Toward a more health
promoting health services
Mohammad Hossein Kaveh
Associate professor, department of health education and promotion,
school of health, Shiraz University of medical sciences
Introduction
• The 1986 Ottawa Charter stressed reorienting health services to
more health promotion as one of the five important developing
action areas to more effectively contribute to population health.
• However, international evaluations over the 20-25 years revealed that
this part of the strategy had the least successful implementation.
Introduction
• The purpose of this paper is to reflect on why progress in this domain
has been less than optimal in practice; possibilities and
responsibilities for change, especially with regard to health
(education/promotion) professionals’ roles, will be briefly discussed
as well.
Health systems are defined as:
• . . . the ensemble of all public and private organizations, institutions
and resources mandated to improve, maintain or restore health.
• Health systems encompass both personal and population services, as
well as activities to influence the policies and actions of other sectors
to address the social, environmental and economic determinants of
health. (WHO Regional Office for Europe, 2008) (ZIGLIO, SIMPSON, & TSOUROS, 2011)
A well-functioning health system
• not only ensures equitable and universal access to a good range of
primary and preventive services but also advocates for better social
and environmental conditions so as to enable people to increase
control over, and to improve, their health. (ZIGLIO, SIMPSON, & TSOUROS, 2011)
What do we mean by re-orienting health services?
• It states that achieving improved population health
outcomes will require an expansion in health promotion and
disease prevention action to achieve an optimal balance
between investments in health promotion, illness
prevention, diagnostic, treatment, care and rehabilitation
services in a health system.
• Such an expanded role need not always be achieved through
an increase in direct health system activity. (Wise & Nutbeam,
2007)
the purposes of re-orienting health services
• In short, 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. (Wise &
Nutbeam, 2007; Johansson, Weinehall, & Emmelin, 2010).
The need to reorient …
• Nevertheless, the need to better balance investment among cure,
care, prevention and health promotion is as important today as it was
in 1986 (ZIGLIO, SIMPSON, & TSOUROS, 2011).
• Current global health issues, including the economic crisis, climate
change and a wide range of public health threats, pose both new
challenges and new opportunities to reframe, reposition and renew
efforts to strengthen health promotion and its role in re-orienting
health services (ZIGLIO, SIMPSON, & TSOUROS, 2011).
Make health systems part of the solution not
part of the problem!
• In today’s context, therefore, strengthening the promotion
and protection of the health of individuals and communities
as a core activity of health systems is not optional but a
must. (ZIGLIO, SIMPSON, & TSOUROS, 2011)
Acting on SDH
• World-wide, the highest risk for the health of both individuals and
communities is still social determinants, particularly poverty.
• Evidence also indicates that life expectancy has been linked more to
improved living conditions than to improved health care services.
• Equally, the capacity of the health care sector to improve population
health and health equity is strongly influenced by other sectors.
• Health interventions including health promotion initiatives that
overlook this fundamental issue may unintentionally increase health
inequities. (ZIGLIO, SIMPSON, & TSOUROS, 2011)
Functions of health systems
• service delivery,
• human and technological resource development,
• financing and
• stewardship (WHO Regional Office for Europe, 2008).
• These functions cannot be effectively performed without a strong
health promotion focus, particularly in light of today’s social and
economic challenges (ZIGLIO, SIMPSON, & TSOUROS, 2011).
Principles of health promotion
• Health promotion:
1. involves the population as a whole in the context of their
everyday life, rather than focusing on people at risk for specific
diseases;
2. is directed towards action on the determinants or causes of
health;
3. combines diverse, but complementary, methods or approaches;
4. aims particularly at effective and concrete public participation;
and
5. health professionals, particularly in primary health care, have an
important role in nurturing and enabling health promotion. (WHO,
2009) (ZIGLIO, SIMPSON, & TSOUROS, 2011).
health promotion can help
• Health promotion principles can help health systems better
achieve their goals of improved health, responsiveness and
financial fairness.
• Health systems have better health outcomes when built on a
primary health-care approach, with health promotion as a
key element (WHO, 2008). (ZIGLIO, SIMPSON, & TSOUROS, 2011)
• Such systems also have better potential for improving health
equity, an important objective of health promotion. (ZIGLIO,
SIMPSON, & TSOUROS, 2011)
health promotion …
• There is also a real risk that with health budgets coming under
pressure and the growing burden of non-communicable diseases, that
health promotion and preventive efforts will focus merely on lifestyle
change and individual responsibility.
• Efforts to mainstream or integrate health promotion within health
systems must be undertaken in such a way that they are consistent
with the principles of health promotion.
• It also means implementing actions that include the five
interdependent action domains of health promotion, e.g. action to
create supportive environments that promote and protect health is
just as important as educating people about healthy behaviours).
(ZIGLIO, SIMPSON, & TSOUROS, 2011).
Re-orienting health services; lethargic progress
• However, it seems that this strategy has been the least systematically
implemented. (Johansson, Weinehall, & Emmelin, 2010).
• Across the world, the role and structure of health systems continues
to be dominated by the provision of care for acute and chronic
conditions. (Johansson, Weinehall, & Emmelin, 2010).
• It is widely acknowledged that closing the implementation gap in
health promotion by reframing, repositioning and renewing efforts to
strengthen the health promotion role of health systems is still an
unaccomplished agenda (ZIGLIO, SIMPSON, & TSOUROS, 2011).
Evidence of lethargic progress towards …
• the percentage of the health budget allocated to public and primary
health efforts:
• it is usually, 3–4% in many countries (IUHPE, 2000; Wanless, 2002). (ZIGLIO,
SIMPSON, & TSOUROS, 2011)
• only 5% (Johansson, Weinehall, & Emmelin, 2010)
• As a consequence of a growing gap between demands and resources,
health services today are becoming more and more overloaded.
• Disease-oriented assignments have received greater funding whereas
preventative measures have been cut down. (Johansson, Weinehall, & Emmelin,
2010)
Evidence of lethargic progress towards …
• There was still significant imbalance between treatment and care
versus health promotion activities. (Johansson, Stenlund, Lundström, & Weinehall, 2010)
• The past 200 years have seen a doubling of the human life span.
Although enormous advances in biomedical interventions and
health technologies have been made during that time, major
inequities in health persist (Baum, Be´gin, Houweling, & Taylor,
2009).
Evidence of lethargic progress towards …
• Yet, countries’ investments in and through the health care sector are
overwhelmingly confined to the provision of curative health services,
especially hospital services, rather than being channeled to
prevention and health promotion.
• Moreover, when health promotion is incorporated at all, it is generally
aimed at changing the behavior of individuals rather than creating
wider physical, social, and economic environments supportive of
healthy behavior. ( Baum, Be´gin, Houweling, & Taylor, 2009)
Consequences
• Inflations in health expenditures
• In any case, an investment emphasis on new medical interventions
tends to increase health inequities because interventions reach more
advantaged groups before, if ever, trickling down.
• In low- and middle-income countries in particular, socioeconomic
inequalities translate into huge inequities in health care use.
• approximately 150 million residents of countries with limited public
sector health care have suffered financial catastrophe ( Baum, Be´gin,
Houweling, & Taylor, 2009)
a study by Zare et al (2014) in Iran
• The results suggest heightened inequality in health care
expenditures in Iran over the past three decades (1984-2010),
including an increase in the gap between urban and rural areas.
Furthermore, inflation has affected the poor more than the rich.
Consequences
• For example, the current emphasis of health systems investment in
tertiary level curative and clinical services cannot be maintained.
• Health systems that predominantly invest in tertiary and curative
clinical services are becoming unaffordable in many countries and
health promotion is an important vehicle to reorient investment so
that health systems are not only more effective but also sustainable.
(ZIGLIO, SIMPSON, & TSOUROS, 2011)
Sustainabilty!
• There is a growing consensus worldwide that our current patterns of
health service development and expenditure are simply
unsustainable. (EDITORIAL, 2014)
• Growth in expenditure on health and aged care that outstrips growth
in GDP will lead to worsening budget positions.
• With the ageing of the world’s population and the rising impact of
chronic diseases internationally most countries – both developed and
developing – are experiencing similar challenges. (EDITORIAL, 2014)
Challenges/barriers
• within our own field of health promotion we often focus on making
the case for action on the social determinants.
• So much so that we often downplay the role and contribution that
health systems can make; and
• the field of health systems and related policy development is still
dominated by the provision of tertiary services and often those who
work at this level—be it developing new clinical interventions or
providing them (ZIGLIO, SIMPSON, & TSOUROS, 2011).
Challenges/barriers
• The health care sector is clearly dominated by a biomedical
imagination.
• In such a worldview, curative medicine is privileged over strategies
that emphasize disease prevention and health promotion. ( Baum, Be´gin,
Houweling, & Taylor, 2009)
•
Challenges/barriers
• leadership
• Management (Johansson, Stenlund, Lundström, & Weinehall, 2010).
Challenges/barriers
• However, along with recent socio-economic developments and
scientific and technological progress, medical disciplines have become
more and more specialized, and clinical and preventive medicine have
become further separated from each other.
• Humanism in medical practice is getting lost. ( Li, Tang, Lv, Jiang, &
Griffiths, 2011)
Challenges/barriers
• Medical education is largely built on the biomedical model of
diseases.
• However, the biomedical model has shown some obvious limitations.
• In this model, an individual is simply taken as a machine.
• Doctors treat symptoms rather than the disease;
• they treat the disease rather than the person. ( Li, Tang, Lv, Jiang, & Griffiths, 2011)
Challenges/barriers
• …, the biomedical model is unable to satisfactorily explain and
effectively deal with many of the challenges we are facing, such as
human immunodeficiency virus/acquired immunodeficiency
syndrome, drug abuse, alcoholism and depression.
• Smoking, physical inactivity and unhealthy diet are all influenced by
the environment in which we live. ( Li, Tang, Lv, Jiang, & Griffiths,
2011)
Challenges/barriers
• escalating health care costs to come with the growing burden of
chronic disease in poor countries—raise the question of the
sustainability of the biomedical model. ( Baum, Be´gin, Houweling, & Taylor, 2009)
The biopsychosocial model
• The biopsychosocial model emphasizes that there are many other
important determinants of health that have not been given sufficient
attention, such as natural and social environments, education and
employment, and organization and delivery of healthcare systems. (
Baum, Be´gin, Houweling, & Taylor, 2009)
Challenges/barriers
• We believe that part of the answer lies in the lack of integration,
active advocacy and leadership from health promotion within health
systems.
• The profession of health promotion has too often separated itself and
been separated from mainstream health systems. (ZIGLIO, SIMPSON,
& TSOUROS, 2011)
Challenges/barriers
• Growing Privatization
• In this environment, health budgets are devoted overwhelmingly to
hospitals, medical and pharmaceutical services, and biomedical
research, and budget incentives encourage patient throughput rather
than health outcomes. ( Baum, Be´gin, Houweling, & Taylor, 2009)
Challenges/barriers
• Research-Supported Interventions
• …., funding for intervention research on social determinants of health
is negligible relative to funding for biomedical science research. (
Baum, Be´gin, Houweling, & Taylor, 2009)
a multifaceted and complex process
• The implementation of a more health-oriented health service is a
multifaceted and complex process.
• It requires changes in professional behaviors and working methods as
well as changes in organizational cultures and structures (Johansson,
Stenlund, Lundström, & Weinehall, 2010).
• The outcome depends on the interaction among:
• the innovation itself,
• the intended adopters, and
• the context (Johansson, Stenlund, Lundström, & Weinehall, 2010).
The intended adopters (the health professionals)
• health professional’s own values, norms, and perceived needs, will or
desire to act, sense of ownership and autonomy with regard to one’s
work are important motivational factors (Johansson, Weinehall, & Emmelin, 2010)
• Other important factors:
•
•
•
•
Organizational commitment:
Job Involvement:
Psychological Empowerment:
Perceived Organizational Support (POS): (Robins and Judge, 2009)
• These factors are largely determined by the characteristics of the
organization (Johansson, Weinehall, & Emmelin, 2010).
The intended adopters (the health professionals)
• lack of time/heavy workload
• Lack of guidelines and unclear objectives
• lack of competence;
• physicians need more skills in health promotion interventions, lifestyle
counseling, empowering communication, and in the task of motivation
(Johansson, Stenlund, Lundström, & Weinehall, 2010).
the context (Organizational structures)
• Organizational structures that provide resources, support and the
opportunity to learn and develop are empowering and enable
employees to accomplish their work.
• directives from “above” do not always get a friendly reception
opportunities for
• There are ample opportunities for health systems to advocate, enable
and mediate for health, to change policies, legislation and practices to
create and ensure more equitable health-promoting environments in
which people play, learn, work and age.
• Health services, however, should also be exemplar of the change they
advocate for and put their own house in order (WHO Regional Office for Europe,
2010a). (ZIGLIO, SIMPSON, & TSOUROS, 2011)
The final word
• Reforms in health curriculums;
• outcome-based and community-based curriculum
• Health promotion oriented
• Reorienting health researches
• Adopting a team-based interdisciplinary approach (involving health
promotion professionals)
• Planning strategically for continuous professional development of
human resources
•Thank you