Abstract

This article reflects on the evolution of the theme of violence within the field of public health. It provides an overview of the strategies and actions developed within Brazil’s Unified Health System developed in response to the country’s main guiding policy on violence, the National Policy for the Reduction of Morbidity and Mortality due to Accidents and Violence, drawing on baseline documents, national and international research, data from the country’s main violence information systems, and the firsthand experiences of the authors from their participation in the abovementioned actions. Violence against children and adolescents, women, and older persons have assumed a prominent position on the health agenda, while other forms of violence, such as child labor, human trafficking, homophobic and racial violence, and violence against street dwellers and people with disabilities, who are deprived of their liberty, are gradually finding their way onto the agenda. Despite undeniable progress in institutionalizing the theme, there is a need for greater investment in various areas including out-of-hospital emergency, rehabilitation, and mental health services. It is also necessary to incorporate the theme into the training and development of all of healthcare professionals and intensify continuing training to enhance capacity for detecting and reporting violence and delivering adequate care to victims.

Violence; Health policy; Morbidity; Mortality

Introduction

This article reflects upon the incorporation of the theme of violence into the field of public health. To do so it provides an overview of the strategies and actions developed within Brazil’s Unified Health System (Sistema Único de Saúde – SUS), drawing on the country’s main guiding policy on violence, the National Policy for the Reduction of Morbidity and Mortality due to Accidents and Violence (Política Nacional de Redução da Morbimortalidade por Acidentes e Violências - PNRMAV)¹1. Brasil. Ministério da Saúde (MS). Portaria GM/MS Nº 737 de 16 de maio de 2001. Política Nacional de Redução de Morbimortalidade por Acidentes e Violência (PNRMAV). Diário Oficial da União 2001; 17 maio..

We trace the evolution of the theme within the health agenda in Brazil stemming from the homologation of the PNRMAV¹1. Brasil. Ministério da Saúde (MS). Portaria GM/MS Nº 737 de 16 de maio de 2001. Política Nacional de Redução de Morbimortalidade por Acidentes e Violência (PNRMAV). Diário Oficial da União 2001; 17 maio. and public debate surrounding specific vulnerable groups and topics. We then go on to discuss the actions developed in response to the guidelines set out in this policy, demonstrating the progress made in each area and limitations in the 16 years since it came into force. The narrative draws on baseline documents, national and international research, data from the country’s main violence information systems, and the firsthand experiences of the authors from their participation in the abovementioned actions. Finally, we present some considerations regarding progress and limitations in light of the current economic, political and social crisis that plagues the SUS.

Bringing the theme of violence into the field of public health

Violence affects both individual and collective health, causing death, injury, and physical and mental traumas. It also decreases the quality of life of individuals and the community and creates an increased burden on healthcare services, revealing the need for an interdisciplinary, multiprofessional, intersectoral, and socially-engaged approach to treatment and prevention. However, the emergence of this theme in health care practice and research is recent.

Violence was officially placed on the health agenda in Brazil in 2001, with the promulgation of the PNRMAV¹1. Brasil. Ministério da Saúde (MS). Portaria GM/MS Nº 737 de 16 de maio de 2001. Política Nacional de Redução de Morbimortalidade por Acidentes e Violência (PNRMAV). Diário Oficial da União 2001; 17 maio., 13 years after the creation of the SUS and five years after the World Health Organization (WHO) made the issue a public health priority at the Forty-ninth World Health Assembly in 1996²2. .World Health Organization (WHO). World Health Assembly: Prevention of violence: public health priority (WHA 49,25). Genève: WHO; 1996.. Both the domestic and international agendas were preceded by a vast body of accumulated knowledge in the area, both in Brazil³3. Minayo MCS, Souza ER, Assis SG. Bibliografia comentada da produção científica brasileira sobre violência e saúde. Rio de Janeiro: Panorama ENSP; 1990.and the rest of the world⁴4. Krug EG, Mercy JA, Dahlberg LL, Zwi AB.The world report on violence and health. Lancet 2002; 360(9339):1083-1088..

The core themes of Brazil’s progressive agenda were: violence against children and adolescents; gender-based violence; violence against older people; road traffic violence; workplace violence, and, more recently, ethnic violence, violence against people with disabilities, and violence against LGBT people.

Violence against children and adolescents was placed on the agenda through the hands of pediatricians, psychiatrists, social workers and other health professionals that deal with this age group. This group of actors, following in the footsteps of Kempe et al.⁵5. Kempe H, Silverman F, Steele B, Droegemueller W. The battered-child syndrome. JAMA 1962; 181(1):17-24., drew attention to the effects of violence on children’s growth and development and physical and mental health, highlighting that it can often bring about suicidal behavior⁶6. Assis SG. Abused Children and Adolescents: past, present, and prospects for the future. Cad Saude Publica 1994; 10(Supl.1):126-134.,⁷7. United Nation (UN). World report on violence against children. Genève: UN; 2006.. In Brazil, the Regional Child Abuse Cares Centers (Centros Regionais de Atenção aos Maus Tratos na Infância - CRAMI) in São Paulo, Brazilian Multiprofessional Association for the Protection of Children and Adolescents (Associação Brasileira Multiprofissional para Proteção das Crianças e Adolescentes - ABRAPIA) in Rio de Janeiro, and Brazilian Association for the Prevention of Child Abuse and Neglect (Associação Brasileira de Prevenção de Abusos e Negligências na Infância - ABNAPI) in Minas Gerais were pioneers in conducting research, developing activities, and supporting the formulation of social policies. This group of organizations and professionals engaged in child protection played a central role in building Brazil’s Child and Adolescent Statute⁸8. Brasil. Lei nº 8.069, de 13 julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul.. The prevention of child violence has drawn the interest of researchers and activists alike over the last 40 years⁹9. Minayo MCS, Assis SG, organizadoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira do campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017.. Led by health professionals and social movements, primary and secondary prevention programs and interventions began to find a place on the agenda of public and private institutions and nongovernmental organizations. The initiatives developed in Brazil have always been in tune with the international movement.

The following pieces of legislation may be considered central pillars of the legal framework for the protection of children and adolescents: Law Nº 12.015/2009, which deals with heinous crimes and abuse of children and adolescents, defining rape and sex crimes against the vulnerable; Law Nº 13.010/2014 (the “Bernardo Boy Law”), which establishes that children and adolescents have the right to be educated and taken care of without the use of physical punishment and other cruel or degrading treatment. It is also important to highlight the Line of Care for Comprehensive Healthcare for Children, Adolescents and their Families in Situations of Violence (Linha de Cuidado para a Atenção Integral à Saúde de Crianças, Adolescentes e suas Famílias em Situação de Violência)¹⁰10. Brasil. Ministério da Saúde (MS). Linha de cuidado para a atenção integral à saúde de crianças, adolescentes e suas famílias em situação de violências. Brasília: MS; 2010., which provides guidelines for the effective provision of continuous comprehensive healthcare for children, adolescents and their families in situations of violence.

The second core theme is gender-based violence, which appears in the Comprehensive Women’s Healthcare Program (Programa de Assistência Integral à Saúde da Mulher - PAISM) created in 1983. This initiative incorporated women’s rights to sexual and reproductive health and emphasized the problem of gender violence, following the trends within the feminist movement¹¹11. Heise LL. Gender-based abuse: the global epidemic. Cad Saude Publica 1994; 10(Supl. 1):S135-S145.. This them can also be observed in various documents produced by the WHO²2. .World Health Organization (WHO). World Health Assembly: Prevention of violence: public health priority (WHA 49,25). Genève: WHO; 1996.,¹²12. .World Health Organization (WHO).World report on violence and health. Geneva: WHO; 2002. In 2004, the PAISM was transformed into the National Policy for Comprehensive Women’s Healthcare¹³13. Brasil. Ministério da Saúde (MS).Política nacional de atenção integral à saúde da mulher: princípios e diretrizes. Brasília: MS; 2004., which prioritizes caring for women and adolescents exposed to violence. Significant advances have been made in legislation, including: the promulgation of the Maria da Penha Law¹⁴14. Brasil. Lei nº 11.340, de 07 Agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher. Diário Oficial da União 2006; 08 ago., a political milestone marking a paradigm shift in tackling gender-based violence; the law that provides for mandatory reporting of gender-based violence in sentinel services¹⁵15. Brasil. Lei nº 10.778, de 24 de novembro de 2003. Estabelece a notificação compulsória, no território nacional, do caso de violência contra a mulher que for atendida em serviços de saúde públicos ou privados. Diário Oficial da União 2003; 25 nov.; the decree that establishes guidelines for the provision of mandatory humanized care for victims of sexual violence by public security professionals¹⁶16. Brasil. Decreto nº 7.958, de março de 2013. Estabelece diretrizes para o atendimento às vítimas de violência sexual pelos profissionais de segurança pública e da rede de atendimento do Sistema Único de Saúde. Diário Oficial da União 2013; 14 mar.; and the Femicide Law¹⁷17. Brasil. Lei Nº 13.104, de 9 de Março de 2015. Altera o art. 121 do Decreto-Lei no 2.848, de 7 de dezembro de 1940. Diário Oficial da União 2015; 13 mar., which treats this type of homicide as a heinous crime, among various other plans and programs that followed.

With respect to violence against older people, Brazil’s Statute for the Elderly, which has the force of law, was promulgated in 2003¹⁸18. Brasil. Ministério da Saúde (MS). Estatuto do Idoso. Brasília: MS; 2003. (Série E. Legislação de Saúde). Old persons’ movements, care professionals and calls made by international movements played an essential role in its creation. The National Elderly Health Policy came into force in 2006¹⁹19. Brasil. Lei nº 2.528, de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa. Diário Oficial da União 2006; 20 out., creating norms for the prevention of violence against older persons in hospitals, clinics, and long term care facilities.

This theme emerged in the international arena in 1975²⁰20. Baker AA. Granny-batterin. Modern Geriatrics 1975; 5:20-24., gradually being incorporated into research and government agendas. A particularly important player in this area is the International Network for the Prevention of Elder Abuse²¹21. World Health Organization (WHO). International Network for the Prevention of Elder Abuse. Missing voices: views of older persons on elder abuse. Genève: WHO; 2002.. Created in 1997, it promotes advocacy, research and policy development. An important milestone at the international level was the Madrid Declaration, in which the prevention of violence against older persons is treated as a priority by the UN. In Brazil, the reporting of violence against older persons became mandatory with the creation of the Statute for the Elderly¹⁸18. Brasil. Ministério da Saúde (MS). Estatuto do Idoso. Brasília: MS; 2003. (Série E. Legislação de Saúde).

National Policy for the Reduction of Morbidity and Mortality due to Accidents and Violence

Health professionals from various areas with experience of treating the effects of violence in urgency, emergency and rehabilitation, and support services, supported by social movements and academic knowledge accumulated in the country since 1970³3. Minayo MCS, Souza ER, Assis SG. Bibliografia comentada da produção científica brasileira sobre violência e saúde. Rio de Janeiro: Panorama ENSP; 1990., played an essential role in the formulation of the PNRMAV¹1. Brasil. Ministério da Saúde (MS). Portaria GM/MS Nº 737 de 16 de maio de 2001. Política Nacional de Redução de Morbimortalidade por Acidentes e Violência (PNRMAV). Diário Oficial da União 2001; 17 maio., which came into force in 2001.

Soon after, the Ministry of Health created a technical area to oversee the implementation of the policy whose first initiative was a road traffic accidents and deaths prevention program. At the time, the main focus was the provision of emergency assistance to victims of accidents and violence, with the creation of the National Policy on Emergency Care and the Mobile Emergency Care Service (Política Nacional de Atenção às Urgências e o Serviço de Atendimento Móvel de Urgência - SAMU)²²22. Brasil. Ministério da Saúde (MS). Política Nacional de Atenção às Urgências. Brasília: MS; 2003..

Various measures followed designed to improve the reporting of deaths and injuries, including the introduction of standardized technical guidelines for diagnosing traumas and injuries, the classification of events, and the general reporting of cases involving children, adolescents and women, people with disabilities, mental health problems, the elderly, and others.

In 2003, with the creation of the Office for the General Coordination Noncommunicable Diseases (Coordenação Geral de Doenças e Agravos não Transmissíveis - CGDANT) within the Ministry of Health, the focus of actions to tackle the various expressions of violence turned more towards surveillance and prevention.

The following section complements this brief overview of the history of the incorporation of the theme of violence into the field of public health by highlighting some of the main actions undertaken in response to the guidelines set out in the policy.

• Promotion of the adoption of safe and healthy behaviors and environments

In 2004, the National Violence Prevention and Health Promotion Network and Violence Prevention and Health Promotion Centers (Brasil, 2004) were created, encompassing states and municipalities. The implementation of this system was most intense between 2005 and 2006, after the promulgation of the National Health Promotion Policy²³23. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006.. In this period, the Ministry of Health also created a group of 15 Academic Centers chosen to be Collaborative Centers. The above network came to cover 1,300 municipalities and was funded by the Ministry of Health between 2006 and 2012.

The WHO’s World Report on Road Traffic Injury Prevention²⁴24. .World Health Organization (WHO). World Report on Road Traffic Injury Prevention. Genève: WHO; 2004., published annually since 2004, has drawn attention to the epidemic of road traffic injuries and deaths in developing countries, the overwhelming majority of which involve motorcyclists, cyclists and pedestrians. In 2009, at the first global conference on the theme held in Moscow, the UN declared 2011 to 2020 the “Decade of Action for Traffic Safety”. Brazil and other countries participated and made commitments. The second global conference was held in Brasília in 2015, showing that the majority of countries had failed to meet the targets set at the first conference²⁵25. Pavarino Filho R. As Declarações de Moscou e Brasília sobre a segurança no trânsito. Cien Saude Colet 2016; 21(12):3649-3660..

In line with WHO recommendations, Brazil developed the Programa Vida no Trânsito (life in the traffic program) in five state capitals, with the support of a group of national and international governmental and nongovernmental organizations coordinated by the Ministry of Health. The program was aimed at reducing accidents and addressing risk factors such as speeding and the use of safety equipment. The results produced by the program included improvements in the quality of data on road traffic accidents²⁶26. Moraes Neto OL, Silva MMA, Lima CL, 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; 22(3):373-382..

• Monitoring the occurrence of accidents and violence

In 2005, the Ministry of Health incorporated the Violence and Accident Surveillance System (VIVA, acronym in Portuguese) into sentinel services throughout the country. Created in 2006, the Sentinel Services Violence and Accident Surveillance Network (Rede de Serviços Sentinela de Violências e Acidentes) aims to analyze trends in violence and accidents based on out-of-hospital emergency care and propose prevention and promotion actions in coordination between surveillance and the care and protection network. VIVA has two components: periodic surveys (VIVA Inquérito) and the notification of violence (VIVA Contínuo). In 2011, the notification of violence became mandatory across all of the country’s health services and the system became known simply as Violence and Accident Surveillance (Vigilância de Violências e Acidentes – VIVA)²⁷27. 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 2016; 26(1):183-194..

Five VIVA Surveys were conducted (in 2006, 2007, 2009, 2011, and 2014). In 2009, VIVA Contínuo was incorporated into the Notifiable Diseases Information System (SINAN, acronym in Portuguese), becoming know as VIVA/SINAN NET. The scope of mandatory reporting of violence was widened to account for situations that were not foreseen by the legislation that require individual intervention and follow-up of cases, as in the case of human trafficking, slave labor, child labor, torture, the effects of legal intervention, and indigenous peoples, among others²⁷27. 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 2016; 26(1):183-194..

The investment in VIVA Sinan Net obtained results in the data shown in Table 1. Between 2009 and 2014, the number of notifying municipalities increased by 370% and the total number of notifications of domestic, sexual and/or other forms of violence increased by 343%. Similar findings were reported by Ribeiro et al.²⁸28. Brasil. Ministério da Saúde (MS). Morbimortalidade por violências no Brasil: um retrato de contornos em construção. In: Brasil. Ministério da Saúde (MS). Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza Saúde Brasil. 10ª ed. Brasília: MS; 2014. p. 151-176.. These findings show that a growing number of municipalities are adhering to VIVA, contributing towards greater visibility of forms of violence that previously went unreported and unmonitored. Another benefit of accurately detecting and reporting the signs and symptoms of violence is that it helps ensure that the victim receives adequate health care in primary care services.

The top five states in the ranking of the number of cases of domestic, sexual, and/or other forms of violence notified during the period were São Paulo, Minas Gerais, Rio Grande do Sul, Paraná, and Rio de Janeiro, while the bottom five were Acre, Roraima, Amapá, Rondônia, and Sergipe.

The most frequently registered forms of violence between 2009 and 2014 were physical, psychological/moral, and sexual violence. Besides these forms, the frequency of self-inflicted injury, neglect/abandonment, and other forms was also consistently high (Table 2).

Women accounted for the largest number of cases across all forms of violence except child labor. The disparity between the victimization of men and women was most striking in the categories sexual violence psychological/moral violence, where victimization was 6.5 and five times greater, respectively, among women. Major disparities can also be observed with respect to torture and financial/economic abuse, where victimization was around 4 times greater in both categories.

With respect to hospital morbidity and mortality, important strides have been taken in improving the quality of data. Regarding hospital admissions, improvements have been made in primary and secondary diagnosis registration, which helps identify not only the procedure employed, but also the external cause of the injury. With regard to mortality, measures were taken together with the Instituto Médico Legal (the coroner’s Office) to improve the registration of the external cause of death and reduce the proportion of deaths where the cause is classified as event of undetermined intent.

Table 3 below shows hospital morbidity and mortality due to external causes in Brazil by sex between 2001 and 2015. A total of 13,161,006 hospital admissions and 2,065,189 deaths due to accidents and violence were registered over this 15-year period, showing that hospital morbidity was 6.4 times greater than mortality. Accidents accounted for 80.2% of hospital admissions due to external causes and 46.2% of deaths due to this group of causes. Self-inflicted injuries accounted for 6.1% of hospitalizations and 44.4% of deaths due to external causes. Men accounted for 70.2% of admissions and 83.1% of deaths across all external causes and the number of deaths due to assault was 11.3 times greater among men.

Although beyond the scope of this article, it is worth mentioning the groups complications of medical and surgical care (Y40-Y84) and sequelae of external causes (Y85-Y89), both of which were shown to be significant causes of mortality and morbidity. Further research on this issue could reveal important issues that need to be addressed to improve the quality of health care.

It is also important to mention events of undetermined intent (Y35-Y36), which is an indicator of the quality of accident and violence data. This group accounts for 5% of admissions and 7.9% of deaths due to external causes in Brazil, indicating adequate clarification as to the accident or violent event that led to admission or death. It is important to mention, however, that these rates vary substantially across regions, revealing that data quality challenges remain.

Graph 1 below shows that rates of mortality and morbidity due to external causes in Brazil increased during the period 2001 to 2015. Mortality rates per 100,000 population deaths rose from 68.6 in 2001 to 74.4 in 2015 (with the total number of deaths increasing from 120,954 to 152,136), while morbidity rates, expressed in hospital admissions, showed a significant increase, from 396.2 to 547.2 (with the total number of admissions increasing from 696,866 to 1,118,717). A time-trend analysis performed using R package version 3.4.3 obtained a positive and significant Spearman correlation coefficient throughout the period for morbidity and mortality rates (rho = 0.917 and 0.746, respectively).

• Systematization, expansion and consolidation of out-of-hospital emergency care

Growth in violence since the 1990s has resulted in a corresponding increase in the demand for emergency care, requiring specialized training for the treatment of transport accident victims and firearm projectile injuries, particularly multiple fractures and wounds and injuries to various organs. The PNRMAV confirms that out-of-hospital emergency care is essential for reducing length of hospital stay, sequelae, and deaths. It also states that it is important for improving the registration of violent events and highlights that regulation centers should set uniform operating procedures for emergency assistance.

A literature review addressing health care provision for victims of violence shows that mobile out-of-hospital emergency care in Brazil suffers from deep structural flaws, lack of service coordination, and ineffective counter-referral and that these problems are severely aggravated by the current funding/political crisis faced by the SUS⁹9. Minayo MCS, Assis SG, organizadoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira do campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017..

• Interdisciplinary and intersectoral care

Increased violence and accidents in recent years has forced the health sector to develop a new approach to healthcare, involving interdisciplinary teams and the development of health actions and services through networks in coordination with other public sector and civil society organizations that also provide assistance to victims of violence.

This new reality demands a different type of healthcare to that which has been traditionally provided to treat infectious and parasitic diseases, resulting in an urgent need to enhance the capacity of professionals and shelter care facilities for delivering care tailored to the specific needs of children and adolescents, women and older persons suffering violence, particularly domestic abuse. In this respect, the government has invested in capacity building and training of healthcare professionals, as outlined below.

A literature review conducted by Minayo and Assis⁹9. Minayo MCS, Assis SG, organizadoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira do campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017. covering the period 2001to 2013 discovered a large number of studies addressing care for violence victims provided through the Family Health Strategy, outpatient services, and specialist care centers. The authors highlight that the growth of literature on this topic reflects the progress made by the SUS in this area.

Promoting greater intersectoral involvement in the implementation of the PNRMAV remains a major challenge, reflecting the fragmentation of knowledge and practices within the sector.

• Structuring recovery and rehabilitation services

Apart from actions developed within the health sector, the Ministry of Health has established various partnerships with other government sectors, through programs addressing road safety issues such as the Lei Seca (dry law), and with nongovernmental organizations, through actions directed at reducing and preventing accidents and sequelae caused by these events. Minayo and Assis⁹9. Minayo MCS, Assis SG, organizadoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira do campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017. have highlighted the precarious nature of actions and publications dealing with this theme. Unfortunately, this level of care has shrunk significantly in recent years, following the dismantling and closure of violence recovery and rehabilitation services. The few remaining services have lengthy waiting lists and do not have sufficient capacity to provide adequate care, making it necessary to discharge patients prematurely.

• Human resource development and capacity-building

Various studies have highlighted challenges faced by professionals and health services in providing adequate care to victims of violence²⁸28. Brasil. Ministério da Saúde (MS). Morbimortalidade por violências no Brasil: um retrato de contornos em construção. In: Brasil. Ministério da Saúde (MS). Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza Saúde Brasil. 10ª ed. Brasília: MS; 2014. p. 151-176.

29. Souza ER, Ferreira Al, Santos NC. Concepções de docentes em relação ao manual sobre violência intrafamiliar. Rev. Brasileira de Educação Médica 2009; 33(3):329-338.

30. Minayo MCS, Deslandes SF, organizadores. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora Fiocruz; 2007.-³¹31. Lima MLLT, Lima MLC, Deslandes SF, Souza ER, Kelly A. Assistência em reabilitação para vítimas de acidentes e violência: a situação dos municípios em Pernambuco, Brasil. Cien Saude Colet 2012; 17(1):33-42..

Nonetheless, a number of partnerships have been established to develop the capacities of health managers and professionals alike. Examples include: the distance learning program developed by the Jorge Careli Department of Violence and Health Studies (CLAVES, acronym in Portuguese), beginning with courses designed to enhance and update knowledge or skills in 2006 and specialist training courses from 2009; the master’s program “Health Promotion and Violence Prevention” offered by the Federal University of Minais Gerais; the distance learning program Vida no Trânsito (life in the traffic) and a Guide to Vida no Trânsito offered by the Federal University of Goiás as from 2015; center assessment conducted by the University of Brasília, CLAVES, and others. Minayo and Assis⁹9. Minayo MCS, Assis SG, organizadoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira do campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017. have presented a number of studies of these kinds of initiatives showing that they have attained significant progress.

• Research support

The Ministry of Health has conducted several studies on violence in partnership with other institutions, including the National Cancer Institute, Ministry of Education, Brazilian Institute of Geography and Statistics, Osvaldo Cruz Foundation, University of São Paulo, and State University of Campinas. Examples include: Inquérito Domiciliar sobre Comportamentos de Risco e Morbidade Referida de Doenças e Agravos Não Transmissíveis (Household Survey of Risk Behaviors and Morbidity Related to Noncommunicable Diseases), conducted in 15 state capitals and the Federal District between 2002 and 2003; Pesquisa Nacional de Saúde dos Escolares (National Schoolchildren’s Health Survey) conducted in 2009, 2012, and 2015; Pesquisa Nacional de Saúde (National Health Survey), which incorporated the theme accidents and violence in 2013; Vigilância de Fatores de Risco de Doenças e Agravos não Transmissíveis por Inquérito Telefônico (Telephone Survey of the Surveillance of Risk Factors for Noncommunicable Diseases), conducted annually since 2006, including alcohol abuse, driving and violence. Efforts were also made to evaluate the implementation of a program directed at reducing morbidity and mortality due to road traffic accidents³²32. Minayo MCS, Souza ER. Avaliação do Processo de Implantação e Implementação do Programa de Redução da Morbimortalidade por Acidentes de Trânsito. Rio de Janeiro: Claves; 2006.,³³33. Souza ER. Avaliação do Processo de Implantação e Implementação do Programa de Redução da Morbimortalidade por Acidentes de Trânsito 2012/2013. Rio de Janeiro: Claves; 2013. and accident and violence prevention centers³⁴34. Souza ER, coordenadora. Avaliação dos Núcleos de Prevenção à Violência e Promoção da Saúde do Brasil frente à Política de Redução de Morbimortalidade por Acidentes e Violências. Rio de Janeiro: Claves; 2012.. The findings of these studies have been widely disseminated in reports produced by the Ministry of Health, scientific articles, mainstream media, and social media channels.

The following organizations have also contributed to the fulfillment of this guideline: the National Council for Scientific and Technological Development, which launched several calls for proposals for research on the theme of violence; Coordination for the Improvement of Higher Education Personnel, which developed courses on the theme; and various state research support foundations. However, incentives for capacity building have waned in recent years in the wake of SUS funding reductions, particularly for actions tackling violence.

Final Considerations

Our findings show that numerous positive results have been achieved at the national and international level through actions directed at organizing the sector to provide healthcare for victims of violence, human resource development and capacity-building, and research development, demonstrating that it is possible to prevent and reduce violence that kills and injures³⁵35. Nardi ACF, Malta DC, Duarte E, Garcia LP. Segurança no trânsito: tempo de resultados. Epidemiol. Serv. Saúde 2015; 24(4):593-594.

36. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, Abera SF, Abraham JP, Adofo K, Alsharif U, Ameh EA, Ammar W, Antonio CA, Barrero LH, Bekele T, Bose D, Brazinova A, Catalá-López F, Dandona L, Dandona R, Dargan PI, De Leo D, Degenhardt L, Derrett S, Dharmaratne SD, Driscoll TR, Duan L, Petrovich Ermakov S, Farzadfar F, Feigin VL, Franklin RC, Gabbe B, Gosselin RA, Hafezi-Nejad N, Hamadeh RR, Hijar M, Hu G, Jayaraman SP, Jiang G, Khader YS, Khan EA, Krishnaswami S, Kulkarni C, Lecky FE, Leung R, Lunevicius R, Lyons RA, Majdan M, Mason-Jones AJ, Matzopoulos R, Meaney PA, Mekonnen W, Miller TR, Mock CN, Norman RE, Orozco R, Polinder S, Pourmalek F, Rahimi-Movaghar V, Refaat A, Rojas-Rueda D, Roy N, Schwebel DC, Shaheen A, Shahraz S, Skirbekk V, Søreide K, Soshnikov S, Stein DJ, Sykes BL, Tabb KM, Temesgen AM, Tenkorang EY, Theadom AM, Tran BX, Vasankari TJ, Vavilala MS, Vlassov VV, Woldeyohannes SM, Yip P, Yonemoto N, Younis MZ, Yu C, Murray CJ, Vos T. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease. Injuries Prevention 2016; 22(1):3-18.

37. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MH, Silva CM, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet 2011; 377(9781):1962-1975.-³⁸38. Malta DC, Minayo MCS, Soares Filho AM, Silva MMA, Montenegro MMS, Ladeira RM, Morais Neto OL, Melo AP, Mooney M, Naghavi M. Mortalidade e anos de vida perdidos por violências interpessoais e autoprovocadas no Brasil e Estados: análise das estimativas do Estudo Carga Global de Doença, 1990 e 2015. Rev. Bras. Epidemiol. 2017; 20(Supl.1):142-156.. Although many of these actions have not stemmed strictly from the health sector, they have an important impact on the area. Such is the case with regulatory frameworks that have contributed to the reduction of violent road traffic deaths, including the so-called Lei Seca and Desarmament Statute. However, numerous action developed by the Ministry of Health lack evaluation and monitoring. Data from the VIVA SINAN NET reveal a general increase in the detection and reporting of cases of violence that is probably due to an increase in adhesion to violence reporting services, increased capacity of professionals for detecting and reporting cases, thanks to continuing training programs, and improved access to services for violence victims. However, it is important to mention that adhesion to the system still falls short of the desired mark.

Violence against children and adolescents, women, and older persons was given priority on the health agenda. Other themes, such as child labor, human trafficking³²32. Minayo MCS, Souza ER. Avaliação do Processo de Implantação e Implementação do Programa de Redução da Morbimortalidade por Acidentes de Trânsito. Rio de Janeiro: Claves; 2006., homophobic³³33. Souza ER. Avaliação do Processo de Implantação e Implementação do Programa de Redução da Morbimortalidade por Acidentes de Trânsito 2012/2013. Rio de Janeiro: Claves; 2013.and racial violence³⁴34. Souza ER, coordenadora. Avaliação dos Núcleos de Prevenção à Violência e Promoção da Saúde do Brasil frente à Política de Redução de Morbimortalidade por Acidentes e Violências. Rio de Janeiro: Claves; 2012., and violence against street dwellers³⁵35. Nardi ACF, Malta DC, Duarte E, Garcia LP. Segurança no trânsito: tempo de resultados. Epidemiol. Serv. Saúde 2015; 24(4):593-594. and people with diabilities³⁶36. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, Abera SF, Abraham JP, Adofo K, Alsharif U, Ameh EA, Ammar W, Antonio CA, Barrero LH, Bekele T, Bose D, Brazinova A, Catalá-López F, Dandona L, Dandona R, Dargan PI, De Leo D, Degenhardt L, Derrett S, Dharmaratne SD, Driscoll TR, Duan L, Petrovich Ermakov S, Farzadfar F, Feigin VL, Franklin RC, Gabbe B, Gosselin RA, Hafezi-Nejad N, Hamadeh RR, Hijar M, Hu G, Jayaraman SP, Jiang G, Khader YS, Khan EA, Krishnaswami S, Kulkarni C, Lecky FE, Leung R, Lunevicius R, Lyons RA, Majdan M, Mason-Jones AJ, Matzopoulos R, Meaney PA, Mekonnen W, Miller TR, Mock CN, Norman RE, Orozco R, Polinder S, Pourmalek F, Rahimi-Movaghar V, Refaat A, Rojas-Rueda D, Roy N, Schwebel DC, Shaheen A, Shahraz S, Skirbekk V, Søreide K, Soshnikov S, Stein DJ, Sykes BL, Tabb KM, Temesgen AM, Tenkorang EY, Theadom AM, Tran BX, Vasankari TJ, Vavilala MS, Vlassov VV, Woldeyohannes SM, Yip P, Yonemoto N, Younis MZ, Yu C, Murray CJ, Vos T. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease. Injuries Prevention 2016; 22(1):3-18., who are deprived of their liberty³⁷37. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MH, Silva CM, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet 2011; 377(9781):1962-1975., are gradually finding their way onto the agenda. Their presence on the agenda depends largely on pressure brought by civil society and international organizations that advocate for these causes.

Drawing on specific research¹²12. .World Health Organization (WHO).World report on violence and health. Geneva: WHO; 2002, it is possible to highlight a number of areas where greater investment is needed to ensure the effective implementation of the PNRMAV: the development of incentives to improve the information system, particularly in relation to out-of-hospital emergency and hospital care; out-of-hospital emergency and rehabilitation services, focusing on decentralization and bringing services closer to users; strengthening mental services; incorporation of the theme into the training and development of all of healthcare professionals and intensification of continuing training.

In the 16 years since the PNRMAV came into force, Brazil may commemorate the fact that it is one of the few countries that has a specific health policy directed at this social problem. This article shows that, although major strides have been taken, many challenges remain, demonstrating that violence, in all its distinct forms of expression, should assume a prominent position on the health agenda given the magnitude of the problem and the impact it has on quality of life.

Acknowledgments

Thiago de Oliveira Pires, pela realização da análise temporal dos dados de morbi-mortalidade.

References

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