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

许多城市，特别是在拉丁美洲的低收入和中等收入国家，都受到高水平的城市暴力的困扰。城市暴力影响到公民的日常生活--杀人、受伤和犯罪增加，精神健康状况变差，压力增加，扰乱了社区文化和日常活动。这些暴力事件大部分发生在城市贫民窟，在那里，提供包括警务和医疗保健在内的公共服务是一个重大挑战。目前，有10亿人居住在城市贫民窟，到2030年，这一数字将增加到20亿。高质量的医疗体系对于确保每个人都能获得高质量的医疗保健至关重要，而不会出现经济困难--特别是对城市穷人和受城市暴力影响的人群。然而，城市暴力如何影响卫生系统的提供和绩效没有得到很好的记录或研究。需要对衡量当地城市暴力的最佳方法进行更多的研究，以更好地描述卫生系统的影响。全球许多城市都引入了应对城市暴力的干预措施，但对这些干预措施对卫生系统绩效的影响进行了一些有力的评估。更好地了解卫生系统在暴露于城市暴力时的表现，对于改善服务、引入医疗政策以应对城市暴力的挑战以及设计干预措施以解决系统中的弱点至关重要。这项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影响。里约热内卢对于这类研究来说是一个有价值的背景，因为由贩毒团伙和巨大的不平等驱动的城市暴力水平很高，集中在三分之一人口居住的大型城市贫民窟(称为贫民窟)。近年来，该市一直在进行投资，旨在解决城市暴力问题，扩大医疗保健供应。这包括针对帮派控制的贫民窟的安抚方案和开设新的初级保健诊所。了解城市暴力如何影响这些投资并受到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。第一个将研究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、警方数据或附近的学校关闭。第二个将了解在2008年至2016年期间，城市暴力在多大程度上阻止了该市初级医疗保健的大规模扩张期间开设医疗诊所。第三项研究将探讨城市暴力与卫生系统绩效之间的关系，并将测试当地发生的暴力事件是否影响了医疗保健的获得或质量。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表现。这些研究的目的是提供证据，供巴西的社区和政策制定者以及其他遭受城市暴力负担的国际城市使用。它还将为今后的研究形成准备工作，以便更好地了解城市暴力和卫生系统之间的关系如何影响人口健康和健康不平等。

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.