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John Catford, Creating political will: moving from the science to the art of health promotion, Health Promotion International, Volume 21, Issue 1, March 2006, Pages 1–4, https://doi.org/10.1093/heapro/dak004
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Twenty-one years ago the first edition of Health Promotion International was published. In the opening editorial Dr Halfdan Mahler the then Director-General of the World Health Organization said, ‘Public health is in a process of change. Our understanding of what constitutes health is broadening, as is our concept of health itself’. In introducing the journal and the new concept of health promotion he emphasized that public health needed to move into positive and active advocacy for health. One of the significant obstacles to progress he considered was that ‘The political will and the intersectoral action necessary to create the healthy environments are sadly lacking in many countries’ (Mahler, 1986).
Over the last two decades there has certainly been sustained and valuable progress in health promotion and the broader field of public health—and this journal has documented many of the advances (Catford, 2004). Across the world there are government health promotion strategies and reviews, statutory authorities and foundations, consumer interest groups, professional associations and journals. University departments and professors proudly bear the name, Masters and Bachelor degrees are in abundance and a new textbook seems to appear every few months. Millions of dollars are now increasingly being invested in health promotion programmes by governments and international organizations, like the World Bank, as well as through voluntary contributions from people themselves.
The health promotion industry is certainly alive and well as was demonstrated by the 6th Global Conference on Health Promotion held in Bangkok 7–11 August 2005. The theme was ‘Policy and Partnerships for Action: Addressing the Determinants of Health’. The conference was attended by a record number of delegates from all parts of the region and a wealth of material was presented, which will form the content of a special edition of Health Promotion International later in the year. But despite all the investments that have taken place particularly in health promotion infrastructure and programmes, there was an overriding consensus at the Conference that the development of healthy public policy had not kept pace with these other valuable developments.
Mahler's assertion over 20 years ago is still true—the battle ground for health promotion is to develop political will. For example, The Bangkok Charter for Health Promotion in a Globalized World (WHO, 2005a) stresses that ‘Progress towards a healthier world requires strong political action, broad participation and sustained advocacy’ (WHO, 2005a). The need for stronger political commitment is also highlighted in the World Health Organization's recent publication, Preventing Chronic Diseases: A Vital Investment (WHO, 2005b).
This excellent WHO report emphasizes that governments need to provide leadership to address chronic diseases through a series of low-cost, high-impact actions implemented in a stepwise manner. Comprehensive and integrated action at country level, led by governments, is the means to achieve success but this requires political commitment from the top down. It is encouraging to note therefore the support offered by the Vice-Minister of Health, Wang Longde, of the People's Republic of China, who stated, ‘We are committed to implementing the strategies outlined in this report to effectively prevent chronic disease and urge the same scale of commitment from others’. We wait with interest to see how these commitments are translated into health outcomes in China.
One of the reasons why progress has been less effective in the political arena is that we as health promoters have not placed as much attention on the process or method of policy making as we have on the content or shape of the policy. Health promotion requires a diverse set of skills and insights but political analysis and strategy has not been at the forefront. This needs to change if we are to be more effective at managing the decision-making processes.
Deciding whether to embark on a new policy or programme goes far beyond considering the intrinsic merit or worth of the proposed intervention. A number of other criteria are equally important in a managerial and political sense to determine whether an intervention is ‘able’ for implementation, as illustrated in the figure below. To have any chance of support within the highly scrutinized and contentious realms of government, candidate interventions need to be shown to be reliable, valuable, acceptable, affordable, feasible and accountable.
Efficacy and Safety | Reli able? |
↓ | |
Potential Health Impact | Valu able? |
↓ | |
Policy and Political Fit | Accept able? |
↓ | |
Cost and Sustainability | Afford able? |
↓ | |
Capacity for Action | Feas able? |
↓ | |
Responsibility, Monitoring | Account able? |
Efficacy and Safety | Reli able? |
↓ | |
Potential Health Impact | Valu able? |
↓ | |
Policy and Political Fit | Accept able? |
↓ | |
Cost and Sustainability | Afford able? |
↓ | |
Capacity for Action | Feas able? |
↓ | |
Responsibility, Monitoring | Account able? |
Efficacy and Safety | Reli able? |
↓ | |
Potential Health Impact | Valu able? |
↓ | |
Policy and Political Fit | Accept able? |
↓ | |
Cost and Sustainability | Afford able? |
↓ | |
Capacity for Action | Feas able? |
↓ | |
Responsibility, Monitoring | Account able? |
Efficacy and Safety | Reli able? |
↓ | |
Potential Health Impact | Valu able? |
↓ | |
Policy and Political Fit | Accept able? |
↓ | |
Cost and Sustainability | Afford able? |
↓ | |
Capacity for Action | Feas able? |
↓ | |
Responsibility, Monitoring | Account able? |
Much effort is focused on the first two criteria of establishing efficacy and safety, and determining the potential health impact. Interventions need to show that they are reliable and valuable primarily through epidemiological and behavioural research which may include intervention studies. This is the focus of much health promotion research, which is successfully being brought together by the Cochrane Health Promotion and Public Health Field. This is an entity of the Cochrane Collaboration, which is funded by the Victorian Health Promotion Foundation (VicHealth) and through project grants, and is now based at Deakin University in Melbourne, Australia. The aim is to promote the production and use of high-quality systematic reviews of effectiveness of health promotion and public health interventions (Cochrane Collaboration, 2006).
Increasingly attention is also being given to the cost and sustainability criteria in the decision-making process. Encouragingly several governments in Australia, Germany, Switzerland and the UK have been examining the economic costs of health care and the role of prevention. Interestingly, the work in the UK was led by the Treasury rather than the Department of Health. Sir Derek Wanless, the author of a major review of health spending in the UK, suggested three different scenarios for future spending in health, with the most cost-effective—the so-called ‘fully engaged’ scenario—relying on more investment in public health (Wanless, 2002). The proponent was not a group of well-meaning health promotion activists, but the ex-chief of one of the UK's biggest banks backed by the strength of the Chancellor of the Exchequer Gordon Brown.
Past experience of promoting public health, however, suggests that, while evidence is important, it is not enough. The skills required in health promotion today are more than the traditional specialist ones taught at university. Health promotion needs to be able to work within existing political and economic systems, to understand how decisions are made and then to know how to influence this decision making. This is the essence of political analysis and strategy and a major ‘art’ of health promotion practice.
The ‘policy and political fit’ criterion is often the area most neglected and the most poorly undertaken. To run the argument that a particular policy or programme is good for the public's health and that it provides value for money is not enough. It does not answer the question of why government should be involved and why government should invest in this measure rather than any other. More is needed to create the necessary political will to act. From the perspective of one who has studied, published, managed and commissioned health promotion policies and programmes over two decades there are a number of key components for creating political will for health promotion:
The issue. In presenting a proposal to senior policy advisers, politicians or ministers it is vital that the intervention is seen to be responding to a perceived problem. If not then the intervention should be ‘reframed’ to optimize the context. There needs to be a strong constituency of support both in and outside government advocating for the measure. The proponents should articulate clearly what is needed and present a simplified construct and set of achievable goals and manageable actions. This is important to give the confidence that the intervention is possible and realistic. Unclear, over complicated proposals which do not get to the heart of the matter are unlikely to win support. This is more so if there is no obvious backing for the intervention externally.
The source. Advocates for a particular measure need to demonstrate their own credibility and status with community, politicians and government. Are they knowledgeable, legitimate and trust worthy? To maximize the impact of such advocacy, alliances should be forged with a range of organizations—both within health and with other groups. This improves the authenticity of the proposal. It is also very important to provide unanimity of advice. Presenting a common front is challenging for health promoters as there may be a range of options and alternatives, so try to agree the main ones and focus on those. If there is conflict, disagreement or indecisiveness over what should be done it is much easier for decision makers to do nothing or request further analysis or investigations. Convening a working party to consider and then report on an issue is a common delaying tactic. Often the problem has ‘gone off the boil’ when the committee reports some time later.
The benefits. A key aspect is to focus on providing solutions rather than adding more problems. Politicians and senior government officials already have too many challenges to deal with—they want answers and help not more difficulties. Short-term as well as long-term ‘pay offs’ therefore need to be demonstrated. Health promotion needs to get better at identifying and costing what the return will be on the investment or else it will lose out in the policy debates against more immediate health issues. Ideally the intervention should also create multiple ‘wins’ for different stakeholders so spreading the benefits to a broader base. Another useful approach is to emphasize that the consequences and risks from not acting are far worse.
The timing. Often proposals fail because of poor timing. Ideally it is best to place issues on the political agenda before an election so that measures can be included in election manifestos, policy platforms and forward commitments. Seeking major funding support during the midterm of a government should normally be avoided; governments commonly are busy financing previous election commitments or holding back resources for pre-election initiatives. The exception is for policy measures which do not require significant resources and may be more acceptable if they are implemented well in advance of the next election. Wherever possible interventions should build on existing policies and political ‘entry points’ that have already been agreed.
The methods. In negotiating with government it is important to develop supportive and constructive relationships. Show empathy and realism, mutual respect and trust with ‘no surprises’. Government officials can be strong allies internally and you do not want them to turn hostile and negative. Proponents also need to demonstrate enthusiasm and commitment, and show in all they do that they are of high quality and performance. The media should be used creatively to highlight the need for action and the benefits that will arise. Messages need to be constantly reinforced from different angles. A positive climate for change needs to be transformed into an overt ‘clamour for action’. Lobbying with influential ‘figure heads’, concerted press campaigns and peaceful protests can also play their part but always make sure that there is a clear and acceptable escape route for your opponents. If decision makers and politicians are backed into a corner they will go on the offensive which could be very counter productive.
Creating political will clearly takes a great deal of time and resources. Action almost certainly will need to be sustained over the long term. This is perhaps why it is less attractive and less well resourced. In Victoria, Australia, Dr Nigel Gray presented the case for a hypothecated tax on tobacco to eight health ministers before he found one who was sympathetic. Moreover, Government ministers are unlikely to even notice policies that cannot demonstrate some kind of outcome within their political lifetime. If decision makers know that you are not going away and are committed for the long haul then they may be more disposed to support you.
In generating public awareness an awkward kind of dance often goes on between the media and government where both accuse the other of failing to make more progress on debating public health issues. The media sees itself as reporting what the public wants to know, while government believes it is at the mercy of a press that will only report news that is headline grabbing. If there is no clearly identifiable victim to a health story (which is the case in most of health promotion) then it is very hard to get any media coverage. Nor are the visual images—so essential for television—as compelling for public health. There are no dramatic shots of doctors running along corridors and ambulance helicopters ferrying patients to hospital. This proposes a real challenge for health promotion advocates and requires even greater attention and skill.
These then are some of the avenues for mastering the art of delivering health promotion. In terms of creating political will the key ingredients can be summed up by the five P's:
• Position | What are you seeking? When do you want action to happen? |
• Perception | How does this fit within the current context? What are the benefits? |
• Players | Who are you? What credibility do you have? How united are you? |
• Power | What resources and influence do you have to influence the agenda? |
• Persistence | How determined are you? Will you stay the course? |
• Position | What are you seeking? When do you want action to happen? |
• Perception | How does this fit within the current context? What are the benefits? |
• Players | Who are you? What credibility do you have? How united are you? |
• Power | What resources and influence do you have to influence the agenda? |
• Persistence | How determined are you? Will you stay the course? |
• Position | What are you seeking? When do you want action to happen? |
• Perception | How does this fit within the current context? What are the benefits? |
• Players | Who are you? What credibility do you have? How united are you? |
• Power | What resources and influence do you have to influence the agenda? |
• Persistence | How determined are you? Will you stay the course? |
• Position | What are you seeking? When do you want action to happen? |
• Perception | How does this fit within the current context? What are the benefits? |
• Players | Who are you? What credibility do you have? How united are you? |
• Power | What resources and influence do you have to influence the agenda? |
• Persistence | How determined are you? Will you stay the course? |
In conclusion may I thank all the authors, reviewers and members of the editorial team for giving so feely of their time and in making Health Promotion International such a vibrant and ongoing success. Now entering our 21st year we have demonstrated sustained quality and performance and have addressed many of the challenges laid out in our ‘riding instructions’ by Halfdan Mahler. But we must continually refresh and remain contemporary—or to quote Mark Twain ‘Even if you are on the right track you will get run over if you just sit there’.
In future volumes of Health Promotion International we would like to give more attention to the neglected area of how to create political will—learning from both the successes and the failures of initiatives. In this regard the two papers in the debate section of this issue, one on mental health advocacy (Funk et al., 2006) and the other on evidence-based public health (Wang et al., 2006), provide a useful start. We have much still to do and much to learn about turning good intents into lasting actions.
REFERENCES
Catford, J. (
Cochrane Collaboration (
Funk, M., Minoletti, A., Drew, N., Taylor, J. and Saraceno, B. (
Wang, S., Moss, J. R. and Hiller, J. E. (
WHO (