A watershed for health promotion: The Shanghai Conference 2016

HEALTH PROMOTION AND THE SDGS

The 9^th WHO Global Conference on Health Promotion - held in Shanghai, China in November 2016 - was extraordinary. It was held almost exactly 30 years after the first Global Conference in Ottawa, Canada that produced the Ottawa Charter (WHO 1986). The Ottawa Charter brought about a genuine paradigm shift in thinking about how to improve public health. The Shanghai Conference could prove to be another watershed for public health action if the ideas and commitments developed at the Conference are taken forward and acted upon meaningfully. The Conference centrally positioned health promotion within the 2030 UN Agenda for Sustainable Development (UN 2015). The actions required to achieve the UN Sustainable Development Goals (SDGs) set the direction, tone and aspirations for the meeting. Critical actions proposed for member states at the national level will need to be complemented with a localized implementation agenda spearheaded by cities; and a strong joint global purpose, led at the United Nations through the SDGs.

The Director General of the WHO Margaret Chan - and many other high level speakers – made clear that the SDGs provide a unique opportunity for addressing health and its many determinants in an integrated and transformative way. This Agenda sees eradicating poverty in all its forms and dimensions as the greatest global challenge, and identifies “ensuring healthy lives and promoting well-being for all at all ages” as one of the most important indicators of progress on our collective journey during the next 15 years. World leaders have committed to leave no one behind. There was a real sense from the Shanghai Conference that the contemporary challenge and opportunity is to convert the Ottawa health promotion action areas into modern tools and methods that will contribute towards the achievement of the SDGs. The two Declarations adopted in Shanghai provide a road map for countries to act on the SDGs in a transformative way.

The Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development (WHO, 2016a) makes clear the continuing relevance of health promotion. At the core of the Declaration are clear statements advocating improved governance for health at all levels; the development of Healthy Cities that are inclusive, safe and resilient for the whole population; and the importance of health literacy that empowers individual citizens and enables their engagement in collective health promotion action. Inevitably, such a document is bound by some of the checks and balances of political consensus building. But the Declaration is unambiguous in its description of the tough political choices faced by decision makers and advocates unashamedly for health in the face of other interests.

The Shanghai Consensus on Healthy Cities (WHO 2016b) is an equally powerful statement of intent that clearly identifies the role of cities in delivering practical, local actions to address the SDGs and through such action, address the social determinants of health.

HEALTH PROMOTION IS ON THE POLITICAL AGENDA

These formal outcomes from the Conference were developed through a process leading up to the conference, including broad on-line consultations, advisory meetings and consultations with member states. This was different from many previous health promotion conferences which were mainly focused on achieving a consensus between conference participants. In Shanghai it was evident that the aspiration voiced at Ottawa to “put health high on the political agenda” had taken significant strides forward. Now the political choice for health has to be addressed at every level of government.

But having health “high on the political agenda” is not without its risks and challenges, as anything that is political will be. The Shanghai Conference demonstrated that political commitment to health promotion has found many different expressions in different political systems. Context specificity is critical. Whereas the social and political context from which the Ottawa Charter emerged was relatively homogenous, in Shanghai cultural and political differences in the conceptualisation of health and health promotion were clearly observable. The political realities, economic pressures and the very different political and economic systems operating in countries that are trying to address the SDGs were clearly recognised. Policy makers from around the world shared their experiences, their successes and the difficulties they have encountered in implementing the vision of the Ottawa Charter.

These real world differences were observable in many ways. There was some irony in the enthusiastic discussions of exciting innovative approaches to use digital media for health promotion at the same time that participants were unable to access their social media accounts (notably twitter) in China. Participants heard just how divergent the reality of women's rights still is in many countries. Participants heard about conflict resolution and the need to have enabling legislative frameworks for participation, but also of vulnerable groups, such as indigenous people who have been systematically excluded from the mainstream. Participants also heard about the harsh impacts of economic policies that disregard people.

A MESSY PLACE

The success of the Shanghai Conference in putting health high on the political agenda took participants into much more uncomfortable and messy places. Places where the purpose and meaning of health promotion is being re-interpreted, and the nature of leadership and practical action on the SDGs taking varied and, in some cases, unfamiliar forms. Those at the conference were challenged to keep health promotion values and ethics in mind, but to have an open mind and open discussions, to be willing to engage, listen, and where possible, find ways to adapt established ideas and methods in response to these social, political and economic differences between nations and communities.

Indeed, it seems as if the centre of gravity of health promotion is shifting. The most obvious demonstration of this came from the political commitment of the host country China. The prime minister himself came to give the message of China's recently adopted 2030 strategy for health - the largest country in the world with 20% of the world's population has committed at the very highest political level to promoting the health of its population. The middle income economies and the Asian tigers are rapidly moving forward in promoting health, improving urban environments and addressing environmental challenges – this was tangible and observable from the presentations by Ministers from different sectors and Mayors from these countries. The “original” Ottawa Conference countries are no longer in the lead.

Inevitably, there were participants who were unhappy and uncomfortable with aspects of the Conference - that not everything presented here was “pure” and “real” health promotion; that health promotion was being hijacked as a term of convenience to describe outdated, regressive methods and approaches. There is some truth to be found in this criticism, but it should actually be turned around: it is a continuous challenge for health promotion professionals and advocates to demonstrate how it can be done better and how health promotion ethics can be upheld. All of us must continue to challenge politicians that will not support health and to support those politicians that are willing to move forward and raise the priority given to health - so that they chose those equity based and integrative strategies which will bring them success. Many of the ministers and politicians present at the conference expressed this and welcomed the learning that was possible for them at the conference.

HEALTH PROMOTION HAS BEEN POSITIONED AT THE CENTRE OF THE SDGS

The Ottawa Charter was transformative in establishing new approaches to public health. The Shanghai Declaration builds on this legacy but challenges the health promotion community to demonstrate that these concepts, principles and strategies are capable of adaptation and implementation in countries around the world. The SDGs have been developed to ensure that all human beings can fulfil their potential in dignity and equality and in a healthy environment. Never before has the promotion of health been placed so clearly at the centre of a global agenda that will transform our world: SDG3 aims to “ensure healthy lives and promote well-being for all at all ages”. The Shanghai meeting was the first major WHO event to put the co-dependencies that exist between the achievement of improved health and the achievement of all of the SDGs onto centre stage.

Through the Shanghai Declaration the participants pledge to accelerate the achievement of the SDGs “through increased political commitment and financial investment in health and its determinants”. These priorities reflect the damaging effects of unsustainable production and consumption that compromise health, and restrict options for the implementation of the SDGs - making clear that profit must not stand above people’s health and well-being. Action to promote health increasingly requires global health action - the SDGs are based on this premise of collective action. This includes making global health governance transparent, fairer and more reasonable and “tightening regulation on health-impairing investment and trading activities through fiscal, taxation and financial policy tools”. Indeed, it was even proposed to conceive of NCDs as a global health emergency of international concern given the same urgency and resource commitment previously only applied to infectious disease outbreaks. This sets tough new challenges and provides an extraordinary opportunity for health promotion approaches to move centre stage.

A STRONG FOCUS ON THE LOCAL – CITIES AS A PLATFORM

A unique feature of the Shanghai Conference was the incorporation of a meeting of more than 100 city Mayors from all regions of the world to exchange ideas and experiences in creating healthy cities, and to locate these discussions in the context of the SDGs. Rapid urbanization in many countries has meant that an ever increasing proportion of the world’s population lives in cities, and depend upon their effective functioning for life’s necessities. Through their Consensus statement the Mayors at the Conference accepted political responsibility to create the conditions for every resident of every city to lead more healthy, safe and fulfilling lives. The Mayors also recognized that cities are places where planning and policy-making is closest to communities and must, therefore, meaningfully incorporate communities’ views, voices and needs.

Impressively, the Mayors acknowledge that “health is created at the local level in the settings of everyday life, in the neighbourhoods and communities where people of all ages live, love, work, study, and play…. The good health of its citizens is one of the most powerful and effective markers of any city’s successful sustainable development. This puts health at the centre of every mayor’s agenda.” The Mayors present at the conference committed to sharing experiences and best practices to bring together global and national goals with local plans and programs. They asked the World Health Organization to support them in this effort and to strengthen its healthy city networks in all regions.

NEW DIMENSIONS OF HEALTH PROMOTION ACTION

The potential of “smart” and digital approaches to bring positive health benefits to more people permeated the conference. There were some sessions that were overtly dedicated to specific technical ideas, for example in using big data to better understand the determinants of health in populations, and to plan for health and healthy cities. Throughout the Conference the great potential of digital technologies to enhance, accelerate and expand access to critical information surfaced time and again. Major ethical challenges in relation to data access and data privacy were also raised.

Health literacy was given a broad scope at the conference - through enhanced access to information citizens are better placed to improve their health literacy in ways that are meaningfully empowering – not only in supporting better informed decisions about their health and the health of their families, but also enabling citizens to better understand and assess the health impact of policies and political decisions, and to hold political leaders and policymakers to account.

The debates on health literacy also opened up new arenas to take health promotion beyond a focus on the NCDs - HIV AIDS, infectious diseases, anti-microbial resistance, responding effectively to health crises. It became clear that all national and international priorities for health can benefit from the strategies developed under the umbrella of health promotion: empowerment, community action and health in all policies. Perhaps one of the greatest challenges for health promotion is to come to terms with this mainstreaming.

THERE IS A NEW SENSE OF URGENCY

Some of the young health promotion leaders at this conference were not yet born when the Ottawa Charter was adopted. They are ready to take on leadership. They have grown up with the experience of the deep inequalities that haunt our global and national systems and can easily observe the exploitation of our planet to an extent that our own survival is no longer ensured; a highly commercialized world where profits often come before people; a world where major gender inequalities persist. For them, health promotion needs to be part of an agenda for change that takes us from the local to the global into areas of finance, trade and investment policy; and agenda that tackles policy incoherence between health and trade, irresponsible business practices, corruption; and an agenda that leads to sustainable production and consumption and fairer economic models. The next steps have to be ambitious and transformational.

WHERE TO NEXT?

In the 2030 Agenda for Sustainable Development world leaders committed themselves to develop ambitious national responses to the overall implementation of the 2030 Agenda. As a result, 95 countries have now started to formulate their national SDG responses, other countries are expected to follow suit in 2017. It is critical that promoting health becomes a cornerstone of all national or local SDG strategies and implementation plans that are now being developed - this will be a priority field of action for health promotion professionals, advocates and organisations. Collectively we have to seek reaffirmation of the commitments made in the two declarations to promoting health in all 194 national SDG responses. The Shanghai meeting can be considered the launch of a multilevel and wide-ranging institutional platform for dialogue and cooperation on promoting health in the SDGs that will support the United Nations efforts to lead, coordinate and implement, supported by the WHO. The role is cut out for health promotion.

A NEW COMMITMENT BY THE WHO

For WHO this conference has meant a renewed commitment to health promotion. It was expressed through the presence (and active participation) for most of the conference by the Director General, Margaret Chan, staff from all WHO regions and from many different programme areas. In the last months before the conference the Director-General, Dr Chan, had involved herself personally and made this into a challenge for the whole organisation not just a health promotion programme. The goodwill and commitment on display at the Shanghai conference will need to be converted into tangible actions if these aspirations are to be met. WHO has an essential role in supporting the exchange of ideas and in monitoring progress against the commitments and obligations necessary for the achievement of the SDGs.

It is essential for WHO to exercise its leadership role in promoting health in the SDG context by

• Working through the WHO governing bodies - for example when discussion the agenda item on Health in the 2030 Agenda for Sustainable Development at the next 140th Executive Board in January 2017

• Engaging in the action priorities stated by the Shanghai declaration - good governance for health, healthy cities, and health literacy - as well as specific health-related targets when supporting countries in setting national SDG responses,

• Playing a more strategic role in framing the UN development system’s support to UN Country Teams’ engagement on how to promote health in the national SDG response for example through joint work plans on health

• Developing and making available a set of tools, guidance and expertise to governments, UN partners and the health promotion networks covering the three areas of the Shanghai declaration with the support of the health promotion networks

• Strengthening its existing Healthy Cities programmes using the mayors consensus

National voluntary reviews will be presented by Member States at the next UN Economic and Social Council (ECOSOC) High-level Political Forum (10-19 July 2017). This will be an important litmus test - how many countries will have integrated health promotion into their national SDG responses, and to what extent? There is a real urgency for WHO in developing a fast-track strategy to support those countries planning to submit a national voluntary review in July 2017.

A CALL TO ACTION

Through this 9th Global Conference, WHO decided to reach out in the first year of SDG implementation to the health promotion community precisely because it has the potential to offer practical solutions to the complex and interconnected challenges represented by the SDGs. Health promotion strategies work: they instinctively work across conventional disease categories and across sectors; they place communities at the heart of workable solutions and give a voice to those who are excluded. Over the past 30 years, collectively health promotion has provided the evidence and the advocacy for action on the determinants of health at all levels of governance. This was a strong vote of confidence from the Director General and the many member states that so enthusiastically engaged in the Conference.

The Shanghai conference has opened a new universe for health promotion through the link to the Sustainable Development Goals adopted by the United Nations in September 2015. This Agenda is the most ambitious and transformational vision the world has ever seen. It provides an unprecedented opportunity for all of us committed to the principles, ethics and practice of health promotion. Whilst we can look to the WHO to provide continuing leadership at an international level, sustainable, transformational change will occur only if this is matched by creative, innovative health promotion action at more local levels. The window of opportunity is NOW.

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