In its 20 years of existence, the Brazilian National Food and Nutrition Policy (PNAN) has been the driving force of food and nutrition actions in Brazil, guiding healthy eating practices and contributing to policies aimed at securing the human right to adequate food (HRAN), a process led by civil society, that took up its place in the government agenda. The existence of a national food and nutrition policy with an updated and consistent theoretical framework; a defined strategic guidelines and attributions among the agents involved; and with its own funding has enabled advances in the health sector organization of food and nutrition actions.

The structuring of a federal coordination favored a decentralized organization of food and nutrition’s technical areas, especially at states levels; although, in many cases, without formal recognition in the institutional organization chart. The decentralization of these actions has occurred due to the formation of a network of food and nutrition technical leaders. The state government mediate the federal government and the municipalities relationship. The Federal Government is responsible for distributing information, consolidating technical references, and monitoring actions; whereas municipal governments are responsible for the implementation of programs, within their respective reach, and management of resources that are transferred by the Federal Government.

To strengthen the development of PNAN at the local level, the General-Coordination of Food and Nutrition (CGAN) of the Brazilian Ministry of Health has diversified funding strategies: transferring resources to states and municipalities, collaborating with educational and research institutions, and by decentralized implementation terms, agreements, and funding notices. Partnerships with universities has added a multidisciplinary characteristic to the program; while the Intersectoral Chambers of Food and Nutritional Security - wherever they are present - play a decisive role in the induction of inter-sectorial aspects. Futhremore, other civil society agents help qualify and broadcast food and nutrition’s strategic agendas.

Managing at state and municipal levels is still a significant challenge; both regarding the institutionalization of coordination structures, as well as in relation to the qualification of local coordination and the lack of technical teams to implement and monitor food and nutrition actions. The interruption of programs, caused by the shifts in public administrations, becomes a problem for the governance capacity of the PNAN; this issue, however, is not restricted to this policy in the Brazilian Unified National Health System (SUS). Similarly, the instability of employment relationship, overlapping of attributions, and high professional turnover hinder the continuity of actions.

To address the complexity of food and nutrition current scenario, the local-level food and nutrition agenda still needs to experience a more effective decentralization; which can be achieved by developing and implementing food and nutrition policies and regulations at state and municipal levels that consider local priorities and needs. The construction of local policies enables innovation due to the possibility of acting on localized knowledge, such as epidemiological and nutritional information of the community through work and partnerships with other public agents and local communities. A more effective decentralization could also be achieved if technical areas had a greater autonomy in their use of resources. However, mechanisms are needed to qualify these technical areas for the use of the food and nutrition fund, the financing actions of the PNAN ¹1. Pires ACL, Ramos MKP, Alves MFM, Alba RD, Bortolini GA, Silva JRM. Um olhar para as experiências de Alimentação e Nutrição do Prêmio APS Forte. APS em Revista 2020; 2:285-97.. Local food and nutrition managers do not always have autonomy or know the processes for operating these resources.

Communication between food and nutrition and social control institution, such as health boards and state, or municipal, food and nutritional security councils, is crucial. The creation of an Intersectoral Commission on Food and Nutrition, by municipal and state health councils, is a recommendation of the Brazilian National Health Council that can collaborate for this objective. The work of municipal and state councils is fundamental for prioritizing resources for food and nutrition actions in the Municipal Plan and the Annual Health Program, which has been driven by food and nutrition fund planning and accountability procedures. The articulation between other governmental sectors - such as education, economy, agriculture - with the legislative and judicial power is necessary for the management of food and nutrition’s public policies, due to the intersectoral nature of the actions of competing competences and shared responsibilities between the different entities.

The management and operationalization of PNAN interfaces with various coordination, due to its very nature. The PNAN’s strategic guidelines provide endeavors integrated with others from the health sector and should be included within the comprehensive care of the Health Care Network (HCN), with primary care as the coordinator and ordering of the network. This calls for a single coordination committed to the intra-sectoral articulation, at the risk of disintegration and fragmentation of actions. In this sense, the perspective of integrality of care demands that the nutritional care organization includes other points of attention.

Overcoming the fragmented, vertical, and parallel character of the teams’ work processes - resulting from the model of program implementation aimed at coping with nutritional problems - also represents a challenge for decentralization, moving towards a model of organization of food and nutrition care that realizes the perspective of integrality ²2. Jaime PC, Coitinho DC, Campello T, Silva DO, Santos LMP. Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do Sistema Único de Saúde. Ciênc Saúde Colet 2018; 23:1829-36..

In this sense, food and nutrition surveillance is a strategic action for an adequate prioritization of food and nutrition actions by health teams. However, most municipalities do not use their information for planning, management, and evaluation; being restricted to data collection. The Food and Nutrition Surveillance System (SISVAN) still has very low population coverage and is centered on mother-child groups and families of the Brazilian Family Income Program. The integration of e-SUS information with other primary health care (PHC) information systems may represent an advance for the legitimation of SISVAN, but it still has limitations in the recording and migration of data, possibly due to the lack of priority of food and nutrition in the health sector.

Another common strategy in the decentralization processes is the publication of technical materials aimed to professionals. These publications are meant to support the implementation of programs, even without guaranteeing the qualification of actions, training of human resources or greater degree of implementation of programs in municipalities ³3. Machado PMO. Atenção nutricional no âmbito da atenção primária à saúde: análise de implantação em municípios brasileiros [Tese de Doutorado]. Santa Catarina: Universidade Federal de Santa Catarina; 2018.. In the case of PNAN, in addition to publications, spaces conceived for communicating, and strengthening public administrators on their roles were fundamental for decentralization. Over these 20 years, CGAN promoted national meetings, demonstrations of successful work, spaces for exchanging experiences, trainings, and professional qualification.

In the HCN, where PNAN is conceptualized, it is evident the extension of the food and nutrition agenda and its role in the genesis and care of the main preventable health problems of the population; requiring that actions take place through partnership with other professionals, within a matrix support. Nutritionists should be potential facilitators for the qualification of these actions, by training other professionals. The recent extinction of the registration and federal funding of the Family Health Support Centers (NASF) by the new Brazilian National Primary Health Care Policy (PNAB 2017) has further compromised the implementation of these actions in PHC, weakening the multiprofessional model ⁴4. Giovanella L, Franco CM, Almeida PF. National primary health care policy: where are we headed to? Ciênc Saúde Colet 2020; 25:1475-82..

The 20 years of PNAN, a pioneering policy among several others in the health sector, show a history of resistance and learning, with new and old challenges. The qualification of PNAN management in the states and municipalities is central to the implementation of its actions in health services - where the policies are actually devised. This involves the training of professionals - including issues related to the processes of purchase and definition of budget and capacity for intra- and intersectoral articulation - with stable employment links. Locally, it is necessary to expand the experiences of implementing the organization of food and nutrition care network, with food and nutritional surveillance as the driving force of the actions.

Acknowledgments

We thank all those who contributed to the preparation of this article, especially to the State Coordination of Food and Nutrition of Mato Grosso do Sul, Pará, Pernambuco, Rio de Janeiro, and Rio Grande do Sul, and the Municipal Coordination of Altamira, Amambaí, Búzios, Itaperuna, Magé, Nova Prata, Paulista, Recife and Vassouras, whose reflections in the meetings held in May/2020, with their respective technical leaders, collaborated substantially with the authors.

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