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Section 3. Healthy Cities/Healthy Communities

    Example 1: The Mayor’s Guide for Promoting the Quality of Life, produced by Maria Teresa Cerqueira, Marilyn Rice, and their colleagues at the Unit on Healthy Settings, the Area of Sustainable Development, Pan-American Health Organization (PAHO)

    PAHO is the Americas’ regional arm of the World Health Organization (WHO). In the Mayor’s Guide, it presents an alternative to the top-down model of health care and maintenance, and an example of the ways in which PAHO encourages the building of healthy communities. Rather than setting out a prescription for creating healthy communities, the Guide offers some basic principles and a framework within which municipalities and communities can work to plan and carry out initiatives that meet their unique needs.

    While PAHO serves all of the Americas, the Guide is – rightly – oriented toward the countries in the region with the greatest needs and most difficult health situations. Its emphasis on shoring up the “infrastructure” of health – the physical, political, economic, and social conditions whose presence promotes, and whose absence prevents, healthy living and a good quality of life – is likely to benefit most the less developed nations where that infrastructure is weakest. At the same time, its encouragement of participatory process and decision-making speaks to all the countries in the hemisphere.

    Rather than simply describing it, we’re including an edited version of the Mayor’s Guide here, as an example of a Healthy Communities framework. Also included are links to relevant Community Tool Box sections and tool kits.

    Guide for Mayors and Other Local Authorities

    Key Concepts related to the Healthy Municipalities and Communities (HMC) Strategy

    This guide is intended to strengthen the implementation of health promotion activities at the local level, placing health promotion on the political agenda of mayors and other local authorities… [I]t is hoped that efforts will be made to ensure healthy public policies, the maintenance of healthy environments, and the promotion of healthy lifestyle.

    What is the Importance of Having a Kit for Mayors and Other Local Authorities?

    …PAHO offers a basic set of tools with which mayors and other local authorities can begin to implement the HMC strategy…[T]his material does not by any means pretend to be a “prescription for, or key to, success”…Successful experiences have shown that there is no single best way to deal with problems that arise.

    [L]ocal government is closest to the people and can use its resources to achieve major improvements in health and the quality of life. As the community’s representative, the municipal government is in the best position to involve politicians, administrators from other sectors, and the community itself in coordinating joint projects. Finally, at the local level it is possible to mobilize the collective will…

    What is the Healthy Municipalities and Communities Strategy?

    The mission of the Healthy Municipalities and Communities Strategy consists of improving the implementation of health promotion and protection activities at the local level and ensuring that such activities are accorded the highest political priority, thereby encouraging the participation of government authorities and the active participation of the community…[Its] objective is to promote health together with people and communities, in settings where they study, work, play, love, and live.

    A municipality begins the process of becoming healthy when its political leaders, local organizations and citizens commit themselves to, and initiate, the process of continuously and consistently improving the health and quality of life of all its inhabitants…It uses local planning as a basic tool, including social participation in management, evaluation, and decision-making. A municipality becomes healthy with sustained long-term improvement in social conditions with a view to ensuring the health and quality of life of all those who live within that particular environment.

    What Do We Mean by a Comprehensive Vision of Health?

    …WHO regards health as a fundamental human right and defines it as “a state of complete physical, mental and social well-being, and not the mere absence of disease or infirmity.” Several factors have been identified that affect, and often determine, the health of individuals and communities, including:

    • Living and working conditions (income, education employment, physical environment, public policies);
    • Psychosocial factors (care groups and/or support networks; sense of belonging to a community; the environment in which children develop; social support of family and friends; support for older adults, adolescents, pregnant women, and other vulnerable populations);
    • Individual behaviors (lifestyles and behaviors: physical exercise, diet, tobacco use, alcohol and drug abuse); and
    • Genetic factors.

    Research indicates that living and working conditions have the greatest influence on health. Therefore, health is as much the result of our physical and social environment…as it is a product of the health-care system and social services. [See Chapter 17, Section 5, Addressing Social Determinants of Health and Development.]

    What Do We Mean by Health Promotion?

    The Ottawa Charter for Health Promotion (1986) defines health promotion as “the process of enabling people to increase control over, and to improve, their health”… Health promotion goes beyond the health-care sector alone, emphasizing that health should be part of the political agenda of all sectors and at all levels of government. Furthermore, the participation of the population/community is essential if health promotion actions are to be sustained.

    [F]ive priority action areas are recommended:

    • Build healthy public policy;
    • Create supportive environments;
    • Strengthen community action;
    • Develop personal skills; and
    • Reorient health services.

    What Do We Mean by Community Participation?

    …Members of a community may or may not reside in the same geographical area. What is important is that they consider themselves to be a community. An organized community is not necessarily a participatory community. To facilitate participation, the community should be given the right and opportunity to make effective decisions regarding issues affecting the lives of its members.

    Steps in Developing Community Participation:

    1. Become familiar with the community…This step permits technical personnel and local government to comprehend how the community understands and explains the world, whether through its beliefs, folklore, or other ways of looking at life, and to know its assets. [See Chapter 3, Sections 1, Developing a Plan for Identifying Local Needs and Resources, 2, Understanding and Describing the Community, and 8, Identifying Community Assets and Resources.]
    2. Build a common vision. [See Chapter 8, Section 2, Proclaiming Your Dream: Developing Vision and Mission Statements.]
    3. Utilize language and communication resources appropriate to the cultural context of the community. [See Chapter 6, Sections 1, Developing a Plan for Communication, and 19, Handling Crises in Communication; Chapter 27, Section 1, Understanding Culture and Diversity in Building Communities; and Chapter 45, Section 5, Promoting Awareness and Interest Through Communication.]
    4. Keep the community informed and ensure that it takes part in decision-making throughout the process. [See Chapter 18, Section 2, Participatory Approaches to Planning Community Interventions.]
    5. As the community members perceive and establish a relationship between the HMC goals and their personal lives, their health, education, housing, and other conditions, they are also able to set personal goals and feel a sense of responsibility, not just for a community initiative but for their lives in general.

    What Do We Mean by Creating Effective Strategic Alliances?

    Strategic alliances are relationships and agreements between different stake-holding sectors, organizations, and actors in order to achieve a desired goal. The most common strategic alliances are carried out with government agencies; health institutions and other related sectors such as education, judicial, transportation and agriculture; nongovernmental organizations (NGOs); schools and universities; the mass media; religious groups and public and private organizations. [See the CTB Toolkit 1: Creating and Maintaining Partnerships, as well as Chapter 5, Sections 5, Coalition Building I: Starting a Coalition, and 6, Coalition Building II: Maintaining a Coalition; Chapter 7, Encouraging Involvement in Community Work; and Chapter 9, Section 3, Developing Multisector Task Forces or Action Committees for the Initiative.]

    What Do We Mean by Healthy Public Policies?

    Healthy public policies are those that have a significant positive influence on people’s health status through their influence in the areas of education, housing, food, human resources, employment, mental health, and sustainable development. [They are] characterized by an explicit concern for health and equity…[,and] the recognition and effective exercise of the rights of the people, based on equality, with no restrictions imposed on access to, or use of services provided by different social sectors.

    Healthy public policies should be translated into legislation that safeguards the conditions necessary for developing healthy lifestyles…:guaranteeing the human rights and fundamental liberties of members of the community; protecting communities, families, and individuals from risk factors; and promoting conditions that ensure that the healthiest options are those that are most accessible and most easily attainable.

    Why Has the HMC Strategy Been So Successful and Appealing in the Region of the Americas?

    [It] has helped to support and focus the decentralization process that many countries have been undergoing, and in light of the democratization of local decision-making, it has provided a platform on which all local stakeholders can participate in defining priorities and key interventions in a collaborative manner…Health promotion programs are more cost-effective than treatment…By coordinating the efforts of different sectors and actors, resources can be maximized and duplications eliminated.

    What are the Essential Elements of a Healthy Municipality and Community?

    Sustainability: How to Guarantee the Continuity of a Healthy Municipality and Community Initiative

    Lessons learned from previous experiences have shown that initiatives that are initiated and/or motivated from outside the community often fail to sustain themselves or continue over time. …Experience shows that in communities where social participation and community organization are high, there is greater opportunity to ensure the continuity of the HMC Strategy and for social organizations and new authorities to negotiate its continuation. The key then is to motivate all community actors sufficiently so that they become involved in and make a commitment to a medium- and long-term process. …Securing the support of the municipal council or legislature is essential in guaranteeing a regulatory framework for the sustainability of HMC because it helps to ensure that the HMC initiative will remain effective and operational regardless of any institutional changes that may occur in the local authority. [See the CTB Toolkit 16: Sustaining the Work or Initiative as well as Chapter 45, Social Marketing of Successful Components of the Initiative, and Chapter 46, Planning for Long-Term Institutionalization.]

    Establishing HMC Networks

    At the Second Latin American Congress on Healthy Municipalities and Communities held in Boca del Rio, Mexico, in 1997, 18 nations signed an agreement to create the Latin American Network of Healthy Municipalities and Communities to build and strengthen their national networks and ensure their sustainability. Networks make it easier to share information about successes and challenges and facilitate addressing the needs of other groups and at different levels, such as the private sector, government, and international organizations, and can play a major role in the development of new experiences. … In some countries of the region, such as Mexico, Costa Rica, Chile, and Cuba, national networks have already been established and have been working for a number of years with good results.

    Why Are Evaluation and Monitoring Important?

    Evaluation and monitoring play a fundamental role in the health promotion and protection process because they empower individuals and communities to make informed decisions, justify the expenditures and the contributions of donors, improve the initiatives, and contribute to the health promotion knowledge-base. Making informed decisions contributes to empowerment – one of the basic concepts of the health promotion strategy – which means achieving the power to make decisions concerning individual or collective actions, with a view to improving the quality of life and social justice. In monitoring it is particularly important to strengthen the information and surveillance systems at the community level in order to collect data and information, and make sure that it is reviewed appropriately by all involved groups, including the community. Evaluation examines how an undertaking meets the standards and objectives of a project, whereas monitoring is concerned with the “continuous overseeing of the implementation of an activity to make sure that inputs, schedules, targets, and other actions required are proceeding according to plan.”

    It is through monitoring that a thorough understanding of a project can be grasped, and all impacts planned and unplanned can be observed. Policy monitoring allows decision-makers and community members to have a thorough grasp of the policies that are being implemented, and how they are affecting the community in order to adjust, modify, or change actions to best serve their own local needs. Evaluation is important because it enables members participating in initiatives to reflect on the work being carried out in terms of its limitations and achievements, determine whether municipalities and communities are indeed adhering to initial proposals, and refine actions or activities in keeping with their needs. It is an important feedback mechanism for all participants in the process, and can also increase the legitimacy of health promotion activities.

    Phases of the Healthy Municipalities and Communities Strategy

    Initial and Organizational Phase (1 to 3 Months)
    Expected Outcome:
    An approved proposed HMC strategic plan

    Suggested Strategies:

    Planning Phase (4 to 6 Months)
    Expected Outcome:
    A work group and detailed work plan

    Suggested Strategies:

    Action Phase (2/3 years and beyond…):
    Expected Outcome:
    A Healthy Municipality and Community

    Suggested Strategies:

    Expected Outcome:
    Community Participation

    Suggested Strategies:

    Expected Outcome:
    Communications

    Suggested Strategies:

    • Use all forms of communication available in the community (mass media, interpersonal discussions, organized groups and all forms of cultural expression including events, songs, dances, story telling, etc.) [See Chapter 6, Communications to Promote Interest.]
    • Ensure that messages and information are shared with the community on a continuous basis.
    • Adapt health promotion messages (addressing action throughout the life cycle) to specific target audiences, taking into account reaching vulnerable population groups.
    • Promote the messages of the HMC Strategy, utilizing existing positive examples and influential personalities. [For more information on how to carry out this and the previous strategy, see Chapter 45, Social Marketing of Successful Components of the Initiative, as well as the CTB Toolkit 13: Implementing a Social Marketing Effort.]

    Expected Outcome:
    Capacity-Building

    Suggested Strategies:

    • Use multiple channels to offer capacity-building (i.e., courses, Internet meetings, etc.)
    • Include orientation and skill development for each aspect of HMC development.

    Expected Outcome:
    Monitoring and Evaluation

    Suggested Strategies:

    Cover process, outcome, and impact, including quantitative and qualitative indicators. Make it participatory and interactive. [See the CTB Toolkit 12: Evaluating the Initiative.]

    Guidelines for Evaluating Healthy Municipalities and Communities

    [PAHO considers evaluation so important that it devotes a separate part of the Mayor’s Guide to it. The Guide explains that, since “[e]valuation should be a continuous cycle of ongoing feedback,” monitoring is an ongoing activity, and that the term “evaluation” includes it. Evaluation is not something that only takes place once a year or at the end of a project, but an ongoing part of the HMC Strategy. The Community Tool Box supports relevant to all of these guidelines for evaluating a healthy municipalities initiative are the Toolkit 12: Evaluating the Initiative and Chapters 36, Introduction to Evaluation; 38, Some Methods for Evaluating Comprehensive Community Initiatives; and 39, Using Evaluation to Understand and Improve the Initiative.]

    Why and What to Evaluate

    Evaluation of healthy municipalities and communities is very important for many reasons, including:

    • Providing the stakeholders the opportunity to reflect on the HMC initiative.
    • Designing the best HMC initiative in the context of the community health resources and needs.
    • Creating accountability, or determining/gauging if the healthy municipality is doing what was proposed, and redirecting efforts when needed.
    • Contributing to general knowledge development; sharing what works and what doesn’t work with other communities.
    • Sustaining the work of HMC over time.
    • Creating opportunities for intersectoral multidisciplinary dialogue, and strengthening participatory efforts within the municipalities.
    • Developing networks, links, and contacts between different community processes.
    • Convincing decision-makers and policy-makers that HMC is a beneficial strategy.

    … Because of the participatory nature of healthy municipality initiatives, it is suggested that participatory evaluation play an important role in the evaluation of healthy municipality initiatives. …[I]t is a collaborative approach that builds on strengths and values the contribution of everyone involved.

    [A PAHO] working group on healthy municipality evaluation in the Americas…recommended different areas that should be taken into account when evaluating HMC initiatives, such as context, planning and implementation of the evaluation, and evaluation methodologies:

    Context

    • Evaluation must factor in the different political, economic, social, and cultural contexts of the country, municipalities, and communities involved in the evaluation. It is important to consider the influence of the following:
      • Socioeconomic and political situation (national and local)
      • Local and national policies
      • Local health situation
      • Administrative structures and management styles, both national and local
      • Geographical, ecological, and demographic characteristics
      • Stage in the development process of the healthy municipality
      • Sociocultural aspects

    Considerations for Planning and Implementing Evaluations

    • The conception and development of the evaluation as a formative process originating from the municipalities and the stakeholders. This implies adopting the rigor and complexity required by the topic and the collective definition of the variables and indicators to be used.
    • The definition of work processes that ensures: a) a broad and diverse commitment that reflects a consensus of joint evaluation objectives, and b) clearly identified ways to disseminate this work to other relevant groups.
    • The relationships between health and well-being and between health and development.
    • The conceptual definitions of what “healthy” means in the context of the psychosocial and physical aspects of the environment, health promotion, human and social development, and equity.

    Evaluation Methodologies

    • Utilize an evaluation methodology that integrates qualitative and quantitative approaches.
    • Develop qualitative indicators constructed with the actors involved in the process itself – this requires intersectoral and participatory work. [See Chapter 3, Section 15, Qualitative Methods to Assess Community Issues.]
    • Aim for an evaluation that covers structures, processes, and outcomes.
    • Take advantage of the information available in each municipality, strengthening the existing databases with qualitative data (and creating databases where they do not exist).
    • Conduct the evaluation recognizing the influence of the various levels (international, national, and local, and, at the local level, institutional/government and community forces or social groups) and contexts (geographical, demographic, political/administrative, economic-environmental, social, and cultural). [See Chapter 36, Section 2, Community-Based Participatory Research.]

    Areas for Evaluation

    The following areas have been identified as key in the evaluation of healthy municipalities:

    • Public Policies
    • Social Participation
    • The Intersectoral Approach
    • Sustainability
    • Development Process Undergone by the HMC Initiative

    Evaluating the Process

    …[I]t is wise to think about evaluation from the very beginning…Good evaluation goes hand in hand with planning. A planning approach that works well with for participatory evaluation is one in which evaluation, implementation, and planning activities interact with each other at any point in the life of the endeavor.

    [E]valuation should review the various steps of the process itself: its successes, difficulties, strengths, and weaknesses. It should not simply register, describe, or quantify attainments and products.

    Evaluating Results

    Results in health promotion are dynamic and diverse in nature, and measuring these results can include information from the following areas:

    • Health education
    • Influence and social action
    • Healthy public policies and organizational practices
    • Healthy living conditions and lifestyles
    • Effectiveness of health services
    • Healthy environment and spaces
    • Social results
    • Health outcomes
    • Capacity-building and development

    [The following] is a list of suggested guidelines [for evaluating healthy municipalities initiatives] but it is not comprehensive; it is recommended that each HMC advisory group or committee review, adapt and augment the guidelines based on the evaluation needs and particular context.

    Describe the context

    Indicate causes for concern

    • What is the purpose of the evaluation? What are the main concerns of the various parties involved?
    • How will the results of the evaluation be used?
    • What are the specific questions that need to be addressed by the evaluation within the context of the healthy municipalities initiative?
    • Are public policy, the intersectoral approach, social participation, and sustainability addressed in the questions and the objectives?
    • Do the evaluation’s questions and objectives address the basic principles of the HMC movement (the concern for equity, the intersectoral approach, social participation, and strengthening local capacities)?

    Organize the data-collection process

    • What methodologies will be used? (This will depend on the responses to the questions above.) Have a range of qualitative methods been considered?
    • Are the methods appropriate to the local context? Have both process and results been taken into account?
    • Is the methodology understandable to those involved?
    • Have pilot studies been conducted, using the same tools that will be used in the evaluation?
    • Have the tools to be used in the evaluation been validated?
    • How will broad participation be achieved?
    • Is care being taken to include marginalized groups or individuals (both from among those who are the object of the evaluation and those in charge of conducting it) in the proposed evaluation? [See Chapter 36, Section 2, Community-Based Participatory Research.]

    Compile the data

    • This task should be carried out using the methods established in the previous steps.
    • This task should be monitored to ensure that the data compiled are of good quality.

    Describe, analyze, and evaluate the data

    • What was learned through the evaluation?
    • How different are the results from what was expected?
    • Were the qualitative and quantitative methods complementary?
    • How can discrepancies be addressed and resolved?
    • Consider the possibility of using other qualitative methods in order to provide more information about unexpected results.
    • Promote the participation of interested parties in the interpretation of the results.
       
      [See Chapter 17, Analyzing Community Problems and Solutions.]

    Make recommendations

    • What are the short- and long-term implications of the conclusions?
    • What changes might be made to address negative results? Analyze recommended changes, taking their costs and benefits into account.

    Disseminate conclusions

    • Communicate conclusions, recommendations, and anticipated actions to donors, all interested parties, networks, etc.
    • Use the Internet to share experiences wherever appropriate.

    Make changes based on the results of the evaluation

    The steps listed might also be presented as a continuous cycle.

    Other principles for evaluation [agreed upon at a 2001 conference by the Working Group on the Evaluation of Healthy Municipalities and Communities Initiatives in the Americas]

    Value

    The evaluation process must reveal any theoretical, ideological, or political assumptions and explicitly indicate any power relationships (including those in which the evaluator is involved). The evaluation should also respect and value experience and local knowledge, recognizing the people as the principal health resource. The evaluation should embody a spirit of hope, happiness, love, and fun, while never forgetting equity, social justice, and solidarity.

    Empowerment

    Evaluation of Healthy Municipalities initiatives should:

    • be based on the community’s strong points;
    • support local problem-solving;
    • ensure equity by allowing all voices to be heard, including the voices of the most vulnerable and least powerful; and
    • make it possible for information about the evaluation to be used by those concerned to lobby for and promote Healthy Municipalities.

    Usefulness

    Evaluation of Healthy Municipalities initiatives is useful when:

    • it answers the questions of who, why, and how;
    • it is integrated into the planning process and oriented toward action and change;
    • it contributes to the creation of resources in the community;
    • it has practical and political relevance;
    • it helps define the healthy municipality as an investment; and
    • it recognizes the need for a range of dissemination methods and feedback mechanisms.

    Learning

    Evaluation of Healthy Municipalities initiatives should:

    • promote a joint learning process;
    • promote dialogue and reflection, and encourage all means of developing knowledge by those affected and influenced by the process, including any external evaluators;
    • recognize that learning is the key to the community and to increasing the capacity for local organization; and
    • lead to action and change.