Foundations: The Driving Force for Health Promotion in Australia by Peter Thompson and Chris Bothwick

In 1997, the WHO Jakarta Declaration highlighted the need to create a sustainable organizational base for health promotion at global, national and local levels. Australia's infrastructure capacity for health promotion has grown over the past decade, due largely to strong health advocacy groups, state-funded independent health promotion organizations, and an ever-increasing knowledge base of effective health promotion interventions.

A Commitment to Health     

A definable commitment by Australia's state and national governments exists to prevent disease and provide multi-faceted approaches to improve health. At the national level, a major review of infrastructure support for national health enhancement took place in 1997. As a result of this review, the National Public Health Partnership was established to enable closer collaboration and coordination between state and national governments. A substantial work program has been initiated to enhance policy and practice in areas such as public health information, workforce development, legislative reform and strategy coordination. Health promotion remains a central focus of the partnership.   

By the late 1980s, an organized anti-smoking lobby had achieved tobacco control at the state level. One result of this legislation was to provide funds, via a new tobacco tax arrangement, to replace tobacco sponsorship for sports and to establish several broadly chartered state-based health promotion foundations.

Foundations Lead the Way    

The Victorian Health Promotion Foundation (VicHealth) was the first of these foundations, and remains the largest. VicHealth's mission both embraces and goes beyond tobacco control to build the capabilities of organizations, communities, and individuals to change social, economic, and physical environments so they support better health for all and strengthen individuals' understanding and skills to support their efforts to achieve and maintain health.   

Similar foundations, such as Healthway in Western Australia and Healthpact in the Australian Capital Territory, have been established. These health promotion foundations, all of which have guaranteed funding, provide invaluable support for Australia's health promotion field. In the past year, health promotion foundations have worked intersectorally for health gain. They have facilitated the increased number of smoke-free places such as sports stadiums, workplaces, and entertainment venues; supported community-capacity building efforts; expanded knowledge to practice via the development of multi-disciplinary public health research centers; and created partnerships with sports and arts organizations that were traditionally favored by tobacco companies for their promotions.

Challenges for the Future   

Challenges, however, continue to exist in Australia. People in the lowest socioeconomic groups consistently have the poorest health status, despite an overall improvement in population health status. National health goals and targets drift towards easily measured disease focus rather than evaluating the progress of such less-easily grasped determinants of health as unemployment or inequality.   

While the 1990s have witnessed rapid progress in health promotion in Australia, necessary collaborative approaches to addressing the social determinants of health appear to have more substantially taken hold at the local practitioner level than made a serious impression on senior administrators or policymakers.

Chris Bothwick is the managing editor of Health Promotion Journal of Australia. He can be reached at: (tel) 61-7-3365-5520 and (fax) 61-7-3365-5540.

Peter Thompson is the Director International Development at VicHealth. He can be reached at: (tel) 61-3-9-345-3200, (fax) 61-3-9-345-3222, (email) vichealth@vichealth.vic.gov.au

"Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change." (American Journal of Health Promotion, 1989, 3, 3, 5.)

Reforms in Publicly Funded Health Care in Finland are Inevitable by Antero Heloma

Like other Scandinavian countries, Finland has health care systems that are universal and primarily publicly funded with revenues from income and other taxes. These systems were built to guarantee equal service for all, regardless of individual income. A few decades ago, the public health system was seen as a more democratic alternative than the private or semi-private insurance-based system.    

Private health care services developed as an alternative to the public system This private sector, however, has mainly organized outpatient services and has few private hospitals. The state compensates about 20 to 35% of private service fees from national insurance funds. Employers are required to provide occupational health care services for all employees, but other health care services are voluntary. Employers receive up to 50% compensation for occupational health services from national insurance funds.   

This system worked well as long as the state economy was balanced and the GNP was rising. Insecurity in funding began in the early 1990s during a severe economic recession. The economy gradually recovered by 1997, but the health care system never regained the secure financing it had once enjoyed. Finland joined the European Union in 1995 and the Economic and Monetary Union (EMU) in 1998, which changed economical structures and lowered income tax rates.

Public Health System at Risk   

New and expensive medical treatments as well as the growing elderly population put the public system at risk. Hospitals in some sparsely populated areas had to be closed, which saved money, but meant longer distances to treatment for many people. Discussion of prioritization became important. It meant balancing available funds with the criteria for delivering services to patients. The determinants in prioritization are, among other things, age, estimated probability for recovery, and the personal and economical benefits achieved by the treatment.   

Today, in general everyone can still get first-class health service in the public system, especially in emergency situations. However, waiting lists for non-emergency operations have become longer and it is difficult to get treatment for some health problems. It has been necessary to reduce the hospital staff, and it is increasingly difficult to hire extra staff to cover the sick leaves and vacations of health personnel. All of this has increased the burden of the remaining personnel. It is difficult to get doctors to work in remote areas. A growing number of trained unemployed nurses have moved to work in England while many doctors have moved to richer Norway in search of better salaries.    

The government has allocated more funds than before for preventive approaches like health education and promotion. The Finnish Parliament has suggested that health promotion funding be elevated to 1% of the tobacco tax revenue, which is the level recommended by the World Health Organization.   

Despite the dark clouds on public health care, the public system is not likely to collapse. Less than 8% of the GNP is used for health care, compared to the 15% used in the United States. However, health care reform must progress and new additional funding systems have to be considered in the future.

Dr. Antero Heloma can be reached at: Uusimaa Regional Institute of Occupational HealthArinatie 3, FIN-00370 Helsinki, Finland tel: +358 9 4747 940, fax: +358 9 556 157 email: Antero.Heloma@occuphealth.fi

China's Systematic Health Reforms by Yu Jiying

China, home to 1.3 billion people, attaches great importance to its people's health. China currently devotes great efforts to health reform to elevate its major health indexes to the advanced level of developed countries and intermediate level of the secondary developed countries by 2010. Reforms involve medical insurance of workers in urban areas; administration and operation systems at various levels; and optimal use and distribution of health resources.

Strides in Child Immunization   

Since 1978, China has achieved remarkable success in its child immun-ization services. Under this system, the incidence and mortality rates of infectious diseases like measles and pertussis have decreased over 95%.   

In 1988, WHO resolved to eliminate worldwide poliomyelitis by 2000. China's government promised to eliminate it by 1995. China achieved this goal in September 1994, over a year ahead of schedule, by reinforcing the administration of vaccine pills to children under four years of age.    

In the mid-1980s, China successfully developed a hepatitis B vaccine. Hepatitis B rates among preschool children has dropped to under 1% since 1992, when the government began administering the vaccine to newborns nationwide. In the early 1990s, the government tightened the control of tuberculosis by giving all newborns the BCG vaccine within 24 hours after birth.   

China's Decree of Mother and Children Care recognizes the need for government attention to matters of maternal and child care. National surveillance data show that infant mortality has dropped to 33.1% and the maternal mortality rate is now 63.6 per 100,000. These figures indicate that China's health reforms have greatly improved maternal and child health.

A Growing Commitment to Health Promotion   

The need for a health promotion component to achieve optimal health is not lost on China. On June 20, 1995, the State Council of the People's Republic of China issued "the Outline of Health Plan for All the People," which called on all people to participate in physical exercise to meet the new needs and challenges of economic construction and social development.    

Local government attaches great importance to the "Health Project for All the People." For example, in Shanghai, 21 exercise facilities totaling 36,000 square meters, were built in 15 districts in 1998. Five years ago, the average exercise facility had 0.13 square meters per person. Now, it is 0.9 square meters per person, due to increased patronage. People exercise more if facilities are in a convenient location. It has been reported that 22 community exercise facilities will be completed next year, thus giving each district and county an exercise facility and paving the way to health for thousands of households.    

Internationally, China's reforms in health may not be as spectacular as those in its economy and various other systems, but it is a gigantic systematic project that plays an important role in improving the health and quality of life for 1.3 billion people.

Prof. Yu Jiying is both President and Professor of the Shanghai Institute of Physical Education in China. She can be reached at 86-21-6-556-8266 (tel), 86-21-6-556-8643 (fax), or <dexinchk@online.sh.cn> (e-mail).

Country Profile: Health Promotion in Romania: A Matter of Time by George Dumitru and Wolf Kirsten

Despite Romania's harsh economic conditions and major primary health care problems such as child malnutrition and high child mortality, health promotion is becoming increasingly popular in this Eastern European country of 23 million people. The first concerted efforts are being made to bring health promotion programs to various settings, including academia and the workplace.    

The World Health Organization (WHO) and the World Bank, in collaboration with Romania's Ministry of Health, recently launched several projects which focus on much needed traditional public health services like immunizations and sanitation improvements, as well as education programs on issues like smoking cessation and HIV/AIDS. However, there is no national policy for health promotion, and effectiveness remains limited due to major barriers to the implementation of services, like lack of coordination.

New Breed of Health Promotion     

At the same time, a "new breed" of health promotion initiatives is currently being developed with a different origin. The Romanian Sport for All Federation ("Federatia Romana Sportul Pentru Toti"), which is based at the Ministry of Youth and Sports in Bucharest, has taken on the task of raising awareness of the benefits of an active lifestyle and aiming it's efforts at the general population.     

The Romanian Sport for All Federation was created in 1992, with the goal to democratize sport and make it available to the general population. The development strategy "National Sport for All Programme - Romania 2000" advocates the need to develop a sports policy that changes the attitudes of citizens and ensures healthy and secure conditions for exercise with the overall goal of increased individual well-being. In its brief history, the Federation has managed to promote Sport for All as an issue of national concern, which has a unique role in decision-making in diverse areas of the population's daily lives, such as culture, environment, health, and education.     

For the first time, the Federation will incorporate a health promotion module, focused on physical activity, in their training courses for coaches and teachers in Bistrita from September 6-12, 1999. The event will feature national and international speakers from the USA and Europe. The goal is to prepare professionals for the new developments in the field and concurrent opportunities in Romania. Federation Director Aurelia Suciu emphasized the significance of physical activity for the well-being of the population: "We need to raise awareness and educate our people to adopt healthy lifestyles, in particular sports and physical activity. It is a social priority."

Health Promotion in Academia and the Workplace

In addition to the efforts of the Sport for All Federation, the Faculty of Physical Education and Sport at Ovidius University in Constanta is in the process of bringing health promotion to the campus and making it part of the curriculum. Professor George Dumitru has been cooperating with international researchers and lecturers for years and has devoted himself to bringing health promotion concepts and materials to the University. In recent discussions with Rector Adrian Bavaru and Dean Victor Albu, the need for students to be trained in health promotion was underlined. Furthermore, a health promotion program for faculty and staff (the first of its kind in Romania) is currently being developed. The program will include educational materials, awareness raising, health risk analysis, and fitness programming.     

Finally, preliminary plans are being made to offer health programs to the employees at Banca Commerciala Romana at the headquarters in Bucharest and in Constanta. Dr. Dumitru displays an optimistic, yet realistic, perspective on these budding initiatives: "In my mind, it is a matter of time for health promotion to take a grip on Romanian society. We have big economic problems and it will be a slow process, but we cannot afford to ignore this global trend."

Dr. George Dumitru is a lecturer at the Faculty of Physical Education and Sport at Ovidius University in Constanta and can be contacted at 40-41-661950 (tel) or 40-41-655485 (fax). The Romanian Sport for All Federation can be reached in Bucharest at 40-1-2111835 (tel) or 40-1-2100161 (fax). Wolf Kirsten, Program Manager of the IIHP, can be reached by phone: 1-202-885-6218, fax: 1-202-885-1346, or e-mail: wk1861a@american.edu

WHO Document on Health Promotion and Health Care Reforms

In 1995, at a meeting in Dublin, The European Committee for Health Promotion Development, a committee of WHO, issued a statement on the successful progress of health promotion in Europe. Titled "Health Promo-tion and Health Care Systems Reforms," this document stresses the importance of investment in health promotion in order to achieve the goals of health care system reforms.

Good health is increasingly recognized as vital to personal, social, and economic development, according to the document. Many European countries are actively reforming their health care systems, and many governments are committed to achieving Health for All via organized strategies for health promotion. Health promotion is recognized as making a unique contribution to the health reform process by encouraging the promotion of health and the prevention of illness. This, in turn, allows for better allocation of health care resources for health care consumers.

The Committee has identified five key activities for encouraging health promotion within different countries:

1. The relation of public policy to society to improve health i.e., discouraging alcohol use via price and availability.
2. The creation of healthier living and workplace environments.
3. The involvement of communities in setting health priorities.
4. The empowerment of individuals to take control of their own health via health education.
5. The reorientation of health care systems to include health promotion.

If properly organized and managed, health promotion can be an effective and important part of health care reform. "Experience in the European region increasingly suggests that this important aspect of health care reforms necessitates paying attention to national and local management arrangements and health promotion, and that these are likely to be at risk if they are not explicitly considered as part of the reform process," states the document.

Creation of health promotion centers to implement local programs, establishment of local health promotion expertise, and appropriate organizational arrangements for intersectoral motivation and action, and setting up appropriate training programs are all cited as necessary foundations to successful health promotion within health care delivery systems.

For more information, please contact the WHO Regional Office for Europe, Investment in Health Programme, 8 Scherfigsvej. DK-2100 Copenhagen ø, +45 39 17 17 17 (tel), +45 39 17 18 18 (fax)

Hypertension in the Americas

Hypertension affects one in four adults regardless of gender or socioeconomic level. Although it is the most prevalent treatable cardiovascular disease in the Americas, it often goes undiagnosed, as those who have it usually display no symptoms. Between 55 and 70 million of the 140 million people who have hypertension are not aware that they have it; over 50% of those who do know receive inadequate treatment. If undiagnosed or improperly treated, hypertension can lead to stroke, coronary heart disease, and renal failure.

To address this burgeoning problem, the Pan American Health Organization (PAHO) and the National Heart, Lung and Blood Institute (NHLBI) at the National Institutes of Health (NIH) have collaborated on the Pan American Hypertension Initiative (PAHI). The goal of PAHI is to reduce morbidity, disability, and premature mortality due to cardiovascular disease with a focus on the prevention and control of hypertension by sharing knowledge, experience, and technology among interested people and organizations.

PAHI's strategic aims are twofold. One tactic is to use an integrated approach for the general population as well as those who are at risk, via a public health strategy using appropriate and effective clinical care and community involvement to address hypertension as well as its risk factors. The second tactic is to create a synergy between available resources already within the health system and those offered by the community to prevent an unnecessary influx of new resources.

PAHI calls on health organizations, professional associations and industry to build health policies that make hypertension control a priority for the countries of the Americas, using epidemiological and economic data for each individual country. National policies should be developed and implemented to include prevention as well as health care.

PAHI also seeks to promote health care systems that provide cost-effective services to prevent and control hypertension in an integrated health care model that combines care and education. These systems also ensure the availability of essential drugs for treatment.

A third aim of PAHI is to empower those who have hypertension to increase their knowledge of the condition to control it better, to effectively communicate their needs with health care professionals, and to develop national organizations to promote public awareness.

In addition, PAHI seeks to create supportive environments for those suffering from the disease to make healthy decisions, and to implement a surveillance system to observe the disease's trends and monitor the prevalence of those who receive inadequate treatment.

For more information, contact PAHO at: Pan American Health Organization Pan American Sanitary Bureau Regional Office of the World Health Organization 525 Twenty-third Street, N.W.Washington, D.C. 20037Tel: 1-202-974-3000Fax: 1-202-974-3663Or the NHLBI at: NHLBIinfo@rover.nhlbi.nih.gov

New Managing Editor for Global Perspectives Saima Huq recently joined the Institute for International Health Promotion as the Managing Editor of Health Promotion: Global Perspectives. She holds a 1995 BA in Print Journalism from the American University, and is currently working on a Master of Public Health in International Health Promotion at the George Washington University, located in Washington, DC.

New Director of Health Promotion at the World Health Organization (WHO)

Dr. Pamela Hartigan was recently appointed as WHO's Director of Health Promotion by WHO's Director General, Dr. Gro Harlem Brundtland. Dr. Hartigan, of Ecuadorian origin, holds a Master of Education degree from American University in Washington, DC and a Ph.D. in Behavioral Psychology from the Catholic University of America in Washington, DC.

Dr. Hartigan started her career as an economist at the World Bank, where she worked extensively in education and curriculum development with a focus on the needs of the immigrant Hispanic community in Washington, DC. In 1988, she got her first position career with WHO at the Pan American Health Organization (PAHO), the regional office of WHO in the Americas, in the area of HIV/AIDS. In 1990, she was appointed by PAHO's Director to spearhead an initiative to foster collaboration between government organizations and NGOs working in health in this region. As a result of this initiative, every PAHO unit now works closely with local and national NGOs to ensure that projects and programs are jointly designed and implemented by both NGOs and government organizations.

In 1994, PAHO's director asked Dr. Hartigan to take charge of its Women, Health and Development Program. Dr. Hartigan and her team: developed a conceptual and practical framework to put gender issues in the mainstream throughout PAHO and in the countries, mobilized over $6 million in US funds to support community-based initiatives to address violence against women; and secured funds to conduct research in the area of gender and quality of care. In 1997, Dr. Hartigan was selected by the Special Programme for Research and Training in Tropical Diseases (TDR) of the World Bank, UNDP and WHO, as Programme Manager and Manager of the Task Force on Gender-Sensitive Interventions.

We congratulate Dr. Hartigan on her prestigious appointment and look forward to enhancing the existing linkages between the IIHP and the WHO.

Initiative to Increase Regional Dialogue

Over the last few weeks, an initiative to increase regional dialogue and cooperation within the IIHP network was launched. This initiative is being coordinated by student representatives at American University. You may have been recently contacted by one of our representatives. Please respond, introduce yourself, and identify what issues you would like to have discussed.

The goal of this initiative is for everybody within the region to get to know each other, build networks, explore cooperative agreements, create periodical regional reports, plan regional seminars and conferences, gather data for country or region reports, and exchange information about research, projects, and conferences.

Regions included in the initiative are: South America, North America, Middle East/Arabian Gulf, Scandinavia, Western Europe, Eastern Europe and Central Asia, East Asia, Africa, and Australia/ Oceania. Some of these regions have not been assigned to representatives yet.

Curitiba Meeting (October 10-13) Update

The Fourth Annual Meeting of the IIHP will kickoff with a reception on Sunday night, October 10.

The reception will be hosted by Mayor Cássio Taniguchi at the Curitiba Prefeitura. The meeting will close on Wednesday night, October 13, with a joint reception for the meeting delegates and participants of the ABQV (Brazilian Association of the Quality of Life) Scientific Congress, on October 13-16.

The Topic of the meeting is Health Promotion: Policies and Economics. For more information visit the website at: http://www.healthy.american.edu/iihpmeetcuritiba.html

Did you know? 
Curitiba is the capital of Párana State, 304 years old and the home of 1.5 million people.

Conferences

September 6-12, 1999: Training Course for Fitness Instructors and Coaches (with a health promotion module), in Bistrita, Romania.

September 11-14, 1999: The International Conference on Movement and Health, hosted by the Faculty of Physical Culture, Palacky University in Olomouc, Czech Republic.

October 10-13, 1999: The Fourth Annual Meeting of the IIHP, co-hosted by the Brazilian Association for Quality of Life (ABQV) and the Prefeitura Curitiba, in Curitiba, Brazil.

October 13-16, 1999: International ABQV Congress in Curitiba, Brazil.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe. It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations. More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation. E-mail the IIHP at <iihpaa@american.edu>. The IIHP website is <http://www.healthy.american. edu/iihp.html>

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