Background: From 1994 to 1999, the Ministry of Health, together with the Pan American Health Organization and supported by the leadership of the mayors, promoted the project "Municipalities Towards Health" in Venezuela, whose main objectives focused on the implementation of healthy public policies that sought to reduce and mitigate the consequences of social inequalities; through the interaction of governmental and non-governmental sectors such as agriculture, commerce, education, sport, industry, among others; and in this way, establish a local culture of governance for health and wellbeing through community projects, for which a methodology was designed. This effort, which had been advanced in 75% of the country's federal regions, was interrupted due to a change in government and project management; however, thanks to iteration in inclusive citizen participation, health promotion activities became sustainable over time. Among the facilitating factors that marked these processes, the strengthening and consolidation of social capital stands out. Methodology: In this qualitative research, we attempt to demonstrate the importance of social capital in this process. The knowledge emerged from the focus groups conducted in the five municipalities with the greatest unsatisfied basic needs at the beginning of the project and involved a total of 200 actors, who recounted their inter-subjective relationships experienced between 1994 and 2013. This evidence was systematized into four constructs that characterize social capital as a determinant of health: sense of community, collective efficacy, community capacity and community competence. We also compared the results in relation to its impact on life expectancy and infant mortality. Results: Psychological sense of community or sense of community. Solidarity and social responsibility were the cardinal principles that facilitated the organization of communities through the union of networks that privileged the promotion of health. From this emerged a group identity to generate their own political culture, promoting social roles, customs and ethical norms such as co-responsibility, freedom with shared social objectives, commitment or the capacity to promise, critical capacity based on trust and the constant will to practice justice; in this framework, they built a participatory agenda through dialogue and agreement with all social, political and economic forces. Collective efficacy. Through a series of acquired values and behaviours such as mutual trust, an inclusive higher identity that allows social identities to overlap, and cooperation for the common good, organised communities gained greater access to decisions, driving negotiated projects that guaranteed their citizenship rights. In this perspective, the government committed itself to facilitating technical and political decision-making through deliberative actions leading to negotiated proposals. To consolidate this process, a number of joint mechanisms for monitoring targets were formalised in different types of collective spaces to inform communities of progress over time. Community capacity. Participants built and coalesced around networks through which they acquired new competencies and skills, and various advocacy mechanisms and technical procedures were established to assist in the implementation of these initiatives. In this way, communities, local government teams and government agencies consolidated their leadership style. Community competences. In these initiatives, the community acquired the competencies to articulate with the government and various public and private institutions. This organisation, a product of the balance between solidarity, social justice and the rights of communities, allowed for targeted, planned and constructive behaviour that provided the triggers and political legitimacy for the elaboration of the social contract that privileged the promotion of health and well-being. Health impact. Life expectancy at birth increased between 0.6 and 4.5 years. The infant mortality rate decreased between 4% and 44%. In this sense, the municipalities with the greatest basic needs satisfied made impressive progress, as evidenced by the fact that the interactions carried out in populations with greater social capital provide greater possibilities of intervening on avoidable and unfair factors that condition differences in life opportunities. Conclusion: The research highlights the need for early recognition of the role that community networks and other citizen activities can play in promoting positive health and wellbeing outcomes through participation An active and resilient citizenship was able to build participatory agendas to interact on the social determinants of health, whose fundamental political objectives were the satisfaction of basic needs in vulnerable populations; The effective development of these agendas was associated with an accelerated process of building social capital to achieve positive health/quality of life outcomes in various sectors through the implementation of healthy public policies; The empowered and effective citizens who helped bring about these democratic gains and benefits did not automatically achieve their goals. New forms of governance and the mobilization of extraordinary public and private resources were also very important; Strengthening these citizen participation processes along with political will and supporting mechanisms, such as interactive methodologies and broader legal instruments, created opportunities to improve government responsiveness; andIt is from the sustainability of these events that citizen participation took on a new cultural significance for the governance of health and well-being. Recommendations: These findings have a number of implications for community associations and policy makers as well as donors and development agencies, which in turn can contribute as a resource for political negotiation in building responsive governments towards health-in-all-policies approaches: A long-term social pact that consolidates political support from the highest authority at each level of government is needed to develop different legal, social and economic structures that engage organised communities; The conceptual and methodological capacity of the different actors involved needs to be strengthened in order to systematically preserve the model in the context of conflicts of interest exacerbated by strictly sectoral judgements in public institutions and the community in general; and Financial sustainability needs to be ensured to maintain structures and processes in the presence of economic uncertainty and the discretionary will of the government of the moment.
Venezuelan/German doctor with a PhD in Political Science and a Masters in Public Health Administration; with courses in Local Development and Social Management in Health and in Management Design of Social Policies and Programmes. He has held various positions in the Venezuelan Ministry of Health at local, state and federal level. He has also represented Venezuela as Temporary Advisor to PAHO/WHO in several countries. He is currently Advisor to the National Academy of Medicine of Venezuela and the Venezuelan Society of Public Health.iedad Venezolana de Salud Pública.
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