1. SOCIAL DETERMINANTS OF HEALTH Sustainable Development and Environmental Health Area (SDE) WHO/PAHO Collaborating Centers Regional Meeting 24-26 October, 2011

2. Concepts Social Determinants of Health Social, economic, cultural, ethnical, psichological, environmental and behavioral factors, that influence the health risk of the population. Social, living and working conditions.

3. The tension among paradigms in the comprehension of social determinants of health along the history Have to be with: ◦ The hegemonic knowledge; ◦ The characteristics of social organization at the moment.  And Generate  Different explicative models;  Different intervention strategies

5. Rio Political Declaration on Social Determinants of Health - 2011 Five 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.

6. Long distance Intermediáriess Very near Intersetoriality Social 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

7. United Nations Conference on Sustainable Development Rio +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.

8. Agenda 21 an instrument for social and sustainable development 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.

9. 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

10. Millennium development goals, another development agenda of ONU

11. Hypothesis: Agenda 21 and Health 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

12. INEQUITIES SOCIAL CAPITAL DEVELOPMENT OF A INTEGRATIVE MODEL FOR MANAGEMENT GOVERANCE AND SUSTENTABILITY SOCIAL PARTICIPATION INTERSETORIALITY AND SOCIAL NETWORKS PUBLIC POLICY KNOWLEDGE RESULTS KNOWLEDGE RESULTS PARTICIPATORY PROSSUPOSITIONS HEALTH Conceptual model

13. Methodology Three phases: 1 st )Working agendas assesment in 5 regions of the country, through phone interview; 2 nd )a impact study, like a retrospective cohort study scheme, with secondary data, (1991 to 1996) to identify the progress related to the Millennium Development Goals - 105 cases and 175 controls selected by width and geographic area; 3 rd ) 24 case studies from five regions of the country, with the best results of MDG indicators, were selected to analize the social experience of the local management and civil society with the development of the agenda

14. A coorte study

15. STUDY 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.

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

18. Results in relation of MDG INDICATOR GroupTimeInteraction 01. Percentage of children under one year with protein/caloric undernourishment0.386< 0.0010.018 02. Percentage of children aged between 1 and 2 years with protein/coloric undernourishment 0.688< 0.0010.706 03. Percentage of families benefited by the Bolsa Família Program0.674< 0.0010.096 04. Municipal revenue per capita from taxes and constitutional and legal transfers0.723< 0.0010.800 05. Median age at conclusion of fundamental education0.961< 0.0010.358 06. Percentage of children aged from 7 to 14 years enrolled in fundamental education0.385< 0.0010.721 drop-out rate in the 1st grade of fundamental education0.865< 0.0010.726 08. Age-grade distortion in the 4th grade of fundamental education0.728< 0.0010.797 09. Age-grade distortion in the 8th grade of fundamental education0.985< 0.001 10. Gender ratio of pupils enrolled in fundamental education0.6760.0670.728 11. Gender ratio of pupils enrolled in secondary education0.3170.6240.745 12. Gender ratio of pupils enrolled in higher education0.2290.4730.272 13. Percentage of salaried women in the non-agricultural sector0.3010.5430.997 14. Percentage of lady town councilors0.6950.0360.595 15. Percentage of women among federal deputies elected by the state0.938< 0.0010.893 16. Male/female ratio among salaried workers0.2540.1850.232 17. Proportional mortality of children under 1 year0.4120.0020.260 18. Coefficient of Infant Mortality by moving average0.9180.4590.685 19. Maternal mortality ratio corrected by moving average0.2190.0040.200 20. Percentage of institutional deliveries0.2190.0000.584 21. Proportion of coverage of pregnancies with 7 or more prenatal visits *0.7840.0020.755 22. HIV Mortality Coefficient*0.0630.3030.343 23. Malaria prevalence0.6190.0010.941 24. Tuberculosis prevalence (confirmed cases)0.0440.0010.869 25. Mortality from Diarrhea in children under 5 years0.4810.1820.682 26. Cardiovascular disease death rate*0.6360.0110.766 27. Mortality rates due to external causes0.1370.7370.679 28. Percentage of the population with piped water supply0.0550.0200.772 29. Percentage of salaried youth between 15 and 24 years0.212< 0.0010.240

19. The 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

20. Recommendations 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.

21. OBRIGADA PELA ATENÇÃO. Marcia Faria Westphal marciafw@usp.br CEPEDOC Cidades Saudáveis Faculdade de Saúde Pública da Universidade de São Paulo