WHO Cities and Health Programme



Helena Ribeiro

Department of Environmental Health of University of São Paulo. Principal Investigator of the Cities and Health Programme in São Paulo



The city of São Paulo presents peculiar problems in terms of public health, very much related to social and economic conditions. Nevertheless, geographical distribution of health issues within the city is very unequal as social, economical and environmental issues are also unequal, and related to specific age groups and to place of residence.

Treated water distribution to population (95%) by the state company SABESP has been responsible for the decrease in infant mortality and for the low number of deaths caused by water-related diseases among the inhabitants. Incidence rates vary from 0 to 9/100,000 inhabitants among the different districts of the city. One can observe that most cases occur in watershed protection areas near the water reservoirs for the city, where most squatter settlements with no sanitary infra-structure are located.

Among youngsters, besides homicides, HIV infection has been responsible for many deaths. An important preventive program has been implemented by the municipality to reduce the number of deaths caused by AIDS. In ten years, there was a reduction from 2,322 deaths to 1,127 deaths per year. However, conditions are still bad mainly among youngsters of low-income families.

In this context, 3 research projects were selected for the Cities and Health Programme under the agreement signed in 2003 by the City of São Paulo, the University of São Paulo, and the WHO Kobe Centre Cities and Health Programme. The Programme has collaborated with cities to develop action-research projects. Through collaborative research between cities, academic partners and the WHO Kobe Centre, new knowledge has been generated on how to improve health and well-being in cities. As principal investigator of the project in São Paulo, indicated by the former dean of the School of Public Health, Dr. João Yunes, I was involved since the start, in the choice of the innovative municipal projects, that once evaluated, could be of interest to other cities in the world.

The three projects from São Paulo were designed to deal with the most serious public health problems of the city: lack of sanitary infrastruture in very poor districts; violence; and AIDS contamination among youngsters of low income families. They were these:

Assessment of post-use and satisfaction level of residents in areas re-urbanized by the Guarapiranga Reservoir Programme

This project was included in the Drinking Water Quality and Impact of Housing on Health components of the Cities and Health Programme. The Guarapiranga Programme was planned in 1991, after an extraordinary blooming of algae in the reservoir due to untreated sewage that flowed to it from squatter settlements located in previous decades in the area, with the risk of condemning that important watershed. A joint project was presented by the state and municipal governments to the World Bank to provide sanitation infrastructure to the area and to remove some of the houses where this was not possible or that were under risk. Infrastructure work in the slums and lots comprised: paving of ways and alleys; drainage of creeks and rainwater; implementation of water and sewage networks; containment of hillsides; construction of squares and community centres; establishment of conditions that guarantee garbage collection; social follow-up; and environmental education. The programme has been ongoing since 1993, but, in 2001, its scope was enlarged. It was observed that urbanization works alone would not solve the problems, as poverty persisted and also new families kept coming to live in the area. The municipality introduced social inclusion programmes in the area: minimum income and Start Again. Besides those, started assessment of the post-use and satisfaction level of residents in those re-urbanized areas to subsidize future actions, including expanding the programme to Billings reservoir watershed.

Assessment of distribution of harm reduction kits in services for sexually transmitted infections/AIDS in Psychosocial, alcohol and drugs centres

The project is part of the Alcohol-related Harm and Youth mental health components of the program and introduced the harm reduction concept in the centres. It shed light on the complexity of the task and the impact of the service within the territory covered.

Youths on Duty: reception and care for adolescents at Testing and Counselling Centres

The distribution of youngsters in the city of São Paulo is unequal and unfavorable: they tend to live in areas of greater social vulnerability, in districts with worst social and economical indicators. Nevertheless, they find great barriers to their access to health care and few innovative public health programmes have been implemented for this age group. Among those, even fewer have adopted participative approaches (Project Final Report, 2005). Youths on Duty are one of these rare innovative initiatives implemented in these centres. The duties involve young people of ages raging from 16 to 24 years working with their peers in reception and counseling activities, educational lectures and in making condoms available in four centres, in areas located in the urban periphery and characterized by high levels of social exclusion.

All three projects confront emblematic problems of São Paulo and of large cities in developing countries with urgent need of innovative ways. Also, the projects were developed in socially deprived areas and were targeted at reducing health inequalities in the city.

The methodology adopted for all three projects aimed, not only to evaluate the works and services provided by the city, but, to encourage and reinforce the need for strong community participation in the solution of these problems. The projects adopted academic methodologies and research techniques for evaluation of public policies for health and the environment, and were supervised by scientists and professors of the University of São Paulo, a Programme partner.

The results obtained, now published in portuguese in Saúde e Sociedade, can contribute to city administration, to academic knowledge, and also to assisting many cities all over the world to face similar issues.

We thank to WHO Kobe Centre, for the invitation to the city to participate in the Programme, for funding the projects and for the discussions and recommendations on all the stages of the projects. We also thank to the Prefeitura do Município de São Paulo, in special to the Secretaries of Relações Internacionais, Saúde and Habitação, for the technical support and for the opening of its doors and data for the University of São Paulo, during two administrative periods (2001-2004 and 2004-2006).


Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. SP - Brazil
E-mail: saudesoc@usp.br