Abstract
International agencies, especially those that are part of the United Nations system, issue documents, reports and statements that are often elaborated by a technical team from one or more agencies, including a previously defined expert panel. This process requires an elaborated consensus-building process that aims to avoid obstacles that can make it unacceptable, in part or entirely, to a significant number of the signatory countries. Declarations that become landmarks in the field of health are examples of this diplomatic achievement. The process of designing a declaration is an interesting object of study, including how concepts that were resisted a few decades ago become more widely accepted. Social determinants of health, social empowerment, health inequities or shifting from ‘an emphasis on individual behaviors to a broad set of social and environmental interventions’ were concepts and interventions previously foreign to mainstream theoretical frameworks of health institutions and other health bodies. The Strategy and Action Plan for Health Promotion in the context of the Sustainable Development Goals 2019–2030 (1) that was recently approved at the 164th Meeting of the Executive Committee of the Pan American Health Organization/World Health Organization in Washington, DC, 24–28 June 2019, recommended a series of important changes to the conceptual map of health policies in the Americas. Decidedly, the strategy situates health promotion as central to health policy. It also highlights that the purpose of the strategy is to renew health promotion through social, political and technical actions, addressing the social determinants of health, the conditions in which people are born, grow, live, work and age, with the goal of improving health and reducing health inequities as part of the framework of the 2030 Sustainable Development Agenda (1).
The strategy is supported by antecedents that account for the advancements of health promotion as one of the essential objectives of public health. These antecedents encompass, from 1978 to today, the 1978 Alma-Ata consensus(2), the consensus in Ottawa in 1986 (3) and the more recent agreement, the Strategy for Universal Access to Health and Universal Health Coverage (4), the WHO Shanghai Declaration on Promoting Health in the 2030 Agenda for Sustainable Development (5) as well as the 2018 Astana Declaration on Primary Healthcare (6).
The social context for the strategy of health promotion
The strategy recognizes that in the Americas there are ‘persisting inequalities’ with a prevalence of ‘chaotic urban growth’, ‘non-regulated industrial development’, ‘environmental pollution’ and ‘increase in violence’, while other obstacles are ‘displaced persons’, ‘lack of commitment and long-term intersectoral actions’, ‘limited participation and empowerment of the community’ and an ‘insufficient documented evidence of health promotion effectiveness that prevents sustainable action that transcends political frames’. The extent to which the full social situation can be characterized, nonetheless, is subject to the limits inherent to the consensus-making process. Other aspects of the current situation in the countries in the region that are not explicitly stated are recent political repression given massive social protests(7), migration of populations at an unprecedented scale in the continent (8), unemployment growth and closure of small and medium-sized businesses(9), an increase in people living in poverty and who are homeless along with the dismantling of inclusive social policies (10) and the weakening of the rule of law and democracy.
The recent report from the Economic Commission for Latin America and the Caribbean (ECLAC) on the social situation in Latin America indicates that despite the significant progress made between the beginning of the last decade and the middle of this one, since 2015 there have been setbacks, particularly the increase in the average regional rate of extreme poverty (10).
An examination of the years in which poverty was reduced and social inclusion ensured for more than 66 million people indicates that only with public policies of social protection, increased employment and income redistribution measures, can improvement in the living, working and health conditions of those who have suffered marginalization across many generations be improved.
ECLAC notes that poverty and extreme poverty were reduced considerably in the region between 2002 and 2014, as were various indicators of social inequality. This process was associated not only with a more favourable economic environment, but also with a political context in which the eradication of poverty and the reduction of social inequality, as well as the objective of broadening social inclusion and extending social protection, were given unprecedented prominence on the public agendas of many Latin American countries and, to a certain extent, the region as a whole. The rights agenda has been expanded, state action and social institutions have been strengthened, investment in social areas has been expanded and redistributive policies have been implemented in the social sphere and the labour market (10).
Positioning citizenship at the center of public policies aligns with a political conception and a horizon of society that privileges social inclusion, democracy and social equity. These values are closely linked to health promotion, as democratic societies and social justice are required for health promotion to be fully realized.
Making the strategy of health promotion a reality in the countries of the Americas
The strategy proposed by the Pan American Health Organization/World Health Organization is a conceptually, politically and technically coherent construction. There is a clear articulation between its purpose of improving the health of the population with the four strategic directions that its implementation privileges, which are to:
‘Strengthen the key healthy settings’ (among others, schools, universities, homes, workplaces, markets and other communal spaces in urban and rural territories and communities).
‘Enable community participation and empowerment and civil society engagement’ (relying on governments to commit themselves to create or facilitate opportunities that ensure the participation of the community in the decision-making that affects its members’ lives, taking advantage of their resources and capabilities).
‘Enhance governance and intersectoral work to improve health and well-being and address the determinants of health’. This strategy recognizes that governance is a relevant element for the four strategic lines. It implies, among other things, that governments have a fundamental responsibility at the local, national and global levels to formulate health and social justice policies through democratic processes that benefit the entire society and, at the same time, that address the harmful effects of unsustainable production and consumption and negative business practices (1).
This is a point of central importance to the strategy as it is demanding that the states position themselves in defense of the collective interests of citizens, possibly in opposition to the interests of private actors. This will undoubtedly be a strategic line where the viability and full implementation of health promotion as a public policy will be defined.
‘Strengthen health systems and services by incorporating a health promotion approach’. Under this strategic direction, the proposed actions cover the performance of the entire health system, from the training of its workers to the mode of care of each of the services that comprise it.
The strategic directions are broken down into actions and, of critical importance, identify indicators to be monitored and evaluated at each level of operation, from local, national, to the region as a whole. With this design, countries already have a valid instrument to move from a discourse on the advantages of health promotion to its effective implementation and achieve the benefits that it will provide in terms of quality of life and social justice.
This strategy poses an additional challenge for academic institutions, in terms of their educational responsibility and their role in building critical knowledge and facilitating social mobilization, which is to investigate and work on those obstacles that international agreements cannot explicitly mention and that constitute obstacles that segregate and marginalize vast segments of society. This challenge can be interpreted as an action plan for universities, research centers and also journals such as GHP that are committed to values of protecting human rights, justice and social equality.