SOCIAL DETERMINANTS SOCIAL DETERMINANTS OF HEALTHOF HEALTH

Sustainable Development and Environmental Health Area (SDE)

WHO/PAHO Collaborating Centers Regional Meeting

24-26 October, 2011

Concepts

� Social Determinants of H ealth

� Social, economic, cultural, ethnical, psichological, environmental and behavioral factors, that influence the health risk of the population .

� Social, living and working conditions.

The tension among paradigms in The tension among paradigms in the comprehension of social the comprehension of social

determinants of health along the determinants of health along the historyhistory

� Have to be with:◦ The hegemonic knowledge;◦ The characteristics of social organization at

the moment.� And

� Generate� Different explicative models;� Different intervention strategies

Rio Political Declaration on Social Determinants of Health - 2011Five key action areas are critical to addressing health inequalities:◦ To adopt better governance for health and

development;

◦ To promote participation in policy making and implementation;

◦ To further reorient the health sector toward reducing health inequities;

◦ To strengthen global governance and collaboration;

◦ To monitor progress and increase accountability.

Long distance

Intermediáriess

Very near

IntersetorialitySocial

participation

The SDH are in different levels of life in society.Health is both a prerequisite for,

and a measure of sustainable development. It was an special issue of

the Conference on Social Determinants of Health

United Nations Conference on United Nations Conference on Sustainable Development Rio Sustainable Development Rio +20+20

� Will focus on two Themes◦ Green Economy in the context of sustainable

development and poverty eradication;

◦ Institutional framework for sustainable development

� Environmental global change and development with sustainability will be the expected result.

Agenda 21 an instrument for Agenda 21 an instrument for social and sustainable social and sustainable

developmentdevelopment� Is an agenda of Rio +10, and will be of

Rio+20;� It was created to promote local

sustainable development;� Green economy was one of the themes

of the projects developed in the whole word and also in Brazil;� A Research Group of seven Brazilian

universities, implement a study in all regions of the country – 2007-2009 - , to evaluate the impact of the agenda 21 on Millennium development goals.

HEALTH AND LOCAL

DEVELOPMENT: EFFECTIVENESS

EVALUATION OF SOCIAL

AGENDAS IN BRAZILIAN CITIES, IN

BASE OF THE MILLENNIUM

DEVELOPMENT GOALS.

A seven university Multicentric project: 5 regions of the country

Millennium development goals,Millennium development goals,another development agenda another development agenda

of ONUof ONU

Hypothesis: Agenda 21 and Hypothesis: Agenda 21 and Health CitiesHealth Cities

1. Development, promote by social agendas, is an important asset to improve living, health and environmental conditions, since they affect the social and economic determinants of health.

2. The impact are supported by principles of action proposed in the 21 Agenda: holistic conception, intersectoriality, empowerment, social participation, equity, multi-strategic actions and sustainability

INEQUITIESINEQUITIES

SOCIAL CAPITALSOCIAL CAPITAL

DEVELOPMENT OF A INTEGRATIVE MODEL FOR

MANAGEMENT

DEVELOPMENT OF A INTEGRATIVE MODEL FOR

MANAGEMENT

GOVERANCE AND SUSTENTABILITYGOVERANCE AND SUSTENTABILITY

SOCIAL PARTICIPATIONSOCIAL PARTICIPATIONINTERSETORIALITY AND SOCIAL NETWORKS

INTERSETORIALITY AND SOCIAL NETWORKS

PUBLIC POLICYPUBLIC POLICY

KNOWLEDGERESULTS

KNOWLEDGERESULTS

PARTICIPATORY PROSSUPOSITIONS

PARTICIPATORY PROSSUPOSITIONS

HEALTHHEALTH

Conceptual model

MethodologyMethodologyThree phases:

1st) Working agendas assesment in 5 regions of the country, through phone interview;

2nd) a impact study, like a retrospective cohort study scheme, with secondary data, (1991 to 19 96) to identify the progress related to the Millennium Development Goals - 105 cases and 175 controls selecte d by width and geographic area;

3rd) 24 case studies from five regions of the country, wi th the best results of MDG indicators, were selected to an alize the social experience of the local management and ci vil society with the development of the agenda

A coorte studyA coorte study

Figura 1 – Desenho de um estudo de coorte

STUDY POPULATIONSTUDY POPULATION

� Phase 1 – Identified 105 municipalities developing social agendas: 21 agenda, Health cities and DLIS;� Phase 2 – For the ecologic study,

were identified 176 control municipalities, more or less two for each study municipality;� Great difficult to find good data for the

indicators of the MDG.

Figura 6 – Mapa de intensidade da concentração (Kernel-intensity) de municípios-caso selecionados para o estudo. Brasil, 2009.

Results in relation of MDGResults in relation of MDGINDICATOR

Group Time Interaction

01. Percentage of children under one year with prot ein/caloric undernourishment 0.386 < 0.001 0.01802. Percentage of children aged between 1 and 2 yea rs with protein/coloric undernourishment

0.688 < 0.001 0.706

03. Percentage of families benefited by the Bolsa F amília Program 0.674 < 0.001 0.09604. Municipal revenue per capita from taxes and con stitutional and legal transfers 0.723 < 0.001 0.80005. Median age at conclusion of fundamental educati on 0.961 < 0.001 0.35806. Percentage of children aged from 7 to 14 years enrolled in fundamental education 0.385 < 0.001 0.721drop-out rate in the 1st grade of fundamental educa tion 0.865 < 0.001 0.72608. Age-grade distortion in the 4th grade of fundam ental education 0.728 < 0.001 0.79709. Age-grade distortion in the 8th grade of fundam ental education 0.985 < 0.001 < 0.00110. Gender ratio of pupils enrolled in fundamental education 0.676 0.067 0.72811. Gender ratio of pupils enrolled in secondary ed ucation 0.317 0.624 0.74512. Gender ratio of pupils enrolled in higher educ ation 0.229 0.473 0.27213. Percentage of salaried women in the non-agricul tural sector 0.301 0.543 0.99714. Percentage of lady town councilors 0.695 0.036 0.59515. Percentage of women among federal deputies ele cted by the state 0.938 < 0.001 0.89316. Male/female ratio among salaried workers 0.254 0.185 0.23217. Proportional mortality of children under 1 year 0.412 0.002 0.26018. Coefficient of Infant Mortality by moving avera ge 0.918 0.459 0.68519. Maternal mortality ratio corrected by moving av erage 0.219 0.004 0.20020. Percentage of institutional deliveries 0.219 0.000 0.58421. Proportion of coverage of pregnancies with 7 or more prenatal visits * 0.784 0.002 0.75522. HIV Mortality Coefficient* 0.063 0.303 0.34323. Malaria prevalence 0.619 0.001 0.94124. Tuberculosis prevalence (confirmed cases) 0.044 0.001 0.86925. Mortality from Diarrhea in children under 5 yea rs 0.481 0.182 0.68226. Cardiovascular disease death rate* 0.636 0.011 0.76627. Mortality rates due to external causes 0.137 0.737 0.67928. Percentage of the population with piped water s upply 0.055 0.020 0.77229. Percentage of salaried youth between 15 and 24 years 0.212 < 0.001 0.240

The 21 agendasThe 21 agendas� The analysis of the interviews demonstrate different

configurations of the agenda according problems and assets of the regions and municipalities

� Focus on diagnostic process and elaboration of plans, as an answer to financial support;

� Sustainability was a recurrent issue mentioned in the interviews

� Democratization of the relations with public power� They are recognized as an innovative model of local

management � Democratic;� Integrative of different sectors of the society;� Strengten social participation practices� Change the environment with the implementation and monitoring

the local agenda;� Change power relations in the population in the cities –

transparency

RecommendationsRecommendations� Is important to continue investing in local

development agendas.� At local level is easier to integrate agendas

and sectors, scientific knowledge related with technology and human and social sciences,

� Local development agendas help in acting in environmental, social and health problems affecting individuals and communities, with their participation.

� So, local developmental agendas are ideal place and methodology to invest in citizenship.

OBRIGADA PELA OBRIGADA PELA ATENATENÇÃÇÃO.O.

Marcia Faria Westphal marciafw@usp.brCEPEDOC Cidades SaudáveisFaculdade de Saúde Pública da Universidade de São Paulo