RESEARCH REPORT

1. 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.

2. 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)

3. 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 Assistant Researchers: Juliana Rochet , Andréa Fucks, Tânia Maria Tosta da Silva International Cooperation - PAHO Lucimar Coser Cannon, Branka Legetic, WHO Cooperation Center/Canada Silvie Stachenco, Ellen Voggel WHO – COORDINATION: Silvie Stachenco

4. BRAZILIAN CASE STUDY: FIVE AXES OF ANALYSIS TOBACCO CONTROL DIET AND NUTRITION POLICY - DIABETES/HYPERTENSION CARE NCD HEALTH PROMOTION AND PHYSICAL ACTIVITY NCD SURVEILLANCE The analysis comprised the decision making process to formulate these initiatives within the different sectors of the Ministry of Health

5. 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. Objectives of the Brazilian case study

6. This 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. Methodological procedures 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.

7. 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

8. Structure to analyze the development of the policy process Awareness about the problem problema/Agenda planning Solution Proposal ------- à Decision ---------------- à Implementing ç Interests Contexcts : Disputants Social Economic Policy Net Physical Environmental How the actors Gender interact Policy Tools : Cultural Policy Planning Capacity and Resources of the actors Legislation atores Expenses/costs Collaborative Planning Information Community Action and Organization Instituições: Ideas: Nets Building Governmental Information Sources New programs Agencies Mandates /servicess Responsabilities Values Formal Processes preferences Legislative structure Current Policy ------------------ Consensus Building ------------------------ à Structure to analyze the development of the National Policies on NCCD

9. Surveillance Organization • The 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.

10. 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

11. 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

12. 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;

13. 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.

14. Ideas and interests – Cont. • Surveillance actions promoted by the WHO and PAHO in other countries are useful to structure the surveillance in Brazil.

15. 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.

16. 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;

17. Conclusions • The 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.

18. Conclusions • The 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.

19. CASE STUDY PROPOSAL: FIVE AXES OF ANALYSIS TOBACCO CONTROL DIET AND NUTRITION POLICY - PREVENTION and SURVEILLANCE NCD DIABETES/HYPERTENSION CARE ALCHOOL AND THE OTHERS DRUGS PHYSICAL ACTIVITY The analysis comprised the decision making process to formulate these initiatives within the different sectors of the Ministry of Health

20. Thank you