The
2nd
International Conference on health promotion, 5-9 April 1988,
The
adoption of the Declaration of
The Spirit
of Alma Ata
The spirit of Alma-Ata was
carried forward in the Charter for Health Promotion which was adopted in Ottawa
in 1986. The Charter set the challenge for a move towards the new public health
by reaffirming social justice and equity as prerequisites for health, and
advocacy and mediation as the processes for their achievement.
The Charter identified five health promotion action areas: build Healthy
Public Policy, create supportive environments, develop personal skills,
strengthen community action, and reorient health services.
These actions are interdependent, but healthy public policy establishes the
environment that makes the other four possible.
The Adelaide Conference on Healthy Public Policy continued in the direction set
at Alma-Ata and Ottawa, and built on their momentum. Two hundred and twenty
participants from forty-two countries shared experiences in formulating and
implementing healthy public policy. The following recommended strategies for
healthy public policy action reflect the consensus achieved at the Conference.
Healthy
Public Policy
Healthy public policy is
characterized by an explicit concern for health and equity in all areas of
policy and by an accountability for health impact. The main aim of health
public policy is to create a supportive environment to enable people to lead
healthy lives. Such a policy makes health choices possible or easier for
citizens. It makes social and physical environments health-enhancing. In the
pursuit of healthy public policy, government sectors concerned with
agriculture, trade, education, industry, and communications need to take into
account health as an essential factor when formulating policy. These sectors
should be accountable for the health consequences of their policy decisions. They
should pay as much attention to health as to economic considerations.
The value of health
Health is both a
fundamental human right and a sound social investment. Governments need to
invest resources in healthy public policy and health promotion in order to
raise the health status of all their citizens. A basic principle of social
justice is to ensure that people have access to the essentials for a healthy
and satisfying life. At the same time, this raises overall societal
productivity in both social and economic terms. Healthy public policy in the
short term will lead to long-term economic benefits as shown by the case
studies presented at this Conference. New efforts must be made to link
economic, social, and health policies into integrated action.
Equity, access and
development
Inequalities in health are
rooted in inequities in society. Closing the health gap between socially and
educationally disadvantaged people and more advantaged people requires a policy
that will improve access to health-enhancing goods and services, and create
supportive environments. Such a policy would assign high priority to
underprivileged and vulnerable groups. Furthermore, a healthy public policy
recognizes the unique culture of indigenous peoples, ethnic minorities, and immigrants.
Equal access to health services, particularly community health care, is a vital
aspect of equity in health.
New inequalities in health may follow rapid structural change caused by
emerging technologies. The first target of the European Region of the World
Health Organization, in moving towards Health for All is that:
by the year 2000 the actual differences in health status between countries and
between groups within countries should be reduced by at least 25% by improving
the level of health of disadvantaged nations and groups.
In view of the large health gaps between countries, which this Conference has
examined, the developed countries have an obligation to ensure that their own
policies have a positive health impact on developing nations. The Conference
recommends that all countries develop healthy public policies that explicitly
address this issue.
Accountability
for Health
The recommendations of this
Conference will be realized only if governments at national, regional and local
levels take action. The development of healthy public policy is as important at
the local levels of government as it is nationally. Governments should set
explicit health goals that emphasize health promotion.
Public accountability for health is an essential nutrient for the growth of
healthy public policy. Governments and all other controllers of resources are
ultimately accountable to their people for the health consequences of their
policies, or lack of policies. A commitment to healthy public policy means that
governments must measure and report the health impact of their policies in
language that all groups in society readily understand. Community action is
central to the fostering of healthy public policy. Taking education and
literacy into account, special efforts must be made to communicate with those
groups most affected by the policy concerned.
The Conference emphasizes the need to evaluate the impact of policy. Health
information systems that support this process need to be developed. This will
encourage informed decision-making over the future allocation of resources for
the implementation of healthy public policy.
Moving beyond health
care
Healthy public policy
responds to the challenges in health set by an increasingly dynamic and
technologically changing world, with is complex ecological interactions and
growing international interdependencies. Many of the health consequences of
these challenges cannot be remedied by present and foreseeable health care.
Health promotion efforts are essential, and these require an integrated
approach to social and economic development which will re-establish the links
between health and social reform, which the World Health Organization policies
of the past decade have addressed as a basic principle.
Partners in the policy
process
Government plays an
important role in health, but health is also influenced greatly by corporate
and business interests, nongovernmental bodies and community organizations.
Their potential for preserving and promoting people's health should be
encouraged. Trade unions, commerce and industry, academic associations and
religious leaders have many opportunities to act in the health interests of the
whole community. New alliances must be forged to provide the impetus for health
action.
Action
Areas
The Conference identified
four key areas as priorities for health public policy for immediate action:
Supporting the health of
women
Women are the primary
health promoters all over the world, and most of their work is performed without
pay or for a minimal wage. Women's networks and organizations are models for
the process of health promotion organization, planning and implementation.
Women's networks should receive more recognition and support from policy-makers
and established institutions. Otherwise, this investment of women's labour
increases inequity. For their effective participation in health promotion women
require access to information, networks and funds. All women, especially those
from ethnic, indigenous, and minority groups, have the right to
self-determination of their health, and should be full partners in the
formulation of healthy public policy to ensure its cultural relevance.
This Conference proposes that countries start developing a national women's
healthy public policy in which women's own health agendas are central and which
includes proposals for:
* equal sharing of caring work performed in society;
* birthing practices based on women's preferences and needs;
* supportive mechanisms for caring work, such as support for mothers with
children, parental leave, and dependent health-care leave.
Food and nutrition
The elimination of hunger
and malnutrition is a fundamental objective of healthy public policy. Such
policy should guarantee universal access to adequate amounts of healthy food in
culturally acceptable ways. Food and nutrition policies need to integrate
methods of food production and distribution, both private and public, to
achieve equitable prices.
A food and nutrition policy that integrates agricultural, economic, and
environmental factors to ensure a positive national and international health
impact should be a priority for all governments. The first stage of such a
policy would be the establishment of goals for nutrition and diet. Taxation and
subsidies should discriminate in favour of easy access for all to healthy food
and an improved diet.
The Conference recommends that governments take immediate and direct action at
all levels to use their purchasing power in the food market to ensure that the
food-supply under their specific control (such as catering in hospitals,
schools, day-care centres, welfare services and workplaces) gives consumers
ready access to nutritious food.
Tobacco and alcohol
The use of tobacco and the
abuse of alcohol are two major health hazards that deserve immediate action
through the development of healthy public policies. Not only is tobacco
directly injurious to the health of the smoker but the health consequences of
passive smoking, especially to infants, are now more clearly recognized than in
the past. Alcohol contributes to social discord, and physical and mental
trauma. Additionally, the serious ecological consequences of the use of tobacco
as a cash crop in impoverished economies have contributed to the current world
crises in food production and distribution.
The production and marketing of tobacco and alcohol are highly profitable
activities - especially to governments through taxation. Governments often
consider that the economic consequences of reducing the production and
consumption of tobacco and alcohol by altering policy would be too heavy a
price to pay for the health gains involved.
This Conference calls on all governments to consider the price they are paying
in lost human potential by abetting the loss of life and illness that tobacco
smoking and alcohol abuse cause. Governments should commit themselves to the
development of healthy public policy by setting nationally-determined targets
to reduce tobacco growing and alcohol production, marketing and consumption
significantly by the year 2000.
Creating supportive
environments
Many people live and work
in conditions that are hazardous to their health and are exposed to potentially
hazardous products. Such problems often transcend national frontiers. Environmental
management must protect human health from the direct and indirect adverse
effects of biological, chemical, and physical factors, and should recognize
that women and men are part of a complex ecosystem. The extremely diverse but
limited natural resources that enrich life are essential to the human race.
Policies promoting health can be achieved only in an environment that conserves
resources through global, regional, and local ecological strategies.
A commitment by all levels of government is required. Coordinated intersectoral
efforts are needed to ensure that health considerations are regarded as
integral prerequisites for industrial and agricultural development. At an
international level, the World Health Organization should play a major role in
achieving acceptance of such principles and should support the concept of
sustainable development.
This Conference advocates that, as a priority, the public health and ecological
movements join together to develop strategies in pursuit of socioeconomic development
and the conservation of our planet's limited resources.
Developing
New Health Alliances
The commitment to healthy
public policy demands an approach that emphasizes consultation and negotiation.
Healthy public policy requires strong advocates who put health high on the
agenda of policy-makers. This means fostering the work of advocacy groups and
helping the media to interpret complex policy issues.
Educational institutions must respond to the emerging needs of the new public
health by reorienting existing curricula to include enabling, mediating, and
advocating skills. There must be a power shift from control to technical
support in policy development. In addition, forums for the exchange of
experiences at local, national and international levels are needed.
The Conference recommends that local, national and international bodies:
* establish clearing-houses to promote good practice in developing healthy
public policy;
* develop networks of research workers, training personnel, and programme
managers to help analyse and implement healthy public policy.
Commitment
to Global Public Health
Prerequisites for health
and social development are peace and social justice; nutritious food and clean
water; education and decent housing; a useful role in society and an adequate
income; conservation of resources and the protection of the ecosystem. The
vision of healthy public policy is the achievement of these fundamental
conditions for healthy living. The achievement of global health rests on recognizing
and accepting interdependence both within and between countries. Commitment to
global public health will depend on finding strong means of international
cooperation to act on the issues that cross national boundaries.
Future
Challenges
1. Ensuring an equitable
distribution of resources even in adverse economic circumstances is a challenge
for all nations.
2. Health for All will be achieved only if the creation and preservation of
healthy living and working conditions become a central concern in all public
policy decisions. Work in all its dimensions - caring work, opportunities for
employment, quality of working life -dramatically affects people's health and
happiness. The impact of work on health and equity needs to be explored.
3. The most fundamental challenge for individual nations and international
agencies in achieving healthy public policy is to encourage collaboration (or
developing partnerships) in peace, human rights and social justice, ecology,
and sustainable development around the globe.
4. In most countries, health is the responsibility of bodies at different
political levels. In the pursuit of better health it is desirable to find new
ways for collaboration within and between these levels.
5. Healthy public policy must ensure that advances in health-care technology
help, rather than hinder, the process of achieving improvements in equity.
The Conference strongly recommends that the World Health Organization continue
the dynamic development of health promotion through the five strategies
described in the Ottawa Charter. It urges the World Health Organization to
expand this initiative throughout all its regions as an integrated part of its
work. Support for developing countries is at the heart of this process.
Renewal
of Commitment
In the interests of global
health, the participants at the Adelaide Conference urge all concerned to
reaffirm the commitment to a strong public health alliance that the Ottawa
Charter called for.