Health Promotion International, 2017;32:2–6

doi: 10.1093/heapro/daw112
Editorial

Editorial
A watershed for health promotion

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The Shanghai Conference 2016

HEALTH PROMOTION AND THE SDGS health promotion action areas into modern tools and
methods that will contribute towards the achievement of
The 9th WHO Global Conference on Health Promotion
the SDGs. The two Declarations adopted in Shanghai
- held in Shanghai, China in November 2016 - was ex-
provide a road map for countries to act on the SDGs in a
traordinary. It was held almost exactly 30 years after the
transformative way.
first Global Conference in Ottawa, Canada that pro-
The Shanghai Declaration on promoting health in
duced the Ottawa Charter (WHO 1986). The Ottawa
the 2030 Agenda for Sustainable Development (WHO,
Charter brought about a genuine paradigm shift in
2016a) makes clear the continuing relevance of health
thinking about how to improve public health. The
promotion. At the core of the Declaration are clear
Shanghai Conference could prove to be another water-
statements advocating improved governance for health
shed for public health action if the ideas and commit-
at all levels; the development of Healthy Cities that are
ments developed at the Conference are taken forward
inclusive, safe and resilient for the whole population;
and acted upon meaningfully. The Conference centrally
and the importance of health literacy that empowers in-
positioned health promotion within the 2030 UN
dividual citizens and enables their engagement in collec-
Agenda for Sustainable Development (UN 2015). The
tive health promotion action. Inevitably, such a
actions required to achieve the UN Sustainable
document is bound by some of the checks and balances
Development Goals (SDGs) set the direction, tone and
of political consensus building. But the Declaration is
aspirations for the meeting. Critical actions proposed
unambiguous in its description of the tough political
for member states at the national level will need to be
choices faced by decision makers and advocates un-
complemented with a localized implementation agenda
ashamedly for health in the face of other interests.
spearheaded by cities; and a strong joint global purpose,
The Shanghai Consensus on Healthy Cities (WHO
led at the United Nations through the SDGs.
2016b) is an equally powerful statement of intent that
The Director General of the WHO Margaret Chan -
clearly identifies the role of cities in delivering practical,
and many other high level speakers – made clear that the
local actions to address the SDGs and through such ac-
SDGs provide a unique opportunity for addressing
tion, address the social determinants of health.
health and its many determinants in an integrated and
transformative way. This Agenda sees eradicating pov-
erty in all its forms and dimensions as the greatest global
challenge, and identifies “ensuring healthy lives and pro-
HEALTH PROMOTION IS ON THE
moting well-being for all at all ages” as one of the most POLITICAL AGENDA
important indicators of progress on our collective jour- These formal outcomes from the Conference were devel-
ney during the next 15 years. World leaders have com- oped through a process leading up to the conference, in-
mitted to leave no one behind. There was a real sense cluding broad on-line consultations, advisory meetings
from the Shanghai Conference that the contemporary and consultations with member states. This was differ-
challenge and opportunity is to convert the Ottawa ent from many previous health promotion conferences

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V
Editorial
which were mainly focused on achieving a consensus
between conference participants. In Shanghai it was evi-
dent that the aspiration voiced at Ottawa to “put health
high on the political agenda” had taken significant
strides forward. Now the political choice for health has
to be addressed at every level of government.
But having health “high on the political agenda” is
not without its risks and challenges, as anything that is
political will be. The Shanghai Conference demonstrated
that political commitment to health promotion has
found many different expressions in different political
systems. Context specificity is critical. Whereas the so-
cial and political context from which the Ottawa
Charter emerged was relatively homogenous, in
Shanghai cultural and political differences in the concep-
tualisation of health and health promotion were clearly
observable. The political realities, economic pressures
and the very different political and economic systems
operating in countries that are trying to address the
SDGs were clearly recognised. Policy makers from
around the world shared their experiences, their suc-
cesses and the difficulties they have encountered in im-
plementing the vision of the Ottawa Charter.
These real world differences were observable in many
ways. There was some irony in the enthusiastic discus-
sions of exciting innovative approaches to use digital me-
dia for health promotion at the same time that
participants were unable to access their social media ac-
counts (notably twitter) in China. Participants heard just
how divergent the reality of women’s rights still is in
many countries. Participants heard about conflict resolu-
tion and the need to have enabling legislative frameworks
for participation, but also of vulnerable groups, such as
indigenous people who have been systematically excluded
from the mainstream. Participants also heard about the
harsh impacts of economic policies that disregard people.
A MESSY PLACE
The success of the Shanghai Conference in putting
health high on the political agenda took participants
into much more uncomfortable and messy places. Places
where the purpose and meaning of health promotion is
being re-interpreted, and the nature of leadership and
practical action on the SDGs taking varied and, in some
cases, unfamiliar forms. Those at the conference were
challenged to keep health promotion values and ethics
in mind, but to have an open mind and open discussions,
to be willing to engage, listen, and where possible, find
ways to adapt established ideas and methods in response
to these social, political and economic differences be-
tween nations and communities.
3
Indeed, it seems as if the centre of gravity of health
promotion is shifting. The most obvious demonstration
of this came from the political commitment of the host
country China. The prime minister himself came to give
the message of China’s recently adopted 2030 strategy
for health - the largest country in the world with 20% of
the world’s population has committed at the very high-
est political level to promoting the health of its popula-
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tion. The middle income economies and the Asian tigers
are rapidly moving forward in promoting health, im-
proving urban environments and addressing environ-
mental challenges – this was tangible and observable
from the presentations by Ministers from different sec-
tors and Mayors from these countries. The “original”
Ottawa Conference countries are no longer in the lead.
Inevitably, there were participants who were unhappy
and uncomfortable with aspects of the Conference - that
not everything presented here was “pure” and “real”
health promotion; that health promotion was being hi-
jacked as a term of convenience to describe outdated, re-
gressive methods and approaches. There is some truth to
be found in this criticism, but it should actually be turned
around: it is a continuous challenge for health promotion
professionals and advocates to demonstrate how it can be
done better and how health promotion ethics can be up-
held. All of us must continue to challenge politicians that
will not support health and to support those politicians
that are willing to move forward and raise the priority
given to health - so that they chose those equity based
and integrative strategies which will bring them success.
Many of the ministers and politicians present at the con-
ference expressed this and welcomed the learning that
was possible for them at the conference.
HEALTH PROMOTION HAS BEEN
POSITIONED AT THE CENTRE
OF THE SDGS
The Ottawa Charter was transformative in establish-
ing new approaches to public health. The Shanghai
Declaration builds on this legacy but challenges the
health promotion community to demonstrate that these
concepts, principles and strategies are capable of adapta-
tion and implementation in countries around the world.
The SDGs have been developed to ensure that all human
beings can fulfil their potential in dignity and equality
and in a healthy environment. Never before has the pro-
motion of health been placed so clearly at the centre of a
global agenda that will transform our world: SDG3
aims to “ensure healthy lives and promote well-being
for all at all ages”. The Shanghai meeting was the first
4 Editorial
major WHO event to put the co-dependencies that exist
between the achievement of improved health and the
achievement of all of the SDGs onto centre stage.
Through the Shanghai Declaration the participants
pledge to accelerate the achievement of the SDGs
“through increased political commitment and financial
investment in health and its determinants”. These priori-
ties reflect the damaging effects of unsustainable produc-
tion and consumption that compromise health, and
restrict options for the implementation of the SDGs -
making clear that profit must not stand above people’s
health and well-being. Action to promote health increas-
ingly requires global health action - the SDGs are based
on this premise of collective action. This includes mak-
ing global health governance transparent, fairer and
more reasonable and “tightening regulation on health-
impairing investment and trading activities through fis-
cal, taxation and financial policy tools”. Indeed, it was
even proposed to conceive of NCDs as a global health
emergency of international concern given the same ur-
gency and resource commitment previously only applied
to infectious disease outbreaks. This sets tough new
challenges and provides an extraordinary opportunity
for health promotion approaches to move centre stage.
A STRONG FOCUS ON THE
LOCAL – CITIES AS A PLATFORM
A unique feature of the Shanghai Conference was the in-
corporation of a meeting of more than 100 city Mayors
from all regions of the world to exchange ideas and ex-
periences in creating healthy cities, and to locate these
discussions in the context of the SDGs. Rapid urbaniza-
tion in many countries has meant that an ever increasing
proportion of the world’s population lives in cities, and
depend upon their effective functioning for life’s necessi-
ties. Through their Consensus statement the Mayors at
the Conference accepted political responsibility to create
the conditions for every resident of every city to lead
more healthy, safe and fulfilling lives. The Mayors also
recognized that cities are places where planning and
policy-making is closest to communities and must, there-
fore, meaningfully incorporate communities’ views, voi-
ces and needs.
Impressively, the Mayors acknowledge that “health
is created at the local level in the settings of everyday
life, in the neighbourhoods and communities where peo-
ple of all ages live, love, work, study, and play. . .. The
good health of its citizens is one of the most powerful
and effective markers of any city’s successful sustainable
development. This puts health at the centre of every
mayor’s agenda.” The Mayors present at the conference
committed to sharing experiences and best practices to
bring together global and national goals with local
plans and programs. They asked the World Health
Organization to support them in this effort and to
strengthen its healthy city networks in all regions.
NEW DIMENSIONS OF HEALTH
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PROMOTION ACTION
The potential of “smart” and digital approaches to bring
positive health benefits to more people permeated the
conference. There were some sessions that were overtly
dedicated to specific technical ideas, for example in us-
ing big data to better understand the determinants of
health in populations, and to plan for health and healthy
cities. Throughout the Conference the great potential of
digital technologies to enhance, accelerate and expand
access to critical information surfaced time and again.
Major ethical challenges in relation to data access and
data privacy were also raised.
Health literacy was given a broad scope at the con-
ference - through enhanced access to information citi-
zens are better placed to improve their health literacy in
ways that are meaningfully empowering – not only in
supporting better informed decisions about their health
and the health of their families, but also enabling citi-
zens to better understand and assess the health impact of
policies and political decisions, and to hold political
leaders and policymakers to account.
The debates on health literacy also opened up new
arenas to take health promotion beyond a focus on the
NCDs - HIV AIDS, infectious diseases, anti-microbial
resistance, responding effectively to health crises. It be-
came clear that all national and international priorities
for health can benefit from the strategies developed un-
der the umbrella of health promotion: empowerment,
community action and health in all policies. Perhaps one
of the greatest challenges for health promotion is to
come to terms with this mainstreaming.
THERE IS A NEW SENSE OF URGENCY
Some of the young health promotion leaders at this con-
ference were not yet born when the Ottawa Charter was
adopted. They are ready to take on leadership. They
have grown up with the experience of the deep inequal-
ities that haunt our global and national systems and can
easily observe the exploitation of our planet to an extent
that our own survival is no longer ensured; a highly
commercialized world where profits often come before
Editorial
people; a world where major gender inequalities persist.
For them, health promotion needs to be part of an
agenda for change that takes us from the local to the
global into areas of finance, trade and investment policy;
and agenda that tackles policy incoherence between
health and trade, irresponsible business practices, cor-
ruption; and an agenda that leads to sustainable produc-
tion and consumption and fairer economic models. The
next steps have to be ambitious and transformational.
WHERE TO NEXT?
In the 2030 Agenda for Sustainable Development
world leaders committed themselves to develop ambi-
tious national responses to the overall implementation
of the 2030 Agenda. As a result, 95 countries have now
started to formulate their national SDG responses,
other countries are expected to follow suit in 2017. It is
critical that promoting health becomes a cornerstone of
all national or local SDG strategies and implementa-
tion plans that are now being developed - this will be a
priority field of action for health promotion profes-
sionals, advocates and organisations. Collectively we
have to seek reaffirmation of the commitments made in
the two declarations to promoting health in all 194 na-
tional SDG responses. The Shanghai meeting can be
considered the launch of a multilevel and wide-ranging
institutional platform for dialogue and cooperation on
promoting health in the SDGs that will support the
United Nations efforts to lead, coordinate and imple-
ment, supported by the WHO. The role is cut out for
health promotion.
A NEW COMMITMENT BY THE WHO
For WHO this conference has meant a renewed commit-
ment to health promotion. It was expressed through the
presence (and active participation) for most of the con-
ference by the Director General, Margaret Chan, staff
from all WHO regions and from many different pro-
gramme areas. In the last months before the conference
the Director-General, Dr Chan, had involved herself per-
sonally and made this into a challenge for the whole or-
ganisation not just a health promotion programme. The
goodwill and commitment on display at the Shanghai
conference will need to be converted into tangible ac-
tions if these aspirations are to be met. WHO has an es-
sential role in supporting the exchange of ideas and in
monitoring progress against the commitments and obli-
gations necessary for the achievement of the SDGs.
5
It is essential for WHO to exercise its leadership role
in promoting health in the SDG context by
• Working through the WHO governing bodies - for
example when discussion the agenda item on Health
in the 2030 Agenda for Sustainable Development at
the next 140th Executive Board in January 2017
• Engaging in the action priorities stated by the
Shanghai declaration - good governance for health,
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healthy cities, and health literacy - as well as specific
health-related targets when supporting countries in
setting national SDG responses,
• Playing a more strategic role in framing the UN de-
velopment system’s support to UN Country Teams’
engagement on how to promote health in the na-
tional SDG response for example through joint work
plans on health
• Developing and making available a set of tools, guid-
ance and expertise to governments, UN partners and
the health promotion networks covering the three
areas of the Shanghai declaration with the support of
the health promotion networks
• Strengthening its existing Healthy Cities programmes
using the mayors consensus
National voluntary reviews will be presented by
Member States at the next UN Economic and Social
Council (ECOSOC) High-level Political Forum (10-19
July 2017). This will be an important litmus test - how
many countries will have integrated health promotion
into their national SDG responses, and to what extent?
There is a real urgency for WHO in developing a fast-
track strategy to support those countries planning to
submit a national voluntary review in July 2017.
A CALL TO ACTION
Through this 9th Global Conference, WHO decided to
reach out in the first year of SDG implementation to the
health promotion community precisely because it has
the potential to offer practical solutions to the complex
and interconnected challenges represented by the SDGs.
Health promotion strategies work: they instinctively
work across conventional disease categories and across
sectors; they place communities at the heart of workable
solutions and give a voice to those who are excluded.
Over the past 30 years, collectively health promotion
has provided the evidence and the advocacy for action
on the determinants of health at all levels of governance.
This was a strong vote of confidence from the Director
General and the many member states that so enthusiasti-
cally engaged in the Conference.
6 Editorial
The Shanghai conference has opened a new universe
for health promotion through the link to the Sustainable
Development Goals adopted by the United Nations in
September 2015. This Agenda is the most ambitious
and transformational vision the world has ever seen.
It provides an unprecedented opportunity for all of us
committed to the principles, ethics and practice of health
promotion. Whilst we can look to the WHO to provide
continuing leadership at an international level, sustainable,
transformational change will occur only if this is matched
by creative, innovative health promotion action at more
local levels. The window of opportunity is NOW.
Ilona Kickbusch1 and Don Nutbeam2
1
Global Health Centre, The Graduate Institute for
International and Development Studies and 2Don
Nutbeam, Professor of Public Health, University of
Sydney
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December 2016)
World Health Organisation (1986) The Ottawa Charter for
Health Promotion. 1986.
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