Print version ISSN 1413-8123
Ciênc. saúde coletiva vol.9 n.3 Rio de Janeiro Jul./Sep. 2004
The authors reply
Os autores respondem
We wish to begin with special thanks to the colleagues who, on very short notice, commented so generously on this article, adding valuable contributions to the topic in debate and to the development of the Health Promotion field in Brazil. We would also like to publicly explain the reason for publishing this debate article in English: far from an attempt to smother "Latium's last flower" [the Portuguese language], as Fernando Cupertino so appropriately warned against, the article aims to foster a closer international dialogue which we intend to expand by sharing these reflections with participants of the 2nd International Conference on Local and Regional Health Programs: Strengthening the Integration of Promotion and Prevention in Health Systems, the theme of which highlights the relevance of this debate.
The HP field, as posited in the article and reaffirmed by the discussants, currently presents a conceptual and operational expansion of the overall health issue, wagering on a redesigning of practices and policies for the reduction of social inequality. An important clarification in relation to the issue raised by Márcia Westphal is that the challenge is to understand social-infrastructure, sanitation, and public health policies in general as "investments" rather than merely as social "expenditures"; therefore, the health sector and the population's health are viewed as a fundamental economic investment for human and social development. The HP field constitutes both a movement and privileged space for critique of the hegemonic biomedical model and prevailing health care practices within a new context of changes in public health (Kickbusch, 2004), where the influence and/or impact of services on health conditions is quite limited. The debate concerning HP actions and programs foster a sectoral agenda for the defense and preservation of health and quality of life against the logic of the market and profit, (re)introducing issues related to the excessive medicalization of practices and the necessary reorientation of health services and systems.
In the current context of globalization and growing complexity of societies as they relate to the need to reduce health inequalities, HP is consolidated through an interdisciplinary approach, inter-sectoral cooperation, and democratic, participatory dialogue. Based on a comprehensive, current discussion of health determinants, HP surpasses the health sector's boundaries to focus on public health policies in dialogue with the range of actors and subjects involved in the multiple social dimensions. HP sees health as a modern right of citizenship, valuing the inherent capacity of social agents to reflect critically on health and living conditions. Empowerment, autonomy, and effective participation by social actors are crucial for the qualification of HP practices and serve as a fundamental dimension for the effectiveness of the proposed changes in health care, management, and local development, as well as in macro development policies, as highlighted by the article. The premise here is that communities, groups, and organizations are active and reflexive agents, shaping policies and practices. The effectiveness and sustainability of the social changes result from this participation and social involvement.
In the debate on the Health Promotion field, a first consensus is that HP is not merely a supply of health actions in poor areas and for unassisted populations, but rather the implementation of more comprehensive strategies and inter-sectoral actions for sustainable development that can impact social inequalities and promote improvement in quality of life and health. The perspective of social development and strengthening of citizenship, as emphasized by Fernando Cupertino in his comments, is a precondition for the success of initiatives in this field.
Another point of consensus and one of the key challenges for the HP field is to transform discourses, principles, and conceptual references into policies and programs, generating effective and sustainable changes including reduction of inequalities and relevant health problems. Citing the recent disarmament policy implemented by the Brazilian Federal government, Odorico and Ivana demonstrate the potential of well-based arguments for developing effective inter-sectoral actions, incorporating the main determinants of the problem at issue. The capacity to generate macro-policies for socially relevant issues clearly highlights the potential for critical reflection on HP approaches and interventions.
Conceptually innovative proposals and practices with plural implementation strategies and committed to equity cannot do without monitoring and evaluation to signal and favor the conditions for success in their results. In fact, the production of "evidence" now occupies an outstanding place in international discussions and forums on evaluation in the Health Promotion field. Yet without a doubt, and agreeing with the comment by Márcia Westphal, the article seeks to view in a relative light and critically analyze this trend, revealing the inherent complexity and limits of evaluation approaches and identification of evidence in HP actions. However, experiences in the evaluation of HP programs and initiatives become indispensable for the analysis of processes, formulation, and implementation and to estimate the results or impact of the proposed interventions, consolidating principles and values in the Health Promotion field.
Let us then consider the debate on evaluation as a strategic theme for the consolidation of the HP field in Brazil and the world, working on the assumption that evaluation should act as a "feedback system" between the program and the context (Potvin et al., 2001), producing useful information for the key actors in the process. Knowledge of the local context variables, appropriately highlighted by Tanaka, is crucial because a program can only function and lead to sustainable changes if it is rooted in (and closely attuned to) local aspirations, needs, and demands. Innovative HP programs using multiple strategies for mobilization and participation, involving diverse actors and inter-sectoral actions, focus on comprehensive social changes with a community-wide scope and not only on epidemiological risk situations, as emphasized by Márcia Westphal, allowing one to perceive the limits of more traditional evaluation approaches.
Further assuming the complex nature of HP initiatives and thus the challenges posed for evaluation approaches, we reiterate how important it is for such initiatives and the corresponding evaluative designs to incorporate the principles of equity when analyzing the effectiveness and/or efficiency of these actions or programs employing public resources. Evidence of the effectiveness of HP actions is particularly important for determining or redirecting approaches, informing the decision-makers, service providers, users, and other stakeholders.
Another point of consensus in the debate is the need to incorporate participatory ("bottom-up") methodologies. In fact, social programs, as in the case of Health Promotion, only work through their actors' diversity and cooperation, where it is crucial for evaluation that local actors identify where to concentrate efforts and exactly where impacts and changes can be felt (Sullivan et al., 2004). We also see a consensus around the need to improve our theoretical and methodological research and evaluation tools in light of the complex nature of HP and local development interventions. Thus, the first "evidence" to be sought relates to the theories of change underlying such actions, based on the knowledge that any program operates on the basis of a given theory and that evaluation is an activity that tests this theory and produces knowledge (Pawson, 2003). The hypothesis is that despite the diversity of local contexts and variables, it is possible to identify common (logical and/or causal) mechanisms which justify the proposed actions and interventions.
However, while we defend this Pawsonian perspective, as expressed by "realist evaluation", it is indispensable to keep in mind the comments by Marcia Hills and Simon on the risk this approach entails if it is treated as a "scientific methodology superior in itself to other forms of knowledge". We support this word of caution against the production of a kind of knowledge based on methodological privileges which lack the "participatory frame" as a principle. By way of conclusion, and drawing further on the same authors' contribution, we would thus like to discuss the limits and difficulties "of demonstrating effectiveness" through the experience of a Canadian Health Promotion project, of (re)opening the (inter)national debate by inviting colleagues to share with us in the search for answers to the question posed by them and that continues to challenge and provide the basis for Health Promotion evaluation (the object of this article), i.e., what type of evidence will convince external funding agencies of the effectiveness of Health Promotion interventions, especially complex community-based work?
Kickbusch I 2004. The end of Public Health as we know it: constructing Global Health in the 21st Century. 10th International Congress on Public Health (WFPHA) Bringhton, UK. (Mimeo).
Pawson R 2003. Nothing as practical as a good theory. Evaluation 9(4):471-490.
Potvin L, Haddad S & Frohlich L 2001. Beyond process and outcomes evaluation: a comprehensive approach for evaluating health promotion programs, pp. 45-62. In IG Rootman et al. (eds.). Evaluation in health promotion. Principles and perspectives. World Health Organization, Copenhagen.
Sullivan JS 2004. In the eye of the beholder: perceptions of local impact in English Health Action Zones. Social Science & Medicine 59:1603-1612