The Ottawa Charter has exerted a great deal of influence on the public health debate and on health promotion practices over the last 25 years. The Charter shifted the main focus from individual risk behaviours to social determinants of health, and introduced innovative strategies such as participatory processes and empowerment of communities.1 This new public health era is based, essentially, on the introduction of health promotion to increase people's opportunities to make healthy choices. Building healthy public policies (HPP) is a core area, even an overriding concern for health promotion,2 as it seeks to put health onto the agenda of policy-makers across different sectors, to improve the conditions under which people live.3 HPP is concerned with equity, and has, by its nature, an intersectoral focus with an explicit interest in the impacts of all policies on the health of the population.4 It represents a reaction against the individualistic and victim-blaming approach of curative medicine and the excessive focus previously placed on health education.5
- Health impact assessment
- health policy
- health promotion FQ
- social inequalities
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Practical steps beyond rhetorical statements
Although health promotion was conceptualised to act from an explicit social model of health, in practice activity has frequently been focused on individual behaviour change, primarily by means of health education.6 Little experience has been gained in the areas of inequalities in health and in the development of HPP.7 In fact, despite their effectiveness,8 HPP have rarely been systematically adopted by any government in the world.9 10 Research efforts have also been more intense on downstream, disease-oriented topics and lifestyles, rather than on the social determinants of health.11 All these trends contribute to the de-politicisation of the economic and social conditions that are largely beyond an individual's control and which put them at risk of illness.12
Problems faced by HPP as a core area of health promotion
Many barriers have been cited to account for the observed lack of connection between the Ottawa vision and any subsequent application. These can be classified as A. conceptual/philosophical, B. organisational/infrastructural and C. political.
Criticisms have been directed against the imprecision of some key concepts underpinning health promotion and healthy public policy such as equity, empowerment and participation. Indeed, it has been claimed that health promotion lacks a strong philosophical basis from which to define clear functions, and ensure the necessary cohesion within the discipline.2 However, the vague formulation of targets and strategies has probably made some public health policies possible, avoiding delicate ideological compromises.13
The holistic approach to health underlying the Ottawa Charter seldom, if ever, fits with current institutional structures, which clearly divide action on the determinants of health between different departments. This reality is judged to be the main factor to explain the difficulty of finding outstanding examples of HPP interventions.6 Likewise, current requirements of accountability in healthcare organisations have turned health promotion activities into service functions to be purchased as discrete packages, hindering collaboration between the healthcare and other sectors,6 and hence a holistic approach to health.
Ideologies underlie all health promotion policies so making them explicit may help some of the barriers and opportunities that exist to be understood and hence be addressed.14 It should be emphasised that the widespread weakening of European social welfare schemes stems from the spread of political philosophies of neo-liberalism, and the underlying values of individualism and materialism, across the current political and civic arena. The overall trend seems to be to decrease public interventions in social and health areas,15 which is of special relevance in the present financial crisis, but also in the more general context of rising globalisation, in which many determinants of health are out of the reach of individuals, communities and even states.9
Empowering communities has traditionally stood out as a primary principle for health promotion. Therefore, perceptions about the real influence of participative processes are of vital importance for the promotion of HPP. Accordingly, the political disaffection (low social participation in political decision-making, and a feeling of distrust with respect to political processes, politicians and certain institutions) that exists in many contemporary democracies may constitute an obstacle.16 The growing weight of private pressure groups and their competing interests can also deepen these feelings of distrust.
Attention should also be paid to the negative influence of the so-called policy myopia, which arises when voters allow elected politicians to distort public investments towards short-term investments. This style of policy-making can act as a notable enemy for the development of future-orientated strategies, such as HPP, the costs and benefits of which are often tangible only in the long term. There is evidence that the quality of democratic institutions and the electorate's lack of effective democratic voice are related to the spread of this short-termism in policy-making.17
Health in All Policies: a breath of fresh air to overcome resistance
The principles of the Health in All Policies (HiAP) strategy have been promoted under various labels for decades. Nevertheless, the contribution of the Finnish EU Presidency (2006) to the development of HPP was invaluable. The message remains the same: health is greatly influenced by policies outside the health sector, but the means claim to be different. HiAP is based on a solid background in science and proposes systematic approaches to examine the social determinants of health that are controlled by other sectors.18 19 An important basis of HiAP is the ability to predict health impacts and their distribution across populations. Health impact assessment (HIA) has emerged as a possible tool to help shift the rhetoric of HPP to real action.20 ‘Instead of alluding to the interrelatedness of health and other sectors, HIA provides a transparent process for making these relationships clear’.21 Could it be that we are moving into a ‘new paradigm’ of health promotion in the evolution of public health eras?2
Some reflections to avoid forgetting the ‘big picture’
The neo-liberal development model of Western societies, based on the belief that humankind can escape from the controls of nature and make unlimited use of resources for production, entails substantial social well-being and health challenges.22 23 As a social product, public health has also been colonised by this neo-liberal market-oriented individualist ideology.24 However, advocates and practitioners of HiAP, greatly concerned with the improvement of population health, should distance themselves from this tendency and support proposals aiming to unite the efforts of those who are critical of this model of development that is putting people's well-being at risk. Recently, proposals such as the degrowth theory25 and the gross national happiness indicator26 have emerged; these attempt to introduce a different way to view quality of life as a means of ensuring the sustainability of human life in the long run.
For this to happen, it is essential that current health promotion practice departs from its functionalist and positivist focus, which hampers social change, as it does not fundamentally question the structures of power and the current socioeconomic development model. Ultimately, equity-related challenges are not being correctly addressed. Tackling the real causes of health/disease requires serious reflection on the roots of the stratification of systems in today's world.25
At this juncture, it is more important than ever to underline the political commitment to HiAP required in order that current social and macroeconomic policies and their impacts on health are seriously considered. It seems that HIA has more often been applied in the fields of urban regeneration and physical accessibility than in wider social and macroeconomic projects. Could this be because the former need much less commitment to a redefinition of the whole economic and political system?
It is absolutely vital that we do not let HiAP lose prestige and become a lost episode in the latest era of public health without contributing to real change. As deep changes and shifts in policy take up to 20 years to take place,7 it is time to act and put in practice Ottawa's principles for health promotion once and for all. Let us try to consider indicators to measure success and outcomes that are more coherent with the social model of health envisioned since Ottawa, and let us defend them as valid and reliable. Let us also stop playing a paternalistic role, considering populations insufficiently informed and educated, and in need of experts to define their priorities.12 Instead, let us make it as easy as possible to make healthy choices, as well as promoting not just community participation but civic activism at policy and structural levels.
In short, let us advocate among politicians for longer term and more thoughtful ways of acting. Only if there are courageous comprehensive strategies at the relevant policy level, will individual health promotion programmes and projects achieve their objectives without forgetting the ‘big picture’.
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