World Health Organization Dr Ilona Kickbusch
Director
Division of Health Promotion,
Education and Communication
World Health Organization
Keynote address presented on
the occasion of the
Healthy People
2000 Consortium Meeting
"Building the Prevention Agenda for 2010:
Lessons Learned"
New York, 15 November 1996
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Setting health objectives has been one
of the most important health policy developments in the last 20 years.
I am therefore very honoured to have been invited to address this
health consortium meeting in the country that spearheaded this development.
In my work at the World Health Organization I have learned much
from the US experiences and from individuals involved in the formulation
and implementation of the objectives for the nation.
I have been asked to share with you
international experiences in setting health promotion objectives
within the context of the World Health Organizations Health
for All Strategy (HFA) and indicate implications this might
have for your own revisiting of the health objectives for the nation. The
international experiences are manifold and go back 20 years and
more. The World Health Organization has promoted an
objective based approach to health planning and accountability
since the late seventies, at first as an instrument at
international and national levels of governance, later as an
approach also to be applied at the regional, district and local
levels and within specific settings (for example schools,
workplaces or hospitals) . In Europe of the 50 European WHO
Member States 17 have formulated "Health of the nation" type policy documents, four countries are just
starting the process, a number of Regions and cities have also formulated
HFA policies and targets. Indeed developing a city based HFA
policy is one of the conditions for becoming a WHO project city.
Of course it must be noted that the context has
changed considerably over the last 20 years since Health For All
was introduced.. Peter Drucker who provided the rationale for "management by objectives" in 1952 now speaks of "The new realities" with which we are faced in our societies: a
changing view of the role of governments, changing demands on
political leadership, a new pluralism of interests, a new view of
political and social responsibility. Most countries are experiencing conflict over
the organization and financing of social security , welfare and
health care no matter what percentage of GNP they are dedicating
to the respective sectors. Issues of global competitiveness and monetary
policy dominate the public debate in many countries, inequality
gaps have widened in most countries and despite continuing GNP
growth job insecurity and unemployment are rising. Drucker (as do
many others) maintains that the change we are witnessing from an
industrial society to a knowledge based society is as profound as
the shift from agrarian to industrial production. For many countries
and social groups this brings rapid transformation with new
problems and new insecurities, creating an environment that is a
far cry from the optimism in which Health for All was first introduced.
The move into the new millennium is seen as much as a threat as
an opportunity. This might mean that we must seriously reconsider
our strategies for global health.
At the same time one could say that
giving direction and setting objectives in such an insecure environment
is even more crucial than it was in the late seventies and early
eighties. The Finnish colleagues state in their most recent
analysis of the Finnish Health For All policy progress:
"It may be said that the
economic crisis has made us more convinced than ever about the
need for a clearly defined strategy and priorities to cope with
short- term problems in a medium and long- term perspective."
But obviously there are different ways
to formulate policies for health promotion. Sceptics continually
ask "Does the strategic
approach of setting goals and targets really make a difference to
population health?"
The answer is that we do not really know. The US experience of 15
years seems to indicate that the health objectives have bundled
energy and led to results - the European experience (albeit much
shorter) is more ambivalent. The Finnish analysis states that " a great deal of progress was made in the
desirable direction and often even at faster pace than
anticipated in aspirational targets." It remains unclear if this was due to the
action taken on the targets or if this was the outcome of a
seminal trend or interventions in other sectors. The Dutch study
on the other hand sees little progress in the Netherlands, yet
still "absolutely
recommends" target
setting . It proposes though to adjust the "high hopes" and move into an era of more realistic
policy making, the Finnish review also proposes to proceed more
selectively. But we must ask if they way to go is with an
understanding of "realistic" and "selective" meaning less of the same or whether we should
not refocus our strategies in a more profound manner?
It might be appropriate to ask
ourselves whether a new perspective and a new mix of strategies might not
show a greater effect. The first generation "objectives for health" (such as "Healthy
People") has helped achieve
two major feats: to understand population health in terms of
health gain, or more simply "
healthy people" and to put
health promotion and disease prevention firmly on the health policy
map. But was that enough? Have we achieved enough? My answer is a
clear NO. I believe that we must seriously consider a second
generation of objectives that take into account what we have learned in
the process as well as the challenges we are now faced with. Or
to be more blunt: to finally apply what we already knew when the Member
States of WHO approved and applauded the Health for All Policy
and the Primary Health Care Strategy.
Let us consider first of all if the
Health for All by the year 2000 perspective proposed by the WHO still
holds. It was a very different world when this policy was
developed. After the tremendous success of small pox eradication
came the frustration and failure of WHO=s
malaria strategy. The vertical programme approach was seriously
challenged. Colonies were increasingly gaining their independence and
were challenged as independent nations to ensure population
health and build new health systems . The cold war was in full
swing with constant competition: which political system,
capitalist or socialist, was producing better health? A new
consensus was needed to hold WHO together and to ensure its
universal appeal. The result was a joint commitment in 1977 to health
and development by ALL WHO Member States: Health for All by
the Year 2000. At present we are in a similar situation: in a
changed environment with many new actors involved at the global
level the specific task and unifying role of the WHO has once
again to be made manifest. This is the process we presently call "Health for All Renewal" and which will have as its result a health
charter and policy for the 21st century.
HFA2000 has been criticized from many
vantage points, but these criticisms in my view have not fully understood
its underlying values, its epidemiological premise and its
unifying nature. Health for All 2000 was a revolutionary statement
on development and I do not use this word lightly. It saw health
status - or as we would say today population health - as an
outcome of development. It set global goals and targets for
population health gain and proposed the key strategy with which
to move forward: the primary health care strategy.
Progress in world health could be measured against jointly agreed goals,
and both the WHO and the Member States would become more
accountable for the health of populations. At the global level of
WHO 12 indicators were set (see graph) that were to be assessed
by all WHO Member States. The Regional Offices of WHO together
with the Member States were then challenged to take this process
further at their level of responsibility and to get the member
states fully involved. WHO spearheaded an approach which by now
most other UN agencies have adopted in one way or another.
Health For All 2000 introduced three
key principles for health policy which remain valid until today:
Health:
For All : Equity
2000 : Timeframes and accountability:
These global principles were
complemented by two major strategic approaches: intersectorality (meaning
the contribution of sectors other than health) and participation
(meaning the full involvement of the communities and the non
governmental sector) which also characterize PHC. These five
components have remained at the centre of WHO Health for All
policy over the years and continue to be central to the health
for all renewal process. One thing is becoming increasingly clear
as we look back: the original goal of Health for All is that we
should act upon health determinants and known health risks so
that all people have the OPPORTUNITY to lead a socially and
economically productive life. But while the goal was
population health the approach remained mostly within the
confines of a medical agenda. "Instead
of the announced health revolution, we retrenched and addressed
the service and delivery aspects."
While some countries were quick to
state that the HFA 2000 approach was just for the developing
countries a reformulation of the basic premise of health policy
in industrialized countries had been underway in Canada.. Just
before the adoption of the health objectives in the US the
Canadian health minister Marc Lalonde presented in 1974 "A new perspective on the health of Canadians" which introduced the health field concept.
It stated that in order to achieve better population health five groups
of determinants must be addressed: biological factors, the
physical environment, the social environment, lifestyle factors
and health care services (Figure 1). The Lalonde report
underlined - just as Health for All 2000 did - that many of the
factors determining population health were outside of the remit
of the health services. Less clear at the time was the
interaction between these factors and their relative weighting.
Canada also did not take the next step, to translate the health
field concept into nation wide objectives even though several
attempts were undertaken, most recently in 1994. It has become an
internationally accepted "exemplar" (Thomas Kuhn) of modern health policy - much
quoted but rarely implemented in its full scope. It opened
Canadian thinking to a broader approach to health promotion,
which was to become the basis for the first international Charter
for Health Promotion, adopted in Ottawa, Canada in November 1996.
This Charter was to significantly influence policies and
programmes around the world and now constitutes a major component
of Health for All Renewal.
The European Office of the World Health
Organization (the only WHO office to deal systematically with
health challenges of the industrialized countries) took the
HFA2000 challenge to the developed world and embarked in 1981 on
setting European health for All targets. The very specific shape
this document took was due to four key influences: the global HFA principles,
the Lalonde "health field", the US approach to "health objectives for the nation" and the Finnish primary health care commitments
(in the early seventies the concept of comprehensive, integrated Primary
health care was introduced in Finland through new
legislation. In 1982 Finland agreed to act as a pilot country for
HFA strategy development and was the first country to present a government
HFA policy report to the parliament in 1985).
The EURO document would influence many
health policies in Europe and beyond. It consists of 38 targets
which together form a logical structure the "HFA strategy pyramid". (Figure 2). These targets were first
approved by all European Member States (then 32) in 1984 after a preparatory
and consensus building process of four years and updated in 1991
by the then 50 Member States. Initially the year 1990 was set for
reaching many of the targets, the 1991 revision changed the goal
post to 2000 and presently they are again being revisited as part
of the organization wide Health for All renewal process.
The lifestyles and health section of
the European target document was under strong pressure to present
its objectives based on diseases and behaviours. Of course the
epidemiological situation in Europe was very similar to the US
(and is reflected in the outcome targets of the European
document) and the same "priorities" appear with slight adjustments throughout the developed world:
the English priorities are coronary heart disease, cancer, mental
illness, HIV/Aids, sexual health, and accidents. The Australian
list contains: Cardiovascular health, cancer control, injury prevention
and control and mental health. The US as you know well has 22
areas of priorities which range from physical activity and
fitness to food and drug safety to sexually transmitted diseases
and of course this includes the priority areas selected in the
English and Australian policies. Given the disease panorama in
developed societies one can hardly expect any other priorities if
one starts out from classical mortality and morbidity data. These
are the major diseases from which people suffer and from which they
die. Given their very high incidence and prevalence any health
policy with a rational base has to take action. We felt therefore
that the crunch lay not in the diseases selected (particularly in
view of substitute morbidity and morality) - but in the approach chosen to
combat or to deter certain disease patterns. Meaning: what action
was going to make the most difference in population health along
the four criteria set by the European targets: reducing the
health gap, adding years to life, adding health to life and
adding life to years.
The view that prevailed for the life
style section of the European target document was based on the health
field model and highlighted the three key strategies: healthy
public policy, supportive environments, personal skills. Two
further "targets" were added which focused on positive and damaging
health behaviour respectively. This approach was confirmed in the
1986 Ottawa Charter for Health Promotion with its selection
of 5 key action areas: healthy public policy, supportive environments,
community action, personal skills and reorienting health
services.
The Ottawa Charter was (and this was part of the brief we had received from the then Director General) to provide new impetus to the debate on determinants of health and to state clearly - through a charter - what actions really matter. The Charter has changed the face of health promotion world wide . I believe is also the sound basis for second generation health objectives.
Since the adoption of HFA 2000 in 1977,
the European targets in 1984 and the Ottawa Charter in 1986 many
policies and infrastructures have been developed at national
level that in essence focus on Health Promotion. The differences
that emerge most clearly when comparing the policies is whether they
focus
Let me address the issues arising from
this by first outlining three premises for second generation objectives
and then moving on to more specific issues that should guide the
setting of objectives.
5.1 First the theoretical premise: second
generation objectives must take their starting point from health.
The most crucial defining factor of any
health promotion strategy is that is starts out from health creation.. The perhaps most famous quote from
the Ottawa charter is the statement:
"health is created and
lived by people within the settings of their everyday life: where
they learn. work, play and love."
In general the policies I have reviewed
(see attached for the list) refer extensively to this new, more active
understanding of health. Not in as much as they believe that "a complete state of physical, mental and social
wellbeing" (WHO definition of health)
can be achieved and measured but in subscribing to a point of
view that acknowledges that health is more than the absence of
disease and that a modern health policy must be concerned with
issues that are broader than just physical health. The more
active definition of health put forward in the WHO European
Target document (EURO targets in the following) and in the WHO
Ottawa Charter for Health Promotion are used in many documents,
as for example in the following definition adopted by the
government of British Columbia:
"Health is the extent to which
an individual or group is able, on the one hand, to develop
aspirations and satisfy needs; and on the other hand, to change
or cope with the environment. Health is therefore seen as a
resource for everyday life, not the objective of living; it is
seen as a positive concept emphasizing social and personal
resources, as well as physical capacities."
5.2 Second the public health premise: second
generation objectives would have an understanding of a health
policy that is investment based.
All documents I have reviewed state
that a modern health policy is much more than a policy for managing,
organizing and funding medical services. The best public health
investment is change which effects large population groups.
Health policy should focus on means to increase the production of
health, this implies interventions that bring with them the need
for broad action in other government departments and in other
sectors of society. While proposed by the health minister some documents
have been adopted by parliament as a whole and are seen as a commitment
of the whole government. Some documents go even further - such as
the Ontario proposals - and state those policies and actions
(outside of health) which would have the most significant health
impact - and form part of the overall "wealth" or "social capital" of a society. Increasingly this view is being
adopted in development policies that are investment based and you can
see more and more of it in the public debate as these two
examples on investments from your own country show.
5.3 Third the practical premise: second
generation objectives would follow a strategic logic based on
community development, organizational development, participation
and partnerships.
Most existing policies set a general
vision, state a set of principles, move on to broad goals, which are then
made more specific through measurable objectives and are
complemented by a set of targets which quantify the amount of
change to be expected for an objective as well as setting a date by
when the objective is to be achieved. The quantified target
statement is based on agreed indicators. Finally the documents
move on to proposing strategies which indicate how to proceed, suggest
mechanisms and assign responsibilities. The first key issue is
whether the approach chosen is vertical or integrative -
and here existing policies differ significantly. The second issue
though might prove even more important: should we continue to set
targets the way we have or choose a different approach to provide incentives
and to ensure measurement? The new pluralism in a society of
organizations (as outlined by Peter Drucker in The new
realities) means that strategies need to be found that motivate a multitude
of actors with quite different main objectives around a (in our
case) commitment to health. Not because they are altruists or
moralists - but because it allows then to do their respective job
better and it contributes to overall societal goals that benefit
all. I believe that health promotion has contributed
significantly through the settings approach how environments
and organizations can improve their health potential. For an
approach based on organizations benchmarking may prove
more appropriate than target setting. An interesting example of benchmarking
is the recent McKinseys study comparing health inputs and outputs
of three systems: US, Germany and UK. The settings projects have
done this with regard to schools, hospitals, cities, prisons,
marketplaces. Benchmarking allows us to measure the health of a
system or a community rather than concentrate on an
epidemiological aggregate. It brings together inputs and outputs.
The network approach developed by WHO brings energy into
benchmarking and provides opportunities for experience exchange
and comparisons.
If the three premises health,
investment and organizational development hold then our policies
need to take quite a different approach than has been the case so
far. We have summarized the starting point for a new type of
health promotion objectives with a set of three questions:
From the Ottawa premise that "health is created and lived by
people........where they learn, work, play and love" we get a very different starting point for "healthy people": the interaction of people with their
environments in the process of health creation. Leonard Syme
in 1986 first threw out a challenge which is pressed upon us ever
more urgently: to develop a classification system for public health
interventions that is not based on diseases but on a
systems/environments perspective.
6.1 The Quebec policy on health and
wellbeing has attempted this new type of classification and this
type of thinking is also reflected more or less expressedly in
most of the provincial strategies in Canada, most recently in
British Columbia.. Let me therefore introduce this policy to you
as an "exemplar" which has taken the health field concept
several steps further.
To begin with the policy defines three
principles that lead it:
The policy paper is divided into three
parts:
The issues, an analysis of the
existing situation, followed by 19 objectives which are
grouped into 5 priority areas: social adjustment,
physical health, public health, mental health, social
integration. But even more important is the fact that section III
on strategies brings all 19 objectives together into an integrated
strategic approach. It identifies six overall strategies which
will support the achievement of all targets:
6.2 Second generation
objectives would aim for a classification based on key
determinants of health. The Ontario proposals start out
from the question: what makes people healthy? This document most
closely reflects what one might call the "Canadian school of health policy which
takes its starting point from an updated health field encompassing:
living and working, social support, individual behaviour and genetic make
up. The strategic proposals then lie in the areas of wealth
creation, child support, education and social support with explicit reference
to: healthy schools, healthy workplaces, healthy environments ,
healthy beginnings, family and friends. We see here a progression
of what is considered a "key cause" for health/ill health from the first
differentiation developed by Michael McGinnis together with W.
Foege (see graph). They compare the ten leading causes of death
with the actual causes of death. One could therefore argue that
the objectives should be set at the "actual cause"
level while the indicator would
be the reduction of the disease. This represents very much the
Finnish view: to clearly differentiate between epidemiological
goals and targets (if we do x and y it is to be expected that by
the year 2005 z will be achievable) and to formulate policy
statements that aim to set x and y not z. The "
actual cause " approach allows for a first visible
balance between structural and behavioural interventions.
But second generation objectives must
go one if not two steps further. The Quebec and Ontario proposals
represent quite another problem definition based on a social
concept of public health. Their chosen categories: social
adjustment, physical health, public health, mental health, and
social integration allow to draw attention to the root causes
and offer explanatory factors for each problem which do not shy
away from addressing the complexity of such issues as child abuse
or rape. Contrary to other documents we find violence in all its
forms highly visible at the beginning of the document under
social adjustment: sexual abuse, neglect and violence against
children, behaviour problems among children and teenagers,
delinquency, violence against women, homelessness, alcoholism,
and drug abuse. The integrated strategies in turn aim to tackle
the problems closest to the root cause. The health goals for BC
follow a similar track.
Goals - Where we will concentrate
our efforts:
Goal 1 Foster positive and supportive living and working conditions in all our communities.
Goal 2 Support all individuals to develop the capacities, skills and attitudes we need to thrive and meet life=s challenges.
Goal 3 Ensure an environment that is naturally diverse and has clean, healthy and safe ecosystems of air, water an dland for humans and all living things, now and for future generations.
Goal 4 Ensure that our public policies and investments recognize all of the important influences onour health, and result in the best possible health outcomes.
Goal 5 Reduce preventable illness, injuries and premature deaths.
Goal 6 Foster joint action to improve the health of Aboriginal peoples.
Given the profile of American health
problems, the deep inequities and tensions in health your country is
facing, this approach might well be worth considering. And given
the following graph - of which I have not yet been able to find
an update - the priority of education seems obvious and paramount.
This is the crunch point of all future
health policies and target documents and I would urge the US to consider
it carefully when revisiting the health objectives for the
nation. It is clear that 20 years ago "lifestyle and health" issues needed to gain attention and be put on
the map. In many countries the goals and targets approach has
helped move this agenda forward and it is now common knowledge in
developed countries that smoking is bad for your health, that
there is a link between unhealthy lifestyles and cardiovascular
disease and that unprotected sex can mean death. Meanwhile all
research in these very areas has shown us that up to 50% and more
of causation cannot be explained by the risk factors normally
studied - which tend to lie in the area of personal behaviour. We
have so far not sufficiently explained the enormous decrease in
mortality from cardiovascular disease in most Western Countries
since the seventies - just as we are not able to fully explain
the enormous increase that we are witnessing in Eastern Europe in
the same period. We have always known that "death is a social disease" meaning that the poor die sooner, what has not
been common knowledge is that in the growth era of the European
welfare states the health gap (or even more specifically the health
gradients) has increased not diminished. For decades research has indicated
the importance of social organisation for health: the
environments where people learn, work, play and love. The Ottawa Charter
for Health Promotion - launched in 1986 - has been a central
guide for those who seek to implement strategies that focus on
health creation and supportive environments for health. The "settings projects" such as Healthy Cities, health promoting
hospitals or healthy schools encourage organizations to set their own
targets and to develop integrated mechanisms to achieve them as
part of a social project for health. This type of approach is far
removed from any "big
government" approach - it is
built on motivation, incentives, energy , creativity and
partnerships. It explicitly starts from strengthening the health
potential within each setting as a democratic exercise. To a
certain extent the Ottawa Charter and the settings have helped a
fair bit along the way of L. Symes challenge for new organizing
principles of public health and health promotion.
But while the scientific evidence
for the very strong influence of social factors on health
increases, the definite lack of a social reform agenda within the
medically and economically driven health debate leads to the
exclusion of these very factors from health policy formulation.
The focus on individual behaviour introduced by behavioural
epidemiology in the 1960s had entered into an easy marriage with
medicine and its focus on the individual patient. In times of
economic stringency and a revamped neoliberalism the division of
labour has become clear: resources go to the curative system
which increasingly questions the universality of access,
prevention is considered a personal responsibility which rational
actors will pursue in their own best interest, systemic
intervention into the lifestyles arena is considered a
restriction of individual freedom. And the negative health consequences
are quick in coming, as the increase in smoking after the easing
of the Canadian tobacco legislation shows.
The world has changed significantly
since the first targets were set: in many countries there is increasing
debate about the role and influence of the state in health
matters. As the economic crisis of health care systems started to
shift the debate to results and output one would have thought
that political commitment to target setting and accountability
would increase, particularly to target setting in the areas of
health promotion, disease prevention and health protection. A
range of calculations are by now available - which indicate
significant amounts of dollars and lives saved through a
commitment to health promotion and protection. Instead we see a
very worrying neglect of the sound evidence which argues for
investment in and action on health determinants. Health promotion
and prevention would actually be one of the most rational ways of
rebuilding health systems and strengthening public health. The
recent discussion paper on Promoting Health in Australia by the
NHMRC makes this point very forcefully. But the political support
to move in this direction is blatantly lacking in most countries:
consuming health care (albeit in a reduced fashion) rather than
producing health remains at the top of the agenda .
Partly this means accepting a different
type of consensus on evaluation of success. Following a proposal
from Australian colleagues from NSW we have at WHO made the
following proposal for the evaluation of health promotion
activities.
Health promotion has not really moved
to centre stage in terms of setting the health agenda. It seems that
in the present climate policy makers are rarely interested in the
real cause or the real cost. Most target documents have remained
within the disease perspective and have targeted the disease
rather than actions needed to improve population health. A new
dimension needs to enter the goals and targets debate in
order to generate energy to improve population health in a period that
is set to retract rather than expand systems of service.
In my personal view a second
generation objectives would be "ecological in perspective, multisectoral in
scope and collaborative in strategy" (Nancy Milio) and build on the five strategic
areas of the Ottawa charter for health promotion. policy. They
would be - as was the case with first generation goals and
targets - a development tool that will help set new agendas
for health promotion and prevention.
Six principles would guide second
generation objectives:
8.1 Build on a social model of
health and target social organisation rather focus on
individual behaviour. Objectives would be formulated around the
factors known to have the greatest influence on our health and
the interaction of individuals and social groups with their
environment(s) at minimum they would follow a health field model
- at maximum they would concentrate on key determinants of health
as outlined in the Ontario document. To me this means to move the prevention agenda
into the health determinants and investment in health agenda.
(This with respect to the subtitle of your conference). Second
generation targets would own up to complexity and focus on
long term sustainable health gains. Impact will therefore be
measured at the level of individuals, social groups and social
environments. Verticality must be replaced by epidemiological
and strategic consistency. Too frequently target documents do
not consider the interaction between targets neither at the level
of epidemiology (for example substitute mortality and morbidity,
i.e. CVD going down and cancers up, smoking going down and body
weight up or the effect of demographic factors) nor at the point
of strategy.
8.2 Set clear investment goals. Second
generation documents will need to make clear statements on resource implications,
i.e. the costs and profits to be expected. The present debate
in the US on diabetes is a very good example - and could be
expanded to a range of other issues using a benchmarking
strategy. The Canadian study warns explicitly that while targets
can help direct resources towards "best Investments" or "best pay
offs" in improving population
health there is little evidence that they would be a key tool,
on their own, for reducing or controlling health care costs." Therefore if the overall health budget
cake does not grow a shift in resources from areas with less health
gain will need to be envisaged, argued well and explained to a
range of stakeholders.
8.3 Second generation objectives would
have a strong commitment to reducing health gaps and social
gradients in health, with an understanding of the new
dimension of intergenerational health gaps. At present we
see that it is children and young people who are paying the price
of the modernization processes. Particularly the US data - but
also data in countries like South Africa - show the need to
invest significantly into youth health. The arguments put forward
under 8.2. apply accordingly. This means a much clearer
identification of the societal stressors at work - and a responsive
strategy that builds health potential, creates buffers and
intermediary support and protection factors. Such strategies need
overall societal commitment through leadership and incentives schemes
- they can be implemented in a multitude of ways at the community level
as we have seen from the Healthy cities project.
8.4. Second generation objectives would
set policy relevant data indices: for example (as proposed by
Nancy Milio) a health equity index, a social stress index, a
community interaction and social support index and an
environmental hazards index. This could allow benchmarking of a
new type, as well as incentive and reward schemes focused on
social groups and organizations. Accountability would gain a
new dimension. The English Health of the Nation document for example goes
to great lengths to spell out HOW to make the strategy
work and sees healthy alliances as a key mechanism. It states clearly
the responsibilities of the National Health Service and indicates
at the end of each section what action the government (not only
the health ministry) will take. It is also one of the few
policies that has been adopted by the government as a whole, not
just the health ministry. Accordingly a Ministerial Cabinet
Committee was established to "oversee implementation, monitoring and
development.....and to be responsible for ensuring proper
coordination of UK wide issues affecting health." But formal political endorsement is not
per se a sign of success (note the Finnish case) or lack of it a
sign of failure. In the Netherlands the proposed Health for All
targets were never quantified nor endorsed by parliament - yet
they provided a significant stimulus for policy development and
had a range of spin offs. In general it must be noted that the
goals and targets process too frequently assumes that policy
making is "rational" business which follows the best arguments and
the best data. A whole school of policy science is dedicated to
showing that this is not the case (Lindblom).
8.5 second generation objectives would
intensify the building of new types of partnerships and alliances.
At the global level we are presently considering a global
public/private alliance for health promotion. Projects such as
Healthy Cities and health promoting schools have shown the value
of coalition building and are explicitly mentioned - alongside
other settings projects - as a key implementation strategy in the
English Health of the Nation document. "They offer between them the potential to
involve most people in the country". For each of the settings - cities,
schools, hospitals, workplaces, prisons, homes and environments -
the strategy indicates the type of support that the government
will examine and seek to establish. One very interesting approach
that emerged in this respect was an initiative on the health
promoting NHS, explicitly addressing the health conditions within
the health sector. The US model of a health consortium of public
and private actors should be carefully considered in other
countries. This is all the more important since it is becoming increasingly
difficult to disentangle the impact of national health goals and
targets from other factors operating simultaneously. I feel
strongly though that you should complement the consortium with a
set of very strong networks for health such as health promoting
schools, sport venues, healthy workplaces etc. The experiences
gained through benchmarking could then be translated into
standards agreed through consensus for organizations and
institutions.
More consideration must be given to the
role of the private sector. The health industry, the lifestyle and
leisure industries and the media and communication industries
have entered the playing field, with both positive and negative
health messages and products and with great potential for significant health
gain. This area is the focus of the 4th International Conference
on health promotion due to take place in Djakarta in July of next
year with the title: New players for a new era.
8.6 Integrate the international and
sustainable development dimensions into the strategy and the
targets. "A successful health
strategy cannot be insular" -
states the English strategy as one of the few documents that
draws attention to the international dimension of health - both
in terms of health threats and in finding solutions. But beyond
this we must measure and compare our health status on the
sustainable development dimension: which means linking health
status gains with the consumption of the worlds ecologically
productive resources. Using such a measurement - rather than life
expectancy only - would show that the most successful countries
are those which maximize their health status while limiting
increases in energy and land consumption. Such comparisons are eye openers
and lead back to the first of the six components: in 1991 Costa Rica
delivered a life expectancy of 76 years to its citizens compared
with an average of 77 for the worlds richest countries. It did
this on a national income of US$ 1,850 per capita compared to an
average of US$ 21,050 for the richest. Costa Rica must be
doing something right: indications are that many of the determinants for
health are successfully addressed. We hope to move in this
direction with the launch of a project bringing together the
seven most populous countries in a serious health promotion
effort and comparing then along the lines of such new criteria.
Goals and targets that are driven by
technical considerations can easily lose sight of the "big picture"
and politicians might well see a different balance between
political and epidemiological arguments than health
professionals. An analysis of the Finnish policy states "No responsible politician will commit himself
or herself to a target set as a percentage reduction of a certain
mortality indicator unless the relevance, meaning, means and
processes to reach it are understandable and beyond reasonable
doubt." This is all
the more important as we need to ask ourselves whether the
wealthy societies be able to maintain their health status? The
challenges are enormous: to reduce health gradients, to expand
healthy life expectancy, increase quality of life for an ageing
population and yet ensure the health and the future of the young? Probably
we only stand a chance if we begin to apply the knowledge we have
about what creates healthy populations and develop new public
health categories around which to group our interventions. Health
technology is more than pipes and drains, medical equipment and computers
- it must create the social technology of creating supportive
environments for health. We need to draw a new health promotion map.
One hundred years after Emile Durkheims seminal findings on the
patterned regularities of death and disease our interventions
should start to weave a pattern of health. That is the least we can
do at the start of the 21st century.
To illustrate the points I wish to raise with regard to setting health objectives I will use examples from a number of health policies that have set goals and targets which have been produced over the last 5 - 6 years besides the Healthy People 2000 (USA): The health of the Nation (England), Better health outcomes for Australians, The policy of health and Wellbeing (Quebec, Canada), the report of the Ontario Premiers Council on Health, Wellbeing and Social Justice "Nurturing health" (Ontario, Canada), A Strategic Direction to improve and protect the public health (New Zealand) and the Draft Health Goals for British Columbia (Canada). I will also use -as mentioned above- the experiences gained in the Dutch and Finnish HFA policy process.
The goals and targets document that I
review here (which are amongst the ones most well known) focus on
health promotion and disease prevention, with the Australian
policy moving furthest into the treatment and care area and the
Canadian papers furthest into the social arena. All policies include
an environmental dimension. The Finnish health policy reflected
all the components of the WHO European strategy but a decision
was made early on in the process not to introduce quantified targets. Each
of these policies can only be fully understood in their own
unique policy environment and of course reflects the policy
styles and political culture of the countries concerned. Yet
there are general issues that can be highlighted and deducted from
a closer, comparative analysis.
The policy papers in order of their publication:
Targets for health for all. The health policy for Europe. World Health Organization. Regional Office for Europe. Copenhagen 1991
The policy on health and well-being. Gouvernement du Quebec. Minister de la Sante et des Services Sociaux. Quebec 1992
The Health of the Nation. A strategy for health in England. Presented to Parliament by the Secretary of State for Health by command of Her Majesty July 1992. London HSMO 1992
Nurturing Health. A new understanding of what makes people healthy. The Premiers Council on Health, Well-being and Social Justice. Ontario 1993
A strategic direction to improve and protect the public health. The Public health Commissions Advice to the Minister of health. 1993-1994. Wellington, New Zealand
Better Health Outcomes for Australians. National Goals, Targets and Strategies for Better Health Outcomes Into the Next Century. Commonwealth Department of Human Services and Health. Commonwealth of Australia 1994
Healthy People 2000. Midcourse review and 1995 Revisions. U.S. Department of Health and Human Services. Public Health Service. 1995
Health Goals for British Columbia: identifying priorities for a healthy Population. A draft for discussion. Office of the provincial health officer. November 1995
Some further reading:
Hammad, A.: Health in Development. Keynote Address, Bellagio, October 1996
Health and Social Organization. Towards a Health Policy for the 21st Century. D. Blane et al. (Eds) , London and New York, Routledge 1996
Health Australia. Promoting health in Australia. Discussion paper. National Health and Medical Research Council. Canberra. December 1995
Kickbusch, I. : Lifestyles and health. In: Social Science and Medicine, 1996
Kickbusch, I. : Health Promoting Environments - the next steps. Article in a special issue of the Australian and New Zealand Journal of Public Health on "Health Promoting Environments", 1996
Leppo, K.: Health For All Policy in a country. The case of Finland. Paper prepared for the European Health Policy Conference, Copenhagen, 5 - 9 December, 1994
McAmmond, D. and Ass., Analytic Review Towards health goals for Canada. Final report and background working paper. April 1994
McGinnis, J.M., Targeting Progress in Health. In: Prevention. July/August 1982, Vol. 97, No.4, pp 295-307.
McGinnis, J.M. and Foege, W.H. : Actual Causes of Death in the United States. In: The Journal of the American Medical Association, 1993, 270, pp 2207 - 2212.
Milio, N., Towards a Turn of the Century Public health: International initiatives and policy support Implications. In: Environments 19 (4), 1988, pp 76 - 88
van de Water, H. And L.M. van Herten, Bulls eye or Achilles heel. WHO=S European Health for All Targets Evaluated in the Netherlands. TNO Prevention and Health, Leiden 1996
Wealth and Health, Health and Wealth. The Premiers Council on Health, Well-being and Social Justice. Ontario 1994