In the past century, the concepts of health and disease have moved from one where health was seen primarily as "absence from disease" to one where promotion of positive health was the primary goal. Accordingly, programmes and interventions have moved away from a curative focus on fighting disease, towards promoting health as a positive goal of its own. The concepts of primary health care (Alma Ata, 1978) and health promotion (Ottawa, 1986) are landmarks in this shift towards a new public health. The key issues are community ownership as opposed to mere participation in preconceived, externally driven programmes, and empowerment as opposed to education. Rather than merely the result of good healthcare services, health and disease are determined by a combination of supportive environments, personal skills, community action and healthy public policies.

In the HIV/AIDS field, early responses to the epidemic emphasised individual sexual behaviour change. Today it is widely accepted that mitigating personal risk and vulnerability, and the impact on families and society also requires healthy policies, legislation and other measures across all sectors. Responses need to move beyond health education to include strategies such as lobbying, advocacy and community mobilisation.

Information gap vs. power gap

The more traditional health programmes and campaigns tend to focus on those factors that are considered easy to change – especially people's behaviour – and may ignore structural, environmental and societal factors, because they are considered too difficult to change. Traditional health perspectives tend to blame the victims for their ill health, while many times factors beyond people's personal control – often gender or poverty-related ones – have a greater impact.
Of course behaviour plays an important role in most sexual and reproductive health problems, including HIV/AIDS. The solutions to sexual health problems, however, also require changing non-behavioural factors, such as improved access to reproductive health services, supportive legislation or other structural/environmental factors.

Rather than merely closing the information gap through health education, we need to address the power gap by focusing on inequity issues --often gender-based– that underlie many of the critical determinants of HIV/AIDS and other sexual health problems. The problems require solutions at the policy and legislation levels.

Many programmes still insist that individual behaviour change is necessary to improve a community's health status. They should realise the importance of public policies and legislation for creating supportive environments, building personal skills and strengthening community action, and design specific strategies to address them.

Lobbying, advocacy and activism

Healthy public policies can be promoted in several ways. Lobbying, for instance, attempts to influence policy directly by intervening through powerful individuals or pressure groups. The example of the failure to secure abortion rights in the article from the Dominican Republic shows the critical importance of having the right connections at decision-making levels. Lobbying was also critical for successful implementation of a new Domestic Violence Act in South Africa, for incorporation of counselling in India's southern states HIV/AIDS policies, and for introducing policy changes on HIV/AIDS in Malaysia.

While advocacy is similar to lobbying, it assumes that the lobbying is on behalf of a third party. It is often less direct; in media advocacy, for example, communities or advocates try to influence the public and political agenda through the media and forward their own (policy) solutions. Media advocacy is most clearly exemplified by the articles on SAfAIDS' media information packs for east and southern Africa and Soul City's media strategy to get the government to implement the legislation on domestic violence.
Activism plays a critical role when policy changes are unlikely to happen through lobbying or advocacy. Rather than trying to influence policies by working with (unwilling) decision makers, activists put pressure on them by mobilising public opinion through the media. In the HIV/AIDS field, for instance, activism has played and continues to play a critical role to put pressure on pharmaceutical companies to lower their prices, and on governments to put in place the right policies to increase access to treatment, as shown by the article from Brazil. Activism has been crucial for promoting women's rights: the article on mobilising community support for vaginal microbicides in the USA provides an interesting example.

It is not necessary to choose one strategy, however. The best approach is to use an effective mix of these three strategies, making use of their unique comparative advantages.

Working with or working for the community?

Lobbyists, advocates and activists often try to influence policies, legislation or environmental and organisational measures by placing issues directly on policymakers' agendas. In this way, policy changes can take place without communities being aware or involved. Community awareness and ownership, however, are critical factors for change because as people become involved, they become their own advocates. Raising people's awareness and promoting community action (the famous Brazilian scholar Paulo Freire called this "conscientizacion") is a goal in itself and a sine qua non for sustained change.
However, increased awareness and empowerment do not always effect behaviour change: health problems often depend on factors beyond people's direct control. These factors need to be addressed through policies, legislation, improved services or other measures. Organisations and communities seeking to improve the status of health should develop specific strategies to address these environmental, structural causes of ill health. Lobbying, advocacy and activism play a crucial role in this.

Effective change is the result of combining different strategies: it is not a matter of personal or social change, but both. While advocates, activists and communities rightly hold governments and policymakers accountable for their decisions, in the end everybody, from policymaker to individual father, mother or sexual partner, will need to take up his/her personal responsibility to make a difference in promoting sexual health.