Pan American

Health Organization
Regional Office for the
World Health Organization

Creating HEALTHY
AND SUPPORTIVE
Environments: the
settings approach in
health promotion

Celebrating 100 Years of Health

 Two starting points of a new
dynamic
z Health z Governance

z New and expanded z New approaches to

role of health in governance in all
modern societies and
in developing societal systems and at
countries that are much all levels of
less health care system governance that are
centered much less state
centered

Organización Panamericana de la Salud • http://www.paho.org

 New realities for policy
z Changing role of governments and institutions
z Changing demands on leadership
z New pluralism of interest
z A new view of political and social responsibilities

z Search for new models of organization and

financing of social security, welfare and health

Organización Panamericana de la Salud • http://www.paho.org

 21st Century: Change in
governance

z 21st century governance characteristics:

z public philosophy based on equity
z participatory value base
z new ecology of collaboration
z OECD Report

Organización Panamericana de la Salud • http://www.paho.org

 The Concept of Settings
 A setting is the context within which and through
which health is produced
 Powerful methodological tool
 Provides a framework for understanding and
identifying the protective factors (physical and
social) that contribute to health, quality of life and
sustainable development
 “Health behavior and health outcomes are products
of their unique environments” (I. Rootman and M.
Goodstadt)

Pan American Health Organization • http://www.paho.org

 The Importance of Settings
 Promote health and protect life, together with people and
communities, in settings where they study, live, love, work,
study and play
 Context and structure for behaviors and lifestyles
 Grounds the analysis, understanding and contribution to
improving the determinants of health and equity
 Settings vary widely
 Large complex communities - municipalities, cities

 Smaller discrete organizational units - schools, workplaces,

marketplace, homes
 Combination of Health Promotion strategies and intersectoral
approaches

Pan American Health Organization • http://www.paho.org

 Healthy Municipalities and
Communities
Prevention
Wo s a t ed
r kp me e g r s
lac
e Ho Int tegie
on a
muni c a t i str
Com Participation
ui ty
n t in
Safe unities Ma
rk Co
om m ls et p
c o l ac
ho es
Sc
Promotion Hospitals

Pan American Health Organization • http://www.paho.org

Healthy Municipalities – Healthy Cities

 A municipality begins the process of becoming

healthy when its political leaders, local
organizations, and citizens commit themselves to
improving the health and quality of life of all of its
inhabitants – A plan of action with health targets
 Establish and strengthen a social pact among
local authorities, community organizations, and
public and private sector institutions
 Use local planning and social participation in
management, evaluation, and decision-making

Pan American Health Organization • http://www.paho.org

 Builds and strengthens a social pact
among key players to promote health
with people and their communities
Comunidades
Saludables
Cantones Saludables
Healthy Communities

Healthy Health Promoting

Cities Schools

Healthy Barrios
Healthy Workplaces
Community
Local Authorities Organization Health Sector
s
Pan American Health Organization • http://www.paho.org
 Healthy Municipalities and
Communities
 Mayors lead and facilitate joint planning with all relevant
sectors and consensus building on the local priorities, policies
and strategic actions to improve health and quality of life with
equity
 A plan of action based on a participatory needs assessment
and the analysis of the determinants of health in each setting
 Establishing communication among all stakeholders and for
the public to share information on activities, progress,
meetings, etc.
 Implement models based on country experiences and sound
public health and health promotion theory and practice

Pan American Health Organization • http://www.paho.org

 Priorities in the US/Mexico
Border

Environmental Health and Housing

 Water
 Sanitation
 Waste disposal
 Recycling
 Protection of natural
resources
 Environmental
education

Pan American Health Organization • http://www.paho.org

 WHY IS HMC STRATEGY EFFECTIVE?

 Creates strong alliances among local authorities, community

leaders and diverse public and private sectors
 Promotes active citizen participation
 Creates dialogue and mutual sharing of knowledge and
experiences
 Supports democratization and decentralization of decisions
and resources
 Strengthens capacity and provides an ordering mechanism

Pan American Health Organization • http://www.paho.org

 Healthy Cities 1986……

Pan American Health Organization • http://www.paho.org

 Adopción de la Estrategia de
Municipios por la Salud en México
1995-2000

1600

1400

1200

1000

800

600

2000
2000

400

200

0
1995
1995

Mexico

Pan American Health Organization • http://www.paho.org

 The Pillars of HMC: the
Ottawa Charter
 Establishing healthy public policies
 Responding to local priorities by involving all stakeholders:
empowering, developing skills and building capacity
 Creating supportive and sustainable environments
 Incorporating collaboration from multiple sectors and partners
 Creating systems changes through process and outcome
modifications - reorienting services

Pan American Health Organization • http://www.paho.org

 Settings approach
 What can your sector do to create
health?

 What can the health sector

contribute to your goals

Pan American Health Organization • http://www.paho.org

 Key strategic questions
 What creates health and well-being? How well are we
addressing major determinants of health?
  Which investment creates the highest well being? Which of the
determinants should we address as a priority (given a set of
technical as well as political criteria in order to assess feasibility)?

Pan American Health Organization • http://www.paho.org

 Key strategic questions
 Does this investment reduce the health gap and ensure human
rights?
 Will the disadvantaged and vulnerable populations be involved in
developing the strategies and approaches?
 Will policy makers be willing to follow up the community based
recommendations?

Pan American Health Organization • http://www.paho.org

 Key strategic questions
  Does the health investment contribute to overall community
well being? How will we account for the use of resources? What
type of measures will we use?

Pan American Health Organization • http://www.paho.org

 PHASES OF THE STRATEGY (1)

INITIAL AND ORGANIZATIONAL PHASE (1 to 3 months):

Expected Outcome: An Approved HMC Action Plan

 Conduct a participatory community-based assessment
 Create an intersectoral and municipal committee and develop an overall
common vision of HMC
 Develop a proposed action plan with health targets through a
participatory and intersectoral process
 Ensure assignment of resources for the plan by the Municipal Council
 Discuss and disseminate the approved plan through a public forum

Pan American Health Organization • http://www.paho.org

 PHASES OF THE STRATEGY (2)

PLANNING PHASE (4 to 6 Months)

Expected Outcome: A Working Group and Detailed Work Plan
 Ensure representation of members of the Intersectoral Municipal
Committee and of a working group for activity implementation and
monitoring
 Develop a detailed work plan with activities, assigned responsibilities
and resources, a timeline, and indicators for monitoring and evaluation
 Identify strategies to encourage sustained participation and partnerships
for the implementation of the plan and resource mobilization

Pan American Health Organization • http://www.paho.org

 PHASES OF THE STRATEGY (3)

ACTION PHASE (2-3 years and beyond):

Expected Outcome: A Healthy Municipality and Community
 Promote local healthy public and institutional policies, and intersectoral
actions, gap analysis, advocacy, public debate
 Develop a policy framework and infrastructure to support and sustain the
implementation of the Healthy Municipalities and Community strategy
 Create a range of healthy spaces, schools, workplaces
 Encourage politicians and other decision-makers to commit themselves to
community capacity-building, strengthening the HMC Strategy and
ensuring its sustainability and intersectoriality

Pan American Health Organization • http://www.paho.org

 The Mayor’s Kit
Promoting health and quality of life

 Guidelines to initiate the

process following the
three phases
 Technical information fact
sheets on priority public
health programs
 Orientation guidelines
 Quick reference brochure
 Informative page

Pan American Health Organization • http://www.paho.org

 Lessons Learned
 National supportive technical
unit and teams
 Local leadership and
investment
 Effective policy and programs
 Engaging academic
institutions in training,
research, development, and
evaluation
 Strengthening information
and surveillance, indicators
 Networks and networking

Pan American Health Organization • http://www.paho.org

 Lessons Learned
Supportive environments sustain behavior change

Homes
Schools
Workplaces
Marketplaces
Hospitals
Slums
Parks
Streets Life Skills
Education

Pan American Health Organization • http://www.paho.org

 Lessons Learned
Developing skills and
competencies
Capacity building and
strengthening
community action
Nurturing leadership
• Health Literacy
• Communication
• Health Education

Pan American Health Organization • http://www.paho.org

 Production of health?

 A society that spends so much on health care

that it cannot or will not spend adequately on
other health enhancing activities may actually be
reducing the health of its population.”
 Evans/Stoddart 1996

Pan American Health Organization • http://www.paho.org

 The evidence is overwhelming

Health promotion strategies
Brownsville 
Healthy public policy
Matamoros 
Working in partnerships
Tijuan 
Citizen involvement and community
a participation
San Diego 
Empowerment
u ar e z 
Capacity building and training
d . J
El Paso/C 
Intersectorial planning and action

Information, surveillance and evaluation

Public education and communication

Continuity

Democracy

Pan American Health Organization • http://www.paho.org

 Characteristic of settings networks

 Loose governance

 Innovation
 Adaptability
 Learning capacity

 A new space for health

Pan American Health Organization • http://www.paho.org

 Pan American
Health Organization
Regional Office for the
World Health Organization

Thank you very much

Celebrating 100 Years of Health