Addressing inequalities in health through intersectoral action Antonio Ivo de Carvalho, Dean, National School of Public Health (Rio de Janeiro, Brazil) Carlos dos Santos Silva, Executive Coordinator of the IAH Project (Canada/Brazil) Simone Moyses, University of Paraná and Local Coordinator (Curitiba, Brazil) Alvaro Matida, Executive Director, ABRASCO (Rio de Janeiro, Brazil) Moderator * Helena Monteiro, Project Coordinator, CPHA

Project INTERSECTORAL ACTION FOR HEALTH Health promotion as a strategy for sustainable local development Canadian Public Health Association National School of Public Health - Fiocruz Brazilian Association of Collective Health

The Project The project seeks to strengthen the capacity of the Brazilian public health to develop and implement intersectoral collaboration to promote health and local development for Brazilian communities. A vital core principle of Brazil’s social development strategy is the strengthening of local capacities to promote a better life for people and their communities. This strategy is used in many federal-level government programs of poverty reduction and social inclusion, such as the Family Health Program. Within this context, the Intersectoral Action for Health Project assist six selected municipalities across the country in undertaking a mix of health promotion interventions and capacity building activities on local development and intersectoral action for health.

Institutional and Political Context 1) Brazil and Canada: health reform in the 1980s 2) Health promotion in Brazil: the 1990s and since 3) Emergence of DSS approach: intersectoral action and sustainable development

Brazil and Canada: Health Reform in the 1980s Ottawa Conference (1986) – Health promotion (attaining health through public policies, enabling environments, community action, adoption of new skills, re-orienting services) VIII National Health Conference (1986) – Health reform (attaining health through social reforms – “social and economic policies that seek to reduce the risk of disease and other problems and provide universal and equal access to actions and services that promote, protect and recover the same” – 1988 Constitution).

In both cases: – Emphasis on social determinant of health-diseases. – Expanded concept of health (quality of life and autonomous capacity). – Protagonism of new actors (outside health): institutions (intersectorial action) and citizenship (community participation). – Contrary to the neo-liberal tide (USA and Europe) of restricting social expenditures and minimization of the State. – Social determinants are political determinants.

In Brazil – Lack of synchronization between services system reform (democratic, universal, inclusive, participatory, redistributing) and dominant economic model (generator of social and regional inequalities). – Improvement in average health outcomes and worsening of relative indicators rates (inequalities) – HP as a social movement and health paradigm (not as level of care, associated with prevention), came late in the 1990s, heavily focused on an agenda of social and cultural change (unconcluded Health Reform agenda)

HP is developed in Brazil in the 1990s: – As an expansion of the health services agenda, in actions on the most immediate determinants (educational and organizational activities, empowerment, of community groups – women, elderly, children, high blood pressure, diabetics, obese, etc – related to new attitudes and behavior); – As experiences of local development, coordinating communities, government, academia, corporations and services around intersectoral projects that seek to produce sustainable improvements at the local level – As the practice of advocacy, seeking to influence governments and society regarding the need for structural policies more committed to well-being and that generate fewer inequalities

Around 2000, certain events signaled a shift in the public health agenda: Signature by the Ministry of Health, States and Municipalities of the Pact for Life, which included several intersectoral policies and measures. Establishment of the National Health Promotion Policy Management Committee (2006). Establishment of the National Commission on Social Determinants of Health (2006) and the publication of its Final Report (2008). Minister of Health, Jose Temporão (2007), initiating a management in the MH explicitly committed to intersectoral action, the advocate for health equity and inclusion within the struggle for sustainable development. Establishment of the Programa Mais Saúde (More Health Program, Dec 2007) consolidating coordination among ministries and with society to achieve health and quality of life, in a four-year plan.

The current situation in Brazil provides favorable conditions to the expansion and enhanced effectiveness of the public agenda to fight inequalities and to address social health determinants: – Health and intersectoral action – Health and sustainable development

Health and Intersectoral Action Health as a theme that generates and mobilizes social policies and programs Socially-defined territories as a basis for coordinating and focusing integrated development policies Examples (federal programs): – TEIAS Program (Integrated Health Care Networks: health + other social programs) – Community Territories Program (integrated actions in 900 of the poorest municipalities in the country)

Health and Development Health as a condition of citizenship and a resource for development; Positive joining up of economic and health logics; Development of a productive infrastructure base linked to health needs, so that universal access favors the expansion of a productive complex market: Source of income, investment and employment generation Source of innovation and knowledge 20% of Worldwide Expenditure in R&D (some US$ 180 billion) Nearly 8% of national GDP 10% of qualified labor in Brazil 9.0 million direct and indirect jobs Platform for new technological developments (fine chemistry, biotechnology, electronics, nanotechnology, materials etc)

New Challenges The role of ENSP (National School of Public Health) in addressing the current challenges in health: – Training and education – Capacity building of the health workforce – Supporting innovation – Influencing policies – National and International cooperation