Abstract
The pandemic has exposed the vulnerability of our civilization and reinforced the importance of living in harmony with nature, not rampaging it in a conquering mode. South and South-East Asia have a vital role to play in achieving the global goal of ‘Health for All’ as the regions have a significantly large share of global income and multidimensional poor compared to other regions. Clearly, the progress in health and development outcomes of these regions cannot be achieved without addressing social determinants of health and ensuring active public participation. These regions must collectively address the social determinants of health following a realistic health promotion model. It is indeed a favourable time to look beyond the so-called predominantly reductionist biomedical model of health care to a more holistic model of health, that places humans and the environment at the centre, and emphasizes the importance of promoting health and wellbeing.
Keywords
The regions of South and South-East Asia have a vital role to play in achieving the global goal of ‘Health for All’. After all, 24.8% and 8.5% of the world’s population resides in South and South-East Asia, respectively (1). Tremendous strides have been made during the last five decades to provide solutions to the problems of health and development within the regions, but these need to be upscaled effectively. The countries in the regions have much in common. Running through them is the thread of a democratic political system. They have given birth to four major religions – Buddhism, Hinduism, Sikhism and Jainism – all of which profess health as one of the main pillars of human enlightenment. This religious underpinning has ensured a well-developed health tradition in the region. Unfortunately, much of this incredibly rich tradition of holistic health has started eroding and it is imperative that sincere efforts be made to preserve and regenerate it before it is too late. The region also has a vibrant and living tradition of volunteerism and has a large body of volunteers and public health networks like the Voluntary Health Association of India (VHAI) (2). Many of them are highly motivated professionals, well equipped to take on the current and future challenges facing the health sector. Unfortunately, critical issues such as centralized planning, inadequate resource allocation, lack of people’s involvement and underutilization of the infrastructure remain unaddressed.
On the one hand, given the enormity of this challenge, there is a long way to go. On the other hand, in many countries of South-East Asia, the importance of health promotion is well recognized. For example, Thailand has established a National Health Commission & Assembly in order to enable Health in All Policies (HiAP) that encourages participatory healthy public policy development (3). Similarly, Sri Lanka has a National Health Promotion Policy, which is central to the national development agenda, making it a core responsibility of all sectors with the partnership of government, private and non-government organizations and partnerships with civil societies and communities (4). Recently, India has launched the concept of Health & Wellness Centres at the community level to provide comprehensive primary health care (5). Bhutan’s Gross Happiness Index, which aims at promoting sustainable happiness and wellbeing, is an important initiative that is worth emulating (6).
South and South-East Asia’s health care goals cannot be achieved without addressing the social determinants of health, given the fact that these regions have been accommodating a significantly large share of global income and multidimensional poor compared to other regions. South Asia’s share of the global poor has increased from 27.3% to 33.4% during the period of 1990–2013, in comparison to the global poverty rate which has dropped dramatically from 94% (1820) to 10.7% (2013) during the last two centuries (7). We can learn from the Sri Lankan example, where the nation has a low poverty rate compared to other regional members and this is mainly driven by the provision of free education and health services since its independence in 1948. Additionally, Sri Lanka’s social protection programmes such as Janasaviya and Samurdhi have also been significant factors in lowering income poverty (8).
It is of the utmost importance when planning and implementing health programmes that efforts are made to tackle some of the key social determinants of health, such as nutrition, drinking water, sanitation and the status of women, among others. While addressing the social determinants of health, a gentle and achievable gradient of change approach needs to be followed, given the polarizing nature of many societies within the regions. The newly established VHAI and International Union for Health Promotion and Education (IUHPE) International Collaboration for South-East Asia will provide a resource centre where global experiences are stored and disseminated within the region. It is also important to encourage collaborative efforts to find evidence-based solutions to new emerging problems in the region.
In this commentary, we consider some of the current opportunities and challenges in advancing health promotion in the region in order to achieve transformative change.
Redefining health promotion in the region
The need for a clear scientific and evidence-based health promotion approach to support the health policy-making process is greater than ever before. Any long-term perspective plan for health promotion has to keep in mind the health priorities of the sustainable development goals (SDGs) (9) and the health reality in the post-COVID-19 world. The current COVID-19 pandemic has exposed the underbelly of our health systems, highlighting the utmost importance of strengthening health promotion efforts in the future. The pandemic has exposed the vulnerability of our civilization and reinforced the importance of living in harmony with nature, not rampaging it in a conquering mode (10).
These regions suffer disproportionately from the high burden of communicable diseases, growing prevalence of noncommunicable diseases (NCDs) and emerging new diseases coupled with widening health inequities and poverty (11). Clearly, progress in health and development outcomes cannot be achieved without addressing social determinants of health and ensuring active public participation.
In these regions, both financial resources and health infrastructure are woefully inadequate. There is a need to examine the financial outlay that is required to meet the unfinished agenda of ‘Health for All’. On average, South Asian governments spend less on health, around 0.85% of gross domestic product (GDP), which remains below the global average (5.84%), but there is a great heterogeneity across the region (12). It is evident that a country’s economic, social and political stability depends on the investment that it makes in its health care. Health should not be treated as an expenditure, but as an essential investment for sustainable development.
Fortunately, we live in times when health has received its due importance in the global develop-ment agenda. Initiatives like the Macroeconomics Commission on Health (13), Global Fund resolve on TB, Malaria and HIV/AIDS elimination (14), World Bank (15) and considerable investment by private foundations (16,17) in the health sector and in achieving the SDGs are important expressions of this concern. It is critical that post-COVID-19, the quest for better health care will receive a further fillip in terms of sustainable investment. However, a favourable wind is of consequence only if the direction of the boat is right. The great economic forces of the market are now sweeping through the health care system worldwide. Health is a vital human good, and public health systems should play a key role in promoting it. Totally commercializing health care, for the sake of choice and efficiency, runs a potent risk of submitting it to the vagaries of market forces. For instance, the share of out-of-pocket spending is particularly high in Bangladesh (72%) and India (62.6%) (12). This illustrates the burden of health care payments on households in these countries – a consequence of the inadequacy of government provision of health services. Therefore, it is important that the State should remain the principal provider of public health and health care to safeguard it from this risk.
During the pandemic, some citizens across the world resisted simple protective measures like use of masks or maintaining physical distancing. This highlights the fact that health promotion needs to be an integral part of the health agenda for the future, so that communities are empowered to practise healthy living and improve their wellbeing. It is important to learn from the best practices in health promotion around the world and upscale effective approaches. In the process of redefining health promotion, we must rework our communication strategy. In the last few years, the significant presence of social and digital media has captured all spheres of our life. Health information, education and communication strategies need to fully utilize the vibrant platform of digital media to reach out effectively to local communities.
Embedding health promotion into the fabric of all government programmes
We must understand that health is an outcome of all policies. The pandemic brought to light the importance of the slogan ‘All for Health’. At the end of the day, not only the health professionals but all of society including local communities, police administration and a range of other sectors had to work collectively to combat the spread of COVID-19. Unfortunately, the non-health sectors in most countries are not trained in the basics of health protection and promotion. We need to ensure that in-service training is provided to all cadres of government and non-government organizations in the basics of promoting population health and wellbeing.
The conditions which influence the health and wellbeing of citizens are largely determined in sectors other than health. Sustainable change can be achieved only if the health sector and related sectors act in harmony. Cross-sectoral partnerships have to be taken into account in the planning stage of health promotion programmes and policies. The health sector can play a catalytic role and facilitate coordination of action that is intersectoral and community-based.
The COVID-19 crisis exposed the fact that the benefits of globalization do not come into active play when such disasters strike. In future, we need to develop a mechanism for horizontal integration of responses to such a crisis of global proportion. IUHPE has a significant role to play by ensuring that the existing knowledge and tools of health promotion are shared globally with key stakeholders and simultaneously working with them to find solutions to new and emerging problems. For example, IUHPE and VHAI have collaborated on COVID-19 prevention and management to build healthy and resilient communities in the remote parts of India. Using risk communication and community engagement strategies, the approach focuses on strengthening the capacity of the local stakeholders/health promoters and health systems for community-based health promotion.
Evolving a realistic health promotion roadmap for the disadvantaged
A few years back, the World Health Organization (WHO) took the initiative to highlight the importance of addressing the social determinants of health (18) but not much action followed. The pandemic showed how more than one-third of the global population, living in urban slums without proper infrastructure, have hardly any chance to protect themselves from the spread of communicable diseases or a pandemic. The impact of the pandemic across many urban centres showed how little has been done to improve the living conditions of the socially and economically disadvantaged. The crisis highlighted the vulnerability of people working in the unorganized sector. They lost their livelihood overnight due to sudden lockdown and had to undertake long inhumane journeys back to their native places. It is imperative that we systematically address the challenges of the social determinants of health to ensure the health and development of the entire population.
We are yet to evolve a realistic health promotion roadmap for people living in economic and social deprivation. Current health promotion strategies largely cater to the needs of the developed countries. However, as per the Global Multidimensional Poverty Index 2020 report released by the United Nations Development Programme (UNDP), 22% of the population, across 107 developing countries, live in multidimensional poverty (19), where they are not able to meet their basic food requirements and do not have access to basic facilities like safe drinking water and sanitation. Recommending expensive dietary options to those who cannot afford to have even one full meal a day is being insensitive to the realities of socio-economically deprived people. However, encouraging people to consume traditional foods that are locally available and affordable would meet their nutritional needs. Our present health promotion approach for disadvantaged groups may sound like Queen Marie Antoinette’s answer to the hungry crowd asking for bread: ‘If you do not have bread, eat cake!’ (20). We have not been able to evolve a clear implementation strategy to address the social determinants of health, in spite of the clear recommendations of Bangkok Charter on Health Promotion in a Globalized World (21).
Governments need to ensure that healthy food options are affordable and accessible to people living in economically deprived communities. There is a need to strengthen sustainable efforts to uplift those living in poverty from their current state by increasing their minimum wages, improving accessibility to health services and ensuring access to good living conditions including clean water and proper sanitation.
Way forward
A healthy nation is the sum total of the health of its citizens, communities and the settlements in which they live. Therefore, it is crucial that there is full citizen participation in efforts to achieve the goal of ‘Health for All’. It is indeed a favourable time to look beyond the so-called predominantly reductionist biomedical model of health care to a more holistic model of health, that places humans and the environment at the centre, and emphasizes the importance of promoting health and wellbeing. With seven decades of successful evidence-based work in numerous settings across the world, IUHPE is well placed to play a vital role in advancing health promotion in the regions, working in collaboration with local partners to ensure that this much neglected but essential aspect of health is implemented effectively.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
