A mapping of ‘ healthy territory ’ initiatives , their characteristics and effectiveness

This paper is part of an excerpt from a study made in eight of the States of the Northeast of Brazil. Its purpose was to map initiatives taken by health organizations of cities, municipalities and communities; to become aware of their mechanisms of operation; and to acquire evidence of their effectiveness, and the characteristics of their key players. Information was collected by internet, telephone, and contact with government and non-government bodies of these Northeastern states. After this collection of data at distance, local visits were made to find out more about each initiative. During the visit a timeline of the activity was recorded, working with local participants. After recording of key information sources, semi-structured interviews were held, and documents analyzed. Under the name of ‘healthy municipality, city or community’, specific initiatives were highlighted in the State of Pernambuco, part of a network that has existed since 2006 and which has been maintained in spite of political and/or administrative changes at both local and State level. Key factors indicated for the effectiveness of the actions in the 23 municipalities were: support of the university; strong engagement of local leaderships; and participation of social movements.


Introduction
The purpose of this paper is to contribute to the field of Health Promotion in relation to formation of the concept of what healthy cities are, and draw conclusions on indicators that will characterize a healthy city/municipality in Brazil.It relates to the partial analysis of a survey financed by a Health Ministry tender, executed by investigators of the Public Health and Social Development Center of the Federal University of Pernambuco -NUSP/UFPE, in the period 2013-2014.
The survey's main aim was to identify the evidences of effectiveness of mechanisms of operating the social agendas of healthy and sustainable Cities, Municipalities and Communities in dealing with the social determinants of health and the promotion of sustainable development in the Northeast of Brazil.
The World Health Organization defines a healthy city not only as a city with a high level of health, measured by indicators of wellness and mortality, but a city committed to the production of health of its citizens; a social development project, that has health and its multiple determinants as a center of attention.This movement gives rise to the establishment of urban policies directed toward improvement of quality of life, with emphasis on inter-sectoriality and social participation 1 .The movement for healthy cities was born with its focus on what is now referred to as urban health and with an eye for the developed countries, and its name has been adapted to the context of Latin America, where it is now known as the Movement for Healthy Municipalities 2 .
In its history, the concept of Healthy Municipalities, based on the prerequisites and guidelines of health promotion, has modified, and new intervention strategies are in the process of development, opening scope for the issues that begin to occupy the local agendas such as poverty, violence, the environment and associative characteristics, in considering their effects on the health conditions of the population 3 .These aspects contribute to programs and initiatives being increasingly complex, including various partnerships, players and contacts.
One of the great challenges in the field of Assessment in Health Promotion and of healthy cities was the difficulty in measuring principles, values and actions that go outside the health sector.These are complex, open interventions, and for this reason the main disseminators of the movement agreed to seek overall evidence of effectiveness, rather than exactitude in objective, direct indicators, thus showing the importance of the subject and of the search for evidence that would make it possible to expand and reproduce the successful experiences, and learn from those that were not successful [4][5][6] .
This view of the subject covers the outlook of acting on the social determinacy of health, which presupposes recognizing equity as a fundamental principal in the formulation of public policies, in the defense of fair distribution of power and resources of every type to favor accessibility to goods and services, making it possible to ensure diversity of ethnicity, gender, sexual orientation and culture 7 .
It is also anchored on the possibility of creating networks of recovery, and convergences to the advocacy of health promotion and in the need for articulation of the agendas of the social movements, events and documents/statements that have taken place all over the world and converge toward recognition of health as a fundamental component for the construction and evaluation of countries and public policies that are focused on sustainable human development.
This is a context for consideration of the Helsinki Statement on Health in All Policies, which puts forward as essential the articulation of international agendas in Health Promotion, Sustainable Development, Healthy Cities/Municipalities, with national agendas.Based on the recognition that health is the biggest target of governments, and the cornerstone of sustainable development 8 , that the challenge of health promotion in Latin America consists of reconciling economic interests with the social purposes of wellbeing for all, and also to work for solidarity and social equity, as indispensable conditions for health and development, there arises the recognition that it is essential to promote the dialogue between health, economics and sustainable development, having socio-environmental justice as the point of view 9 .
Looking at this from the territorial perspective is also important, since it is vital for the sustainability, equity and quality of life that result from actions of health promotion and Healthy Municipalities.Some studies in this field [10][11][12] have discussed the need to look at the territory that is lived in, as the locus for making inter-sectoriality operational, and give a voice to the people who live there, who have their desires and resolve their problems there, and also the already existing, and emerging, social networks, based on the demands and complexities of the territory, the location or the region.
It is known from one recent study 13 that in the Northeast of Brazil there have already been various Healthy Municipality initiatives since the 1990s, in the States of Rio Grande do Norte, Alagoas, Paraíba and Ceará.However, after a study in eight of the nine States (Piauí was not visited) of the region, we confirm the highlight position of the Pernambuco State Healthy Municipalities Network (Rede Pernambucana de Municípios Saudáveis, or RPMS),comprising 24municipalities throughout all the regions of the State of Pernambuco.
As well as carrying out a mapping of the initiatives that exist in the Northeastern region, the studies sought to identify structuring axes, mechanisms of operationalization and articulation, critical factors and responsible and/or qualified players for taking part in the initiatives in Pernambuco, in the ambit of the RPMS.The expectation of this work is to share and disseminate the issues that have been learned from the experience of healthy territories, that can stimulate the debate and reflection on the subject, in the context of management, academia and other interested sectors.

Methodology
Based on the theoretical suppositions and the methodological strategies and tools developed in previous studies on health promotion and equity in the Northeast of Brazil 14,15 , the design of the study included a search for concepts, comprehensions, descriptions, and evidences of Healthy Cities/Municipalities/Communities in the Northeast Region.
The method of the survey was in three phases.Initially, we held orientation/leveling workshops with a technical team of the survey to train 8 students of the following graduation courses of the UFPE:4 in Social Sciences, 1 in Social Services, 1 in Nursing, 1 in Psychology and 1 in Medicine, selected to participate in the mapping of the initiatives via internet, telephone contact, and surveying of the projects financed by the Sustainable Development, Violence Prevention and Peace Culture Unit of the Health Ministry's Health Promotion Network, among others.The training with the interns, and the sharing of concepts and methodology of the study with the technical team, was an interactive process, in dialogue with the International Course in Promotion of Health, Development and Healthy Municipalities, and interdisciplinary and intersectorial training in the workshop Weaving of Knowledge -the Conversation with the World.At the invitation of the DSAST (Environmental and Workers' Health Inspectorate) of the Health Ministry, the technical team took part in a methodology workshop and a visit to the project Sustainable Territories, promotion of equity and health in traditional communities of the Bocaina Mosaic -Brasília and Rio de Janeiro, coordinated by Edmundo Gallo 11 , with the purpose of sharing knowledge and deepening designs for research in healthy and sustainable territories and communities.
We made a bibliographical review on the subject, with a cataloguing of the projects that were financed by the National Health Promotion Network of the Health Ministry (a branch of the Sustainable Development, Violence Prevention and Peace Culture Unit), Health Ministry Projects, a document of the Health Ministry DSAST, theses, dissertations and papers.We listed key words that emerged from studies on healthy municipalities: healthy cities, healthy municipalities, healthy communities, healthy territories and/or sustainable territoriality, environment, inter-sectoriality, social participation, sustainability.These words oriented the search for the initiatives of healthy municipalities in the Northeast of Brazil through the internet, and after they were identified we contacted them by telephone to get to know their initiative better, and to seek to schedule visits and contacts with key information sources for interviews.We had the assistance of student interns from UFPE selected for carrying out this mapping by internet and by telephone contact.Priority was given to contacts with the State and Municipality Departments -health, education, environment, cities, social development, agriculture, and Universities and NGOs.
In the second phase, research instruments were prepared: interview sheets, timelines, informed consent form and a script for an interview to be applied with the players identified in the studies.The interview sheet contains general data, personal identification of the interviewee and of the investigator.The informed consent form was read jointly with the interviewee and signature requested.
The questions were constructed in the form of a script to orient the interview so as to facilitate apprehension of information on the initiative, including: name and objective of the initiative, time of existence, actors responsible for the initiative, capacities and actions developed, principal results, existence of training, intersectorial research and actions, values and principles that orient the initiative, etc.The timeline was used as a tool to assist perception of significant changes in the course of the initiative and help in analysis of controversies 16 , inspired on the sociology of translation 17 .
The third phase was the field work, which took place in eight states.Using the data of the telephone mapping a travel plan was made with pre-scheduling of visits to the initiatives and interviews with the key workers.Using the snowball technique, we amplified the number of key information sources and identification of other local initiatives.The interviews were recorded on an iPad and transcribed for the purpose of analysis.

Results and discussion
Mapping of the initiatives existing in the Northeast Region was successfully carried out, extracting twenty-three of the twenty-four municipalities that take part in the RPMS, since the municipality of Itaquitinga had only recently joined the network.These municipalities had been carrying out Healthy Municipality activities since their joining the RPMS, which was instituted in 2006.Since it is a network with a trend to distributed typology 18 , it is structured on the basis of voluntary work, based on the autonomy of the subjects, in continued formations, grounded on the principles and values of health promotion 19 .The RPMS has operated on various fronts in its quest for improvement of the population's quality of life and health.
After identification of the initiatives in the municipalities of the RPMS, we sought to identify the characteristics of their mechanisms of operationalization and articulation, critical factors and actors responsible for and/or capable of the activity.A large part of those interviewed are promotors of Healthy Municipalities 20 , acting in accordance with the opportunities and possibilities that present themselves in their daily working life, their neighbors, family, leisure and groups of action.The actions range from proposal and formulation of local public policies to micro-actions in the territory, in the quest for improvement of quality of life, development of potentials, individual and collective capacities, on the foundation of the culture that connects and gives meaning to the local experience of belonging.
Although this is only one network and in a single state of the Northeast, the mechanisms of operationalization in each location are very specific and different.We found a range of attitudes to management, from 'local protagonists' to an approach that gave little support to the initiatives of the healthy and sustainable locality.We found some leaders to be committed and active, and others not so much.The Federal University of Pernambuco (UFPE) which has supported the RPMS since its creation, seeks to support and monitor all initiatives.In recent years, as well as accompanying the actions of the RPMS, it has monitored the initiatives relating to prevention of violence, which with the support of the Health Ministry maintains the commitment to training of local managers and leaders in eleven of the 24 municipalities.Chart 1 below summarizes the initiatives of the healthy municipalities studied and their characteristics.
One can see the relationship between municipality support, committed leadership, support from university and/or state government and encouragement to integration between training, research and policy, and evidence of effectiveness.The mechanisms of operationalization involving planning, engagement of the local community, leadership, integration of training and policy showed themselves to be the most successful in sustainability and strengthening of healthy-territory initiatives.
Excerpts from speeches of the interviewees give an idea of the characteristics of the initiatives and the involvement of the actors: The meetings of the RPMS always bring us new things, they always have something good to teach.We have a lot of personal growth.
I have been working in this network since I was a younger girl, right back at the beginning, I had to leave to study, I have now come back.I like to take ideas of sustainability, of healthy living, to the population.
With the Network, one's head, one's perception, in fact changes.You move out of the consensus view and think differently, you evolve and you try to bring the proposal of sustainability to the management of the municipality -the proposal for healthy life and improvement of quality of life.
I feel jealous when other municipalities succeed in getting the support of their management -we haven't got there yet.Sometimes one feels like giving up, but when we see that together we achieve that a lot…..that's why we're here.Brazilians don't give up…..since the beginning we knew that some municipality would come out well, and it was (municipality x) that did, it lives and breathes Healthy Municipality.It's in the life of (municipality x).The conception of cleaning of garbage in (municipality y) has also changed.And this was a consequence of Healthy Municipality.The idea from Shiroi in Japan of dealing with garbage is what we are seeing here.
Figure 1 shows the factors that facilitate and impede the effectiveness and the sustainability of the initiatives.
It is seen that the majority of the initiatives have presented continuity of the actions proposed, in spite of changes in local and state policy and administration.The commitment of the local managers and the existence of committed leaderships allied to effective external support, whether from the university, or the state government, are the most important factors for the activities to be maintained.Encouragement for training and/or research has the same weight and should be associated with the factors mentioned.Constant monitoring by the university supporting local leaders and offering training, workshops, and spaces for reflection and dialogue, have been reported as fundamental factors for sustainability of the initiatives.The municipalities where local managers involve themselves directly with the principles and values of the movement for healthy municipalities make more progress, as for example the municipality of Sairé, where the management is being indicated by local municipalities as a model and significant changes in the feeling of belonging, and in the population's commitment are easily measurable and visible, and the municipality has adopted the 'brand' of 'healthy municipality' as a mark of its management.The presence and persistence of committed leaders is necessary in the process of making the proposals effective.
It has been confirmed that the initiatives that maintain training programs are more effective and more sustainable.However, it needs to be noted that one cannot invest in the development of abilities and in training without the responsible institutions, working groups or networks also being strengthened 14,21 .Further, it is necessary to look at the role of the local leaders and actors that take part in these training and teaching activities and provide continuity for the actions.The desires, interests and controversies of these actors need to be accompanied to make it possible to mobilize around the implementation of activities of programs and projects, and maintain them.

Final Considerations
This new study reaffirms previous studies 14 on the effectiveness of these initiatives.It is found that the involvement of local management, committed leaders, maintenance of a specific teaching experience for the intervention, inter-sectorial collaboration, existence of a collectively built social technology (the Bamboo Method),  realization of the importance of reflexive action through systematic monitoring and evaluations, the support of Brazilian partners/investigators -these factors, among others, led to these interventions seeking effectiveness and permanence and showing greater stability than in other municipalities of the state.Since this is a health promotion experience, and further, a network experience, effectiveness and sustainability were not related to routine-ization of activities.In these cases, it is preferable to carry out complex analyses 22 and agree what signifies sustainability and also effectiveness for a given initiative.Scheirer and Dearing 23 say that, although routine-ization is important, it is not a synonym of sustainability, because sustainability is influenced by the characteristics of the intervention, the organizational team and structure and the environment (financial, political,  cultural).
In this mapping of the present activities of the municipalities in the RPMS we have looked at the specific characteristics depending on the local contexts.Not all of them use the Bamboo Method -which was designed specifically for this Network -as was intended, and not all the municipalities encourage the integration of playing/ learning with local practices, research or policies.The municipalities that were the pilot entities for the formation of the Network continue to be the most involved and the ones that are closest to the UFPE.The relationship of trust established and the cognitive support also appear as factors favoring success in initiatives of this type.

Collaborations
MSMF and RPSS worked on the conception, introduction, methodology, research of data, excerpting of the study, analysis and final approval.RMP Franco de Sá worked on the conception, critical review, summary and final approval of the paper.

Chart 1 .
Summary of the initiatives of healthy municipalities and their characteristics.In the Right Measure Project: physical activity in control of diabetes and hypertension • Healthy food in schools • Tourist activities • Education and health in festivities • Health and Reforestation Fair • Old people's group • Theater and dance group • Production of artisan products • Activities in environmental education and combat of the use of drugs with Quilombo and indigenous communities of the Fulni-ô group • Old people's group • Articulation of environmental education and artisan production for promotion of health and healthy municipalities • "Warriors in quest for change" martial arts group • Gender violence prevention women's support group • Prevention of sexually transmissible diseases • Healthy Environment -art and culture promoting the Healthy Municipality • Healthy School: actions in environmental education and prevention of violence in the schools • Artisan and environmental groups • Camociense Center for Support to the Disabled (CECAPED) • Creation of 'citizen house' to welcome victims of violence • Health promotion and prevention of violence center • Standardization of stalls in front of schools, adaptation of products sold, and stimulus to generation of income Characteristics • Support from university and from the government of the state • Continuity of the actions proposed • Local initiatives led by the Education sector • Support from university • Continuity of the actions proposed • Intersectoriality in the local management • Support of the local management • Continuity of the actions proposed • Diversity with focus on the local culture • Territorialized initiatives • Support from the local management and the university • Continuity of the actions proposed • Cultural diversity • Engagement of social movements • Training and practice operating together • Application of the Bamboo Method • Support from local management • Continuity of the actions proposed • Training, research and practice between community and university • Strong leadership in the area of human rights and prevention of violence • Integration of policies • Application of the Bamboo Method • Support from university • Continuity of the actions proposed in spite of little encouragement from local management • Training, research and practice between community and university • Permanence of qualifications acquired • Policies for youth in dialogue with healthy municipalities • Application of the Bamboo Method • Continuity of the actions proposed • Training, research and practice between community and university • Strong local leaderships in the area of environment, prevention of violence and gender sporting activities, artisans' group • Group of young people to discuss health promotion and sexuality • Old people's center with health promotion activities • Bee keeping group with native flora for generation of income • Environmental education • Bela terapia School of happiness by the Okada health method • Healthy environment and local development • Generation of income for (female) shellfish vendors • 'Flag of Peace' young people's group • Work with old people in the country areas • Project: • Cuisine based on banana produced locally • Group of embroidery artisans • Old people's group • Physical activity in the town square • Old people's group • Artisans' group • Preservation of historic and cultural heritage • Community theater • Artisans' group • Old people's group Characteristics • Leadership in the area of organic agriculture and artisan production • Participation of social movements • Support from the state government • Community engagement • Support from local management • Training and practice • Strong leadership in the environmental issues • Sense of belonging to the location • Redemption of 'city of flowers' culture • Support from the state government • Empowerment of women • Leadership in local development • Local teams committed • Strengthening of citizenship and local culture • Sense of belonging to the location • Support from the local management • Strong integration with the PSE • Intersectoriality in local management • Leadership in environmental issues and healthy diet • Sense of belonging to the location • Local culture highlighted • Local development • Integration of policies • Focus on the local culture • Local management distanced from the RPMS • Isolate initiatives • Management distance • Municipality de-structured by climate accident it continues I love the Healthy Municipality Project, this project (sic) has my very personality.It takes work like an army of ants for the work not to die off.

Figure 1 .
Figure 1.Factors that facilitate, and impede, effectiveness and sustainability of the initiatives of the Pernambuco Healthy Municipalities Network.Source: Authors.