What is known in the field under consideration?
Taking care of health is not only a matter of the individual and national politics, but also to a large extent the responsibility of decision-makers at the local level.
What new does this article reveal?
Local decision-making processes are key to public health. The goals of the 2030 Agenda for Sustainable Development represent the broadest framework that supports the local community in caring for the well-being of its residents. By transferring global guidelines into concrete measures, municipalities create environments where everyone can use their maximum potential.
Summary
In creating a vision of a healthy and inclusive society, we first need a more inclusive definition of health. In this regard, living with and managing illness will probably need to be recognized as a central component of lifelong well-being.
Healthy and balanced community development is based on strategic planning, both locally and nationally. The goals of the 2030 Agenda for Sustainable Development represent the broadest framework that supports the local community in taking care of the health and well-being of its residents. Local authorities are the initiators of change and are the level most suitable for connecting global goals with the local community, as they are closest to the people and know best what they need. The goals of sustainable development are interrelated and inseparable. They equally combine all three dimensions of sustainable development: economic, social and environmental, which is why they are an excellent basis for intersectoral cooperation and the creation of mutual benefits for all involved parties (this approach is health for all policies).
In order to achieve the goals of sustainable development, it is necessary to transfer them from the global level to the local level - by preparing a new strategic document or by coordinating and updating already existing strategies of the municipality. The implementation of strategic measures, projects and programs should be based on the full involvement and cooperation of local stakeholders, as this creates co-responsibility and serves the effective mobilization and reallocation of resources.
Health should be treated as a long-term investment, not a short-term expense. Investing in the health and well-being of all makes our society and economy stronger.
Introduction
Most of us need support or care at some point in our lives. In other words, anyone can become "vulnerable" at any time if their physical capacities (such as limited mobility after a stroke) and political, economic or social circumstances (such as job loss) change (1). It is necessary to strengthen joint responsibility through the perspective "we need care = We Need Care". It is necessary to build inclusive communities. Communities that have flexible boundaries and the ability to adapt to different interests, as shown in the diagram in Figure 1. Communities that seek common ground and are creative. Such a community is supported by dedicated people who care for each other and take joint responsibility for social tasks (2).
Figure 1. Scheme of an inclusive community (2).
For an inclusive society, we may need a more inclusive definition of health
In the years since the adoption of the World Health Organization (WHO) definition of health until today, life expectancy has increased, and the population of older adults has increased numerically and proportionally. Significant changes in population aging and disease management over the past 70 years require a new consideration of the health needs of the elderly as an essential component of health in an aging world. The WHO definition of "perfect" health either sets unrealistic expectations or excludes the elderly and people with chronic disease from the health framework. Changes in screening, diagnosis and treatment have affected the long-term management of many disease states, posing a particular challenge to the disease-free concept of health. Many people live with the disease, as it can be reasonably managed with the right resources (3). According to the National Health and Healthcare Survey 2019 (EHIS), 38.4% of Slovenian residents aged 15 or over have a long-term illness or health problem. Nevertheless, only 8.1% of them rate their health as poor or very poor (4). Living with and managing illness will probably need to be recognized as a central component of lifelong well-being. Here, it should be emphasized that in certain respects the absence of disease remains the main direction - such as, for example. prevention of infection with the influenza virus, as it concerns the elderly and younger population. People of all ages deserve the opportunity to “be healthy” (3).
Health, well-being, prosperity, welfare... well-being?
In the article, we use the term welfare in accordance with the position of the Terminological Section of the Fran Ramovš Institute for the Slovenian Language. As the most appropriate term that sufficiently accurately defines the concept of "health and well-being", they suggest the equivalent human health and well-being . Prosperity and well-being, which are often used in this context, refer to an abundance of material goods, and the term well-being, according to the terminology section, is an insufficiently precise term, as it only denotes an individual's psychological and physical state (5, 6).
Health as a determinant, result and indicator of sustainable development
Health is created where people live and work, where they socialize and spend their free time. Health care is therefore not only a matter for each individual and national policy, but to a large extent also the responsibility of decision-makers at the local level (7). The most important public health policies are those that affect the factors with which people have the most contact. Safe drinking water, safe food, safe roads, safe air, and medical practices are partly locally controlled (8). Two global milestones have fueled the idea that local decision-making processes are key to public health. The first is the approval of the 2030 Agenda for Sustainable Development (9), which was adopted in 2015. It consists of 17 Sustainable Development Goals (SDGs), which are shown in Figure 2, and 169 specific goals with a global geographic scope. Another milestone occurred in 2016 with the adoption of the New Urban Agenda at the United Nations Conference on Sustainable Urban Development. In the agenda, "health" appears for the first time as a cross-sectoral issue and is explicitly recognized as a central component of urban planning and management, and not only in the context of the provision of health services (10).
The Sustainable Development Goals represent the broadest framework that supports the local community in caring for the well-being of all and creating a stimulating environment where everyone can use their maximum potential. They combine all three dimensions of sustainable development equally: economic, social and environmental . They are interconnected and inseparable, which is why they are a good basis for intersectoral action and integration (9).
Figure 2. Goals of sustainable development (11, 12).
Let's think globally and act locally
The Secretary-General of the United Nations, Ban Ki-moon, stated: “Our battle for global sustainability will be won or lost in cities.” (13). Namely, local authorities are the initiators of change and the level most suitable for connecting global goals with the local community, as they are closest to people and know best what they need (14, 15). The international community recognizes the importance of the local level in achieving the goals of sustainable development, as evidenced by the inclusion of the eleventh goal in the 2030 Agenda, fully dedicated to promoting the sustainable orientation of cities and settlements. The remaining 16 objectives also refer to the competences of local authorities.
Useful linksA visual representation of the connection between the goals of sustainable development and the functioning of local authorities is available in the online application " The sustainable development goals: What local governments need to know" . 17 sustainable development goals and 169 specific goals are presented in Slovenian at the following link . The " Local 2030 " platform offers various tools that can help local actors in channeling the global goals of sustainable development into local actions. The tools do not provide strict instructions or one-size-fits-all solutions, but rather provide practical, flexible mechanisms and instruments to address a variety of development challenges. One of the tools is the guide "Roadmap for localizing the SDGs: Implementation and monitoring at subnational level", which is summarized below. |
The four steps of implementing the 2030 Agenda at the local level (13):
Step 1: Raising awareness of sustainability goals in the local environment.
Step 2: Advocating local needs and priorities in national plans.
Step 3: Implementation of sustainable development goals at the local level.
Step 4: Monitoring the effects.
The first of the four steps envisages raising public awareness of the importance of the Sustainable Development Goals for every individual, as they cover the challenges of everyday life, including gender inequality, health in the narrow sense, climate change, educational opportunities, air quality, water quality, energy, living conditions, the problem poverty etc. Some local authorities may take the view that as a community they are "too small" or they lack the necessary knowledge, capabilities (human, technical or financial resources) to contribute to the achievement of sustainable development goals. From this point of view, awareness campaigns should also be carried out by associations of local and regional authorities, which mobilize their members and make them aware of their own role in achieving the goals of sustainable development. An excellent tool for raising awareness and encouraging local authorities to realize the goals of sustainable development is also the selection of champions of local or regional leaders who actively advocate for the achievement of the goals of sustainable development. It is recommended that the selection of a champion be organized by an association at the national level, and committed local leaders can also become ambassadors for sustainable development (13).
The second step emphasizes that local and regional authorities should strive for a bottom-up process in which local needs, priorities and expectations shape national strategies (13).
Implementation of sustainable development goals at the local level and monitoring of effects
The implementation of sustainable development goals must follow local needs and priority areas and at the same time take into account national guidelines. First of all, it is necessary to review already existing plans and programs at the local level and place them in the framework of sustainable development goals, as well as to identify cross-sectoral connections and areas that have not yet been addressed through existing programs (13).
The priorities of municipalities in the context of sustainable development must be locally oriented, take into account the availability of resources and include the interests of different decision-making levels and local stakeholders, including minorities and vulnerable groups . Inter-municipal cooperation and co-design of goals, transfer of knowledge and practices, pooling of resources and capacities are encouraged. For the implementation of the goals of sustainable development at the local level, intersectoral mechanisms , both formal and informal, are needed, which preferably include civil society organizations, representatives of the economy and the education sector. These mechanisms should be accessible to all segments of society, balanced (no group dominates the other) and transparent. Within the cross-sectoral group (e.g. local health groups), everyone should contribute to the discussion with their opinions, information and experiences, and decision-making should be transparent and widely communicated, as this builds trust. Where possible, already existing cross-sectoral mechanisms should be used for the planning and implementation of sustainable development goals at the local level. As a rule, representatives of the local authority in the intersectoral group take a leadership role , while respecting the independence of the representatives of the non-governmental sector. The role of the group leader includes ensuring the minimum infrastructure, creating the meeting agenda, proposing specific topics, distributing relevant materials and, within the given possibilities, also allocating grants (13).
The implementation of sustainable development goals at the local level can be planned through the preparation of a new strategic document or through the coordination and updating of existing municipal strategies. Local strategies should reflect the comprehensive vision of the municipality and be based on an integrated, multi-sectoral approach. Strategic planning, implementation and monitoring of effects should be based on participatory management (13).
|
The recommended elements of a strategic plan in the field of health are (13):
|
The implementation of strategic measures, projects and programs in the direction of sustainable development should be based on the full involvement and cooperation of local stakeholders (NGOs, the private sector, community services, research organizations, the education sector, community members). Such an approach creates co-responsibility among all actors, and serves the effective mobilization and reallocation of resources. While partners and local stakeholders have different agendas, roles and expectations, their common goal is generally sustainable and inclusive development of their (domestic) environment. Their contribution through the different phases of strategic planning (definition, financing, implementation, monitoring and evaluation) should be in accordance with their capacities and resources (technical, technological and financial resources, knowledge-based skills and innovation). It is necessary to go beyond the aid approach and shift to strengthening partnerships (13).
Key approaches to achieving the goals of sustainable development at the local level
1. Reducing inequality
"We will leave no one behind" is the general commitment of the 2030 Agenda. Equality is a cross-cutting theme of the Sustainable Development Goals and at the same time a central element of the second, fifth and tenth specific goals. Social inequalities in health arise from inequalities in the conditions of everyday life, with the main factors being inequalities in power, money and resources (10). In Slovenia, the area of income and social security can explain 42% of the difference in self-assessed health between more and less affluent population groups (16). In order to ensure an even distribution of health outcomes and to improve the general state of health, it is therefore necessary to focus on those who are more sensitive and most often exposed to risks, i.e. children, older people, women, the disabled and the less wealthy (10).
2. Health for all policies
The covid-19 pandemic has shown how a health threat can cause major disruptions and consequences in most aspects of life. We have also seen how policymakers can come together and work with different branches of government to create large-scale cross-sectoral responses to protect health if the perceived threat to health is large enough and the agreed measures are justified (17, 18).
The Health in All Policies approach is an approach to public policy in various sectors that systematically considers the health consequences of decisions, looks for synergies and avoids harmful effects on health, with the aim of improving the health of the population and equality in health. For example, local urban planning can improve mobility, walkability and social cohesion (cohesion) and thus the health and well-being of all. Efficient public transport combined with cycling networks encourages more physical activity, reduces air pollution and reduces overall traffic deaths and injuries. Green and blue open spaces in and around cities (e.g. green belts or urban river banks) improve resistance to heat waves, protect residents from the heat island effect, provide corridors with less polluted air, increase biodiversity and encourage physical exercise. Recycling and reusing waste eliminates the need to incinerate or bury it, thereby improving air quality, reducing water and soil pollution. Local policies that aim to reduce air and noise pollution and increase physical activity or green open spaces can dramatically reduce the morbidity, mortality and associated costs of many diseases – from cardiovascular disease, to cancer and mental health problems ( 10).
However, in "non-crisis" periods, the involvement of other sectors in health protection and promotion activities often presents a challenge. Instead of offering only the one-way relationship envisaged by the health-in-all-policies approach (i.e. the health sector benefiting from other sectors), it is necessary to expand the concept towards a two-way relationship (i.e. both the health and other sectors benefit from the partnership ), which is shown in Figure 3. The Health for All Policies approach enables the health sector to promote health and put initiatives for dialogue in the direction of strengthening and protecting health on the policy agenda, thereby also creating mutual benefits (ie outcomes that benefit all sectors involved). Mutual benefit is simply the benefit of one policy (e.g. promotion of vaccination among employees) that contributes to the achievement of other policies (e.g. less absenteeism) (17).
Figure 3. Linkage of health with other sectors through both approaches: health in all policies and health for all policies (19).
The health for all policies approach has two main perspectives (17):
- Impact of health outcomes (health status and health inequalities) on policies outside the health sector.
Examples: Children's health (CTR 3) affects their academic performance (CTR 4). Inequalities in health affect the ability of women (CTR 5) and people living in poverty and vulnerable groups (CTR 10) to take full advantage of educational opportunities and subsequently secure equal access to good jobs (CTR 8).
- The impact of health policies (eg health employment conditions, school health initiatives) on policies outside the health sector.
Example: The covid-19 pandemic has shown that the resilience of the health system is critical to the economy and security of a country.
The goals of sustainable development should be a source of inspiration, and the municipality should determine the path that is feasible for it
There are several ways to prepare a health strategy, as well as several ways to form a group for health and sustainable development. The municipal strategy is always a unique document adapted to the needs and opportunities of the municipality. The ultimate goal is for the municipality to place sustainability at the center of its organization and policy (15).
One of the possible ways is the inclusion of the municipality in the Slovenian national network of Healthy Cities , which supports activities at the local level, namely with directions, transfer of knowledge, practices and connecting local stakeholders with various ministries and other important institutions at the national level. The Healthy Cities Network is a long-term program of the World Health Organization and is a key partner and, at the same time, a means to facilitate the achievement of the goals set in the field of sustainable development in local communities (20).
The integration of sustainable development goals into the overall municipal strategy means that the municipality connects its goals to the framework of Agenda 2030 to the greatest extent possible. An important advantage of using sustainable development goals as a framework for strategic planning is an integrated approach . The realization of sustainable goals requires a horizontal organizational structure based on a project-based way of working (15).
Some ideas and practical tips
In the introduction of the strategic document, the municipality states the challenges it will address in the coming years. Ideally, the goals of sustainable development have their place in the presentation of the vision and mission of the municipality. Each objective of sustainable development can be linked to several measures at the municipal level and vice versa (15). An example of this is the municipal measure "Evaluation of existing and creation of new cycling and walking routes to residential areas to encourage cycling and walking", which can be linked to the 3rd, 11th, 13th and 15th goals of sustainable development.
When the current structure of municipal policies does not allow the recommended approach or the municipality has just become familiar with the goals of sustainable development, the framework of sustainable goals is useful in evaluating the effects of already existing policies. Existing strategies can also be upgraded in terms of content, and goals and measures can be equipped with icons of the sustainable development goals to which they refer. A list of local goals of Agenda 2030 can be prepared as an annex to the existing strategic document, where all planned measures of the municipality are placed under the 17 goals of sustainable development (15). All this gives added value to already existing strategic documents.
A final thought
Health should be treated as a long-term investment, not a short-term expense. By valuing and investing in "health for all", our economy and society are stronger. The cost of "not investing" in health is a multiple of the cost of investing in health, mainly due to the social costs that result from the poor health of the population. Despite the fact that investing in health contributes to the productivity of the economy, it should not be the ultimate goal. The economy should serve the health of people and the planet (18).
RESOURCES
1. Pahor M, ed.. Healthy community: Handbook for developing a community approach to health. Ljubljana: National Institute of Public Health, 2018.
2. EuroHealthNet. EuroHealthNet Country Exchange. Visit on the Potential of Caring Communities for Health Promotion [e-publication]. Retrieved 08/01/2024 from the website: https://eurohealthnet.eu/wp-content/uploads/publications/2023/230823_cevvienna_report.pdf.
3. Fallon CK, Karlawish J. Is the WHO Definition of Health Aging Well? Frameworks for "Health" After Three Score and Ten. Am J Public Health. 2019;109(8):1104–6. doi:10.2105/AJPH.2019.305177.
4. National Institute of Public Health. National Health and Healthcare Survey (EHIS). Retrieved on January 8, 2024 from the website: https://podatki.nijz.si/pxweb/sl/NIJZ%20podatkovni%20portal/.
5. Fran Ramovš Institute for Slovenian Language ZRC SAZU. Human health and well-being. Retrieved on January 8, 2024 from the website: https://isjfr.zrc-sazu.si/sl/terminologisce/svetovanje/zdravje-in-dobrobit-cloveka.
6. Fran Ramovš Institute for Slovenian Language ZRC SAZU. Community welfare. Retrieved on January 8, 2024 from the website: https://isjfr.zrc-sazu.si/sl/terminologisce/svetovanje/skupnostna-dobrobit.
7. Health in the municipality. Municipality of health - Which local communities do the most for the health of their residents. Retrieved on 11/01/2024 from the website: https://obcine.nijz.si/vsebine/obvestila/obcina-zdravja-katere-lokalne-skupnosti-naredijo-najvec-za-zdravje-svojih-prebivalcev-112/.
8. Bishai DM, Frattaroli S, Pollack KM. Public Health Policies: Go Local!. Am J Public Health. 2017;107(5):672–4. doi:10.2105/AJPH.2017.303682.
9. Agenda for sustainable development until 2030 [e-document]. Retrieved on January 8, 2024 from the website: https://www.gov.si/assets/ministrstva/MKRR/Agenda-2030/Agenda_za_trajnostni_razvoj_2030.doc.
10. Ramirez-Rubio O, Daher C, Fanjul G, et al. Urban health: an example of a "health in all policies" approach in the context of SDGs implementation. Global Health. 2019;15(1):87. doi:10.1186/s12992-019-0529-z
11. Organization of the United Nations. Sustainable Development Goals [website on the Internet]. Retrieved 2/13/2024 from the website: https://unis.unvienna.org/unis/sl/topics/sustainable_development_goals.html.
12. GOV.SI. Why international development cooperation [website on the Internet]. Retrieved on 13 February 2024 from the website: https://www.gov.si/teme/zakaj-mednarodno-razvojno-sodelovanje.
13. Global Taskforce of Local and Regional Governments. Roadmap for localizing the SDGs: Implementation and monitoring at Subnational level [e-book]. Retrieved 13/02/2024 from website: https://www.uclg.org/sites/default/files/roadmap_for_localizing_the_sdgs_0.pdf.
14. LOCAL 2030. Discover tools [website on the Internet]. retrieved 2/15/2024 from the website: https://www.local2030.org/discover-tools.
15. The Association of Flemish Cities and Municipalities. Inspiration guide: Integrating the SDGs into your multi-annual policy plan [e-book]. Retrieved 15/02/2024 from website: https://www.local2030.org/library/707/SDGs-in-policy-plan.pdf.
16. Gabrijelčič BM, Kofol BT, Zaletel M, Hočevar GA, Lesnik T., ed. Inequalities in health: the challenge of the future in intersectoral integration. Ljubljana: National Institute of Public Health, 2021.
17. Greer SL, Falkenbach M, Siciliani L, McKee M, Wismar M, Figueras J. From Health in All Policies to Health for All Policies. Lancet Public Health. 2022;7(8):e718-e720. doi:10.1016/S2468-2667(22)00155-4.
18. WHO Council on the Economics of Health for All. Final report: transforming economies to deliver what matters. Geneva: World Health Organization, 2023.
19. Greer SL, Falkenbach M, Siciliani L, Perroud J, Chantel Montás M, Wismar M. Finding and understanding co-benefits. In: Greer SL, Falkenbach M, Figueras J, Wismar M, editors. Health for All Policies: The Co-Benefits of Intersectoral Action. Cambridge: Cambridge University Press; 2024 19–33. (European Observatory on Health Systems and Policies).
20. National Institute of Public Health. Healthy city. Gazette of the Slovenian network of healthy cities [website on the Internet]. Retrieved on 20 February 2024 from the website: https://nijz.si/zdravo-mesto/.