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 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 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. 3 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