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- Public Policy and Health
- A Renewed Focus on Public Policy
- Health Promotion and Health Policy
- Signs of Change: Health Promotion and Healthy Public Policy
- What Has Been Learned
- Acknowledgements
- References
Public Policy and Health
Policy, police, politics – the words have a common root. They suggest forms of action and control. Foremost, policy entails the enunciation of principles, stating outcomes or ends that are valued. It implies a measure of social regulation and standardisation. A policy specifies deliberate intentions, it sets goals, it limits and defines choices, it implies the giving of orders, and it involves accountability. 1
Policy, police, politics – the words have a common root. They suggest forms of action and control. Foremost, policy entails the enunciation of principles, stating outcomes or ends that are valued. It implies a measure of social regulation and standardisation. A policy specifies deliberate intentions, it sets goals, it limits and defines choices, it implies the giving of orders, and it involves accountability. 1
The central role of public policy in influencing the health of populations emerged during the 19th century. During this period, legislation and engineering combined with public health advocacy led to environmental changes that had a significant positive impact on the health of the populations of the emerging industrial cities of Europe.
The provision of clean water, sewerage and waste disposal systems, improved public housing and food safety regulations all had substantial public health benefits. These advances were followed by the development of social welfare systems, the provision of free school education, and legislation governing working hours and conditions (for those in paid employment). In each case these policy directions had both direct and indirect benefits for the health and well-being of the majority of the population.
By the middle of the 20th century most developed countries had achieved control of the major causes of communicable disease and associated premature mortality across most of their populations. Non-communicable diseases, with their causes seemingly based on individuals’ lifestyle choices, began to predominate as major causes of premature mortality and morbidity. Biomedicine appeared to offer the greatest hope for addressing these issues. Health policy goals became focussed on the provision of health care services and on ensuring widespread (if not universal) access to services and programmes. The link between public policy and population health outcomes became less obvious than it had been in previous decades. Responsibility for improving the health of the population was vested in health care services, with little reference to the roles of other sectors. Access to high quality health care services was viewed as the central means by which further significant improvements in the health of populations was to be achieved.
By the 1970s, however, it had become apparent that the rapid growth in investment in health care services was not delivering the hoped for improvements in the health of populations. The increasing costs of providing high quality health care services (particularly hospital services) and the challenge of ensuring equal access to these services by the whole population caused governments to begin to review the directions of health policy in the 1980s.
Many countries, including Australia, began to re-think the limits of medicine and the relative importance of formal health services and health services policy in improving the health of the population. 2 , 3 , 4 This disillusionment with the existing services, programmes and policies for health found an outlet through the development and articulation of the contemporary concept of health promotion. 5
A Renewed Focus on Public Policy
In 1986 the Ottawa Charter for Health Promotion provided a contemporary model for effective public health action – defining health promotion as a combination of strategies that included ’healthy public policy’ alongside established approaches such as ’developing personal skills’ and mobilising communities for change. It was entirely appropriate that the Charter was developed in Canada, as the Canadians had played a leading role in the 1980s in revisiting the roots of public health, and re-focussing attention on the underlying social, economic and environmental determinants of health. 6 As a result, the Charter reflected the role of public policy in shaping the economic and political environments which so profoundly influence the health of individuals and populations. 7
The Charter drew attention to the fact that healthy public policy is characterised by an explicit concern for health and equity in all areas of policy. The main aim of healthy public policy is to create supportive environments to enable people to lead healthy lives. Such policy makes healthy choices possible or easier for citizens. It makes social and physical environments health enhancing. 8 And health promotion has come to be understood as public health action which is directed towards improving people’s control over all modifiable determinants of health.
Health Promotion and Health Policy
Such a strategy has posed major challenges for health promotion practitioners, most of whom work within the constraints of the health sector and prevailing health policy. The health sector’s agenda is dominated by a biomedical paradigm that identifies needs in terms of individuals’ illness and proposes solutions in terms of the provision of health care services. This has meant that within the health sector, health promotion has been a marginal activity with limited capacity to influence either the goals of government investment in health, or the distribution of health sector resources. The last decade has, however, seen growing understanding within the health sector of the relationship between individuals’ health and the social and environmental determinants of health. There are some signs of recognition that the biomedical approach must be complemented by a population health approach if further progress in improving the health of Australia’s population is to be achieved.
It was not until the mid 1980s that Australian health policy showed signs of committing the health sector to being accountable for improving the health of the population, in addition to being accountable for the provision of health care services. This gradual shift is most apparent in Australia’s history of using national health goals and targets to determine priorities for public health action and investment. The first national attempt was published in 1988 in the Health for All Australians Report. 9 This Report set goals and targets relating to major causes of premature death and morbidity, and major behavioural risk factors. Targets were only proposed in areas where substantial national health statistics existed, and for these reasons made little progress in identifying the possibilities for change in the social, economic and environmental determinants of health referred to above.
The Commonwealth Health Department commissioned a review of these targets in 1991 which led to proposals for a major revision in a Report Goals and Targets for Australia’s health in the Year 2000 and Beyond published in 1993. 10 This report not only included revisions to many of the originally proposed health targets concerning premature mortality and morbidity, and behavioural risks, but also proposed two new categories of health targets concerned with personal health literacy and healthy environments. The Report made a strong case for co-ordinated public health action to address all of the determinants, particularly by adding to existing efforts to promote health literacy and healthy individual lifestyles with matching attention to the creation of healthy environments through public policy changes across government.
The subsequent history of this Report and its proposals is somewhat mixed and highlights very clearly the tensions and challenges of operating outside a narrowly conceived concept of health policy. The Report itself served as a catalyst for the inclusion of a commitment to development of national health goals and targets as a part of the Medicare Agreement between the Commonwealth Government and States and Territories in 1993.
Thus for the first time Australia had a health policy statement concerning desired national health outcomes within the legislative agreement that governs the release of resources for the publicly funded health system. The Agreement committed the Commonwealth and States to a process leading to finalisation of national health goals and targets in a limited number of priority areas within one year. The product of this effort, Better Health Outcomes for Australians, 11 is disappointing in many respects, particularly in the extent to which it fails to adequately encompass the social, economic and environmental determinants of health, which were a prominent feature of the recommendations from the review which preceded it. The report acknowledges that ’improvement in the social and environmental determinants of health has the potential greatly to reduce health inequalities between population groups’, but rather lamely concluded, ’the healthy environments concept, in its broadest context, has not been addressed within the current national health goals and targets process. A mechanism will need to be found to ensure that this important area is addressed’. 12 No such mechanism has been found to date.
As a result, the health policy framework within which health promotion operates remains dominated by ’risk factor’ or hazard identification and reduction – with the consequence that ’high risk’ approaches have tended to dominate debate in key fields such as illicit drug use or sexually transmitted infections.
Signs of Change: Health Promotion and Healthy Public Policy
What is apparent from the evolution of the health promotion concept, and the corresponding analysis of factors influencing the health of Australians referred to above, is that public policy made by and implemented by other sectors of government and private industry has a greater impact on the health of individuals and populations than does health policy. This fact is at the heart of public health strategies promoted through the Ottawa Charter. Public policy, in this view, is not within the ’control’ of the health sector although clearly, the health sector can and sometimes does, have considerable influence as one of the key stakeholders.
Australia has had some notable successes in implementing public policy changes in response to identified health problems. These included policies to address road safety, tobacco use and occupational health and safety. Many of these policy changes were initiated by people from outside the health sector although health professionals have played a role in each. 13
The goals of such policies have ranged from behaviour change (wearing sun hats or bicycle helmets); to environmental change (provision of shade in public places; banning smoking on public transport; banning the sale and consumption of alcohol in communities); to structural change (increased taxation on cigarettes; enforcing laws banning the sale of cigarettes to minors); to organisational change (food supply at sporting venues).
The processes through which policies have been developed and implemented have differed greatly too – with some being the result of national community-based action (gun control); some being the result of consensus within a specific community (banning alcohol sale and consumption); and others being the result of advice (and public advocacy) from professional groups (seat belts; drink driving; banning tobacco advertising).
Despite these obvious successes, it is also clear that much public policy is made without reference to its impact on the health of communities and populations. There is a growing interest in the assessment of ’health impact’ as a precursor to the development of public policy and some encouraging signs of its gathering strength as an area of research. 14
Even when it is possible to assess the potential or actual health impact of specific policies, however, there will still be a need for the health sector to collaborate effectively with other sectors. While there are some notable examples of successful collaboration in Australia between the health and other sectors these are still the exception rather than the rule.
What Has Been Learned?
There is still considerable work needed to develop public policy, including health policy, in Australia that is directed to improving the health of the population and more particularly, to reducing inequalities in health.
Health promotion has the potential to contribute to the process of developing effective policy (through its community development and mobilisation strategies), to the content of policy (through evidence of what works), and to ensure that policy implementation is also effective (through evaluation of implementation). Moreover, a fundamental principle of best practice in health promotion is the active engagement of communities in all aspects of health promotion work. The consultation processes and community mobilisation used to define needs, to generate solutions and to oversee and review the implementation of health promotion programs have been recognised by governments as fundamental to effective policy development and implementation at all levels and across sectors. Health promotion practitioners’ work at local levels with diverse communities, too, potentially prepares us well for wider engagement in developing and implementing healthy public policy. As evidence of the effectiveness of health promotion grows 15 , 16 so are its proponents being invited, increasingly, to participate in the development of health (and public) policy in Australia 17 (and internationally). Health promotion professionals’ and communities’ experiences in implementing effective health promotion have resulted in the identification of the knowledge and skills that are needed to contribute effectively to the development and implementation of healthy public policy.
Public policy can be a powerful tool for promoting health but it is not always effective. Australia’s experience appears to demonstrate that policy change is most effective when it is introduced to support changed community attitudes (rather than to lead) and when the policy is supported by active and on-going measures of reinforcement or enforcement. It follows that there is need to develop a strong public health presence in policy discussions in a wide range of portfolios and settings. It should include activities directed toward building a constituency for change at the grass roots level as well as within the political system. 18
Our experience in Australia has identified several prerequisites that appear to determine the likely effectiveness of public policy as a health promotion strategy:
- evidence that the proposed ’solution’ will address the problem effectively
- political/health sector commitment to address the problem and to apply the proposed solution
- a high level of public awareness of the problem or issue and of the proposed solution
- a high level of public support for the implementation of the proposed solution
- agreement among all sectors/organisations with a stake in the solution about the proposed action and each sector’s contribution or role in this
- action by these sectors and organisations to enable or support action by individuals and communities
- a high level of voluntary adoption of the proposed solution by individuals and organisations
- a high level of public acceptance of the introduction of policy to support or enforce action on the part of the whole community
- enforcement or follow up of the implementation of the policy to ensure adherence.
Clearly, there are examples of effective public policy that do not fulfil each of these conditions. Nor is the introduction of public policy as rational as this list of conditions might imply.
However, such a list is a reminder of the interaction between policy and the other strategies of the Ottawa Charter for Health Promotion (and the later Jakarta Declaration). The most effective policy is that which is grounded in a strong constituency in the communities that are most affected. This, in turn, presupposes that individuals and communities have the knowledge, skills and collective capacity to participate in developing policy.
In summary, public policy has played and continues to play a significant role in promoting the health of populations. The challenges to health posed by the globalisation of economic, trade and industry policies require health promotion and public health professionals to become more vigilant in identifying the contributing policy development processes. 19 Having identified the processes, health promotion practitioners must build their own capacity to influence policy directions, to work with communities to develop alternative ’solutions’ to public health problems and to negotiate to ensure that the solutions are adopted.
Recognising and supporting diversity and encouraging individuals, communities and nations to participate in all decisions affecting our lives and health are fundamental challenges for the future. The goals of equity and justice for all people remain at the heart of health promotion. As the earliest public health activists demonstrated, public policy can be a powerful instrument for improving the health of populations. The challenge now is to ensure that public policy is an instrument for achieving equity and justice for all rather than an instrument of oppression and inequality.
Acknowledgements
The authors would like to thank Mr Shane Hearn and Dr Lynne Madden for their helpful comments on the paper.
References
- Leeder SR. Health promoting environments: the role of public policy. Aust NZ J Public Health, 1997;21(4):413–4
- McKeown T. The role of medicine: dream, mirage or nemesis. Oxford: Basil Blackwell; 1979
- Lalonde M. A new perspective on the health of Canadians. Ottawa: Ministry of Health and Welfare, 1974
- Better Health Commission. Looking forward to better health. Canberra: Australian Government Publishing Service, 1986
- World Health Organisation. A discussion document on the concept and principles of health promotion. Health Promotion International 1986; 1(1): 73–76
- Lalonde M. A new perspective on the health of Canadians. Ottawa: Ministry of Health and Welfare; 1974.
- Legge D. Globalisation: what does ’intersectoral collaboration’ mean? Aust NZ J Public Health 1998;22(1):158–162
- World Health Organization. 2nd International Conference on Health Promotion. Report on the Adelaide Conference. Geneva: World Health Organization; 1988
- Health Targets and Implementation Committee. Health for all Australians. Canberra: Australian Government Publishing Service; 1988
- Nutbeam D, Wise M, Bauman A, Harris E, Leeder S. Goals and targets for Australia’s health in the year 2000 and beyond. Canberra: Australian Government Publishing Service; 1993
- Commonwealth Department of Human Services and Health. Better health outcomes for Australians. National goals, targets and strategies for better health outcomes into the next century. Canberra: Australian Government Publishing Service; 1994
- Commonwealth Department of Human Services and Health. Ibid, p18
- National Health and Medical Research Council. Promoting the health of Australians. Case studies of achievements in improving the health of the population. Canberra: National Health and Medical Research Council; 1997
- Merseyside Health Action Zone. 2nd UK Health Impact Assessment Conference, October 1999. Organised by the Liverpool, St Helens and Knowsley, Sefton and Wirral Health Authorities, The University of Liverpool, Liverpool School of Tropical Medicine, Liverpool John Moores University; 1999
- National Health and Medical Research Council. Promoting the health of Australians. Case studies of achievements in improving the health of the population. Canberra: National Health and Medical Research Council; 1997
- International Union for Health Promotion and Education. The evidence of health promotion effectiveness: shaping public health in Europe. A report for the European Commission. Brussels-Luxembourg: European Commission; 1999
- National Public Health Partnership. Conversations with advisory group members. The Australian Association of Health Promotion Professionals. In: News (March). Melbourne: National Public Health Partnership; 1998
- Legge D. Globalisation: what does ’intersectoral collaboration’ mean? Aust NZ J Public Health 1998;22(1):158–162
- Labonte R. Globalism and health: threats and opportunities. Health Promot J Aust 1999;9(2):126–132
