Health For All (HFA) was adopted by the member states of the WHO in 1977 in recognition that large numbers of people did not have an acceptable standard of health (Parish, 1995; Tones, 1996; Pappas and Moss, 2001). It was launched at the Alma-Ata Conference in the Soviet Union in 1978, with the Alma-Ata Declaration
(WHO, 1978). At the heart of this declaration was the recognition that social justice and equity are pre-requisites for health, and that “health is primarily about politics” (Kelly and Charlton, 1995, p.80). These ideas became influential at the local level, and in Britain this was spearheaded by the adoption of a Health For All framework by the Mersey Regional Health Authority in 1984 (Ashton, 1992), reflecting Liverpool’s history of being at the cutting edge of public health developments (Green, 1992).
The discipline of health promotion developed in the WHO alongside Health For All, from the recognition that health education on its own would not be sufficient to radically improve health (Parish, 1995; Tones, 1996). Tones (1996) describes health promotion as “a kind of militant wing of HFA2000” (ibid, p.10). The member states of the European region of the WHO adopted the 38 targets of Health For All in 1984 (Kickbush, 2003). This helped to give this broader approach to health promotion legitimacy and contributed to the positive political environment that led to the Ottawa Charter for Health Promotion (Tones, 1996; Kickbush, 2003).
According to the Ottawa Charter (1986), health promotion is “the process of enabling people to increase control over, and to improve, their health” (Ottawa Charter, 1986, p.1). Health is “seen as a resource for everyday life, not the objective of living” (Ottawa Charter, 1986, p.1). The purpose of health promotion is to advocate, enable and mediate for health and wellbeing, and is built upon the principles of building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services towards prevention.
Despite the adoption of a Health For All strategy by many countries, progress towards new national policies based on the principles of Health For All was slow (Ashton, 1992). The Health For All process was relaunched in 1995, recognising the limited success of the policy to that date (Pappas and Moss, 2001; WHO, n.d.). The relaunched policy re-affirmed the principles of Health For All in response to accelerated global change and new thinking (WHO, 1998). It recognised poverty as the greatest threat to health, and that new responses were needed to tackle emerging challenges such as: demographic shifts - urbanisation, ageing, increase in chronic diseases; social, behavioural, biological changes – sedentary lifestyles, increasing levels of violence, increasing disease resistance to drug treatments; transnational factors – global economic policies and processes, environmental degradation. Similarly, The Jakarta Declaration on Health Promotion in the 21st Century (Jakarta Declaration, 1997) was a restatement of the principles of the Ottawa Charter in the light of the new Health For All process. The Jakarta Declaration (1997) states the new priorities for health promotion in the 21st century as: social responsibility; increased investments for health development; to consolidate and expand partnerships for health; increased community capacity and individual empowerment; and to secure an infrastructure for health promotion. This latter priority promoted settings, such as schools, hospitals, workplaces, universities and prisons, as sites for health promotion (Tones, 1996; Dooris, 2004). These ‘healthy settings’ were to afford an opportunity to put the principles of Health For All and the Ottawa Charter into action (Tones, 1996; Johnson and Baum, 2001; Kickbush, 2003; Dooris, 2004). Perhaps the best known example of WHO endorsed health settings is the Healthy Cities initiative (Tones, 1996; Kelly and Killoran, 2003; Kickbush, 2003; Dooris,
2004). Liverpool was amongst the first eleven WHO sponsored Healthy Cities (Liverpool Healthy City 2000, 1997), and John Ashton and others working from Liverpool were influential in the European Healthy Cities project (Ashton, 1992; Green, 1992). The Healthy City projects
advocated partnership and network-based approaches of change management to allow creation of political commitment, generate visibility for health issues, embark on institutional change, and create space for innovative health action. (Kickbush, 2003, p.386).
Healthy City work is based on the principles of Health For All, defined as equity, intersectoral collaboration, community participation, and sustainable development (Naidoo and Wills, 2000; UKHFAN, n.d.). These two functions of the healthy settings approach combine to form a ‘whole systems’ approach to health improvement (Dooris, 2004).
The Healthy Cities concepts helped to shape the development of the HAZ policy (MHAZ, 2000), and the HAZ Principles reflect the aims of Health For All (see Box 1.1 in Chapter 1). In Merseyside, it was clear that the Liverpool Healthy City work directly influenced the development of the HAZ programme. One participant in this research who worked closely with the Healthy City project in Liverpool explained:
I think being able to input the experiences that we’d had in Liverpool around joint working on public health, the development of the City Health Plan, etc, helped to lay some of the foundations for the HAZ. Because it’s the same ... Health For All, Healthy Cities. (MHAZ co- ordination, 03/2002).
Although, almost inevitably, the local focus of the Liverpool Healthy City project has been lost in the development of the HAZ, the MHAZ has been beneficial in that “the Health For All way of working has expanded right across Merseyside” (op. cit.).
This settings approach to health development, and particularly the emphasis on healthy public policy4 and intersectoral work, reflected the need to tackle health improvement and health inequalities from a broad base, as discussed earlier. To be successful health promotion needs to be part of the core values of an organisation and the people involved need to be committed to the process (Johnson and Baum, 2001). Just as health promotion remains a contested concept (Tones, 1996), so health promotion has been undertaken differently in various settings (Johnson and Baum, 2001). Consequently, such settings based health promotion projects have had mixed results (Baum and Cooke, 1992; Duhl, 1992; Dooris, 2004).
The Ottawa Charter promoted a holistic socio-ecological model of health (Dooris, 2004), where the focus is on health generation and not disease alleviation (Kickbush, 2003). However, Kickbush (2003) concedes that the tendency has been to fall back to health education methods of trying to change individual behaviours (smoking, exercise, diet, and so on). This tension between health care provision and health promotion has been evident throughout the life of the HAZs. In part it reflects the fact that different models of health are competing with each other. The socio- economic model of health might now be widely accepted, but it is not always widely acted upon.