The World Health Organisation (WHO) has an important role in setting the global agenda on public health priorities.
WHO member states expect, inter alia, support and guidance from the WHO secretariat on health policy issues. As a health policy issue, physical activity was arguably a bit of a late bloomer. The earliest WHO publication dedicated to physical activity available on its website is the Global Strategy on Diet, Physical Activity and Health from 2004. For comparison, the WHO website hosts policies tackling the issues of tobacco and nutrition which were published in the eighties. Lack of policy attention led researchers working in the field to describe physical activity as the ‘Cinderella’ of non-communicable disease risk factors.
Fortunately, over the last decade or so there has been an explosion of interest in physical activity policy. Furthermore, in 2018, the WHO published its most significant document on physical activity: the Global Action Plan on Physical Activity Plan (GAPPA). GAPPA is intended to guide WHO member states towards achieving increased levels of physical activity. It provides a systems-based framework for action based around four distinct policy areas termed active systems, active societies, active environments and active people.
GAPPA contains a range of actions for member states to implement and a goal of reducing inactivity by 15% by 2030. The best available trends data suggests that the proportion of people achieving physical activity guidelines was stagnant in the decades preceding GAPPA. If the plan is not properly enacted, it stands to reason that these trends are likely to continue and the targets set out in the plan will not be met.
In October 2022, the WHO published an update on the GAPPA: the Global Status Report on Physical Activity. The report presents a framework used for monitoring increasing physical activity. Progress is monitored using indicators of implementation, indicators of outcome and indicators of impact (see figure 1, for an overview of how this is conceptualised in the report).
Figure 1 GAPPA policy model. Note the 3 different types of indicator at the bottom and the 4 policy areas in the implementation section
So, in light of these new developments, how is the global policy effort to promote physical activity levels going? Well, it’s probably fair to say, not particularly well. While it should be acknowledged that the COVID-19 pandemic frustrated policy implementation efforts considerably, the fact is that progress has been ‘slow and uneven’ [pviii, p90 & p100]. Most implementation indicators are reported as not implemented in most member states (hence ‘slow’) [p88]. Further, high income countries are more likely to report progress on almost all indicators (therefore ‘uneven’) [p89]. These findings on implementation lead the report to state bluntly that, globally, implementation must be accelerated to achieve the GAPPA target [pviii].
There are also a host of gaps and limitations with the process of monitoring and surveillance itself. These are acknowledged throughout the report and in the limitations section.
On implementation, policy indicators do not record the content, extent or reach of policy implementation and therefore are not fully informative [p94]. Fantastically well implemented policies are therefore not easily distinguished from a box ticking exercise. Furthermore, data on implementation is not available at all for a number of key settings and GAPPA actions (for example on workplaces).
On outcomes (i.e. on physical activity behaviours) data is not available for all population groups (for example; data on the activity of older adults or people with disabilities is often unavailable) [p94]. Also, physical activity promotion efforts would benefit from being strengthened in some key areas. Better domain specific physical activity monitoring to identify the contribution of various activities to total activity (e.g. sport and active transport) [p82]. Further, the report recommends expediting the move from measurement of physical activity via self-report to device based 24 hour physical activity surveillance [p82].
Finally on impact (i.e. the effects on society of achieving increased physical activity) there is good evidence of the effect of inactivity on healthcare costs. According to the report, no change could lead to $300 billion of incurred costs between 2020 and 2030 [pvii, p10]. This estimate is based on direct costs alone (essentially costs of hospital treatment, excluding for example costs of reduced productivity and sick days) and is therefore conservative. Measures of the other societal benefits of physical activity (e.g. increased volunteering, improved educational outcomes, crime reduction) need to utilised more widely.
Taking account of the evidence (and its limitations) the report provides five key recommendations to member states to advance the physical activity agenda:
- Strengthen whole-of-government ownership and political leadership
Indicators of impact demonstrate that activity has many benefits impacting many sectors. By corollary, many government departments should recognise their duties to deliver their respective physical activity policy commitments.
- Integrate physical activity into relevant policies and support policy implementation with practical tools and guidance
The report notes that the WHO has developed a suite of tools to support countries to implement GAPPA. I suggest that the Physical Activity Environment Policy Index (PA-EPI) can also make a useful contribution.
- Support partnerships, engage communities, build capacity in people
Policy efforts should, as much as possible, utilise the capacity of the entire system. Therefore, the report recommends that policy implementation is not limited to delivery by the public sector. Partnerships with the private sector, NGOs and the local community should be explored. Further the skills and knowledge that facilitate physical activity should be developed in the workforce.
- Reinforce data systems, monitoring, and knowledge translation
The reasons for this recommendation are clear from the limitations section. Invest in national monitoring of physical activity. Monitoring of physical activity levels for people of all ages and abilities please and thank you!
- Secure and align funding with national policy commitments
The evidence of impact demonstrates that the cost of no change is very steep indeed. It’s important to stress that promoting physical activity is an investment.
Hopefully these recommendations will be enacted, expediting progress toward physical activity goals. The WHO’s 2022 Global Status Report on Physical Activity can be accessed here.
Mr Kevin Volf is a Postgraduate student in the Department of Physical Education and Sport Sciences in the University of Limerick.
Contact: Email: firstname.lastname@example.org Twitter: @kevin_volf Facebook: Kevin Volf LinkedIn: Kevin Volf Instagram: kevinvolf
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