Strengthening public health capacity through a health promotion lens

Public health systems across the world are under severe pressure. Although most health systems are still largely focused on treatment, cure, and care (Beaglehole and Dal Poz, 2003), the growing burden of non-communicable diseases, with a double burden of chronic and infectious diseases in low- and middle income countries, creates increasing and shifting demands on health care and public health services. At the same time, widening health inequalities, increasing antimicrobial resistance, and globalization are a threat to the very existence of the global public health system (Garrett, 2003). Rampant infectious disease such as the H1N1 influenza pandemic of 2009, the outbreaks of Ebola in West Africa and of the Zika virus in the Americas, and the recent cholera epidemics in Yemen and Cote d’Ivoire, bring out the shortcomings of the ability of health systems to prepare for and respond to public health emergencies. Addressing these challenges will require a reorientation of health services, with a more prominent role for public health and health promotion. But to strengthen this role, a better understanding is necessary of the specific capacities that are needed and of the training facilities, career opportunities, and professional organizational support that must be mobilized to establish these capacities. In January 2017, the European Regional Office of WHO convened a 2-day expert meeting in Copenhagen with organizations and experts from the international public health community. The purpose of the meeting was to establish a ‘Coalition of Partners’ that will take on the formidable task of strengthening public health capacities and services. The focus of the initiative will initially be on Europe, but it is obvious that its significance will not be limited to the European Region. The need for strong, comprehensive public health services does not come about by chance. Strong national health systems and a competent public health workforce have been considered key conditions for the delivery of effective public health services for decades. Their importance has been attested in the European Union’s (EU) second and third Health Programmes (European Commission, 2007, 2014), which emphasize a need for strengthening training and public health structures in the Member States. More recently, they have been underscored by World Health Assembly Resolution WHA69.1 (2016), which considers effective and comprehensive public health services a means to support the achievement of universal health coverage in the context of the Agenda for Sustainable Development. Already in 2012 WHO-EURO adopted the European Action Plan for Strengthening Public Health Capacities and Services (EAP-PHS) as a key pillar to implement Health 2020, the policy framework for health in the European Region. Central to the EAP-PHS are ten Essential Public Health Operations (EPHOs), which provide a conceptual framework for the delivery of public health services. However, a mid-term progress review on implementation of the EAP-PHS made clear that their potential remained largely unrealized (WHO, 2016), and that there is a gap between the stated level of political commitment to strengthen public health services and the actual resources allocated to them. To accelerate the strengthening of public health services, the report goes on, there should be a stronger focus on the ‘enablers’ of these services, which include governance for health and health equity, financing of public health services, public health legislation, organization of the delivery of public health services, and a professional public health workforce. The Coalition of Partners (CoP) will develop an agenda that sets out joint objectives co-owned by WHO/Europe, the Member States and the partner organizations, and agreed-upon actions that will be delivered through collaborations between members of the coalition, thus enabling the pooling of resources and expertise. For health promotion, the work of the CoP presents both an opportunity and a challenge. It is an opportunity, first of all, because strengthening public health capacities creates a real chance to strengthen specific health promotion capacities. As health promotion continues to gain importance within public health (McQueen and Kickbusch, 2007), the need for more capacity to deliver health promotion was already firmly embedded in the EAP-PHS. A stronger focus on the enablers of health services can only enhance the strategic importance of a whole-of-government and whole-of-society approach. Health improvement should thereby be seen as part of all health governance activities, and decision-making should reflect the underlying principles of human rights, social justice, participation, partnership and sustainability. Second, the CoP provides an opportunity to showcase the achievements of the health promotion community with regard to identifying and defining core professional competencies. Unlike other domains of public health, health promotion has managed, through the joint efforts of the International Union for Health Promotion and Education (IUHPE) and the Society for Public Health Education (SOPHE), to establish a consensus on an elaborate and detailed set of core competencies that health promotion specialists need to possess. These core competencies, which reflect input from a range of countries from across the world, are set out in the Galway Consensus Statement (Allegrante et al., 2009; Barry et al., 2009; IUHPE 2009). Building on this shared vision, a comprehensive set of professional standards has been developed through the EU-funded CompHP project. Along with this, a full-blown accreditation mechanism for health promotion specialists and university courses has been set up (Battel-Kirk et al., 2011). This accreditation system, which is currently being rolled out worldwide, is unique in the public health domain and can serve as a valuable inspiration for other public health areas. Lastly, the CoP also provides an opportunity to look at the process of capacity building through a ‘health promotion lens’. Capacity building is a well-known concept in health promotion, more than in other domains of public health. Although it was not invented by health promotion specialists, they were amongst the first to introduce it in their work, as it very well reflects the emancipatory focus of health promotion. Capacity building shifts the focus from directly trying to influence the health of the population towards enabling systems and networks to promote health in a self-determined and sustainable manner, thus enhancing, prolonging and multiplying the health effects of actions undertaken (Labonte et al., 2002). The added value of a capacity building approach, compared to the health outcomes achieved by singular educational interventions, was already highlighted in a seminal paper by Hawe et al. (1997) and further developed in a series of attempts to conceptualize and assess health promotion capacities by scholars from different parts of the world (Alwan et al., 2001; La Fond et al., 2002; Catford, 2005). A review of these frameworks by Aluttis et al. (2014) resulted in the identification of seven core domains for public health capacity: resources organizational structures workforce partnerships leadership and governance knowledge development, and country specific context. Each of these domains can be further broken down into a number of sub-components, which provide more in-depth insights into the dimensions of public health capacity. By virtue of its systemic and holistic nature this framework looks at capacity building from a health promotion perspective. As such, it can serve as a theoretical guide for the organizations and experts participating in the CoP to assess capacities at regional, national and international level, and to mainstream specific health promotion principles and competencies into the training curricula and professional standards of public health specialists. Despite these opportunities, strengthening public health capacities and services by mainstreaming health promotion also presents the challenge of preserving the unique identity of health promotion. Experience from the UK and Canada has shown that mainstreaming the ideas and methods of health promotion within the broader field of public health can result in the weakening of its organizational capacity, and to it being absorbed into a traditional, individualized public health discourse, dominated by other, usually medical, professions (Jackson, 2011). The same has also occurred in international agencies like WHO and PAHO, where mainstreaming health promotion as a cross-cutting theme across the organization resulted in a loss of dedicated champions, visibility and power (Davies, 2013). In some cases even the term ‘health promotion’ disappeared: in England, it has been replaced by ‘health development’ and, later on, by ‘health improvement’; in Canada the term ‘population health’ was introduced as an alternative, and Australia it has regressed to ‘preventative health’. This potential loss of identity is related to the unclear disciplinary status of health promotion. Health promotion has been varyingly described as a social movement, an ideology, a field of practice delineated by commitment to key values, and a profession (Green and Tones, 2010), but it is the attempt to consider it as a discipline that seems to be the most disputed. Some scholars think that health promotion cannot be considered a scientific discipline because it lacks a distinctive institutional structure, an operational accreditation system, and an oversight by a professional body. This means that de facto anyone can call him/herself a health promoter (Potvin and McQueen, 2007). On the other hand, health promotion does have its own university programmes and courses, handbooks, journals (including this one), a series of global conferences and numerous regional conferences, dedicated Non-Governmental organizations (including the IUHPE), and a number of national Foundations (e.g. in Switzerland, Thailand, Tonga and Victoria Australia), all supporting its development as a discipline. And as already mentioned, the accreditation system developed for health promotion specialists and courses developed through the CompHP is gradually being implemented worldwide. As Davies (2013) recalls, a field of study can be considered a discipline when it possesses its own specific knowledge domain, history, value base, traditions, codes of conduct, and preferred research methods. To be considered a profession, it needs a recognized workforce, professional competency and capacity-building methods. Health promotion certainly has developed its own set of concepts and values, which crystallize around the paradigm shift it introduced from an individualistic to a holistic and emancipatory approach that relates to equity, social justice, participation and empowerment. It also favors a methodology that extends the notions of ‘best evidence’ used in (evidence based) medicine to other kinds of information, which better capture the complex interactions between various determinants of health situated at different levels. But as a study domain, health promotion is not yet based on a single paradigm with its own epistemological, theoretical and methodological foundations. Instead, its theoretical and disciplinary roots are borrowed from longer established disciplines, such as sociology, psychology, education science, political science, communication science, marketing and ethics (Bunton and Macdonald, 2002). As such, health promotion is at best an emerging discipline (Nutbeam, 2002). To reach disciplinary status and attain a separate professional entity, health promotion should tread carefully and not ‘sell its soul’ to public health. Yet at the same time, it should not be insular and miss the opportunities that arise from contributing to strengthening public health capacities. One way to solve this conundrum is to differentiate more clearly between specialist and mainstreamed health promotion. The first refers to a scholarly body of knowledge and practice, with its own specialists at both academic and professional levels, while the second designates health promotion as a social movement, embedded in the work of people inside and outside the health sector who work to promote health as defined by the Ottawa Charter, regardless of their professional designation (Davies, 2013). The contribution of health promotion to public health development lies precisely in the complementary nature of these two approaches. On the one hand, mainstreaming health promotion can ensure that the holistic and empowering approach of health promotion, with its emphasis on equity, social justice, and participation, finds its way in the broader public health domain, and is reflected in the training curricula and professional standards of public health specialists. On the other hand, training and supporting a core body of health promotion specialists within academia, policy and practice settings can help to maintain the identity and traditions of the emerging discipline, and further advance the body of knowledge, values, competencies and research methods that make health promotion unique. This unique contribution of health promotion is not just an intellectual exercise, but reflects a true academic and societal need. In recent years, a growing number of scholars in political sociology and related fields have voiced their criticism that, by mimicking the natural sciences, social science research has disconnected itself from the real world. As an alternative, they propose a ‘phronetic’ social science (from Aristotle’s notion of phronēsis), which goes beyond analytical (episteme) and technical (techne) knowledge to focus on real world problems as people experience them (Schram et al., 2013). In a similar way, public health should steer away from an overly analytical and technical approach to addressing the health of the population, and focus on health as it is experienced by the people themselves. As such, the public health capacities that need strengthening must be intimately connected to the needs of individuals, organizations, communities and networks that are involved, and should ultimately enable them to promote health in a self-determined and sustainable manner. Health promotion is the only (sub) discipline within the field of public health that is principled enough to take on that challenge. The continuing development of health promotion as a specialist discipline can thus nurture the broader group of mainstreaming health promoters, but does not preclude health promotion to develop as a discipline and establish collaborations and alliances with other disciplines. As the pre-eminent journal representing the field of health promotion, Health Promotion International supports this process by publishing research that is cutting edge and inspirational, while adhering to the values and ethos of health promotion. The journal welcomes articles that not only study and write about these processes, but also put them to practice. Research that integrates collaboration, for instance in the form of participatory action research, is particularly relevant, as are studies that highlight the political ethics of public health. This issue of the journal again presents some fine examples of such research. For instance, the article by Dumrongpanapakorn and Liamputtong (2017) shows that trying to understand and being sensitive to the experiences and challenges of women with breast cancer enables health care professionals to provide more individualized support for women during a vulnerable period of their life. The case study by Nathenson et al. (2017) describes how an innovative market-based intervention changed the gender dynamics in a Kenyan fishing community, and empowered women who previously had few alternatives to exchanging sex to purchase the best fish. It thus demonstrates that even small approaches addressing the root causes of economic and social inequality can improve health and promote sustainable economic development. Holt et al. (2017) present interesting ethographic fieldwork which shows that intersectoral policymaking to address the social determinants of health tends to favor smaller-scale interventions in various settings, while more overarching interventions on the health impacts of broader welfare policies tend to be neglected. All of these are only examples of the rich and varied array of contributions that collaborative, participatory and principled health promotion research can make to public health, with a view to return the focus on health as it is experienced and created by individuals, organizations, and communities.