Forty years ago, health was largely framed through the lens of medical care and individual behaviour. In 1986, the Ottawa Charter changed the health narrative. It placed the systems and structures that shape people’s lives at the centre of health promotion. In doing so, the charter drew attention to the social, economic, commercial and political forces that determined who has the opportunity to be healthy, making the politics of health impossible to ignore. As Halfdan Mahler, former director of the World Health Organization, said, “The health of its people is one of the most positive and productive resources society can have.”
The Ottawa Charter showed that health and equity are shaped by how power is distributed, whose interests influence public policy, and which institutions and systems shape the conditions in which health is created “within the settings of their everyday life; where they learn, work, play and love”. Its five action areas – building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services – provided a practical framework for acting on those conditions. They offered a way to reshape the policies, environments, institutions and power structures that determine who has the opportunity to have good health.
On its 40th anniversary, the political ambition of the Ottawa Charter remains at the heart of health promotion. There is so much to celebrate in its influence and achievements. But there is also value in asking where progress towards ‘health for all’ has proved more difficult.
Build healthy public policy
The charter recognises that public policy itself creates the conditions for health. Tobacco control showed what governments can achieve when they are prepared to regulate harmful products and place population health ahead of commercial interests. However, tobacco is still the exception. Powerful commercial actors have substantial resources to influence policy and public debate. Australia’s recent approach to the online gambling industry illustrates this tension. Despite a major parliamentary inquiry recommending a ban on online gambling advertising, and strong public support for such action, government reforms stopped well short of these recommendations. While acknowledging the significant harms of the gambling industry, the language of ‘getting the balance right’ was used to justify a partial ban, showing how commercial interests shape policy even where the case for stronger public health action is compelling.
Create supportive environments
Asking people to make healthy decisions makes little sense when the environments around them make good health difficult to achieve. The settings in which people live, work and play are changing. Climate change, housing insecurity and rising living costs are reshaping the conditions of everyday life, while digital technologies are transforming the environments in which people receive information, communicate and make decisions. Supportive environments should do more than help people navigate harmful conditions. They should change the conditions that create harm.
Strengthen community action
The charter called for communities to have meaningful control over the decisions affecting their health. There has been important progress through community-led health promotion and co-design. But participation is not the same as power. Strengthening community action requires asking whose knowledge is recognised, whose has been marginalised, and who ultimately gets to make decisions that affect communities. In the next 40 years, strengthening community action must mean more than participation.
Develop personal skills
The action area of developing personal skills exposes one of health promotion’s most enduring tensions. It is easier to teach people how to navigate unhealthy systems than it is to change the systems themselves. Yet many responses still focus on the individual. They encourage people to become more resilient, improve their literacy, manage risk or make better choices within these environments. We encourage healthier diets without transforming food systems. We teach young people to recognise harmful marketing while allowing industries to develop increasingly sophisticated ways of targeting them. Developing personal skills should therefore build critical agency without transferring responsibility for health onto individuals.
Reorient health services
Health systems continue to operate under enormous pressure. Yet there is still limited focus on prevention, which remains less visible in health policy and planning. If the evidence shows us that poor health is largely created by structural factors – poverty, harmful industries, the climate crisis and ongoing inequities – governments must play a stronger role in advocating for action in these areas.
The next era of health promotion must do more than help people navigate the risks in their everyday environments. It must also address the political and commercial actors, institutions and industries that create those risks. The enduring strength of the Ottawa Charter is that it is a framework for asking who has power, who benefits and who is held accountable. Forty years on, this is the political ambition of the Ottawa Charter that we need to reclaim.
