Urban violence and pacification in Rio's favelas: innovative approaches to measurement and quantifying health system impacts

许多城市，特别是拉丁美洲低收入和中等收入国家的城市，都受到严重的城市暴力的困扰。城市暴力影响着市民的日常生活——谋杀、伤害和犯罪增加，心理健康状况恶化，压力增大，社区文化和日常活动受到干扰。这种暴力大多发生在城市贫民窟，在那里，治安和医疗等公共服务的提供是一项重大挑战。目前，有10亿人生活在城市贫民窟，到2030年，这一数字将增加到20亿。高质量的卫生系统对于确保每个人都能在没有经济困难的情况下获得高质量的卫生保健至关重要，特别是对于城市贫困人口和受城市暴力影响的人口。然而，城市暴力如何影响卫生系统的提供和绩效并没有得到很好的记录或研究。需要进行更多的研究，找出衡量地方城市暴力的最佳方法，以便更好地描述卫生系统的影响。全球许多城市都采取了干预措施来解决城市暴力问题，但对这些干预措施对卫生系统绩效的有力评估很少。更好地了解卫生系统在面临城市暴力时的表现，对于改善服务、引入应对城市暴力挑战的卫生保健政策以及设计解决系统弱点的干预措施至关重要。本研究项目将探讨城市暴力对里约热内卢市卫生系统绩效的作用。巴西的里约热内卢是进行这类研究的一个有价值的环境，因为由贩毒团伙驱动的城市暴力程度很高，而且严重的不平等集中在大城市贫民窟（称为favelas），那里居住着三分之一的人口。近年来，该市进行了一些投资，旨在解决城市暴力问题，扩大医疗保健服务。这包括一项针对黑帮控制的贫民窟的平定方案和开设新的初级保健诊所。了解城市暴力如何影响和受这些投资的影响是本研究的主要目的。这项研究将涵盖四个关键领域。第一个项目将考察衡量里约热内卢城市暴力的创新方法。它将使用来自多个来源的数据，包括凶杀案地点、基于应用程序的暴力报告、警方数据或附近学校关闭。第二项研究将了解2008年至2016年期间该市初级卫生保健大规模扩张期间，城市暴力在多大程度上阻碍了医疗诊所的开设。第三个研究将探讨城市暴力与卫生系统绩效之间的关系，并将检验当地暴力事件是否会影响医疗保健的可及性或质量。这将通过诊所关闭、家访、开放时间和员工流动率等指标来衡量。第四个研究领域将了解该市的安抚计划是否影响了卫生系统的绩效。这些研究目标将提供证据，供巴西和国际上其他遭受城市暴力困扰的城市的社区和政策制定者使用。它还将为今后的研究提供准备工作，以便更好地了解城市暴力与卫生系统之间的关系如何影响人口健康和卫生不平等。

Many cities, especially in low- and middle-income countries in Latin America, are plagued by high levels of urban violence. Urban violence affects the everyday life of citizens - with increased homicides, injuries, and crime, poorer mental health and higher levels of stress, and disrupted community culture and day-to-day activities. Much of this violence is located in urban slums where the provision of public services, including policing and healthcare, is a major challenge. Currently, one billion currently live in urban slums, which will increase to two billion by 2030.High-quality health systems are crucial for ensuring everyone can access high quality healthcare without financial hardship - particularly for the urban poor and populations affected by urban violence. However, how urban violence affects the provision and performance of health systems is not well documented or researched. More research is needed on the best ways to measure urban violence in local areas to better characterise health system impacts. Many cities globally have introduced interventions to address urban violence, but there a few robust evaluations of these interventions on health systems performance. Better understanding how health systems perform when exposed to urban violence is vital for improving services, introducing healthcare policies to respond to the challenge of urban violence, and designing interventions to address weaknesses in the system. This research project will explore the role of urban violence on health system performance in the city of Rio de Janeiro. Rio de Janeiro is a valuable setting for this type of research as there are high-levels of urban violence driven by drug-gangs and large inequalities which are concentrated in large urban slums (called favelas) where one-third of the population live. There have been investments in the city in recent years aiming to address urban violence and expand healthcare provision. This includes a pacification programme for gang-controlled slums and the opening of new primary care clinics. Understanding how urban violence influences and is influenced by these investments is the key aim of this research. The research will cover four key areas. The first will examine innovative approaches to measuring urban violence in Rio de Janeiro. It will use data form multiple sources, including locations of homicides, app-based reports of violence, police data, or nearby school closures. The second will understand to what extent urban violence deterred the opening of healthcare clinics during a large expansion in primary health care in the city between 2008 and 2016. The third will explore the relationship between urban violence and health system performance and will test whether local episodes of violence affected the access or quality of healthcare. This will be measured through metrics such as clinic closures, home visits, opening hours, and staff turnover. The fourth area of research will understand if the city's pacification programme affected health system performance. These research aims will deliver evidence that can be used by communities and policymakers both in Brazil and internationally in other cities burdened by urban violence. It will also form preparatory work for future research to better understand how the relationships between urban violence and health systems can impact population health and health inequalities.