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Understanding Health Promotion
The United Nations recognizes 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 and communication.
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 recognizes 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 recognizes 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. In resource poor settings, a health promotion approach appeared to make particular sense: helping poor people protect their health and prevent illness was recognized to be as critical a role for health care providers as helping them to get well
when they fell sick.
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:
Build healthy public policy: Health promotion goes beyond health care. It puts
Ottawa Charter and draws on the learning from 20 years of health promotion workacross both developed and developing countries.1
Five action areas are put forward to build a global “all for health” movement as a means to realize the human right to “health for all”:
Providing clients with the information and skills they need to enable them to protect their own health and prevent the spread of common illnesses can help to break the links between ill health and deepening poverty, since sickness often results in considerable unplanned expenditures as well as time away from productive labour for poor families.
Health promotion can be defined as “gender-sensitive” when it examines policies, supportive environments, community roles, personal skills and health service delivery issues in light of the realities of women’s lives and the gender differences in health and life experience between women and men.Gender-sensitive health promotion incorporates strategies to respond to women’s practical gender needs (based on the existing gender divisions of labour) as
well as their strategic interest for greater equality.
Inclose to twenty years since the Ottawa conference in 1986, Canada has remained one of the international leaders in research and practice on health promotion. There are university-based centres on health promotion in both Ontario and British Columbia (one of which offers a regular summer institute on health
promotion) and a wide range of tools, strategies, case studies and other resources have been developed. Where relevant and appropriate, these resources,as well as the lessons learned in operationalizing health promotion in Canada will be shared with our Pakistani partners through SOHIP.
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 utilized by those who need them, and community perceptions of service quality is a major factor in decisions to use particular service providers.2
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.3 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…. 4
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 recognize 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 mobilize community action.
Capacity Building and Systems Strengthening for Health Promotion
The SOHIP design team 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 design for SOHIP laid out in this PIP embraces health promotion as a central theme for capacity building and systems strengthening. It also embraces health promotion as a theme for the research and knowledge-sharing component of the project, including research to understand the community context for health promotion, particularly the gender dimensions of health promotion practice within communities.
Regarding capacity building, SOHIP will focus on developing tools and materials to ensure that the ideas and principles of health promotion can be integrated into the training of different health workers. This approach, making health promotion second nature for a new generation of service providers at different levels,
has the greatest potential for operationalizing a health promotion approach in public health services, and ultimately for sustaining it.
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. Agriteam recognizes 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.5 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 SOHIP design presented in this document has 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 SOHIP, Agriteam will analyze district-level management capacity and systems through a “health promotion lens” 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 described above. 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:
for achieving the policy objectives highlighted above, including for the achievement of the MDGs for health.
The United Nations recognizes 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 and communication.
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 recognizes 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 recognizes these broaddeterminants 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. In resource poor settings, a health promotion approach appeared to make particular sense: helping poor people protect their health and prevent illness was recognized to be as critical a role for health care providers as helping them to get well
when they fell sick.
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:
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. - 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.
- 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. - 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. - 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.
Ottawa Charter and draws on the learning from 20 years of health promotion workacross both developed and developing countries.1
Five action areas are put forward to build a global “all for health” movement as a means to realize the human right to “health for all”:
- Advocate for health based on human rights and solidarity
- Invest in sustainable policies, actions and infrastructure to
address the determinants of health - Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy;
- Regulate and legislate to ensure a high-level of protection from harm and enable equal opportunity for health and well-being for all people; and
- Partner and build alliances with public, private, non-governmental and international organizations and civil society to create sustainable actions
Providing clients with the information and skills they need to enable them to protect their own health and prevent the spread of common illnesses can help to break the links between ill health and deepening poverty, since sickness often results in considerable unplanned expenditures as well as time away from productive labour for poor families.
Health promotion can be defined as “gender-sensitive” when it examines policies, supportive environments, community roles, personal skills and health service delivery issues in light of the realities of women’s lives and the gender differences in health and life experience between women and men.Gender-sensitive health promotion incorporates strategies to respond to women’s practical gender needs (based on the existing gender divisions of labour) as
well as their strategic interest for greater equality.
Inclose to twenty years since the Ottawa conference in 1986, Canada has remained one of the international leaders in research and practice on health promotion. There are university-based centres on health promotion in both Ontario and British Columbia (one of which offers a regular summer institute on health
promotion) and a wide range of tools, strategies, case studies and other resources have been developed. Where relevant and appropriate, these resources,as well as the lessons learned in operationalizing health promotion in Canada will be shared with our Pakistani partners through SOHIP.
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 utilized by those who need them, and community perceptions of service quality is a major factor in decisions to use particular service providers.2
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.3 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…. 4
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 recognize 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 mobilize community action.
Capacity Building and Systems Strengthening for Health Promotion
The SOHIP design team 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 design for SOHIP laid out in this PIP embraces health promotion as a central theme for capacity building and systems strengthening. It also embraces health promotion as a theme for the research and knowledge-sharing component of the project, including research to understand the community context for health promotion, particularly the gender dimensions of health promotion practice within communities.
Regarding capacity building, SOHIP will focus on developing tools and materials to ensure that the ideas and principles of health promotion can be integrated into the training of different health workers. This approach, making health promotion second nature for a new generation of service providers at different levels,
has the greatest potential for operationalizing a health promotion approach in public health services, and ultimately for sustaining it.
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. Agriteam recognizes 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.5 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 SOHIP design presented in this document has 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 SOHIP, Agriteam will analyze district-level management capacity and systems through a “health promotion lens” 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 described above. 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
for achieving the policy objectives highlighted above, including for the achievement of the MDGs for health.
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