care addresses these diseases and other issues in their social context, using a process that recognises the expertise that ordinary people have and their right to exert control over their own lives. There are differences in how Primary Health Care is implemented. Box 1.1 provides four key areas in which selective Primary Health Care compares poorly with comprehensive Primary Health Care.
1. By focusing on the eradication and prevention of diseases, selective Primary Health Care assumes that health is the absence of disease rather than, as in the broader WHO definition, a state of complete physical, mental and social wellbeing. This then locates action for health almost solely within the realms of specialists trained to treat disease.
2. Through its emphasis on those diseases and problems most likely to respond to treatment, selective Primary Health Care ignores the need to address issues of equity and social justice, which are at the root of many health problems.
3. In establishing medical interventions as the most important part of Primary Health Care, selective Primary Health Care ignores the importance of all those non-medical interventions, such as the provision of education, housing and food, which have a greater bearing on health than health services themselves.
4. Selective Primary Health Care limits the value of community development as a strategy for improving health to being a technique for increasing community compliance with medically defined solutions, rather than as a mechanism for community empowerment. It thus identifies expertise as residing with medical workers and denies the great expertise that people have with regard to their own lives and the issues that affect them.
(Source: Rifkin S, Walt G 1986 Why health improves: defining the issues concerning ‘comprehensive Primary Health Care’ and ‘selective Primary Health Care’. Social Science and Medicine. 23(6):12–13)
A good example of comprehensive Primary Health Care is the way in which some non-government organisations (NGOs) work internationally. In countries where the health sector is weak or non existent, NGOs such as Médecins Sans Frontières (MSF) (MSF www.msf.org/) dispense essential drugs such as vaccines, and assist local communities with water and sanitation programs. MSF also provides training of local personnel to work with disadvantaged groups in remote health care centres and slums. MSF works at both preventing illness and treating disease by providing essential medical care, and also assists with essential infrastructure support in a socially acceptable and empowering way.
When the philosophy of Primary Health Care is implemented, a particular strategy for the organisation of health care becomes apparent. A balanced system of health promotion, disease prevention, rehabilitation and illness treatment can be developed, with the entire system built to meet the goals of Primary Health Care. To deal with the increasing burden of communicable and non-communicable diseases worldwide requires ‘upstream’ health promotion and disease prevention in the community as well as ‘downstream’ disease management within health care services. A health system based on Primary Health Care will:
The term ‘Primary Health Care’ is often used to refer to primary-level health services; that is, the first point of contact with the health system for people with health problems. In a Primary Health Care system, this level of care should be the most comprehensive. In this way, problems can be dealt with where they begin. Primary-level health services include community health centres, pharmacies and general medical practices. Non-government organisations and community groups can also be an important part of Primary Health Care services. However, these services can only be regarded as Primary Health Care services if the Primary Health Care philosophy underpins the way in which those first-level services are provided. That is, Primary Health Care practitioners’ work is guided by the principles of equity, social justice and empowerment. Community participation in decision-making, collaboration with health and other workers to deal effectively with health issues, and incorporation of health promotion and disease prevention is essential to their work.
The term ‘primary care’ is often used interchangeably with Primary Health Care, and some, especially those in medical care settings and agencies, view primary care as being synonymous with Primary Health Care. Very often primary care denotes selective Primary Health Care (described above) with an emphasis on the medical model of physical illness. In the New Zealand Health Strategy 2000, primary care means selective primary care directed to address acute and chronic medical health problems. A distinct range of Primary Health Care services with a focus on illness prevention and health promotion is administered through the New Zealand Primary Health Care Strategy. In the United Kingdom (UK) National Health System primary care trusts describe a mechanism of funding allocation to communities based on medical and social profiles (Battersby et al 2005). In Australia the coordinated care trials such as SA HealthPlus, attempted to create a shift from a funding-based model of care to a population-based model of care. The focus of the care changed from acute illness to chronic illness with the aim of providing integrated services (Battersby et al 2005). In Victoria the Department of Human Services has a Primary Care Partnerships strategy designed to prevent illness and reduce morbidity using health promotion strategies, agency partnerships and better coordination of care, especially for the management of chronic conditions. These can all be described as primary care, not Primary Health Care as it is outlined in the Declaration of Alma-Ata. Primary care is not necessarily the same as Primary Health Care, unless it is underpinned by the philosophy and meets all of the criteria set out in the section above.
The Ottawa Charter for Health Promotion (see Appendix 2) was built on the progress made through the Declaration of Alma-Ata and defines health promotion as ‘the process of enabling people to increase control over, and to improve, their health’ (WHO 1986). The Ottawa Charter for Health Promotion is regarded as the formal beginning of the New Public Health movement, a term that has widespread recognition, despite having been used several times before (Beaglehole & Bonita 2004: 214–17). The charter was the outcome of the first WHO International Conference on Health Promotion and was held in Ottawa, Canada, in 1986. The aim was to increase the relevance of the Primary Health Care approach to Minority countries that had largely ignored the Declaration of Alma-Ata. The Ottawa Charter for Health Promotion (WHO 1986) highlighted the conditions and resources required for health and set out the action required to achieve Health for All by the Year 2000. Like the Declaration of Alma-Ata, the Ottawa Charter for Health Promotion was, and is, a landmark document, laying out a clear statement of action that continues to have resonance for health workers around the world.
The New Public Health movement arose out of the recognition that ill-health arises from a combination of biological, social, economic, emotional and environmental factors. Actions to improve health and prevent ill health will likewise need to be directed at these broad determinants. The major improvements in health status during the 20th century, mentioned above, are attributable to improvements in these determinants for some people, rather than as a result of biomedical interventions (Marmot & Wilkinson 2006; Baum 2008; WHO 2008a, b).
Primary Health Care, Health Promotion and the New Public Health are based on the same philosophy, strategy and activities for achieving health. Addressing the determinants of health through social justice and providing a balanced system of health care, is at the core of this approach. The Ottawa Charter provides fundamental guidance about how this can be done.
The strength of the Ottawa Charter lies in the fact that it incorporates both selective and comprehensive perspectives of Primary Health Care. Further, the five action areas of the Charter, used collectively within any population and within any setting, have a far better chance of promoting health than when they are used singularly (Kickbusch 1989). The Ottawa Charter for Health Promotion highlights the role of organisations, systems and communities, as well as individual behaviours and capacities. The five action areas of the Charter (see Figure 1.1) are designed to promote health by:
1. Building healthy public policy. It is not health policy alone that influences health: all public policy should be examined for its impact on health and, where policies have a negative impact on health, we must work to change them. For example, if a local government has a policy of allowing industrial complexes near residential areas, this would need to change if it was having a negative impact on residents’ health.
2. Creating environments which support healthy living. The protection of both the natural and built environment is important for health. In the built environment we need living, work and leisure environments organised in ways that do not create or contribute to poor health. For example, we need to provide affordable child care for working parents. We also need to conserve the natural environment for health. These will come through the establishment of healthy public policy.
3. Strengthening community action. Communities themselves are the experts in their own community and can determine what their needs are, and how they can best be met. Thus, greater power and control remain with the people themselves, rather than totally with the ‘experts’. Community development is one means by which this can be achieved.
4. Developing personal skills. If people are to feel more in control of their lives and have more power in decisions that affect them, they may need to develop more skills. This could include being provided with necessary information, training or other resources that would enable people to take action to promote or protect their health. Those who work in health must work towards enabling people to acquire the necessary knowledge and skills to make informed decisions.
5. Reorienting health care. Health promotion is everybody’s business and intersectoral collaboration is the key. Within the health system there needs to be a balance between health promotion and curative services. One prerequisite for this reorientation is a major change in the way in which health workers are educated.
The New Public Health movement builds on traditional public health approaches in three important ways. Firstly, the broad nature of health promotion is recognised, and the need to work with other sectors of government and private institutions whose work impacts on health. This intersectoral collaboration has become recognised as a central feature of effective health promotion. Secondly, the need to work in partnership with communities to increase community control over issues affecting health is recognised. Thirdly, the primacy of people’s environments (both physical and social) in determining their health, and the need to work for change to the environment rather than focusing on change solely at the level of the individual is recognised (Tones, Tilford & Robinson 1990, pp 3–4; WHO nd, available: www.who.int/water_sanitation_health/resources/intersectcoll/en/index.html).
New Public Health is ‘based on a clear articulation of a social model of health’ (Baum 2002: 311; WHO 2008a) that emerged from philosophical underpinnings of the Declaration of Alma-Ata and the action areas of the Ottawa Charter for Health Promotion. A social view of health implies that we must intervene to change those aspects of the environment which are promoting ill health, rather than continue to simply deal with illness after it appears, or continue to exhort individuals to change their attitudes and lifestyles when, in fact, the environment in which they live and work gives them little choice or support for making such changes (South Australian Health Commission 1988a: 3). A social view of health implies that improvements in health are achieved by addressing the many cultural, environmental, biological, political and economic determinants of health. In the New Public Health it is acknowledged that medical and behavioural interventions used alone have a limited role because of their failure to deliver more equitable health outcomes within and between population groups. The social model of health sets very wide parameters for health promotion practice and it resonates well with comprehensive Primary Health Care.
The philosophy of Primary Health Care and the social model of health are gradually being incorporated into health care service provision, especially in the community sector, but much more slowly in the medical care sectors. The planning frameworks, funding application proformas and reporting documents used by agencies, such as the New Zealand Primary Health Care Strategy, state government Primary Health Care Strategies, such as PCP in Victoria, and Health Promotion Foundations, such as VicHealth, provide useful examples of how philosophy can be integrated into practice, which can be drawn on, or improved on, for local, community-based activities.
The philosophy and activities guiding the Environment movement and the Human Rights movement provide added weight to the philosophy of Primary Health Care. The United Nations (UN) Universal Declaration of Human Rights (Appendix 3) and The Earth Charter, 2000 (Appendix 4) resonate well with the Ottawa Charter for Health Promotion. In 1987, the year after the release of the Ottawa Charter, ‘Our Common Future’ (the Brundtland Report, UN 1987) called for ‘sustainable development’. This document, like the Declaration of Alma-Ata and the Ottawa Charter, is considered to be a seminal document. The principles that underpin sustainable development are:
Globally, there was a good deal of community and political action afoot at the time of the emergence of Primary Health Care philosophy, the New Public Health movement and the Environment movement. It is important to discuss both ecological and social justice perspectives and the relationship between the two. Ife and Tesoriero (2006) state that the perspectives of both need to be integrated to bring about a truly sustainable society. One of the reasons a social justice perspective is inadequate without an ecological perspective is because of the conventional economic prescription for many social problems brought about through economic growth. People working for ecological sustainability can challenge both the feasibility and desirability of continued growth, which Ife and Tesoriero (2006) see as contributing to the current ecological crisis. Both perspectives need to be understood in working toward enhancing health. Chapter 3 addresses these issue in more detail.
Each international health promotion conference, since the first in Ottawa, has reaffirmed the philosophy that underpins Primary Health Care outlined in the Declaration of Alma-Ata and further, the action areas of the Ottawa Charter for Health Promotion have been celebrated and built upon each time.
The theme of the Second International Health Promotion Conference held in Adelaide in 1988 was Healthy Public Policy. It was acknowledged at the conference that public policies in all sectors influence the determinants of health and are a major vehicle for actions to reduce social and economic inequities. In addition to making clear the importance of healthy public policy and the responsibility of all who produce public policy to observe and be responsive to the health impact of their policies, the conference urged industrialised countries to develop policies that reduce the growing disparity between rich and poor countries.
Supportive environments for health was the theme of the Third International Health Promotion Conference. The 1991 Sundsvall Statement on Supportive Environments for Health stressed the importance of sustainable development. There was recognition that degradation of the environment was having an impact on people’s health worldwide and the way forward lay in making the environment — the physical, the social, the economic and political environment — supportive to health rather than damaging it. The report from the conference was presented at the Rio Earth Summit in 1992 and contributed to the development of Agenda 21.
The theme for the fourth conference, held in Jakarta (1997), was New Players for a New Era: Health Promotion into the 21st Century. It was the first time that the private sector had been included and there was some concern expressed at the conference about the difficulties of involving the private sector in health promotion policy development, with questions raised about the extent to which the private sector can be meaningfully involved without fundamental conflicts of interest (Hancock 1998). The conference declaration called for decision-makers in both the public and private sectors to demonstrate social responsibility by preventing harm to individuals and the environment, by restricting trade in harmful products and by integrating concern for equity into all policy development. In addition, conference delegates called for an increase in investment in health and areas that impact on health, including housing and education, demanding that particular attention be paid to groups who have poor health or are most vulnerable, including women, children, older people, and indigenous, poor and marginalised populations. The conference delegates stated that effective health and social development requires collaboration between all levels of government and society to make the changes necessary to improve health chances for all and that these partnerships must be ethical and based on mutual respect. Further, as health promotion is a participatory process, communities and individuals need to be provided with the necessary skills for, and access to, decision-making power to enable them to influence the determinants of health. Developing local-level expertise through education and dissemination of health promotion experience is necessary, as is ensuring that all countries have the necessary political, legal, educational, social and economic environments to support health promotion (WHO 1997). The conference delegates called for funding to establish and maintain infrastructures for health promotion locally, nationally and globally. They believed that efforts to motivate government and NGOs to mobilise resources for health promotion needed to be made (WHO 1997: 263).
Commitment to the fundamental principles of Primary Health Care continued at the Fifth International Conference on Health Promotion in Mexico, in the year 2000. The Mexico Ministerial Statement for the Promotion of Health: From Ideas to Action and Framework for Countrywide Plans for Action (WHO 2000) outlined the processes to address the determinants of health, to ensure greater equity in health. The technical themes for the conference demonstrated the path that the conference delegates took, namely: