Health Promotion in the Implementation of SDG
Health promotion (HP) is a comprehensive social and political process. It embraces actions not only dedicated to strengthening the skills and capabilities of individuals but also directed at changing social, environmental, and economic conditions to alleviate their impact on public and individual health. Health promotion is the process of enabling people to better control the determinants of health and, thereby, improve their health. Participation is essential to sustain health promotion actions (WHO 1998a).
Health promotion is based on an integral perspective of the health-disease process and focuses on addressing social conditioning factors and determinants of health such as housing, sanitation, working conditions, health and education services, as well as social and community networks that positively impact the quality of life (WHO 2017).
Social determinants of health (SDH) are “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life which include economic policies and systems, systems shaping the conditions of daily life which include economic policies and systems, development agendas, social norms, social policies and political systems” (WHO 2017).
Therefore, health promotion must dialogue with various areas in the field of health and integrate different forms of knowledge and practices between government sectors and the society in order for each of these parties to also care for life, developing networks of commitment and co-accountability, but considering the cultural, social, political, and economic specificities of each territory.
The idea of HP was first defined in the 1940s as one of the primary healthcare elements of preventive medicine, based on the model of natural history of disease (Leavell and Clark 1965).
In the 1970s, HP emerges internationally as a “new perspective of health,” the result of a debate on social and economic determination of health and the development of an idea of health not centered around disease, as promoted by the Lalonde Report – A New Perspective on the Health of Canadians (Lalonde 1974).
The report was crucial to questioning the exclusive role of medicine in tackling health problems and was considered to have started a new era of social and political interest in public health.
The Lalonde Report was critical to the biomedical healthcare paradigm and was based on the health determinants, branching the health field out into four encompassing health components: human biology (genetics and human functions), environment (natural and social), lifestyle (individual behaviors affecting health), and the organization of health services (Labonte 1993; Macdonald 1998).
Health became a social product, a consequence of factors related to the quality of life, to adequate standards for food and nutrition, housing, sanitation, and education, which are the bases of the health promotion paradigm.
In the 1970s, the health sectors of most countries went through a crisis because of the high costs of the use of high-tech curative medicine, but also because research showed that expenses were not producing equivalent results in terms of quality of life for the population.
Then, based on a holistic perspective of health that incorporated not only physical and psychological aspects but also social, economic, and environmental aspects, a broad discussion emerged and inspired a search for new ways of overcoming disease-centered notions.
There are various understandings of HP (Seedhouse 1997; Vasconcelos and Schmaller 2014). A few experts consider it to be a new paradigm opposed to the biomedical model (Raphael 1999; Bryant 2002), whereas others treat it as a field of knowledges and practices (Hall 1993; Sabatier 1993; Sackett et al. 1996; Correia and Medeiros 2014). Moreover, other authors also define HP as an expanded perspective on the operationalization of emergency social policies (Marmot 2005; Castelo 2013).
International Conferences on Health Promotion
Based on the World Conferences, goals for health equity and actions toward disease prevention were established for each region, focusing on endemic diseases. It was a proposal for a contemporary public health perspective disseminated by the World Health Organization.
The 1st International Conference on Health Promotion was carried out in 1986, in Ottawa. The Ottawa Charter, the outcome document of the event, became a reference for the development of HP ideas and actions around the world. It defined HP as the process of training communities to promote actions concerning the improvement of their quality of life and their health, including a greater participation in the control of the process. To attain a state of total physical, mental, and social well-being, individuals and groups must know how to identify aspirations, satisfy needs, and positively change the environment (WHO 1986). Health must be seen as a resource for life, not a life goal. Therefore, HP isn’t exclusively a responsibility of the health sector and extends beyond having a healthy lifestyle and into a form of global well-being through the adoption of health public policies.
The Ottawa Charter guided later conferences and declarations, especially concerning its emphasis on social factors and the importance of fundamental strategies for people to attain their full health potential: develop healthy public policies, create supportive environments for health, strengthen communities, action for health, develop personal skills, and reorient health services (WHO 1998a).
The charters/declarations of the following international conferences maintain the spirit of the Ottawa Charter, with a few aspects to be highlighted.
Healthy public policies fundamentally promoted through intersectorality are central in the Adelaide Declaration. Such policies are addressed in four different areas: support to women’s health, food and nutrition, tobacco and alcohol, and the development of favorable environments. Although it doesn’t refer directly to the social determinants of health (SDH), it states that “health inequities are rooted in social inequalities” and emphasizes the public responsibility for health, especially of the underprivileged and vulnerable groups (WHO 1988).
The Sundsvall Declaration points out the fact that millions of people in the world are at risk and in extreme poverty and emphasizes the need for urgent actions to produce greater “social justice in health.” It highlights the need for strengthening community actions, as well as the education and training of individuals and communities to control health and the empowerment of people to mediate conflicting interests. The declaration also affirms that inequities and environmental degradation prove that the current approach toward development is in crisis (WHO 1991).
The Jakarta Declaration (1997), however, was the first to address the SDH in a specific item and include the private sector as a supporter of HP. Poverty is considered the greatest threat to health, and the Declaration emphasizes the need for new responses within the field of HP, which must address the SDH to reduce health inequities and assure human rights and the formation of social capital. It also points out that, in order to improve community capacity and promote health, people need to participate in the decision-making process, to access essential knowledge and acquire skills to effect changes (WHO 1997).
The central theme of the Mexico Declaration (2000) was equity based on impact assessments of HP strategies in the health and the quality of life of the poor. It states that health problems hinder social and economic development and emphasizes the protagonism of the civil society in making HP a priority in government policies and programs at the local, regional, national, and international levels (WHO 2000; Xavier 2017).
The Bangkok Charter (2005) stresses changes in the context of global health, including the growth of chronic diseases (such as heart disease, cancer, and diabetes). It states that policies and alliances dedicated to empowering communities and improving health conditions and health equity must be central in the global development agenda. It raises the need for naming and controlling the effects of globalization in health, such as the increase in inequities, fast urbanization, and the degradation of the environment (WHO 2005).
The 7th International Conference on HP took place in Nairobi, and its output document, entitled “Nairobi Call to Action,” highlights the following actions as fundamental for promoting health: strengthening leadership in HP and the health systems, strengthening participatory processes, and developing and implementing HP knowledge. The document lists a few action strategies to attain such responsibilities, such as assuring adequate financing and universal access, as well as improving the actions of health systems and the management of their performance (WHO 2009; Xavier 2017).
The final document of the 8th Conference on HP is the Helsinki Declaration (2013) on Health in All Policies. Through the declaration, governments and other entities signed a commitment with “health equity” and “health in all policies.” Equity was, therefore, stressed again and defined in Helsinki as an expression of social justice. In the document, health appears as the responsible for improving the quality of life, increasing learning capacity, strengthening families and communities, as well as augmenting the productivity of the workforce. It stresses that equitable policies increase health levels, reduce poverty, and promote social inclusion and safety (WHO 2013; Xavier 2017).
Lastly, the 9th Global Conference on Health Promotion was carried out in Shanghai (2016) and produced the “Shanghai Declaration on Promoting Health in the 2030 Agenda for Sustainable Development.” The conference sought to discuss the principles of the Ottawa Charter 30 years later. The document highlights health literacy, good governance, and the important role of municipal authorities and communities in the improvement of health (WHO 2016).
One of the discussions that emerged during the conference was the dominance of trade and fiscal interests, which guide and influence life on the planet, over social rights. In that context, Europe has good examples of how public health can be undermined by authoritarian politicians and how governments cannot respond to such threats (Greer et al. 2013).
Commitments on health literacy were brought back from the Ottawa Charter. They include the development of national and local strategies to raise the awareness of citizens on how to live more healthily, as well as to increase their capacity to control their own health and its determinants through pricing policies, transparent information, and clear product labeling (WHO 2016).
As to good governance, the following was agreed upon: protecting health through public policies; strengthening legislation, regulations, and the taxing of unhealthy products; and implementing fiscal policies to allow new investments in the health and well-being of the population. The declaration also emphasizes the importance of universal health coverage and the need for a better approach concerning cross-border health-related issues (WHO 2016).
Despite government advances and commitments in these conferences – the definition of concepts, principles, and areas of action – which place HP in the broader context of globalization, the contents of health promotion charters focus on individuals, in their control over their own health, and prioritize changes in behavior and lifestyles (Ayo 2012).
Issues included in the expanded concept of health (such as “social justice in health,” “equity,” “empowerment,” “social participation,” “alliances with the private sector,” and “sustainable development”) were developed under the coordination of the World Health Organization (WHO) but influenced by funding agencies such as the World Bank and the International Monetary Fund, a muddy terrain full of political tensions and conceptual disparities (Czeresnia 2009; Xavier 2017).
The solution for inequality stems mainly from the capacity of individuals and communities, and the addressing of the SDHs is generally associated with training. Therefore, the charters/declarations of the International Conferences on Health Promotion neither include a transformative praxis of addressing problems nor necessarily promote emancipation.
The Conceptual Development of HP
Health promotion is a promising strategy to tackle multiple health problems that affect human populations and their surroundings. Based on an expanded concept of the health-disease process and its determinants, it promotes an articulation of technical and popular forms of knowledge, as well as the mobilization of institutional and community-based resources, public and private, to address and resolve them.
The World Health Organization (WHO) defines SDH as “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life which include economic policies and systems, systems shaping the conditions of daily life which include economic policies and systems, development agendas, social norms, social policies and political systems” (WHO 2017).
Theories that seek to explain behaviors and behavioral changes with a focus on individuals
Theories that explain changes in communities and community-based actions in the health field
Models that explain changes in organizations and the development of organizational practices that incentivize healthy habits (HPA 2004)
Therefore, it should be mentioned that the field of health promotion adopts a range of political strategies that includes from conservative perspectives to critical, so-called “radical” or “libertarian” perspectives. Under a more conservative eye, health promotion could be a way of making individuals take responsibility for their own health and, while doing so, reducing the financial weight of healthcare. In a different, reformist perspective, the goal of health promotion is to change the relationship between citizens and states through a focus on public policies and intersectoral actions aimed at producing more profound social changes, such as popular education proposals (Castiel 2004).
To focus on health promotion actions implies breaking from the perception that health is exclusively the result of medical care, raising the awareness of collectivities concerning social and environmental conditionings and determinants of health and promoting the strengthening of community services, healthy public policies, and popular participation, thus seeking empowerment as a key element in improving health conditions (Kickbusch 2007).
In this context way, health, as one of the SDGs, has the challenge of imposing an intersectoral agenda that addresses its social determinants, in a process of participative governance able to identify the needs of the territory and build techno-political solutions based on the ecology of knowledge (Gallo and Setti 2014).
Sustainable Development and Health
Sustainable development aims at a new normative horizon and implies a paradigm shift from a form of development based on inequality and the super exploration of natural resources and environmental services to one requiring new forms of responsibility, solidarity, and accountability (Shiva 2005; Jelsøe et al. 2018).
“Health” is understood more broadly than the mere absence of disease. Health is part of the dynamics of social organization, of lifestyles, and of consumption standards and is influenced by the biophysical environment (Hancock 1993, 1999; Kickbusch 2010; WHO 1986, 1997, 2010).
Neither environmental nor health problems can be addressed without considering the relationship between these two spheres. Trevor Hancock (1993) developed a theoretical model called “The Human Development Model” in which he discussed the relationship between sustainability and health (Hancock 1993). Years later, Ilona Kickbusch (2010) added an important contribution to the discussion.
The integration of the regimes of health promotion and sustainable development encounters further challenges in implementation at the political level. Both regimes emerged during the 1980s and share certain characteristics, such as being visionary, calling upon deliberative governance and stakeholder democracy with an aim of enhancing positive health, ecology, and a fair distribution of resources and life chances. Furthermore, they both called for new policy styles, new actor constellations, and radical new forms of addressing positive health and ecosystem development (Almlund and Holm 2015). Both regimes pose challenges to existing policy structures and systems if they are to be implemented according to how they are framed as policy regimes in the international contexts of the different UN organizations (Jelsøe et al. 2018).
Habitable environments and social systems based on participatory processes that promote or restrict both health promotion and development
Viable resilient ecosystems and economic systems that promote or restrict the sustainability both of growth and health promotion
Socioeconomic support systems that promote or restrict health promotion and sustainable development (Pedersen et al. 2015).
With that reconceptualization, health promotion can be understood and discussed in its expanded relationship with the idea of sustainable development. Within that domain of understanding, health problems become a shared social responsibility that moves beyond the responsibility of the individual (Pedersen et al. 2015; Jelsøe et al. 2018).
Strategies for Implementing Health Promotion in the Context of the SDG
The Sustainable Development Goal (SDG) is a proposal of the United Nations for an agreement on a set of global objectives that all countries must attain in all levels (international, national, regional, and local) until 2030 that reaffirms commitments with peace, human rights, the eradication of poverty, democracy, and, above all, environmental sustainability (UN 2015).
The commitments that countries made concerning the implementation of the SDG must be understood as complementary to the incentives to readjusting development models, thus highlighting the idea of changing the exploration of resources and guiding technological development and the expansion of economic and social investments.
This new universal agenda demands integrated approaches toward sustainable development and collective actions at all levels to tackle the challenges of our time with the comprehensive imperative of “no one is left behind” and of considering inequalities and discrimination as its major guidelines (UN 2016).
It is, thus, assumed that governance for sustainable development must assure more democratic, participatory, inclusive, and efficient forms of government that place social, economic, environmental, and health equity at the center of its results, emphasizing the need to continue with the implementation of the principles of the Agenda 21 and of related agendas such as that of Healthy Municipalities and Cities (Buss 2003).
The process of internalization of the SDG starts with an analysis and translation of this international agenda to people and communities with different cultural references. Local and regional programs must be reviewed to identify the most important needs, priorities, gaps, and intersectoral connections within each territory, as well as their relations with the SDG and national priorities (UN 2016).
Therefore, national strategies must be aligned with this agenda. SDG must be integrated to the set of national policies with clear mandates, with political planning at all scales, and with participatory monitoring and evaluation of its implementation, all based on the actual needs of territories.
The Healthy Cities agenda may play a crucial role in the implementation of the SDGs given their capillarity and potential to mobilize actors at different levels of action, as well as the fact that it is a strategic space dedicated to strengthening the capacity of communities to promote sustainable actions through a process of training and experience exchange.
The Healthy Cities (HC) Movement is one of the most important contemporary references in public health strategy planning in urban environments. With experiences in all continents, Healthy Cities initiatives have proven powerful motivators of local populations and governments to assume projects and plans dedicated to improving urban life and working conditions. These experiences have also shown that initiatives were more successful because cities involved were connected to national networks, which helped them creating the conditions for exchanging experiences and rationalizing resources, thus stimulating programs to advance and social mobilization to develop (Westphal et al. 2017).
The emergence of the HC strategy/policy/movement necessarily refers to a discussion on how to approach cities, health, the environment, and other elements in the conceptual core of the proposal.
According to Duhl (1963), cities can be understood as geographic spaces in which people live and work. They may also be conceptualized as administrative entities or as communities or a social group. In that space, different structures in which balance and consensuses are mediated through conflict and power relations coexist and interact.
Cities are increasingly represented as social actors since the citizens that inhabit them occupy a symbiotic space and organize themselves as an instance of political power, the civil society. Similarly, the symbolic space of the civil society integrates it culturally and may even produce collective identities, which stimulates social relations. Cities are, therefore, spaces that respond to the economic, political, and cultural goals of our time (Westphal 2000).
Within institutions, many actors assume that HC is a tool to evaluate actions. However, according to Duhl (1963), Healthy Cities aren’t just cities with elevated levels of health as measured by indicators of mortality and morbidity but cities committed with the health of its citizens.
A key element that emerges from the conceptual core of HC is health promotion. Behind the idea, there was always the strategy to motivate governments and societies to commit to extensive programs aimed at improving the life and health conditions of urban populations. To do that, it was necessary to develop theoretical and methodological frameworks to implement social policies in multiple sectors.
In that context, the Healthy Cities agenda is one of the most effective local approaches for health promotion. It is based on a perspective of health as quality of life, and its operationalization is premised on popular participation, democratization, political commitment to equity, intersectorality, and the search for new forms of local management.
Healthy Cities experiences in Latin America have grown in the last decade. However, few allow for the evaluation of the impact of political/administrative and cultural changes or of the empowerment of citizens and their participation in the decision-making process concerning their future and the future of the city (OPAS 2005).
It is expected that projects realign local public policies to solve problems through popular participation, which, in turn, increases transparency and the trust between governments and the civil society. Theoretically, the type of social development that could improve health and promote social equity is health promotion through actions that address social determination.
Politics and the Public Sphere
Developing an integrated and encompassing perspective of urbanity is crucial for the production of health-relevant knowledge. The great challenge is to develop a shared agenda between health and sustainability, between the public sphere and the civil society, the territories, to allow for more effective responses to the social problems that affect health (Westphal 2000; Tsouros 2013; Rabelo et al. 2000).
Public policies are, therefore, a concrete aspect of healthy cities, given the transversal potential of its interventions (Tsouros 2013).
To do that, Meresman et al. (2010) suggest strengthening alliances with the most active sectors in the society, such as youth, cultural, business, academic, and productive organizations because, given their specific processes, they have a great potential of influencing the formulation and implementation of intersectoral and interdisciplinary public policies.
SDG have shown potential for linking national and international equity promotion agendas so that they may be incorporated into public policies that address the true needs of territories through organizations that work to attain SDGs, promoting from the implementation of projects concerning the social, environmental, institutional, and economic dimensions of sustainable development to the articulation of inter-scale (local, regional, global) networks connected to the issue.
Health promotion is challenging because it proposes a broad agenda of social reforms to attain equity in territories and promotes the development of various sectors in the society, working integratedly. This requires commitments, investments, monitoring, and the interdependent actions of different sectors.
Although in health promotion, there has been a tendency to focus on individual lifestyles and campaigns targeting risk behavior, the Healthy Cities strategy may help align the SDG agenda to local action plans.
Incorporating SDG to territorial experiences implies strengthening institutionalized spaces of social participation with the goal of promoting the capillarity and sustainability of collaborative actions.
This implies establishing a governance process that recognizes the society and the environment non-dualistically, articulating politically with governments and the legislative branch, producing and disseminating knowledge, strengthening strategic partnerships, qualifying social actors, and including SDGs in governmental planning and management tools.
Governance for sustainable development assumes a deliberative praxis, a perspective of fairness and development as instruments to expand individual and collective freedoms and capacities, and, therefore, must be structured toward and promote autonomy, equity, and socioenvironmental justice.
For such, nation-states must recognize the importance of territorial health promotion and sustainable development policies and promote dialogue and collaboration between different government spheres, the civil society, and the private sector.
In this context, challenges will include adopting fiscal and political decentralization measures; assuring funding and financial and decision-making autonomy for actions; respecting the diversity of small, midsized, and large municipalities; and establishing indicators that are compatible with different local realities.
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