Challenging every determinant of health: Governance and the role of practitioners in the future of public health

Abstract

Although public health programs have evolved rapidly, the structure of governance has not noticeably changed. Public health practitioners should play their changed role in social reform to challenge every determinant of health. In the review of public health for the last century, Fairchild and colleagues1 urged us to go to the future and create a base of power for progressive social change. Their argument is to turn the helm of public health practices away from laboratory toward social reform to meet health needs of the public. In addition to this, I'd like to highlight the importance of concrete public health programs to back up the political action. For a century, public health programs have evolved greatly to enable the social reform to be conducted in the daily lives of people. Since the late twentieth century, public health has evolved into new areas that tackle determinants of health that have not traditionally been considered to be a focus of public health programs (Fig. 1). This evolution is associated with a new understanding of health, which views the etiology of disease as complex and health-disease status as continuous. This has led health policy to address health problems in areas beyond the biomedical field. Lalonde's health field concept, 2 which marked the beginning of this change, indicated that, in addition to biological factors and health care organizations, lifestyle and environment should be considered in health policy. In practice, the primary health care movement, 3 led by the World Health Organization, emphasizes a comprehensive view of health through the delivery of essential services and resources to meet basic needs of the community. Public health programs based on this comprehensive view of health and health policy have proliferated since the appearance of health promotion4 and the healthy cities movement.5 Figure 1 illustrates the evolution of public health programs that cover the neglected determinants of health. In addressing the determinants of health, traditional public health programs have attempted to manage disease by concentrating solely on biological factors. Meanwhile, the proponents of health promotion began to notice lifestyle factors, such as smoking, drinking, and physical activity. More comprehensively, healthy cities projects address the impact of the environment and other related determinants of health, including socioeconomic status and social environment (the relationship between a person and people surrounding him/her). Another breakthrough occurred when the impact assessment of public policies enabled public health professionals to prevent man-made disasters. Health impact assessment 6 or the Health in All Policies (HiAP) approach7,8 has provided an innovative way to consider the institutional determinants of health, which include a multitude of policy decisions that affect public health. In addition to the policies directly affecting health, such as healthcare and public health policies, other policies that affect any determinant of health can be included in the category of institutional determinants. Although public health programs have been developed to address the vast majority of health determinants, the structure of governance managing these programs continues to follow traditional methods. However, it is my belief that new programs require new governance. In Figure 1, responsibility for health status is related to its causal determinants. Social responsibility is greater particularly for institutional and environmental factors as society created the man-made health hazards. In this new public health arena, throughout the policy process, political leadership and strong community involvement are required. In essence, these two factors positively impact each other. Since politicians need political support from the public, they may favor people's participation in the programs that they are involved in. On the other hand, strong community involvement in a specific program may persuade politicians to take part in it. …