Equality, Equity and Policy: International Influences on Health and Social
For a few decades after the formation of the World Health Organization (WHO) in 1948, developed countries tended to invest in health care services and paid relatively little attention to public health. In the last 40 years many
international organizations and key reports have shaped public health policy around the world, as detailed by Irvine et al (2006) in Box 1.
Box 1: A review of major influences on current public health policy in developed countries in the second half of the 20th century.
The importance of public health was slowly recognised over theperiod from 1970 to 2000 with the publicationof several reports from different organisations. The first authoritative policy statement that the importantdeterminants of health lay outside health carewas in the LaLonde Report from Canada. These ideas were subsequentlyexpressed in the WHO The Alma-Ata Declaration andwere emphasised a year later by the US SurgeonGeneral. The idea of setting goals for health improvement alsobegan in the 1970s. The Lalonde Report and theUnited Kingdom Black Report recommended that targets be used, but the first explicitly stated health targetswere set by the US in 1979. WHO also identifiedthe need for such targets at this time, but did not introduce them until 1984. Since then health targetshave become a central feature of public healthpolicy in developed countries.
The Ottawa Conference on Health Promotion in 1986 championedthe view that health promotion was central toachieving health goals internationally. It helped clarify the types of actions needed: that individualsneed to be provided with the supportive environmentand economic resources to be able to lead healthy lives. Ina further development, the Healthy Cities Project was launched with the specific aim of involvingpolitical decision-makers in building a strong lobby for publichealth at the local level. The Healthy CitiesProject illustrates how to provide means and opportunity for interventions to be implemented in communities.
Concerns with inequalities in health were emphasised in theWHO declaration of Alma-Ata, and were the focusof the United Kingdom Black Report. The Jakarta Conference on Health Promotion in 1997 urged internationalaction on poverty, as it is the major threatto health. International acceptance of the need to tackle inequalities took longer than the acceptance ofhealth targets, but it is now an important featureof public health policy.
The advent of the 21st century marked the coming of age of publichealth. The renewed version of Healthfor All, Health for All in the 21st Century, emphasised the one constant goal of WHOthat all individuals should achieve their fullhealth potential. Public health is now regardedinternationally as being a priority with this WHO goal beingadopted as the overarching goal of policy. Thechallenges it faces in tackling problems such as obesity, inequalities in health, smoking, alcohol and substanceabuse are great and will require policies whichtackle the economic, social and environmental determinants of health.
Source: Irvine et al, 2006.
Notes on the publications mentioned and highlighted in Box 1:
The LaLonde Report, written in 1974 in Canada, marked a shift from focussing on medical care to an examination of the wider determinants of health. The report introduced the health fields concept and argued that four
health fields were interdependently responsible for individual health:
- Health care organisation
- Human biology
The Alma-Ata Declaration of 1978 affirmed health as a fundamental human right. The declaration called for Health for All by the year 2000 and suggested achieving this goal through a transformation of conventional
health care systems, broad inter-sectoral collaboration and community organisation.
Black Report For a description of the report see section 10: Inequalities in the distribution of health and health care and its access. For a description of the origins of the Black Report see http://www.sochealth.co.uk/history/blackorigin.htm
The Ottawa Conference on Health Promotion in 1986 launched the Ottawa Charter for Health Promotion. The Ottawa Charter formalised the view that health services should incorporate health promotion concepts such as community development, empowerment and advocacy. It identified five action areas of health promotion:
- Building healthy public policy
- Creating supportive environments
- Strengthening community action
- Developing personal skills
- Re-orientating health care services toward prevention of illness and promotion of health.
The Healthy Cities Project, first implemented in 1987 by the WHO, aims to engage local governments in health development through a process of political commitment, institutional change, capacity building, partnership-based planning and innovative projects. It also strives to include health considerations in economic, regeneration and urban development efforts.
The Jakarta Conference on Health Promotion in 1997 reflected on lessons learned since the Ottawa conference. It identified a range of issues that were impacting on the determinants of health (pinpointing poverty as the
greatest threat to health), and argued that health promotion was helping to achieve greater equity in health.
Health for All in the 21st Century, developed in 1998, is a policy to help attain the goals of Health for All set forth at the Alma Ata Conference in 1978. The policy establishes, for the first 2 decades of the 21st century,
global priorities and targets to create conditions supportive of people worldwide to reach and maintain the highest attainable level of health throughout their lives.
It is now widely recognised in public health that poverty is the most important cause of preventable death and disability worldwide (Beaglehole and Bonita, 1998), therefore public health and social policy are linked. Key
international actors and influences in social policy include the World Bank, International Monetary Fund (IMF), World Trade Organisation (WTO) and the United Nations (UN). However, the effect of these organisations on health is
controversial (see Section 13: Critical Analysis of Investment in Health Improvement for a discussion of controversy surrounding the World Bank and IMF; see Section 11 Migration, and the
Health Effects of International Trade for details of the WTOs influence on health).
- Beaglehole R, Bonita R (1998). Public health at the crossroads: which way forward?. Lancet, 351: 590-92.
- Irvine L, Elliot L, Wallace H, Crombie I (2006). A review of major influences on current public health policy in developed countries in the second half of the 20th century. Perspectives in Public Health,
- The LaLonde Report
- The Alma-Ata Declaration
- Black Report
- The Ottawa Conference on Health Promotion
- The Healthy Cities
- The Jakarta Conference on
© Rebecca Steinbach 2009