The Ottawa Charter After 30+ Years: relevance, bias and reflection

The Ottawa Charter has been touted as the guiding vision for health promotion. The field of health promotion, however, has expanded significantly on a global scale since the Charter was first developed back in 1986. Scholars have critiqued the framework for several reasons. Public Health Ontario (2023) describe the following shortcomings:

• The Global Health Promotion Conference included 38 industrialized countries, with exclusive focus on the needs of those countries.

• Indigenous peoples and developing countries were excluded from attending (invitation only).

• The Charter is considered a Euro-centric and colonial document.

• The action item “healthy public policy” came from an analysis of national public policies in   democratic, wealthy industrialized countries with social welfare systems.

• Questionable whether the chosen action items are transferable to countries with different circumstances.

• Insufficient evidence for successful re-orientation of health services and strengthening community action (could not be measured given the intended interconnectivity of these action items).

  
  

Furthermore, Public Health Ontario (2023) discussed how health promotion has not been fully implemented as intended, resulting in gaps between theory and practice. The theory-to-implementation gaps are referred to as “push/pulls”. Several interrelated gaps, have been identified and include:

• Health behaviourism – the behaviour change focus places responsibility on the individual, while overlooking the wider social and political forces that shape health behaviours.

• Lifestyle drift - despite efforts to address upstream social determinants of health, efforts gradually shift focus “downstream” toward individual lifestyle behaviours. Again, placing emphasis on the individual and neglecting to recognize that choices are largely shaped by social, economic, commercial and political determinants.

• Individualism - the Ottawa Charter shifted health promotion away from the individual‑focused education models that once dominated the field and redirected it toward a socio‑ecological approach grounded in the structural determinants of health. Choices are constrained by social and cultural structures.

• Prioritization of healthcare – the focus is on treating and preventing disease rather than promoting health. There is over-reliance on the “default lever” of expanding access to clinical care which reflects a biomedical model and frames health as a simple binary between health and disease.

• Single‑issue response - focus on isolated programs rather than the interconnected, multi‑level strategies emphasized in the Ottawa Charter. Because action areas are designed to reinforce one another, efforts like developing personal skills are most effective when paired with broader structural and community‑level actions.

  
  

Health promotion cannot be viewed solely as an outcome of the Ottawa Charter, and the Charter itself needs to be interpreted and applied within a much broader contemporary context than the one in which it was originally developed (Public Health Ontario, 2023).

McPhail-Bell et al. (2013) argue that health promotion must engage in reflexive practice and critically examine its own history of privilege to avoid reproducing colonial patterns. They call for deeper reflection and action to ensure that the field applies its own principles and values so it can advance its original vision of health promotion for all people.

References

McPhail-Bell, K., Fredericks, B., & Brough, M. (2013). Beyond the accolades: a postcolonial critique of the foundations of the Ottawa Charter. Global health promotion, 20(2), 22–29. https://doi.org/10.1177/1757975913490427

Public Health Ontario (2023). Focus on foundations of health promotion. https://www.publichealthontario.ca/-/media/Documents/F/2023/focus-on-foundations-health-promotion.pdf

World Health Organization. (1986). Ottawa charter for health promotion. https://www.canada.ca/content/dam/phac-aspc/documents/services/health-promotion/population-health/ottawa-charter-health-promotion-international-conference-on-health-promotion/charter.pdf