Healthier societies for healthy populations

The COVID-19 pandemic makes the importance of health and wellbeing clear. The pandemic's implications for societies are far reaching. Yet the response to this pandemic and the creation and promotion of health and wellbeing require action beyond the health sector—and beyond the usual ways of working in global health. Governments are not adequately tackling inequality, ongoing economic crises, or continuing environmental damage, which undermines the health of current and future generations. For example, tobacco and alcohol use, unhealthy diets, air pollution, and insufficient physical exercise contribute to most non-communicable diseases (NCDs), which account for 72% of all global deaths.¹ High NCD prevalence is contributing to the impact of COVID-19.² Obesity has tripled since 1975, and around 2 billion people are overweight worldwide.³ Some 2·2 billion people around the world do not have safely managed drinking water and 4·2 billion people do not have safely managed sanitation.⁴ Air pollution is responsible for an estimated 7 million deaths annually, and every year 5 million people die from preventable injuries or violence.⁵

Action is needed in all these areas, but there have been inadequate improvements to people's living, working, and social conditions over time, which are so key to health and wellbeing. To achieve Sustainable Development Goal (SDG) 3—to ensure healthy lives and promote wellbeing for all at all ages—and help achieve other SDGs, WHO aims to address three interlinked goals: to keep people healthy, to achieve universal health coverage, and to manage health emergencies.⁶ The first goal of keeping people healthy requires drastic changes to make societies safer, cleaner, and more supportive. Yet, previous attempts to address these challenges remain unfulfilled,7, 8, 9 and there is no consensus on how to create and sustain healthy populations.

In this context, the Government of Sweden, WHO, and the Wellcome Trust convened a meeting on Healthy Societies for Healthy Populations with Wilton Park on Feb 10–12, 2020, at Wiston House in the UK. Nearly 60 participants working on health, climate, food, and urban planning issues from governments, the UN, civil society, academia, and the private sector joined a dialogue on ways to promote healthy populations. Together, participants examined determinants of health through a political economy lens; considered the importance of leadership, public demand, and social power; discussed how inclusive knowledge creation can strengthen the implementation agenda; and made commitments on taking the next steps.

Creating healthy populations is a collective endeavour that requires navigating competing interests, institutions, and ideas. Policy makers and governments have a crucial leadership role in managing contestation between the public good, private sector demands, and competing political interests. A more strategic and intersectional consideration of history and political economy would help improve future efforts. There is a need for more caution and recognition of potential opportunities when engaging with the private sector,¹⁰ and for greater clarity on how government, the private sector, and civil society interact.¹¹ To better understand these challenges, policy makers should build on past efforts to manage multisectoral governance and cooperation in health¹² and, most importantly, apply insights from political, behavioural, and organisational sciences.

No single sector, discipline, stakeholder, community, or country has the solution to address these complex, interlinked challenges. For example, at the local level, the space and social relations in and around a school can positively influence children's development and health outcomes; but beyond the school, commercial advertising and opportunities for consumption can expose children and adolescents to harm.¹³ At the global level, there is growing knowledge of how climate change, biodiversity loss, freshwater depletion, tropical deforestation, mineral extraction, overexploitation of fisheries, ocean acidification, and soil degradation are interacting with profound implications for human health with acute, long-term, and intergenerational effects.¹⁴ Evidence also shows that policies to promote more sustainable dietary choices, zero carbon energy, and transport systems can improve health and mitigate climate change.¹⁵ It is clear that leadership and public demand for improved health are fundamental to motivate meaningful change.

We need to understand how individual and social power can be organised to advance knowledge of what makes for healthy populations, and how this power can raise issues. We need to be mindful that harnessing that power does not further entrench gender and class inequalities. This means framing healthy and sustainable options for decision makers and holding governments accountable for the collective right to health and to healthy places to live, grow, move, work, and play, both locally and globally. We need to connect to develop solutions with existing and emerging social movements in health equity, gender, transport, climate, environment, labour, tax governance, and other areas. This effort must include the voices of affected communities, particularly young people whose futures are determined by today's choices. There is considerable evidence on what leads to health and wellbeing, and what harms health, but this evidence is unevenly adopted and implemented. What interventions make the biggest difference? How can they be implemented?

First, we need to build on global knowledge about the commercial, political, environmental, and social determinants of health. Second, we need to link this agenda to specific actions. Policy makers sometimes understand the issues, but they often do not know how or where to create consensus, particularly since many of the barriers and solutions are outside the health sector. Third, policy makers need to build or strengthen working relationships across professional and sectoral boundaries—a governance challenge with which global health and development actors have traditionally struggled. Fourth, a responsive systems and policy research agenda means immersion in local, geopolitical, and cultural contexts, learning from experience and improving understandings of the broader determinants of health. Fifth, policy makers need to include more outside voices in the policy making process.

Indeed, progress requires a range of voices, perspectives, and viewpoints, many of which were under-represented or missing from our discussion at the Wilton Park dialogue. The next steps are summarised in the panel and involve a commitment to reach out to and invite collaboration with individuals, communities, institutions, and social movements seeking to make a difference in achieving healthy populations. Our first priority must be to evolve our societies to enable people to stay and remain healthy. Healthy societies are not only important for people's health, but also for sustainable development.

Panel. Vision for an agenda moving towards healthy populations.

• •Listen to and work with all people and communities when framing the concepts, evidence, principles, and goals of healthy societies. Ensure that efforts are implemented and messages are communicated in ways that make sense to people's lives.
• •Develop a vision and strategy so that these efforts are as well understood and appreciated by all actors at local and global levels.
• •Demonstrate the vision of healthy and sustainable societies and share experiences through various innovations, practices, and exchanges.
• •Nurture and build leadership in the public and private sectors as well as in civil society; facilitate cooperation and collaboration across sectors and actors to create sustainable multisectoral progress; and promote future leaders and political champions who can advance these efforts.
• •Develop a systems and policy research agenda focused on political science and behavioural economics to complement efforts in public health.