IMPLEMENTING CHANGES IN PUBLIC HEALTH AND PUBLIC

HEALTH PROMOTION

By
IBRAHIM HALLIRU KANKIA
halliruibrahim31@gmail.com
MSC. PUBLIC HEALTH

JOIN PROFESSIONALS TRAINING AND SUPPORT INTERNATIONAL

ABSTRACT
Health promotion and public health has moved up on the political agendas of
most governments around the globe. The interdependence of economic,
environmental and social conditions and health is increasingly understood. In
turn, the experiences in health promotion with building healthy public policies
become more important. Future “health in all policies” efforts, however, need
to consider changing political contexts. There is some scope to review the
focus on GDP when measuring economic development, and how health
promotion considers both the opportunities and responsibilities of industry as
part of implementing healthy public policies.

Key words: public policy; health promotion; Ottawa Charter; implementing

health public policies

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INTRODUCTION

The January 2011 statistics from the USA indicate that detected cases of

diabetes cost the country $174 billion a year, of which $116 billion goes to

direct medical costs. That is a huge pile of money for a largely preventable

disease. Prevention is by far the better option, yet most risk factors for these

diseases lie beyond the direct control of the health sector.

This is just one example for the increasing importance of putting public health

on the agenda of policy-makers in all sectors and at all levels. As the drafters

of the Ottawa Charter poignantly put it, this would direct policy-makers ‘to be

aware of the health consequences of their decisions and to accept their

responsibilities for health’.

The following quote from the Ottawa Charter (WHO, 1986) still holds true

today:

Health promotion policy combines diverse but complementary approaches

including legislation, fiscal measures, taxation and organizational change. It is

coordinated action that leads to health, income and social policies that foster

greater equity. Joint action contributes to ensuring safer and healthier goods

and services, healthier public services, and cleaner, more enjoyable

environments. Health promotion policy requires the identification of obstacles

to the adoption of healthy public policies in non-health sectors, and ways of

removing them. The aim must be to make the healthier choice the easier choice

for policy makers as well.

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The costs of health not being involved in broader policy-making, influencing

the cost effective policies and measures that can promote and protect health,

have been high.

Governments have underestimated the whole of society costs of diseases. The

economic impacts can be astounding. In 2003, SARS gained worldwide media

attention not just as a new infectious disease but also because of the costs to

the airline and tourism industries.

At an estimated cost of US$30 billion, SARS was not the first disease to have

enormous societal costs. Just 3 years earlier, in 2003, plague cost India US$1.7

billion; cholera cost Peru US$770 million in 1990; and over an

8-year period (1990–98) bovine spongiform encephalopathy cost the UK an

estimated US$39 billion. Astonishingly, these are all costs after accounting for

the direct economic impact of human sickness and death, and most have roots

in policies outside the health sector (Krech, 2010).

In the past, much of the work on ‘healthy public policy’ was dealing with the

bilateral relationship between individual sectors and health. Future health

promotion needs to consider the broader impact of policy-making in the global

environment in which health plays an important part. Global leaders have

acted in this regard: health is now a key issue addressed at the G8/ G20

meetings, and at the United Nations General Assembly. The global community

has become increasingly aware of how rapidly problems spread across the

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world, with new or exacerbated crises in finance, food, public health and the

environment, among others.

Moreover, these crises have clearly demonstrated how the interconnectedness

of the modern world means that countries cannot confront these challenges on

their own, or through action in single sectors. Policy-makers and key decision-

makers increasingly understand the nature of health as a global public good

and increasingly recognize health security, including humanitarian assistance

in fragile states as a prime concern for development.

The need for systemic approaches in public health has become more evident

where both the problem and the solutions are systemic (such as in obesity).

Action on ‘healthy public policies’ or ‘health in all policies’ through

coordinated interventions in multiple sectors has proven to be essential not

only to improve health and reduce inequities, but also to overcome other

national and global obstacles to development. This requires coherence between

policies of different sectors, types of actors and of different levels (e.g.

between global, national and local levels). Future health promotion needs to

strive for aligned policies which will synergistically contribute to

development.

Beyond being an essential driver for security and economic development,

health is a social value and a human right, and reducing inequities is key to

achieve the Millennium Goals. The WHO Commission on Social Determinants

of

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Health (WHO, 2008) defined health inequities as differences in health

outcomes between different population groups, which are avoidable, unfair

and remediable. As we argue in the discussion paper for the 2011 World

Conference on Social Determinants of Health, action to reduce health

inequities therefore rests on notions of fairness in health outcomes and social

justice as political goals. Societies that place fairness as a core value will find

it easier to implement actions on health inequities, regardless of technical

expertise (WHO, in press). Underpinning the social determinants approach is

also a claim for the broader value of health to society. The contributions of

health to other important societal priorities such as education, social cohesion

and economic development are now well understood. The rationale for the

whole of society to adopt a social determinants approach and engage in efforts

to reduce health inequities is linked to these benefits.

However, it goes further. The social determinants approach places the

distribution of health, as measured by the degree of equity in health, as a key

indicator not just of fairness and social justice in a society, but also of its

overall functioning.

Health and health equity are therefore of interest beyond the health sector not

just because of the benefits of improved health, but because all sectors have an

interest and responsibility in creating fairer and more inclusive societies by

implementing coherent policies that increase opportunities and promote

wellbeing.

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Policy-makers who seek coherent responses to reduce health inequities need to

grapple with how societies come to value reduced health inequities as a

measure of this societal fairness. Better understanding of how acting on social

determinants contribute to other development goals, such as environmental

protection and economic growth, can contribute to increased prioritization of

health outcomes as a measure of societal progress (WHO, in press). Increased

knowledge is also needed to show how systems that reduce health inequities,

by delivering better performance and improving outcomes more rapidly for

disadvantaged groups, may perform more effectively for all.

LITERATURE REVIEW

MOVING AHEAD

Like public health, other sectors have advocated for policy coherence,

intersectoral action and joined-up government for many years. Along with

other initiatives, the conceptual thinking behind the Ottawa Charter and the

health promotion action that had followed may well be instrumental now in

shaping the global efforts to ensure human security in the future. Despite the

bulky term ‘healthy public policy’, this action area of the Ottawa Charter will

be (and has been) a principal resource for the global movement on the social

determinants of health. It can also be applied to shape global trade, migration

policies, the prevention of global crime and terrorism.

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Whether or not health promotion will be able to contribute to this broader

human security agenda will depend on some fundamental insights that can be

drawn from the experiences of health promotion action.

CONSIDERING THE POLITICAL DETERMINANTS OF HEALTH

Despite some drawbacks, 25 years of health promotion action has resulted in

tangible outcomes. Researchers, advocates and activists basically know what

works and what does not, and how policies and programmes need to be

designed, measured and evaluated. They have understood that simplistic

technocratic solutions are not sustainable but that they inter alia need to

understand the political agendas and administrative imperatives of other

sectors (WHO and Government of South Australia 2010). Structural barriers

that hamper successful implementation have been identified as well as

‘cultural and language’ ones, and challenges with regard to process are as

known as those regarding technical and capacity inadequacies.

Success in health promotion depends on the highest technical performance.

Even more so, it depends on the political environment. For future health

promotion initiatives, we need thus to consider both structural and

processrelated political determinants for development. It is clear that

organizational partnerships necessary for health promotion to reduce health

inequities start with individual negotiation skills. As always, it is imperative to

ensure that the right people are engaged in the intersectoral process, including

those who actually have the power to make decisions. But it is also important

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to include disadvantaged groups who have the greatest potential to benefit,

linked to civil society groups and social movements who can press for action.

Bridging differing understandings of a problem between sectors requires

identifying which sectors have vested interests in activities on a particular

issue. Thus, a sound understanding of the interests and objectives of the main

stakeholders is an absolute requirement in the first place (WHO, 2010a). It is

interesting to note that the major international health negotiations have been

led by experienced diplomats—and not health experts. There is a need for

health negotiators. Health promotion tools which ‘enable, mediate and

advocate’ can be instrumental to advance the quality and success of health

negotiations.

Coming back to the example of diabetes, city planning that enhances moderate

physical activity, food industry that promotes healthy food, public transport

systems that are easily accessible for all, together, would create healthier living

conditions. Even more so, it is clear that coordination amongst various

stakeholders is essential. Thus, political advocacy work is needed to join

forces with the entire range of stakeholders, and not only with some.

Health promotion often concentrates on ‘win–win’ situations when engaging

with other sectors. Understanding the political determinants means to manage

situations that involve costs or trade-offs, while preserving an effective

collaborative working relationship. This requires both technical and diplomatic

negotiation skills of those who manage the process.

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THE WAY WE LOOK AT ECONOMIC GROWTH

Often, policies are evaluated on whether they promote economic growth or

not. Economic growth is often measured by using the gross domestic product

(GDP) as an indicator of economic performance and social progress.

Stiglitz, Sen and others have argued, however, for a long time that ‘GDP is an

inadequate metric to gauge well-being over time, particularly in its economic,

environmental, and social dimensions, some aspects of which are often

referred to as sustainability’ (Stiglitz, 2009).

A range of global leaders in macroeconomics have therefore started to

advocate fundamentally rethinking macroeconomics. For example, the aim of

the ‘Commission on the Measurement of Economic Performance and Social

Progress’ (CMEPSP) has been to identify the limits of GDP as an indicator of

economic performance and social progress, including the problems with its

measurement; to consider what additional information might be required for

the production of more relevant indicators of social progress; to assess the

feasibility of alternative measurement tools and to discuss how to present the

statistical information in an appropriate way.

Global crisis in the past decade, such as on finance and food, originated from

policy decisions in other sectors and had vast health implications which then

were themselves the reason for huge economic losses in third sectors. Thus,

health is the link between different policy decisions. Current macroeconomic

thinking does not reflect this reality. Public health outcomes of a national

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policy may be global, and the economic consequences felt in other sectors in

other domestic economic systems. The intersectoral economic impacts of

different events, actions and policies, need to be more explicitly accounted for.

Without doing these two things, it will also be hard to make policies for, or to

anticipate the impacts of raising events or policies on, the social gradient in

health. ‘Economic growth is important but, although it often seems to be

forgotten, is only a means to an end. Rather, we must ask what economic

growth allows us to do. Although often equated with greater human happiness,

a growing body of literature has shown how the two measures have become

disconnected’ (McKee, 2010).

Also, other researchers have argued to use the genuine progress indicator

(GPI) for health (see, for instance, Anielski, M. and Soskolne, C.,

http://www.anielski.com/Documents/Anielski%20Soskolne%20Paper.pdf). An

intermediate step towards this would be to introduce responsibility

mechanisms for due diligence as well as full risk bearing.

THE WAY WE LOOK AT HEALTH PROMOTION INTERVENTIONS

Part of the change that may influence the health promotion agenda in the next

couple of years is to better understand development strategies of industries.

They have a major stake in population health, both as contributors and as

recipients.

The role of global industry in global health has put health into trade and

influenced innovative industry approaches. A ‘health in all policies approach’

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should be seen as a resource in managing this interdependence. A

complementary picture of public health practice is being created a picture that

includes risk behaviour and risk factors, risk conditions and life conditions. In

the past, the health sector only talked about why people smoke and how to

make the healthier option become the easier option. Now, we are also looking

at the tobacco industry, their strategies, powers and markets; and how their

‘tobacco in all policies’ approach influences people’s lives, drives national and

global economies and sets political agendas. As successful and groundbreaking

as the Framework Convention on Tobacco Control has been, smoking and

other forms of tobacco consumption are increasing in developing countries

(WHO, 2010b) and tobacco is still a highly profitable industry. Why is this so?

As health professionals, we dislike their products, but we have to learn from

their business model to develop more effective countermeasures.

The health sector as a whole needs to better understand the institutions that

have such an enormous effect on population health. By employing a health in

all policies approach, we open doors to getting to the crux of the matter—to

the analysis, systematization and identification of options that complement

multiple sectors to the benefit of broader societal wellbeing. The World Health

Organization is determined to move health in all policies forward. It is clear

that health has moved up the political agenda. This is true for both global and

domestic politics, and WHO is eager for health and wellbeing to prosper from

this reality.

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Those who are looking at development through a health promotion lens will be

able to contribute to development if they see and understand the coherence of

advocating, enabling and mediating for health, and if they do so in the five

action areas and at the different policy levels, by looking at the

complementarities of health promotion action.

BEHAVIOUR CHANGE OR MODIFICATION MODEL

This approach focuses on encouraging individuals to change their behaviour to

increase their chances of avoiding ill health or of developing a better level of

health. It usually focuses on the adoption of a healthy lifestyle. We are

bombarded with messages coming from this approach, e.g. stop smoking,

drink in moderation, practice safe sex, eat low fat/high fibre diets. Some

people may feel they are being ‘told’ what to do and that they are at fault if

they do not follow the advice – does this sound familiar in relation to

smoking? This approach appears to have two underlying assumptions: that

health status is determined by individual behaviour, and that individuals can

choose to change their behaviour, and have the resources to do so, if they are

advised of the healthy alternatives. We’ll explore this idea in more detail later

but think back to the WHO definition of health promotion we looked at earlier.

This emphasized health promotion, and enabling people to take healthy

options, which requires more than information or advice giving.

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INFORMED CHOICE MODEL

This approach is more concerned with increasing knowledge and

understanding so that individuals can make the most appropriate choice for

their situation, often referred to as an informed choice. Although there appears

to be more partnership with the client in this approach, it is usually the

professional or State who chooses which subject will be addressed. For

example, it may be the national school curriculum or the school governors who

decide if sexual health education will be part of school education.

There’s an assumption here that everyone has equal opportunities to make an

informed choice. We’ll return to this issue later.

CLIENT-FOCUSED MODEL

The ownership of the interaction is much more with the client. This approach

should be responsive to what the client wants to know or consider. The client,

not the health professional, sets the agenda. This approach has much in

common with community development approaches to care. It sounds good and

appears to avoid some of the pitfalls we’ve identified in the other models. It

means that the client’s priorities, interests and concerns are addressed, but we

have not found perfection, there are still some potential problems. An

important point to consider is ‘Do we always know what we need to know’? Is

it fair to leave agenda setting solely to the client, what about those issues they

are unaware of or choose to avoid, what should be done about them?

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COLLECTIVE OR SOCIETAL MODEL

This model moves away from the individual level and takes on a societal

approach to health education/prevention/promotion. It may involve political or

legislative issues, e.g., seatbelt use or the provision of cycle paths. As a

consequence of this model it may be easier for individuals to choose the

healthy option or to fulfil their health potential with e.g., provision of leisure

facilities, subsidized rates for leisure facilities or it may enhance the

population’s chances of not encountering a negative health risk and so increase

their chances of being able to pursue a healthy lifestyle. This model generally

operates on a longer time scale to the other models we’ve discussed. This type

of health promotion is often imposed rather than chosen through, for example,

smoking bans.

The type of actions people working with this model might take include:

 protecting in a preventative way, e.g., provision of clean water supply;

supplementing certain food with extra minerals and vitamins.

 protecting in an educative way – this could be directed towards policy-

makers lobbying politicians or service providers for a particular service or

legislation; it could also relate to general dissemination to the public about

a health care issue, e.g., the mass education and publicity campaign

associated with HIV or action to prevent ‘cot death’ campaigns.

 protecting against negative health effects through, e.g., legislation

regarding levels of lead emissions from car exhausts.

The behaviour change approach promotes health through individual changes in

lifestyle that are appropriate to people’s settings. The assumption is that,

before people can change their lifestyle, they must first understand basic facts

about a particular health issue, adopt key attitudes, learn a set of skills and be

given access to appropriate services. The simple logic is that some behaviour

leads to ill-health, and so persuading people directly to change their behaviour

must be the most efficient and effective way to reduce illness. This reasoning

is attractive to decision-makers because it promises quantifiable results within

a short time frame, can deal with high prevalence health problems, is relatively

simple and offers savings in health care services, especially for people

suffering from chronic diseases.

The evidence about the effectiveness of behaviour change approaches is

unclear, for example, about hand-washing among children and cooking and

food skills among adults. However, this has not prevented health promoters

from continuing to extensively invest in this approach. Behaviour change

communication is a widely-used intervention manifested through approaches

such as communication for development (C4D), water, sanitation and hygiene

(WASH) and social behaviour change communication. These approaches

attempt to provide new knowledge and skills that people need to adopt a

healthier lifestyle. They use a range of techniques including interactive

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communication technologies, motivation, counselling, persuasion, influencing

social norms and coercion. Health promotion has also relied on pre-packaged,

top-down programs especially for health education and multi-risk factor

reduction interventions. These have not guaranteed a change in behaviour and

have led to a “blaming of the victim”, for example, for drinking too much

alcohol or continuing to smoke even though people know the behaviour is

harmful. This can create feelings of mistrust between “expert” practitioners

and the public, further exasperated by changes in health messaging, for

example, on the safe levels of alcohol consumption. Laverack, G (2017)

Fundamentally, people do not resist change, but they do resist being changed.

This is a situation made worse by health promotion programs that have an

over-reliance on didactic styles of communication, inadequate audience

segmentation, and inappropriate message content and weak material

development. Corcoran, N (1997)

The art of health promotion is knowing when and how to use the science to

produce a desired outcome but many practitioners lack the competence and

confidence to achieve this in different contexts (Laverack, G, 2017).

Behaviour change and health promotion can be made more effective and

sustainable if the following elements are included (1) a strong policy

framework that creates a supportive environment and (2) an enablement of

people to empower themselves to make healthy lifestyle decisions.

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BEHAVIOUR CHANGE AND POLICY FRAMEWORKS

Despite decades of acknowledging the direct influence of poverty,

unemployment and housing on people’s health, the policy problems often end

up being defined as a behavioural risk such as physical inactivity. We know

that diseases are caused by a complex interaction of factors; in particular, those

that are driven by political, social and economic determinants. The importance

of a broader determinants approach is recognized in health promotion work

that moves beyond the individual behavioural model. However, this requires

an understanding that health is determined by how societies themselves are

structured and the political nature of health policy agendas. Syme, L (2017)

Health promotion interventions that directly address behavioural risks can, at

best, support policy to promote health and, at worse, maintain inequalities in

society. This is because behaviour change approaches have little impact on the

broader conditions that create poor health, especially for vulnerable people

such as migrants, low socio-economic and indigenous groups. Behaviour

change approaches are better implemented as part of a wider, comprehensive

policy framework and not as a single intervention that relies on top-down,

communication strategies to target a specific disease or behaviour.

In Estonia, 89% of schoolchildren drink sugar-sweetened beverages. The

Estonian government has used a policy framework to reduce the consumption

of sugar-sweetened drinks which are associated with increased energy intake

strategy uses a policy framework with four options: (1) regulation of food

advertising; (2) labeling of sugar-sweetened beverages and raising awareness

about their health effects; (3) school health promotion interventions and

nutrition policies; and (4) imposing taxes on sugar-sweetened beverages,

subsidizing other food groups and/or substituting alternative beverages. It was

concluded that these options complement each other and, if implemented in

combination, would help to reach the goal of better health outcomes. Corcoran,

N (1997)

Comprehensive, multicomponent interventions are more appropriate to change

behaviours that can lead to negative health effects. In particular, a strong

policy framework is empowering because it gives people more control over

their lives, rather than simply telling them what to do. Behaviour change

interventions must therefore be supportive of a strong policy framework.

BEHAVIOUR CHANGE, PARTICIPATION AND EMPOWERMENT

Health promotion programs are often dependent on the participation of

targeted people. People also want to participate and will do so in large

numbers if they are properly engaged and have a shared interest in the

program. Successful participation should be congratulated; for example, the

“walking for health” project recruited 8300 volunteer walk leaders and the

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Heritage Lottery Fund (2007) recruited 5900 park friends and user groups

across the UK (up 1100 from the previous year).

However, participation is insufficient to help people to empower themselves

and to take the necessary actions to have a healthier lifestyle.

If the health promotion approach gives the practitioner the authority to control

the situation for example, through setting the agenda or releasing specific

resources—it is less likely to be empowering. If it facilitates a process of needs

assessment, capacity building and local action it has a much better chance of

being empowering. In practice, an empowerment approach involves helping

people to work together to gain more control over their lives and health

(Mouy, B.; Barr, A., 2007) such as by organising exercise classes or self-help

groups. The behaviour change approach can be paternalistic and often

disregards the individual’s own perception of what is important. Furthermore,

the behaviour change approach can lead to stigmatization and to increased

inequalities in health, as its focus is on individual behaviours instead of the

“causes of the causes” of poor health. The empowerment approach does not

have these problems but can lead to empowering some groups over others, as

the focus is not primarily on health and empowered people might still choose

to behave in ways that can damage their health because this is secondary to

other personal goals. However, the empowerment approach, on the whole, has

been considered to be superior to the behaviour change approach.

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In practice the key question is: “Do I want to help others to empower

themselves or to simply change their behaviour?”. The added value of

empowerment is that it gives the individual, group, or community greater

control, in achieving healthier, sustainable lifestyles. The “Altogether Better

project”, for example, was established in 2008 and has engaged over 18,000

volunteers as community “health champions” who have in turn reached over

104,000 other participants. The project aims at building capacity to empower

communities to improve their own health and well-being largely by extending

the skills and expertise of local volunteers. The project approach has

demonstrated effectiveness in supporting positive behaviour change,

improving health, the use of health care services and by decreasing hospital

admissions. Baum, F (2006)

THE FUTURE OF BEHAVIOUR CHANGE AND HEALTH

PROMOTION

In reality, the modest success of behaviour change in health promotion

programs has been with those at the top of the social gradient andmay even, at

least temporarily, have led to an increase in health inequalities (Tengland, P.,

2016). The future of behaviour change and health promotion is through the

application of a comprehensive strategy to better enable people to have a

healthy lifestyle. A comprehensive strategy includes the points raised in this

commentary: (1) a behaviour change approach; (2) a strong policy framework

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that creates a supportive environment; and (3) the empowerment of people to

gain more control over making healthy lifestyle decisions. A comprehensive

strategy will require the better planning and coordination of policy frameworks

so that they systematically include both community empowerment and

behaviour change communication opportunities. The agencies involved in

delivering behaviour change and empowerment interventions at the

community level will have to work closely together as well as with

government to help develop policy at the national level.

CONCLUSION

Health has moved up on the political agendas of most governments around the

globe. The interdependence of economic, environmental and social conditions

and health is increasingly understood. In turn, the experiences in health

promotion with building healthy public policies become more important.

Future “health in all policies” efforts, however, need to consider changing

political contexts. There is some scope to review the focus on GDP when

measuring economic development, and how health promotion considers both

the opportunities and responsibilities of industry as part of implementing

healthy public policies.

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Krech, R. (2010) Reflections on the Adelaide 2010, Health in All Policies

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http://www.health.sa.gov.au/pehs/publications/publichealthbulletin-

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McKee, M. (2010) Responding to the economic crisis: Europe’s governments

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Community Health

http://jech.bmj.com/content/early/2011/02/18/jech.2010.129999.extract.

Stiglitz, J. E., Sen, A. and Fitoussi, J. P. (2009) Commission on the

Measurement of Economic Performance and Social Progress.

http://www.stiglitz-senfitoussi.fr/documents/rapport_anglais.pdf

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http://www.who.int/hpr/archive/docs/ottawa.html

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of health.

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Health Organization, Geneva.

http://www.who.int/social_determinants/thecommission/en/

WHO and Government of South Australia. (2010) Adelaide Statement on

Health in All Policies.

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df

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