Creating supportive environments for health: a case ...

Vol. 10, No. 1 Printed in Great Britain

HEALTH PROMOTION INTERNATIONAL C Oxford University Press 1995

Creating supportive environments for health: a case studyfromAustralia in developing national goals and targets for healthy environments1 Department of Public Health, University of Sydney, Sydney, Australia

SUMMARY Creating healthy living and working conditions are central goals in public health which have re-emerged in prominence in the past decade. The roots of this revival of interest can be traced to include improved understanding of the relationship between living conditions and health, prompting by the World Health Organization (WHO) through its 'Health for All' strategy which has drawn attention to underlying causes of inequities in health in society, and a more general international concern with ecologically sustainable development. Australia has responded uniquely to the challenge of developing a strategy to create sustainable, supportive environments for health through its National Health Goals and Targets. These targets, published in 1993, include a range of targets for Healthy Environments which were developed from a 'health' perspective, but in co-operation with the different sectors of government responsible for action to achieve them. These include

housing, transportation, education and employment. Early responses to the publication of the targets are encouraging, but will require sustained governmental support to reach fruition. Critical to success in developing and implementing the targets will be recognition by government, and particularly the health sector, of the legitimacy of inter-sectoral action for health. Negotiations to resolve potential conflicts in the priorities of different sectors should ensure that attention is focused on the common ground for practical inter-sectoral action to improve health. The Australian Targets Report identifies a series of concrete actions required to create supportive environments for health. A willingness to account for progress in achieving the targets for Healthy Environments will be an important measure of the commitment of the Australian federal and state governments to the health and well-being of their citizens.

Key words: health promotion; re-orienting health services; supportive environments BACKGROUND: LINKING ENVIRONMENT AND HEALTH

Achieving improved health through environmental management has long been a central goal in public policy. In the past century, achieving the separation of water supply and waste disposal, improving the quantity and quality of food, and providing adequate shelter have been major public policy goals for developed and developing countries alike. Since its inception, the World 1 A version of this paper was first presented at the WHO/ UNEP Meeting on Supportive Environments for HeaJth, Nairobi, Kenya, June 1993.

health Organization (WHO) has consistently pursued the achievement of these basic environmental prerequisites for health, and has highlighted the continuing relevance of environmental management as a central part of its Health for All strategy (WHO, 1981). The Health for All strategy, with a strong emphasis on prevention and primary health services (WHO, 1978) has influenced the development of health services in many countries of the world. However, in developed countries, health 51

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DON NUTBEAM and ELIZABETH HARRIS

52 D. Nutbeam and E. Harris

Health promotion and supportive environments for health As part of its continued efforts to promote Health for All, WHO has sponsored a series of meetings at which these emerging issues have been considered and advanced. In 1986 WHO sponsored a meeting in Ottawa, Canada to consider the challenge of health promotion in industrialised countries. The Ottawa Charter (WHO (EURO), 1986) came from this meeting and provided an expanded framework for examining health promotion and identified key strategies for action, including both the need to create environments supportive to health and the importance of re-orientation in the health systems in many developed countries. These two themes are central to this paper. The strategies described in the Ottawa Charter have provided a useful reference point for health promotion actions not only within the health care system, but within non-government organisations and in other sectors of government such as educa-

tion and transport. Following the Ottawa meeting, two further meetings have explored international experiences in two of the key health promotion strategies described in the Ottawa Charter. The first was held in 1988 when WHO and the Australian government organised a conference on health promotion which examined experiences in the development of healthy public policy at local, and national levels. The Adelaide recommendations on healthy public policy (WHO (EURO), 1988) made explicit the important role of government in the achievement of Health for All, particularly in securing equitable access for all citizens to prerequisites of health—such as clean water, adequate waste disposal and shelter—which in many cases can only be achieved through public policy regulation and legislation outside of the health sector. The most recent international meeting in this sequence, the Sundsvall Conference on Supportive Environments, focused on the need to ensure that the physical environment, and social and economic conditions provided opportunities and resources for health. The Conference was organised by WHO in association with the United Nations Environment Program (UNEP). It identified a pressing need to articulate the common ground between the Health for All concept and the growing international environmental movement. The reports from that meeting have offered an ecological view of health, illustrating how human activity and health are inextricably linked with the physical environment, and social and economic conditions (Haglund etal, 1993). Promoting health, protecting the physical environment and achieving sustainable economic growth are now more widely recognised as being interdependent (Labonte, 1991; Brown et al, 1992; Hancock, 1993). Achieving better health for all, both now and in the future demands that attention is given to the physical environment, and social and economic conditions within a country. Translating this renewed understanding of the relationship between the environment, health and the use of resources into concrete action poses a major challenge to those committed to achieving the aspirations of the Health for All movement. It represents a significant challenge to health care systems which have progressively become divorced from these fundamental issues. The paper describes one such attempt to plan for change in Australia by setting targets for 'Healthy Environments' as part of a larger set of

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care systems have become increasingly characterised by high cost, high technology specialised medical services, largely divorced from preventive activities and entirely separate from programs directed toward improving living and working conditions. Although expenditure on health care services has risen markedly in the past three decades, it appears to be offering progressively marginal returns in its impact on population health, and in many countries is failing to offer equitable health outcomes between different population groups. Increasing attention to the return on investment in health services by countries has been accompanied by a re-emergence in concern about the impact on health of local, national and global environmental conditions. This concern stems from a better understanding of both of the direct effects on health of economic disadvantage and a poor environment, and from the indirect effects in influencing personal-health-related behaviours such as alcohol and drug use (Watt and Ecob, 1992; National Health Strategy, 1992; Wilkinson, 1992). Rapid, unplanned urbanisation, particularly in developing countries, has further heightened awareness of the impact of environmental conditions on health,and increased the need for effective action. The 1980s saw a revitalised interest in public health in response to these changes in the nature of health problems in many countries.

Creating supportive environments for health 5 3

'National Health Goals and Targets'. We consider the approach taken from within the health sector to engaging other sectors in the preparation of goals and targets for healthy environments in Australia, examine the implications of a leading role for the health sector in their achievement, and consider early progress in implementation. HEALTH FOR ALL IN AUSTRALIA

GOALS AND TARGETS FOR HEALTHY ENVIRONMENTS In the light of these perceived failings, the Australian Federal Department of Health commissioned a revision of the National Health Goals and Targets by a group of public health academics based at the University of Sydney (including the authors). In 1993 Goals and Targets for Australia's Health in the Year 2000 and Beyond (Nutbeam etai, 1993a) was published following a 2 year period of consultation and review. This process is described in detail elsewhere but included an extended period of consultation with the states, with professional groups and with health consumer groups (Nutbeam etai, 1993b). The report presented a new framework for developing goals and targets established following a year-long process of review and consultation. It built on the 1988 goals and targets and included a refined range of targets concerning avoidable mortality and morbidity, healthy lifestyles and risks to health. More significantly, the report drew upon an analysis of both immediate and underlying causes of ill health, and considered the social

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During the 1980s Australia's response to Health for All took shape through the establishment of a Better Health Commission in 1986. The Commission's report Lookingforward to Better Health (Better Health Commission, 1986), was followed by a second report focusing on the development of a range of health targets, and a strategy for implementation. This Report, Health for All Australians (Health Targets and Implementation Committee, 1988), identified two underlying principles of increasing the health status of all Australians, and decreasing the inequalities in health status between population sub-groups. It reflected an approach to target setting which had been established in other countries, notably the United States (US Office of Disease Prevention and Health Promotion, 1980). The report recommended that a 'National Better Health Program' be established to develop and implement strategic plans for thefivepriority areas identified in the Health for All Australians report, namely: injury prevention, the health of the elderly, preventable cancers, high blood pressure and improved nutrition. The National Better Health Program helped develop a broad based commitment to Health for All in Australia. As a Federal government initiative operated jointly with the seven states and territories, the program sponsored a large number of activities and projects in pursuit of the priority targets. However, over time it became apparent that the framework within which the targets were set, and the response to the targets through the National Better Health Program, were too limited to have a substantial impact on the national health priorities. The National Better Health Program was labelled as Australia's response to Health for All. As a consequence, virtually no other part of the health system, or any other agency of government responded in a substantial way to the challenge of Health for All. The program became marginalised within the health care system, inadvertently re-

inforcing the belief that achieving Health for All was not a major responsibility of federal and state government as a whole, or even the 'mainstream' health services (Ministerial Panel on the Evaluation of the National Better Health Program, 1992). During the same period, in Australia as in the rest of the world, there was an unprecedented increase in interest in the relationship between the environment and the use of resources. This concern was articulated by national leaders and culminated in a discussion paper on ecologically sustainable development which paved the way for an ecologically sustainable development strategy for Australia (Hawke, 1989; Department of the Prime Minister and Cabinet, 1990). As a part of this process, the Australian National Health and Medical Research Council (NHMRC) contributed significantly to developing the link between the environment, resource use and health through the publication several discussion papers and reports (NHMRC, 1989,1991,1992). Unfortunately, with one or two notable exceptions, such as the Australian Healthy Cities Project, the links between efforts to promote better health and ecologically sustainable development were limited to these technical contributions.

54 D. Nutbeam and E. Harris

e.g. community action, serf help and social support

ment; housing, home and community infrastructure; and transport. The three other sections encompassed settings where there was already a clear existing link with the health sector and existing, successful health promotion activity, namely: work and the workplace; schools; and health care settings. Through such a construction it is readily apparent that actions to achieve better health through change in the environment would largely be taken outside the normal functioning of the health care system. In such circumstances it was essential that any health goals and targets be developed to reflect the priority issues and concerns of these other sectors. Achieving a common understanding of 'healthy environments' In attempting to develop a joint agenda between different sectors of government, different conceptual and ideological perspectives to the same issue were exposed. Part of the task of developing the goals and targets for healthy environments was to define these differences and, through a process of negotiation, find a common approach which recognises the legitimacy of the different perspectives.

Healthy Environments

e.g. clean water and alr.safe.affordabJe housing, safe and healthy workplaces

i

r

Health Literacy and Life Skills

e.g. traffic management environmental controls, school policies

r

Mortality, Morbidity Quality of Life i 1

i

e.g. coping skills, knowledge and motivation

r

Healthy Lifestyles and Risk Factors

Fig. 1: The relationship between the four groups of health targets.

e.g. smoking, regular physical activity and balanced diet

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and environmental actions necessary to address these issues. As a consequence two new groups of targets were developed relating to health literacy and health skills, and to healthy environments, respectively. An overview of the relationship between the groups of targets in this new framework is provided in Figure 1. This basic construct reflects a comprehensive assessment of the relationship between health, individual actions and the environment. The inclusion of 'healthy environments' as a major section in the report has provided the means through which the underlying inequities in health could be more clearly articulated, and has helped to legitimise activity to address these problems. This section of the report was structured partly to reflect the way in which government was organised, and partly to build upon existing working relationships between the health system and sectors. Such an approach was seen as important both in defining the respective roles, and in establishing a workable mechanism for monitoring progress and determining accountability for the achievement of the targets. The first three groups of targets cover broad aspects to the environment: the physical environ-

Creating supportive environments for health 55

Such a process of negotiation ensured that the different sectors were engaged in defining the problems and arriving at solutions which made sense within the context of existing workplans and priorities. There was no overt attempt to 'impose the health agenda'. Through this process important progress in achieving understanding and ownership of the health goals and targets by other sectors was achieved. Overcoming technical difficulties The development of goals and targets for Healthy Environments also posed several technical difficulties which were different from the other major sections of the report. There were two main problems. Firstly, to identify how goals and targets could be expressed in a way that clearly denned the health problem but was also meaningful to other sectors and, secondly, to express goals and targets in ways that could be measured. The technical solution to these problems was to propose a series of intermediate indicators which provided a mechanism for working backwards from 'health outcomes', to the identification of the fundamental issue. For example, the health target to increase the proportion of the population with access to safe drinking water uses as an intermediate indicator of success those mechanisms which are in place to provide and monitor water quality, in this case the number of water monitoring sites and the frequency with which the site met agreed water quality standards. Given these indicators, the relevant targets would be to achieve an increase in the number of monitoring sites, and an increase in the proportion of times the agreed national standards of water quality are met at individual sites. This provides a more easily measurable target, is expressed in a way that is meaningful to those in the water industry who are currently responsible for ensuring a safe water supply and, indirectly, ensures that the health target of ensuring access to safe drinking water is met. By using these intermediate indicators (see Figure 2 for further examples) goals and targets were developed to link the defined health problem and the social, economic and environmental concerns of different sectors in a way that made the document more obviously relevant to the agency responsible for meeting them. Indirectly, this approach to the definition of indicators also identifies the agency or department of government responsible for taking action to achieve, and to monitor the achievement of targets.

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To initiate the process of negotiation, the project team prepared background briefing papers for each of the six settings described above. These provided a health perspective to the different environments/settings and identified the government department or agencies most able to take action to address the priority issues. The papers were included in a progress report which was distributed mid-way through the project in 1992 as the basis for widespread consultation. This allowed feedback from the various government departments, agencies and individuals which helped to further clarify their concerns, and identify common issues and current activity that could be built into the final goals and targets. It became evident through this process that practical mechanisms had to be established to mediate between the different interests of the different sectors. This was approached in several different ways, where possible by using an identified lead agency or government department to directly propose the health goals and targets. In cases where no obvious lead agency existed, an expert workshop was organised to engage key individuals or agencies directly in discussion and negotiation on the goals and targets. In each case, attention was given to existing policy and priorities in the relevant sectors. Thus for example in the section on housing, home and community infra-structure, although some of the major health issues concern infectious disease control, domestic safety and access to health services, the health goals and targets were developed to fit a comprehensive structure provided by a previously published National Housing Strategy (1991). This approach was perceived to be far more relevant to those working in the housing sector, who were ultimately responsible for taking the action necessary to create a supportive housing environment. Consequently, the major sub headings in the report concerned adequate housing, secure and affordable housing, and appropriate housing, as well as safe housing. Although not all of the conceptual and ideological differences were resolved through this process of mediation, in each case it proved possible to find a significant area of common ground which addressed the major health issues in a way that was relevant and meaningful to the different sectors involved. Wherever possible, the existing priorities of the different sectors were identified and health goals and targets were developed in a way that met these existing priorities.

56 D. Nutbeam and E. Harris

Transport

The physical environment

GOAL: To ensure all Australians have access to a safe water supply

Target

To increase the proportion of people with access to safe drinking water Intermediate To increase the number of indicator monitored water drinking sites Intermediate To increase the proportion of indicator monitored water drinking sites which meet NHMRC standards

PRIORITY POPULATIONS: The whole population To reduce exposure to pollution generated by vehicles that do not meet noise and gaseous emission standards Intermediate To increase the proportion of indicator vehicles that meet noise and gaseous standards

Target:

Housing, Home and Community Infrastructure

Work and the Workplace

GOAL: To increase the proportion of people living in adequate housing GOAL: To reduce the health impact of unemployment

PRIORITY POPULATIONS: Aboriginal and Torres Strait Islanders in rural communities and settlements To reduce exposure to risks to health associated with poor living conditions Intermediate To increase the proportion of indicator Aboriginal and Torres Strait Islanders living in remote and rural communities who live in dwellings which have: potable water for drinking/cooking adequate water supply electricity bathing and laundry facilities waste and sewage disposal

PRIORITY POPULATION: Young people aged 14-25 years People who have been unemployed for >12 months

Target

Target

To increase the proportion with opportunities for paid employment and/or training programs Intermediate The proportion of target populaindicator: u'ons in paid employment or training programs

Fig. 2: Examples of goals and targets for healthy environments

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PRIORITY POPULATIONS: The whole population Aboriginal and Torres Strait Islanders Rural and remote communities

GOAL: To reduce transport-generated pollution

Creating supportive environments for health 5 7

Again, it was not possible to overcome all of these technical difficulties through this process, and the section of the report on Healthy Environments remains technically the least well developed of all parts. One of the major recommendations of the report is that continuing attention is given to the outstanding task of defining goals and targets in these key settings.

CONCLUDING REMARKS The rhetoric of Health for All has been accepted by Australian governments at both federal and state levels, and the Targets Report provides a concrete manifestation of this commitment. The early action taken by the federal and state governments to date in response to the report indicate a level of commitment beyond the rhetoric. One important marker of this commitment will be the degree to which the challenge of creating supportive environments for health through healthy public policy is met. The experience in setting the

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Engaging the health care system Ultimately, the targets for healthy environments proposed in the Australian document will not be achieved without the overall commitment of government, and the specific commitment of the health sector to provide the necessary leadership for a long term process of dialogue and partnership with other sectors of government. This is an unfamiliar role for the health sector. Achieving change will require significant political will and a clearer commitment by the health care system to promoting population health. This is an issue highlighted in the Target Report. As is the case in most countries with a national public health system, the current management and funding arrangements in the Australian health system are largely focused on institutional funding for hospitals, and management issues of process, throughput and cost containment. There is relatively little debate about the balance of service provision (between prevention, diagnosis, treatment and palliation) needed to achieve optimal community health, and no place for serious discussion about the role of the health system in improving population health. In such circumstances there has been little scope for collaborative activities between an introverted health sector and other sectors. In Australia, as in other countries, renewed attention to cost containment has offered an opportunity to introduce a fundamental discussion about the efficiency of investment in health services and about the role of the health care system in achieving improved population health. By focusing attention on population health status (as opposed to the funding of institutions and issues of service provision), and on the underlying reasons for disparities in health status between populations, the way is opened for a more substantial and legitimate discussion of investment choices in the health care system, and on the role of the health sector in achieving optimal population health. Through such a discussion the need for a government-wide commitment becomes clear, and the importance of collaboration

between the various parts of government in pursuit of healthy public policies, becomes much more obvious. These issues are considered in a separate section of the Targets Report on 'Challenges for the Health Care System' which makes a series of recommendations for reforms to health care policy, funding and management. In summary, the report argues that within a policy framework where health gain is the focal point, prevention and health promotion—including inter-sectoral action—can more reasonably compete for funding on the evidence of their efficacy in achieving greater gains in population health for a given cost. These proposals represent radical change for the way in which the health 'system' is conceived of in Australia. The early signs of action in response to these challenges is encouraging. The goals and targets have been approved by the Australian Federal and State Health Ministers, and the framework described in Figure 1 incorporated within the Medicare Agreement. This agreement is the major mechanism governing the funding of health services in Australia over the next 5 years (19931998). The recently re-elected Labour government incorporated the goals and targets into their policy platform and, together with the states, has decided upon priorities for action. These priorities are cardiovascular disease, cancer, injury and mental health. The present commitment is to tackle these priorities using the framework articulated through the Targets Report, thus opening the door to action to create supportive environments for health. Within the health system, a program of research and demonstration projects has been established by the National Health and Medical Research Council to progressively introduce a 'health outcome' dimension to service management and funding.

58 D. Nutbcam and E. Harris

ACKNOWLEDGEMENTS The authors are grateful to Lona Kickbusch and Hans Saan for helpful reviews of earlier drafts, and to Monika Bhatia for assistance in preparing the text.

Address for correspondence: Don Nutbeam Department of Public Health University of Sydney A27 Fisher Road NSW 2006 Australia REFERENCES Better Health Commission (1988) Looking Forward to Better Health, vols 1-3. Australian Government Publishing Service, Canberra. Brown, V., Ritchie, J. and Rotem, A. (1992) Health promotion and environment management: a partnership in the future. Health Promotion International, 7,219-230. Department of the Prime Minister and Cabinet (1990) Ecologically Sustainable Development. Commonwealth discussion paper. Australian Government Publishing Service, Canberra. Haglund, B., Petterson, B., elal (1993) The SundsvaU Handbook. We Can Do It. 3rd International Conference on Health Promotion. Karolinska Institute Kronan Health Centre, Sundbyberg, Sweden. Hancock, T. (1993) Health, human development and the community ecosystem: three ecological models. Health Promotion International, 8,41-48. Hawke, R. J.L.(1989) OurCountry, Our Future: Statement on the Environment. Australian Government Publishing Service, Canberra. Health Targets and Implementation Committee (1988) Health for All Australians. Report to the Australian Health Ministers' Advisory Council. Australian Government Publishing Service, Canberra. Labonte, R. (1991) Econology, integrating health and sustainable development. Part 1: theory and background. Health Promotion International, 6,49-64. Ministerial Panel on the Evaluation of the National Better Health Program (1992) Towards Health for All and Health Promotion. Australian Government Publishing Service, Canberra. National Health and Medical Research Council (1989) Health Effects of Ozone Depletion. Australian Government Publishing Service, Canberra. National Health and Medical Research Council (NHMRC) (1991) Health Implications of Long Term Climate Change. Australian Government Publishing Service, Canberra. National Health and Medical Research Council (1992) Ecologically Sustainable Development The Health Perspective—June 1992. Department of Health, Housing and Community Services, Canberra. National Health Strategy (1992) Enough to Make you Sick. How Income and Environment Affect Health, Research paper no. 1. Treble Press, Melbourne. National Housing Strategy (1991) Australian Housing: The Demographic, Economic and Social Environment. Australian Government Publishing Service, Canberra. Nutbeam, D., Wise, M., Bauman, A., el al. (1993a) Goals and Targets for Australia s Health in the Year 2000 and Beyond. Australian Government Publishing Service, Canberra. Nutbeam, D. Wise, M., Bauman, A. and Leeder, S. (1993b) Achieving Australia's National Health Goals and Targets. Health Promotion Journal ofAustralia, 3,4-11. Downloaded from http://heapro.oxfordjournals.org/ at University of Southampton on October 15, 2014

targets for Healthy Environments offers some insight into how this challenge can be met and identifies some outstanding work to be done. Firstly, government as a whole, and the health sector in particular (including its leaders and professions) have to recognise the important role of change in the wider environment in achieving optimal community health and in reducing health inequities. Part of this will be recognition of the legitimacy of action across the different sectors of government to promote better health. Second, once the health sector comes to recognise the legitimacy of action by and from other sectors for health, it must also recognise the fact that different sectors have different priorities to those being pursued by the health sector. In recognising these differences, it is important for health agencies to provide leadership where appropriate, and to negotiate and to adapt to existing agendas and priorities, rather than simply seeking to impose the 'health' agenda. Third, nothing succeeds like success. Limited experience of inter-sectoral action in Australia indicates that success is most likely when activities focus on a well defined project. Government departments in particular dislike open-ended commitments which involve other departments. Collaboration, and trust for future developments, has to be built slowly, and on solid foundations. Many of the specific challenges highlighted by targets in the Australian Health Goals and Targets Report offer a basis for concrete, intersectoral action in pursuit of measurable outcomes. Progress in the form of action to achieve these targets for Healthy Environments will be an important measure of the Australian government's commitment to Health for All. Finally, the technical tasks associated with the development of jointly agreed and measurable targets for healthy environments needs to be completed. The 1993 Targets Report contains a large number of'proposed targets' for healthy environments, which need further debate and, in many cases, considerable refinement. The federal government and health department will need to take action to ensure that progress in establishing this joint agenda for action continues.

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