MEDICAL RESEARCH COUNCIL (UNIVERSITY OF DURBAN-WESTVILLE)

Submission on Chapter 18 (Health Promotion and Communication) of the White Paper for the Transformation of the Health System issued by the Department of Health.

18 March 1998.

This presentation will be done in two parts. Firstly Priscilla Reddy will provide an overview and a framework for action, and thereafter Anil Bhagwanjee will propose an integrative framework for implementing Health Promotion focusing on resources, and capacity development

The Department of Health is to be congratulated for having the insight to dedicate a chapter in the White Paper to Health Promotion. This chapter has succeeded in moving away from the traditional narrow definition of health promotion which in the past focused solely on individual behaviour change and on the ability of individuals to make healthy choices. This chapter provides the background and philosophical basis for a comprehensive yet focused framework of action.

By locating the South African health promotion movement within the Ottawa Charter the chapter also incorporates the five pillars of health promotion, namely

· healthy public policy
supportive environments
· community action
· personal skills
reorientation of health services

Another strength is clearly articulated on page 181 where the directorate is identified as being responsible for ensuring that all policies that emanate from the state are health promoting. This recognises the importance of intersectoral action, and provides an opportunity to locate health promotion interventions across the sectors.

While we recognise that a policy document such as this White Paper needs to be broad and enabling, and not prescriptive, we would like to suggest a framework for action that allows the philosophy underpinning the document to be implemented. Such a framework may enable health promotion practitioners to implement specific interventions, that aim to change the determinants of health and health behaviours in ways that this chapter envisages. The framework may be adapted for any health promotion initiative.

An Integrative Framework for Health Promotion

People cannot be developed. They can only develop themselves. If is possible for an outsider to build a man a house, but that outsider cannot give a man pride and self confidence in himself as a human being. These things a man has to create for himself; by his own actions. He develops himself by his own knowledge and ability and by his participation as an equal in the life of the community he lives in. People develop themselves by joining in free discussions. Development of the people can in fact only be effected by people themselves. Development should therefore be seen as a dynamic process of change. In people's attitudes, behaviour and practices conducive to their development. This development should be one that the community and country can sustain.
Julius Nyerere

While the White Paper offers a broad range of implementation strategies in a number of defined categories, what appears to be lacking is an integrative framework to ensure the effective, coherent and co-ordinated implementation of these strategies. Following the Ottawa Charter, Health Promotion is really a mediating strategy between people and their environments, synthesising personal choice and social responsibility in health to create a healthy nation. Health Promotion is thus a process of enabling people to increase control over and to improve their health. In this context, therefore, we argue that the central role of government should not be to "provide" health promotion through a package of strategies, but rather to provide the resources necessary in order to play an enabling and facilitatory social role in a sustainable fashion. It is this enabling function that should receive primary consideration in this White Paper, and that should be legislated herein in the interests of sustainable people-driven health promotion.

The fulcrum of a successful national health promotion policy therefore hinges on our ability to mobilise all sectors of society into a cohesive partnership that will take collective ownership and responsibility for promoting the health of the nation. Thus the central role of the National Health Promotion and Communication Directorate should arguably be to facilitate these partnerships in a systemic and formal fashion. Given the many crucial roles already assigned to the Directorate in this White Paper (i.e. with regard to co-ordinating and monitoring governmental decisions, policy and legislation), what is arguably required is an appropriate stakeholder forum, co-ordinated by the Directorate, in order to ensure thd effective implementation of th& many strategies offered in this White Paper.

We accordingly propose the formation of a National Health Promotion Foundation, as the implementation arm of the National Health Promotion and Communication Directorate. The National Health Promotion Foundation should include, as outlined in the White Paper, all relevant Government Departments, nongovernmental and community-based organisations, the business community, the education sector, the media and other mass~communication bodies, professional associations, trade unions, policy makers and the public.

A Health Promotion Foundation
Health Promotion activities are often long term in nature. Such a foundation would therefore provide a sustainable resource that would be protected by legislation.

The suggested functions of the Health Promotion Foundation are as follows:
· To sponsor sports and arts events
· To direct and fund health promotion research initiatives - often neglected by Health System Research funders
· To direct fund and oversee capacity building at all levels such as
- tertiary training and credentialling
- training of community members in grant writing skills and evaluation methods To set national health promotion priorities using a process of stakeholder participation

It is further suggested that the National Health Promotion Foundation should be funded, at least in part, by the excise tax levied on the sale of tobacco and related products, to be negotiated between the Department of Health and the Department of Finance.

Capacity Building and Training
We support the need for capacity-building, both in the areas of research and practice, but suggest that these sections emphasise the following:

· the need to build the principles of equity, redress and empowerment into the selection of suitable sites and individuals, both to carry out the training and research and to decide who should be trained and what comprises the primary domains of research.

the need to ensure that all available local resources are harnessed for capacity-building and research, that includes not only the full spectrum of local education institutions but also other organs of civil society, e.g. NGO's, CBO's, professional associations etc.