What would the Ottawa Charter look like if it were written today?

By Don Nutbeam, Pro-Vice-Chancellor and Head, College of Health Sciences, University of Sydney, Australia

---

The Ottawa Charter has been phenomenally influential in guiding the development of the concept of health promotion, and in shaping public health practice in the past 20 years. The magnitude of the impact belies the fact that the Ottawa Charter was developed at a relatively small WHO meeting (only 38 countries were represented), and, as Helena Restrepo (2005) and others have reminded us, was focussed almost exclusively on the needs of "industrialised countries". There is also a somewhat romantic view that the process leading to the Ottawa Charter was highly consultative. I suspect that time has dimmed some memories, but my recollection is that there was a high level of consultation, but among a very small group of people - none of whom came from developing countries.

I retain a strong attachment to the basic concepts and principles in the Ottawa Charter, but there is no doubt that the world has changed somewhat since 1986 in ways that may not have been anticipated by those drafting the Charter. Substantial social and economic changes have occurred, for example, the globalisation of trade has had a profound effect on the lives of all of us. New threats to health have emerged and changes to the profile of the burden of disease have occurred in both developed and developing countries. These changes, in turn, have important social and economic consequences for countries. Such profound changes require adaptations to our existing health promotion strategies and the development of new strategies.

Like Ilona Kickbusch (2005),  I believe that the Ottawa Charter “is a living document with deep vision and practical orientation. Ilona recommends that “we should let it stand….. but at the same time we should look forward”.  I thought it might be useful to further a discussion/provoke a debate on what the Ottawa Charter would need to account for if it were written in 2005, drawing upon more recently developed ideas, and in response to contemporary health problems in both industrialized and developing countries.

How has the meaning of healthy public policy changed – Globalization and localization for health

What are the origins? The original concept of “healthy public policy” was primarily derived from an analysis of the impact on health of national public policies (particularly social policies) in industrialized countries with functioning, democratic governments.

What has changed? Although the fundamental concept is sound, this strategy needs to be re-constructed to better reflect and respond to the dominant economic growth policies being pursued by most countries in the world, and particularly to reflect the impact of the globalization of trade on health.

The original concept also implies an interventionist role for governments that may have made sense to a group of industrialized nations in 1986, but may not be viable in an era of globalization, and simply may not be achievable in many of the world’s poorer counties with dysfunctional or corrupt national governments. 

What remains to be done? The concept of healthy public policy needs to evolve to assist us in identifying and taking action to mitigate the negative impact on health of globalization, and to harness the positive benefits that flow from economic development and improvements in access to material resources. This will almost certainly involve partnership with the private sector in ways that were inconceivable in 1986.

Separately, the concept needs also to reflect better the impact of more locally determined “policy” that governs the day to day lives of many, and could, for example, better reflect the many variations on the healthy cities movements that have significantly influenced health promotion practice in developed and developing countries alike.

Our challenge is to reinterpret the basic concept of healthy public policy, and make it relevant for the far greater range of political and governance structures that are experienced by people in different parts of the world.

What do we mean by supportive environments for health – learning from experience in health promoting settings

What are the origins? This strategy is one of the basic foundations of public health. The underlying threats to the ecology of the planet that provided impetus for the environmental movement of the 1980’s remain, and in some cases have become much worse. The continued degradation of the physical environment, and continued urbanization in many countries, including many of the poorest countries, has created living and working conditions that are unsafe and hazardous to health.

What has changed? Whilst many engaged in health promotion practice recognize these fundamental threats to the physical environment and work to address them, the concept of supportive environments for health has been interpreted in more subtle ways in practice. Health promotion actions have evolved to encompass many of the settings of everyday life such as schools, workplaces, and health care facilities.

This focus on settings over the past 10-15 years has enabled the development of practical and locally relevant health promotion interventions that have the potential to address a full range of the determinants of health by creating a defined “supportive environment”. The concept of a supportive environment has extended to not only include the physical environment, but also the social environment. As with healthy public policy, our greatest success in interpreting this concept has come from thinking globally and acting locally.

What remains to be done? One challenge is to capture the learning from the different settings-based approaches, and again, to consider ways in which these practical interventions can be adapted to a greater variety of social, political and economic circumstances. Much of our existing evidence of success is derived from studies in developed countries. More evidence needed to be “captured” from developing countries.

Why have we made so little progress in re-orienting health services – achieving investment in health promotion

What are the origins? At the time of the Ottawa Charter there was a strong sense among participants at the Conference that health systems were so focused on the provision of care for acute and chronic conditions that the contribution it needs to make to primary prevention and health promotion was neglected. In most countries this resulted in inadequate and unsustained funding for health promotion.

What has changed? Very little has changed. For the majority of people in the world, access to appropriate and affordable health care, especially primary health care, remains a fundamental challenge. Our role in reorienting health services has remained substantially unfinished, and our task is to assemble compelling evidence of the return on investment, long and short term, offered by health promotion.

What remains to be done? The IUHPE has played a leading role in gathering evidence concerning the economic and social benefits of health promotion, particularly through its work for the European Union. This work, and the underlying conclusions is beginning to have an impact on funding decisions in some countries. One challenge is to support equivalent analyses of evidence of costs and benefits for investments in health promotion in developing countries, and to advocate for sustainable funding for health promotion.

Should the development of personal skills be more central to health promotion – building health literacy.

What are the origins? The development of the concept and principles of health promotion were, to some extent, responses to unduly simplistic, individual behavioural health interventions that had emerged in the 1970’s and early 80’s. The Ottawa Charter makes clear that efforts to develop personal skills through traditional health education methods are only a part of a more complex and sophisticated set of tools to promote good health.  

What has changed? To some extent the orientation of the Ottawa Charter led to a relative neglect of health education as a tool for health promotion. Activists focused almost exclusively on “upstream” influences on health, and the community action, policy and environmental changes that were necessary to address them.

Fortunately, a strong theoretical base for educational interventions has emerged in the period since the Ottawa Charter was written. More sophisticated forms of health education have emerged. The evolution of the concept of “health literacy” demonstrates how different approaches to health education can produce significantly different outcomes.

What remains to be done? Education, and the enlightenment and empowerment it can produce, remains the cornerstone of health promotion. Disappointingly, governments and international development agencies often limit investments in health promotion to unsophisticated IEC (information, education and communication) projects. One of our challenges is to ensure that investment in health education is made into communication and educational methods that that have a sound theoretical base and achieve the higher levels of health literacy.

How can we strengthen Community Actions for Health – creating community capacity, strengthening social capital

What are the origins? Like health education, community development was one of the most fundamental strategies that informed the development of the concept and principles of health promotion, and featured as a strategy in the Ottawa Charter.

What has changed? The theoretical base for community action has developed, for example, being informed by research into community capacity building, and concepts such as social capital.

What remains to be done?   There is an extraordinary range and quality of experience of community action for health that has not been adequately considered in the development of the concept and the evidence to support it. Developing countries, in particular in non-English speaking Latin America, and in countries like India have a wealth of experience that is not fully reflected in the scientific literature. Although there have been important developments in the theory to guide community interventions, these concepts have not been well tested. More evidence needed to be “captured”, particularly from developing countries.

What is happening in Bangkok?

What should be obvious from the comments above is that much has changed since 1986, and that we must use the opportunity presented by the Bangkok Conference to refresh and revitalize the concept of health promotion, and to bring to public attention the evolving theory and science that supports it.

WHO is using a variety of networks to engage a wide range of people in the development of the scientific program and the management of a political statement (a Bangkok Charter). The Charter is only one of several "products" that are planned from the meeting.

The IUHPE is an important partner in this process and we should use all available opportunities between now and next August to engage in the process. There is no point in being a commentator from the sidelines.

You want to react to this text? Click here!