Introduction
Growth, development, equity and stability
Political leaders increasingly perceive health as being crucial to achieving growth,
development, equity and stability throughout the world. Health is now understood as
a product of complex and dynamic relations generated by numerous determinants at different
levels of governance. Governments need to take into account the impact of social,
environmental and behavioural health determinants, including economic constraints,
living conditions, demographic changes and unhealthy lifestyles in many of the World
Health Organization (WHO) Member States. This understanding and increasing globalization
means it is very timely to review the role of (global) public health in this changing
societal and political environment.
Globalization
The positive and negative impacts of globalization need to be better understood by
public health professionals and more widely acknowledged by policy makers. Globalization
is marked by increased interconnectedness and interdependence of peoples and countries,
based on the opening of borders to increasingly fast flows of goods, services, finance,
people and ideas across international borders and the changes in institutional and
policy regimes at the international and national levels that facilitate or promote
such flows. It is recognized that globalization has both positive and negative impacts
on health development. Increasingly trade agreements provide frameworks for intergovernmental
relationships; however, possible impacts on human health are not routinely assessed
prior to signing.
The proposal for a Global Charter for the Public’s Health
In this context, the World Federation of Public Health Associations (WFPHA) has developed
the A Global Charter for the Public’s Health (GCPH) as the main output of its collaboration
plan with the WHO to adapt today’s public health to its global context in the light
of and in conjunction with the Sustainable Development Goals (SDGs). GCPH brings together
the best of all the existing models and provides a comprehensive, clear and flexible
framework that can be applied globally and within individual countries, whether low,
middle or high income.
The WFPHA has engaged with its over 100 national public health associations to discuss
the new roles that global public health professionals have to assume and the needed
changes with regard to education and recruitment of public health personnel. A literature
review and widespread consultation formed part of this initiative.
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Outcome of literature review and consultation
As part of the consultation process, several key points were raised:
The need for genuine political engagement was stressed, underlying that too often
politicians only paid lip service to public health.
Commercial, social and environmental determinants of health, as well as social inequalities
should be tackled and resources allocated in a sustainable and accountable way.
The impacts of underlying ideologies should be taken into consideration.
More comprehensive and reliable data are needed in many programmatic areas of the
public’s health.
The multisectoral and holistic approach should be reached, engaging public health
in big dialogues and in the concerted decision-making processes.
Participants of the consultation stressed that WHO should provide leadership in this
process.
New leaders for public health are required.
A flexible common framework of instruments to influence governments has been suggested.
New creative solutions are needed.
Specific projects of selected countries where public health has a strong voice and
is integrated in government policies and initiatives might be possible models for
other settings.
While publications on global public health are exponentially increasing in the literature,
the term ‘Global public health’ itself remains ill defined. The term is frequently
used though, but more in the context of a ‘problem’ or a ‘challenge’. The framing
of global public health is frequently medical and technical. This may be a result
of the vertical technically oriented programs that are run throughout the world. Political
and economic constraints found in the literature are important but there is not a
large body of literature around this topic.
Despite the evidence that the different public health functions need to be much better
integrated into health systems, a ‘know-do-gap’ is apparent. While multi-sectoral
approaches in public health are increasingly chosen, they are by no means mainstream.
A Global Charter for the Public’s Health
Resilient public health systems are needed locally to globally and within each country.
However, the current reality consists of fragmented, variable and incomplete public
health services and functions, with little common understanding of what a good public
health service looks like.
Currently, there is no global agreement on what public health functions or services
consist of, and the lack of a common vocabulary in public health adversely affects
the efforts of public health systems, including security and workforce development
and quality standards across the world. Many public health policies, especially those
that look at disease specific topics, remain vertical, even if they outline some inter-sectoral
components. Many are not well coordinated with other related societal fields and,
therefore, have a huge impact on population health. A GCPH has the potential to become
an established framework to allow public health systems to communicate globally, compare
capacity and improve performance through systematic action.
Functions and services
The proposed GCPH consists of two groups of functions/services including:
Services: a group of core services—Protection, Prevention and Promotion
Functions: a group of enabler functions—Governance, Advocacy, Capacity and Information
Headings for the GCPH
There exists overlap between all these services and functions, especially between
health promotion, primary prevention and environmental health, which benefit from
a cross-sector approach. Specific public health topics require components drawn from
across the range of services and functions. These include:
Governance: public health legislation; health and cross-sector policy; strategy; financing;
organisation; assurance: transparency, accountability and audit.
Information: surveillance, monitoring and evaluation; monitoring of health determinants;
research and evidence; risk and innovation; dissemination and uptake.
Protection: international health regulation and co-ordination; health impact assessment;
communicable disease control; emergency preparedness; occupational health; environmental
health; climate change and sustainability.
Prevention: primary prevention: vaccination; secondary prevention: screening; tertiary
prevention: evidence-based, community-based, integrated, person-centred quality health-care
and rehabilitation; healthcare management and planning.
Promotion: inequalities; environmental determinants; social and economic determinants;
resilience; behaviour and health literacy; life-course; healthy settings.
Advocacy: leadership and ethics; health equity; social-mobilization and solidarity;
education of the public; people-centred approach; voluntary community sector engagement;
communications; sustainable development.
Capacity: workforce development for public health, health workers and wider workforce;
workforce planning: numbers, resources, infrastructure; standards, curriculum, accreditation;
capabilities, teaching and training.
Recommendations
Recommendation 1–Consensus: A common conceptualization of global public health should
be defined and adopted by the WFPHA and its members and used as a basis for public
health education and training. It should be followed by a process of engagement with
partners and Member States to adopt a WHO action plan on public health functions,
based on the approved GCPH.
Recommendation 2–Co-ordination: WFPHA in association with partners supports and recognises
WHO's leadership role to facilitate global public health in global multi-sectoral
dialogues, co-ordination and decision making.
Recommendation 3–Leadership: Public health leadership to be strengthened to integrate
the public health charter into cross-sector policy, health systems policy and governance
mechanisms, building on and enhancing existing frameworks.
Recommendation 4–Workforce: Applying the GCPH encompassing functions, services and
healthy public policy to scale up the public health workforce to ensure global health
security and the sustainability of health systems.
Recommendation 5–Tools and application: Case studies, tools and standards to be developed
to illustrate the application of the GCPH at the global, national and local levels
and for use in public health education and training. Adoption of a GCPH will require
skilful communication and practical application.
Recommendation 6–Resources: In order to strengthen Global Public Health, political
commitment is needed, with co-ordinated roles and resources with partners and donors.
Conclusion
In the broadest sense, public health in our globalized world is multi-faceted, serving
as a basis for everyday life, crucial for growth and development, equity and stability
and is a function of numerous social, environmental and behavioural determinants,
not least of which are the impacts of globalization itself. To realize the potential
of a healthy global citizenry to support economic growth and development, equity and
stability, there is an urgent need for genuine political acknowledgement of, engagement
with and leadership for the public’s health supported by a global public health system.
Action on two levels is required. First, consensus on a conceptualization of global
public health and on a framework for sustainable and secure health infrastructures
and services are essential first steps to underpin health in everyday life and to
minimize the negative economic, social and environmental impacts of globalization
on health development and community stability. Additionally, new models and skill
sets are needed to address new and re-emerging public health challenges within the
different socio-economic realities around the world, varying political capacities
and new political entities.
Second, development of global public health requires political engagement, use of
social networks, identification of political leverage points and steerage of public
health agendas through the new societal and political environments. Importantly, global
public health values should inform, be embedded within and be used to assess political
and policy decisions.