30 years have passed since the Ottawa charter on health promotion was presented, changing our understanding of health and introducing novel approaches for the maintenance and promotion of health. Here, we look at the future challenges for health promotion and the relevance today of the principles derived from the Ottawa charter.
By Matej Vinko, Monika Robnik, and Mojca Gabrijelčič Blenkuš.
The Ottawa Charter provided a breakthrough for the way we think about health and the way public health is practiced. Health promotion has become a vital, if not the leading, component of modern public health in the last 30 years1. The Charter broadened the normative framework of public health and introduced innovative elements with its three strategies (enable, mediate, advocate) and five action areas (build healthy public policy, create supportive environments, strengthen community actions, develop personal skills, and reorient health services)2. The subsequent conferences on health promotion – the 9th being held this year in Shanghai – have since then solidified the key principles for health promotion action.
Thirty years on, what are some of the challenges are facing in the field of health promotion today, and what opportunities and tasks lie ahead for future generations of public health practitioners active in the field of health promotion?
Many of us entering the public health field today had not yet been born when the Charter was being drafted – but the message it carries has not lost any significance. When looking at what challenges lie ahead of us, it is clear it will remain relevant for years to come. The significance of the Charter upholds the challenge of time because the changes it introduced were not only of practical importance but had rather strong philosophical implications on the way health is conceived. Health was conceptualised as a resource for everyday life and not as the objective of living. Important conditions and resources for health such as peace, shelter, education, a stable eco-system, social justice, and equity, among others, were listed as a foundational requirements for improvement in health – improvement, which cannot be ensured by health sector alone2. In order to advance population health, the conception of health as addressed in the Charter should permeate all spheres of life – public and personal. That is still not the case – some might even argue we, as a society, are moving further away from that ideal3. Therefore, reconceptualisation of health might be the biggest and the most comprehensive challenge our generation faces in the future.
Here, we present five broad and interconnected groups of challenges we believe health promotion will have to tackle in the future. It was not our intention to provide a complete list of all possible challenges – instead, our goal was to spark a discussion on what lies ahead by presenting few selected issues which will define public discourse from here on.
New technologies and new ethical dilemmas
We are living in the age of telecommunications and information. New technologies that have been developed in recent years, as well as those that are yet to be introduced in years to come, have the potential to contribute vastly to population health. Still, there are number of pitfalls to be aware of when it comes to using new technologies for health promotion. Considering only digital health technology, which includes health information distribution, health-related digital gaming, personal self-tracking with wearable technologies etc., we encounter numerous ethical and political dilemmas.
The majority of digital health promotion strategies have strong emphasis on personal responsibility for health, drawing attention away from social determinants of health. In the current age of austerity measures, public as well as private enterprises have placed substantial focus on self-responsibility4. Acknowledging the fact that use of digital technology is strongly associated with age, income and education level, we can see how inequalities in society are bound to widen unless approaches to digital health promotion start changing in the future. More effort has to be put into raising health and digital literacy in disadvantaged social groups.
Another challenge we are facing in the field of digital health technology is enormous quantity of self-tracking data gathered with wearable technologies and its potential uses and misuses. Multiple ethical dilemmas emerge concerning the use of such data by employers and insurance companies, privacy, security, and access to such data, etc. Digital technologies are becoming more advanced and intertwined with our daily lives with every passing day. Sometimes, it is even hard to draw the line between what is real and what is imaginary – a situation with potentially damaging consequences on health that previous generations were not faced with; for example some digital games are so sophisticated and targeted that they easily cause addiction in vulnerable individuals5, 6.
Nonetheless, digital technology provides us with multiple opportunities for health promotion practice:
- unprecedented data surveillance capabilities,
- participatory health education and communication,
- engagement of individuals and communities in developing healthy public policies,
- community (and healthy environment) development and political engagement of the population (raising awareness on poverty, degradation of environment and other issues of globalized world).
Those were just a handful of opportunities for us to exploit – digital technology has wider and deeper influence on our society. Most of the outcomes are yet to be measured and evaluated. Undoubtedly, it will be a major driver of social change in the future.
Social and economic dynamics
Social and economic environment plays one of the – if not the – most important roles in modern public health. Some of the most pressing issues associated with socio-economic dynamics are the following: inequities in all spheres of life, migrations of marginalised populations, “eternal austerity” and its impact on public health- and social care, commercialisation, privatisation, and individualisation of health in a market-oriented world.
The impacts of economic globalisation, the domination of multinational corporations and the primacy placed on private profit at the expense of the majority of people, have been mostly harmful for the health of the population7. Governments have a vital role in regulating the economy and therefore employment, providing education, social care in times of economic or other difficulties, setting up strategies to counteract poverty, crime and drug abuse, and stimulating equitable and sustainable economic and social development. All of these actions have a decisive impact on health 7. Economic aspects of government policy have to be placed high on the priority list – but not higher than health. Other important actors in the field of health promotion are non-governmental bodies, community organisations, and individuals themselves – health promotion demands coordinated action of all concerned.
Socioeconomic issues are continually widening the disparities in health. Consequently, society will need to engage in network governance, partnership, and multi-stakeholder approaches in order to achieve health goals and to develop a sustainable system, that will be able to respond to changes in social and economic dynamics- demographic changes being one of the most pressing8.
The usual response to the majority of challenges in health care is the reduction of costs and optimisation of workflow usually by ad interim solutions. As pointed out in the Ljubljana Charter, this is a severely limited ‘downstream’ approach. This limitation needs to be recognised and the illusion of control, through short-term technical responses, needs to be abandoned in favour of more holistic and sustainable solutions9.
Leadership and public health workforce
Health promotion relies heavily on competent workforce with motivated and capable leadership. Public health problems often carry a large burden for society; they are caused by numerous and interconnected causes which are hard to manage, and usually require long-term solutions which again need the cooperation of many stakeholders in order to be successful. A sufficiently funded and staffed workforce lead by visionary professionals with influence, and well-grounded values and competencies is essential for the future effectiveness of health promotion.
Aside from sufficient number of public health professionals, there is a need for quality education and training of new generations of health promotion workers. An important element for capacity building of health promotion professionals in Slovenia, for example, is Slovenian terminology; in order to properly use the terms and concepts in health promotion, they need to be translated to the Slovenian language. Terminology in native language surely is a central prerequisite for ensuring quality of health promotion, but much more has to be done. With the rapid pace of change we are experiencing in ecological, social, and economic spheres of life, health promotion must be highly responsive and effective – a feat hardly accomplished without a systematic public health educational system designed to deliver core and specific competencies to a wide array of professionals in the field of public health10.
Demographic changes – population growth
Understanding the demographic changes that are likely to unfold over the coming years, as well as the challenges and opportunities that they present for achieving sustainable development, is important for designing and implementing the post development agenda. Currently, demographic changes relate to aging population, changes in ethnic and cultural composition of population, and urbanisation.
Europeans are currently witnessing migration of populations on a scale previously unseen. Migrants are travelling from all over the world, bringing with them different ways of thinking about and perceiving the environment and culture they are migrating to (or through). The current political climate promotes negative attitudes towards migrants, which puts them at risk of social, economic, and/or cultural marginalisation, and living on the fringes of society – the very reasons most of them left their homelands in the first place. The implications for health promotion are self-evident11.
The second important demographic change is growth of the global population. In July 2015, the world population reached 7.3 billion. The global population has grown by one billion people since 2003 and two billion since 1990. Global human population growth amounts to around 75 million annually, or 1.1% per year. It is expected to keep growing, with estimated total population of 8.4 billion by mid-2030, and 9.6 billion by mid-205012, 13. Rapid population growth can be attributed to hygienic measures, medical advances, lower mortality rates, increasing longevity, and a massive increase in agricultural productivity.
Population increase in more developed countries is already low and is expected to stabilise14. The concentration of population growth in the poorest countries will make it harder for those governments to eradicate poverty and inequality, combat hunger and malnutrition, expand education enrolment as well as the affordability and acceptability of health systems, improve the provision of basic services, and implement other elements of a sustainable development agenda to ensure that no-one is left behind12, 15.
Future population growth is highly dependent on the path future fertility will take, as relatively small changes in fertility behaviour, when projected over several decades, can generate large differences in total population.
Measures should in future focus on:
- participatory and transparent policy making on human reproduction/reproductive health16,
- sociological imagination (to understand problems associated with poverty, malnutrition, inequalities, climate change, unemployment, etc., as consequences of human population growth17,
- create supportive environments that will inform people around the world about population, health, and the environment, and empower them to use that information to advance the well-being of current and future generations2.
Population growth also has an important impact on another key global problem – climate change. Connections have been made between population growth and global carbon emissions18.
Achieving universal access to family planning throughout the world could be one the interventions used to manage health problems associated with rapid growth of the population in underdeveloped countries. It would result in fewer unintended pregnancies, improve the health and well-being of women and their families, and slow population growth – contributing to climate compatible development19.
Climate change is a global problem. It is disrupting national economies and effecting the lives of every single person, community, and country on our planet through the degradation of land and water, depletion of resources, and new patterns of communicable and non-communicable disease distribution.
Climate change is an issue that requires solutions coordinated at the international level. Affordable, scalable solutions are now available to enable countries to leapfrog to cleaner, more resilient societies. The UN and The World Health Organization has recognised climate change in the sustainable development goals, and targets have been defined relating to this. Emissions anywhere affect people everywhere. To address climate change, countries are working to adopt and implement the global agreement made in Paris last December which addresses adaptation, mitigation and capacity building15, 20.
A lot of information is available regarding climate change, its causes, and the consequences for the environment and human beings. Actions to combat the climate changes are also proposed. We believe that it is essential to focus on:
- strengthening resilience and adaptive capacity to climatic changes,
- realising that this is a complex global problem, affecting all of us which reqires changes in behaviour,
- integrating measures into national policies, strategies and planning, and
- promoting low carbon development technologies and energy use.
Numerous opportunities based on the principles of Ottawa Charter are emerging for our young generation. These are just a few – doubtless, many more are going to arise.
Opportunities based on the five action areas of Ottawa charter for younger generations:
- Build Healthy Public Policy
- Participatory policy making
- Transparency in policy making
- Speeding up the evidence based policy making process (from research to implementation, from scientists to practitioners to politicians and back again)
- Create Supportive Environments
- Global and sustainable approach
- Public-private sector partnerships and socially responsible marketing that is transparent and regulatory independently evaluated
- Healthy urban planning
- Strengthen Community Actions
- Vertical and horizontal partnerships
- Open and transparent communication and funding of local communities
- Reversing the current trend of individualisation in all spheres of life
- Increasing the level of solidarity and social cohesion
- Develop Personal Skills
- Improving health literacy
- Using information and telecommunication technologies to facilitate social cohesion instead of social isolation
- Better implementation of life skills education in basic education
- Reorient Health Services
- Further integration of health and social services into “wellness” services
- Building strong health promotion on national level to facilitate international health promotion network integration
- Ensuring universal access to health care
EuroHealthNet as a major player in the EU public health has expressed the challenge of the Ottawa Charter use in present and further times in the revision called REJUVENATE. The word is composed of letters in 10 steps we can take to achieve the 2030 agenda21:
- Be Responsive (adopt to challenges and use opportunities)
- Be Equitable (address the causes of the causes)
- Be Joined-up (build partnerships and governance across sectors)
- Be Updated (act smartly to influence 21st century realities)
- Be Value driven (develop values and the right to health in new contexts)
- Be Ethical (promote fair standards in all we do)
- Be New (create and implement new ideas)
- Be Active (practice inclusive engagement)
- Be Technological (understand and apply technical and digital advances)
- Be Ecological (sustain and protect our environments).
The REJUVENATE framework for health promotion clearly echoes the message of the Ottawa Charter. From our point of view, the carter provides a key framework for health promotion action regardless of the challenges we are facing now or in the future. Now, it is up to us to implement it.
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- World Health Organization. The Ljubljana Charter on Reforming Health Care in Europe. World Health Organization, Copenhagen; 1996.
- Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al.. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. December 2010;376(9756):1923–58.
- Buzeti T, Djomba JK, Gabrijelčič Blenkuš M, et al. Health inequalities in Slovenia. Ljubljana: National Institute of Public Health; 2011: 96-7.
- United Nations. World Population Prospects – The 2015 Revision; 2015.
- Population Reference Bureau.2014 World Population Data Sheet; 2014.
- United Nations. World Population Prospects – The 2008 Revision; 2009.
- Sustainable development goals. Goal 13: Take urgent action to combat climate change and its impact. United Nations; c2016 [citirano 2016 Jun 2]. Dosegljivo na: (http://www.un.org/sustainabledevelopment/climate-change-2/
- Family planning/Contraception. Fact sheets. World Health Organization; c2015 Canada; c2016 [citirano 2016 Okt 18] Dosegljivo na: http://www.who.int/mediacentre/factsheets/fs351/en/
- Mills Wright C. Sociological imagination. Oxford: Oxford University Press, fortieth anniversary edition; 2000.
- Patterson KP. Climate Change, Health and Population Dynamics: A View From Tanzania. Cool Green Science; 2016.
- Population Reference Bureau. Making the Connection: Population Dynamics and Climate Compatible Development; c2016 Canada; c2016 [citirano 2016 Maj 27]. Dosegljivo na: http://www.prb.org/About/ProgramsProjects/PHE/Climate-Change-Working-Group.aspx
- Framework Convention on Climate Change. United Nations; c2016 [citirano 2016 Maj 27]. Dosegljivo na: http://newsroom.unfccc.int/
- EuroHealthNet: Promoting health and wellbeing towards 2030: Taking the Ottawa Charter forward in the context of the UN Sustainable development agenda 2030; c2016 [citirano 2016 Okt 18]. Dosegljivo na: http://eurohealthnet.eu/sites/eurohealthnet.eu/files/press-release/EuroHealthNet%20Health%20Promotion%20Statement%20-%20Short.pdf
About the Authors
Matej Vinko, Monika Robnik, and Mojca Gabrijelčič Blenkuš represent Nacionalni institut za javno zdravje (NIJZ), The Slovenian National Institute of Public Health. The ideas in this article were first presented at a joint conference of EuroHealthNet, NIPH, MoH and the WHO Europe Regions for Health Network, dedicated to 30th anniversary of the WHO Ottawa charter.The conference was linked to a study visit which gave participants an opportunity to find out about the healthy and active ageing initiatives being developed in Slovenia. A summary of the visit can be found on the EuroHealthNet website.