A human rights approach to quality of life and health: Applications to public health programming

 Armando De Negri Filho

Health and Human Rights 10/1

Published June 2008

Abstract

Approaching health as a basic human right has a profound impact on the way we treat it politically. Viewing health as a public good — with both individual and collective dimensions — shapes the nature of health policies. The concept of a right to health can be used to formulate policies, organize systems and services, and develop actions that promote better health outcomes.  Building on experiences in Latin America, this article discusses lessons learned for achieving policies and health systems that contribute to building democracy into a system that guarantees social justice. Drawing on work in Latin American Social Medicine, it specifically proposes new ways of thinking about social fragility (instead of risks) and developing inter-sectoral programming to improve care, as well as to reduce inequalities among population groups. The article argues that a right-based approach can be a concrete tool for restructuring both public policies and action.

Introduction

Approaching health as a basic human right has a profound impact on the way we shape its political concept. Viewing health as a public good — with individual and collective dimensions — has a significant effect on the nature of health policies. When rights underpin definitions of health, health policies can be targeted to respond to social needs. The right to health can be a driving force for political action that builds democracy on the foundation of social justice.

The argument for exercising this right to health has often been located in the field of ethics and moral discussion about solidarity. If we are to discuss it as a political asset, however, the conversation must move into the language of public policy, where it can be used to formulate policies, organize systems and services, and develop actions that realize health.

Policy-makers and others engaged in promoting the right to health in Brazil, Colombia, and Venezuela have already taken such steps to implement the right to health as a political tool, particularly at the level of local governments. This article builds on these experiences, examines their strengths and limitations, and discusses lessons learned for achieving policies and health systems that contribute to building democracy into a system that guarantees social justice. Through such discussion a rights approach may become a concrete tool for restructuring policies and action.

Health as a social product

A rights-based response to social need integrates three concepts: universality, equity, and comprehensiveness. This integration is discussed in more detail later in this article. The approach outlined here is that of the “Promotional Strategy of Equity in Quality of Life.”1 This approach applies ethics to social needs and understands “health” as a social outcome to realizing quality of life. The success of this approach in health policy is rooted in its role within a broader commitment to guarantee human and social rights and in the development of the social environment as “spaces of humanization.”

Such a strategic focus makes it possible to develop public health policy proposals that project across sectors, influencing social determinants and the resulting social exposures. The strategy assumes the need for a deep understanding of the causes that generate social harm and illnesses, as well as their collective and individual consequences. These consequences demonstrate the relationship between illness and poverty.

This article draws on experiences since 2001, in Porto Alegre, Bogotá, and Caracas, identifying certain universal aspects of these experiences and discussing inherent political, technical, and scientific challenges they raise that underlie any effort to guarantee the right to health in political and practical terms. The specific results of each of these programs will not be discussed.

Realizing the right to health: Responding to social needs

A political approach that ensures human rights must focus on realizing rights by satisfying needs — that is, in the material substance of rights in daily life. It must also explicitly identify the interdependence between rights and needs.2 This is especially apparent in the area of social causes. Satisfying needs allows people to attain quality of life and well-being, individually and in society. A political approach based on such a vision must consider all of the ways in which causes interact. It is impossible to design an effective intervention without taking into account the impact that the intervention may have on the social production of “harm” (if we wish to think about harm from the viewpoint of health) or illness.

Such an approach also presupposes an ethics that affirms the absolute value of life. Within this view, health is understood as an expression of the basic right to life; determinants of health are those necessary conditions that enable life to exist and develop fully. Within this moral position, there are mandatory options that make it possible to translate basic ethics into practice. This framework is essential and fundamental, since it consolidates the coherent nature of resulting decisions. Such decisions then configure a system of social responses that can guarantee the rights that lead to ethically imperative action and work toward satisfying the social needs derived from those rights.

This view differs diametrically from existing social policies, where the failure to guarantee human rights and effective social responses is taken as normal. In current systems, supply is viewed as a factor that limits and shapes social response. This limit, treated as an entity that is somehow dissociated from need, is used to justify the status quo, as if social policies should, by nature, do nothing more than mitigate and compensate. Thus, economic policies and government structural adjustment options actively produce the exclusion and poverty that can then be “managed” by mitigating policies. The result is structural schizophrenia in which both society and government are acting as guarantors of a process that does not reflect the priorities of protecting society’s members and establishing institutional responsibility for fulfilling human and social rights.

Universality, equity, and comprehensiveness: A triad to guarantee human rights
A rights perspective in public policy builds on three inseparable ideas: universality, equity, and comprehensiveness. Universality means that rights are for all men and women, or there is no right. Equity measures inequalities using an ethical or moral judgment that is based on the broad concept of justice; it recognizes and gives voice to existing inequities among social classes, social territories, genders, ethnic groups, and ages. The social response must be of a comprehensive nature if understanding and practice are to experience radical change, affect determinants and social exposures, and break down those factors that cause people to be excluded from exercising their rights and attaining equity.

Neoliberal reform in many countries builds public policy for health care on an exclusive focus that inherently lacks a rights perspective. A universalist approach, in contrast, understands rights to health care as an imperative driven by social need. A needs perspective presupposes social responses that identify necessary resources on the basis of need rather than balanced budgets. Yet to apply the universalist approach responsibly, we must ask certain questions: What must be done to guarantee rights for all, both for men and for women? How much will such guarantees cost? And how will we produce the necessary resources to pay the costs? These questions follow a logic that differs radically from the current neoliberal health system imperatives, where the debate is driven by arguments about economic viability and fiscal balance.3

The work of Agnes Héller offers a model that enables a focus on what she calls “radical needs.”4In her Teoria de las Necesidades de Marx, Héller argues that needs of a radical nature are those that cannot be met within the prevailing social framework. Such a view invites us to ask whether it is possible to guarantee for everyone the right to quality of life (and health) in the current social framework. It also invites us to imagine how society should order its institutional and organizational systems to effectively respond to such radical needs. There is in this view an intellectual imperative to consider how any new framework that we build can bring us politically closer to constructing future alternatives where rights can be realized.

In this idea of universality, equity — defined as a form of justice (“from each according to his ability, to each according to his needs”) — becomes enormously important. Inequity is here identified as a systematic difference that affects people’s lives in ways that are unjust, unnecessary, and avoidable. Inequity establishes differences that are not morally acceptable, defining the individual’s potential and opportunities on the basis of determinants and exposures that increase fragility in the already-difficult quest for quality of life.5 This becomes evident when we evaluate standards for quality of life that appear to define a society even when groups within that society cannot enjoy them.6

There are risks to discussing equity from a perspective of targeting, where actions are targeted to the poorest of the poor while ignoring the social factors that cause poverty and exclusion. A view that approaches equity through social policies that seem to discriminate positively, in fact, risks merely consolidating the dominant social divisions, normalizing inequities and a chronic social disrespect for rights.7

To adopt the equity approach, we must systematically question whether proposed policies and actions create a principle of justice; we must also examine how our initiatives consolidate universal and comprehensive responses. This ongoing critical questioning will force us to maintain an intellectual discipline that will affect the analytical representation of the problems.8 It will also shape the way that we construct responses. This is no easy task in the context of a social hegemony that fragments reality into social patches that effectively conceal the overall tensions of conflict and injustice. Such a status quo can easily lull us into being satisfied with responses that do not address social causes, only to find ourselves later surprised by the inevitable failure of fragmented public policies that respond inadequately to rights-based needs.

We must also consider status-based inequities in our examination of determinants and their resulting exposures. Such status-based inequities may be based on social class, social territories, age, gender, or ethnicity. This critical analysis can also compare the distance between the various social groups in terms of degree of quality of life — where needs are addressed that fulfill their rights and where inequities and equity gaps between groups take shape. We can also analyze equity between groups in terms of their differential exposure to social determinants, as well as differences in how illness or social “damage” is distributed (by differences in status or people’s quality of life). Other measurable differences in such an analysis include access to responses or social services and allocation of resources to satisfy needs.

Universality, equity, and comprehensiveness are, consequently, an inseparable triad in realizing the guarantee of human rights for all. This is why an approach that analyzes the efficacy of social policies on the basis of equity must bear in mind the needs of people and their relevant groups as well as measure the relative distance among groups in order to guarantee the rights of all people. In the long run, this means that we have to reduce diseases, early deaths, or loss of quality of life at the same time that we are reducing inequitable differences among social groups.

Analyzing what causes social realities requires an expert understanding of the complexities of the problems that face us. When public institutions are fragmented by so-called social problems, they may quickly become incapable of dealing with the complexity of structuring policies and actions. The resulting paralysis inhibits engagement with the complexities of the structuring process while also making it more difficult to change situations due to an increasingly limited ability to represent the problems and address them at root cause.9

Implications of a rights approach for quality-of-life policy

Several issues are key to addressing the complex nature of social realities, in a manner that constructs a new reality based in respect for human rights and the universality-equity-comprehensiveness triad. These issues and their implications for quality-of-life policy are explored below.

Social determination and complex causation
The complexity of social events may be illustrated in terms of how they begin and are perpetuated. To address social events in a way that also addresses their causes, we must understand how the social context ends up weakening or strengthening the social condition of the individuals and their collectives. Acknowledging this possibility allows us to recognize and shape social changes in the direction of the guarantee of rights and equitable social inclusion. Doing so allows us to visualize the social exposures that people face as a result of problematic determinants. It also allows us to visualize how damages and their social consequences interrelate in a way that facilitates an understanding of how to rank interventions in the hierarchy of causal processes. Such ranking enables us to adjust our goals in ways that increase our ability to transform processes that perpetuate a problematic status quo. This dynamic is illustrated in the following figure.10

FilhoFigure

Any strategic planning with a design for action must build from an understanding of what causes the relevant complex processes that will affect its implementation. But the very nature of complex processes calls for constructing an integrated view of the issues from the diverse representations that are offered by all of the social actors who are affected by the problems the plan seeks to address. That is, we must figuratively give voice to the problems, based on the words of those who suffer their effects. For example, we cannot discuss ways to combat maternal mortality unless we examine its causalities in light of the circumstances under which they occur and if we do not respond to them based on this concrete expression of the experience itself. Thus, in this specific example, a response to problematic causes begins at the point of social determinants and exposures, forcing us to consider such factors as the families’ level of income, their material living conditions, and their access to social protection services. Other issues that come into focus include income and educational level of the mother, available financing for health care, and cultural views of class that affect pregnancy. Such variables should be analyzed in terms of their complex interdependencies, with the aim of confronting and eliminating structures and circumstances that cause such deaths.

By systematically investigating social causes, we can identify the critical links in the causal chain and then define strategies and initiatives to remedy the situation most effectively. Failure to take this analytical step hinders the development of a promotional strategy of equity in quality of life and health. It exposes the fragile nature of political and social action that might otherwise have power to transform reality, but that continues instead to perpetuate problems within the framework of the prevailing hegemony.

We must, however, ensure that any action to confront causalities is directed toward guaranteeing rights and realizing the universality-equity-comprehensiveness triad. We must also attempt to ensure that responses operate within the framework of a practical rationality as  a perspective which subjects technical rationality, a dominant feature of administrative space, to the imperative principle of action that guarantees rights, tangibly modifying peoples’ quality of life.

Social fragility vs. risk management
Any discussion of addressing complexities must also address the risk factors that are attributed to individuals or populations and the ways in which they are managed — for example, by local authorities or technical project coordinators. In the field of health, consideration of risk factors often competes with the social determination of problems. Looking at risk factors, however, may limit a full understanding of complexities, insofar as this view attributes the distribution of health problems to particular personal choices and offers only limited responses, such as changes in living habits, and education on making healthy choices. Reducing the problem in this way to a few modifiable behaviors ignores factors of social determination and, consequently, disregards the concept of social production of health. This focus on risk management also excludes social exposures that stem from a disregard for guaranteeing rights as an interdependent system, particularly in the context of poor living and working conditions. Rather, the risk management approach holds that the power to change structural conditions lies in the management of personal or group conditions, effectively masking the role of social determinants as causes by blaming them on the victims rather than on the social conditions (the non-rights) in which they live.

The concept of social vulnerability follows a similar path by ignoring the social production of problems. By directing actions toward “vulnerable” populations and individuals, this approach treats affected individuals and collectivities as exceptions in a context that assumes lack of vulnerability as the rule. From a rights perspective, in such situations, we find that problems do not result from people lacking protection against vulnerability. Instead, we see a structural expression of entire populations that find themselves socially vulnerable and in need of social protection based on human and social rights, rather than circumstantial protection against particular or conceptually isolated risk factors. These rights must be organized within an expanded concept of social security, ultimately creating guarantees of economic security. In this scenario, we seek to affect structural social conditions, discussed above, within a political project that strives to resituate peoples’ social conditions so they may rise out of the social fragility in which they find themselves structurally.

One particularly complex issue in this discussion is the universal entitlement to safety. The traditional view on accidents, violence, and suicides assumes that dangerous environments, chance, and the occurrence of traumas are normative, and that they occur because people accept risk or engage in risk behavior. However, when we look at the issue from the vantage point of social determinants and the exposures and inequities that govern them, we find the causality of such events in a condition of structural fragility. Fragile social structures are innately unsafe. To address this problem, we must understand the complex causalities and confront them within their matrices of expression.

An effective rights-based response would not only exercise inter-sectorality in a radical way, but also fill social territories and spaces with viable alternatives that guarantee quality of life. For example, applying this view to traffic accidents calls for a profound re-conception of the logic of human mobility as a right, combined with protection for life and the right to safety, and these factors would guide the evaluation of all existing universal, equitable, and comprehensive options. A similar rights-based approach related to living conditions, for example, would lead to a new conception of cities, communities, and environments that are safe and that protect life. Thus, if we view social spaces that are designed to guarantee safety as a fundamental right, such a view would then serve as a guide for action based on the ethical imperative to respond to social needs. Other issues would benefit from a similar approach, such as the debate over the production, sale, and price of alcohol; the strength and safety of automobiles; the criteria for driver training and control; impunity; and urban space and transportation. Such groups of complex elements can be effectively understood within a causal chain that shapes intervention strategies centered on social responses to social needs.

Co-responsibility, rights, and duties
The focus in hegemonic discourse on fulfillment of duties may present a fundamental obstacle to achieving the goal of building public policies that are centered on rights. In a true rights approach, duties have no conditions; the limit to each person’s right is located in respect for the right of the other. The imperative political action here is public education, so that citizens can understand that the guarantee of “my” rights lies in the guarantee of the rights of each and every person. The concept of social co-responsibility must be viewed anew as the emancipatory participation of the citizenry — within the full exercise of their civil rights — in debate, decision, and subsequent actions that take place in conjunction with and supported by government. Ongoing political education must target both the general population as well as government officials. In this perspective of rights for all, the duty of the state is to act as guarantor of rights with responsibility for all of society. The citizenry engages in an active construction of society’s responsibility to guarantee the right of all, building a reality where this is actually possible.

Implementing an inter-sectoral strategy
The issue of social territories as it relates to democratic governance is another area of discussion in the construction of a human rights approach to health. Rights can be realized only within specific social territories which are, therefore, a key element in representing issues of causation and the opportunities for exercising inter-sectorality. Decentralization offers an opportunity to realize an inter-sectoral approach by territories.

The adoption of a concept of social territories requires that problems be contextualized in specific social and political spaces, understanding social territories as living spaces where social determinants as well as exposures are produced and reproduced in the lives of real people.

Decentralization can increase governability by moving government administration close to local realities. Such a move allows for an inter-sectoral response to the causal chains, thus affecting the determinants and their social exposures. If governance is understood as ideally democratic, defining effective forms of participation and societal control over the state, with citizens entitled to make decisions about priorities and able to construct viable alternatives, decentralized governance can be even more effective, provided it avoids matrices of fragmentary and scattered participation. For instance, we often lack a unity — or, at least, a systematization — of spaces for participation, decision-making, and monitoring the consequences of even decentralized decisions.

Yet territorialization is a critical process in building inter-sectorality. It fosters the design of a new institutionality that is closely linked with the existing situation and therefore capable of building social alternatives in response to complexity, which creates governability with democratic governance. Institutional responses often take this approach, for example, in issues such as the fight against hunger; infancy policies; and social policies, in general. These attempts at inter-sectorality in territorial settings often still lack the means for attending to and managing the initiatives in a truly inter-sectoral manner. This politico-organizational weakness is most evident in the difficulty of adapting ministries’ vertical organization to a horizontal integration that fosters a true sharing of concepts, methods, objectives, resources, and operation that would reflect the conceptualization of the interdependence of rights.

Satisfaction of social needs, ethical imperative to respond to social needs, and promotion of quality of life

If we choose to order public policy using the rights-based ethical imperative outlined above, we must understand the hierarchy that such a principle generates. To implement this approach, we must begin in a manner that gives coherence and scope to the ethical imperative of response. This, in turn, requires that we adopt a management approach that is appropriate to this goal. A hierarchy that places ethics first effectively reorients the traditional ways in which we organize our tasks — that is, based on available resources rather than social needs. Inverting these priorities induces a true orientation toward social needs and enables the political struggle for attaining all that is necessary to concretize the right to quality of life and health for all.

This new political construct operates by a promotional mode of care. Unlike the traditional “assistance-based” mode of care, which focuses almost exclusively on illness, the promotional mode of care focuses on maintaining and developing people’s lifelong right and realization of autonomy as well as the creation of equity among  social groups. In other words, it works to guarantee the material realization of rights throughout life with the concomitant production of social justice. Thus, if promoting quality of life is adopted as a strategy that orders the mode of care, we need to bring a promotional perspective to all the actions that take place within this framework,
whether they are educational, protective, or preventative, or whether they concern diagnosis and treatment or rehabilitation. Promotion, in this framework, is defined as a strategy that is expressed in public policies and that orders all actions related to such policies. Promotion and prevention are thus two distinct concepts. This approach allows us to eliminate the confusion between them.

Satisfaction of social needs derived from the framework of human and social rights is expressed in particular definitions about quality of life. Quality of life may be defined in terms of five interdependent spheres:

  1. The individual sphere is understood as autonomy or functional independence — that is, the socio-economic capacity to provide for one’s needs and the full exercise of political emancipation;
  2. The collective sphere represents equity among groups and the construction of public democratic spaces;
  3. The institutional sphere involves the demand for institutional democratization, a comprehensive response to social needs, and the resulting inter-sectorality in the building of responses that should have an effect on the determinants of quality of life and health problems in order to result in the social production of quality of life;
  4. The environmental sphere emphasizes the principle of sustainability; and
  5. The subjective sphere, extensive and enveloping, focuses on adopting new forms of subjectivation toward the construction of new social visions, as well as the consolidation of values such as solidarity, justice, and respect for differences.11

From the perspective of a rights approach, guaranteeing an effective response to social needs in quality of life and health is critical to the means of management in defense of rights. This engenders the funding, management, and training conditions for workers, for example, as well as the information system, logistics, and infrastructure necessary for responding to the social needs derived from human and social rights.

The development of the means of management is strategically defined to the degree that the legal limit is constantly “explored.” This process combines testing the maximum limit of the law with promoting and legitimizing an organized effort of broad social participation, in order to guarantee democratic governance. That is, here we envision an emancipatory participation capable of generating new and autonomous powers for the social sectors that engage in these exercises. Participation is unfettered and therefore independent in its potential to serve a critical role with respect to the state. Decentralization should never jeopardize the guarantee of a universal social contract, which is the reference point of the rights approach as one which unifies government action.

In this promotional perspective, inter-sectorality as an applied exercise of the trans-disciplinarity of knowledge is subject to the need to respond effectively to social determinants, social exposures, damages, and social consequences of the damages. This broad range of required responses infers what one or another sector can offer separately, forcing the complex nature of the problems to demand different disciplines of knowledge and corresponding necessary actions, including the mode of management that could generate the required responses. The principal objective of inter-sectorality is to dissolve the causal chains that produce the social problems that affect quality of life and health, and to foster the social production of well-being. The concrete settings for this inter-sectoral exercise are social territories: cities and rural areas, and the populations that inhabit them.

If we understand this strategic promotional approach to quality of life as one that sees care as responding to social needs derived from rights, we must then adopt a model of primary health care — or any other component of a health system characteristic of a promotional mode of care — that would preserve coherence of the models that are adopted.

Conclusion

In summary, this paper argues that the promotional strategy of equity in quality of life and health has political strength as a group of concepts that, articulated in terms of an ethical imperative to respond to social needs, requires reflection and action toward universality, equity, and comprehensiveness. These three elements may be usefully discussed as an interdependent triad in the concept of human rights in quality of life and health.

The strategy outlined here functions to establish a social perspective in which scarcity is not perceived as normative. It also exposes contradiction between the necessary and the available in terms of the guarantee of human and citizens’ rights, contesting the idea of the minimum possible as a response to social and human rights.

Developing a human rights approach that can be effectively applied to restructure the way public health programs are designed requires a complex process. Such a process must have political sustainability to reach maturity and solid results. Within this perspective, securing the support of political leadership for the strategy is essential, as is a technical team capable of developing and creating ways to apply it, and above all, social and community workers capable of incorporating it into their political objectives and vision of the future — materializing their possibilities to transform reality.

Such a strategy, if consistently implemented, can have a strong impact on inter-sectoral and even sectoral reordering of planning and programming in collective health. However, there are significant obstacles to breaking the traditional logic of corporate organization and regulation of services, particularly when we try to reorient the curative and specialized rehabilitation aspects within the principles of the promotional strategy of equity on quality of care and health.

Training and research are essential in order to fill the gaps in the theoretico-methodological perfection of the strategy and its applications in real life. This is particularly true since its anti-hegemonic nature conflicts with many of the instruments available today for its implementation.

Finally, the degree of political development of life in society defines the possibilities for progress in such a strategic perspective. There is, therefore, a central need for political discourse around human and social rights, as well as the equity of sustainable human development. Such a discourse can define and realize the path toward achieving the full application of these goals and mobilizing the energies of social actors who are capable of promoting the desired social transformation.

­Translated from Spanish by Victoria J. Furio

References

1.    Y. D’Élia, A. De Negri, M. Huggins, et al., Estrategia de Promoción de la Calidad de Vida. La Construcción de Políticas Públicas por la Calidad de Vida Desde una Perspectiva del Derecho y la Equidad (Caracas: Ministry of Health and Social Development of Venezuela, German Cooperation Agency, 2002); Ministry of Health and Social Development, Plan Estratégico Social (Caracas: Ministry of Health and Social Development, September, 2003); Bogotá Mayor’s Office, Capital District, Plan De Desarrollo Económico, Social y de Obras Públicas, Bogotá 2004-2008; Bogotá sin Indiferencia. Un Compromiso Social Contra la Pobreza y la Exclusión (Draft agreement) (Bogotá, April 30, 2004): Art. 1.

2.    Corporación para la Salud Popular-Grupo Guillermo Fergusson (Guillermo Fergusson Group-Popular Health Corporation); School for Leadership Training in Health, El Derecho a la Salud y su Exigibilidad (Bogotá: Misereor, 2005).

3.    L. Carmona, N. Molina, and A. Casallas, “La Desprotección Social se Profundiza,” in N. P. Hernández (ed), El Embrujo Autoritario: Primer Año de Gobierno de Álvaro Uribe Vélez (Bogotá: Plataforma Colombiana de Derechos Humanos, Democracia y Desarrollo, 2003): pp.59-70. Available (in Spanish and English)at http://www.plataformacolombiana.org/embrujoinicio.htm.

4.    A. Héller, Teoría de las Necesidades de Marx, 3rd Edition (Barcelona: Peninsula, 1998).

5.    F. Diderichsen, T. Evans, and M. Whitehead, “The Social Basis of Disparities in Health,” in T. Evans, M. Whitehead, F. Diderichsen, A. Bhuiya, and M. Wirth (eds), Challenging Inequities in Health: From Ethics to Action (New York: Oxford University Press, 2001).

6.    L. Jadue and Fabiola Marín (eds), Determinantes Sociales de la Salud en Chile: En la Perspectiva de la Equidad (Santiago de Chile: Policy Institute of Epidemiology and Public Health, 2005).

7.    B. Lautier, “Las Condiciones Políticas de la Universalización de la Protección Social en América Latina,” presentation delivered at the Seminario Internacional de Protección Social, Centro de Investigaciones para el Desarrollo, Universidad Nacional, September 2005.

8.       P. Freire, Pedagogy of the Oppressed , trans . M. B. Ramos (London, UK: Penguin, Harmondsworth, 1972).

9.    Some definition of terms may be helpful here. I understand public policies to be all policies that affect the lives of people, with the potential to generate public goods from public values (where it is understood that economic policies must also be present), and that as public policies they must be appropriated by the society and criticized and reoriented by it whenever necessary to satisfy its needs. I understand as social policies all policies that affect the production of quality of life for people, even policies of urban infrastructure development, economic development, energy, and water — in other words, all that impacts the social condition and in this way contrasts with the definition that restricts social policy to the classical areas of education, health, and social service.

10.  F. Diderichsen, “An Ethical and Epidemiological Framework and Targets for a New National Health Policy in Sweden,” in A. Oliver (ed), Health Care Priority Setting (London, UK: The Nuffield Trust, 2003).

11.  Taken from A. De Negri Filho, “Adoção de Uma Estratégia Promocional da Qualidade de Vida e Saúde: Transetorialidade das Políticas Públicas,” in A. M. Girotti Sperandio (ed), O Proceso de Construção da Rede de Municipios Potencialmente Saudáveis (Campinas-São Paulo: IPES, Unicamp, PAHO/WHO, 2004): p. 27.