Declarations, Charters and Statements – Their role in health promotion
The recent IUHPE Conference, held in Vancouver, Canada, provided opportunities for the many participants to hear about innovative practices, access some fine research from around the world and to debate the successes, failures and future of health promotion. It was also fitting that the Conference celebrated the 21st birthday of the Ottawa Charter for Health Promotion which was written at an inspiring meeting in that city in Canada in 1986. Many of the participants at the IUHPE Conference also attended satellite meetings and conferences examining particular aspects of health promotion, such as the settings approach.
Ilona Kickbusch, one of the driving forces in health promotion for over three decades, presented a challenging and inspiring critique of progress in the field by anchoring many of her observations around the Declaration of Alma Ata, which emerged in 1978 from the UNICEF/WHO Conference on Primary Health Care in the USSR city with the same name. Her comments unpacked what was behind many of the 10 components of the Declaration and why it was important to renew efforts to achieve their intentions.
One week prior to the recent IUHPE Conference, I was part of a WHO Technical Meeting on School Health, also in Vancouver, entitled, ‘Building School Partnerships for Health, Education and Development’. This meeting, held over 4 days, involved about 80 invited participants from the health and education sectors, international organizations and NGO's. They discussed about the ‘Evidence of Effectiveness of School Health Promotion’, the ‘Role of Schools in Alleviating Social and Economic Disadvantage’, the ‘Impact of Media on the Health Behaviour of Children and Adolescents’ and ‘Partnerships for Promoting Health and Education for all School Age Children’.
A three-page statement was crafted by a small group of participants to reflect the outcomes of the meeting and the priorities for the next decade (WHO, 2007). Participants had regular opportunities before and during the 4 day meeting to shape the statement. I played a small role in editing and writing the statement. This role, and Kickbusch's reflection on Alma Ata, raised some questions for me:
- What is the purpose of these Declarations, Charters and Statements?
- Have their intentions been achieved?
- Who uses them?
- Were they right? (with the luxury of hindsight)
- Could they have been developed better, in ways which would have facilitated more universal ownership and implementation of their proposed actions?
In sitting with the lead author, Don Nutbeam, of the Statement from the School Health meeting called ‘Schools for Health, Education and Development – A Call for Action’, I was impressed by Nutbeam's capacity to encapsulate the evidence presented at the meeting and the issues raised and discussed in the small group and plenary sessions. More impressive was his skills in crafting language that was inspiring, challenging and consistent with the points of reference of international and national peak bodies, in this case WHO and the Pan Canadian Joint Consortium for School Health. But why was the Statement written? Is it just traditional to do this, or do statements such as these actually improve policy development and field practices?
There was a sense that the meeting's statement provided a pithy and coherent summary of the main issues and strong reiteration of earlier published beliefs, e.g. ‘Every child has a human right to education, health and security. The central role of schools is teaching and learning, but they are also a unique community resource to promote health and development for children, families and teachers’. [(WHO, 2007
), p. 1].
The Statement also summarized, albeit briefly, the state of the art and science of school health promotion in the section ‘Schools make a difference – evidence of progress’. It identified the five key challenges to emerge from the meeting, before concluding with ‘A Call for Action’. The first few words of each of the proposed five areas of action are worth stating where the meeting called for ‘leadership by local school communities, governments and international organisations ... to attain education, health and development goals over the next decade’. [(WHO, 2007), p. 2]. The five action areas began with the words:
– invest in education...These priorities did accurately reflect the outcomes of the Technical Meeting on School Health. All five areas will need National and Regional Governments and their education sectors to ensure the action priorities are implemented. But there were only about 20% of the participants at the Technical Meeting on School Health who had qualifications in education and experience in school education. Yet, as participants, we mainly identified priorities for a sector other than health namely the education sector. In other words, we were telling others what they should do.– build school infrastructure...
– invest in capacity...
– implement what we know to be effective... and
– harmonise action among partners for sustainable partnerships...
The central issue then is about the impact and effectiveness of such statements. Do we in health promotion readily access and use Statements, Declarations and Charters written by other sectors, e.g. education, housing, transport, even though these domains form some of the fundamental building blocks of the pre-requisites for health as identified in the Ottawa Charter? What should the meeting participants, who were largely from the health sector, do with this statement to ensure it reaches schools and education officials, in ways that respect their work, yet enables them to see benefits in ‘signing on’ to our statement which we all believed would make a difference? Clearly, a role for all participants in the Technical Meeting on School Health is to take some major responsibility for its dissemination, explanation and advocacy back in our communities and with the education sector in particular. But will this actually happen?
The Ottawa Charter for Health Promotion continues to be contemporary, even with the intense debate about its status and its relationship to the Bangkok Charter for Health Promotion in a Globalised World. What was it about the Ottawa Charter that has facilitated its widespread adoption and adaptations to assist national and local health promotion planning and implementation strategies? Was it its simplicity?—five action areas (which are easily understood); three clear overarching strategies viz: advocate, enable, mediate; and a call for action to become more assertive in certain areas, such as public health policy and closing the gaps in health inequities within and between communities.
I was also present at the Third International Conference on Health Promotion in Sundsvall, Sweden in 1991 which focussed on Supportive Environments for Health. Its statement (WHO, 1991) reiterated many of the principles of the Declaration of Alma Ata and the Ottawa Charter as they applied to the ‘supportive environment’ component of the Charter. The document was clear and concise in its wording, and is still relevant 16 years later—indeed it could have been written in 2007. Does this mean it made no difference? Or, are the things we say in these Statements, Charters and Declarations about health promotion so fundamental and continually true, that they need to be regularly restated to remind governments about priorities and basic human principles? Are they required to reaffirm a documented set of beliefs, values and actions to support and challenge all those working in the fields of public health, health promotion, and education and justice and local government etc?
Kickbusch articulated many of the reasons behind the Health for All and Declaration of Alma Ata documents in her address at the closing ceremony of the Vancouver conference. She reiterated logically and simply why we need to keep reminding governments and others about reducing inequalities and ensuring individual and community participation in shaping policies and practices affecting people's health and well-being. The Statement from the Technical Meeting on School Health in Vancouver also addressed these issues. It is a sad reflection that 30 years after Health for All we still need to state basic principles about access, equity and justice. It may even be more important now than then to ensure that principles such as these, that underpin health promotion in its widest sense, do not get lost in a globalized economy when advances in communication technologies expand, yet sometimes limit what we see and hear.
Some of the international, national, regional and settings-based Statements, Declarations and Charters may have had little impact on how nations and organizations shape their policies and practices. Yet others probably have made a difference. Demonstrating a causal link is difficult. Whatever their strengths and weaknesses, they provide many people, organizations and governments with a common and consistent set of beliefs, principles, arguments and actions about why it is essential to promote the health and well-being of everybody. They also affirm and provide direction for the excellent work done, often under extreme conditions, by those working in the field of health promotion.
But let's be more committed to ensuring that statements are used by more than those at the conferences where they were born, or only those working in the field. Their value will be better realized if they are seen as enhancing change and confronting lethargy in addressing equity, Health for All, and the other key components of the Alma Ata Declaration and the Ottawa Charter. Those of us who are privileged and fortunate to attend conferences which generate policy statements should accept our moral responsibility to ensure that they are owned and actioned by sectors and professionals other than ourselves.
References
World Health Organisation. Sundsvall Statement on Supportive Environments for Health (1991) Geneva: WHO.
World Health Organisation. Schools for Health, Education and Development: A Call for Action (2007) Geneva: WHO.
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