Marilyn Wise

Enabling health systems transformation: what progress has been made in re-orienting health services?

The Ottawa Charter has been remarkably influential in guiding the development of the goals and concepts of health promotion, and in shaping global public health practice in the past 20 years. However, of the five action areas identified in the Ottawa Charter, it appears that there has been little systematic attention to the challenge of re-orienting health services, and less than optimal progress in practice. The purposes of re-orienting health services as proposed in the Ottawa Charter were to achieve a better balance in investment between prevention and treatment, and to include a focus on population health outcomes alongside the focus on individual health outcomes. However, there is little evidence that a re-orientation of health services in these terms has occurred systematically anywhere in the world. This is in spite of the fact that direct evidence of the need to re-orient health services and of the potential benefits of doing so has grown substantially since 1986. Patient education, preventive care (screening, immunisation), and organisational and environmental changes by health organisations have all been found to have positive health and environmental outcomes. However, evidence of effectiveness has not been sufficient, on its own, to sway community preferences and political decisions. The lack of progress points to the need for significant re-thinking of the approaches we have adopted to date. The paper proposes a number of ways forward. These include working effectively in partnership with the communities we want to serve to mobilise support for change, and to reinforce this by working more effectively at influencing broader public opinion through the media. The active engagement of clinical health professionals is also identified as crucial to achieving sustainable change. Finally we recognize that by working in partnership with like-minded advocacy organizations, the IUHPE could put its significant knowledge and experience to work in leading action to transform health care systems to make a major contribution to the improvement of public health. (Promotion & Education, 2007, Supplement (2): pp 23-27).

Healthy aboriginal communities.

Abstract: Improving the health of Aboriginal and Torres Strait Islander populations is the greatest challenge facing public health in Australia today. The gains in the health of the population overall have not been matched by gains among these communities. Much of the information about the health of Aboriginal and Torres Strait Islander communities and people is negative, and little information is available about what Aboriginal and Torres Strait Islander people themselves consider to be indicators of healthy people and healthy communities.

Health promotion in Australia: Reviewing the past and looking to the future

Over the last three decades Australia has very successfully adopted and applied the values, methods, and practice of health promotion to improve the average life expectancy and health of the population. Australia has, also, been part of and contributed to the global evolution of the field of health promotion. There is, now, substantial organisational capacity (including a specialist workforce) within the health sector (including the non-government and community sectors), although total financial investment as a proportion of total recurrent health expenditure remains consistently below 2%. However, despite its significant successes, health promotion in Australia has had little impact on improving the health of Indigenous Australians. Closing the 17-year gap in life expectancy is one of the greatest challenges facing health promotion in the future–necessitating a much more substantial investment in working across sectors to redistribute the social determinants of health, including political power.

The influence of professional values on the implementation of Aboriginal health policy

Objective: This article explores the role of professional values and the culture of the Australian health care system in facilitating and constraining the implementation of an Aboriginal health policy. Methods: Thirty-five semi-structured in-depth interviews were conducted in a case study on the implementation of the Northern Territory Preventable Chronic Disease Strategy (PCDS). Results: PCDS included three major evidence-based components - primary prevention, early detection and better management. The research revealed that PCDS changed as it was implemented. The values of the medical and nursing professions favoured the implementation of the clinically-based component of PCDS - better management. But there was dissonance between the values of these dominant professional groups and the values and expertise in public health that were necessary to implement fully the primary prevention component of PCDS. While Aboriginal health workers have valuable knowledge and skills in this area, they were not accorded sufficient power and training to influence decision-making on priorities and resources, and were able to exercise only limited influence on the components of the PCDS that were implemented. Conclusion: The findings highlight the role that a myriad of values play in influencing which aspects of a policy are implemented by organizations and their agents. Comprehensive and equitable implementation of policy requires an investigation and awareness of different professional values, and an examination of whose voices will be privileged in the decision-making process. If the advances in developing evidence-based, culturally-appropriate and inclusive policy are to be translated into practice, then care needs to be taken to monitor and influence whose values are being included at what point in the policy implementation process.

The role of advocacy in promoting health.

Strengthening advocacy for social and economic policy that promotes the health and well-being of populations and that ensures a sustainable environment are major challenges for health promotion in the 21st century. Although advocacy is known as a powerful strategy for promoting health there has been much less success in using advocacy to reduce inequalities in health--to influence the policies and practices of governments private sector and nongovernmental organizations to create conditions for health. This concern with inequality is shared by many sectors other than health but it has proven difficult to form and maintain the partnerships needed to work together to advocate for goals and decisions that promote and protect the health and well-being of populations. However such partnerships are being developed by certain international agencies and the essentially political nature of health promotion and public health has been obscured by an emphasis on gathering evidence. It is noted that the quest for evidence is and will remain a vital thread of health promotion activity.

Enable, mediate, advocate

The authors of the Ottawa Charter selected the words enable, mediate and advocate to describe the core activities in what was, in 1986, the new Public Health. This article considers these concepts and the values and ideas upon which they were based. We discuss their relevance in the current context within which health promotion is being conducted, and discuss the implications of changes in the health agenda, media and globalization for practice. We consider developments within health promotion since 1986: its central role in policy rhetoric, the increasing understanding of complexities and the interlinkage with many other societal processes. So the three core activities are reviewed: they still fit well with the main health promotion challenges, but should be refreshed by new ideas and values. As the role of health promotion in the political arena has grown we have become part of the policy establishment and that is a mixed blessing. Making way for community advocates is now our challenge. Enabling requires greater sensitivity to power relations involved and an understanding of the role of health literacy. Mediating keeps its central role as it bridges vital interests of parties. We conclude that these core concepts in the Ottawa Charter need no serious revision. There are, however, lessons from the last 25 years that point to ways to address present and future challenges with greater sensitivity and effectiveness. We invite the next generation to avoid canonizing this text: as is true of every heritage, the heirs must decide on its use.

Health Impact Assessment for Urban and Land-use Planning and Policy Development: Lessons from Practice

Abstract There is increased interest in, and awareness of, the health impacts of urban and land-use planning. At the same time, health impact assessment (HIA) has emerged internationally as an approach to strengthening the possible positive impacts of a proposed development or plan and mitigating the possible negative health impacts. This article first provides an overview of HIA, focusing on the history of HIA and its core conceptual underpinnings. The article then critically reflects on the value of undertaking HIA based on experiences from 13 HIAs on planning proposals in Australia. In doing so, the article makes the case for the use of HIA in urban and land-use planning based on practical examples of how HIA has been applied to different types of urban policies and plans to improve healthy urban places.

Analysing NSW state policy for child obesity prevention: strategic policy versus practical action.

BackgroundThere is increasing worldwide recognition of the need for government policies to address the recent increases in the incidence and prevalence of childhood obesity. The complexity and inter-relatedness of the determinants of obesity pose a genuine policy challenge, both scientifically and politically. This study examines the characteristics of one of the early policy responses, the NSW Governments Prevention of Obesity in Children and Young People: NSW Government Action Plan 2003–2007 (GAP), as a case study, assessing it in terms of its content and capacity for implementation.ResultsThis policy was designed as an initial set of practical actions spanning five government sectors. Most of the policy actions fitted with existing implementation systems within NSW government, and reflected an incremental approach to policy formulation and implementation.ConclusionAs a case study, the NSW Government Action Plan illustrates that childhood obesity policy development and implementation are at an early stage. This policy, while limited, may have built sufficient commitment and support to create momentum for more strategic policy in the future. A more sophisticated, comprehensive and strategic policy which can also be widely implemented and evaluated should now be built on this base.

Australia: planning for better health. Opportunities for health promotion through the development of national health goals and targets.

Health promotion is the process of enabling individuals and communities to increase control over the determinants of health, and thereby improve their health (1). This definition was incorporated into the Ottawa Charter on Health Promotion (1986), which has guided much health promotion strategy and action in developed countries since that time (2). Health promotion, as described in the Charter, is based upon a combination of actions by individuals, communities, and governments designed to have optimal impact on lifestyles and living conditions which influence health status and the quality of life. Health is conceived of as a resource for life, rather than an end in itself. Key themes for health promotion include the need for government leadership and action to ensure healthy public policy, particularly that which is directed at creating supportive environments for health. A major component of healthy public policy, emphasised in the Ottawa Charter, is the need for the re-orientation of health services to ensure that

Policy- and System-Level Approaches to Health Promotion in Australia

This issue of Health Education & Behavior presents articles from researchers and practitioners in Australia who are working to create supportive political and social environments for health. Much of what happens in health promotion in Australia at the individual, workplace, group, or community level shares similarities with interventions conducted by colleagues across the world. What differs, and what visitors to Australia often remark on, is the high degree of public acceptance of, and legislative-level support for, promotive and protective health practices. At a national level, these include, for example, extensive regulation of smoking in public spaces, vehicle passenger safety restraints, blood alcohol restrictions for drivers supported by random breath testing, bicycle helmet laws, private swimming pool fencing regulations, gun control legislation, and laws preventing the use of hand-held mobile phones in moving vehicles. In this editorial, we briefly describe the Australian context, give a brief overview of the articles in this special issue, and attempt to account for how and why health promotion in Australia has developed a strong policy and system-level focus. 1 Australia is roughly the size of the United States with a population of 19 million people. The population is culturally and linguistically diverse. Indigenous Australians make up 2% of the population. Currently, 8 million residents were born overseas or have parents who were born overseas. More than 280 languages are spoken, including 170 Australian indigenous languages. A language other than English is spoken at home by 16% of the population. Universal access to publicly funded health care has been provided through