The World Health Organisation (WHO) defines Health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and defines Wellness as “the act of practicing healthy habits on a daily basis to attain better physical and mental health outcomes, so that instead of just surviving, you’re thriving”. Both without a doubt important concepts but result in different challenges for those responsible for their achievement.
“A new name, a new direction?” is the title of a recent article published in Daily Maverick 1. The authors draw attention, as so many have done in the past, to the work of Sydney and Emily Kark in the 1930’s and 1940’s and the Alma Ata Declaration of 1978 emphasising primary healthcare focusing on promoting health and preventing disease. The authors mention that the current Director-General of the World Health Organisation recently urged a “paradigm shift” to “promoting health and wellbeing and preventing disease by addressing its root causes recognising that health starts not in hospitals and clinics but in homes, streets, schools and workplaces”. It is ironic that it is still necessary to do so over forty years after Alma Ata.
The article also refers to the Geneva Charter for Well-being 2. As was the case with the Alma Ata Declaration, the Geneva Charter sets out wide ranging, lofty, and some would say idealistic goals, for what are termed “well-being being societies” underpinned by (a) a positive vision of health that integrates physical, mental and social well-being, (b) principles of human rights, social and environmental justice, solidarity, gender and inter-generational equity and peace. (c) a commitment to low-carbon development grounded in reciprocity and respect among humans and making peace with nature, (d) new indicators of success beyond gross domestic prodigy that take into account human and planetary wellbeing and lead to new priorities for public spending and (e) the focus of health promotion on empowerment, inclusivity, equity and meaningful participation.
A “21st century health promotion response’ is highlighted with five areas: (1) Value respect and nature planet earth and its ecosystems, (2) design an equitable economy that services human development with planetary and local ecological boundaries, (3) develop healthy public health policy for the common good, (4) achieve universal health coverage and (5) address the impacts of digital transformation. Each of the areas is described in more detail in the Geneva Charter which I will not repeat here.
A key statement in the document is that “well-being is a political choice” and that “well-being requires a whole-of-society approach”. The charter states that these actions should be supported by “the sustained investment in healthcare workers, health promotion, public health infrastructure and research”. It is declared that “the global development landscape will change if the well-being of both people and the planet becomes central to the definition of success”.
In 2014, the Western Cape Department of Health, which I then headed, published Healthcare 2030, The Road to Wellness. This document with political approval at that time committed the Government of the Western Cape to Wellness as defined by the WHO and in addition to ensure access by the citizens of the Western Cape to “person-centred quality care”. Prior to that date, I had initiated the first burden of disease study in the province in 2005. The first report3 was tabled after extensive work by various task teams in 2007. This report identified the quadruple burden of disease in the Western Cape (communicable and non communicable diseases, maternal and infant mortality, injuries and trauma) Alcohol together with other societal factors was identified as a major factor driving the incidence of trauma and interpersonal violence in the province. Other causes of the burden of disease resulted largely from lifestyle factors outside the realm of the health department were highlighted by the report. While the report was tabled to the provincial top management and political leadership and some found the report interesting, there was little concrete support for concerted action.
In 2020, the department published a rapid review of the Western Cape Burden of Disease4 comparing the results of the 2007 report to that in 2019. While there were variations in the overall ranking of the various causes of death in the province during the period under review, the overall burden remained essentially unchanged and the findings of the 2007 report remain as valid today as then. The reality is that the nature of government funding on a departmental basis mitigates then as now against a whole-of government approach which is a policy direction in which the province has adopted.
A recent report released by the South African Medical Research Council (SAMRC) published in the South African Medical Journal 5 in a series of related articles identifies unsafe sex, interpersonal violence, high body mass index (BMI), alcohol consumption and high systolic blood pressure as the top risk factors for disease and death in South Africa in 2012. This is the most recent year for which data is available. This study focuses on trends from 2002 to 2012 in the underlying risk factors rather than the eventual cause of death. In a related South African Medical Journal Editorial6, Jewkes and Gray, indicate that the need is to focus on these underlying drivers of disease and death in South Africa to improve the health, and by inference the wellness, of South Africans. While this study was far more extensive than the Burden of Disease study to which I have alluded above and had a different focus, the findings are similar.
Yogan Pillay and his co-authors indicate that the Western Cape “leveraged a strong capability for an evidence-informed and data-led whole of society approach during the COVID-19 pandemic”, which in their view “places the department in a good position to similarly address the social and commercial determinants of the quadruple burden of disease”. The authors conclude by offering ideas for departments of health and wellness to consider new ways of working. However the current role of departments of health or the goal of achieving wellness as envisaged in the Geneva Charter for Well-being falls outside the existing mandate of a health department. The challenge of meeting even what is contained within the WHO definition of health is a formidable one that stretches the resources of health departments across the world. If there is indeed a desire to promote societal wellness, it is, as stated earlier, a wider whole-of-society challenge and thus I would argue should be located at a higher level than that of the department of health alone. Rather, if wellness is a pressing government policy priority, is could be located within the offices of the President and the Premiers. A Ministry of Wellness, as exists in some governments, could be alternatively be considered that assumes an overarching role as regard policy and resource allocation together with Treasuries to address the priorities identified to promote the well-being of societies.
I support any efforts, whole-of-society or otherwise, to address the risks identified as driving the burden of disease both within and outside the health sector and initiatives that ensure that data-driven policies when implemented are assessed for their efficacy. The public health sector in South Africa, whether it addresses the health or wellness of the population, urgently needs the effective management of the resources at its disposal to ensure the best quality of healthcare possible is delivered to the citizens that are dependent on their health services. However without doubt, increased levels of wellness in any community is a noble whole-of government goal that will allow departments of health to concentrate their efforts on those areas that are currently under resourced.
- Yogan Pillay, Keith Cloete, Anders Nordstrom Daily Maverick 31st October 2022
- Geneva Charter for Well-Being World Health Organisation December 2021
- Myers J, Naledi T. Western Cape Burden of Disease Reduction Project: Final Report 2007
- https://www.westerncape.gov.za/assets/departments/health/burden_of_disease_report_2020.pdf
- The Second Comparative Risk Assessment Study (SACRAZ2) September 2022 Policy Brief SAMRC Burden of Disease Research Unit
- R Jewkes, G Gray S African Med J 2022;112(8b):555 https//doi.org/10.7196/SAMJ.2022v112i8b.16718
