The adoption of the Declaration of Alma-Ata a decade ago was a major milestone in the Health for All movement which the World Health Assembly launched in 1977. Building on the recognition of health as a fundamental social goal, the Declaration set a new direction for health policy by emphasizing people's involvement, cooperation between sectors of society. and primary health care as its foundation.
THE SPIRIT OF ALMA-ATA
The spirit of Alma-Ata was carried forward in the Charter for Health Promotion which was adopted in Ottawa in 1986. The Charter set the challenge for a move towards the new public health by reaffirming social justice and equity as prerequisites for health, and advocacy and mediation as the processes for their achievement.
The Charter identified five health promotion action areas:
These actions are interdependent, but healthy public policy establishes the environment that makes the other four possible.
The Adelaide Conference on Healthy Public Policy continued in the direction set at Alma-Ata and Ottawa, and built on their momentum. Two hundred and twenty participants from forty-two countries shared experiences in formulating and implementing healthy public policy. The following recommended strategies for healthy public policy action reflect the consensus achieved at the Conference.
HEALTHY PUBLIC POLICY
Healthy public policy is characterized by an explicit concern for health and equity in all areas of policy and by an accountability for health impact. The main aim of health public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes health choices possible or easier for citizens. It makes social and physical environments health-enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry, and communications need to take into account health as an essential factor when formulating policy. These sectors should be accountable for the health consequences of their policy decisions. They should pay as much attention to health as to economic considerations.
The value of health
Health is both a fundamental human right and a sound social investment. Governments need to invest resources in healthy public policy and health promotion in order to raise the health status of all their citizens. A basic principle of social justice is to ensure that people have access to the essentials for a healthy and satisfying life. At the same time, this raises overall societal productivity in both social and economic terms. Healthy public policy in the short term will lead to long-term economic benefits as shown by the case studies presented at this Conference. New efforts must be made to link economic, social, and health policies into integrated action.
Equity, access and development
Inequalities in health are rooted in inequities in society. Closing the health gap between socially and educationally disadvantaged people and more advantaged people requires a policy that will improve access to health-enhancing goods and services, and create supportive environments. Such a policy would assign high priority to underprivileged and vulnerable groups. Furthermore, a healthy public policy recognizes the unique culture of indigenous peoples, ethnic minorities, and immigrants. Equal access to health services, particularly community health care, is a vital aspect of equity in health.
New inequalities in health may follow rapid structural change caused by emerging technologies. The first target of the European Region of the World Health Organization, in moving towards Health for All is that:
by the year 2000 the actual differences in health status between countries and between groups within countries should be reduced by at least 25% by improving the level of health of disadvantaged nations and groups.
In view of the large health gaps between countries, which this Conference has examined, the developed countries have an obligation to ensure that their own policies have a positive health impact on developing nations. The Conference recommends that all countries develop healthy public policies that explicitly address this issue.
ACCOUNTABILITY FOR HEALTH
The recommendations of this Conference will be realized only if governments at national, regional and local levels take action. The development of healthy public policy is as important at the local levels of government as it is nationally. Governments should set explicit health goals that emphasize health promotion.
Public accountability for health is an essential nutrient for the growth of healthy public policy. Governments and all other controllers of resources are ultimately accountable to their people for the health consequences of their policies, or lack of policies. A commitment to healthy public policy means that governments must measure and report the health impact of their policies in language that all groups in society readily understand. Community action is central to the fostering of healthy public policy. Taking education and literacy into account, special efforts must be made to communicate with those groups most affected by the policy concerned.
The Conference emphasizes the need to evaluate the impact of policy. Health information systems that support this process need to be developed. This will encourage informed decision-making over the future allocation of resources for the implementation of healthy public policy.
Moving beyond health care
Healthy public policy responds to the challenges in health set by an increasingly dynamic and technologically changing world, with is complex ecological interactions and growing international interdependencies. Many of the health consequences of these challenges cannot be remedied by present and foreseeable health care. Health promotion efforts are essential, and these require an integrated approach to social and economic development which will re-establish the links between health and social reform, which the World Health Organization policies of the past decade have addressed as a basic principle.
Partners in the policy process
Government plays an important role in health, but health is also influenced greatly by corporate and business interests, nongovernmental bodies and community organizations. Their potential for preserving and promoting people's health should be encouraged. Trade unions, commerce and industry, academic associations and religious leaders have many opportunities to act in the health interests of the whole community. New alliances must be forged to provide the impetus for health action.
The Conference identified four key areas as priorities for health public policy for immediate action:
Supporting the health of women
Women are the primary health promoters all over the world, and most of their work is performed without pay or for a minimal wage. Women's networks and organizations are models for the process of health promotion organization, planning and implementation. Women's networks should receive more recognition and support from policy-makers and established institutions. Otherwise, this investment of women's labour increases inequity. For their effective participation in health promotion women require access to information, networks and funds. All women, especially those from ethnic, indigenous, and minority groups, have the right to self-determination of their health, and should be full partners in the formulation of healthy public policy to ensure its cultural relevance.
This Conference proposes that countries start developing a national women's healthy public policy in which women's own health agendas are central and which includes proposals for:
Food and nutrition
The elimination of hunger and malnutrition is a fundamental objective of healthy public policy. Such policy should guarantee universal access to adequate amounts of healthy food in culturally acceptable ways. Food and nutrition policies need to integrate methods of food production and distribution, both private and public, to achieve equitable prices.
A food and nutrition policy that integrates agricultural, economic, and environmental factors to ensure a positive national and international health impact should be a priority for all governments. The first stage of such a policy would be the establishment of goals for nutrition and diet. Taxation and subsidies should discriminate in favour of easy access for all to healthy food and an improved diet.
The Conference recommends that governments take immediate and direct action at all levels to use their purchasing power in the food market to ensure that the food-supply under their specific control (such as catering in hospitals, schools, day-care centres, welfare services and workplaces) gives consumers ready access to nutritious food.
Tobacco and alcohol
The use of tobacco and the abuse of alcohol are two major health hazards that deserve immediate action through the development of healthy public policies. Not only is tobacco directly injurious to the health of the smoker but the health consequences of passive smoking, especially to infants, are now more clearly recognized than in the past. Alcohol contributes to social discord, and physical and mental trauma. Additionally, the serious ecological consequences of the use of tobacco as a cash crop in impoverished economies have contributed to the current world crises in food production and distribution.
The production and marketing of tobacco and alcohol are highly profitable activities - especially to governments through taxation. Governments often consider that the economic consequences of reducing the production and consumption of tobacco and alcohol by altering policy would be too heavy a price to pay for the health gains involved.
This Conference calls on all governments to consider the price they are paying in lost human potential by abetting the loss of life and illness that tobacco smoking and alcohol abuse cause. Governments should commit themselves to the development of healthy public policy by setting nationally-determined targets to reduce tobacco growing and alcohol production, marketing and consumption significantly by the year 2000.
Creating supportive environments
Many people live and work in conditions that are hazardous to their health and are exposed to potentially hazardous products. Such problems often transcend national frontiers. Environmental management must protect human health from the direct and indirect adverse effects of biological, chemical, and physical factors, and should recognize that women and men are part of a complex ecosystem. The extremely diverse but limited natural resources that enrich life are essential to the human race. Policies promoting health can be achieved only in an environment that conserves resources through global, regional, and local ecological strategies.
A commitment by all levels of government is required. Coordinated intersectoral efforts are needed to ensure that health considerations are regarded as integral prerequisites for industrial and agricultural development. At an international level, the World Health Organization should play a major role in achieving acceptance of such principles and should support the concept of sustainable development.
This Conference advocates that, as a priority, the public health and ecological movements join together to develop strategies in pursuit of socioeconomic development and the conservation of our planet's limited resources.
DEVELOPING NEW HEALTH ALLIANCES
The commitment to healthy public policy demands an approach that emphasizes consultation and negotiation. Healthy public policy requires strong advocates who put health high on the agenda of policy-makers. This means fostering the work of advocacy groups and helping the media to interpret complex policy issues.
Educational institutions must respond to the emerging needs of the new public health by reorienting existing curricula to include enabling, mediating, and advocating skills. There must be a power shift from control to technical support in policy development. In addition, forums for the exchange of experiences at local, national and international levels are needed.
The Conference recommends that local, national and international bodies:
COMMITMENT TO GLOBAL PUBLIC HEALTH
Prerequisites for health and social development are peace and social justice; nutritious food and clean water; education and decent housing; a useful role in society and an adequate income; conservation of resources and the protection of the ecosystem. The vision of healthy public policy is the achievement of these fundamental conditions for healthy living. The achievement of global health rests on recognizing and accepting interdependence both within and between countries. Commitment to global public health will depend on finding strong means of international cooperation to act on the issues that cross national boundaries.
1. Ensuring an equitable distribution of resources even in adverse economic circumstances is a challenge for all nations.
2. Health for All will be achieved only if the creation and preservation of healthy living and working conditions become a central concern in all public policy decisions. Work in all its dimensions - caring work, opportunities for employment, quality of working life -dramatically affects people's health and happiness. The impact of work on health and equity needs to be explored.
3. The most fundamental challenge for individual nations and international agencies in achieving healthy public policy is to encourage collaboration (or developing partnerships) in peace, human rights and social justice, ecology, and sustainable development around the globe.
4. In most countries, health is the responsibility of bodies at different political levels. In the pursuit of better health it is desirable to find new ways for collaboration within and between these levels.
5. Healthy public policy must ensure that advances in health-care technology help, rather than hinder, the process of achieving improvements in equity.
The Conference strongly recommends that the World Health Organization continue the dynamic development of health promotion through the five strategies described in the Ottawa Charter. It urges the World Health Organization to expand this initiative throughout all its regions as an integrated part of its work. Support for developing countries is at the heart of this process.
RENEWAL OF COMMITMENT
In the interests of global health, the participants at the Adelaide Conference urge all concerned to reaffirm the commitment to a strong public health alliance that the Ottawa Charter called for.
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