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Health MinistryHealth Surveillance SecretariatDepartment for the Analysis of the Health ConditionGeneral Coordination of Non-Communicable Diseases and Illnesses

RESEARCH REPORT

Mapping of surveillance, prevention and control initiatives for non-communicable

chronic diseases in Brazil, 1999-2006: subsidies to formulate a national policy

on integrated surveillance.

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Coordination Team of the Observatory for Surveillance, Prevention and Control of

Non-Communicable Chronic Diseases (OPDCNT)

Deborah de Carvalho Malta (SVS/MS)Denise Bomtempo Birche de Carvalho (University of Brasília)Otaliba Libânio de Moraes Neto (SVS/MS)Elisabeth Carmem Duarte (SVS/MS)Luciana Sardinha (SVS/MS)Lenildo de Moura (SVS/MS)Marília Mendonça Leão (CGPAN/MS)Anelise Rizzolo (CGPAN/MS)

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Assistant Researchers:Juliana Rochet , Andréa Fucks, Tânia Maria Tosta da Silva

Specialists linked to the Brazilian Committee of the Observatory for Surveillance, Prevention and Control of NCCD (OPDCNT) Isabella Samico - Health Evaluation (CGIAE-SVS), Iná Santos – Epidemiologist (UFPEL);Sonia Natal – Health Evaluation (ENSP); Aloysio Achutti – Cardiologist / Tobacco policy (AMRIGS); Pedro Rodrigues Hallal – Phys Ed (UFPEL); Yara Carvalho – PhysEd /Dr. Collective He. (USP); Dilian Goullart - CGPAN –MS

International Cooperation - PAHO Lucimar Coser Cannon, Branka Legetic,

WHO Cooperation Center/CanadaSilvie Stachenco, Ellen Voggel

WHO – COORDINATION: Silvie Stachenco

4The analysis comprised the decision making process to formulate

these initiatives within the different sectors of the Ministry of Health

NCDDIET AND NUTRITION

POLICY -

HEALTH PROMOTION AND PHYSICAL

ACTIVITY

TOBACCO CONTROL

BRAZILIAN CASE STUDY: FIVE AXES OF ANALYSIS

NCD SURVEILLANCE

DIABETES/HYPERTEN

SION CARE

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Objectives of the Brazilian case study

•Analyzing the process to formulate these public actions initiatives aiming to promote health;

•Analyzing how such initiatives may be included in a more global future strategy to face this problem and to formulate an integrated policy for NCD prevention and control in Brazil;

•Identifying elements that facilitate or impair the formulation and approval of policies in this area;

•Subsidizing the formulation of an integrated policy for NCD prevention and control in Brazil;

•Analyzing the Brazilian results compared to the NCD prevention and control policies formulation processes in Costa Rica and Canada.

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Methodological proceduresThis is a qualitative research aiming at understanding the interpretations of the actors on the formulation process for public policies on health promotion, which may contribute for the formulation of an integrated policy in NCD surveillance, prevention and control.

Secondary data

Laws that created and ruled the actions and programs analyzed;

Presidential decrees, plans, programs, bulletins, reports issued by qualified governmental organisms;

Publications of international organizations;

Articles in national newspapers;

Speeches, reports, opinions;

Minutes of inter-ministerial and intra-ministerial meetings, work groups;

Cientific event proceddings;

Others documents.

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Methodological procedures

• Primary data

• 29 semi-structured interviews with key informants were carried out, based on an interview form.

• Key informants were pointed out by the Policy Observatory committee using the following selection criteria:

• Public decision makers that significantly participated in the 5 AXES formulation process;

• Experts in scientific evidences of health epidemiologic basis related to DIET AND NUTRITION POLICY , NCD SURVEILLANCE, HEALTH PROMOTION AND PHYSICAL ACTIVITY, DIABETES/HYPERTENSION CARE AND TOBACCO CONTROL

• Experts in 5 AXES with proved experience in the formulation of food and nutritional programs and actions

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Structure to analyze the development of the National Policies on NCCD

Structure to analyze the development of the policy process

Contexcts :

SocialEconomicPhysicalEnvironmentalGenderCultural

Ideas:

InformationSources

Valuespreferences

Interests

Disputants

Policy Net

How the actors interact

Capacity andResources of theactors

atores

Instituições:

Governmental AgenciesMandatesResponsabilitiesFormal Processes

Legislative structureCurrent Policy

Policy Tools :

Legislation

Expenses/costs

Information

Nets Building

New programs

/servicess

Policy Planning

CollaborativePlanning

Community Action and Organization

Awareness about the problem problema/Agenda planning Solution Proposal ------- Decision---------------- Implementingç

------------------ Consensus Building ------------------------

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Surveillance OrganizationThe beginning of worry to control the smoking habit started with the

figures showing the increase of mortality caused by chronic-degenerative diseases, including cancer, that began to gain international visibility in the 1970´s when the process of epidemiological transition in the patterns of mortalitity in the population became clearer;

In 1990, the World Health Assembly convocated its Member States to adopt urgently comprehensive strategies to control the tobacco consumption;

The National Institute of Cancer, with the mission to consolidate a National Policy of Cancer has the smoking habit as its priority because this practice is one of the main risk factors associated to some types of cancer;

The conscientization of a big part of the population about the impact of smoking habit in the health;

Brazil’s adhesion to the Global Strategy on Diet, Physical Activity and Health, promoted by the WHO, whose main focus is the integrate attention to prevent and control the NCDs.

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Surveillance Agenda and the NCD prevention

2003: creation of the CGDANT

Structuring of NCD Surveillance System and its Risk Factors (RF) and Protector Factors (PF)

Management (Regulamentation, sponsoring, human resources, social control and participation, responsability, sustainability

Intervention to prevent (health promotion, interface with assistance, intersectoriality, integrality)

Evaluation and Research support

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Political, economic and social contexts

The Brazilian redemocratization process triggered, in the 1980’s, a progressive social movement towards public policies, specially the related to health;

The New Federal Constitution of 1988 – health as a human right matter;

The 8th Nacional Health Conference, the most important event of the last decades under a sanitary and political point of view;

Regulamentation of SUS (Unified Health System);

Health Organic Law, Federal Law number 8080;

The 1st Nacional Seminar on Epidemiological Surveillance, in 1992

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Political, economic and social contexts

In 1999, the movement inside the Ministry of Health to structure the NCDs surveillance area;

In 2003, the Global Forum of NCD Surveillance and Control, in Rio de Janeiro;

Brazilian participation in the Global WHO Strategy - 2004;

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Ideas and interests

Strong social demand since the mid-1980’s, when started an international movement to control the risk factors associated to smoking habit and obesity in many countries;

Pression of the critical mass of expertise from institutions especialized in collective health put the subject insided the debates of the Ministry of Health;

Intersectorial work inside the Ministry of Health in order to support the NCDs prevention initiatives is fundamental to consolidate the surveillance actions in the area;

Consolidation of the CGDANT-General Surveillance Coordination of Non-Communicable Diseases and Damages.

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Surveillance actions promoted by the WHO and PAHO in other countries are useful to structure the surveillance in Brazil.

Ideas and interests – Cont.

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Relevant Institutions in the process Internationals

•Center for Disease Control (CDC);•World Health Organization (WHO);•Pan-American Health Organization (PAHO);•World Bank;

Nationals•Ministry of Health;•Committe of the National Policy on Intersectorial Health Promotion (the committee is composed by technicians of all the Secretariats, including the Secretariat of Science and Technology, the Oswaldo Cruz Fundation and the National Cancer Institute);•National Cancer Institute (INCA);•National Agency for Sanitary Surveillance (ANVISA);•Brazilian Society of Clinic Oncology;•Brazilian Society of Pneumology and Tisiology.•Universities – Collaborating Centers (UFMG, UFBA, FIOCRUZ, UFPEL, IMIQE, FSP/USP;•Brazilian Association of Post-Graduation in Collective Health – ABRASCO;•CELAFISCS;•IBGE.

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Conclusions

•The silent advance of the chronic diseases in the work force suggested the importance of the establishment of actions aimed to promote health;

•The international AGENDA indicates to Brazil the necessity to formulate strategies to insert the NCD theme in the governmental agend;

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ConclusionsThe creation, in 2003, of the Health Surveillance

Secretariat, and the General Surveillance Coordination of Non-Communicable Diseases and Damages aimed to fill an important space inside the Brazilian Health Service;

The regulamentation of the Health Surveillance Secretariat strenghtned the surveillance system and possibilitated the formulation of comprehensive and inclusive governmental strategies in the whole Brazilian territory;

The integration of the data base, the analyses of health situations, the production of studies about the perspectives of the health problems were the strenghtning basis for the NDC Prevention and Surveillance in Brazil.

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ConclusionsThe international agenda strengthens the establishment of

actions aimed to promote health among the Brazilian population;

Beginning of the establishment of directives aimed to combat sedentarism, promote physical activity, health diet and good health maintenance;

Awareness about the relevance to call the attention of the population about the importance of a good diet and physical activity practice as a preventive factor against the NCDs;

The intersectoriality is fundamental in the process because the health promotion envolve many governmental and non-governmental actors;

The participative policy elaborating process is a positive factor that affects the formulation and approval of the National Policy on Health Promotion in Brazil, in 2006.

19The analysis comprised the decision making process to formulate

these initiatives within the different sectors of the Ministry of Health

PREVENTIONand

SURVEILLANCE

NCD

DIET AND NUTRITION

POLICY -

PHYSICAL ACTIVITY

TOBACCO CONTROL

CASE STUDY PROPOSAL: FIVE AXES OF ANALYSIS

ALCHOOL AND THE OTHERS

DRUGS

DIABETES/HYPERTENSION CARE

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• Thank you