FEDERAL UNIVERSITY of RIO GRANDE DO SUL School

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Analysis of the Urban HEART Methodology and its Applicability to Urban Health in the Restinga Neighborhood

Projeto Saúde Urbana-UFRGS/Urban HEART Kobe Center/PAHO/WHO

The Restinga Neighborhood

August 2014

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Foreword

This study was proposed as a PAHO/WHO urban health survey and initially foresaw the analysis of feasibility of the implementation of the Urban-HEART methodology and to assess how a private hospital and referral center of excellence (Hospital Moinhos de Vento) could have an impact on the Restinga, a low-income neighborhood in the city of Porto Alegre, Rio Grande do Sul, Brazil.

The study was designed to be conducted in three stages: i) local health governance, ii) measurement of health inequities, and iii) a proposed methodology for impact identification—new indicators of local sustainable development.

It was idealized by members of the Extension and Research Program in Urban Health, the Environment and Inequalities of the Department of Social Medicine at the Federal University of Rio Grande do Sul (UFRGS) School of Medicine. For many years, this group has researched topics such as health promotion, social inequalities in health, urban health, and economic burden of disease.

Work was coordinated by Professor Roger dos Santos Rosa, MD, PhD, with the assistance of Professor Maria Inês Reinert Azambuja, MD, PhD, Professor Aloyzio Cechella Achutti, MD, and Morgana Carollo Fernandes, RN. The study was funded by the WHO KOBE Centre and reviewed and improved by Paulo Fernando Pizá Teixeira, regional advisor for urban health, and Dr. Oscar Mujica, regional advisor for social epidemiology, both of the PAHO/WHO Special Program for Sustainable Development (SDE), who promoted seminars and meetings with a variety of institutions and stakeholders—including faculty from several UFRGS departments, Hospital Moinhos de Vento personnel, community organizers, and government technicians—to make this study possible.

Acknowledgments

The authors would like to thank:  The WHO KOBE Centre for Health Development, for funding the preliminary diagnosis presented herein;  Dr. Luiz Antonio Nasi, Chief Medical superintendent of Hospital Moinhos de Vento, and his team, for facilitating and participating in several stages of this study;  Ms. Jenny Sherr for proofreading and final layout;  PAHO personnel at Brasília and Washington, D.C., for their support; Also to the personnel of 2

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

 “Citizen Security Observatoty of Rio Grande do Sul”,  ILEA,  Metropolis Observatory- ObservaPOA,  IFRS,  “Peace Territories Coordination of RS,  Brigada Militar and All those who made this study possible.

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Introduction

The underlying hypothesis of this study was that the establishment of a large hospital in a low-income community could constitute a major stimulus to local development, not only by improving the delivery of services (sanitation, citizen security, public transport, telecommunications, etc.) to the local population but also by creating jobs, generating income, and encouraging the implementation of other economic activities.

The study first describes the population and territory of interest to this study, municipal government commitments to sustainable development, and mechanisms for social participation implemented in the city of Porto Alegre, such as the municipal health and urban development councils and the Participatory Budget.

Finally, it reports on the implementation of a unit of Hospital Moinhos de Vento— a renowned private hospital—that will treat patients exclusively under the Unified Health System (SUS) framework in the outlying Restinga neighborhood, and is believed to have the potential to drive local urban development. This section presents the model for universalization of health services employed by the Brazilian SUS, as well as aspects concerning urban governance and social participation.

Hospital Moinhos de Vento

In line with the expectations of the WHO KOBE Centre for Health Development1, this project sought to identify and enable information exchange on initiatives and partners relevant to the development of metrics for monitoring of sustainable development and social inequalities in health at the local level. Toward this end, we conducted a review of the literature to search for historical information on the Restinga neighborhood and interviewed people and representatives of institutions of reference,

1 Report of Consultation Meeting on Urban Health Metrics Research, 23–25 February 2011. World Health Organization, Centre for Health Development (WHO Kobe Centre), Kobe, Japan. 4

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

local leaders, and local media, in an attempt to meet the first step (community outreach) advocated in the Urban HEART User Manual.

Furthermore, the “Nossa São Paulo” project was used as a reference and model to guide development of the proposal, and several meetings were held with Hospital Moinhos de Vento staff and local residents.

The main source of data on health and intra-urban inequalities used in this study was ObservaPOA.2 Additional information on health and urban development in the Restinga neighborhood were obtained by searching the minutes of Porto Alegre city councils and by exchanging information with other UFRGS faculty and with representatives of local institutions and community organizers.

Joint planning of activities sought to bridge diagnosis and intervention. The mere presence of the investigators and their communication with the various players in the community was expected to promote and encourage change and new metrics, in a virtuous cycle of social improvement.

The Post-2015 Development Agenda, launched in 2012 by the United Nations,3 mandates two core tasks for multilateral organizations (such as PAHO/WHO) and for all countries: (i) to reach the Millennium Development Goals (MDG)i where they have not yet been reached; and (ii) guide the world toward a path of greater sustainable development. The Agenda is meant to be “unified” and “universal”. The goals of this Agenda are to be implemented starting 2015, but they will first be discussed at the UN General Assembly in September 2014. Urban issues such as the eradication of poverty, the eradication of urban segregation, and socially and environmentally sustainable development will be at the center of the debate.5

UN General Assembly

2 Observa-POA (Observatório da Cidade de Porto Alegre). Website: http://www.observapoa.com.br/

3 http://www.un.org/en/ecosoc/about/mdg.shtml, last retrieved 13 November 2013. 5

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

This project seeks to cover three aspects at different stages in Porto Alegre: (i) to describe local health governance; (ii) to test the feasibility of using Urban HEART indicators to assess and monitor social and health inequalities at the intra-urban district level; and (iii) to assess, with the involvement of stakeholders, the possibility of testing alternative metrics for monitoring of modifications in sustainable development at the local level. These three aspects guide the three main sections of this document.

Context

As many other cities and regions worldwide, Porto Alegre has undergone a process of accelerated rural-urban transition, which has worsened social inequalities and the living and health conditions of the population4.

In Brazil, the urban population rose from 12 million in 1940 to 138 million in 2000, i.e., it grew eleven-fold in the space of 60 years, whereas the rural population largely remained stable and has recently been decreasing (Fig. 1).

Figure 1. Progression of the Brazilian population stratified by rural or urban residence, 1940-2000.

180 160 140 120 100 80 60 40 20 0 1940 1950 1960 1970 1980 1990 2000 Urban 12 19 31 52 80 111 138 Rural 28 33 39 41 38 36 32

Source: Brazilian Institute of Geography and Statistics (IBGE)

The capitals of Brazilian states became natural magnets for large contingents of the population. Between 1940 and 2010, Porto Alegre grew 5.6-fold in population to

4 In Europe, the populations of London and Paris grew fivefold – and that of Berlin, tenfold – in the 100 years that followed the Industrial Revolution. Between 1820 and 1845, Villermé in France and Chadwick and Engels in England provided arresting descriptions of the living conditions and health status of workers. The precarious living conditions of the time were conducive to massive mortality during epidemics, particularly the cholera epidemics that struck London in 1833, 1848, and 1849. Nevertheless, tuberculosis, pneumonia, and influenza were possibly the leading causes of death in adults. Child mortality was a sensitive marker of social and environmental disparities. Whether comparing country and town, middle-class and poor city blocks, or districts with low and high population density, child mortality was always higher in the latter. In the U.S., the impact of urbanization on living conditions is reflected by the progression of child mortality rates in New York City: 145 per 1,000 live births in 1810, 180 per 1,000 in 1850, 220 per 1,000 in 1860, and 240 per 1,000 in 1870. In Latin America, the pace of urbanization increased in the 1940s, and by the 1960s, the ratio of rural to urban populations in the region had already inverted (Figure 1).

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

accommodate 800,000 more people than its 270,000 residents of 1940. Its current population is 1.4 million.

Figure 2. Progression of the populations of Porto Alegre and São Paulo, 1900-2010.

Porto Alegre São Paulo 2000000 12000000 10000000 1500000 8000000 1000000 6000000 4000000 500000 2000000 0 0 1880 1900 1920 1940 1960 1980 2000 2020 Porto Alegre São Paulo Source: Porto Alegre, http://en.wikipedia.org/wiki/Porto_Alegre#cite_note-31, last retrieved 13 November 2013. São Paulo,http://smdu.prefeitura.sp.gov.br/historico_demografico/tabelas/pop_evo.php, last retrieved 13 November 2013.

As early as the 1970s, several studies suggested a correlation between economic and social indicators (GDP, income concentration, real minimum wage, educational attainment) and health metrics, particularly child mortality (Lezer, Yunes & Ronchezel), life expectancy at birth (Singer), and occupational accident rates (Tambellini Arouca)5 in Brazil.

Figure 3. Progression of Brazilian GDP, 1950-2014.

BRAZILIAN GDP GROWTH Sources: IMF / Angus Maddison

Source: http://www.youtube.com/watch?v=1UhPENaZz-4

5 Tambellini Arouca, A. Análise dos determinantes das condições de saúde da população brasileira (p. 147-154). In: Reinaldo Guimarães (Org). Saúde e Medicina no Brasil, Contribuições para um Debate. Rio de Janeiro, RJ: Graal, 1978. 7

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

In the 1980s, Victora et al.6 showed, in a population-based sample from the municipality of Pelotas, an association between child nutritional status and a series of social variables (household income, parental educational attainment, employment, number of siblings, ethnicity) and environmental variables (housing, crowding, clean water, sewerage). In the same period, Guimarães and Fischmann7 reported a difference in child mortality between slum dwellers (75.5/1,000 live births) and non- slum dwellers (25/1,000 live births) in this municipality, which had one of the lowest overall child mortality rates in Brazil (36.4/1,000 live births).

In 1979, a study on blood pressure and other risk factors in the adult population of Rio Grande do Sul conducted the year before (Costa & Achutti) found that excess mortality among the poor was not restricted to infectious diseases, i.e., to “diseases of poverty”; this was reaffirmed by later studies, including a 1987 investigation partially funded by PAHO that focused on the adult population of Porto Alegre. Excess mortality was also seen in deaths due to heart disease and cancer, conditions supposedly associated with “more advanced stages of economic development” (Costa, 19788; Tambellini Arouca, p. 150)”.8 Furthermore, a high incidence of occupational accidents and diseases was seen among the workers paid the lowest wages (Tambellini Arouca).9

However, studies on social inequality and health in Brazil declined significantly after the late 1980s. According to Campos (1995),10 the 8th National Health Conference of 1986 and the victory achieved with the creation of the Unified Health System (Sistema Único de Saúde, SUS) (Federal Constitution of 1988, Organic Law of 1990), followed shortly thereafter by the neoliberal changes started in the country by Collor de Mello (1992), account for this new scenario. The most comprehensive perspectives of public health experts from recent decades became fragmented, giving way to an increasing specialization that made health managers, epidemiologists, researchers, etc. limit themselves more and more to their technical scopes of practice and commit less and less to any topics not associated with their most immediate own interests.

6 Victora CG, Vaughan P, Kirkwood BR, Martines JC, Barcelos L. Bull World Health Organ., v. 64, n. 2, p. 299– 309, 1986. 7 Guimarães JJL, Fichman A. Risco de morrer no primeiro ano de vida entre favelados e não favelados no município de Porto Alegre, RS (Brasil), em 1980. Revista de Saúde Pública, v.20, p.219-226, 1986. 8 Costa E, 1978. Hipertensão Arterial Sistêmica no Rio Grande do Sul. Doctoral dissertation. 9 Tambellini Arouca. O Trabalho e a Doença (p. 93-119). In: Reinaldo Guimarães (Org), Saúde e Medicina no Brasil, Contribuições para um Debate. Rio de Janeiro, RJ: Graal, 1978. 10 Campos GWS, 2005. Romance de formação de um sanitarista: um estudo de caso (p. 121-150). In: Lima NT, Gershman S, Edler FC e Suárez JM (Org), Saúde e Democracia. Rio de Janeiro: Fiocruz, 2006. 8

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

The topic of social inequalities in public health was only reintroduced in Brazil circa 2005-2006,11 and as an outside-in process—the result of advances in social epidemiology in developed countries (Krieger et al., 1997; 12 Lynch et al., 2001;13 Marmot & Wilkinson, 200114) and in global health projects, now supported by two distinct approaches: the human rights approach (social determinants of health) (Marmot, 2005;15 Marmot, 200816 ) and the macroeconomics approach (economic determinants of health) (Sachs, 2001;17 Sachs, 2012a;18 Sachs 2012b19).

Recently, and perhaps as a possibility for these two approaches to interface through the introduction of a new category (space), a new overarching field has been introduced: urban health (WHO’s theme of the year for 2010).

The City of Porto Alegre

Porto Alegre, located in Southern Brazil (30ºS 51ºW), is the capital of the country’s southernmost state, Rio Grande do Sul. It has over 1.4 million inhabitants across an area of nearly 500 km². The city’s population grew 5.6-fold between 1940 and 2010. It is a geographically diverse settlement, with hills, lowlands, and a large lake—Lake Guaíba—fed by a complex system of rivers that drain an extensive area of major agricultural and industrial importance for the state.

Overall, the socioeconomic indicators of Porto Alegre are good, especially on comparison with those of other Brazilian state capitals. The municipal gross domestic product (GDP) was approximately R$45 billion (7th highest in the country) and the GDP per capita was R$32,203.00 in 2011 (IBGE, 2011). The city’s municipal HDI is 0.805, which is considered very high (PNUD, 2010); its Gini coefficient is 0.60 (2003);

11 Buss PM, Pellegrini Filho A. Iniquidades em Saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e o trabalho da Comissão Nacional sobre Determinantes Sociais. Cadernos de Saude Publica, v. 22, p. 2005-8, 2006 12 Krieger N, Chen JT, Ebel G. Can we monitor socioeconomic inequalities in health? A survey of US Health Departments. Public Health Rep, v. 112, p. 481-491, 1997. 13Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality impotyanve to health of individual income, psychosocial environment or maternal conditions. BMJ, n. 320, p. 1200-4, 2000. 14 Marmot M, Wilkinson RG. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. BMJ; n. 322, p. 1233-6. 15 Marmot M. Social determinants of health inequalities. Lancet, n. 365, p. 1099–104, 2005. http://www.who.int/social_determinants/strategy/en/Marmot- Social%20determinants%20of%20health%20inqualities.pdf 16 Marmot M, Friel S, Bell R, Houweling TAJ, Closing the gap in a generation: health equity through action on the social determinants of health, on behalf of the Comission on Social Determinantes of Health. Lancet, v. 372, n. 9650, p. 1661 -1669. 17 Sachs JD, 2001. Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. WHO. http://whqlibdoc.who.int/publications/2001/924154550x.pdf 18 Sachs JD. From Millennium Development Goals to Sustainable Development Goals. Lancet , v. 379, n. 9832, p. 2206 – 2211, 2012a. 19 Sachs JD. Achieving universal health coverage in low-income settings. Lancet, v. 380, n. 9845, p. 944 – 947, 2012b. 9

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

and its literacy rate is high at 96.7%. Porto Alegre also has one of the highest tree cover rates among Brazilian cities.

As of 2010, the city had an overall mortality rate of 7.9 per 1,000 and a child mortality rate of 10.5 per 1,000 live births. However, the city also is also exposed to major socio-spatial inequalities.

From a political standpoint, every 4 years, the city elects a Mayor (the head of the executive branch) and a 35-member council, which constitutes the legislative branch. Since the 1990s, the city has adopted a system of popular involvement for definition of public investment, known as the “Participatory Budget”. This has been a relatively successful experiment in interaction between the population and the various sectors of municipal public government.

The Restinga neighborhood

The Restinga is a neighborhood located approximately 22 km from central Porto Alegre. It was formally established in 1990, but developed largely since 1966, with the settlement of city inhabitants removed from their homes in more central areas during the urban modernization process. The migration of populations to the Restinga took place over several “waves” and by means of different processes over the last 60 years.

Restinga–Zona Sul

According to ObservaPOA (Observatório da Cidade de Porto Alegre) data based on the 2010 Brazilian census, the Restinga neighborhood has approximately 60,000 inhabitants, who account for 4.3% of the population of population. The neighborhood covers an area of 38.6 km2 (8.1% of the total area of the city), and, as of 2010, the population density was 1,575 inhabitants per km2. The illiteracy rate was 4% and the mean head of household income was equivalent to 1.86 times the local minimum wage (roughly US$560.00 in current dollars). A more appropriate characterization of the region would name it Restinga–Zona Sul, and cover the 50,000 inhabitants of adjacent neighborhoods such as Lajeado, Lami, Belém Novo, Ponta Grossa, and Chapéu do Sol, many of which share similar challenges. 10

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Due to its distance from the city center, large territorial expanse, and large population, the Restinga is sometimes regarded as “a city apart”. It is divided into the “Old Restinga” (Velha Restinga) and the “New Restinga” (Nova Restinga), separated by a main road (Estrada João Antônio da Silveira). The “Old” neighborhood is the result of the first clearances, whereas the “New” sector is the result of public construction projects undertaken in the early 1970s and is occupied by higher-income families (Zamboni, 200920).

Map 1. Location of the Restinga neighborhood in Porto Alegre, Brazil.

The Unified Health System (SUS)

To enable analysis of the local governance model and health conditions in the Restinga, this study will first present the Brazilian health system as it pertains to aspects such as private sector involvement (represented in this case by Hospital Moinhos de Vento), social organizations, health funding, and relevant legislation.

The Federal Constitution of 1988 set forth, in its Health chapter, that health “is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other threats and at the universal, equal access to actions and services for its promotion, protection and recovery”. It also established that “Health actions and public services make up a regionalized hierarchical network and constitute a single system, organized…”

20 Zamboni V. Construção social do espaço, identidades e territórios em processos de remoção : o caso do bairro Restinga - Porto Alegre / RS. Porto Alegre: UFRGS, 2009 (master’s thesis). 11

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

according to the following guidelines: (i) decentralization, under unified management at each level of government; (ii) comprehensive care, prioritizing preventive activities without detriment to care services; and (iii) community participation.

Pursuant to Law No. 8,080/90, on the conditions for promotion, protection, and recovery of health and the organization and operation of corresponding services, among other provisions, the different levels of health express the social and economic organization of the country; determining and conditioning factors of health include housing, basic sanitation, transportation, work, income, education, physical activity, diet, leisure, and access to essential goods and services.

Health care activities are open to the private sector in Brazil. Private health care services are characterized by the involvement of legally licensed personnel (health care professionals) and privately held legal entities in activities pertaining to the promotion, protection, and recovery of health.

We must also mention the home health care services and companies of Porto Alegre, which serve approximately 5,000 patients per year. One such company, Hospitalar Home Care, also conducts charitable projects involving donation of health supplies and devices that become useless once patients complete their treatment (are cured) or die. It is estimated that 5% of the Restinga population may benefit from these donations.

The Unified Health System (SUS) is composed of a set of health activities and services provided by federal, state, and municipal public institutions, agencies of the direct and indirect public administration, and government-run foundations (health units, health centers, and hospitals). These institutions also include the federal, state, and municipal agencies involved in quality control, research, and the manufacturing of health supplies, medicines, blood and blood products, and medical devices.

The private sector may participate in the SUS, but in a supplemental manner. When SUS capabilities are insufficient to ensure the provision of care to the population of a given area, the System may use the services provided by the private sector. The supplemental participation of private services in the SUS must be formally established by means of a contract or agreement, in compliance with the relevant standards of public law. In the situation described above, for instance, charitable and not-for-profit entities are given precedence for supplemental participation in the SUS.

The services thus contracted are subject to the technical and administrative standards and to the overarching principles and guidelines of the SUS, so as to maintain the economic and financial balance of the contract Private health care services must also abide by the ethical principles and standards issued by the relevant SUS management body as they pertain to its operating conditions. 12

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

SUS funds are deposited in special accounts for each level of government (federal, state, or municipal), and can only be used with the oversight of the corresponding Health Councils. At the federal level, funds are managed by the Ministry of Health through the National Health Fund (Fundo Nacional de Saúde), and at the municipal level, they are managed through the Municipal Health Fund (Fundo Municipal de Saúde) of each municipality.

Councils and governmental and non-governmental bodies

The Organic Municipal Law of Porto Alegre of 1990, which is the equivalent of a municipal “Constitution”, set forth that Municipal Councils are “bodies for direct community involvement in the public administration, and their purpose is to propose, oversee, and deliberate on issues concerning each sector of the administration, within the terms of the supplemental law” (art. 101). In 1992, Supplemental Law No. 267/92 regulated the implementation of Municipal Councils and defined their general mandate.

Nearly two decades later, in 2011, the city of Porto had 26 Municipal Councils created by force of law, 25 of which were in operation. These are collegial bodies organized under specific supplemental laws and Supplemental Law No. 661/2010, which, among other provisions, created the Municipal Forum of Municipal Forum of City Councils (Fórum Municipal dos Conselhos da cidade). The municipal Department of Political Coordination and Local Governance (Secretaria Municipal de Coordenação Política e Governança Local) is in charge of coordinating the various Municipal Councils, which cover areas such as health, social welfare, urban and environmental development, education, human rights, consumer rights, science and technology, and land use and housing, among others.

These Councils make up a network of citizen involvement in municipal public policy, alongside the systematic mechanisms of participatory budgeting; people’s councils; child welfare councils; planning, security, and citizenship forums; and City Congresses.

Health Councils (Conselhos de Saúde) are collegial bodies, enshrined in federal, state, and municipal law, and created in response to the constitutional mandate for community participation in the Unified Health System (SUS). The role of these Councils is to represent SUS users, managers, health care professionals, and service providers in the management of public health policies. They are deliberative bodies in the health planning process and play a strategic role in controlling and overseeing the management and delivery of health care activities and services.

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

The Porto Alegre Municipal Health Council has its origins in the Interinstitutional/ Municipal Health Committee (Comissão Interinstitucional / Municipal de Saúde, CIS/CIMS) of the 1980s. These structures for community participation were created in response to the actions of social movements dating back to the 1970s and were consolidated within the framework of the Integrated Health Actions (Ações Integradas de Saúde, AIS) of the 1980s. The creation of the SUS by the Federal Constitution of 1988 and the regulation of social control under Law No. 8142/90 provided an institutional framework for participatory structures. In 1992, after a broad debate, the Porto Alegre City Council approved Supplemental Law No. 277/92, which created the Porto Alegre Municipal Health Council (Conselho Municipal de Saúde de Porto Alegre, CMS/POA).

According to the CMS/POA bylaws, the Plenary it its highest deliberative body. The Plenary convenes for regular meetings at least twice monthly. Its composition is defined by Law No. 277/92 and includes approximately 80 members. Meetings are open to the public and all those present are entitled to the floor.

The CMS/POA is coordinated by a Coordination Team (Núcleo de Coordenação) composed jointly of four user representatives, two health care professional representatives, and one service provider representative—elected by the Plenary for 2-year terms—and one representative of the municipal health manager as an ex officio member. The Coordination Team meets weekly in accordance with a predefined schedule, to discuss a predetermined agenda.

The CMS/POA structure also includes an Executive Secretariat, a Technical Secretariat, special advisors, and topic-specific and executive committees, as well as District Health Councils, Local Health Councils, Boards of Managers, and Technical Chambers.

District Health Councils (Conselhos Distritais de Saúde, CDSs) are decentralized and regionalized bodies provided for in the CMS/POA bylaws. The city has 13 CDSs, which play a deliberative and planning role in their respective territories and are tasked with overseeing and assessing the SUS within their coverage areas (Health Districts, Distritos de Saúde).

Each CDS is led by a District Coordination Group (Núcleo de Coordenação Distrital) and has a District Plenary (Plenário Distrital), which is the highest deliberative body of each Health District. The District Plenary is characterized by parity of representation, i.e., it is composed of 50% user representatives, 25% health care provider representatives, and 25% representatives of the Municipal Department of

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Health (manager) and service organizations, such as hospitals, laboratories, etc. Each CDS, in turn, has a representative at the CMS/POA Plenary.

Local Health Councils (Conselhos Locais de Saúde, CLS) are the highest deliberative body and channel for community participation within the scope of each health unit. They conduct planning, co-management, and oversight activities and perform functions of CDSs and of CMS/POA in a decentralized and regionalized manner. Each Local Health Council also has a plenary and local coordinator. Local Health Councils appoint representatives to the District Health Council.

Finally, the Boards of Managers (Conselhos Gestores) are decentralized bodies of CMS/POA that liaise with hospitals, with the municipal Referral Center for Occupational Health (Centro de Referência em Saúde do Trabalhador, CEREST- Regional POA), and with municipal public emergency departments and urgent care services. Technical Chambers (Câmaras Técnicas) are decentralized bodies of the CMS/POA that liaise with SUS-affiliated private hospitals in Porto Alegre.

Involvement in these bodies is voluntary and is considered a service of public relevance. Councilmembers receive no stipends or honoraria of any kind for their service. Bus fares for trips made when councilmembers are acting in their capacity as designated representatives of CMS/POA are refundable, but not those for trips made for activities involving its subsidiary bodies.

Despite expansion of the decentralized network for social control of health in the city, it still lacks: (i) CLSs at all facilities of the primary health care network; (ii) CLSs at specialized and substitute services; (iii) CLSs at all emergency and urgent care services; (iv) technical chambers or boards of managers at all SUS-affiliated hospitals.

Hospital Moinhos de Vento

Hospital Moinhos de Vento (HMV), located in Porto Alegre, was founded in 1927. It is a private facility that also has Ministry of Health-funded charitable care operations and is accredited by Joint Commission International (JCI), an agency that certifies worldwide hospitals that meet certain standards of patient care quality and management. It is classified by the Brazilian Ministry of Health as one of six hospitals of excellence in the country. The HMV website is http://www.hospitalmoinhos.org.br/

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

As of 2012, the hospital had 354 beds, all destined for private use, with an occupancy rate of 92.3%; 2,872 employees; and 2,925 physicians with privileges. Its 354 beds include 269 inpatient beds and 72 intensive care beds, among others. Also in 2012, 115,359 patients per day were treated at HMV on average, with 63,475 Emergency Department patients, 18,226 surgical procedures, 4,490 deliveries, and 25,858 admissions. The hospital focuses its services on five areas of expertise (cardiology, maternal and child medicine, neurology and neurosurgery, oncology, orthopedic surgery and trauma) and 86,000 m2 of facilities.

HMV has conducted educational, management and research activities of public interest in the Restinga area for nearly a decade. Its activities in the region are exclusively SUS-oriented and include an urgent care center (taken over by the hospital in 2004), three basic care centers operating within the Family Health Strategy framework (Paulo Viaro, opened in 2010; Chapéu do Sol, in 2011; and Núcleo Esperança, in 2012), and a medium-complexity hospital slated for opening in 2014, with 19,000 m2 of facilities, 135 beds, four operating theaters, two surgical delivery suites, and capacity to treat 1,500 patients/day between the emergency department, specialty clinics, and diagnostic medicine center.

As part of its institutional relationship with the Ministry of Health and with the Porto Alegre municipal government, HMV is in charge of the implementation of a health system in the Restinga–Extremo Sul region. This project, known as the “Restinga Extremo Sul Social Project” (Projeto Social Restinga Extremo Sul), includes the aforementioned general hospital (under construction) and urgent care center, a School of Health Management (Escola de Gestão em Saúde), and a breast center (Núcleo Mama Porto Alegre). The system will also include community follow-up activities to encourage health prevention and is meant to operate under the SUS framework and meet sustainability criteria.

The new hospital under construction in the Restinga will have adult medical and surgical wards, a pediatric ward, a rooming-in obstetric and neonatal ward, an obstetric suite with surgical capabilities, resuscitation and stabilization rooms, and procedure

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

rooms (for dressings, nebulization, and infusions). It will also include an outpatient specialty center with clinics for women’s, maternal, and child health; surgical specialties; internal medicine; dental services; mental health; and rehabilitation. A diagnostic testing and imaging center with CT scanning, radionuclide testing, mammography, ultrasonography, blood tests, ECG, stress testing, endoscopy, and electroencephalography capabilities is also included in the design. The whole health complex was designed to provide comprehensive care for all age ranges to a population that is severely lacking in prevention and treatment services.

The aforementioned urgent care center, which has been in operation since 2004, will be transferred to the new structure and expanded to provide orthopedic and trauma care.

The Restinga Extremo Sul Social Project was designed within the overarching concept of sustainability. In addition to service quality, the architectural project also incorporates concepts advocated by international agencies for certification of environmentally friendly buildings. The design thus includes provisions for lower power usage; increased thermal comfort through gardening, a green roof, and a brise-soleil system; and integrated landscaping. The construction process will also be tailored to generate less waste and include mass participation of the local workforce, as well as prioritize locally produced materials.

HMV investment will create over 250 jobs, primarily for local residents. A School of Health Management is being implemented to develop and strengthen SUS policies in the area as well as create knowledge and provide education. The first classes (nursing technician, dental assistant, and dental hygienist programs) enrolled in 2010 and currently include 60 students, all living in the community, who may be called on to work at the new hospital complex after completing their studies.

In addition to operating in the health system, HMV has established partnerships with the construction company in charge of the Hospital da Restinga project (MPD Construtora), the state construction workers’ union (Sindicato da Indústria da Construção Civil, Sinduscon-RS), and the national industrial apprenticeship and vocational education service (Serviço Nacional de Aprendizagem Industrial, SENAI- RS) to train specialized construction workers. In 2011, 84 persons were trained, thus improving employment prospects for local residents. As noted above, in addition to using the local workforce, HMV sought to use locally produced materials and reduce waste generation during the construction project.

In partnership with the Ministry of Health and the Porto Alegre municipal government, this HMV unit should become a SUS referral center for the Restinga–

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Zona Sul region and play an important role in structuring a local network of basic services in this area so lacking in infrastructure and geographically distant from resources required by the population. This initiative is one of the largest ongoing social projects in Brazil and is notably comprehensive, as it will cover approximately 10% of the population of Porto Alegre, create jobs, and train the local workforce. It was designed to meet a longstanding demand for health services, with a particular focus on reducing mortality and treating conditions so as to promote improvements in quality of life.

In addition to the Restinga–Extremo Sul project, HMV is conducting other social projects, which are beyond the scope of this paper.

Photo 1. Restinga unit of Hospital Moinhos de Vento, Porto Alegre, Brazil

The Porto Alegre City Observatory (Observatório da Cidade de Porto Alegre, ObservaPOA)

The Porto Alegre City Observatory (Observatório da Cidade de Porto Alegre, ObservaPOA), an entity linked to the municipal Department of Political Coordination and Local Governance (Secretaria Municipal de Coordenação Política e Governança Local), was developed as the result of a 2005 proposal. It seeks to disseminate 18

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

knowledge of the city by building a broad knowledge base of georeferenced data and thus contribute to the consolidation of citizen involvement in city management.

The Observatory was established to develop indicators capable of improving the quality of participatory management (participatory budgeting, City Councils, and Local Solidary Governance) from three perspectives: (i) social—impacts on improvement if quality of life and community living; (ii) management—impacts on the efficacy, transparency, and decentralization of municipal government; and (iii) political—impacts on democratic development, citizenship, expansion of social capital, and restoration of local identity.

ObservaPOA was structured so as to provide a wide-ranging database of georeferenced information on the city of Porto Alegre. The disaggregation of this data by region and neighborhood was designed to play an educational and political role, seeking to reinforce local identity and foster a sense of community in people and their families. The Observatory’s main communication channel is a web portal: http://www.observapoa.com.br/.

ObservaPOA has a Board of Managers, an advisory committee composed of representatives of universities (including UFRGS), the state and municipal governments, the Participatory Budget Council, the Porto Alegre Forum of City Councils, and the media. Topics judged to warrant in-depth discussion are referred to a Technical Committee for assessment of the feasibility of further study.

The establishment of ObservaPOA took place within the broader context of the objectives of the International Observatory on Participatory Democracy (IOPD), part of the European Union URB-AL program, and of the United Cities and Local Governments (UCLG) organization.

Measurement of health inequities and feasibility of the Urban HEART indicators at the district (intra-urban) level in Porto Alegre

This section presents the procedures performed to assess the feasibility of using Urban HEART indicators to assess and monitor social and health inequities at the district level within the city of Porto Alegre. It reviews the main references of the theoretical framework that supports the proposal and presents a discussion on urban health, sustainable development, and the Urban HEART methodology, as well as some results obtained with existing data.

Hospital Moinhos de Vento is expected to contribute to the local governance model insofar as it can bring its current standard of quality in the delivery of medical

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

and hospital services to the local health system. However, the implementation of so large a facility in a community like the Restinga is expected to produce economic impacts beyond those related to its end activity.

One of the challenges of this study is in how to quantify and measure the positive impacts of implementation of Hospital da Restinga/HMV by means of indicators of sustainable development such as employment and income generation, poverty reduction, improvement of environmental conditions, and, of course, access to health promotion and health care services—and its impact on life expectancy, infant and maternal mortality, and sequelae of violence-related injuries, chronic diseases, and communicable diseases.

1. Local Governance and Health

To provide a better understanding of local governance and health, this section presents some descriptive aspects of the city of Porto Alegre, of the Restinga neighborhood, of the Unified Health System (SUS), of government and non- governmental councils and their liaisons, of Hospital Moinhos de Vento and of the Porto Alegre Observatory (ObservaPOA).

According to the UN, governance as a political and social process that promotes democracy and calls on institutions and citizens to act in response to social needs. Sustainable development can only be possible with good governance that ensures access to health for all, social justice, and an efficient public administration that enshrines the universal access to health services as a constitutional right.

To WHO, the private sector (private hospitals and other private health care services), acting together with local governments, can promote good governance because of its responsibility for and direct impacts on the health of populations and by creating jobs and promoting development. Also according to WHO, local (municipal) governments are theoretically or presumably those best placed to promote governance, due to their direct responsibility over the services that have the greatest impact on the life of the population, particularly education, health care, sanitation, the environment, and housing. In addition, municipal administration is the first line of representation of the people and the sphere of government closest to the grassroots organization of social groups and community action.

In the particular case of the Restinga region, the governance model under analysis is intrinsically dependent on municipal local governance, which, in turn, is tied to a broader context that is formally connected to and involves the state and the

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

country (as well as the global economy), and may be broader still if one considers social interests and forces that do not feature in official documents.

The private involvement in the local governance model analyzed in this study is that of Hospital Moinhos de Vento (HMV), a benchmark in terms of private healthcare and hospital quality in Latin America that recently built a hospital dedicated exclusively to the care of SUS patients in the Restinga neighborhood.

Urban Health and Local Sustainable Development

Health is the result of where and how one is born, raised, lives, works, and plays (Unnatural Causes, 200821). The majority of the world’s population currently lives in cities, and it is widely known that poverty and disease are highly correlated in urban settings.

Birn et al. (20093), in a debate on how to effect change in the social determinants of health, present comparisons as to how, starting from the selfsame diagnosis of the association between poverty and disease made by Villermé, Chadwick, and Engels, different paths could be chosen (laissez-faire, reform, and revolution).22

The rationale for a sustainable urban development proposal shares many similarities with Chadwick’s utilitarian view. When it comes to sustainable development, health can be both a prerequisite (health for development) and a goal (development for health). This justifies the defense of health improvement both as an individual human right and as a common good, with the potential to improve the living conditions of all.

21Unnatural causes – places matter.... is inequality making us sick? California Newsreel Production 2008. Public Engagement Campaign in Association with the Joint Center for Political and Economic Studies Health Policy Institute. [acesso em 2010 Abr 9]. Disponível em: http://www.unnaturalcauses.org/assets/uploads/file/UC_Transcript_5.pdf 22 French surgeon and social researcher Louis-René Villermé (1782–1863) demonstrated, in a study published in 1826, that patterns of mortality in Paris correlated almost perfectly with poverty rates: the poorer a neighborhood, the higher its mortality rate. But as a liberal defender of the free market, Villermé opposed public policies for social melioration. He regarded poverty as a personal failing to be overcome both through individual effort and through the advancement of capitalist industrialization. He thus proposed a laissez-faire paradigm and absolved the bourgeoisie of any responsibility to fight misery and inequality, whether through public health measures or social welfare policies. Friedrich Engels (1820–1895), the son of a German industrialist, published The Condition of the Working Class in England in 1845, in which he described social inequalities in health and the oppression and suffering of workers. But his call to action was a revolutionary one. Shortly thereafter, he joined Marx in a lifelong collaboration, beginning with their joint publication of the 1848 Communist Manifesto. Edwin Chadwick (1800– 1890), lawyer, utilitarian, and civil servant, reached the same diagnosis in a large study published in 1842, the Report on the Sanitary Condition of the Labouring Population of Great Britain, and on it based his proposed sanitary reform. This was the chosen path.

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Porto Alegre has historically ascribed great value to the environment (e.g., Lutzenberg and other environmentalists) and to social development (World Social Forum). A recent project expanded the potential capacity for treatment of wastewaters from the city center to nearly 80%, but still depends on additional public works for this potential to be reached. The outskirts of the city are still underserved, especially in squats and illegal allotments, which are still the predominant forms of land use in the Restinga. Hence, there is much room for investments on urban reform, which can contribute to the sustained economic and social development and improvement of health in the population.

Urban HEART

Recognition of the need to address intra-urban inequities has grown substantially, particularly since 2010—the year devoted by OMS to the topic of Urban Health. Several methodologies and indicators have been proposed, including the Urban HEART (Urban Health Equity Assessment and Response Tool), an instrument developed by WHO for the identification and reduction of social inequities within cities.23 This instrument proposes a series of indicators designed for universal application and already tested in the field in some countries.

Figure 5. Urban HEART User Manual

The method suggests 12 standard indicators and recommends that additional indicators be selected that meet the local context. The 12 standard indicators are: (i) infant mortality; (ii) diabetes prevalence; (iii) smear-positive tuberculosis detection rate; (iv) road traffic death rate; (v) proportion of the population with access to safe water; (vi) proportion of the population with access to sanitation; (vii) number of new entrants

23 http://www.who.or.jp/urbanheart 22

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

in the last grade of primary education/expected number; (viii) proportion of births attended by skilled health personnel; (ix) proportion of fully immunized children by 1 year of age; (x) prevalence of tobacco smoking; (xi) unemployment; and (xii) government spending on health.

3.4 Applicability to Porto Alegre

The following table, generated from a 2006 research project employing some metrics similar to those suggested in the Urban HEART list, provides evidence of social and health inequalities across groups of neighborhoods in Porto Alegre.24

Table 1. Number of neighborhoods, population, and distribution or means of selected variables in the four socioeconomic strata defined by these variables.

Source: Bassanesi et al., 200830.

In the above case, the variables selected to summarize social differences either (i) encompassed different dimensions—education, income, house overcrowding (housing), aging, and fertility (demographics) or (ii) proved able to capture, as markers, spatial variations associated with social and environmental determinants (whether measured or otherwise)—in this case, child mortality and mortality due to violent causes.

24 Bassanesi SL, Azambuja MI, Achutti AA. Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action. Arq Bras Cardiol, v. 90, n. 6, p. 403-412, 2008. 23

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Of a list of tested variables, these seven proved to have the best specificity and sensitivity to characterize socioeconomic conditions in the neighborhoods of Porto Alegre and demonstrate differences between them.

Child mortality and violence-related mortality (social markers) and cardiovascular and cerebrovascular mortality (study outcomes) varied significantly and consistency across the spectrum of neighborhood characterization, revealing a social gradient in health.

The same methodology showed that, in the 2000–2004 period, child mortality due to respiratory diseases in Porto Alegre ranged from 0.26 per 1,000 live births in neighborhoods in the least disadvantaged quartile in terms of social indicators to 1.73 per 1,000 live births among residents of the most disadvantaged quartile (Azambuja et al., 2009)25—and thus apparently constituted a highly sensitive marker of inequity. The incidence of smear-positive TB in the 2000–2005 period was eight-fold higher in neighborhoods classified into the fourth quartile, with the worst social indicators (Acosta et al., 2008)26. Furthermore, a 10-year difference in life expectancy at birth was detected between neighborhoods in extreme strata (Bassanesi, 2009).

In November 2013, during a seminar on measurement and monitoring of intra- urban health inequities held in Porto Alegre and organized by the research group involved in the present project, Dr. Oscar Mujica of PAHO used ObservaPOA data to present an exploratory analysis of inequalities in mortality between Porto Alegre neighborhoods, as made possible by the available information (Table 2).

Using an Excel®-based software he developed himself to explore inequalities in geographically disaggregated data, Dr. Mujica first stratified neighborhoods into three tertiles according to the variable “proportion of households with income >10x the minimum wage” for the years 2000 and 2010, which are shown as cutoff points in the last column of the tables. As shown in the tables below, both in 2000 and in 2010, the Restinga was among the neighborhoods with the lowest household income.

25 Azambuja MI, Bassanesi SL, Achutti AA. A mortalidade por doenças respiratórias em Porto Alegre é maior em áreas da cidade com piores indicadores sociais. Boletim de Saúde, Porto Alegre, v. 23, n. 1, p. 31-39, 2009. http://www.escoladesaudepublica.rs.gov.br/img2/04%20A%20MORTALIDADE.pdf 26 Acosta A. Conferencia sobre os determinantes das desigualdades sociais em saúde, 2010. http://cmdss2011.org/site/wp-content/uploads/2011/08/EXP.POA-apres-porto-alegre.pdf

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Table 2 Data from ObservaPOA, Porto Alegre, circa 2000 and 2010 by regions.

population under age 3 % income+10 infant mortality rate POA region 2000 2010 2000 2010 2004 2012 Centro 8,877 7,277 50.02 24.93 6.2 5.8 Centro Sul 6,677 4,899 20.12 6.91 13.2 7.7 Cristal 1,878 1,193 27.33 11.35 16.3 15.9 Cruzeiro 5,520 3,510 17.83 7.09 11.8 9.2 Eixo Baltazar 5,856 4,688 13.73 3.31 9.8 10.2 Extremo Sul 2,345 1,822 7.41 3.34 22.9 19.9 Glória 3,482 2,223 11.32 3.06 14.6 6.9 Humaitá / Navegantes 2,791 2,186 14.01 3.46 21.1 16.0 Ilhas 724 545 3.48 1.39 17.9 7.6 Leste 8,331 5,328 21.08 9.75 10.0 7.3 Lomba do Pinheiro 5,175 3,903 3.37 0.87 5.0 10.8 Nordeste 3,021 2,653 1.11 0.60 20.5 7.3 Noroeste 5,359 4,267 36.37 17.09 8.6 4.5 Norte 6,441 4,759 7.06 1.87 18.2 11.8 Partenon 7,928 5,726 18.81 5.26 13.1 8.2 Restinga 4,784 3,914 3.82 0.73 13.9 18.9 Sul 3,861 3,778 36.23 17.74 15.7 9.0 Source: ObservaPOA [accessed Nov 29, 2013]

The following figures show the progression of mortality and social inequalities in relation to mortality between 2000 and 2010 in different neighborhoods of Porto Alegre.

2000

base SES health POA region population variable rate u3pop income10 15.0 Nordeste 3,021 1.11 20.5 Lomba do Pinheiro 5,175 3.37 5.0 Ilhas 724 3.48 17.9 Restinga 4,784 3.82 13.9 Norte 6,441 7.06 18.2 Extremo Sul 2,345 7.41 22.9 Glória 3,482 11.32 14.6 Eixo Baltazar 5,856 13.73 9.8 Humaitá / Navegantes 2,791 14.01 21.1 Cruzeiro 5,520 17.83 11.8 Partenon 7,928 18.81 13.1 Centro Sul 6,677 20.12 13.2 Leste 8,331 21.08 10.0 Cristal 1,878 27.33 16.3 Sul 3,861 36.23 15.7 Noroeste 5,359 36.37 8.6 Centro 8,877 50.02 6.2 83,050

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

2010

base SES health POA region population variable rate u3pop income10 15.0 Nordeste 2,653 0.60 7.3 Restinga 3,914 0.73 18.9 Lomba do Pinheiro 3,903 0.87 10.8 Ilhas 545 1.39 7.6 Norte 4,759 1.87 11.8 Glória 2,223 3.06 6.9 Eixo Baltazar 4,688 3.31 10.2 Extremo Sul 1,822 3.34 19.9 Humaitá / Navegantes 2,186 3.46 16.0 Partenon 5,726 5.26 8.2 Centro Sul 4,899 6.91 7.7 Cruzeiro 3,510 7.09 9.2 Leste 5,328 9.75 7.3 Cristal 1,193 11.35 15.9 Noroeste 4,267 17.09 4.5 Sul 3,778 17.74 9.0 Centro 7,277 24.93 5.8 62,671

Fig 5: Porto Alegre: intra-urban inequalities in infant (under-1) mortality by social position defined by household income, 2000-2010.

2000 2010 20 20

15.0 15 13.1 15 11.7 10.4 10.5 10 10 7.3

5 5

0 0 most middle tertile least most middle tertile least disadvantaged disadvantaged disadvantaged disadvantaged

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Comparison of the intra-urban distribution of infant mortality across neighborhoods classified by rate of household incomes >10x the minimum wage shows that while infant mortality was reduced in all neighborhoods, the inequality in infant mortality between poor and rich actually grew.

Based on the experience of the investigators and on prior studies conducted in Porto Alegre, we may state that nearly all of these indicators could be generated for the city—if not as a routine practice, at least within the framework of research projects. The city has robust databases of births and deaths, georeferenced by place of residence, and some databases on specific-cause mortality and in-hospital mortality, georeferenced for specific periods, are available and could be explored. Furthermore, an observatory affiliated with the municipal government—ObservaPOA—has made available, whenever possible, demographic, social, and economic data collected during censuses and other demographic surveys, as well as health data, so as to enable comparison across neighborhoods.

Alternative metrics for detection of changes in sustainable development at the local level

However, although results show that use of the methodology to obtain measures of intra-urban inequity in the city of Porto Alegre is feasible, there remain limitations that must be addressed.

The ease of comparing different neighborhoods of the city does not necessarily extend to analyses focused on a single neighborhood—namely, the Restinga—which is the purpose of our intended study. This would require not only investigation of the availability of georeferenced data—which is hindered by the fact that many addresses correspond to irregularly occupied land—but, mainly, assessment of which criteria should be used to conduct stratification within the neighborhood, so as to not only measure but facilitate intervention. This is relevant because one of the concerns of the WHO KOBE Center, which is part of the Knowledge Network on Urban Settings (KNUS) and promotes the topic of social determinants and health equity in urban areas, is how to turn knowledge into action at the local level.

Action has been receiving growing attention from policy-makers and academics involved in the measurement of inequality. It is recognized that, when it has even been feasible, measurement has still been largely descriptive in nature, and translated little into actual changes in reality.4,24,27,28

27 Pochmann M, apud R.J. Pochmann: Pobres que trabalham e estudam têm jornada superior à dos operários no século XIX .2011. Available at: http://www.afaiterj.org.br/noticias/2399-marcio-pochmann-realca-desigualdades- sociais-e-economicas-que-geram-a-alienacao-intelectual-no-brasil.html. Retrieved 20 October 2011. 27

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

In 2013, speaking on social-spatial inequalities during the Urban Dynamics and Health conference held in Paris, France, Diez-Roux29 wondered whether people or areas can be changed by technical design, noting that epidemiology has documented what common sense already knew, and stressing that research for action is required. It is widely admitted that, for such action to take place, we must work toward building consensuses based not on the mere sharing of objective knowledge, but rather on building trust—i.e., shared values (not ideologies) between academia and decision makers, with a focus on the problems of the community30.

Although technical manuals on the implementation of tools for diagnosis of inequality always stress the importance of the preliminary (and continued) stage of building political commitment—without which it is impossible to obtain a good diagnosis, let alone translate this diagnosis into action—, in practice, this stage is still commonly skipped by researchers who would rather dive headfirst into building databases and producing quantitative analyses.

Therefore, in the specific case of Projeto Restinga, we believe it is important to devote time toward what the WHO Urban HEART User Manual regards as the most important and most time-consuming step of the investigation: the initial process of building political commitment to the pursuit of a pro-equity agenda.31

As early as 1979, Tambellini Arouca stated that “the occurrence of disease is a result of environmental factors, and the health services, namely those involved in the provision of medical attention, are powerless in the face of the morbid state of the population... One might say that diseases produced by the ‘environment’ follow their ‘natural’ course, as if imprisoned by the classification of diagnoses made at the hands of professionals armed with techniques to manipulate living matter, objects, and data” (p.149).

28 B. Jacobsen, Urban, Health Observatories: a possible solution to filling the gap in urban health intelligence. London Health Observatory, International Conference “Urban Dynamics and Health, Sept 11th-13th, 2013, Symposia 1(Sept 11th 2013). 29 Diez-Roux A. Multidisciplinary cross-perspectives about urban health. International Conference “Urban Dynamics and Health”, Sept 11th-13th, 2013, Conference 2(Sept 12th 2013). 30 Bradshaw C; Evin C; Ménival S; Vaillant Z, Collaboration between researchers and decision-makers. International Conference “Urban Dynamics and Health, Sept 11th-13th, 2013, Round Table 2(Sept 13th 2013) 31 “The goal is to build political commitment to pursue a health equity agenda for your city. Building an inclusive team may be the most time-consuming step in the Urban HEART process, yet it may also be the most important step. Core activities include partnership building, education and advocacy; obtain buy-in from influential champions; raise awareness in other sectors about the importance and relevance of Urban HEART; form a core team of individuals who will have dedicated time to implement Urban HEART; promote the sustainability of the use of the tool by integrating Urban HEART into existing structures and responsibilities http://www.who.int/kobe_centre/publications/urban_heart_manual.pdf, p.5, step 1. 28

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Human Development Index Education Health Income Region HDI HDI HDI HDI Porto Alegre 0.865 0.951 0.775 0.87 Centro 0.919 0.995 0.771 0.99 Noroeste 0.892 0.99 0.767 0.92 Sul 0.874 0.962 0.759 0.9 Cristal 0.86 0.948 0.766 0.87 Leste 0.834 0.932 0.744 0.83 Centro Sul 0.832 0.942 0.741 0.81 Eixo Baltazar 0.825 0.943 0.749 0.78 Partenon 0.819 0.932 0.722 0.8 Cruzeiro 0.813 0.906 0.736 0.8 Humaitá / Navegantes 0.797 0.908 0.713 0.77 Ilhas 0.797 0.908 0.713 0.77 Glória 0.788 0.902 0.705 0.76 Norte 0.78 0.903 0.714 0.72 Extremo Sul 0.779 0.887 0.729 0.72 Restinga 0.761 0.901 0.707 0.68 Lomba do Pinheiro 0.751 0.884 0.693 0.68 Nordeste 0.726 0.858 0.704 0.62 Source: ObservaPOA, 2011.

Even in a country with universal health coverage, such as Canada, major inequities in population health remain, and these inequities tend to increase as income inequality increases. Virtually every measure of population health—from child mortality to rates of cancer, cardiovascular disease, and trauma—is worse in poor areas than in rich areas. Furthermore, health tends to improve across the income spectrum. People living in poor neighborhoods are at 37% greater risk of having a heart attack, and those in middle-income neighborhoods, at 21% greater risk than people living in high-income areas. In Porto Alegre (Bassanesi et al., 2008),18 the difference in early mortality due to ischemic heart disease between the most disadvantaged and the least disadvantaged quartiles was 230%! However, the truly remarkable finding is that, in all of these cases, the affected individuals received similar medical care—therefore, access to treatment is not the issue; the underlying causes of disease are32.

If treatment of ill health is less susceptible to health systems than we believe, on the other hand, ill health has a major economic impact on their expenditures. In

32 http://m.theglobeandmail.com/news/national/time-to-lead/wealth-begets-health-why-universal-medical-care- only-goes-so-far/article15385519/?service=mobile

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Canada, for instance, a study estimated that if the poorest 20% of the population earned as much as the next 20% on the income scale, this would mean a yearly savings of 7.6 billion dollars for the health system.34 If ill health among the poorest members of society impacts the economy through lost productivity and adds costs to an already overburdened health system, the production of health must become an explicit objective of policies in all sectors—housing, education, labor, environment, income, etc.—in what has become known as “placing health in all policies”.

If, in 19th-century Europe, investments in basic sanitation were tested as cost- effective for economic and social development, which other investments could be tested here and now, taking into account our moment in history and the possibilities of productive integration of workers into the workforce? And how could we move forward in this discussion in such a way that the social and health indicators selected for measurement are those that best guide change in the desired direction. Even before, perhaps, how can we invest—as did Chadwick—on making the desired changes?

Conclusions This Report consolidates the initial step of a process of establishing closer relations among PAHO, an international organization; UFRGS, a public federal university; and the Restinga neighborhood, a large, heterogeneous community perhaps best characterized by the social exclusion of its residents, not only due to their social inequality but due to their difficulty in accessing the city center in view of its distance (22 km) and of the precarious nature of the local urban mobility system. After this initial step, UFRGS and PAHO are now more ready to form closer ties to the Restinga, an action that in and of itself will bring added social visibility to this neighborhood. We hope the process triggered by this study will be able to promote innovative and collaborative mechanisms between the community, academia, and public and private institutions locates in the neighborhood and in the city, and that this will, in turn, result in a more empowered Restinga community. The study concludes that application of the Urban HEART methodology in the Restinga neighborhood is feasible. However, it is paramount that major information gaps regarding the dynamics of the community, such as the lack of information on the issue of drug trafficking and its impacts on the local economy and social organization, be addressed.

On the other hand, this methodology does not address “education” sufficiently in the broadest and most comprehensive sense of the word, without which one cannot expect to obtain the commitment of new generations (sustainable development). Furthermore, the indicators proposed by the Urban HEART methodology fail to capture the complexity of the process of devising and implementing urban public policies in

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Porto Alegre in general and in the Restinga in particular (through participatory venues institutionalized both under the purview of national policies and as a result of local peculiarities). This deficit could be mitigated by a greater understanding of the mechanisms whereby the formal and informal groups of this community interact. Only good local governance can improve the self-determination capacity of the Restinga communities and bring better health care services and urban planning. Within this context, ascribing greater value to empiric knowledge and personal experience, securing access to useful information, implementing learning processes (education), and developing leadership are essential. Access to and knowledge of the data and emerging social mechanisms for contact between the community and academia as made possible by this project may strengthen and define strategies to fight for advancement in the achievements of participatory budgeting and other mechanisms of social participation, so that budgetary resources can be used toward the good of all, i.e., the preservation and/or recovery of individual and collective health. Thus far, the identified leadership positions do not appear to have been renewed; they are still held by older residents who remain as leaders. Is this an opportunity to secure the commitment of younger community members? We must find out how to promote enlightened leaders that can effectively mobilize all social players and get them involved in urban health actions through coordinated instruments, with clearly defined strategies and precise outcomes. Hospital Moinhos de Vento, given its characteristics and history of quality, may be a fine example of best practices in universal health care and may constitute a driver of urban development, attracting improvement in public services such as, sanitation, public safety, and transportation. It is important that UFRGS researchers take part in exchange programs with other PAHO/WHO collaborating centers on related matters, such as the research group on child environmental health at the Catholic University of Rio Grande do Sul (PUC/RS). The identification of shared actions and activities may boost contributions in the field of public health. We cannot lose the perspective that we are agents of a knowledge or recognition process running in parallel (and at a different pace) to the process of political and social evolution/development of a heterogeneous, unstable population, that interacts with a metropolis at the fringes, with all of the attendant ills and vices, over which our power—and even our ability to understand them—is extremely limited.

Discussion of this topic in broader venues (including international forums) keeps the debate alive and fosters awareness of the analyzed issues, which may give rise to

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

the illusion that any positive phenomena observed longitudinally are the result of our presence or interaction. We hope the process triggered by this study can promote innovative and collaborative mechanisms among social actors and public and private institutions so that the Vila Restinga community, motivated and encouraged, can take upon itself the responsibility of recognizing and appreciating the creative ability of its residents to solve their own problems and interact with government authorities to achieve new political instruments for decision making, as well as integrated, effective, and sovereign arrangements for community organization. We believe this will allow interfacing with the social and environmental determinants of health, optimize reduction of social inequities in health, and create jobs and income. We now present some conclusions and recommendations: 1. Only good local governance can improve the self-determination capacity of the Vila Restinga communities and bring better health care services and urban planning. Within this context, ascribing greater value to empiric knowledge and personal experience, securing access to useful information, implementing learning processes (education), and developing leadership are essential. 2. The complexity of the process of devising and implementing urban public policies in Vila Restinga could be mitigated by a greater understanding of the mechanisms whereby the formal and informal groups of this community interact. 3. The social movement should fight for further advancement of the achievements of participatory budgeting, so that budgetary resources can be used toward the good of all, i.e., the preservation and/or recovery of individual and collective health. 4. A major challenge faced by Vila Restinga is finding out how to promote enlightened leaders that can effectively mobilize all social players and get them involved in urban health actions through coordinated instruments, with clearly defined strategies and precise outcomes. 5. As good governance presupposes facilitation of the democratic election process, it is essential that a branch office of the Regional Electoral Court be established in Vila Restinga so as to facilitate access of local residents to voter registration. 6. The Vila Restinga community should also be consulted regarding urban planning design and inspection of compliance with municipal codes. For this purpose, the community must be represented in the city Councils. 7. Hospital Moinhos de Vento may be a fine example of best practices in universal health care and may constitute a driver of urban development, attracting improvements in public services such as sanitation and public safety. 8. Within this context, we hope that the KOBE Centre will continue to support initiatives such as ours, so we may encourage political decision makers, program managers, and communities—the main stakeholders—to make strategic decisions and implement specific interventions that are sensitive to the needs of the poorest and most vulnerable groups, as well as experience and celebrate sustainable development.

FEDERAL UNIVERSITY OF RIO GRANDE DO SUL School of Medicine/Department of Social Medicine Extension and Research Program in Urban Health, the Environment and Inequalities

Photo 2. The Restinga map localization).

Source: www.skyscrapecity.com.br apud Zamboni (2009)13

i Azambuja et all, 2014 : (Achutti, 1987a; Achutti, 1987b), (Duncan et al., 1993; Bassanesi et al., 2008, Azambuja et al., 2009; Achutti, 2009), (Azambuja et al., 2011; Azambuja et al., 2014) (Azambuja et al., 2009). Helena Bonetto : “As percepcoes Topofilicas/topofibicas das lideranca comunitarias do Bairro Restinga. Nola Patricia Gamalho: “A producao da periferia: Bairro Restinga”