The first Lancet series on physical activity and global health quantified the startling annual global mortality due to physical inactivity—more than 5 million deaths spread across the world, the very definition of a pandemic.^1,2 Since 2012, we estimate that an additional 45 million lives have been lost due to the continued lack of systematic action to intervene on physical inactivity.^3,4 Although there is justified criticism on how some countries have handled the current global pandemic of COVID-19, the failure to better address the longstanding public health crisis of physical inactivity has been largely ignored. Why is there continued inattention to a global public health problem that is large, not improving, and seemingly solvable with evidence-based strategies?³ As with most major public health issues, progress on physical inactivity requires surveillance, evidence, prioritization, investment, and leadership, all leading to policy action at global, regional, national, and local levels. Evidence is plentiful regarding health impact,⁵ prevalence,⁶ and interventions.^3,7 Here, we briefly examine progress, or lack thereof, in policy development and implementation globally and nationally.

There has been progress over the past decade. This is probably best exemplified by the 2018 launch of the World Health Organization (WHO) Global Action Plan for Physical Activity—a comprehensive, evidence-based, modern, multisectoral public health plan created with extensive input from around the world.⁸ WHO released updated recommendations for physical activity at the end of 2020, a second example of well-crafted global policy for physical activity. So, global policy development for physical activity has progressed in obvious ways since 2012.

What about implementation at a global level? Has WHO followed up with funding, staffing, and programs to take these policy documents off the shelf and make them real? There is a glimmer of light here, as WHO headquarters has created a small new physical activity unit nested within health promotion, and the WHO Europe office continues to support a network, annual conference, and multiple programmatic and policy initiatives around physical activity, obesity, and noncommunicable diseases. However, little to no action on physical activity has taken place at the other 5 WHO regional offices—no dedicated staff, no budget, no evidence of physical activity policy or programs on their websites, and no perceptible implementation of the Global Action Plan for Physical Activity.

One might argue that the national level is where physical activity policy really needs to be operationalized into population-based programs. The Global Observatory for Physical Activity evaluates national physical activity policy, surveillance, and research, and in 2020 surveyed 173 countries on both policy development and implementation.⁹ In contrast to a decade ago, most (92%) of the 76 countries that responded now have national plans and policies for physical activity. Many also have published national physical activity guidelines (62%) and have quantifiable national targets for physical activity (52%). However, implementation remains spotty with only about half of policy components implemented, and self-reported effectiveness of national physical policy and programs was low to moderate. These policies were predominantly developed in high-income countries, and adaptation and implementation in low- and middle-income countries remains a pressing need.⁹ Perhaps more worrisome is a recent study that noted the number of countries adopting physical activity policies fell between 2015 and 2017.¹⁰ Physical activity may be a “flavor of the day” that momentarily catches the attention of national policy makers before slipping back into obscurity.¹¹

Implementing physical activity policy has proven challenging for health ministries, in part because most of the societal levers that influence population levels of physical activity are in “nonhealth” sectors such as urban planning and development, education, environmental protection, and transportation. Without effective cross-sectoral collaboration that includes multiple sectors, even the best policies will have little impact on population levels of physical activity. Cross-sector collaboration is difficult and usually requires leadership from presidents, prime ministers, or governors. Because leadership changes frequently, so do priorities, reducing the likelihood of sustained multisector efforts. A cascade from global to national to local levels is a critical missing piece. Perhaps, the local (municipal) level, where cross-sector collaboration is easier and more common, is where we should be evaluating physical activity policy and implementation? Unfortunately, there is no standardized global database of physical activity policy for cities so we must rely on case studies drawn from the enormous heterogeneity of city public health efforts.^3,12 There are stellar examples of cities in both high-income countries (i.e., Copenhagen) and low- and middle-income countries (i.e., Bogotá and Mexico City) that have transformed public space to prioritize pedestrians, cycling, public transit, and green space in ways that have increased physical activity.^3,7,12 However, many of these transformations occurred without much formal public health policy or leadership from the public health sector.

We have an odd dichotomy in which physical activity policy development is quite good at the global and national levels but implementation is poor, in contrast to impressive implementation in at least some municipalities in the near absence of public health policy or leadership. What to make of this? Perhaps the key roles for public health are agenda-setting and consistent guidance at the global and national levels, coupled with a much greater emphasis on partnering with other sectors at the local level.

To improve the implementation of physical activity policies and programs at the national and local levels will require more physical activity capacity, investment, and partnering within and by health departments and ministries, and perhaps within other sectors that seem to have been more effective at addressing physical inactivity on the ground. The need for an appropriate share of public health resources for physical activity remains a defining challenge of the field.¹¹ Even as the world’s attention is focused on the threats of the COVID-19 pandemic, the physical inactivity pandemic continues to be a leading cause of morbidity and mortality. The 5 million-plus people who die prematurely of physical inactivity each year should also be cause for concern, and they deserve a reasonable investment in interventions known to be effective.