population health and wellbeing,
conceptual and policy frameworks,
health promoting health systems,
barriers and enabling mechanisms,
Health in All Polices,
health promoting health services,
Health promotion has a critical role to play in improving the health and wellbeing of current and future generations of EU citizens.
Based upon a socio-ecological model of health, health promotion has been defined by the WHO (1986) as “the process of enabling people to increase control over, and improve, their health”.
Health promotion moves the focus from individuals at risk of developing illness to systems and environments that shape the development of good health at a population level.
As such, it is an essential component of modern health systems in order to ensure that all human beings can have healthy lives, can maximise their health potential and that no one is left behind.
Cost-effective and feasible health promotion interventions have been shown to make a real difference in improving population health, reducing risks for non-communicable diseases, improving mental health, increasing health literacy, and addressing the social determinants of health and health equity.
However, the level of infrastructure and capacity to support health promotion action varies considerably across EU countries. The concept of health promotion is often poorly understood and there is a limited appreciation of the infrastructure, resources, knowledge and skills that are required to translate health promotion into action.
As a result, there are significant gaps in implementation in many countries, particularly in terms of mainstreaming health promotion within health services, and there is a lack of investment in developing the necessary health promotion systems for substantive progress to be made.
Embracing a health promotion framework requires a significant shift in focus from illness to health and calls for intersectoral action and partnership working as an integral aspect of health promotion practice. Health promotion embraces a new and broader understanding of health and its determinants and calls for a new base of multidisciplinary knowledge, skills and competencies that extend beyond the traditional healthcare approach. While successive EU health policies and strategies have endorsed the need to invest in health promotion, and some countries have made good progress in developing health promotion capacity, political commitment to implementing health promotion is lacking in many countries. Health policies and budgets remain focused primarily on curative interventions. Balancing the prioritization of treating and preventing diseases against the promotion of longer-term health improvement is a difficult trade-off when funding and resources for health systems are under pressure.
This Opinion considers what progress has been made in implementing health promotion within the EU region, and considers what mechanisms can be used for strengthening the integration of health promotion within health systems. Current conceptual and policy frameworks for health promotion are outlined, and the rationale for the development of health promotion and its continued relevance within the context of current policy objectives, including the Sustainable Development Goals, is considered. A critical reflection is
undertaken of current enablers and barriers to progress including the need for: advocacy and high-level political leadership and support; enabling governance structures and processes for implementation; sustainable funding mechanisms and incentives; organizational and workforce capacity development. Building on this reflection, a number of enabling mechanisms are outlined and practical examples provided including: policy structures and processes for the implementation of a Health in All Policies (HiAP) approach; the integration of health promotion within health services, with a particular focus on strengthening health promotion within primary care; sustainable financing for health promotion; and mobilising wider community participation and engagement.
Health promotion is an essential strategy for improving health equity and a key action underpinning the reform of health systems in Europe. Applying the principles of the European Pillar of Social Rights and the competences of the EU treaties for the promotion of wellbeing and protection of health across all EU policies, we recommend that a range of policy measures and financial mechanisms at the European level are applied to support the implementation of transformative health promotion policies and practices in EU Member States. This shift in focus from disease to health can be considered ‘a disruptive innovation’ due to the need to transform existing organisational structures, workforce, and services. More specifically, the following actions are recommended for implementation at the EU level in cooperation with key partners, citizens and national governments in Member States:
• Advocate for the importance of health promotion
o Develop effective advocacy for health promotion to increase the visibility and relevance of health promotion and ensure that its contribution to human, social and economic development in Europe is recognised across the political spectrum and in communications for public health, especially for vulnerable and underserved population groups.
o Advancepoliticalcommitmenttoeffectivehealthpromotionpoliciesandaction plans through the formulation of specific health promotion goals and the development of feasible and evidence-informed policy options for health promotion action in Europe and among high-level policymakers, including those from the non-health sector.
• Provide strategic leadership for health promotion at EU level
o Provide leadership and coordination at EU level in ensuring the implementation of a HiAP approach in EU Member States and the integration of health promotion as a priority within European and national policies by supporting Members States in developing the required organisational
structures and processes for innovative intersectoral health promotion actions
and strengthening capacity development in different country contexts.
o Promote the integration of health promotion within health services, especially in primary care to ensure universal access to health promotion programmes thereby improving the scope and range of services to health service users, reaching out to the most vulnerable groups in society to ensure better health for all.
o Invest in developing a dedicated workforce for health promotion in Europe, through leadership in advancing recognition of the need for a dedicated health promotion workforce with the necessary skills and competencies for quality professional practice and the inclusion of health promotion in the educational curricula of health professionals.
• Protect and promote sustainable financing mechanisms for health promotion o Invest in the development of robust health promotion policies and programmes at EU level by ensuring sustained investment for the implementation of comprehensive health promotion strategies in EU Member States.
o Apply EU funding and investment mechanisms to ensure that health
promotion is included in EU, national and regional programming priorities,
thereby protecting funding for capacity development.
o Explore the use of EU financial instruments such as the ESIF, and co-financing
mechanisms, to support the re-orientation of health systems to health
o Support Member States in reviewing current health budgets and exploring new
ways of balancing spending towards health promotion and developing mechanisms and incentives for ensuring its sustainability.
• Develop the capacity to implement health promoting health systems at EU level and in Member States
o Apply the EU Semester process and other available policy mechanisms to enable countries to establish the system requirements for health promotion policy and programme development, including high-level leadership and political responsibility at a country level for the implementation of health promotion policies and programmes.
o Provide technical guidance on implementing health promotion in practice through the setting of European norms and standards for best practices and
Options to foster health promoting health systems
evidence-based priority interventions to be delivered at all levels of the health
o Support the assessment of health promotion capacity in Member States through the development of tools for assessing and benchmarking infrastructure capacity and performance for core health promotion action.
• Invest in health promotion research in Europe
o Support the development of interdisciplinary and innovative health promotion
research through the EU framework programmes for research, development and innovation, with a particular focus on: monitoring of positive indicators of population health and wellbeing status across the social gradient at a country level; the comprehensive evaluation of complex upstream and multilevel health promotion interventions; multi-country implementation trials of evidence-based approaches; economic analyses to determine the cost-benefit and cost-effectiveness of health promotion strategies; health equity impact assessments of policy making across sectors; and the dissemination of feasible evidence-based strategies.
o Develop knowledge translation mechanisms for health promotion in the EU region by developing a network of dedicated health promotion knowledge translation centres to promote the timely use of scientific research and knowledge to strengthen health promotion practices and policies.
• Strengthen health promotion partnerships at EU level
o Support sustained partnerships for health promotion through active collaboration with dedicated health promotion foundations, NGOs such as IUHPE and EuroHealthNet, academic partners and national focal points with a health promotion remit.
o Support effective and sustainable multi-level partnerships across diverse sectors in order to progress implementation of HiAP and to meet the targets set by the SDGs.
• Support social mobilisation strategies
o Invest in improved consultation processes and community engagement strategies to actively engage European citizens in creating a greater demand for health promotion in Europe and advocating for the implementation of policy decisions that impact on population health and wellbeing.