2012/11/09 by I. Kickbusch, Ilona Kickbusch · 71 citations
Business, Management and Accounting · Health Professions · Medicine · Pharmacology, Toxicology and Pharmaceutics · Psychology · #Business #Computer science #Environmental health #Global Public Health Policies and Epidemiology #Health Services Management and Policy #Interface (matter) #Medicine #Pharmaceutical industry and healthcare #Political science #Politics #Psychology
paper · pdf · doi:10.1093/heapro/das057
published in Health Promotion International 27(4), 427-428 (Oxford University Press)
openalex publication_date 2012/11/09 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
If we were to rewrite the Ottawa Charter 25 years later I would focus on five key determinants of health that our societies need to address: the political, the commercial, the social, the environmental and the behavioral determinants of health. Their interface creates the 21st century dynamics of health—in particular the relationship between the political and commercial determinants of health. Policy-making for health has become more complex as an increasing array of interests is at stake (Kickbusch and Gleicher, 2012). Key political, economic and social driving forces shape its direction, including globalization; European integration processes; the power of markets and business, in particular transnational companies and their marketing; the strong voice of civil society and the financial pressures that many countries and agencies are experiencing. The economics of health is also changing. In many countries in the European Region health now constitutes 10–15% of GNP and 10–15% of the work force—health is a major business sector, a major employer, part of the economic competition between countries, the import and export of goods and services and of foreign and development policy. This has changed the perspective in a number of countries to now consider health as a growth industry. In Germany, where health spending was not curtailed during the recent economic downturn, the health sector provided a stabilizing influence on the economy. Countries that are required to cut their health systems as a consequence of the economic crisis do not only suffer health but also broader economic impacts of the cutbacks—such as unemployment of health professionals and bankruptcy of small suppliers. Some countries have included commercial health diplomacy as part of their foreign policy goals—the business of health has also become the business of diplomacy. Health is, moreover, a major component of the seminal demographic change most countries are experiencing—it is a key factor in determining whether European countries will be able to finance health and retirement systems. In fact, the European Union has set an additional two years of healthy life expectancy as a key determinant of its economic growth policy expecting a longevity dividend in return. This type of reasoning has also been applied when negotiating the Ministerial Declaration on NCDs at the United Nations in 2011—by calculating the significant loss of GNP emerging powers will experience if they do not address the health challenges at hand. These are examples of a decisive new positioning of health within government, economy and society. They illustrate the constant dynamics between the determinants of health and health as a determinant and the challenges that arise when advocating, mediating and negotiating for health in the face of other major political or economic interests. We continue to regard and present the health ministry as a ‘weak’ ministry at the cabinet table. On the other hand, many companies clearly see the ministry of health as a very powerful actor—particularly in relation to regulation and pricing. The health sector continues to be one of the most highly regulated sectors in most developed countries—for example, in relation to medicines, insurance or service provision. The recent debates around the US health-care reform showed that no lobbying effort was spared in opposing or weakening the government's regulatory power—there were reportedly 3300 lobbyists working on the issue of medical reform. That is a six-to-one ratio of lobbyist to law-maker in the US Congress. While the economic importance of additional healthy life years for the whole of society has been calculated it is still difficult to instigate change in the face of major commercial pressures—be it in relation to care or to health promotion. In the mid-1980s we understood health promotion to be a political and social movement—yet we totally underestimated globalized corporate power combined with its global marketing onslaught and its transnational influence on political decision-making. Here is a recent example: 10 years after receiving a public health prize from the WHO for its actions to fight tobacco, in 2012 the FIFA General Secretary brazenly stated ‘Alcoholic drinks are part of the FIFA World Cup, so we are going to have them’. Access to beer in stadiums was declared non-negotiable for the World Cup in 2016 despite a Brazilian law adopted in 2003 prohibiting the sale of alcoholic drinks at sporting events. National law does not carry weight in view of the combined transnational economic power of the FIFA and their beer producing sponsor. The 24/7 society is full of prepackaged, easily accessible food and (alcoholic) drink; making the healthy choice the easier choice now sounds naïve. It has become a venture that is similar to the fate of the Greek hero Sisyphus. Research indicates that our biological control mechanisms do not seem to function under such circumstances. A recent overview of marketing research comes to the conclusion that ‘the supermarket customer has been more extensively researched than any laboratory mouse’. And new mental health challenges arise in relation to the addictive nature of the new virtual media. We must explain better to a range of political and societal actors how health contributes to societal and economic development and how a wide range of political, economic and social factors and processes contribute to population health. Our environment has become toxic in new and insidious ways and few politicians are willing to take action in arenas that seem to limit citizens and consumers in their everyday life—even at the expense of their health. It has become common practice to turn a health challenge into a fundamental debate about individual freedom and choice. Because health is at the intersection of values and ideology, between market forces and ‘the state’ it is becoming essential that parliamentarians—who make many of the laws that impact on health—are fully aware of the (health and other) consequences of their decisions and non-decisions. While NGOs are critical watchdogs and advocates we must ensure that our democratic institutions value health. We must invest in the health literacy of parliamentarians and of the citizens who elect them. The voices are increasing that call for a ‘radical shake up’ of public health and health promotion: ‘Marmot's focus on the social determinants of health needs to be matched with an equal concern for the commercial determinants of health’ writes Gerard Hastings recently in the BMJ. (Hastings, 2012) I would add that this needs to be matched with a concern for the political determinants of health—and above all the interface between these determinants and their impact on how health is created in the context of our everyday lives. This will significantly change the role of health advocates, ministries of health and the World Health Organization. A new way of joining forces across separate health issues and organizational silos is needed. Positioning health and framing our agenda in relation to the key determinants—political, commercial, social, environmental and behavioral—could help us move the agenda forward.