Twenty-five years after the Ottawa Charter: the critical role of health promotion for public health.

Potvin, Louise ; Jones, Catherine M.

The year 2011 marks the twenty-fifth anniversary of the Ottawa Charter for Health Promotion. (1) The document is sometimes presented as health promotion's founding document (2,3) but also as only the "tip of a much more complicated set of ideas and values". (4) Independently of the role assigned to the Ottawa Charter, public health has integrated health promotion extensively in the past few decades. In the Western hemisphere, where its development has been concentrated, health promotion has been identified as the third revolution (5) and as a necessary critical discourse (6) for public health. Recently, the health promotion discourse has gone global. (7) The Bangkok Charter repositioned the field in a global context with a reinforced vision and new commitments for a global community of health promotion practitioners. (8) Taking advantage of the occasion of the 25th anniversary of the Ottawa Charter, this paper proposes a reflection on health promotion and its recent impact on public health. It examines achievements in the field of health promotion over the past 25 years and attempts to identify some of the challenges that lie ahead.

The Ottawa Charter: A public health innovation

In 1986, the Ottawa Charter was adopted by a group of researchers, policy-makers and public health practitioners assembled in Ottawa, Canada, as a road map for the countries involved in the WHO EURO * region for pursuing the Declaration of Alma Ata's vision of "Health for All by the Year 2000". (9) Three documents are often cited as inspiration for the Ottawa Charter: the positive definition of health in the preamble of the WHO constitution, (10) the Lalonde Report (11) and the Alma Ata Declaration. (9)

The preamble of the WHO constitution proposed, for the first time, a positive definition of health: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". (10) Although this definition is difficult to translate into population indicators, (12) it remains to this day the most encompassing and engaging definition of health. This definition establishes that health is a positive project to pursue (13) rather than the avoidance of negative consequences. It serves as an introduction to both the Alma Ata Declaration and the Ottawa Charter, and establishes the claims that 1) health is a human right and 2) the main factors that shape health are societal. (14)

Another source of inspiration for the Ottawa Charter is a report entitled: "A New Perspective on the Health of Canadians" (11) by then Canadian Minister of Health, Marc Lalonde. Two major innovations mark this Health Canada policy document: it defines prevention as a priority for the health system, and it identifies the health field as being composed of four elements--human biology, social and physical environments, lifestyles and the health care system. The proposition that health is not solely produced by health care is central to this report. In order to fulfill its mandate of ensuring a healthy population for a country's development, public health, as an institution, must deploy strategies that reach well beyond health care.

Finally, the Alma Ata Declaration adopted by the World Health Assembly in 1978 proposes an encompassing and utopian vision for public health systems. Health is a human right and pursuing

"Health for All by the Year 2000" (itself a call for health equity) is a responsibility for every nation. Health can be achieved through community structures that involve the participation of concerned populations and that implement comprehensive programs in coordination with other sectors. (10)

A close examination of the Ottawa Charter1 reveals four innovative elements for public health. First, and following in the footsteps of the Alma Ata Declaration, it reiterates the positive definition of health found in the WHO constitution. (10) Health promotion is the only public health area of action to have strongly endorsed this positive definition that orients public health action toward people's living conditions and toward health equity. Second, it unmistakably situates health as a product of daily life (5) and explicitly lists some prerequisites for health. Third, it proposes a set of core values and principles that should be promoted and pursued through public health action and that are, in and of themselves, conducive to health. In addition to participation and empowerment, which they frame as fundamental principles for health promotion, Rootman et al. (15) identify five other values and principles: equity, holism, intersectoral action, sustainability and multiple strategies. Fourth, and this is usually what the Charter is recognized for, it proposes three strategies and five action areas that extend well beyond the health care sector. The strategies are: advocate, mediate and enable. The action areas are: "build healthy public policy, create supportive environments, strengthen community actions, develop personal skills, and reorient health services". (1)

We agree with Kickbusch2 and Breslow5 that the Ottawa Charter's main target for change was public health practice and organization. Taken together, the innovative elements of the Ottawa Charter propose a radical agenda for public health, namely that its values need to be explicitly articulated and integrated in all of its activities. The Ottawa Charter fundamentally addresses the normative nature of the public health enterprise. Public health has always been a normative enterprise. It has always been used by nations to legitimate coercive actions in the pursuit of a superior collective good: the public's health. (16,17) However, the normative nature of public health is often masked by the highly scientific content of the field. Critical discourses are often perceived as paralyzing, and seen to decelerate indispensable actions revealed by scientific research. (18) There is a tendency to ignore that scientific facts alone cannot drive action; it is the normative lens through which scientifically established facts are read that ultimately dictates public action. (19)

In addition, the Ottawa Charter proposes that health as a value should not stand alone. The values underlying the processes by which health is pursued are also important. By making those values explicit, the Ottawa Charter accomplishes two results. First, it increases public health practitioners' awareness of the normative aspects of their work, which is a necessary condition for the reflexivity of the field. Second, it proposes complementary values that should also be weighted and considered in actions that promote population health.

1986-2011: The consolidation and expansion of health promotion

Our conception of the Ottawa Charter is that of an agenda-setting document. It took stock of existing ideas both inside and outside of the health sector, and repackaged them to legitimate specific orientations for action that were made possible by the social transformations associated with late modernity. (20) Although the Ottawa Charter itself could not have constituted the field of health promotion, we believe that it has provided a framework for public health practitioners and decision-makers to explore alternative practices that promote alliances with other sectors, emphasizing the process by which health is produced and who benefits from public health programs and policies.

The past 25 years have witnessed the consolidation and institutionalization of health promotion; it has clearly become a "name on the door" within the more general domain of public health. (21) A diverse range of practitioners, policy-makers and researchers identify with this field, contribute to its discourse and practice, and advocate for the recognition of its role in the pursuit of the public's health. There are university programs and degrees in health promotion. There is a global dialogue on the professional competencies that should be required for health promoters. There are professional associations of health promoters, and there exist a number of scientific and professional journals that have health promotion in their name. Public health systems and public health practices have integrated health promotion principles and values at all levels of governance. In the following section, we examine examples of this expansion.

Changing Systems

Because of its strong association with a WHO EURO document, health promotion has long been considered a product of high-income countries. However, the adoption of a Resolution on Health Promotion in 1998 by the World Health Assembly recognized the vision of the Ottawa Charter, established a health promotion mandate for WHO and urged Member States to translate the priorities and implement strategies for health promotion. (22) Embedding health promotion within the coordinating authority for health in the UN system supported the process that led to the adoption in 2005 of the Bangkok Charter for Health Promotion in a Globalized World, (7) which constitutes in itself the recognition of the global expansion of the innovations underlying the Ottawa Charter. Involving representatives from all regions, and resulting from a global dialogue, the Bangkok Charter has confirmed the role and relevance of health promotion for low- and middle-income countries and for the development of public health capacity. It underlines the responsibility of all sectors for health and development. Even, or especially, in areas of the world where basic public health services are scarce, principles of participation and empowerment are seen as necessary ingredients for successful implementation of public health programs.

At the national level, there are numerous examples of how health promotion has started to permeate and transform public health systems. This is exemplified by three general and related trends. The most significant of these trends is the integration of health promotion as a specific function for public health. In the UK, Canada and Quebec, for example, laws and public health policy documents explicitly recognize health promotion as a core public health function, on par with more traditional functions such as protection, prevention or surveillance. Other jurisdictions, such as Ontario in Canada, have created a specific Ministry of Health Promotion, distinct from the Ministry of Health and whose mandate is not related to the provision of health care. And in other jurisdictions such as the states of Western Australia and Victoria in Australia, Switzerland, Thailand, Austria and others, foundations have been established by legislation with specific mandates for health promotion.

A second trend is the explicit mention of health equity as an overarching objective for national public health programs. Over the past thirty years, many jurisdictions have developed extensive health plans to guide the action of their public health systems. Notably, over the past ten years, there is an increasing number of such plans that formally propose the reduction of health inequalities together with the increase of population health as the overarching objectives of their action. With its program entitled "Health on Equal Terms", Sweden proposes 15 objectives, most of which address social conditions, such as housing and sense of community, that are not related to specific disease risk factors. (23) Although recent elections of more conservative governments in Europe are associated with a return to more traditional public health strategies focusing on diseases and risk factors, there is still a tendency to maintain a formal objective of reducing health inequalities.24 This is also true in Canada. The Pan-Canadian Healthy Living Strategy, adopted in 2005 by all of Canada's health ministers (with the exception of Quebec's health minister, as Quebec has its own similar strategy) and reaffirmed by them in the 2010 Declaration on Prevention and Promotion, "identifies two goals: improved overall health and reduced health disparities." (25)

The third trend is the adoption in some jurisdictions of governance instruments that promote health in all policies as a principle of governance. The 2010 Adelaide Statement on Health in All Policies (26) proposes that "government objectives are best achieved when all sectors include health and well-being as a key component of policy development. This is because the causes of health and well-being lie outside the health sector and are socially and economically formed." The most popular of these instruments is the Health Impact Assessment (HIA), which is used to evaluate projects, programs and policies based on their potential impact on health or health equity. Quebec, in 2001, was the first jurisdiction in the world to empower its Minister of Health to conduct such assessments on any policy and ruling presented to the parliament. (27) Another example is that of Finland, who championed and promoted Health in All Policies during its tenure holding the presidency of the European Union. (28)

Changing Practices

Health promotion is also identified with innovative programs that have transformed public health practices on a global scale, mainly through the implementation of a settings approach that promotes the creation of environments that are supportive of health. (29,30) Healthy Cities (Healthy Municipalities or Healthy Communities in the Americas) is a flagship program for which WHO and its regional offices have a leadership role. They have created a global network of national and regional networks that connect hundreds of cities and towns across the world and that facilitate intersectoral actions and citizen participation to improve local living conditions. (31) The Healthy Schools movement engages schools and school administrations in a redefinition of school as a living environment which needs to provide children with a wide spectrum of resources to ensure their healthy development. First and foremost, it pleads for a better integration of the school with children's other meaningful environments such as the family and the community. (32) Finally, reforms have also affected the health care sector. The Baby Friendly Hospital Initiative rests on contractual commitment by hospital and birth centres to actively promote breast-feeding through their adherence to and implementation of a 10-step process. (33) Created in 1991, this UNICEF-WHO joint initiative was further developed into a network of Health Promoting Hospitals under the auspice of the WHOEURO office, which proposes a series of standards that hospitals should meet in order to join the network. (34)

Challenges for the future

It is outside of the scope of this short paper to conduct an exhaustive analysis of the achievements of health promotion. We think that the examples described in the previous section provide ample evidence that the innovative features of the Ottawa Charter have impacted public health practices. At this point in time, it seems to us that the most important challenge for health promotion concerns its capacity to integrate both the values and other normative aspects with the scientific rationality of public health in order to support those innovative practices. In other words, health promotion must find a way to use research to better understand how the values, principles and processes it advocates result in an increased capacity for public health to fulfill its mandates. This calls for an action plan that covers three elements.

The first element is to debunk the myth that reinforces the ideological elements of health promotion at the expense of a rational approach. Health promotion is value-laden and process-oriented; this however is insufficient to legitimize its integration into a state mandate for public health. It needs to show outcomes. It has to demonstrate that taking into account processes and promoting explicit values and principles into public health practices and programs do result in better health and/or more equitable health distribution. Although theoretically sound at this point, the proposition that empowerment and participation are health-promoting processes in and of themselves is still highly hypothetical, as are claims that applying health impact assessment and promoting health in all policies result in more health-enhancing public policies and improved health.

This research should be respectful of the nature of health promotion, and it must not undermine health-promoting processes. As a mirror image to the first element, the second part of the action plan is to discredit the myth that public health intervention is essentially biomedical and that biomedical research is the method of choice to understand how health promotion works. (35) Indeed, the major contribution of health promotion to public health is its upfront affirmation that in order to increase health and the equity of its distribution, one must transform social conditions that shape the distribution of health, which was the central focus of the recent WHO Commission on the Social Determinants of Health. (36) Understanding how these transformations can be oriented and fostered by public health action requires methods and theories of the social sciences. (37)

The third element is to find ways to better integrate health promotion research and practice. This needs to occur within public health institutions and organizations where research needs to be accompanying the development, deployment and scaling up of new programs in a manner that both informs local action and produces knowledge relevant for other places. There is also a need to educate researchers and practitioners of health promotion so that they can collaborate with each other. This means that the former develop valid methods of knowledge production that do not necessarily require absolute control over the intervention process, and the latter learn to adapt research results for their local contexts and integrate evaluation results into innovation development.

CONCLUSION

Health promotion is actively being defined through practice taking place across the globe. To use Kickbusch's analogy, (38) the roots of health promotion are spreading as a rhizome. The emergence of new challenges for the field does not negate the relevance of the Ottawa Charter. On the contrary, the significance of the Ottawa Charter lies in its longevity as a mouthpiece for the field of health promotion. It continues to confirm a vision, orient action, and underpin the values that comprise health promotion today. Building capacity of the workforce, organizations and infrastructure for health promotion will be the crux for assessing the next round of achievements.

The challenges for moving the health promotion agenda forward are multiple. (39) The Bangkok Charter highlighted issues for sustainable health promotion focusing on investment needed to meet the health challenges of globalization. Recently, the Nairobi Call to Action resulting from the 7th WHO Global Conference on Health Promotion emphasized a set of over 50 specific actions to support the implementation of health promotion strategies and "close the implementation gap". (40) Three implementation gaps were identified for the attention of the health promotion field: lack of evidence implemented in practice, lack of application of evidence of health impacts in public policy, and lack of sufficient capacity for health promotion practice in many countries. ** One answer to these challenges lies in the integration of the scientific and normative contents in both practice and research.

Acknowledgement: Louise Potvin is the holder of the CHSRF-CIHR Chaire approches communautaires et inegalites de sante (CHSRF-CIHR no. CP1- 0526-05).

Conflict of Interest: None to declare.

Received: February 14, 2011

Accepted: May 23, 2011

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Louise Potvin, PhD, [1,2] Catherine M. Jones, BA [1,2]

* At that time, many Canadians were collaborating with the WHO EURO office in Copenhagen rather than the Pan American regional office of WHO (PAHO) in Washington DC.

** A Primer for Mainstreaming Health Promotion. This primer was prepared as a working document for discussion at the 7th Global Conference on Health Promotion, "Promoting Health and Development: Closing the Implementation Gap", Nairobi, Kenya, 26-30 October 2009. www.who.int/healthpromotion/conferences/7gchp/documents/en/index5.html

Correspondence: Louise Potvin, Departement de medecine sociale et preventive, Universite de Montreal, C. P. 6128 Succursale Centre-Ville, Montreal, QC H3C 3J7, Tel: 514-343-6142, Fax: 514-343-5645, E-mail: Louise.Potvin@UMontreal.ca

Author Affiliations

[1.] Chaire Approches communautaires et inegalites de sante (FCRSS-IRSC), Universite de Montreal, Montreal, QC

[2.] Departement de medecine sociale et preventive, Ecole de sante publique, Universite de Montreal, Montreal, QC