Contributions for Repositioning a Regional Strategy for Healthy Municipalities, Cities and Communities (HM&C): Results of a Pan-American Survey

Abstract

This article presents the results of the 1st Regional Survey of Healthy Municipalities, Cities and Communities (HM&C) carried out in 2008 by the Pan American Health Organization (PAHO) and ISALUD University of Argentina. It discusses the responses obtained from 12 countries in the Americas Region. Key informants in Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Paraguay, Peru, and Uruguay were selected and encouraged to answer the survey, while informants from Canada and Honduras answered voluntarily and were included in this analysis. The discussion of the results of the Survey provides insight into the current status of HM&C in the Region and suggests key topics for repositioning the Regional strategy relative to: (1) the conceptual identity and tools for HM&C; (2) challenging areas in the implementation process (scale, legal framework, and development of capacities); (3) related strategies and participatory processes such as the ways citizen empowerment in governance is supported; (4) the need to monitor and assess the impact of the HM&C strategy on the health and quality of life of the populations involved; and (5) the need for developing a strategic research and training agenda. The analysis and discussion of these results aims to provide useful input for repositioning the strategy in the Region and contributing to the emergence of a second generation of concepts and tools capable of meeting the developing priorities and needs currently faced by the HM&C strategy.

Introduction

The Pan American Health Organization and ISALUD have been conducting a process of discussion and exchange of ideas with key individuals and institutions in Latin America, with the objective of generating inputs for repositioning the Healthy Municipalities, Cities and Communities strategy (HM&C)¹ in the Region, based on prior experiences, new priorities in cities, and opportunities that are opening up in local health agendas².

This article presents the results of the Regional Survey on Healthy Municipalities, Cities and Communities (HM&C) carried out in 2008 by the Pan American Health Organization (PAHO) and ISALUD University of Argentina, and it discusses the responses obtained from the 12 countries in the Americas Region. Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Paraguay, Peru, and Uruguay were selected and encouraged to actively answer the survey; Canada and Honduras answered voluntarily and were included in this analysis.

Since its introduction in 1987 by the World Health Organization,^1,2,3 health promotion knowledge and experience has been gained in cities, towns, and communities of our Region through events that have given new meaning to its mission. The need to reposition the initiative is reflected in the variety of responses to the changing map of challenges and opportunities posed by local development and health promotion in our Region.⁴

The purpose of this survey was to contribute to knowledge of local development and health promotion processes at the municipal level in the Americas Region and identify the main challenges being faced. To this end, qualitative and quantitative information was gathered from key informants, and secondary sources were consulted through PAHO offices in the selected countries.

The study sought to identify the type of demands and expectations (social and institutional) of the groups involved, as well as the existing capacities of the participating institutions and countries, with the aim of accurately describing the present status of the HM&C strategy in the Region and the challenges it is facing related to development issues.

Methodological Aspects

An exploratory–descriptive methodological design was selected and applied through a semi-structured instrument (survey³) to an intentional sample of key informers, with the aim of generating contributions and hypotheses for the restructuring of the HM&C strategy in the Americas Region. In view of time and cost considerations, most of the surveys were answered in a self-administrated manner. Answers to open questions were recorded and subsequently classified according to their core meaning relative to the topics and questions posed: (a) description of initiatives in progress; (b) judgment about/perception of processes; (c) judgment about/perception of impacts; and (d) current and potential demand for technical assistance.

In view of the characteristics and the purpose of the project, the selection of key informants comprised a “sample” that was established by using criteria that were neither mechanical nor based on probability formulae, but which arose from a set of pre-established guidelines with intentionality.⁵ Among the results obtained, priority was given to those with the richest quality of information rather than quantity. The value of this information resides in the belief that it reflects knowledge of the key players related to the topic analyzed. The selection criteria applied for choosing the informants included a model profile comprised of the following elements: knowledge of the HM&C strategy; capacity for contributing recommendations for the repositioning of the initiative; and heterogeneity of the group through the inclusion of representatives from various sectors, gender diversity, professional integration, and multi-disciplinary training backgrounds.

Data Analysis

The analytical process used to prepare this report focused mainly on the aggregate responses of 100 key informers from the participating countries. Additionally, it included contributions that stemmed from surveys completed by key informants in Honduras (which were added in a National Report prepared by the Postgraduate course on Public Health of the National University of Honduras) and Canada.

This information was analyzed by processing responses to the applied questionnaires using the software tool Survey Monkey. Subsequently, these results were analyzed by combining:

1. the 10 country reports prepared by the designated consultants, with particular attention to their observations and recommendations; and

2. reports that resulted from presentations and shared analysis by seven consultants during the Regional Workshop held in Buenos Aires in October 2008.

This cross-referencing sought to include multiple dimensions and outlooks to the analysis of the answers obtained, encouraging the introspective and critical capacity contributed by the cumulative experience of the main players in HM&C initiatives over the years.

Results

Aspects that Describe the Initiatives in Progress

Places of Implementation

The places where the HM&C strategies are implemented are very diverse. Municipalities and schools appear as the most frequently mentioned physical locations, although centers of work, universities, homes for the elderly, markets, child care centers, old people’s homes, medical consultation rooms, prisons, hospitals, seaside resorts, neighborhoods, and seats of civil and state organizations as well as soup kitchens for children and community centers are also mentioned.

In several countries, there are reports that HM&Cs are implemented in large as well as small municipalities and communities. In Uruguay and Cuba, the initiative incorporates a perspective of “productive and healthy” communities, which includes mainly rural communities, and explores the convergence of health promotion strategies in association with production and marketing ventures.^6,7

Most Frequent Approaches

The question relating to “most frequent approaches” provided insight into the extent to which the initiative is being driven by short-term actions due to “problems emerging in relation to the health and/or quality of life of the population” (17.2% of responses) or by medium- and long-term actions “focused on the causes and determinants of the health and/or quality of life of the population” (25.3%). The remaining 57.6% of the responses indicated that the HM&C agenda combined both types of actions.

Political–Institutional Aspects

Only 12.2% of the responses indicated that the initiative could be considered as “part of the national public policy”. This reveals that the initiative had not yet gone to scale (in institutional and operative terms), had not yet been completed, and that in most of the countries surveyed the HM&C strategy consisted of specific limited experiences in certain locations. Rare exceptions are Cuba, where the “Red Nacional de Municipalidades por la Salud” (National Network of Municipalities for Health) has been in place since 1994, and Chile, where 12 of the 13 informants classified the initiative as a National Public Policy.

The reports from Argentina, Chile, Colombia, and Honduras indicate, however, that the initiative is consolidated as a permanent program in various municipalities, thus constituting a stable policy of the municipal government. Table 1 systematically classifies and quantifies the responses from all the key informers. Evaluating whether the initiative has beem scaled up to the point where it can be considered as a national policy has significant implications for the stability and sustainability of the efforts. As an ad hoc initiative of a local government or an external agency, HM&Cs are often subject to the whims of political shifts and unreliable availability of resources. Only when the initiative becomes part of a permanet public policy can it seek to achieve long-term goals and change the determinants of health and wellbeing.

Table 1.

Institutional classification of the work of HM&C

	Percentage	Total
As a national public policy	12.2%	12
As a permanent program or a public policy of the local government	38.8%	38
As a project or work plan of a given sector	19.4%	19
As an initiative that involves various agencies, institutions, or sectors	46.9%	46
Total responses		98

Main Topics Addressed

Comparing the relative frequency with which the different topics were addressed in the context of HM&Cs, it is evident that the ones most frequently mentioned related to lifestyle improvement in the population⁴: mainly promotion of healthy eating habits, physical activity, and prevention of alcohol, tobacco, and drug abuse. Actions relating to the improvement of programs and services come in second place, and included vaccination campaigns, prenatal and perinatal care, prevention of teenage pregnancy, and prevention of sexually transmitted diseases. The group of actions that related to the area of environmental health in municipalities also appeared among those most frequently mentioned: including vector control, water and sanitation, waste management, and environmental quality. In Peru, for example, topics that related to the environment were the ones expanded upon the most, especially in regards to solid waste management (Table 2).⁸

Table 2.

Comparison of the relative frequency with which the different topics were addressed in the context of HM&Cs

Main topics addressed	Percentage with high and very high frequency
Lifestyle improvement
Promotion of healthy eating habits	73%
Physical activity	70.5%
Prevention of alcohol, tobacco, and other drug abuse	70%
Improvement of programs and services
Vaccination campaigns	75%
Prevention of sexually transmitted diseases	61.8%
Prenatal and perinatal care	53%
Prevention of teenage pregnancy	51%
Environmental health
Vector control	67%
Water and sanitation	60%
Waste management	55.5%
Environmental quality	51%

Since most countries demonstrated synergies between actions that have an impact on risk factors and lifestyles and others directed at promoting social participation and having an impact on environmental and social factors and which are recognized as “determinants” of the main health problems, it seems clear that these two “conceptually” divergent trends are, in practice, complementary.

It is also worth taking note of the less frequently addressed topics. The prevention of work-related accidents was mentioned with extremely low frequency by 70.5% of the informants.

The prevention of urban violence registered an equally low frequency rate of 55.8% by the informants, and issues that related to mental health were equally infrequent for 45% of the respondents. Issues relating to “housing”, “transportation”, “employment”, and improvement in “urban development” (accessibility and friendliness of public spaces) were also identified as those dealt with the least by an average of 55% of the informants.

Given that certain topics (such as accidents, violence, and those relating to mental health) are recognized as priority public health issues, and considering that issues relating to employment, housing, transportation, and urban development are social determinants of health that have a high impact, the low frequency of actions in these areas probably reflects an absence of sufficient capacity to address them. Consequently, these areas should be strengthened in future training and research programs. A (apparently increasing predominant) focus on rather traditional “health promotion” actions such as lifestyle and services will not accomplish the need to address the causes of ill health as recommended by the WHO Commission on the Social Determinants of Health.⁹ The lack of emphasis on urban planning, transportation, housing, mental health, and the prevention of violence often means initiatives are mainly focused on symptoms rather than causes and it invites new efforts focused on these important areas.

Population Groups

The question relating to the population groups that are most frequently involved in Healthy Municipality actions was meant to identify the main target populations for HM&C initiatives (Table 3).

Table 3.

What population groups are most frequently involved in HM&C actions?

	Percentage	Total
Adolescents	68.7%	68
Older adults	59.6%	59
Boys and girls <5 years old	30.3%	30
Boys and girls >5 years old	36.4%	36
Women	84.8%	84
Disabled persons	4.0%	4
Migrants	2.0%	2
Indigenous people	4.0%	4

It is evident that the people involved in HM&Cs are predominantly women, adolescents, and, to a lesser extent, older adults. The involvement of women probably reflects their frequent participation in core institutions (district and neighborhood organizations and groups) and the fact that women are the head of most Latin American households, particularly in lower income communities. Additionally, this could also be a way of offsetting the disadvantageous position of women in countries with “longstanding gender inequality relative to social participation and employment opportunities, to the detriment of women.”⁶ In any event, the experience of young people and women’s groups with HM&Cs is particularly rich and it would be opportune to further document and systematize this information.

Map of Players

Multiple players are involved in HM&C initiatives. This question intended to identify the most frequent “partners” in the strategy, but a high diversity of answers were encountered.

The development of collaborative alliances is more consolidated at the local level. Municipal Secretariats systematically appeared to play a main role (Health, Education, and Environmental Secretariats all had response percentages ranging between 55% and 80%, indicating their high level of involvement), while 50% to 60% of respondents indicated that Non-Governmental Organizations and Neighborhood Councils were frequently involved.

This confirms the impression that there is space to expand and create more stable alliances at the local level, as ad hoc undertakings featuring specific players are rather predominant.¹⁰ In contrast to this, there were more stable long-term alliances at the national level which was indicated as one of the main factors in the sustainability of the HM&C strategy.^6,7,11,12

The players that were infrequently involved in collaborative activities included religious institutions (with almost 65% of responses that position them in levels 1 and 2 in frequency of collaboration)⁵, the private sector (60% of answers placed them at the same level, with the exception of Brazil), and universities (50% of responses placed them at the same level, with the exception of Brazil and Cuba). Municipal Secretariats for Culture, Youth, Planning, and Transportation were also identified among those less frequently associated with the HM&C strategy.

Opportunities for Articulation

The question relating to what other sectors, ministries or agencies implemented initiatives that were similar to HM&Cs was meant to identify opportunities for convergence with similar processes that might be currently under-used by the initiative. Almost 80% of the answers indicated that these opportunities existed. For example, the report from Brazil exemplified these opportunities when it stated that “there are hundreds of municipalities that have innovative social projects, and that act under the premise of strengthening the local government and participatory inter-sectorial management, with the aim of improving the quality of life of citizens, … the same assumptions that define a Healthy City. During the last decade, some of these initiatives have become aligned with the movement toward healthy municipalities, while others adhered to the development of local urban agendas, such as Agenda 21 of DLIS (Integrated and Sustainable Local Development), and others.”¹³

The numerous responses to the question regarding similar initiatives and the institutions that implement them revealed a broad range of opportunities for collaboration and articulation with ongoing programs, such as programs implemented by central government agencies, multi-agency programs, local development programs, housing programs, and regional and sub-regional networks.

The points where these initiatives converged and facilitated articulation were numerous, since they dealt with the “problems affecting certain social groups and propose solutions that entail the active involvement of the beneficiary population, so that they are not only recipients, but part of a local development approach. They share the objectives of improving the quality of life and the wellbeing of population groups”, using “social participation strategies and inter-sectorial work.”¹¹

The potential points of convergence additionally revealed the different versions and expressions of common efforts existing in the area of health promotion and local development, which constitute an important element for the repositioning and future agenda of the HM&C initiative.

Sources of Funding

The answers from key informants indicated that the National and Municipal Public Spending Budget was the most frequent source of funding for HM&Cs. From the aggregate of the responses, the sources of funding for HM&Cs can be estimated as follows:

• Municipal Budget (45%)

• National Budget (25%)

• International Cooperation (25%)

• Others (5%)

In Chile, a little more than half of the US$ 7 million invested in 2007 in the implementation of Community Plans originated from the Ministry of Health, followed by the resources contributed by municipalities (30%), other sectors (10%), and the communities themselves (6%).¹¹ In Cuba, the highest proportion of funding available for HM&Cs came from municipal budgets, although these were allocated by the Central Treasury.⁷

International cooperation continued to contribute significant financial support to the initiative, while the private sector contributed the lowest amount of funding. The funding contributed by Foundations and NGOs was even lower, and self-funded activities were very infrequent.

This information helped with the the identification of priority areas to be supported by the continued mobilization of genuine resources (mainly the municipal budget, and local trade and industry) in countries where this resource commitment had not been achieved. “International technical cooperation agencies (mainly PAHO/WHO) are currently enabling the viability of the strategy, together with national resources…. This situation must be assumed through a national, local and municipal commitment in order for the initiative to be sustainable.”⁶

Training Programs

Eighty percent of the respondents indicated the existence of training activities, as opposed to 19.4% that provided a negative answer to this question. Furthermore, it is evident that there was no permanent training program available, since most of the respondents (88.2%) identified these as “specific activities”.

This varied from one country to another. Some countries (Colombia, Honduras, Uruguay) continue to indicate training and updating of human resources as a priority for HM&Cs (“There have been few opportunities for promoting systematic training programs. The current context requires immediate attention to training by all of the social players involved”. “The training activities carried out are specific and limited.”)⁶ while others, like Chile and Cuba, had more periodic activities. In Uruguay, training and updating constituted a key challenge for the initiative in the immediate future.

Research Programs

The answers obtained reveal a perception that there is an accumulated regional human capital for research activities. However, this capital was not suitably distributed and while some countries (Brazil, Chile, Cuba) had a reasonable level of installed capacity and valuable background in the matter, others indicated this was one of their structural weaknesses.

Even in Chile, where there is a broad installed capacity for public research, research carried out in the context of the HM&Cs was very specific. “…this has not led to stable lines of research. It has not been possible to establish study groups. Practices are not researched …. However, the quality of research work and the systematic documentation of experiences obtained at Health Promotion Congresses have improved.”¹¹

Brazil stood out at as a regional leader in terms of installed capacity for health promotion research activities, and particularly for programs that evaluated the strategy of Healthy Municipalities.

With regard to topics recently researched, the survey obtained 44 responses that indicated that research was carried out in the area of program evaluation, evaluation of effectiveness and systematic documentation and analysis of good practices, and in specific issues relating to lifestyles and environmental factors. Several final reports indicated that research projects carried out constituted isolated events, often dependent on the availability of funding, and did not lead to the establishment of lines of research or stable study groups.

Perception of Impact

The general impact of the HM&C initiative was perceived positively in most cases, although most informants chose to indicate that although there are some signs of change, these have not been become permanent. Only in the case of Cuba did most of the informants choose the option of a “noticeable improvement in health and in the quality of life of individuals”. Additionally, 20% of the respondents indicated improvements in “certain minor aspects, but no substantial improvement”.

The positive answers regarding the impact of the initiative were clearly focused on two areas: (a) its contribution to the development of integrated and inter-sectorial policies; and (b) its contribution to the development of citizen participation in decision-making, governance, management control, and transparency.

Elements for Re-positioning the HM&C Initiative

Below is a discussion of the elements that are considered key to the HM&C strategy in Latin America and to the objective of establishing hypotheses for re-positioning the strategy based on the results and discussions raised by this study.

Conceptual Identity and Tools for HM&Cs

The results of the Regional Survey showed a need to strengthen the identity of HM&Cs, and update the conceptual framework and “practical tools”. The high degree of variability in the responses obtained relative to the “most frequent spheres of implementation”, “topics addressed”, and “beneficiary population of the actions carried out” reflects the wide variety of versions of HM&Cs that have grown up during the last decade. This diversity in approaches is attributed to the need to adapt to new scenarios in the health environment and in local government, and to changes in the demand for and offering of services, the transformation of the configuration of players and sectors, and changes in institutional dynamics and management of public policies.

As a result, the “identity” of HM&Cs was not defined so much “by what they do” (their results) as it was by “how they do it” (their processes). The essential features of the methodologies and strategies applied (political commitment, community participation, inter-sectorial collaboration) remained constant, while the scenarios in which they operated, the topics addressed and populations with which they interacted were highly variable and diverse.

Accordingly, there is a pressing need to generate a process of updating the HM&C approaches by revisiting the conceptual, reference, and operating frameworks and respective strategies in a practical manner. In order to do this, it will be necessary to strengthen the concepts and tools that remain valid, highlight those that can be utilized in new ways, and incorporate new and innovative approaches based on demonstrated local and national transformations.

This should support the establishment of a “second generation” of concepts and tools, encouraging intense dialogue about the fundamentals of the HM&C strategy and the recommendations of the report of the Commission on the Social Determinants of Health⁶, the Renewal of PHC⁷, and the Health Agenda of the Americas⁸.

There is a need for greater articulation between actions relating to health and those relating to productivity. HM&C need tools that will facilitate their advancement and support activities related to productive undertakings (generation of income) at the local level, as well as housing programs and social inclusion and protection programs carried out within the framework of determinants of health and the causes of the causes of health-related issues. This articulation between health and productivity requires a new focus at the political (institutional) and technical levels that will facilitate this more pro-active approach (development of indicators, preparation and use of evaluation criteria, guidelines and rules for the selection of interventions, and strategies tailored to the local development challenges).

This poses a historical opportunity for conceptual and methodological renewal and innovation of health promotion in the framework of decentralization and local development processes. The tension between renewing and innovating implies addressing historical aspects of the conceptual framework and the accumulated experience, and integrating new planning, administration, information, and evaluation tools from a non-technocratic viewpoint (based on historical experience and prior learning).

Tensions in the Implementation Process, Micro and Macro Policy, Legal Framework, and Development of Capacities

There is evidence of a constant need to link each HM&C experience (micro level) with public policies (macro level), while simultaneously appraising the unique and diverse contribution inherent in each of these experiences. In Chile, Cuba, and Uruguay, HM&Cs have gone hand in hand with national health promotion programs. However, in most countries, HM&Cs expand as if they were “contagious”, as a result of the implementation by local governments and communities, resulting in a series of model “micro” experiences that are at the same time linked to macro policy”⁹. The example of Vida Chile stands out for being “institutionalized as a National public policy that has continued over time despite changes in government.”¹¹

It is worth noting that only 12% of the responses recognized the HM&C initiative as “part of a national public policy”. In some cases, the scaling up of the initiative was mentioned as the major challenge faced by HM&Cs. In order to achieve broad implementation, the technical, political, and institutional conditions that are necessary to achieve articulation between specific experiences and public policies must be strengthened, and networks must be developed to expand the reach and support the scaling up of the initiative.

The survey responses identified factors that are perceived as key to strengthening the HM&C implementation processes: (a) institutionalization of the strategy with technical, political, and legal tools, providing stability for the HM&Cs and their technical teams; (b) availability of a legal–institutional framework that favors multi-sectorial and multi-player convergence; (c) establishment of multi-player and multi-institutional management councils; (d) putting in place inter-institutional consultation instruments and abilities, and flexible, stable, integrated management and funding tools; (e) availability of permanently assigned staff for collaborative work; (f) strengthening of coordination and management competences; and (g) availability of integrated financing funds for collaborative projects.

“Tensions” in the implementation process can be inferred from the need expressed for collaboration though networks, while having some coordination with the central level, and simultaneously getting encouragement through autonomous channels. The challenge that arises from the tension between centralized coordination and decentralized management offers an opportunity to stimulate processes that create new technical interactions¹⁰ and that establish the necessary competences at each level, making them complementary with one another; this favors individualized processes at each of these levels that are in keeping with their respective needs and available capacities. The strengthening of national and regional HM&C networks will contribute to the processes designed to improve opportunities for exchange and integration of learning experiences and resources among local actions.

Participatory Processes, Related Strategies, and Networking of HM&Cs

The development of alliances at the local level is one of the most valuable assets of the HM&C strategy. The best results are recognized at the local level, mainly due to ad hoc collaboration and undertakings. Additionally, the need to strengthen strategic alliances at the central level is highlighted as a requirement for long-term sustainability.

There is consensus regarding the progress and expansion of opportunities for social participation, with specific mention of valuable experiences such as “participatory budgeting¹⁰”, the creation of Regional Advisory Councils, and the growing number of independent projects conducted by civic organizations. The integration of “virtual” participatory forums and networks and e-government models were mentioned as emerging strategies that can be used to jump start collaboration.

These new opportunities for participation should lead to organizational structures that empower the population and give rise to effective citizen-controlled tools, with the purpose of contributing to the quality of governance. This expansion of social participation should be protected from selfish manipulations that threaten their legitimacy.¹¹

Many countries mentioned the benefits of HM&C approaches to processes that strengthen the implementation of territorial policies. HM&Cs should be a vehicle for strengthening decentralization processes. This reinforced a positive outlook toward articulating the HM&C strategy with local development strategies based on shared principles and objectives. This requires specific tools and skills (to be taken into account in training proposals), and an open and inclusive policy of alliance that is able to set aside the individual agendas of the participants.

There is a traditional “conservative” approach to the strategy of creating alliances which has historically given priority to people with political clout and to institutions that hold formal power as the main drivers of the initiative, thus limiting participatory and collaborative dynamics by often submitting them to bureaucratic processes. In order for the strategy of building partnerships through a multi-sectorial and multi-player approach¹⁴ to be successful, new relationships that draw from the most dynamic players and experiences similar to these of HM&Cs must be created. In some countries, alliances with institutions and players from cultural, youth, academic, and private sector organizations (business and productive organizations) are still not being considered.

It is worth noting that progress still needs to be made in developing inter-sectorial and intra-sectorial activities. The agenda of alliances and collaboration outside of the initiative taken by the traditionally most committed sectors (health, education, the environment) does not preclude the need for progress in actions that facilitate the mainstreaming of the HM&C strategy throughout the health sector; it is acknowledged that there still remains room for strengthening coordinated health actions, taking advantage of collaborative opportunities.

The jury is still out on the effectiveness and achievement of national networks. The degree of development of national HM&C networks varies across the countries included in the Survey. Argentina displays significant achievements, while Brazil has generated regional networks, some of which are extremely active and dynamic. The main challenge continues to be the availability of stable opportunities for exchange among networks (events requiring attendance, forums, joint publications, etc.).

Impact Analysis

Informants universally said that the impact of HM&Cs was favorable.

There was also a positive consensus regarding the need for more and better evaluations of the HM&Cs. Brazil, Chile, Colombia, and Cuba, among other countries, have been conducting sustained efforts to expand their knowledge base regarding HM&C implementation processes, drawing from the experience of the different components, assessing their impact on health and on quality of life and their contribution to local development. In 2005, PAHO published a Guide for Participatory Evaluation of Healthy Municipalities, Cities and Communities¹¹. There are also articles that specify evaluation experiences at national and local levels,^15,16,17 and other useful international instruments such as the Guide for the Impact Evaluation on Health¹² prepared by the Basque Government for the World Health Organization.¹⁸

The advantages of developing and applying technical expertise accompanied by the promotion of cross-cutting cooperation activities in this area were mentioned repeatedly as an opportunity and a challenge for the initiative in the years to come.

Training and Research Agenda

Human resources were considered to be one of the strengths of the initiative. However, professional training and processes of continuing education are weak and not sustained in most countries. There is an urgent need to expand available training through the identification of priorities for training and consensus on the necessary compentencies (knowledge and skills) needed for each level of implementation and for each field of expertise.

The need to promote in-service training indicated that (for planning, evaluating, coordinating, negotiating, advocating, and developing communication strategies) the learning processes should be based on practical conduct of activities that address an application in the field of the competencies to be developed. Therefore, it is necessary to offer in-service training that includes critical reflection on personal practice as well as access to supervision, tutoring, study groups, and forums that promote reflection and exchange among peers. This implies that the content of the courses should lead to frequent analysis of situations and the identification of the most successful strategies, and participating in HM&C projects should provide physical space, time, and guidance for in-service training and learning from experience.

A broad initiative is required to establish alliances and networking with universities and resource centers throughout the Region, so that the continuous training of human resources will contribute to creating new interactions, putting theories into practice within academic institutions and communities, and strengthening technical resources. Evidence needs to be shown of the effectiveness of applying these approaches to local decision making and implementation of local development strategies.

Among the priority areas that require training, the development of competencies in program planning, management, and evaluation stands out. Reference is also made to the need for training in associated management skills (communication, negotiation, problem solving, and leadership). Lastly, the need to generate capacity in emerging topics, such as mental health promotion, violence prevention, and urban development, must be considered.

Another priority need is the generation of strategic lines of research, through national councils that include renowned researchers from different disciplines, with the mobilization of technical capacities of the PAHO/WHO Collaborating Centers. Among the countries surveyed, Brazil, Chile, Colombia and Cuba showed the highest production in the area of research associated with the HM&C initiative. A cross-cutting collaborative strategy is required to disseminate knowledge and strengthen capacities for the implementation of permanent research programs.

It is necessary to encourage applied and participatory research models that will generate evidence of the results and the impact of the initiative, raise the awarerness of the public, and provide an opportunity for technical training and education.

Future Directions

The results of the Regional Survey on HM&Cs provide novel elements that will contribute to furthering the discussion and analysis of its achievements and pending challenges, and they shed light on the current status of the strategy in the Region, contributing key elements for re-positioning it. The topics that arise as key elements for advancing this discussion are summarized below:

• ○It is necessary to strengthen the identity of the HM&Cs, opening up the way to a “second generation” of concepts and tools, renewing the framework and updating methodologies and approaches. This indicates a subsequent need of expanding the production and availability of publications and resources, particularly those that address emerging topics and introduce elements for innovation.

• ○ Scaling up of HM&Cs into national policy is still a challenge in most countries, although there are a few successful cases where this has been accomplished. As a national policy, HM&Cs are not only more likely to overcome political and budgetary instabilities but they are also better suited to contribute to achieving the aims laid out in the SDH Commission’s report on urban settlements and healthy urban governance.

• ○ There seems to be an increasingly predominant focus on lifestyles and services and a relative dearth of focus on urban planning/transportation/housing/mental health and prevention of violence. This will not accomplish the need to address the causes of health as recommended by the WHO Commission on the Social Determinants of Health. Such a focus on rather traditional “health promotion” actions is different from the European model of Healthy Cities. This highlights the need to build bridges with the experiences in more developed countries as well as the need to expand partnerships with sectors responsible for these areas of development.

• ○ The development of public policies must go hand-in-hand with the development of networks that accompany the diffusion of these participatory processes (scaling up) by encouraging cross-cutting horizontal cooperation that values the uniqueness and diversity of the HM&Cs.

• ○ The way forward for HM&Cs in Latin America will need to be based on greater integration of health actions with productivity activities. HM&Cs need to be more connected with local production undertakings (generation of income), housing programs, and social inclusion initiatives.

• ○ Key factors that strengthen and improve the HM&C implementation processes have been identified: (a) institutionalizing the strategy; (b) maintaining stability of technical teams; (c) defining a clear legal–institutional framework; (d) establishing multi-player and multi-institutional management councils; (e) integrating instruments for inter-institutional consultation and stable and flexible tools; (f) permanently assigning staff to collaborative work; (g) developing appropiated coordination and management competences; and (h) making integrated financing funds available.

• ○ In the near future, HM&Cs will have to collaborate in line with the new forms of social participation (development of virtual networks and e-government tools), using them to improve governance processes through empowerment by employing effective tools for citizen decision-making.

• ○ Future alliance strategies will require the generation of new relationships, focusing on the more dynamic players and sectors: culture, youth, and academic, business, and productive organizations.

• ○ The availability of a permanent training and updating agenda for professionals involved in HM&C initiatives is a key element, with emphasis on new topics (social determinants of health, local development), providing specific tools that correspond with the level of responsibility and emphasizing coordination and associated management competencies.

• ○ Priorities in research feature the need to establish a permanent research agenda and mobilize existing technical capacities, establishing national councils in each country and with researchers from different disciplines.

• ○ The knowledge and evidence base regarding the effective contribution of HM&Cs to the improvement of the health and wellbeing of the population must be expanded, making use of existing evaluation and documentation guides and documenting the impact and processes in terms of their complexity and multi-dimensionality.