PHM-Exch> New framework promises to give practical effect to WHO definition of 'health'

Tue Mar 14 21:05:02 PDT 2023

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From: People's Health Mov

But needs much more work

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New framework promises to give practical effect to WHO definition of
'health'

Item 14, at this week's meeting of WHO's Executive Board, addresses
Well-being and Health Promotion. The item emerged as a follow up to the
10th Global Conference on Health Promotion, held in Geneva in December
2021, which produced the Geneva Charter for Well-being (2022)
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ad268e19da&e=125964ddcc>
.

A draft resolution on Well-being and Health Promotion was submitted for
EB150 (EB150/CONF./5
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d532404d98&e=125964ddcc>)
by UAE but was not considered, apparently on the grounds of time. The draft
was also full of brackets.  A more polished draft resolution was presented
to WHA75 (here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3a70c73850&e=125964ddcc>).
This was adopted, with virtually no debate, as WHA75.19
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3c0afab361&e=125964ddcc>.
This resolution requested the DG to develop a framework on achieving
well-being including innovative approaches using health promotion tools.

The draft Global Framework
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773347f34b&e=125964ddcc>,
published in late 2022, was designed to incorporate health promotion
approaches and tools in responding to major global challenges related to
environment, public health, social, economic and political instability
affecting the health and well-being of populations.

EB152/20
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=24999f3670&e=125964ddcc>
describes the background and development process of the draft WHO framework
and invites the Board to note the report and to provide further guidance.
Appreciation

This draft framework promises to give practical effect to the definition of
health enshrined in the WHO Constitution
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cd5ccc26d8&e=125964ddcc>:
“Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.”

This is appreciated. However, the draft framework needs more work and
perhaps closer supervision of its development.
Style: rhetoric or technical

The present draft includes slabs of text taken from the Geneva Charter for
Well-being
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=fea1d667bb&e=125964ddcc>,
generally expressed in the same rhetorical style. This use of inspirational
rhetoric is customary in the outcome document of a conference of experts
but it is not appropriate in what should be a sober, evidence based,
technical document, as was called for in WHA75.19.
Conceptualisation of health promotion

Operative Para 2(1) of WHA75.19
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=a5a91f3a85&e=125964ddcc>
asks
the DG to identify the role that health promotion could play in achieving
well-being. It is clear from context that the purpose of this request was
to clarify the role that health promotion could play in promoting
well-being if the proposed framework were to be adopted and implemented by
WHO.

However, the conceptualisation of ‘health promotion’ which is offered is
ambiguous, variously treating health promotion as an institutional sector,
comprising experts and organisations, versus treating health promotion as a
body of principles and practices that health practitioners, agencies and
administrations might apply in their work. To say that ‘Health promotion
seeks to influence policies and programs’ (page 6 of the draft Global
Framework
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=64b0c4829b&e=125964ddcc>)
treats ‘health promotion’ as a singular entity with its own agency. Further
on, health promotion is described as “a lever for strengthening empowerment
at individual and community levels beyond consultation, participation or
other forms of engagement”.

It would be useful to recognise a bit more clearly that the project of
creating a well-being society (or civilisation) is informed in different
sectors and communities by a very wide range of principles and paradigms of
practice. Indeed the professional and civic practice of health
practitioners is informed by a wide range of principles and paradigms,
including but extending well beyond ‘health promotion’ (whether understood
as an institutional sector or a body of principles and practices).

On page 6 of the draft framework we are advised that “Health promotion is
the process of enabling people to increase control over, and improve, their
health”. But health promotion is clearly not the only “process of enabling
people to increase control over, and improve, their health”. For many
people the use of traditional or complementary medicines is a process of
increasing control over and improving their health. Health promotion is not
the only body of principles and practices which support governments,
communities and individuals “to cope with and address health and well-being
challenges in order to advance healthier populations and environments”
(page 6).

The framework does acknowledge that “that promotion of health and
well-being is often achieved by professionals who are not trained as health
professionals” but even here health promotion (however conceptualised)
claims a role, in this case mediating between different interests.
No theory of change

There is no theory of change articulated in this draft and it is hard to
discern a robust theory of change from the text.

The first requirement of a theory of change is to identify whose practice
will be directly impacted by the action in question - in this case the
adoption by WHO of the proposed framework.

On page 10 we are advised that the main target audience “includes key
stakeholders from communities and governments, local and national, working
within and beyond the health sector”. Presumably this is intended to mean
that these are the agents whose practice might be influenced, however
indirectly, by this framework. However OP2(2) of WHA75.19 is clear that the
framework will support the “translation into practice of innovative
approaches for well-being using health promotion tools, new technologies
and approaches to contribute to the WHO general programme of work”. The
closest the actual draft gets to this is the statement on page 12 that “The
Framework is also expected to accelerate actions outlined by existing WHO
global action plans” but it is far from clear how.

The reference to a vision could form part of a theory of change. However,
the vision statement (“Societal well-being that enables all people to
flourish and achieve their full physical and mental health potential
throughout their lives and across generations”) seems tautologous; societal
well-being enables personal well-being; presumably personal well-being
aggregates into societal well-being.

A vision for well-being should also speak about relationships including our
relationships with each other (solidarity, listening, collaborating), our
relationships with our communities (giving and receiving, collaborating),
our relationship with our work (contributing, being creative, being
appreciated, being useful), and our relationships with Mother Earth.

The body of the draft framework comprises a series of six strategic
directions, four of which are taken directly from the Geneva Charter.
Each strategic direction comprises a series of ‘policy orientations’ with
‘examples of interventions at national level’. These directions, policy
orientations and interventions are good and if implemented widely would
probably contribute to well-being societies.

But there are no drivers.  Taking a random example (from page 14):
“Re-orient investments and dis-incentivize production and consumption of
health-harming products and services, towards health-promoting
alternatives”. Many governments, organisations and people are working in
various ways towards this end but there is nothing in this draft framework
which suggests how the adoption of this framework by WHO will add value to
their work.
Lack of senior involvement

This text suggests limited involvement of experienced technical writers.

The draft Global Framework
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=21077af6c1&e=125964ddcc>
is entitled “Achieving well-being: A global framework for integrating
well-being into public health utilizing a health promotion approach” on
page 1 but on page 8 there is reference to “The WHO Promoting healthier
populations framework” which apparently refers to this document.

The structure of the document is confused. On page 9 the framework is
described as comprising “a key vision, an overarching goal, key objectives,
guiding principles and an initial implementation and monitoring plan”.
However, as the document proceeds, the section of ‘Guiding principles’ is
replaced by ‘Fundamentals of Well-being’; 'Implementation and monitoring
plan' is replaced by 'Strategic directions and actionable policy
orientations' and the promise of a monitoring plan is not fulfilled.

The ebullient rhetoric, the failed proof reading, the confused structure of
the document, and the lack of a theory of change all suggest a lack of
senior involvement in its development.
Underlying causes

The oddly titled section, ‘Underlying causes of well-being erosion and
societal impacts’ is somewhat limited in scope.

The reference to ‘economic development models’ is appreciated. However, the
dominant contemporary model of economic development is neoliberalism and
this has been deliberately put in place by very powerful agents and forces
over many decades, including the devastations of structural adjustment and
selective liberalisation (liberalising trade and investment but not the
movement of people or access to knowledge). How the proposed framework
might strengthen WHO's approach to the 'well-being erosion' due to the
neoliberal ascendancy is not spelled out.

The reference to rapid urbanisation is appreciated and the implied
reference to the huge informal settlements in the Global South where
poverty, unemployment and lack of basic urban infrastructure are major
barriers to health and well-being. However, many of these people were small
farmers who have been driven off their land as part of the transformation
of global food systems, driven by transnational food corporations and
protected by WTO agreements. How the proposed framework might strengthen
WHO's engagement with the political economy of food systems is not spelled
out.

Patriarchy and misogyny are threats to the well-being of half of the people
on the planet. It is surprising that these are not noted.
What happened to the call for a NIEO articulated in the Alma-Ata
Declaration?

It is disappointing that there is no reference in this draft to the call
for a new international economic order (NIEO, adopted by the UN General
Assembly in 1974) which is referenced in para 3 of the Alma-Ata
Declaration.

A core principle informing the Alma-Ata Declaration is that primary health
care practitioners and organisations should work with their communities to
identify, analyse and respond to the factors in their lives and
environments which shape their health and well-being. This is particularly
clear if the Alma-Ata Declaration is reviewed in the light of WHO’s ‘Health
by the People’
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773b94819f&e=125964ddcc>
by Kenneth Newell (1975) which informed the development of the Declaration
and included a range of case studies where primary health care
practitioners and organisations were working with their communities to
engage directly with the forces shaping their health.

The significance of the reference to the NIEO in the Alma-Ata Declaration
is that it goes beyond high level goals to articulate quite specific
reforms to global economic governance. The implication is clear that if PHC
practitioners and their communities want to engage with the processes which
reproduce their poverty, food insecurity, etc here are some specific policy
reforms to advocate for.

The author/s of the framework would do well to consult the 2014 Declaration
of Santa Cruz
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e97bfd6e85&e=125964ddcc>:
*For a new world order for living well* and the address by Evo Morales at
the same conference, ‘For a global brotherhood among the peoples’
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ee00c81275&e=125964ddcc>
.
Listening to the Latin American school of social medicine and collective
health

WHO has been slow to recognise the power of ‘living well’ or *buen vivir*
which has been very influential in Latin American public health. The
author/s of the draft framework are to be appreciated for hinting that the
new interest in well-being might owe something to the indigenous traditions
from which the idea of buen vivir emerged.

The framework would benefit from two other innovations from the Latin
American school of social medicine/collective health.

One of these is the insistence on distinguishing between *social
determinants* (as factors which are shown to influence population health)
and *social determination* (which focuses on the forces and dynamics which
reproduce those factors). There is very little in the draft framework which
addresses the social and political *determination* of health except at a
very general level.

The second innovation is the turn from public health to *collective health*
in order to avoid over-stating the role of the government in shaping
population health and to highlight the ways in which the health of
populations is shaped by the forces, engagements and dynamics of
communities and civil society more broadly.
Donor transparency

One of the issues not being discussed in the current debate about
Sustainable Financing for WHO is about donor transparency. Who has agreed
to fund this initiative? What has been their role in the development of the
initiative and in its progression through the governing bodies?  Have all
proprieties in relation to conflict of interest been complied with?

*PHM urges the Board and the DG* to review the oversight arrangements and
consultative processes in place for the drafting of this framework. It is
too important to allow it to fail through technical weakness, donor
indulgence, and great power cynicism.
------------------------------

See our more detailed commentary on this item here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e1455138d2&e=125964ddcc>.
The Tracker page for EB152 is here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=67ca385819&e=125964ddcc>
.

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<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0142e3a183&e=125964ddcc>
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<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=72e94689a7&e=125964ddcc>,
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<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=497dcc7f06&e=125964ddcc>
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