Understanding health promotion...

The United Nations recognises that the enjoyment of the highest attainable standard of health is a fundamental right of all people.

The United Nations recognises that the enjoyment of the highest attainable standard of health is a fundamental right of all people. Health promotion is based on this critical human right and offers a positive and inclusive concept of health as a determinant of the quality of life, encompassing mental and spiritual well-being. Health promotion is the process of enabling people to increase control over their health and its determinants, so ultimately to improve their health. It is a core function of public health and contributes to the work of tackling both communicable and non-communicable diseases and other threats to health. Health promotion not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond to embrace how different sectors can contribute to healthy life-styles and overall well-being. As an integrated and multi-sectoral approach, health promotion draws on strategies from multiple fields of study including anthropology, epidemiology, sociology, psychology, public health, political science, education Health promotion emerged in the 1980s as an integrated approach to health development for achievement of the Alma Ata goal of “health for all by the year 2000”. The health promotion perspective advocated focusing more attention on addressing the broad, underlying determinants of health as opposed to the manifestations of ill health. A health promotion approach recognises that people’s health is affected by a broad range of factors (determinants) beyond their individual genetic makeup, including the conditions in which they live and work, personal habits, environmental factors, and social and cultural norms. Unless the health care sector fully recognises these broad determinants of health through policy directions and through how health services are planned and delivered, health care interventions run increased risks of not improving people’s health in a sustainable way. 

The Ottawa Charter for Health Promotion, adopted in 1986 at the first International Conference on Health Promotion, identifies three basic strategies for health promotion. These are advocacy for health to create the essential conditions for health, enabling all people to achieve their full health potential, and mediating between the different interests in society in the pursuit of health. These strategies are supported by five priority action areas:

1. Build healthy public policy: Health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make the healthier choice the easier choice for policy makers. 

2. Create supportive environments: Heath is critically linked to and affected by other social, economic and developmental sectors. Health promotion action works to generate living and working conditions that are safe, stimulating, satisfying and enjoyable. 

3. Strengthen community action: Health promotion works through community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities - their ownership and control of their own endeavours and destinies, including developing flexible systems for strengthening public participation in and direction of health matters and health services. 

4. Develop personal skills: By providing information and education for health and for enhancing life skills, we increase the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health. This has to be facilitated by all levels of the health system, as well as in schools, home, work and community settings. 

5. Re-orient health services: The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. 

Health promotion and effective management systems

There are five basic ways in which embracing health promotion can also serve to strengthen health sector management systems and structures, particularly at the district level. First, strengthening staff skills and mandate in health promotion can contribute to improved quality of care and client-responsiveness of care. Part of the measurement of effective management systems is their ability to ensure that services are being utilised by those who need them, and community perceptions of service quality is a major factor in decisions to use particular service providers.

Second, open and transparent communication is a crucial process in health promotion, as well as a critical management skill. Strengthening supervision processes rests substantially on communication skills and enabling interactive sharing and learning from both supervisor and supervisees.

Third, implementing a health promotion approach as described above requires the formation and effective functioning of networks both within the health sector (such as between public, NGO and private providers), and across multiple sectors (education, agriculture, community development and others). These networks can also help in providing information relevant to a variety of district health management decisions (particularly for sectoral planning and monitoring), and for helping decisions to be implemented.

Fourth, health promotion can contribute to enhanced cost-effectiveness. Helping people to understand the causes of ill-health and how to protect against illness will save resources that might otherwise be spent on treating recurrent cases of illness. This is particularly true where partners are involved in health promotion messages. For example if teachers providing messages about sanitation or nutrition can positively influence family practices, a health benefit is achieved with little direct cost to the health sector. A health promotion approach, particularly when combined with analysis of HMIS data and other information sources, can also help to ensure more effective allocation of limited resources (including human, financial, and pharmaceutical) between primary, secondary and tertiary services.

Finally, good management at a district level includes appropriate implementation of national and provincial policies, part of internal responsibility or accountability within the health sector. As noted below, there is a strong foundation for a health promotion approach within the national health policy framework in Pakistan.

Health promotion in Pakistan

GoP policy documents are strongly supportive of embracing a health promotion perspective in the public health system in Pakistan, particularly the PRSP and the MTDF which set the road-map for future health interventions in the country. The overall health sector vision for 2005-2010 outlined in the MTDF is for a healthy population practicing a healthy lifestyle, with a sound health care system that is effective, efficient and responsive to the health needs of low-socio-economic groups especially women in the reproductive age. Several strategies are proposed to “make the paradigm shift in the policy from curative services to preventive, promotive and primary health care”. The following excerpt from the PRSP also highlights this shift: “Pakistan, being a signatory to MDGs, needs to improve the performance of the health sector significantly to ensure good progress towards reaching the MDGs. With this in view, the medium term health strategy is focused towards raising public sector health expenditures through a focus on prevention and control of diseases, reproductive health, child health, and nutrient deficiencies. The thrust of public expenditures is geared towards primary and secondary tiers. The approach provides a clear shift from curative to preventive health care and focuses in disadvantaged, weaker sections of society especially those belonging to rural areas. It aims at promoting gender equity through targeted interventions….”

However, while these policy documents at national (as well as provincial) levels have endorsed a health promotion approach, how to make this shift in practice is still very little understood. Furthermore, “health promotion” is usually equated with the narrower “health education”, and particularly with creating widespread public awareness on health issues through the use of mass media. Currently, responsibilities for health promotion are not clearly laid out, and the training of most health care workers does not emphasise communication skills or client-oriented approaches. Health workers are not trained to help people understand and then respond proactively to the diverse factors in their own environments and communities that affect their health. Lady Health Workers, the backbone of preventive health services for women, are perhaps the only cadre whose responsibilities fully embrace client-focused health education, but even LHWs have little in the way of time or tools or materials to help them convey broad messages around nutrition, hygiene, or infection control on top of their responsibilities related to family planning provision and advising on pregnancy care. District government officials recognise that the best and most cost-effective way to improve the health of poor women and men in rural Punjab is to help them prevent or avoid illness, yet this is not explicitly the mandate for public health workers at BHUs, nor is it integrated into how health workers are monitored and managed. In part, they are hampered by a lack of information about how communities themselves understand health promotion and what traditional knowledge suggests about illness prevention, which should be a starting point for crafting effective health education messages as well as for health worker efforts to mobilise community action.

Capacity building and systems strengthening for health promotion

Based on a research it was concluded that a more systematic approach is required to build broad-based capacity for health promotion across a wide range of cadres, and to build recognition of the central role that a health promotion in effective and efficient primary health care among planners, managers and policy makers at various levels. 

The focus on health worker training needs to be supplemented with advocacy and awareness building among managers. Systems for health promotion, or even for health education, are not well defined at any level of the public health service in Pakistan. A social work organisation recognises that, starting from this base, it will be difficult to achieve strong systems development within a comparatively short timeframe of five years. One key objective at the systems level will be to identify an appropriate institutional or operational home for Health Promotion within the Department of Health and the Department of Population Welfare in Punjab. Consequently, we are proposing to focus on strengthening the “orientation”, first of managers and staff, and then of policies and procedures towards gender-sensitive health promotion. These are the necessary first steps in systems strengthening, which should be viewed on a ten to fifteen-year timeframe.

The strategy to improve health in Pakistan should have a dual focus on health promotion and on management systems. With the goal of increasing access to health services by poor women and men, these two themes are more like two sides of a single coin. Social audits and poverty assessments have shown that poor women and men are often not choosing to use public health services in Pakistan because they are treated badly by service providers and do not feel that the services really respond to their needs, or have experienced the lack of responsibility within the system (absence of providers during working hours, charging inappropriately for services). Implementing a health promotion orientation in health services can help to ensure that services are seen as relevant by poor women and men, addressing the first deficiency, while the focus on management systems, particularly related to supervision, responsiveness and responsibility or accountability, will help to address the second deficiency. In implementing this strategy an  analysis of the district-level management capacity and systems through a “health promotion lens”  is needed in order to ensure that systems strengthening promotes the intended shifts from curative to preventive care and tertiary to pro-poor primary care as outlined in the national policy frameworks. 

Strengthening management capacity in areas such as evidence-based planning and supportive supervision and monitoring in turn will facilitate implementation of a health promotion approach within primary and secondary-level facilities.

Capacity development, and over time systems development for health promotion needs to take place in several directions. At the fourth international conference on health promotion in Jakarta in 1997, five priorities for health promotion in the 21st century were identified:

• promoting social responsibility for health 

• increasing investments for health development 

• expanding partnerships for health promotion 

• increasing community capacity and empowering individuals 

• securing an infrastructure for health promotion 

These priorities were again embraced in the 2005 Bangkok Charter on Health Promotion in a Globalised World. To date all five of these priorities are immediately relevant for Pakistan  Action in these areas will be critical for achieving the policy objectives, including for the achievement of the MDGs for health.