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Even in the most affluent countries, people

who are less well off have substantially

Debate around poverty and health has been shorter life expectancies and more illnesses
going on for decades. More central to this than the rich. Not only are these differences
debate in recent times is the argument in health an important social injustice, they
whether poverty leads to ill-health, or poor have also drawn scientific attention to some
health is a precursor of poverty. Although of the most powerful determinants of health
ample scientific evidence currently sup- standards in modern societies [3].
ports both arguments, the fact remains the This paper frames a debate around the
same: poverty and ill-health almost always nexus between ill-health and poverty and
co-exist. articulates the various dimensions of health
In recent years, governments and devel- promotion, viz. exploring the dynamics of
opment partners have placed greater focus how health promotion interventions can
on addressing the determinants of health. be relevant in poverty reduction, and thus
Health promotion, as defined in the Ottawa improving the health of the population.
Charter in 1986, has been shown to be an
important element of public health [1]. By
virtue of this phenomenon, health promo-
tion has been shown to address the causes
of the causes of health, thereby improving The definition of health promotion as out-
the health of the population. The nexus of lined in the Ottawa Charter is Health pro-
health and poverty has also been reinforced motion is the process of enabling people
in the United Nations Millennium Devel- to increase control over, and to improve,
opment Goals. The importance of these their health. To reach a state of complete
goals in health is, in one sense, self-evident. physical, mental and social well-being, an
Improving the health and longevity of the individual or group must be able to identify
poor is an end in itselfa fundamental goal and to realize aspirations, to satisfy needs,
of economic development. But it is also a and to change or cope with the environment.
means to achieving the other development Health is, therefore, seen as a resource for
goals relating to poverty reduction [2]. The everyday life, not the objective of living.
linkages of health to poverty reduction and Health is a positive concept emphasizing
to long-term economic growth are powerful, social and personal resources, as well as
much stronger than is generally understood. physical capacities. Therefore, health pro-

motion is not just the responsibility of the health outcomes would improve. This has,
health sector, but goes beyond healthy life- however, proven not to be an automatic
styles to well-being [1]. This definition has process [7]. Moreover, studies in recent
been amplified in practice and has been the years have shown that improvements in
subject of 6 global conferences. To many, health contribute significantly to economic
the Ottawa charter for health promotion growth.
became the gospel and foundation stone of Health is a continuum that ranges from
a new public health movement [4]. the healthy, unexposed population through
In many parts of the world, health pro- to the population that suffers from specific
motion goals and processes are firmly em- diseases and their consequences. Health
bedded in national and multinational health promotion incorporates both upstream ap-
policies, objectives and targets. The focus proaches (aiming to improve the contexts
of health promotion on the prerequisites for health generation, improving social
for health and equity in health is recog- capital and community capacity to act on
nized nationally and globally through the health) as well as downstream actions (risk
Millennium Development Goals and other reduction through behaviour change com-
policies to address social and economic munication, promotion of self-help in dis-
determinants of health and inequalities in ease and coping with the consequences of
health. The Ottawa Charters call to work disease).
in partnership with other sectors to develop The focus is on upstream approaches,
healthier public policy has been widely with the Bangkok charter for health promo-
adopted and implemented. This has taken tion in a globalized world [8] identifying
shape in various ways, reflecting social, actions and commitments in 4 areas:
cultural and economic contexts and the the global development agenda
stage of development of health promotion whole-of-government approaches
practice [5].
action by communities and civil society
The number of people living in abso-
lute poverty and despair is growing stead- health promotion as an integral part of
ily despite unprecedented wealth creation good corporate practice.
worldwide in the past 2 decades. Today
nearly 1300 million people live in absolute
poverty [6]. Poverty is a major cause of
ill-health; it contributes to the spread of
disease, undermines the effectiveness of
health services and slows population con- Health is unevenly distributed among so-
trol. Morbidity and disability among poor cial groups in the population. We have to
and disadvantaged groups lead to a vicious acknowledge that we live in a stratified
spiral of marginalization, to their remain- society, where the most privileged people,
ing in poverty, and in turn, to increased in economic terms, have the best health.
ill-health. In the past, spending on health These inequalities in health are socially
and health programmes was considered determined, unfair and modifiable. At the
to be expenditure on welfare and welfare same time there has been a paradigm shift
programmes. It was thought that economic in the perception and vocabulary of de-
growth would make more resources avail- velopment in recent years. Where once
able to health systems and that as a result development was equated with economic

growth, which was seen as the ultimate social services, productive employment
goal, now poverty reduction is seen as the opportunities and better governance, not as
overarching achievement of development. an end in itself.
Where the route to economic growth was As Williamson says, poverty isa
once seen as running through investment in complex phenomenon rooted in an array
physical capital, it is now recognised that of factors and conditions, many of which
many forms of capital, including human extend beyond the control of the health
and social capital, contribute to the growth sector [10]. Poverty reduction is not a
of output [9]. Poverty itself is recognised as feature that can be accomplished by any one
a multifaceted concept, not simply a matter person in any one sector because poverty is
of insufficient income, but also a matter of multi-faceted and deeply rooted in many
insufficient or inappropriate earning capaci- socioenvironmental conditions. It calls for a
ties in relation to ill health, ignorance, and community-based, multisectoral approach.
lack of power and voice. Where once it The nexus between poverty and health is
was assumed that the benefits of economic best articulated in Figure 1.
growth would eventually trickle down to At a purely material level, income has an
the poor, the delivery of welfare to the poor obvious impact on health insofar as it pro-
in the forms of improved livelihoods, social vides the means of obtaining the fundamen-
services, and benevolent governance is now tal prerequisites for health such as shelter,
seen as both a direct assault on those multi- food, warmth and the ability to participate
ple deprivations and as an investment in the in society. Low income, therefore, increases
capacities of the poor to lift themselves out individuals exposure to harmful environ-
of poverty. ments, e.g. inadequate housing, and reduces
Economic growth is still perceived as a familys ability to purchase necessities
desirable, but it is for its instrumental value such as a healthy diet. Poverty also rein-
in enhancing the resource base to deliver forces health-damaging behaviours [11].

reinforcement and extension of health

systems to provide better management
of poor communities by increasing the
Health promotion is a basic building block budget of ministries of health and using
of public health. Together with popula- their resources more effectively;
tion health assessment, health surveillance, strengthening inter-sectoral collabora-
disease and injury prevention, and health tion for the benefit of the poor in order
protection, health promotion is a central to have a positive impact on the key
public health function that furthers all public determinants (education, employment,
health work. Health promotion and disease nutrition, participation of the poor in
and injury prevention can be approached by decision-making).
addressing individual risk factors for spe- Priority interventions aimed at reducing
cific health outcomes (e.g. poor nutrition, poverty must be based on certain major prin-
physical inactivity, excessive sun exposure) ciples such as equity and ethics, relevance
or by addressing the underlying societal of health interventions to the needs of the
risk conditions (e.g. poverty and socioeco- poor, accessibility, quality, efficiency and
nomic-related linked inequities) [12]. For sustainability, participation of communities
many years, the international health com- concerned, and the taking into account of
munity has been pointing to the large gaps gender specificity.
in health outcomes between rich and poor Interventions may comprise actions
countries. Extensive scientific evidence is aimed at improving health through the in-
now available on the factors that contribute tensification of the fight against practices
to good health outcomes in childhood, the harmful to health, tuberculosis, maternal and
reproductive period and adulthood. For ex- child mortality, tobacco use, malnutrition
ample, much is known about preventive and and HIV/AIDS, and also through immuni-
curative health services that promote good zation, education, environmental health and
health among small children, sound dietary clean water supply.
and sanitary practices and the importance of A common claim that is incessantly
stimulation for young children [13]. reiterated in health promotion is lack of
Healthalong with educationis seen resources. There is a broadly held belief
as one of the key ultimate goals of develop- that economically poor countries have far
ment. Indeed, increasingly health is seen fewer resources than others with which to
as a dimension of poverty in its own right. engage in interventions to promote health.
This is reflected in the fact that no less than Moreover, this issue of resources seems to
4 of the 7 Millennium Development Goals be a feature that distinguishes the practice
relate to health broadly defined. The role of health promotion in the economically-
that health promotion can play in combating developed world from that carried out in
poverty is based on 3 essential components, the economically-poor world. This may
namely: not, however, accurately represent the situ-
definition and implementation of prior- ation. The argument can surely be made that
ity interventions and health services, resources are more than purely financial,
taking into account the major causes and that communities throughout the world
of morbidity and mortality among the have many different kinds of resources with
poor; which to support and carry out interventions

that are health promoting. In fact, an entire to managing and improving health at in-
area of research and practice has arisen on dividual, community, national and global
how to recognize, foster and benefit from levels [15]. The commonplace of arguing
assets for health promotion. Nonetheless, for the place of health promotion in poverty
in terms of visibility of health-promoting reduction clearly has convergent theoreti-
interventions, financial resources seem to cal foundations. They refer to the need to
be the cornerstone for subsistence and dis- work upstream, to address the causes
semination. It is, however, the case that of the causes. They are founded on strong
quite often there are important and critical ideology and have complementary evidence
interventions occurring in the less eco- bases. They recognize the need to operate
nomically developed world that are indeed on social structures, to involve non-health
effective, but these are not seen because the sectors and indeed to base the emphasis of
financial issues associated with evaluation, their work on whole-of-government com-
publication, diffusion, etc. are not available. mitment. Together, these areas demonstrate
The assumption that there are noteworthy the scope, breadth and depth of actions that
and vital effective interventions occurring governments and society as a whole must
in the developing world has come to be an undertake in order to achieve better health
accepted belief among many in the field of outcomes. Indeed, a key challenge for a
health promotion [14]. unified approach to these areas would be to
demonstrate what it would take for public
health to navigate complex social and po-
litical processes that are driving the way in
which health and resources for health are
Many factors play a part in creating and per-
petuating social inequalities in health. The
Convergence, though, is not identity.
situation is complex, but we can neverthe-
The juxtaposition of the work of these fields
less state that it is generally social circum-
raises a number of areas of difference such
stances that affect health and not the other
as those outlined below (World Health Or-
way round. Although in many cases serious
ganization, unpublished report, 2007). The
health problems lead to loss of income and
following scenarios are simplified versions
work and difficulties completing education,
of actual situations that demonstrate the
social status still has a bigger impact on
different contributions to be made within
health than health does on social status.
a unified structure that addresses all the
The Ottawa Charter formally recog-
determinants of health:
nized that health services should incor-
porate health promotion concepts such as Burden versus gradientHow are poli-
community development, empowerment cy-makers to reconcile efforts to improve
and advocacy, and called upon the health the public health situation of the popula-
sector to move in this direction. The charter tion generally (e.g. broad improvements
states that ... the health sector must move in nutritional status) with the observa-
increasingly in a health promotion direc- tion that this may be associated with
tion, beyond its responsibility for providing worsening inequity (as better-off social
clinical and curative services. The charter classes get proportionally greater im-
provides logic and order to health promo- provement)? Broad improvements, the
tion. It also discusses normative approaches population approach to prevention, may

need to be balanced against high-risk ap- smaller portion of the burden is caused
proaches (intensive targeted prevention by indoor air pollution which is con-
for the poorest classes). But how are we centrated in the poorest segments of
to develop an investment framework for the population. Clearly, both are issues
such activities? that need addressing, but capacity is
Conflict of interestA soft drinks com- limited and local public health officials
pany mini-sizes its products (sells it in need guidance on whether to primarily
small bottles priced at a level affordable invest in tobacco control (the traditional
by poorer families) and uses micro- public health approach) or in promotion
finance strategies to ensure a distri- of safer fuels (a primarily equity-based
bution mechanism that extends to the strategy).
farthest reaches of the poorest shanty That being said, fair distribution of re-
towns. Is this an example of a pro-poor sources is a good public health policy [17].
initiative offering a way out of poverty The primary goal of future public health
and generation of small businesses? Or work is not to further improve the health of
is it an example of cynical marketing de- the people who already enjoy good health:
signed to maximize sales while diverting the challenge now is to bring the rest of the
poor families incomes into the purchase population up to the same level as the peo-
of empty nutrients? ple who have the best healthlevelling up.
Side-effects of structural interven- In conclusion, it may be argued that
tionsRaising people out of poverty health promotion has an in-built survival
has an energy cost. If poorer countries kit since it deals not only with disease pre-
develop via the use of environmentally vention, but the changing or promotion of
unsound technologies, then the net ef- conditions within which health can thrive
fect of massive poverty alleviation pro- [18]. Health promotion seeks to promote
grammes could contribute to intolerable conditions supportive of health improve-
global warming. For instance, biofuels, ment, and for this reason both the developed
which supposedly have a neutral effect and developing countries must cooperate
on the environment and promote income to ensure that the discipline is well estab-
for poorer countries that export the raw lished in the latter. All policymakers and
materials (e.g. palm oil), have recently programme managers are keen to see better
been documented as causing widespread health outcomes for the populations they
environmental degradation as slash and serve. Better health outcomes are achieved
burn agricultural techniques and clear- through well-functioning health systems,
ance of peat areas are adopted to make characterized by good governance, adequate
way for increased palm oil production and fair financing, optimal distribution of
[16]. resources and accessible services, priority
Priority settingConsider this scenario health programmes targeting problems that
for a community which has a significant are responsible for the major burden of
burden of chronic respiratory diseases. diseases, and promotional components that
Most of the burden is due to tobac- tackle the upstream health determinants
co smoking, concentrated in the richer [19].
parts of this middle-income country. A