Commentary: Governance: does it matter in shaping health in urban settings? How in-depth can we go?
1 Urban Health Observatory, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
2 Departament of Social and Preventive Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
* Corresponding author. School of Medicine, Av. Alfredo Balena, 190 – sala 728 – 30130-100-Belo Horizonte-MG, Brazil. E-mail: wcaiaffa{at}medicina.ufmg.br
Accepted 5 June 2008
It has never been an easy case when universal health access is a stated country condition for a society. In Brazil, it is acknowledged that the Unified Health System (SUS) ensures equal and decentralized access, leaving the management of resources and provision of services to cities. So through the district system it is potentially possible for local governments to apply available resources in accordance with local needs and priorities. Also, this system makes possible the achievement of citizenship participation in the management of health.1
However, considering its continental size as well as its social and cultural diversity, Brazil harbours many different and thus far from homogeneous and simple health care and management systems. Additionally, the complex Brazilian health situation, both in terms of its epidemiological profile and the well-established, persistent inequality in allocation of public health resources are problematic. So, further elaboration is needed.2,3
In this context, the paper by Cavalini and Ponce de Leon4 is a welcome contribution. Central points are to be discussed under the light of this article, summarized as follows: the exposure variables, the ecological design and the analysis.
Of all the exposure variables at any level, attention here is given to the innovative way to try to target a proxy of governance; understood as political decisions at the local level, in modelling the local health care system—‘left-winged (pro public health care) or right-winged (pro private health care) parties’. It fits well with the recent definition of urban heath governance, which refers to the decision-making processes, mobilization and use of resources, quality of government and the capacity to design, implement and evaluate policies that affect the health of urban residents. This includes the means through which levels of participation and decentralization, social innovations and diverse stakeholders’ interests influence urban health.5
Ecological designs sometimes are necessary because of the lack of individual data. Although ecological studies had received a negative press and reputation, nowadays they have been considered more legitimate as a public health analytical tool to better understand the interdependence between health related events and several multilevel and multisectoral determinants.6–8
In a country marked by high rates of poverty and social inequality, several studies have sought to understand how inequalities in policies, socioeconomic, ethnic, racial, regional and gender have an impact on the morbidity and mortality profile of the population, access to and use of health services.2,3 Public policies in Brazil have low capacity to promote equity, although political and organizational innovations can have redistributive impacts. The approach of health promotion emphasizes the importance of assessing the impact of public policies not only in the figures of poverty, but also on indicators of health, access to services and political decisions at the local level.3,9
Finally, the inclusion of new variables such as political affiliation proposed in the study of Cavalini and Ponce de Leon4 might broaden our epidemiological vision in an attempt to elucidate new determinants of health, perhaps forming an additional piece of evidence in the jigsaw puzzle that exists about political decisions and health events in Brazil.
In conclusion, what are the implications? Along with numerous recommendations, this article reinforces the need to pursue an aggressive approach on using publicly available datasets, to accurately measure variables, use as strong as possible a design and rigorous analysis with a priori hypothesis testing.
However, to better understand the determinants, and assuming that in a unified health system, local governments apply the resources in accordance with political priorities, there remains the question as to which level the relevant exposures lie. Is this ecological approach an unfailing way to make the invisible visible? Assuming that the authors' a priori hypotheses was operationalized through a multilevel ecological study a recommendation ought to be considered on incorporating individual level variables to this sort of analysis.
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Dr WTC and FAP are recipient of Brazilian National Council for Scientific and Technological Development (CNPq) scholarships.
Conflict of interest: None declared.
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3 Magalhães R, Burlandy L, Senna MCM. Desigualdades sociais, saúde e bem-estar: oportunidades e problemas no horizonte de políticas públicas transversais. Ciên Saúde Colet (2007) 12:1415–421.
4 Cavalini LT, Ponce de Leon ACM. Morbidity and mortality in Brazilian municipalities: association with socioeconomic and health care indicators. A multilevel study. Int J Epidemiol (2008) 37:775–83.
5 World Health Organization (WHO). Our Cities, Our Health, Our Future: Acting on Social Determinants for Health Equity in Urban Settings. In: Report to the WHO Comission on Social Determinants of Health from the Knowledge Network on Urban Settings (2008) Kobe, Japan: WHO.
6 Berkman L, Kawachi I. Social Epidemiology (2000) New York: Oxford University Press.
7 Morgenstern H. Ecological studies. In: Modern Epidemiology—Rothman KJ, Greenland S, eds. (1998) 2nd. Philadelphia: Lippincott-Raven.
8 Susser M. The logic in ecological: I. The logic of analysis. Am J Pub Health (1994) 84:825–29.
9 Krieger N. Proximal, distal, and the politics of causation: what's level got to do with it? Public Health (2008) 98:221–30.[CrossRef]
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