Over the past three decades, countries in the Western Balkans (WBCs) have undergone profound demographic, social, economic as well as epidemiological transformations. These shifts have created both challenges and opportunities for advancing health promotion as a core component of public health policy (1). In response to emerging health threats, the WBCs have increasingly prioritized health promotion in the frame of primary healthcare strengthening within their national agendas (2, 3). However, no comprehensive regional study has reviewed the legal frameworks, strategic objectives, and action plans for health promotion in the Western Balkan countries (WBCs), using the Ottawa Charter for Health Promotion as a conceptual and analytical framework. This represents a critical research gap, as understanding how the Charter’s principles are reflected in national policies is essential for assessing progress, identifying implementation gaps, and informing future regional and EU-aligned health promotion strategies (4).

Similar to other regions, the Western Balkans face a rising burden of non-communicable diseases (NCDs). Major conditions include cardiovascular diseases, cancer, diabetes, and chronic respiratory illnesses. These are largely caused by modifiable lifestyle factors—tobacco use, unhealthy diets, physical inactivity, and excessive alcohol consumption (5, 6). Health promotion and disease prevention efforts are therefore essential to reduce this burden, alongside quality-of-care improvement and primary healthcare service utilization (7). Health promotion not only addresses behavioral risk factors but also empowers individuals and communities to make informed decisions and adopt healthier lifestyles (4).

An additional dimension of this context is the shared aspiration of the WBCs to join the European Union (EU). This aspiration entails alignment with EU public health standards and regulatory frameworks. Key instruments include Directive 2003/33/EC on tobacco advertising (8), Regulation (EU) No 1169/2011 on food information for consumers (9), and action plans targeting obesity, alcohol use, and mental health (10, 11). The EU also provides strategic guidance on nutrition, health systems strengthening, and cross-border health information exchange (12, 13).

The Ottawa Charter for Health Promotion, introduced in 1986, marked a paradigm shift from biomedical to biopsychosocial approaches to public health, emphasizing empowerment, equity, and multisectoral action (4). The Charter’s five action areas structured our comparative analysis. The framework emphasizes key action areas that guide the assessment and analysis of health promotion efforts in the WBCs.

Previous research on health promotion in the WBCs has been limited and largely fragmented, often focused on disease-specific interventions or individual risk factors rather than comprehensive, policy-level, and national strategies. Analyses of national health systems have also pointed to insufficient resource allocation, poor intersectoral coordination, and a lack of standardized indicators for monitoring health promotion efforts (13–15).

Comparative assessments show persistent gaps between EU member states and the Western Balkans in implementing EU-aligned public health policies. Although the EU has introduced several frameworks—such as the Action Plan on Childhood Obesity and the European Alcohol and Health Forum—data on their adaptation in the Western Balkan context remain limited (8–18). To date, no comprehensive regional study has reviewed the legal frameworks and strategic objectives and action plans for health promotion in the WBCs using the Ottawa Charter as a conceptual lens.

This study aims to describe the development of contemporary health promotion strategies and action plans, in the WBCs: Albania, Bosnia and Herzegovina (BiH), including the Federation of BiH and the Republic of Srpska—, Montenegro, North Macedonia and Serbia, to identify priorities, implementation challenges and the gap between legislative intent and practical outcomes.

Research questions:

This study employed a qualitative, cross-country comparative design to map and describe health promotion policy development in the WBCs over the last two decades, within the framework of the “Western Balkan Strategic Partnership for Health Protection” (WASP) project, which is implemented by the Robert Koch Institute on behalf of the German Federal Ministry of Health from 2023 to 2025 approach. This was an observational study that triangulated data and information sources (a purposive narrative review of the focused literature (desk research), a descriptive analysis of health promotion action plans, and a qualitative analysis of experts’ opinions).

A purposive narrative review was undertaken, grounded in a comprehensive literature search across PubMed/Medline, Scopus, and Google Scholar. This search encompassed original articles and reviews published in English and various domestic languages from 2019 to 2024. The literature search was conducted collaboratively by two authors from each participating country.

The search employed a range of keyword combinations that reflected specific criteria related to: the population (Western Balkans, Balkan countries, Southeast Europe, and specific nations), context (public health policies, strategies, action plans, and objectives), and purpose (health promotion and improvement, principles of the Ottawa Charter, disease prevention, preventive care, and community engagement).

The selection process for included papers was based on comprehensive criteria, ensuring that only those addressing all three dimensions were retained, with authors JG and AR overseeing this process. Subsequently, the study utilized a legal mapping methodology, which is widely recognized in public health law research (16).

All authors engaged in a meticulous qualitative thematic and content analysis, adhering to a structured three-step approach. Step (i): Regular Consultative Meetings. WASP project partners met regularly to coordinate data collection, validate findings, and exchange institutional experiences.

Step (ii): Desk Review. A structured desk review assessed national legal frameworks and health promotion action plans. Each country’s documents were reviewed to evaluate their alignment with the Ottawa Charter (4). Documents were examined in native languages or translated into English. Priority was given to European WHO-endorsed action plans or those adopted by national governments (17–19). Key components reviewed included: the epidemiological and social context addressed in each plan; alignment between strategic objectives, indicators, and funding; and integration of equity-focused measures.

Step (iii): Consolidated template. Findings were synthesized into a shared consolidated template summarizing common trends and country-specific insights (Tables 1, 2). All analysis was performed manually. Each national focal point conducted preliminary data extraction and thematic coding for their respective country. The results were then compared and validated through joint review sessions involving all partners. The final synthesis and interpretation were coordinated by the lead author, the methodological co-lead, and the project leader, who ensured coherence, analytical rigor, and alignment with the Ottawa Charter framework.

The study used the Ottawa Charter for Health Promotion as a guiding analytical framework to describe national strategies, legal instruments, and health promotion action plans implementation mechanisms across five countries: Albania, Bosnia and Herzegovina (including the Federation of BiH and Republic of Srpska), Montenegro, North Macedonia, and Serbia.

The study focused on five WBCs participating in the WASP project. Data collection and analysis were conducted between October 2023 and November 2024.

The Ottawa Charter for Health Promotion, introduced in 1986, was used as the conceptual framework (10). The Ottawa Charter focuses on enabling people to take control over and improve their health through the following action areas: (1) building healthy public policy, (2) creating supportive environments, (3) strengthening community action, (4) developing personal skills, and (5) reorienting health services (see Appendix 1 for explanations of each area/action).

Aligned with the five action areas of the Ottawa Charter, a structured review template was created to guide data collection across WASP participating countries, and synthesis regarding the Charter’s five actions (4).

The primary study units in the review were national regulatory frameworks, strategic documents, and action plans related to health promotion in the five countries. Key variables reviewed included (i) Legal and institutional frameworks for health promotion; (ii) Strategic objectives and foreseen activities; (iii) Budget allocation and funding mechanisms; (iv) Indicators for monitoring and evaluation; (v) Reported outcomes and implementation gaps. The selection of variables was grounded in the Ottawa Charter for Health Promotion and the WHO Health System Building Blocks framework (17). These frameworks provided the conceptual basis for assessing how countries translate political commitment into practical health promotion actions.

Each variable captured a distinct aspect of policy design and implementation. Examining legal and institutional frameworks helped assess political commitment and the extent of alignment with the Ottawa Charter actions. Reviewing strategic objectives and activities showed how national priorities are operationalized in practice. Analysis of budget allocations and funding mechanisms offered insight into financial commitment and the sustainability of interventions. Monitoring and evaluation indicators were used to explore systems of accountability and performance assessment, while reported outcomes and implementation gaps revealed barriers to translating policy into action and areas for improvement.

The desk search (in the national languages and English) included the following keyword combinations: health promotion, WBCs, Ottawa Charter, action plans, public health policy, non-communicable diseases, legal framework, and community health.

Data sources included published and unpublished national and international literature, national legal databases, health strategies, action plans, and WHO and EU policy documents (2, 3, 6, 14–18). Additional materials were retrieved via PubMed, Google Scholar, national ministry websites, and grey literature shared by WASP partners.

This study used secondary data from publicly available documents and institutional workshops under the WASP project. No human participants were involved. Ethical clearance was therefore not required, in line with the Declaration of Helsinki and journal guidelines (19).

Across the WBCs, notable progress has been made in revising national legislation to align with European Union standards, particularly in the domain of public health.

Serbia was the first Western Balkan country to adopt a law on public health in 2008; Albania adopted a law on public healthcare in 2009, while North Macedonia enacted the law on public health in 2010. The new legislation was built to be in line with the EU directives and legislation. Bosnia and Herzegovina adopted in 2010 the roadmap for EU integration of the sector.

Table 1 assembles the main documents from our desk research, on Regulatory Frameworks and Main National Strategies for Health Promotion and Prevention in Albania, Federation of Bosnia and Herzegovina, Republic of Srpska, Montenegro, North Macedonia and Serbia. Table 1 shows that while all Western Balkan countries have adopted public health laws, the scope and enforcement mechanisms differ substantially across jurisdictions (see Appendix 1).

These legislative actions align partly with EU acquis requirements, especially in areas such as compulsory health insurance, health information systems, and essential service packages. However, convergence remains uneven due to political decentralization and limited institutional capacity. EU competences in health are limited to selected areas such as tobacco control and consumer safety; therefore, harmonization largely remains a voluntary process (20, 21).

Following the assessment of national strategies, step three explores how these actions correspond to the Ottawa Charter’s five domains (see Tables 3, 4).

Table 4 summarizes self-assessment of countries alignment with the five Ottawa Charter action areas. Countries align strongest in developing legislation and strategies—particularly in Building Healthy Public Policy—while persistent weaknesses are found in Creating Supportive Environments, Reorienting Health Services, and Developing Personal Skills.

As shown in Table 4, most Western Balkan countries demonstrate substantial progress in establishing legislative and strategic frameworks for health promotion. Albania, Serbia, the Federation of BiH, and Montenegro stand out for their strong public policy foundations, reflecting advanced tobacco-control laws, NCD prevention plans, and multi-sectoral coordination mechanisms. In contrast, Creating Supportive Environments and Reorienting Health Services emerge as common weaknesses across the region. These shortcomings stem largely from insufficient infrastructure, limited intersectoral investment, and the lack of mechanisms connecting health, education, and environmental sectors. Overall, the findings underscore a pattern of policy maturity but implementation fragility across all Ottawa Charter pillars.

This study has several methodological limitations. First, the analysis relied exclusively on publicly available national documents and secondary data sources, which may not capture the most recent policy updates, subnational initiatives, or implementation practices. Variations in document quality, completeness, and availability across countries may have resulted in uneven levels of detail and comparability. Second, because no standardized monitoring or evaluation reports were available, the study could not assess the effectiveness of health promotion strategies or measure implementation outcomes. Third, the absence of harmonized indicators across countries limited the ability to conduct systematic comparisons aligned with the Ottawa Charter action areas. Fourth, the document review template, while structured, was not externally validated and may be subject to interpretive bias, despite joint review and cross-validation by national focal points. Finally, the study adopted a formative, descriptive approach and did not include primary data collection; therefore, findings reflect policy intent rather than operational performance. Future research incorporating mixed methods, stakeholder interviews, and validated assessment tools would provide deeper insights into implementation processes and impact.

Building on the observed gaps and variations in health promotion strategies across the WBCs, several avenues for future research are warranted. First, in the absence of official evaluation reports, conducting qualitative interviews with key stakeholders—such as health policymakers, public health practitioners, and civil society actors—can offer valuable insights into the context-specific barriers and successes and inform strategies for institutional capacity-buildings in health promotion in WBCs.

Secondly, there is a strong rationale for developing a regional monitoring framework that employs a standardized set of indicators to track progress in major disease prevention. A shared digital dashboard, accessible to both national and regional actors, could enhance performance transparency, support further development of evidence-based health promotion policies, and facilitate cross-country best practices exchange and collaboration.

Thirdly, strengthening national public health capacities for health promotion should prioritize enhancing the health and care workforce policies, including their recruitment and retention in adequate numbers, improving competencies and salaries, and providing safe, better working conditions, along with opportunities for career development and growth in and equitable ways. On the other side there is need to introduce behavior change mechanisms that orients the patients toward PHC and preventive service utilization, rather than hospital ones (45–47).

Finally, promoting policy harmonization and mutual learning across the region is crucial for attracting top international and global actors in health promotion. Developing open platforms for cross-country exchange—especially on budgeting, community-based program delivery, and evaluation—can encourage convergence toward implementing more effective and equitable public health policies. These efforts would not only improve national outcomes but also strengthen regional coherence and readiness for future EU integration.