Monitoring Millennium Development Goals in Brazilian municipalities: challenges to be met in facing up to iniquities Monitorando Objetivos de Desenvolvimento do Milênio em municípios brasileiros: desafi os ao enfrentamento das iniquidades

The Healthy Cities and Agenda 21 programs improve living and health conditions and affect social and economic determinants of health. The Millennium Development Goals (MDG) indicators can be used to assess the impact of social agendas. A data search was carried out for the period 1997 to 2006 to obtain 48 indicators proposed by the United Nations and a further 74 proposed by the technical group for the MDGin Brazil. There is a scarcity of studies concerned with assessing the MDG at the municipal level. Data from Brazilian health information systems are not always consistent or accurate for municipalities. The lack of availability and reliable data led to the substitution of some indicators. The information systems did not always provide annual data; national household surveys could not be disaggregated at the municipal level and there were also modifications on conceptual definitions over time. As a result, the project created an alternative list with 29 indicators. MDG monitoring at the local community can be important to measure the performance of actions toward improvements in quality of life and social iniquities. Equity in Health; Social Indicators; Millennium Development Goals; Local Development; Health Status Indicators Introduction The United Nations (UN) held a summit meeting in the year 2000 to draw up an ambitious agenda to diminish global social iniquities by 2015 1. A total of 189 countries accepted undertaking the socalled Millennium Development Goals (MDG). The proposal was to monitor important dimensions of life presented in terms of eight goals expressed as actions to fight poverty and hunger, promote education and sexual equality, improve health status and access to sanitation and housing, and enhance sustainable development and integration. These goals were divided into 18 targets, to be monitored using 48 indicators. The World Health Organization (WHO) and the World Bank organized and held discussion forums with political leaders to speed up the paths to achieve the health MDG. The first was held in Geneva, Switzerland, in January 2004; the second in Nigeria in the same year and the third in France in November 2005. The 47th Directing Council report of the Pan-American Health Organization saw health investments as a central issue in this new development agenda 2, suggesting then the strategic importance of the health sector for countries’ political agendas (http://www.paho.org/spanish/gov/cd/cd47in dex-s.htm, accessed on 09/Jun/2010). Brazil is one of the signatories of the UN document and, by Presidential decree (31/Oct/ 2003), created a Technical Group to accompaARTIGO ARTICLE Westphal MF et al. S156 Cad. Saúde Pública, Rio de Janeiro, 27 Sup 2:S155-S163, 2011 ny the MDG. Information was systematically collected for the surveillance of the MDG. The Planning and Strategic Investment Department of the Brazilian Ministry of Planning (Secretaria de Planejamento e Investimentos Estratégicos, Ministério do Planejamento – SPI/MP) coordinated the studies and the Institute of Applied Economic Research (Instituto de Pesquisa Econômica Aplicada– IPEA) was responsible for the agenda 2,3. There was also a major movement towards improving the mechanisms to evaluate living and health conditions. The main focus of this initiative was the questioning of the adequacy of the use of strictly economic indicators to represent the population’s quality of life. The discussion of the limitations of using Gross Domestic Product (GDP) per capita for this purpose is well-known 4. The Human Development Index (HDI) was already employed worldwide. This Index was anchored on the theoretical formulations of important thinkers, among them Sen 4 and his discussion of the freedom of choice. The HDI is a synthetic indicator comprised of three elements: longevity, expressed by life expectancy at birth, understood as the synthesis of a set of indicators of health conditions (child mortality, maternal mortality, access to drinking water, garbage collection, sewage systems etc.) 5; education, which aggregates two indicators: the literacy rate of individuals 15 years of age and over, and the combined gross rate of schooling of the three teaching levels 5; and the income dimension, measured by the GDP per capita, which expresses the conditions necessary for the maintenance of a dignified life, and people’s access to opportunities and economic resources (occupation, employment, income, technologies, credit, land and others) 5. The Sarkozy Committee, established in 2008, released its final report in 2010 and presented substantial reflections on how to improve instruments for measuring quality of life. This report recommended that in order to measure quality of life, it is also necessary to take into account people’s opportunities and the freedom to choose among them 6. Many initiatives have been taken to adjust measures and to monitor the population’s living conditions and health status, throughout the world: it is worth making special mention of the initiatives taken by multilateral organs – the UN Development Programme (UNDP), the UN Children’ Fund (UNICEF), WHO, the World Bank, the Joint UN Programme on HIV/AIDS (UNIAIDS) and the UN Development Fund for Women (UNIFEM). Some mechanisms have been built to improve precise diagnoses of social situations, to guide political decisions and the empowerment of the population in Brazil over the last 20 years. Some examples are: the Annual Human Development Report, the Municipal Human Development Index (M-HDI), the Atlas of Human Development (http://www.pnud.org. br/atlas), the Map of Social Inclusion/Exclusion in São Paulo (http://www.dpi.inpe.br/geopro/ exclusao/mapas.html), the Hunger Map (http:// www.dpi.inpe.br/geopro/exclusao/mapas.ht ml). Synthetic indicators were also generated in this period, such as the São Paulo Social Responsibility Index – IPRS (http://www.seade.gov.br/ projetos/iprs/) – and the Map of Environmental Injustice (http://www.conflitoambiental.icict.fi ocruz.br/), among others. Inter-Agency Health Information Network (Rede Interagencial de Informação para a Saúde – RIPSA; http://www.ripsa.org.br) – aimed to improve and to consolidate information systems and databases in order to define and to obtain a set of indicators to evaluate Brazilian health status and health services. The RIPSA is constituted by important institutions that are information generators, such as the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE), the Brazilian Ministry of Health (Ministério da Saúde), IPEA and the Oswaldo Cruz Foundation (Fundação Oswaldo Cruz – Fiocruz), João Pinheiro Foundation (Fundação João Pinheiro), Josué de Castro Foundation (Fundação Josué de Castro), São Paulo Data Analysis System Foundation (Fundação Sistema Estadual de Análise de Dados – SEADE). RIPSA also counts on the participation of universities, the Brazilian Public Health Association (Associação Brasileira de Pós-graduação em Saúde Coletiva – ABRASCO) and the Brazilian Population Studies (Associação Brasileira de Empresas de Pesquisa – ABEP). There were also academic and non-governmental organizations initiatives to study particular aspects of life in society. There are, however, well established methodologies to evaluate the impact of MDG at the national level, even in countries with incomplete datasets, while studies directed to evaluate the impact in small administrative units are scarce. This is mainly due to the incompleteness of the data necessary to obtain MDG indicators at this level. The Multi-Center study coordinated by the School of Public Health of the São Paulo University (Faculdade de Saúde Pública, Universidade São Paulo), with the participation of the Paraná Catholic University (Pontífica Universidade Católica do Paraná), Goiás Federal University (Universidade Federal de Goiás), Dom Bosco Catholic University (Universidade Católica Dom MONITORING MILLENNIUM DEVELOPMENT INDICATORS S157 Cad. Saúde Pública, Rio de Janeiro, 27 Sup 2:S155-S163, 2011 Bosco), Pernambuco Federal University (Universidade Federal de Pernambuco), Amazônia University (Universidade da Amazônia), Tocantis Federal University (Universidade Federal do Tocantis), had the objective of assessing how social agendas – Healthy Cities, Agenda 21 and Sustainable Integrated Local Development (DLIS) – contributed towards achieving the MDG, in municipalities of the five geographical regions of the country. This objective was based on the assumption that social agendas will act through the social determinants of health. The project found great difficulties to obtain and to monitor MDG indicators at the municipal level 2. The social agendas stimulated by both multinational and Brazilian organizations were understood as opportunities for social development. Social agendas can have a structural effect, as when they are implemented they become integrated into society. Social agendas could also be a means of approximation to the principles of Health Promotion, like inter-sector, multistrategic approaches, sustainability/continuity of actions, equity, holistic concepts, social empowerment and participation, as defined by the WHO 7. The local development promoted by social agendas is believed to contribute to the improvement of the quality of life and health status, as it clearly affects the social and economic determinants of health. Many difficulties arose in the process of evaluating the role of social agendas in achieving the MDG. Brazilian health information systems showed a large list of datasets, and although there is available data at the municipal level, these data are not always consistent or accurate to obtain indicators for health and living conditions. The aim of this article is to describe the process of defining and building MDG indicators at the municipal level in Brazil. This paper presents the difficulties found and the efforts to overcome them, as a partial result of the investigative process, trusting that these considerations will contribute to monitoring MDG in Brazilian municipalities