Advancing the 'science of delivery' of health promotion: not just the 'science of discovery'

How can health promotion best be delivered? What are the optimal roles and responsibilities of individuals, health and other practitioners, professional associations, public and private organizations, and governments at different levels? This is a conundrum that we have been grappling with for more than two decades and are still feeling the way forward. Compared with our investment in understanding the causes and consequences of health issues and to a lesser extent the effectiveness of interventions, we have not adequately investigated the best ways to organize, manage and finance health promotion. The ‘science of discovery’ has tended to dominate the ‘science of delivery’. This is understandable given the common criticism over the last decade that ‘health promotion does not work’ or at least ‘health promotion does not work well enough’. As documented in Health Promotion International and other sources, the tide has turned with mounting evidence of the value and cost–benefit of health promotion. For example, the UK Treasury examined the economic costs of health care and the role of prevention by commissioning merchant banker Sir Derek Wanless to review the options. He suggested three different scenarios for future spending in health, with the most cost-effective—the so-called ‘fully engaged’ scenario—relying on more investment in public health and health promotion (Wanless 2002). In Australia, at the same time, the Department of Health and Ageing commissioned a study that showed impressive long-term benefits from earlier investments in tobacco control, immunization and road safety (Abelson et al., 2003). A subsequent Treasury study concluded that ‘a focus on health promotion that leads to an overall healthier population will increase labour force participation rates and labour productivity, thereby improving the wellbeing of Australians and putting health care expenditure on a more sustainable path as the population ages’ (Murphy, 2005). More recently in the United States a report released by the Trust for America's Health found that a small strategic investment in disease prevention could result in significant savings in the US healthcare costs—a return of $5.60 for every $1 spent. An investment of $10 per person per year in proven community-based programmes to increase physical activity, improve nutrition and prevent smoking and other tobacco use could save the country more than $16 billion annually within 5 years (Trust for America's Health, 2008). Building on this strong foundation of cost-effectiveness, the challenge now is to assess objectively the strengths and weaknesses of alternative delivery and capacity-building structures at local, regional and national levels. Although the delivery mechanisms for effective health promotion may be poorly researched, the tasks for health promotion have remained remarkably constant over the last 25 years. The specific challenges identified in the Ottawa Charter (WHO, 1986) are still as relevant to day—build healthy public policy, develop personal skills, strengthen community action, create supportive environments and reorient health services. These ‘agendas for action’ have commonly become the framework for many health promotion strategies at local, regional and national levels as they simply and clearly set out the mix of action that is required. An excellent example of this has recently come from Australia. A discussion document and three technical papers have recently been prepared by the National Preventative Health TaskForce (NPHT), which map out a range of priorities for action required in the areas of overweight and obesity, tobacco and alcohol (NPHT, 2008). Three complementary ways to foster health promotion were described at the First International Conference on Health Promotion in Ottawa in 1986. Health promoters were encouraged to advocate, to mediate and to enable rather than to dictate, to rule and ‘to blame the victim’. Through advocacy, health promotion action aims to make the underlying determinants of health as favourable as possible. These include political, economic, social, cultural, environmental, behavioural and biological conditions. Health promotion action also seeks to reduce the differences in current health status and to ensure equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. Finally, the prerequisites and prospects for health cannot be ensured by the health sector alone; coordinated effort is needed across all sectors—government, public, private and community. Health promoters therefore have a major responsibility to mediate between different interest groups in society for the pursuit of health. These tasks was reinforced and extended in the Bangkok Charter for Health Promotion in a Globalized World (WHO 2005) which stated: ‘All sectors and settings must act to: advocate for health based on human rights and solidarity invest in sustainable policies, actions and infrastructure to address the determinants of health build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people partner and build alliances with public, private, nongovernmental and international organizations and civil society to create sustainable actions’. When governments are weak or disorganized, there are calls for separate health promotion agencies or authorities. Then, as the capacity and engagement of governments grow, these organizations can become a competitor, disempowering central agencies and resulting in confused relationships and actions. Similarly, when health services are focused solely on treatment and care services, specialized health education/promotion units emerge to fill the gap at local level. However, over time as primary care professionals come on board and participate in health promotion, the need for specialist expertise become less apparent. Likewise, in one decade a compelling case may emerge to appoint school health education coordinators, for example, focused on drugs, only to disappear in the next. The UK and Australia provide two contrasting examples of this apparent uncertainty, but there are many other case studies that could be cited. In the early 1980s, the Health Education Council (HEC) was a strong independent voice for health promotion and disease prevention in England with its own Board of independent directors and a team of professional staff recruited specially for the tasks required. But the HEC's role never sat easily with central government; significant policy and programme disagreements emerged and then escalated. This resulted in a series of reorganizations and restructures first into the Health Education Authority, then into the Health Development Agency before the responsibilities were finally shared out between central government and other health agencies. At the same time, as the national structures in the UK were under pressure, a number of Australian States were establishing quasi-autonomous health promotion foundations, financed initially from hypothecated tobacco taxes, i.e. Victoria in 1987, South Australia in 1988, Australian Capital Territory (ACT) in 1989 and Western Australia in 1990. The momentum and interest generated by Vic Health in Victoria and Healthway in Western Australia spawned a growing number of similar agencies in other countries such as Austria, Poland, Korea, Thailand and Switzerland. Fifteen of them have since joined together as the International Network of Health Promotion Foundations (INHPF). Proposals for a nation-wide prevention agency in Australia are now gaining ascendency following the recommendations from the incoming Labor Government's 2020 Summit (Australian Government, 2008) and the report of the National Preventative Health Taskforce (NPHT, 2008). The suggested roles are similar to those elaborated by the International Network of Health Promotion Foundations (INHPF, 2008): Interestingly, the health promotion foundations established in ACT and South Australia did not survive more than a decade, and New South Wales, the most populous State in Australia, did not adopt this delivery approach. This indicates that the model may not be suitable for all situations whatever the similarity. One commonly heard criticism of a separate agency is that the engagement, commitment and capacity of central government, and the health portfolio in particular, can be weakened by this approach. Given the importance of regulatory and legislative changes and the need to influence the direction of health services through funding and service agreements, the role of Ministers and Health Departments will remain vital for advancing health promotion and prevention strategies. As the Ottawa Charter stated: ‘The aim must be to make the healthier choice the easier choice for policy makers as well’ (WHO, 1986). New health promotion structures must be careful not to weaken indispensable ones. Specialist agencies must not provide an excuse for governments to disengage from policy and funding enhancements and sideline the actions needed to improve health. Funding health promotion initiatives to promote health and prevent disease; Building of a health promotion evidence base; Flexibility and an ability to work collaboratively across sectors; Advocating for health promoting policies; Ensuring public accountability; Addressing equity issues; Trialing innovative programs in sensitive areas (drugs, sexually transmitted infections and so on) that may expose governments to political criticism. Ability to harness community involvement Ability to work with government but not as government Ability to work across a range of government departments and political parties Budget stability An impartial observer would comment that health promotion delivery mechanisms appear to be in a continual state of flux. This could indicate a lack of knowledge, confidence, commitment or all three. Alternatively, we could recognize that there will always be diversity in the delivery of health promotion and that this should be expected and indeed fostered. One standard delivery model is not appropriate because of the variable contextual, economic and political landscapes that health promoters need to work within. ‘Form must follow function’—not the reverse. Nevertheless, a few prerequisites are apparent for the optimal delivery of health promotion: These are key elements of the eight tracking indicators proposed for national capacity building for health promotion, which was a special focus of the Bangkok Conference (Catford, 2005). In moving forward, we should recognize that the solid advances in the ‘science of discovery’ of health promotion have not matched those of the ‘science of delivery’. Applied research is required urgently to assure that the additional resources that are now being invested are well used. There have been numerous natural experiments in the delivery of health promotion with both failed and successful policy and service measures—but few have been written up or analysed. Our knowledge of sustainable resourcing and funding models for health promotion are also poorly developed although a start has been made with tobacco taxes (e.g. Carol A, 2004). Over future volumes of Health Promotion International, we would like to give more attention to the neglected area of how to build stronger vehicles for delivering health promotion. In this regard, the two papers in the perspectives section of this issue, one on schools and the other on research centres, provide a useful start. Strong and engaged government health department—with high levels of administrate skills and content knowledge to drive new policies, programmes and funding mechanisms; Innovative and resourceful networks of non-governmental organizations (NGOs) and professional associations—able to advocate for new responses and assist in the delivery of programmes; Skilled and motivated primary healthcare workforce—which can reach out and provide relevant services to the whole population and those particularly at risk; Applied research and development organizations—able to monitor progress, and develop evidence-based solutions and support their effective dissemination and uptake; Relevant and responsive education and training bodies—focused on developing ‘best practice’ knowledge, advanced practical and leadership skills and relevant industry experience; Informed and empowered communities and civil society stakeholders—able to respond to and participate in opportunities to improve health and wellbeing. National policies and plans: national government policies and plans for health promotion priorities, which embrace the underlying concepts of the five Ottawa Charter strategies. National leadership: core of expertise and leadership within the national Ministry of Health for health promotion development, coordination and partnerships. Joined up government: coordinating mechanisms within the Ministry of Health and across national government for policy development and plan implementation for health promotion priorities. Programme delivery: delivery structures and mechanisms for health promotion priorities at national and/or sub-national levels, including support for inter-sectoral partnerships. National partnerships: national partnerships among NGOs, civil society, private sector and government for health promotion priorities. Professional development: national-level advanced education and training programmes, and a professional association for health promotion practitioners, policy makers and researchers. Performance monitoring: national-level research and evaluation, and information systems to track and report on health indicators relevant to health promotion policy, priorities and programmes. Sustainable financing: transparent and sustainable source of public financing for health promotion priorities at national or sub-national levels. In conclusion, may I thank all the authors, reviewers and members of the editorial team for giving so freely of their time and in making Health Promotion International such a vibrant and ongoing success. Now entering our 24th year we have demonstrated sustained quality and performance. A special vote of thanks goes to Lawrence St Leger who is stepping down as Associate Editor. Lawry has given thousands of valuable hours to advancing the art and the science of health promotion. We are indebted to him for his commitment, professionalism and good will.