Health Promotion International Advance Access published online on September 7, 2007
Health Promotion International, doi:10.1093/heapro/dam025
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Article |
Emergence Model of social and human capital and its application to the Healthy Municipalities project in Northeast Brazil
1Bureau of International Cooperation, International Medical Center of Japan, Tokyo, Japan 2Center of Public Health and Social Development, Federal University of Pernambuco, Recife, Brazil 3Planning and Research Agency, State Government of Pernambuco, Recife, Brazil 4Department of Social Health Science, School of Health and Sports Science, Juntendo University, Inba, Japan
* Corresponding author. E-mail: yuamokun{at}yahoo.co.jp
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONAN EMERGENCE MODEL OF...THE HEALTHY MUNICIPALITIES...DISCUSSIONREFERENCES |
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We developed the Emergence Model and introduced the concept of social and human capital into designing and evaluating the Healthy Cities/Municipalities project to ensure health promotion infrastructure. This model hypothesizes that through the interaction and utilization of the other forms of capital, namely financial, physical and natural, the emergence of collective action takes place in the community or municipal setting. Subsequently, collective action may influence health and quality of life determinants. Once health and quality of life improvements are achieved, the enhancement of the social, human and other capital may be brought about through positive feedback, and successive collective action is thereby facilitated. According to the model, practitioners and policy makers of the Healthy Cities/Municipalities project should primarily strengthen social and human capital.
The model is currently applied to designing the Healthy Municipalities project implemented in rural areas of Northeast Brazil, where infrastructure and a supportive environment to facilitate collective action for control over health and health determinant have been considerably frail due to geographical, historical, social and cultural reasons. Various interventions have been conducted in the scope of the project to enhance social and human capital on three levels, namely the state, municipality and community. Through the capacity development of health promoters, obliging volunteers and so on, the project attempts to create the social mechanism that enables people to build healthy public policies through inter- and trans-sectoral collaboration as well as to address and resolve day-to-day issues using their potentialities.
Key words: Healthy Cities/Municipalities; social capital; human capital
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONAN EMERGENCE MODEL OF...THE HEALTHY MUNICIPALITIES...DISCUSSIONREFERENCES |
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In 1988, The World Health Organization (WHO) initially launched the Healthy Cities/Municipalities Campaign in 34 European cities (Norris and Pittman, 2000
). In 1995, the program expanded to five cities in developing countries (Harpham et al., 2001) and has recently become a worldwide health strategy. A number of diverse activities in the Healthy Cities/Municipalities program are not finished products, as it is an ongoing endless process concerned with a daily-life continuum. It encourages untapped human resources, organizes collective actions, controls health determinants, improves health and monitors health and life outcomes, and the process is repeated without interruption.
However, practitioners and policy makers of the Healthy Cities/Municipalities program are often required to implement activities such as a ‘project’ with a specific duration, restricted budgets and explicit objectives. To manage and monitor the project efficiently, practitioners and policy makers seek a framework designed for both practical and theoretical application. A number of models and frameworks have been developed and applied to actual cases (Flynn et al., 1991; Israel et al., 1994; Purdey et al., 1994; Fawcett et al., 1995). Although many of them are based on an empowerment theory, there are only a few models dealing directly with the relationships and interactions of social and human capital.
Social capital and infrastructure for health promotion
As well as human capital regarding human capabilities and techniques situated within the individual, social capital is the interaction and relationship between people to be a currently noteworthy concept for addressing social factors such as social networks, social support systems, institutions, trust, norms and so on (Coleman, 1988). As Hancock states, ‘it constitutes the "glue" that holds our communities together’ (Hancock, 1999). It is generally acknowledged that collective action may be established with a greater degree of ease in communities with well-accumulated social capital (Coleman, 1988; Putnam, 1993). Such social capital can influence health as social and environmental determinants (Kawachi et al., 1997; Keating, 2000; Kawachi and Berkman, 2001) and encourage people to promote collective action. Therefore, social capital plays a crucial role in the Healthy Cities/Municipalities program (Hawe and Shiell, 2000).
Attention has recently been called to the need for adequate infrastructure for the feasibility and sustainability of health promotion activities (Tang et al., 2005). The concept of infrastructure was initially discussed at the Fourth International Conference on Health Promotion in Jakarta (WHO, 1997) and raised again at the Fifth Global Conference in Mexico City (WHO, 2000). Through these discussions, it was made clear that infrastructure does not imply developing new bureaucracies or centers, but building upon what already exists, strengthening the capacity to act, developing the proper mechanisms for such and, in turn, moving away from traditional vertical structures toward networking structures (WHO, 2000). This structure of health promotion is not like the integrated horizontal stratums of health services in primary health care strategies (Duane et al., 1988). It is a broader structure, including components beyond the health field. The term ‘infrastructure’ is defined as the human and material resources, organizational and administrative structures, policies, regulations and incentives which facilitate an organized health promotion response to public health issues and challenges. This concept encompasses primary health care, government, the private sector, nongovernmental organizations and self-help organizations, as well as dedicated health promotion agencies and foundations (WHO, 1998). The infrastructure discussed at the above-mentioned international conferences can be regarded as human, social, material and institutional resources for constituting a supportive environment or setting for health, whereby the concepts of both social and human capital can be utilized to design the infrastructure for the Healthy Cities/Municipalities project. Although there have been a large number of academic papers emphasizing the importance of the concepts of both forms of capital, few articles have addressed a model for designing the infrastructure of the project using such concepts. Thus, the authors of this article have attempted to develop just such a model. The aim of this paper is to delineate a model of a health setting using both social and human capital and demonstrate an example designed by the model.
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AN EMERGENCE MODEL OF A HEALTH PROMOTION SETTING |
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TOPSUMMARYINTRODUCTIONAN EMERGENCE MODEL OF...THE HEALTHY MUNICIPALITIES...DISCUSSIONREFERENCES |
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The British Department for International Development (DFID, 1999) addresses a patrimony in which there are five forms of capital for enhancing human well-being, namely physical (substance and goods), financial (property and money), natural (natural resources), human and social capital. Hancock (Hancock, 1999
) classifies all wealth under four forms: human, natural, social and economic capital. The World Bank also acknowledges the existence and importance of these forms of wealth. According to the discourses, we can suppose that these four or five forms of capital describe every social and human activity and phenomenon in a given society. The authors of the present article use the five-capital classification for distinguishing financial capital from physical capital.
Figure 1 displays the model we developed using the five forms of capital. It outlines a flow of health promotion action in a particular setting for the Healthy Cities/Municipalities project. Initially, the project intervenes in the setting through the five health promotion actions listed in the Ottawa Charter (WHO, 1986), which are schematized at the bottom of the figure. The interventions would enhance and strengthen the five forms of capital existing within and/or outside of the setting. As long as the interventions last, interactions would be brought about especially between social and human capital. When both forms of capital become considerably enhanced, interacting with one another and able to make use of other financial, physical and/or natural capital, collective action of those within the setting would take place and would influence environmental, human and/or social determinants of health and quality of life. This phenomenon is known as ‘emergence’, a term from complexity science, which is defined as the process of complex formation from simpler rules (http://en.wikipedia.org/wiki/Emergence). Throughout the collective action, diverse stakeholders in the setting could interact and dynamically utilize various financial, physical and/or natural resources. As we are concerned with the occurrence of collective action, we have named it the Emergence Model of health promotion setting.
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This model leads practitioners and policy makers of the project to pay particular attention to two forms of social and human capital as an explicit target point for the intervention. Human capital includes health literacy as well as general literacy. Health literacy implies the achievement of a level of knowledge, personal skills and confidence in taking action to improve personal and community health by changing personal lifestyles and living conditions (WHO, 1998
). Therefore, health literacy is a key target point for intervention of the Healthy Cities/Municipalities project (Kickbusch, 2001; Ratzan, 2001). Social capital is also an important focal point of the intervention of health promotion activities. Social capital encourages various individuals in the setting to come together and initiate collective action for improving health (Kunitz, 2004) and is one of the mechanisms by which people gain access to financial and physical resources (Baum and Palmer, 2002). These perspectives support the model in which the collective action emerges in the setting with well-accumulated social capital as well as human capital and influences health determinants by using and developing existing resources within and/or outside of the setting. Indeed, social capital has a range of variants in different social contexts (Edmondson, 2003), but it can generally be seen that social capital is likely to promote collective action and access to resources. Once collective action emerges and achieves improvements in health or the quality of life, positive multidimensional feedback takes place in the setting. This achievement may inspire the people connected to the action and strengthen their self-reliance, self-determination, motivation and/or skills. It may also facilitate the emergence of sequential collective actions through the rule, social system, legislation or procedure that was already developed in the way which the first collective action took place. Thus, a successful experience within the setting should enhance capital and generate a positive spiral of empowerment.
The model indicates that intervention in the five forms of capital ensures the formation of infrastructure for health promotion, as such infrastructure consists of human and material resources, as well as social capital such as organizational and administrative structures and policies. The model reveals the significance of investment and the dynamic reaction in all forms of capital, but prioritizes the operational input to both social and human capital. Thus, the model is one of the human-centered developments, and the other three forms of capital are merely means and resources.
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THE HEALTHY MUNICIPALITIES PROJECT IN BRAZIL USING THE EMERGENCE MODEL |
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TOPSUMMARYINTRODUCTIONAN EMERGENCE MODEL OF...THE HEALTHY MUNICIPALITIES...DISCUSSIONREFERENCES |
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Project background
Although Brazil is an economic powerhouse, with a gross domestic product ranked 10th in the world (World Bank Statistic, 2006), it has the widest income gap, with the 8th worst Gini coefficient of all countries. The northeast region of the country in particular has suffered economic and social underdevelopment due to an arid natural environment and remnants of the ancient colonial era. As in the past, when a small number of landowners sustained the lives and health of their workers, a sense of ‘paternalism’ toward the public, derived from such colonial patriarchy, is still a commonplace occurrence. Political vulnerabilities, such as the complete interruption of policies due to a change of government administrations, a lack of financing, poor governance, restricted civil participation and limited intersectoral collaboration, are also commonplace. There are human resource problems in rural areas that are difficult to solve: a lack of human resources, few non-governmental organizations and a poor sense of trust among people. Furthermore, the poor general and health literacy of the public makes untapped resources of the potentiality and opportunity for development. These psychological, social, political and human issues have hindered the process of empowering people and improving health and the quality of life.
The formation of an infrastructure and supportive environment is required to help people overcome obstacles and bring about autonomy in carrying out individual and collective actions geared toward good health and well-being. Thus, in 2003, the federal government of Brazil launched a project to ensure infrastructure and a supportive environment for health promotion, namely the Healthy Municipalities project in Northeast Brazil, with a duration of 5 years, supported by a technical assistance from the Japan International Cooperation Agency (JICA).
Framework of the project based on the Emergence Model
The Center of Public Health and Social Development (CPHSD) of the Federal University of Pernambuco and the Planning and Research Agency of the state government of Pernambuco (PRAPE) are currently implementing the project in which both institutions support the five rural municipalities as pilot areas located in the inner scrubland region of the state with a distance of 
140 km from the state capital of Recife. The Human Development Index (HDI) of the five municipalities in the year 2000 averaged 0.588, which was near the mean HDI (0.554) for lower income countries throughout the world (Human Development Report, 2000). Among the total of 97, 295 inhabitants in the region (2000), most are considerably poor and engage in tomato, orange, sugar cane and livestock agriculture.
On the basis of the concept of health promotion, the project should lead people to change their awareness and concepts regarding value into more autonomy and democracy. To address this challenge, the CPHSD and PRAPE have designed the framework of the project that aims to encourage people to take collective action autonomously through an advocacy of the concept of health promotion and healthy municipalities and generate supportive social mechanisms that enable the people to do so. In other words, the objective of the project is to enhance both human and social capital.
The enhancement of both forms of capital has been implemented on three levels, namely, state, municipality and community. Table 1 shows the concrete items related with both forms of capital at each level. The state level centers on the CPHSD and PRAPE institutes for strengthening networks and the capacity of persons connected to the project. The CPHSD should be a referral center of health promotion to provide skilled technicians, relevant information, training courses and networking to the pilot-municipalities where the Healthy Municipality project is conducted. The PRAPE needs to be an institute for generating healthy public policies through which subsidies and policies from the federal and state governments are provided to the municipalities. Thus, both institutes have the function of offering the five forms of capital in the exterior setting of the municipalities and communities and also of enhancing the five forms of capital in the interior setting. On the municipal level, health promoters and obliging volunteers are the main human resources. The former are selected by the people and trained during a special 7-day course offered by the CPHSD. They coordinate various activities of the project, mediating between people and local government and promoting intersectoral collaboration. The most crucial function of the health promoters is to engage in the ‘Venue for the Articulation and Promotion of Healthy Public Policy’, where representatives of the people and the municipal staff collaborate in constructing healthy public policies. The latter are volunteers whose role is to encourage non-participants to join in and to inform people of project activities. They thereby enhance social capital such as networks, rules, procedures and norms through the participation of diverse stakeholders. On the community level, there are meetings for people to create group objectives and achieve them using as much of their potentialities as possible. Objectives should not be addressed through a problem-oriented approach, but through an ideal-oriented perspective with regard to day-to-day living and health, and be accomplished through self-potential, acceptable methods and affordable resources. The community approach respects the principle of self-help so as to empower the community and promote a sense of collaboration and trust among the people.
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This project is primarily focussed on enhancing human and social capital at the state, municipal and community levels, respectively. Thus, financial and material assistance have been limited. It is expected under the project that even if initial collective action is very small, it gradually increases the quality and quantity of human and social capital as well as financial and physical capital and grows to greater collective action through the positive spiral of empowerment.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONAN EMERGENCE MODEL OF...THE HEALTHY MUNICIPALITIES...DISCUSSIONREFERENCES |
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It has been acknowledged that interventions in the community surely bring about some results (Itzhaky and York, 2002
). However, a review of 32 community-based health promotion programs was reported to have had only modest impact (Merzel and D'Afflitti, 2003). The issue here is how to evaluate these activities. An assessment of community-based health promotion is different from a methodology for assessing an individual, and if an improper measure is applied to health promotion activities, it could mislead decision makers regarding the value and potential of such activities (Shiell and Hawe, 1996). Therefore, development of a methodology for evaluating health promotion activities in the community is of practical importance in order to advocate and diffuse the health promotion approaches. For such, the concept of social capital is useful. The measure of such capital has been developed through efforts of a large number of researchers and practitioners. The SOCAT (Social Capital Assessment Tool) (Krishna and Shrader, 1999) and the SCIQ (Social Capital Integrated Questionnaire) (Grootaert et al., 2003), for example, are useful measurement tools.
As the Healthy Cities/Municipalities activities are complexity phenomena, as mentioned earlier, the sum of individual activities does not indicate the whole. Diversity and reciprocity in such activities should be evaluated (Axelrod and Cohen, 1999). Therefore, the introduction of the concept of social capital, representing diversity and reciprocity in the design and evaluation of the Healthy Cities/Municipalities project, may lead to improvements to the project assessment process as well as further understanding of the impact and values of the health promotion approach.
Social psychologists Turner and Killian (Turner and Killian, 1987) assumed there is no uniformity regarding the motivations of participants in collective action and asked how individuals with different motivations can join forces for collective action. They reached the conclusion that collective action results from the formation of an emerging norm among people, shifting from chaos to order. This norm is a form of social capital, which is an important aspect to consider, as it enables people to move in a single direction through collective action.
We can understand that in Figure 1, the five health promotion actions described in the Ottawa Charter signify the ‘input’; the interaction of the five forms of capital in the setting is the ‘process’; the stage of emergence of collective action is the ‘output’; the change of various determinants of health and quality of life through collective action is the ‘outcome’ and the improvement to health and quality of life is the ‘impact’.
Beaglehole et al. (Beaglehole et al., 2004) state that collective action is the key strategy of modern public health theory and practice in the new era. As collective action is indispensable to the Healthy Cities/Municipalities project, contemplating a collective action mechanism is an essential part of designing and evaluating the project. The Emergence Model draws the attention of practitioners and policy makers of the project to the mechanism through which collective action occurs. The model emphasizes the significance of initial investments in social and human capital, and that other forms of capital, such as financial, physical and natural capital, are not always necessary, though they facilitate collective action. Furthermore, the model shows that social and human capital can ensure the infrastructure for health promotion. Through positive feedback, the achievement of improving health and the quality of life will in turn enhance social and human capital, and thereby facilitate subsequent collective action. The mechanism for amplifying both forms of capital, as well as financial and physical capital, may generate entrepreneurship in the setting as well (De Leeuw, 1999).
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ACKNOWLEDGEMENTS |
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We would like to express special gratitude for all our colleagues who collaborated with the development of the Emergence Model and helped apply it to the Healthy Municipalities project in Northeast Brazil.
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