Abstract

This article examines progress made towards the implementation of the core priorities laid out in the National Health Promotion Policy (PNPS, acronym in Portuguese) and current challenges, highlighting aspects that are essential to ensuring the sustainability of this policy in times of crisis. It consists of a narrative review drawing on published research and official government documents. The PNPS was approved in 2006 and revised in 2014 and emphasizes the importance of social determinants of health and the adoption of an intersectoral approach to health promotion based on shared responsibility networks aimed at improving quality of life. Progress has been made across all core priorities: tackling the use of tobacco and its derivatives; tackling alcohol and other drug abuse; promoting safe and sustainable mobility; adequate and healthy food; physical activity; promoting a culture of peace and human rights; and promoting sustainable development. However, this progress is seriously threatened by the grave political, economic and institutional crisis that plagues the country, notably budget cuts and a spending cap that limits public spending for the next 20 years imposed by Constitutional Amendment Nº 95, painting a future full of uncertainties.

Health promotion; Health policy; Intersectorality; Regulation; Smoking

Introduction

Health promotion consists of a set of strategies and measures designed to support healthy living, meet society’s health needs and improve quality of life¹1. Buss PM, Carvalho AI. Desenvolvimento da promoção da saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316.. The Ottawa Charter for Health Promotion, signed in 1986 by 35 countries, states that health promotion should tackle health inequities, promote opportunities for making healthy choices, and enable people to take control of those things which determine their health and quality of life¹1. Buss PM, Carvalho AI. Desenvolvimento da promoção da saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316..

Although the guiding principles of health promotion are set out in both the 1988 Constitution and Basic Health Law (Lei Orgânica de Saúde), which came into force in 1990, the National Health Promotion Policy (PNPS, acronym in Portuguese) only became reality almost two decades later in 2006. This policy was later reviewed by the Tripartite Intermanagement Committee (CIT) and National Health Council and changes were approved in 2014²2. Brasil. Portaria MS/GM n.º 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 11 nov. that recognize the importance of social determinants of health and the adoption of an intersectoral approach to health promotion based on shared responsibility networks aimed at improving quality of life²2. Brasil. Portaria MS/GM n.º 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 11 nov.

3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694.-⁴4. Rocha DG, Alexandre VP, Marcelo VP, Regiane R, Nogueira JD, Sá RF. Processo de Revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Cien Saude Colet 2014; 19(11):4313-4322..

Thirty years after the creation of Brazil’s Unified Health System (Sistema Único de Saúde - SUS), it is important to conduct a critical review of the implementation of the PNPS. Accordingly, this article examine progress made towards the implementation of the core priorities laid out in the policy and current challenges, highlighting aspects that are essential to ensuring the sustainability of the PNPS in time of crisis.

Methods

A narrative review of the implementation of the core priorities of the PNPS was conducted drawing on relevant literature, regulatory instruments issued by the federal government between 2005 and 2017, reports and publications published by the Ministry of Health, and books and other publications on the PNPS found on institutional websites. We consulted the data bases of the Latin American and Caribbean Center on Health Sciences Information, better known as BIREME, and the Virtual Health Library using the following describers: “national health promotion policy”, “Brazil”, and “health promotion”.

The analysis focused on the following core themes set out in the PNPS: a) tackling the use of tobacco and its derivatives; b) tackling alcohol and other drug abuse; c) promoting safe and sustainable mobility; d) adequate and healthy food; e) Physical activity; f) Promoting a culture of peace and human rights; and g) Promoting sustainable development.

The results refer to PNPS priorities identified in the review and the methodology of the studies is briefly outlined in the description of the results.

Results

Tackling tobacco use

A study of Brazil’s overall disease burden showed that tobacco use moved from second to forth in the ranking of the leading global risks for burden of disease between 1990 and 2015⁵5. Malta DC, Felisbino-Mendes MS, Machado ÍE, Passos VMA, Abreu DMX, Ishitani LH, Velásquez-Meléndez G, Carneiro M, Mooney M, Naghavi M. Fatores de risco relacionados à carga global de doença do Brasil e Unidades Federadas, 2015. Rev. Bras. epidemiol. 2017; 20(1):217-232.. This can be explained by a notable decline in the prevalence of smoking in Brazil, which fell from 36.4% in 1989 to 15% in 2013⁶6. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SM, Reis AAC. Tendência de fumantes na população Brasileira segundo a Pesquisa Nacional de Amostra de Domicílios 2008 e a Pesquisa Nacional de Saúde 2013. Rev. bras. epidemiol 2015; 18(2):45-56.. Annual national telephone surveys conducted between 2006 and 2016 as part of the Noncommunicable Disease Monitoring System (VIGITEL, acronym in Portuguese) showed that the prevalence of smoking in state capitals decreased from 16% in 2006 to 10.2% in 2016 and that prevalence was highest among men (Table 1). This reduction was shown to be statistically significant, demonstrating the effectiveness of the country’s tobacco control efforts⁷7. Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2016: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2017.,⁸8. Malta DC, Stopa SR, SMAS, ASSCA, Oliveira TP, Cristo EB et al. Evolução de indicadores do tabagismo segundo inquéritos de telefone, 2006-2014. Cad Saude Publica 2017; 33(Supl. 3):e00134915..

A notable measure was the prohibition of tobacco advertising in the 1990s, which has been intensified during the last decade. Decree Nº 5.659 issued in 2006 ratified the Framework Convention on Tobacco Control, while Law N^o 12.546, which came into force in 2011, prohibited smoking in closed public areas, increased taxes on cigarettes to 85%, defined a minimum selling price, and aimed to curb cigarette smuggling. Presidential Decree Nº 8.262 issued in 2014 increased the size of warning labels on cigarette packets, regulated smoke-free areas, and provided that states and local governments shall be responsible for health enforcement and surveillance and imposing penalties for infringement. It is also important to mention that the government improved access to medications and treatment for smoking cessation in SUS services⁶6. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SM, Reis AAC. Tendência de fumantes na população Brasileira segundo a Pesquisa Nacional de Amostra de Domicílios 2008 e a Pesquisa Nacional de Saúde 2013. Rev. bras. epidemiol 2015; 18(2):45-56.,⁸8. Malta DC, Stopa SR, SMAS, ASSCA, Oliveira TP, Cristo EB et al. Evolução de indicadores do tabagismo segundo inquéritos de telefone, 2006-2014. Cad Saude Publica 2017; 33(Supl. 3):e00134915..

These results serve as encouragement for the country to continue investing in health promotion policies directed at smoking prevention. A 30% reduction in smoking prevalence is one of the targets of the Strategic Action Plan for Tackling Noncommunicable Diseases in Brazil: 2011-2022⁹9. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol. Serv. Saúde 2011; 20(4):425-438., the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2015-2025¹⁰10. World Health Organization (WHO). WHO Global NCD Action Plan 2013-2020. Geneva: WHO; 2013. [acessado 2017 Out 20]. Disponível em: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... , and the Sustainable Development Goals outlined in Agenda 2030¹¹11. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS. [acessado 2017 Out 20]. Disponível em: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... . Brazil is considered a primary reference point around the globe for its success and has received a number of awards from the World Health Organization (WHO), Bloomberg Foundation, and Pan American Health Organization (PAHO)⁶6. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SM, Reis AAC. Tendência de fumantes na população Brasileira segundo a Pesquisa Nacional de Amostra de Domicílios 2008 e a Pesquisa Nacional de Saúde 2013. Rev. bras. epidemiol 2015; 18(2):45-56..

The measures implemented by the country are in tune with good practices recommended by the WHO¹²12. World Health Organization (WHO). Best Buys’ and other recommended interventions For the prevention and control of noncommunicable diseases. Geneva: WHO; 2017. [Updated (2017) appendix 3 of the global action plan For the prevention and control of noncommunicable diseases 2013-2020].. It is important to highlight, however, that further steps need to be taken, such as generic packaging, inspection of smoke-free areas and retail outlets, and tackling the illicit cigarette trade. The Supreme Federal Court (SFC) is currently considering Direct Action of Unconstitutionality N^o4874, brought by the tobacco industry in 2012, questioning the regulatory role of the National Health Surveillance Agency (ANVISA, acronym in Portuguese) in the restriction of the use of chemical additives in tobacco products. The approval of this action by the SFC would have serious consequences for regulatory policy and represent a significant setback for the control of tobacco.

Tackling alcohol abuse

The WHO’s global strategy to reduce harmful use of alcohol published in 2010 details a number of strategies to reduce alcohol consumption, especially among young people. One of the principal initiatives developed by the Ministry of Health to tackle alcohol abuse was the creation of the Alcohol and Drugs Psychosocial Support Centers (CAPS-Ad, acronym Portuguese) in 2010, marking a shift in approach to treating and tackling alcohol dependence in accordance with WHO guidelines¹²12. World Health Organization (WHO). Best Buys’ and other recommended interventions For the prevention and control of noncommunicable diseases. Geneva: WHO; 2017. [Updated (2017) appendix 3 of the global action plan For the prevention and control of noncommunicable diseases 2013-2020]..

The Ministry of Health took the lead in approving laws that tighten the rules for drinking and driving, such as Law N° 11.705/2008, known as the Lei Seca (dry law), and Law N° 12.760/2012, known as the Nova Lei Seca (new dry law), which strengthen the role played by traffic enforcement agents in enforcing life protection and road traffic accident prevention measures related to alcohol. VIGITEL data demonstrate the effectiveness of these types of regulatory measures in changing drink driving behaviors, revealing a statistically significant fall in the consumption of alcohol and drink driving in the years following their implementation¹³13. Malta DC, Bernal RTI, Silva MMA, Claro RM, Silva Júnior JB, Reis AAC. Consumo de bebidas alcoólicas e direção de veículos, balanço da lei seca, Brasil 2007 a 2013. Rev Saude Publica 2014; 48(4):692-696. (Figure 1).

However, these measures are still rather tentative, bearing in mind the measures advocated by the WHO: a) banning of or imposing wide-ranging restrictions on alcohol advertising, b) restrictions on alcohol sales (limits on opening times for retail alcohol sales)¹²12. World Health Organization (WHO). Best Buys’ and other recommended interventions For the prevention and control of noncommunicable diseases. Geneva: WHO; 2017. [Updated (2017) appendix 3 of the global action plan For the prevention and control of noncommunicable diseases 2013-2020].. Other shortcomings include poor enforcement of Law Nº 13.106/15, which criminalizes the sale of alcohol to children and adolescents. The WHO also recommends the adoption of measures to regulate sponsorship activities that promote alcoholic beverages and ban promotions in connection with activities targeting young people¹²12. World Health Organization (WHO). Best Buys’ and other recommended interventions For the prevention and control of noncommunicable diseases. Geneva: WHO; 2017. [Updated (2017) appendix 3 of the global action plan For the prevention and control of noncommunicable diseases 2013-2020].. Another problem is the outdated Law Nº 9.294/1996, which imposes restrictions on the marketing of beverages containing an alcohol content of over 13 degrees Gay Lussac¹⁴14. Brasil. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Diário Oficial da União 1996, 15 Jul., thus excluding beers and ice beverages. Changing this law is essential and demands extensive mobilization of civil society considering the commercial interests involved¹⁵15. .World Health Organization (WHO). Global Status Report on Alcohol and Health. [Internet] 2010. [acessado 2017 Out 20]. Disponível em: http://www.who.int/substance_abuse/activities/globalstrategy/en/index.html.
http://www.who.int/substance_abuse/activ... ,¹⁶16. Vendrame A, Pinsky I, Faria R, Silva R. Apreciação de propagandas de cerveja por adolescentes: relações com a exposição prévia às mesmas e o consumo de álcool. Cad Saude Publica 2009; 25(2):359-365..

Safe and sustainable mobility

The PNPS provides for the promotion of safe, healthy and sustainable environments and surroundings aimed at improving human mobility and quality of life, through participatory integrated planning involving the establishment of partnerships and definition of the functions, responsibilities, and specificities of sector. One notable initiative is the Road Safety in 10 Countries Project coordinated by the WHO and other international organizations, dubbed in Brazil Projeto Vida no Trânsito (life in traffic project – PVT, acronym in Portuguese)¹⁷17. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Júnior JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol. Serv. Saúde 2013; 22(3):531-536.,¹⁸18. Morais Neto OL, Silva MMA, Lima CM, Malta DC, Silva Júnior JB; Grupo Técnico de Parceiros do Projeto Vida no Trânsito. Projeto Vida no Trânsito: avaliação das ações em cinco capitais brasileiras, 2011-2012. Epidemiol. Serv. Saúde. 2013 Jul/Set; 22(3):373-382.. The PVT was implemented in five municipalities (Belo Horizonte, Curitiba, Teresina, Palmas, and Campo Grande)¹⁷17. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Júnior JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol. Serv. Saúde 2013; 22(3):531-536.,¹⁸18. Morais Neto OL, Silva MMA, Lima CM, Malta DC, Silva Júnior JB; Grupo Técnico de Parceiros do Projeto Vida no Trânsito. Projeto Vida no Trânsito: avaliação das ações em cinco capitais brasileiras, 2011-2012. Epidemiol. Serv. Saúde. 2013 Jul/Set; 22(3):373-382.. Give the project’s success, in 2002 the initiative was expanded to all state capitals and cities with over one million inhabitants¹⁷17. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Júnior JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol. Serv. Saúde 2013; 22(3):531-536.,¹⁸18. Morais Neto OL, Silva MMA, Lima CM, Malta DC, Silva Júnior JB; Grupo Técnico de Parceiros do Projeto Vida no Trânsito. Projeto Vida no Trânsito: avaliação das ações em cinco capitais brasileiras, 2011-2012. Epidemiol. Serv. Saúde. 2013 Jul/Set; 22(3):373-382..

The PVT prioritizes two accident risk factors: drink driving; and excess speed/inappropriate speed for the road conditions. Intervention priorities are defined jointly between different sectors and actions are implemented according to the responsibilities and specificities of each partner institution, which include the Military Police, municipal transport agencies, state and federal highway police forces, and State Transport Department¹⁷17. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Júnior JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol. Serv. Saúde 2013; 22(3):531-536.,¹⁸18. Morais Neto OL, Silva MMA, Lima CM, Malta DC, Silva Júnior JB; Grupo Técnico de Parceiros do Projeto Vida no Trânsito. Projeto Vida no Trânsito: avaliação das ações em cinco capitais brasileiras, 2011-2012. Epidemiol. Serv. Saúde. 2013 Jul/Set; 22(3):373-382.. A study conducted by John Hopkins University of the impact of the PVT in Belo Horizonte, Curitiba, Teresina, Palmas, and Campo Grande in partnership with the Federal University of Rio Grande do Sul, Federal University of Minas Gerais, and Pontifical Catholic University of Paraná used interrupted time series analysis and the Holt-Winters method to analyze rate of mortality due to land transport accidents (LTA), where the control group was all causes of death except external causes. The findings showed that there was a relative reduction in the rate of mortality due to land transport accidents in all the capitals studied except Campo Grande¹⁷17. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Júnior JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol. Serv. Saúde 2013; 22(3):531-536. (Table 2).

Another important initiative was the United Nations/WHO Second Global High-Level Conference on Road Safety held in Brazil in November 2015. Attended by numerous countries and around 2,000 people, the conference culminated in the “Brasilia Declaration”, which was centered on safe and sustainable human mobility¹⁹19. Organização Mundial de Saúde (OMS). Declaração de Brasília sobre Segurança no trânsito [Internet]. 2015 [acessado 2017 Dez 01]. Disponível em: http://www.who.int/violence_injury_prevention/road_traffic/brasilia_declaration_Portuguese/es/
http://www.who.int/violence_injury_preve... .

Promoting a culture of peaces and human rights

Health promotion and violence prevention actions have focused on the organization of surveillance of these previously invisible events and local level actions through structuring the country’s health promotion and violence prevention centers. Actions were directed at education, training and capacity building, supporting the implementation of regulatory instruments governing the institutionalization of care, prevention, and protection programs, advocacy, and support for setting up an effective legal framework.

The following advances were made in the establishment of an effective intersectoral legal framework: the Maria da Penha Law (Law Nº 11.340, 7/8/2006); the National Policy for Combating Human Trafficking (Decree Nº 5.948, 26/10/2006); and intersectoral and sectoral plans, such as the National Plan for Combating Sexual Violence against Children and Adolescents (2007) and the VIVA Youth Plan, the latter of which deals with black homicide victimization. These advances are a reflection of intersectoral coordination, which is one of the pillars of the PNPS³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694..

Violence and Accident Surveillance (Vigilância de Violências e Acidentes - VIVA) in the SUS aims to analyze trends in accidents and violence, particularly domestic violence which has traditionally been underreported. VIVA, created in 2006, helps to bring to light previously invisible domestic and sexual violence and capture self-inflicted violence, like attempted suicide, and other forms of violence, such as child labor, psychological/moral violence, neglect and abandonment, human trafficking, violence caused by legal intervention²⁰20. Silva MMA, Mascarenhas MDM, Lima CM, Malta DC, Monteiro RA, Freitas MG, Melo ACM, Bahia CA, Bernal RTI. Perfil do Inquérito de Violências e Acidentes em Serviços Sentinela de Urgência e Emergência. Epidemiol. Serv. Saúde 2017; 26(1):183-194., and homophobic violence²⁰20. Silva MMA, Mascarenhas MDM, Lima CM, Malta DC, Monteiro RA, Freitas MG, Melo ACM, Bahia CA, Bernal RTI. Perfil do Inquérito de Violências e Acidentes em Serviços Sentinela de Urgência e Emergência. Epidemiol. Serv. Saúde 2017; 26(1):183-194.. In 2011, violent events began to be registered in the Notifiable Disease Information System in accordance with Ministerial Order 104/2011²¹21. Brasil. Portaria nº 204, de 17 de fevereiro de 2016. Define a Lista Nacional de Notificação Compulsória de doenças, agravos e eventos de saúde pública nos serviços de saúde públicos e privados em todo o território nacional, nos termos do anexo, e dá outras providências. Diário Oficial da União 2014; 17 fev..

Figure 2 shows that the number of mandatory notifications of violence increased between 2011 and 2015, from 107,530 to 242,347, and that 70% of cases involved violence against women. This increase shows that reporting and surveillance of violent events improved over the period. Furthermore, the data provides important inputs to help promote the integration of victim protection actions between the health sector and victim care and protection networks²⁰20. Silva MMA, Mascarenhas MDM, Lima CM, Malta DC, Monteiro RA, Freitas MG, Melo ACM, Bahia CA, Bernal RTI. Perfil do Inquérito de Violências e Acidentes em Serviços Sentinela de Urgência e Emergência. Epidemiol. Serv. Saúde 2017; 26(1):183-194..

One of the challenges faced by the PNPS is the alignment of the policy with the “Curitiba Charter”²²22. Associação Brasileira de Saúde Coletiva (Abrasco). Carta de Curitiba sobre Promoção da Saúde e Equidade [Internet]. Curitiba, PR 2016 [acessado 2017 Dez 01]. Disponível em: https://www.abrasco.org.br/site/wp-content/uploads/2016/08/Carta-de-Curitiba-Portug%C3%AAs.pdf
https://www.abrasco.org.br/site/wp-conte... . One of the legacies of the 22nd IUHPE World Conference on Health Promotion held in May 2016, the charter reaffirms the need for health promotion to tackle the social and environmental determinants of health, firmly placing equity at the center of the health promotion agenda as an essential element for the promotion of human rights and a culture of peace and nonviolence.

Another major challenge is the risk of setbacks for human rights policies and regulatory framework. Examples include pressure from commercial interests and the arms lobby for changes to the Disarmament Statute (Law Nº 10.826, 22/12/2003), which has played a major role in reducing homicide in 2004, demonstrating that it is possible to prevent violence and that this sort of measure cannot be abandoned. A study conducted by Souza et al.²³23. Souza MF, Macinko J, Alencar AP, Malta DC, Morais Neto OL. Control Reductions In Firearm-Related Mortality And Hospitalizations In Brazil After Gun. Health Affairs 2007; 26(2):575-584. showed that the voluntary hand over of firearms in 2004 led to a drop of around 3,200 homicides in 2004. Additional threats that need to be addressed include calls for a reduction of the minimum age of criminal responsibility and changes to the Child and Adolescent Statute, and proposals to tighten abortion laws, which currently allow abortion in specific cases.

Adequate and healthy food

The right to adequate food is a fundamental human right and a determinant of health. Various food and nutrition security actions were developed by the Ministry of Health between 2003 and 2015, including: intersectoral and intrasectoral collaboration to promote the care and autonomy of individuals and communities²2. Brasil. Portaria MS/GM n.º 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 11 nov.,²⁴24. Souza AKP, Jaime PC. A Política Nacional de alimentação e Nutrição e seu diálogo com a Política Nacional de Segurança alimentar e Nutricional. Cien Saude Colet 2014; 19(11):4331-4340.; implementation of family health support centers; systemic monitoring of compliance with the health-related requirements of the family benefit program Bolsa Família; implementation of the National Food and Nutrition Surveillance System (SISVAN, acronym in Portuguese); promotion of breastfeeding; actions to promote healthy eating developed under the School Health Program, created by Presidential Decree in 2007 and implemented across around 87% of Brazil’s municipalities in 2015; and actions developed under the Strategic Action Plan for Tackling Noncommunicable diseases in Brazil 2011-2022 to encourage the consumption of fruit and vegetables, reduce salt intake, and curb the growth in obesity⁹9. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol. Serv. Saúde 2011; 20(4):425-438..

The Food Guide for the Brazilian Population version 2006 and the revised 2014 edition mark a new paradigm for understanding eating habits within the context of the food system and the nutritional transition currently occurring in the country, becoming a reference point for various countries²⁵25. Brasil. Ministério da Saúde (MS). Guia Alimentar para a População Brasileira. 2ª ed. Brasília: MS; 2014.. The guide contains a comprehensive set of recommendations regarding foods and eating habits aimed at supporting health promotion and well-being²⁵25. Brasil. Ministério da Saúde (MS). Guia Alimentar para a População Brasileira. 2ª ed. Brasília: MS; 2014.,²⁶26. Monteiro CA, Cannon G, Moubarac JC. Martins AP, Martins CA, Garzillo J, Canella DS, Baraldi LG, Barciotte M, Louzada ML, Levy RB, Claro RM, Jaime PC. Dietary guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from Brazil. Public Health Nutr 2015; 18(13):2311-2322..

Another important initiative was the Salt Intake Reduction Plan, which coordinated actions together with the food industry aimed at reducing sodium levels in processed foods. Implemented gradually, voluntarily and based on biannual goals, the plan focuses on the development of new technologies and formulations and changing consumer palates²⁷27. Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Publica 2012; 32(4):287-292.,²⁸28. Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L’Abbé M. Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients [journal on the Internet]. 2017 Jul [cited 2017 Dec 01]; 9(7):42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537856/
https://www.ncbi.nlm.nih.gov/pmc/article... . The terms of commitment were monitored in 2011, 2013-2014, and 2017. Nilson et al.²⁸28. Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L’Abbé M. Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients [journal on the Internet]. 2017 Jul [cited 2017 Dec 01]; 9(7):42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537856/
https://www.ncbi.nlm.nih.gov/pmc/article... analyzed the results of the monitoring, obtaining the levels of sodium of industrialized foods directly from the mandatory information that must appear on product labels taken from the food company websites and packaging. Table 3 shows the average sodium levels of the 16 food subcategories evaluated by the study. Levels showed a continual decline over the period for all products except corn-based savory snacks. Statistically significant reductions in the level of sodium against the baseline were found in 65% of the subcategories²⁸28. Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L’Abbé M. Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients [journal on the Internet]. 2017 Jul [cited 2017 Dec 01]; 9(7):42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537856/
https://www.ncbi.nlm.nih.gov/pmc/article... .

Despite progress, significant challenges remain in the fight to curb the growth of obesity in the country, including the need to improve the effectiveness of regulatory measures, approve legislation governing the taxation of ultra-processed foods, create subsidies for healthy food, and restrict or ban food advertising aimed at children¹²12. World Health Organization (WHO). Best Buys’ and other recommended interventions For the prevention and control of noncommunicable diseases. Geneva: WHO; 2017. [Updated (2017) appendix 3 of the global action plan For the prevention and control of noncommunicable diseases 2013-2020].. It is important to mention that such measures face strong opposition from the food industry and the extensive mobilization of civil society is critical to ensure their implementation.

Physical activity

Actions related to this theme gained momentum in 2005 and include the following: a) organization of the surveillance of risk factors and protection against noncommunicable diseases, enabling the monitoring of the practice of physical activity through population surveys such as VIGITEL between 2006 and 2016⁷7. Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2016: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2017., the three editions of the National School Health Survey (PENSE, acronym in Portuguese), conducted in 2009, 2012 and 2015, and household surveys, such as the health component of the National Household Sample Survey (2008) and National Health Survey (2013)³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694..

Other initiatives include the funding of municipal physical activity projects and the Health Gym Program created in 2011 involving the installation of community fitness facilities and community health promotion activities³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694.. Studies conducted by various universities using quantitative and qualitative methodologies show that this program is effective³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694.,²⁹29. Pratt M, Brownson RC, Ramos LR, Malta DC, Hallal P, Reis RS, Parra DC, Simões EJ. Project GUIA: A model for understanding and promoting physical activity in Brazil and Latin America. J Phys Act Health [journal on the Internet]. 2010 Jul [cited 2017 Dec 01]; 7 (2):S131-S134. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20702900
https://www.ncbi.nlm.nih.gov/pubmed/2070... ,³⁰30. Simões EJ, Hallal PC, Siqueira FV, Schmaltz C, Menor D, Malta DC, Duarte H, Hino AA, Mielke GI, Pratt M, Reis RS. Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment. Prev. Med. 2017; 103S:S66-S72., demonstrating that community-based strategies to promote physical activity are effective in increasing the level of physical activity among the population²⁹29. Pratt M, Brownson RC, Ramos LR, Malta DC, Hallal P, Reis RS, Parra DC, Simões EJ. Project GUIA: A model for understanding and promoting physical activity in Brazil and Latin America. J Phys Act Health [journal on the Internet]. 2010 Jul [cited 2017 Dec 01]; 7 (2):S131-S134. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20702900
https://www.ncbi.nlm.nih.gov/pubmed/2070... ,³⁰30. Simões EJ, Hallal PC, Siqueira FV, Schmaltz C, Menor D, Malta DC, Duarte H, Hino AA, Mielke GI, Pratt M, Reis RS. Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment. Prev. Med. 2017; 103S:S66-S72.. The coordination of activities with primary health services through family health support centers and the incorporation of health promotion into the daily practices of family health teams has been essential to the success of the program.

Promoting sustainable development

Between 2006 and 2015, numerous intersectoral partnerships were established involving the Ministry of the Environment, Ministry of National Integration, Ministry of Cities, the Executive Office of the President, and state and local government health departments to implement sustainable development plans in areas such as the Mid North Tourist Region (states of Piauí, Maranhão, and Ceará) and the Xingu Sustainable Regional Development Plan, among others. Brazil also hosted Rio+20, whose outcome document recognizes that health is a precondition for sustainable development and played an important role in ensuring that health was incorporated as one of the goals of the United Nation’s 2030 Agenda for Sustainable Development¹¹11. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS. [acessado 2017 Out 20]. Disponível em: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... ,³¹31. Buss PM, Ferreira JRF, Hoirisch C, Matida A. Desenvolvimento sustentável e governança global em saúde – Da Rio+20 aos Objetivos de Desenvolvimento Sustentável (ODS) pós-2015. RECIIS 2012; 6(3)..

Discussion

This article provides an overview of the results of the PNPS, highlighting progress made towards the implementation of the core priorities laid out in the policy and current challenges. Various health promotion projects have been developed at local level together with the implementation of various national programs, such as Vida no Trânsito, the Health Academy Program, Health Promotion and Violence Prevention Centers, and the School Health Program. The review of the PNPS carried out in 2014 was an important milestone for enhancing this policy and stakeholder engagement⁴4. Rocha DG, Alexandre VP, Marcelo VP, Regiane R, Nogueira JD, Sá RF. Processo de Revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Cien Saude Colet 2014; 19(11):4313-4322.. Other important steps forward have been taken, including the incorporation of the PNPS into the budgetary planning process, allocation of funding to projects to promote physical activity, healthy eating, smoking prevention, and violence prevention, as well as human resource development and capacity-building and social mobilization³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694.. The Health Promotion Policy Steering Committee met on a monthly basis between 2005 and 2015, articulating and coordinating intra and intersectoral actions, setting joint agendas, and facilitating the integration of processes³3. Malta DC, Morais Neto OL, Silva MMA, Rocha D, Castro AM, Reis AAC, Akerman M. Política Nacional de Promoção da Saúde (PNPS):capítulos de uma caminhada ainda em construção. Cien Saude Colet 2016; 21(6):1683-1694.. The continuity of this body is essential for the sustainability of the PNPS.

The guiding principles and core priorities of a policy such as the PNPS and the efforts and funding directed towards its implementation say much about the values that guide the concepts of health, citizenship, sustainable development, and quality of life for a given society. They also reveal the government’s capacity to develop actions and programs in line with the principles laid out in this type of policy.

However, the progress made to date is seriously threatened by the grave political, economic, and institutional crisis that plagues the country, aggravated by the parliamentary coup instigated in 2016, painting a future full of uncertainties marked by a minimal state, budget cuts, fiscal austerity, deregulation, and the discontinuation of measures to promote social inclusion³²32. Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez.,³³33. Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Tudo a temer: financiamento, relação público e privado e o futuro do SUS. Saúde Debate 2016; 40(n. esp.):122-135.. One can only speculate as to what will become of the SUS and social policies in the coming years. The approval of Constitutional Amendment Nº 95 and the New Fiscal Regime have frozen government spending for the next 20 years³²32. Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez.,³³33. Reis AAC, Sóter APM, Furtado LAC, Pereira SSS. Tudo a temer: financiamento, relação público e privado e o futuro do SUS. Saúde Debate 2016; 40(n. esp.):122-135.. The reduction of federal funding is set to affect local and state government and shrink public health actions and services, including those envisaged under the PNPS and that depend on intersectoral efforts, signalling huge challenges that threaten the very sustainability of the PNPS and the SUS.

Stucker et al.³⁴34. Stuckler D, Basu S. A Economia Desumana: Porque Mata A Austeridade. Lisboa. Editorial Bizancio; 2014.show that countries that adopt budget cuts gravely jeopardize health. Fiscal austerity only aggravates the crisis, deepening inequalities, which are unfair given the unequal redistribution of burdens. Thus, the above measures adopted by the government are only likely to aggravate the crisis and jeopardize health, resulting in the urgent need for research into the impacts of fiscal austerity on the living conditions and health of the Brazilian population.

Another critical issue is the weakening regulatory role of the government. The country is witnessing the ever-growing power of business in Brazilian politics and the coming together of political forces around conservative agendas. In this respect, various attempts have been made to delegitimize the regulatory role of ANVISA, both by the National Congress, in relation to anorectic drugs, agrochemicals, and cancer drugs for example, and by the tobacco industry, which, through an action in the Supreme Court, is seeking to prevent the enforcement of restrictions on the use of chemical additives in cigarettes. The weakening of the regulatory role of the government will have serious impacts on the SUS and the Brazilian population.

As to the outlook for the PNPS, Agenda 2030¹¹11. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS. [acessado 2017 Out 20]. Disponível em: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... , with its 17 Sustainable Development Goals, offers a new perspective on health promotion. The Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development calls for a vigorous integrated response designed around four pillars: “healthy cities”, “good governance”, “health literacy”, and “social mobilization”. This key international agenda should be coordinated at the national, state and local level and calls for the reactivation the PNPS Steering Committee to strengthen intrasectorality and seek new alliances outside the health sector.

Conclusion

Writing “history of the present” or, as Sayuri³⁵35. Sayuri J. Folha de São Paulo. 2017; 11 ago. Disponível em: http://www1.folha.uol.com.br/ilustrissima/2017/08/1908986-crise-politica-amplia-interesse-pela-chamada-historia-do-tempo-presente.shtml
http://www1.folha.uol.com.br/ilustrissim... suggests, “writing history hot off the press”, is a challenge subject to limits, since it describes “temporary dwellings” of history. Despite significant progress in the short history of the PNPS, we recognize that 30 years after the creation of the SUS we are still far from overcoming a health care model centered on disease and medical-hospital care. On the whole, the health promotion actions developed over recent years do not constitute a new and necessary way of delivering healthcare and tackling the social determinants of health.

It is essential to resignify the role and importance of the PNPS for the SUS, particularly considering the need to develop strategies to address the challenges imposed by the trends in the country’s epidemiological, demographic, and nutrition profiles.

The reform movement currently underway signals that we are living in difficult times, characterized by the restoration of a conservative order³⁶36. Bourdieu P. Contrafógos: táticas para enfrentar a invasão neoliberal. Rio de Janeiro: Jorge Zahar Ed.; 1998. that influences all walks of life and has a major impact on policy. Rising unemployment and an increase in precarious work, the breakdown of the welfare state, the dismantling or scrapping of social protection and inclusion policies, relaxation of environmental protection policies and regulations, the rearmament of society, and other conservative reforms currently underway, are indicative of the challenges facing not only the SUS and policies such as the PNPS, but also democracy, social justice, and citizenship. It is necessary to go one step further and combat the predominance of individualism, empowering society to demand that the government fulfils its commitments to ensure the effective implementation of the PNPS.

References

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