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Responding to the health society
Graduate Institute of International Studies, Geneva
E-mail: kickbusch{at}bluewin.ch
THE SHIFT TO THE HEALTH SOCIETY
Over the last decade we have begun to witness a major shift with regard to health and its role in society. We now live in a health society that is characterized by two major social processes: expansion of the territory of health and expansion of the reflexivity of health. A reorganization of how we approach health in 21st century societies is in the making, as the boundaries of what we call the ‘health system’ are becoming increasingly fluid. Our understanding of the determinants of health makes it obvious that every policy decision a government makes also impacts on health and our knowledge of risk factors implies that at the individual level every behavioral choice also has a health consequence. We must discuss how we can use these developments to move public health policy forward forcefully in the 21st century—far beyond what we envisaged in 1986 in the Ottawa Charter for Health Promotion.
It is specific to the health society that all four domains of the health system—personal health, public health, medical health and the health market—expand. In all four dimensions health is presented as do-able: through behaviors, through governmental measures, through medical interventions and through products and services. The dominant issue at stake is no longer ‘medicalization’ and the power of the medical profession; rather the debate revolves around public and private responsibility, privatization and commercialization, health and wealth, empowerment and participation and social inclusion and exclusion. Health is both a major factor in 21st century economies and a critical component of citizens' expectations. The number of players in health has expanded exponentially at all levels of governance. Many investors see health as ‘the next big thing’ and recent global happiness surveys have identified health next to wealth and education as one of the three key factors for societal wellbeing.
DISEASE HAS BOUNDARIES; HEALTH DOES NOT
While the territory of the medical system can be relatively clearly circumscribed and framed in terms of expenditure for and consumption of health care services, the territory of health becomes ever less tangible and increasingly virtual. Health is everywhere and its infinite nature and social relevance has consequences for all four domains of the health system. We will need to track these developments much more systematically than has been the case so far.
One consequence is the rapid growth of a health market, which attaches the active added value ‘health’ to an ever-increasing set of products and services and translates health into a product that promises wellbeing. These health goods and services include health tourism, the fitness market, cosmetic surgery, lifestyle drugs, the market for vitamins, minerals and health foods and new types of health insurance, for example for alternative therapies. This is by no means the case only in highly developed countries; this market is of particular relevance in the rapidly growing middle-income countries such as China, India and Brazil. Governments are beginning to explore the economic potential and global competitiveness of health products and services. In Germany a number of regional states (Länder) have established working groups and developed governmental plans for the expansion of the health industry; the Swiss health minister recently commissioned a study on the future of the health market in Switzerland and the Philippines includes the remittances by Philippine nurses abroad in its plans for economic development.
Another consequence is that in the health society the role of the State in health expands through new types of regulations as well as new forms of public–private partnerships and platforms. Who would have even thought five years ago that a health minister would regulate the body mass index of fashion models as in Spain? That television advertising of fast foods would be severely restricted as in England? That a country could accept a total ban on smoking in public places, including restaurants and bars, as in Ireland? That heads of government would get involved in health issues as in the G8? This development is also articulated through the debate about policies that focus on the determinants of health. Within government this implies a ‘Health in All Policies’ approach as put forward by the Finnish presidency of the European Union in 2006; beyond government it means that health becomes everybody's business. At the global level it is reflected in the high prominence health issues have received in the Millennium Development Goals. The European Platform on Diet, Physical Activity and Health initiated in 2005 by the DG Sanco of the European Commission allows the Commission to work with a wide range of players across the public, private and non-governmental sectors. A new type of policy mix is emerging between governmental measures, consumer pressure and demand and policies—such as self regulation—put into place by companies and the private sector at large in different settings.
The consequences for the citizen are that the expansion of health choices and the complexity of health systems demand an ever higher degree of sophistication and participation. Health literacy is of critical importance, and there is a growing offer and demand not only for health information, but for advice, skills development and knowledge brokering. Providing platforms for access to information on health and new health products and services including e-health has become one of the greatest business opportunities of the foreseeable future. But they are also increasingly on offer as a public service. The University of Hannover has initiated a ‘Patients University’, which aims to improve health literacy and communication skills of both patients and providers. As more and new health information, products and services become available, making health decisions and navigating health systems becomes a difficult challenge and new health inequalities can emerge. The active and critical consumer is an ideal that only few members of the population can aspire to achieve, particularly if they are not well educated or even functionally illiterate.
Of the four dimensions of the health system, the medical sector has been the one most resistant to change. The relentless growth of health care expenditures in the health society has led to an increasing concern with efficiency and effectiveness and persistent reorganization, but to this day most health service organizations are still not accountable for their health outcomes and demonstrate a severe lack of transparency for patients and consumers. Despite mounting evidence—as for example by the Wanless Report in England—that the investment in prevention, health promotion and public health must be increased in order to ensure the sustainability of the health care system, OECD countries rarely reach more than a 3% average of the overall ‘health’ budget for prevention, health promotion and public health. Other social systems, such as schools or workplaces, are still too-rarely analyzed in relation to their prevention and health promotion potential.
HEALTHY PUBLIC POLICY IN THE 21ST CENTURY
It is one of the characteristics of the health society that the do-ability of health has expanded far beyond the ever-rising expectations of the curative medical care and repair system. Health is considered a right, and its do-ability is driven also by the promise that health can be created, managed and produced by addressing the determinants of health as well as by influencing behavior and lifestyles. It is also a necessity. Human health as much as the environment is a key sustainability issue in 21st century society: HIV AIDS, SARS, influenza, mental health and obesity, all are warning signs that our way of life is at odds with our health and that we might all lose the health gains achieved in the last century—as Sub Saharan Africa has already.
In order to respond adequately to the health challenges of the 21st century new governance mechanisms will need to be established that separate political responsibility for the curative care system from governance for health and wellbeing. Some countries are moving in this direction and we must use their experience as exemplars for discussions at the Vancouver Conference 2007 of the International Union for Health Promotion and Education.
For example, it will be critical to disentangle the responsibility for health and health care at the political level in order to create the political space for action on the determinants of health and health promotion. Canada for a while had a minister for public health with cabinet rank, England and Sweden both have junior ministers for health and the Australian Labour Party shadow cabinet now also includes a shadow minister for health promotion. Many countries will need to revisit their constitutions and will have to write new public health laws that allow new types of regulations and consider new types of health policies.
The basis for the work of a minister for health could be a health policy that sets goals and targets with respect to the determinants of health—as does the Swedish Health Policy ‘Health on Equal Terms’—and sets accountability mechanisms throughout government. Exemplars for such approaches have been collected during the work of the Finnish EU presidency on Health in All Policies. Such policies need to highlight that not only is health an outcome of other policies, it also contributes to other policies and to overall societal and economic goals. A strong organizational infrastructure that ensures quality and monitors and measures impact will be an essential component. Existing national institutes of public health are usually not equipped to fulfill the broad scope of the network governance required.
Financing mechanisms need to be looked at in greater detail. The first steps to separate health promotion funding were made through the establishment of health promotion foundations but these have not spread or expanded to the extent envisaged. We should consider how the expansion of the health market could provide financing for increased health promotion; for example, through a dedicated percentage of the value added tax. We should also consider setting a minimum standard for national public health expenditure, which should not be below 5.5% of the overall health sector budget. Minimum standards for investment in health promotion and prevention also need to be set in other sectors and settings, including in the health insurance sector.
There is in general a big democratic deficit in relation to health and health policy, which needs to be addressed with urgency. Policies that aim to promote better health must take into account that the very presence of health in all areas of everyday life can lead to a variety of reactions—either to attempts to reach an unrealistic body image, or to conscious risk taking in opposition to an overpowering set of health messages and expectations. While the health society offers many opportunities of empowerment through health, it can also be prescriptive and exert social control through health. Within a health society there has to be constant democratic dialogue about health and its role in society, a debate that has barely begun. Both in health and in medical care the reorientation towards participation and involvement will be one of the most important governance shifts.
Finally, many determinants of health are no longer in the control of nation states and the neglect of health responsibility in one State can seriously endanger others. Global and regional agreements can seriously endanger health—as experienced in rising alcohol rates when Finland and Sweden joined the European Union, or the impact of structural adjustment policies of the Bretton Woods Institutions on the public health systems of developing countries. But they can also move the health agenda forward, as for example the Framework Convention on Tobacco Control and the International Health Regulations. Other less binding approaches such as the policy by the European Union to consider the health impacts of all policies of the EU, the discussions on health at the Davos World Economic Forum or the new priority assigned to health in the OECD all illustrate the global driving force that health has become.
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