Abstract

OBJECTIVE:

to describe the actions undertaken by the Strategic Action Plan for Tackling Chronic Non-Communicable Diseases (NCDs) in Brazil, from 2011 to 2015.

METHODS:

the actions were identified through sectorial and interministerial meetings, annual forums, as well as document reviews of publications and laws on government websites.

RESULTS:

the actions found were: national surveys and monitoring of mortality and risk factor reduction targets; encouragement of physical activity, adequate nutrition and health promotion through the creation of the Health Gym Program (Programa Academia da Saúde); the publication of legislation on tobacco-free environments; free of charge drugs for hypertension, diabetes, and asthma; organization of the emergency service network for cardiovascular diseases; and expanding access to diagnosis and treatment of cancer patients.

CONCLUSION:

we found progress regarding surveillance, health promotion and comprehensive care; in general, the goals of the Plan are being met.

Key words:
Epidemiological Surveillance; Chronic Disease; Risk Factors; Public Policies; Monitoring

Introduction

Chronic Non-Communicable Diseases (NCDs) were responsible for 63% of all deaths in 2008, according to the World Health Organization (WHO). The NCDs are the leading cause of mortality worldwide, with a prevalence of premature mortality, especially in low-income populations.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde). In Brazil, NCDs accounted for about 74% of deaths in 2012,2 and represents high morbidity burden.

In this context, in September 2011 and July 2014 important High-Level Meetings on this issue took place at the United Nations (UN), with the participation of government representatives from many countries. On those occasions some commitments of the heads of States to deal with this group of diseases were strengthened.³3. United Nations. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases [Internet]. [New York]: United Nations; 2011 [cited 2014 Oct 20]. Available from: Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/66/L.1
http://www.un.org/ga/search/view_doc.asp... ^,44. United Nations. General Assembly High-Level Meeting on Non-Communicable Diseases Urges. National Targets, Global Commitments to Prevent Needless Loss of Life [Internet]. New York: United Nations; 2014 [cited 2014 Oct 20]. Available from: Available from: http://www.un.org/News/Press/docs/2014/ga11530.doc.htm
http://www.un.org/News/Press/docs/2014/g... As a result, the Global, Regional and National Plans for NCDs were approved.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde).^,55. World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013 [cited 2014 Oct 20]. Available from: Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... ^,66. Organização Pan Americana de Saúde. Plano Estratégico da Organização Pan Americana de Saúde, 2014-2019. Washington: Organização Pan Americana de Saúde; 2014. Also, some targets were established for reducing the NCDs and their risk factors, aiming at the commitment of Health Systems and the intersectoral coordination to fight the problem.⁷7. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2013 out-dez;20(4):425-38.^,88. Malta DC, Silva JB. O Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiol Serv Saude. 2013 jan-mar;22(1):151-64.

The Brazilian government presented the Strategic Action Plan for Tackling Chronic Non-Communicable Diseases in Brazil - 2011-2022 at the UN meeting in 2011. The Plan established the management compromise and priority actions and investments needed to tackle and stop NCDs and their risk factors.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde).^,77. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2013 out-dez;20(4):425-38. The plan covered the four main groups of chronic diseases - cardiovascular, cancer, chronic respiratory and diabetes - and their common modifiable risk factors - tobacco use, heavy drinking, physical inactivity and unhealthy diet - and defined three strategic pillars: I. Surveillance, Information, Monitoring and Evaluation; II. Health Promotion; and III. Comprehensive Care.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde). The Plan also set goals and commitments made by Brazil in relation to the NCDs, commissioning its national coordination and monitoring to the Secretariat of Health Surveillance of the Ministry of Health.⁷7. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2013 out-dez;20(4):425-38.^,88. Malta DC, Silva JB. O Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiol Serv Saude. 2013 jan-mar;22(1):151-64.

The analysis of the actions carried out between 2011 and 2013 was presented in a previous article,⁹9. Malta DC, Silva JB. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil após três anos de implantação, 2011-2013. Epidemiol Serv Saude. 2014 jul-set;23(3):389-95. in which important advances were highlighted, especially actions for (i) surveillance and monitoring of the targets, (ii) health promotion and prevention of NCDs, such as tackling the four risk factors in common, and (iii) strengthening of health care systems for NCDs approach. This article presents an overview of the actions undertaken since 2011, adding to them those carried out in 2015.

Periodic monitoring is essential, including the publication of the actions and goals achieved, in order to support the Brazilian Government and civil society in monitoring the Plan and to strengthen the commitment of governments and the community to reduce NCDs and improve the population's health situation. This study is justified because it contributes to the consolidation of the monitoring of actions undertaken by the Ministry of Health and other partners, based on the three pillars of the Strategic Action Plan for Tackling Chronic Non-communicable Diseases in Brazil.

The aim of this paper was to describe the actions carried out under the Strategic Action Plan for Tackling Chronic Non-communicable Diseases (NCDs) in Brazil, from 2011 to 2015.

Methods

Two strategies were used to describe the actions: (1) listing and revising the records of the annual meetings and (2) document reviews of publications and laws on the Government websites, in order to complement, when necessary, the presented information.

First, to monitoring the actions of NCDs Plan, intersectoral meetings were held within the Health sector and also interministerial, in order to gather the responsible areas for the various strategies of the Plan and socialize the main actions carried out by each area. These meetings are preparatory and culminate in annual forums for monitoring, where representatives of Ministries, the Brazilian National Health Surveillance Agency (Anvisa), the State Health Departments (SES) and Municipal Health Departments (SMS), educational and research institutions and non-governmental organizations (NGOs) meet.

The interministerial meetings were organized by the Executive Secretariat and the Health Surveillance Secretariat, of the Ministry of Health, and involved about 20 ministries, responsible for the development of actions within the Plan, especially the Ministry of Sports (ME), Ministry of Agriculture, Livestock and Food Supply (MAPA), Ministry of Culture (MINC), Ministry of Education (MEC), Ministry of Social Development (MDS), Ministry of Labor and Employment (MTE), Ministry of Tourism (MTUR), Ministry of Science and Technology (MCTI), Prosecution Service (MP), Ministry of Social Security (MPS), Ministry of Defense (MD) and Ministry of Foreign Affairs (MRE).

After listing the involved organizations, we described the actions taken by the Ministry of Health under the three pillars of the Plan, namely:¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde).

Its objectives are presented in Figure 1. In addition, intersectoral actions by other ministries have been described.

Results

After five years of the implementation of the NCDs Plan, great progress has been achieved. Among the initiatives developed under Pillar I, we can highlight the results of the Vigitel survey - Surveillance System of Risk and Protective Factors for Chronic Diseases by Telephone Survey - conducted annually since 2006. In 2015, a report was published presenting the following trends for the period 2006-2014: reduction in the number of current smokers and passive smokers at households, and reduction of regular consumption of soft drinks; increased consumption of fruits and vegetables and higher practice of leisure time physical activity; increased mammography coverage; increasing prevalence of overweight and obesity; and increased numbers of individuals with clinical diagnosis for diabetes.¹⁰10. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2015.

The Vigitel has also been used to monitor the achievement of the goals of the Plan from its baseline, since 2010.⁷7. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2013 out-dez;20(4):425-38. According to the 2014 survey results, and to 2013 data from the Mortality Information System (SIM), a reduction was observed in premature mortality (30-69 years old) due to NCDs, from 392/100 thousand inhabitants (2010) to 359/100 thousand inhabitants (2013), analyzing together the four main groups of NCDs (cardiovascular, cancer, diabetes and chronic respiratory): an average reduction for the period of about 2.5% per year. In the Vigitel monitoring from 2010 to 2014, we could notice a reduction in tobacco consumption (23.4%) and heavy drinking (8.8%); an increase in the recommended consumption of fruits and vegetables (23.5%), in physical activity (17.3%) and mammography coverage (5.9%). On the other hand, there was stability in Pap smear tests, and increased obesity (18.5%).⁷7. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude. 2013 out-dez;20(4):425-38.^,1010. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2015.

In 2013, the National Health Survey (PNS) was carried out, resuming the supplement on health of the National Household Sample Survey (PNAD), conducted in 1998, 2003 and 2008, with the proposal to be produced every five years. The PNS is a household-based survey that aims at collecting national data on health situation, risk and protection behavior, access to health care, and use and funding health services by the Brazilian population. The anthropometric and blood pressure measurements, and blood and urine collection (in subsample) for laboratory tests were the highlights of the PNS.¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014 [citado 2014 dez 22]. Disponível em: Disponível em: http://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
http://ftp.ibge.gov.br/PNS/2013/pns2013.... ^,1212. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde [Internet]. Brasília: Ministério da Saúde; 2014 [citado 2015 dez 1]. Disponível em: http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/leia-mais-o-ministerio/673-secretaria-svs/vigilancia-de-a-a-z/doencas-cronicas-nao-transmissiveis/l2-doencas-cronicas-nao-transmissiveis/14127-pesquisa-nacional-de-saude-pns
http://portalsaude.saude.gov.br/index.ph...

The National School-based Health Survey (PeNSE) is being held every three years, since 2009, with interviews with students from the ninth grade, enrolled in public and private schools. That survey is a partnership between the Brazilian Institute of Geography and Statistics (IBGE), the Ministry of Health and the Ministry of Education. The full report of PeNSE 2012 was published in 2013;¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar 2012 [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística ; 2013 [citado 2014 jan 29]. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/pense/2012/pense_2012.pdf .
http://www.ibge.gov.br/home/estatistica/... in 2014, the Brazilian Journal of Epidemiology (Revista Brasileira de Epidemiologia) published a thematic issue presenting different analyses of the research data.¹⁴14. Malta DC, Andreazzi MAR, Oliveira-Campos M, Andrade SSCAA, Sá NNB, Moura L, et al . Trend of the risk and protective factors of chronic diseases in adolescents, National Adolescent School-based Health Survey (PeNSE 2009 e 2012). Rev bras epidemiol. 2014;17 Suppl 1:77-91. Also in 2014, a planning and survey review for PeNSE 2015 was carried out, and the data collection was successfully conducted in 2015, and published in 2016. Another recent initiative was the National Survey on Access, Use and Promotion of Rational Drug Use (PNAUM), held in 2013. Respondents answered questions on their chronic diseases, treatments they undergo, what drugs they use and how they get them, the health services used and their lifestyle habits, such as smoking and alcohol consumption. The first results of this research, focused on some NCDs, were presented in September 2014; the other results will be presented in a thematic issue of the Journal of Public Health.¹⁵15. Costa KS. Acesso e uso de medicamentos: inquéritos de saúde como estratégia de avaliação [tese]. Campinas (SP): Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Saúde Coletiva; 2014. More details of the presented researches can be found in Figure 2, in addition to other actions taken on the Pillar I - Surveillance, Information, Monitoring and Evaluation.

Regarding Pillar II - Health Promotion -, one of the prominent programs is the Health Gym Program, which main objective is to build physical spaces for the health promotion actions development, production of care and healthy lifestyles, covering healthy eating activities, physical practices and prevention of NCDs and violence, actions commissioned to health professionals together with the community. The Ministry of Health has been transferring funds to the construction of poles of the Health Gym Program - as well as to fund the actions envisioned for the program - and those classified as similar, according to predefined criteria.¹⁶16. Ministério da Saúde (BR). Programa Academia da Saúde [Internet]. Brasília: Ministério da Saúde ; 2016 [citado 2014 out 21] Disponível em: Disponível em: http://portalsaude.saude.gov.br/index.php?option=com_content&view=article&id=13812&Itemid=766
http://portalsaude.saude.gov.br/index.ph... Studies to evaluate the effectiveness of programs for the promotion of corporal practices/physical activity in the Brazilian municipalities were also conducted. Preliminary results of the study on the Pernambuco Health Gym Program pointed that the program encourages physical activity, especially among the poorest populations, women and the elderly.¹⁷17. Hallal PC, Tenório MCM, Tassitano RM, Reis RS, Carvalho YM, Cruz DKA, et al. Avaliação do programa de promoção da atividade física Academia da Cidade de Recife, Pernambuco, Brasil: percepções de usuários e não-usuários. Cad Saude Publica. 2010 jan;26(1):70-8.

In the year of the Soccer World Cup in Brazil, the Program 11 for Health (11 pela Saúde) - a partnership between the International Football Federation (FIFA), the Brazilian Football Confederation (CBF) and the Ministries of Sport, Education and Health - was implemented in public schools of the 12 host cities of the World Cup, for children aged 11 to 12 years old, with the objective of bringing them 11 messages on health and the practice of physical activity (soccer). More information about the actions on promotion of physical activity is shown in Figure 3.

With regard to actions to promote healthy eating, the revision of the 'Dietary Guidelines for the Brazilian population', released in November 2014, containing information, analysis, advice and guidance on the selection, preparation and consumption of food is to be highlighted. That is a clear and objective instrument of food and nutrition education that aims at promoting the health of individuals, families and communities.¹⁹19. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2 ed. Brasília: Ministério da Saúde; 2014. Besides revising the Guide, the publication 'Brazilian Regional Food' was also revised, with the objective of enriching the Brazilian food, and released in March 2015.²⁰20. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Alimentos regionais brasileiros. 2 ed. Brasília: Ministério da Saúde; 2015.

Still in the context of food, the voluntary agreement with the productive sector, involving the Ministry of Health, the Brazilian Association of Food Industry (ABIA), the Brazilian Association of Pasta Industry (Abima), the Brazilian Association of Wheat Industry (Abitrigo) and the Brazilian Association of Bakery and Confectionery Industry (ABIP) set national targets for the reduction of sodium in processed foods in Brazil: this partnership resulted in the signing, on April 7, 2011, of an agreement to salt reduce in the processed food to be consumed by Brazilians in subsequent years.²¹21. Ministério da Saúde. Termo de Compromisso que firmam entre si a União, por intermédio do Ministério da Saúde, e a Associação Brasileira das Indústrias de Alimentação (ABIMA), a Associação Brasileira da Indústria de Trigo (ABIBTRIGO) e a Associação Brasileira da Indústria de Panificação e Confeitaria (ABIP), com a finalidade de estabelecer metas nacionais para a redução do teor de sódio em alimentos processados no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2015 dez 8]. Disponível em: http://189.28.128.100/nutricao/docs/geral/termo_abia.pdf
http://189.28.128.100/nutricao/docs/gera...

The daily salt intake in Brazil was 12g in 2008, and the target set was to achieve 5g in 2022, contributing to the reduction of high blood pressure and other NCDs.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde). So far, the first two terms of commitment (TC) signed with the productive sector have been monitored. The proposed target was achieved in 80.8% of the products in the first TC and 99.0% in the second TC. Therefore, the monitoring showed positive and empowering results regarding the strategy to reduce the population's sodium intake, transforming Brazil into a reference country for this agenda in the Americas, along with Argentina and Canada. More information on the food monitored and the results found can be seen in Figure 3, along with other actions related to the promotion of healthy eating.

Concerning legislation, the year 2015 was known by the publication of Decrees No. 8,473, dated 22/06/2015 and No. 8,552, dated 03/11/2015.²²22. Brasil. Decreto nº 8473, de 22 de junho de 2015. Estabelece, no âmbito da Administração Pública federal, o percentual mínimo destinado à aquisição de gêneros alimentícios de agricultores familiares e suas organizações, empreendedores familiares rurais e demais beneficiários da Lei nº 11.326, de 24 de julho de 2006, e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 jun 22; Seção 1:9.^,2323. Brasil. Decreto n° 8552, de 03 de novembro de 2015. Regulamenta a Lei nº 11.265, de 3 de janeiro de 2006, que dispõe sobre a comercialização de alimentos para lactentes e crianças de primeira infância e de produtos de puericultura correlatos. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 nov 22;Seção 1:5. The first Decree established, within the Federal Public Administration, the minimum percentage of 30% of food purchase from family farms, by agencies and entities of the federal level.²²22. Brasil. Decreto nº 8473, de 22 de junho de 2015. Estabelece, no âmbito da Administração Pública federal, o percentual mínimo destinado à aquisição de gêneros alimentícios de agricultores familiares e suas organizações, empreendedores familiares rurais e demais beneficiários da Lei nº 11.326, de 24 de julho de 2006, e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 jun 22; Seção 1:9. The second Decree regulated Law No. 11,265, dated 03/01/2006, about the marketing of foods for infants and toddlers, as well as related childcare products.²³23. Brasil. Decreto n° 8552, de 03 de novembro de 2015. Regulamenta a Lei nº 11.265, de 3 de janeiro de 2006, que dispõe sobre a comercialização de alimentos para lactentes e crianças de primeira infância e de produtos de puericultura correlatos. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 nov 22;Seção 1:5.

In relation to obesity control, the 'Intersectoral Strategy for Prevention and Obesity Control: Recommendations to States and Municipalities' was published in 2014, bringing together various actions of the Federal Government that aimed at reducing obesity in the country, in order to motivate and support states and municipalities in the implementation of the proposed actions.²⁴24. Ministério do Desenvolvimento Social e Combate à Fome (BR). Câmara Interministerial de Segurança Alimentar e Nutricional. Estratégia Intersetorial de Prevenção e Controle da Obesidade: recomendações para estados e municípios [Internet]. Brasília: Ministério da Saúde; 2014 [citado 2015 dez 8]. Disponível em: Disponível em: http://www.mds.gov.br/webarquivos/publicacao/seguranca_alimentar/estrategia_prevencao_obesidade_recomendacoes.pdf
http://www.mds.gov.br/webarquivos/public...

Still regarding Pillar II of the Plan, the advances of Brazil in fighting tobacco use are internationally recognized. In the country, the frequency of smoking has declined significantly from their baseline. The National Survey on Health and Nutrition, held in 1989 showed smoking prevalence of 34.8% in individuals over 18 years old.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde). After that, the 2003 World Health Survey showed a reduction of this prevalence to 22.4% and, according to the National Tobacco Survey (PETab), it fell to 18.5% in individuals aged 18 years or older (2008).¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde).^,2525. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SMF, 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. No prelo 2015. The PNS showed 14.7% of current tobacco smokers in the country and 12.5% in the capital cities, pointing to a reduction of about 20% of prevalence from 2008 to 2013 for men, women, and for all education levels.²⁵25. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SMF, 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. No prelo 2015. This success resulted from educational, preventive, legislative and regulatory measures. We can highlight the regulatory actions, such as banning advertisements, promotions and sponsorship of tobacco (except in sale areas), use warning images in tobacco product packages, banning smoking indoors, among others. Brazil has become a global reference for anti-tobacco initiatives, due to the results achieved and regulatory measures taken. The main actions are described in Figure 3.

With regard to alcohol consumption, heavy drinking is responsible for many health problems, such as liver disease, cancer, mental disorders, accidents and violence, bringing high costs to society, resulting in productivity loss, health care expenses, and absenteeism at work, among others.¹1. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise e Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. (Série B. Textos básicos de saúde).^,55. World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013 [cited 2014 Oct 20]. Available from: Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... Given the fact that this is a serious situation, the Ministry of Health has promoted intersectoral and interdisciplinary actions. With regard to legislation, the health sector played an advocacy role for the implementation of Law No. 11,705, dated 19/06/2008, an initiative of the Federal Government to ban the commerce of alcoholic beverages in federal highways; and the so-called 'Dry Law' - Law No. 12,760, dated 20/12/2012 - which increased the value of the fine, in addition to authorize the use of evidence, such as videos, testimonials or other means that could prove drunkenness of the driver, in a criminal process.²⁶26. Brasil. Lei nº 11.705, de 19 de junho de 2008. Altera Lei no 9.503, de 23 de setembro de 1997, que 'institui o Código de Trânsito Brasileiro', e a Lei no 9.294, de 15 de julho de 1996, que dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4o do art. 220 da Constituição Federal, para inibir o consumo de bebida alcoólica por condutor de veículo automotor, e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2008 jun 19;Secão 1:1.^,2727. Malta DC, Berna 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 ago;48(4):692-966.

According to a comparative study of VIGITEL, the prevalence of adults who reported driving after drinking alcohol fell from 2.0% in 2007 to 1.1% in 2013, with significant drop between 2007 and 2008 and between 2012 and 2013, possibly caused by the implementation of the Dry Law, its reissue and supervision.²⁷27. Malta DC, Berna 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 ago;48(4):692-966. However, in the period between 2010 and 2014, there was no statistically significant change, which reinforces the need of progress in this issue.¹⁰10. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2015.

Still on Pillar II of the Plan, the actions taken in the promotion of active aging and communication activities carried out annually in global days of physical activity and health are to be emphasized, especially with the release of the health promotion campaign entitled 'We should care for health every day', in 2015.²⁸28. Ministério da Saúde (BR). Promoção da Saúde - SUS [Internet]. Brasília: Ministério da Saúde ; 2016 [citado 2015 dez 09]. Disponível em: Disponível em: http://promocaodasaude.saude.gov.br/
http://promocaodasaude.saude.gov.br/... Finally , after eight years of the National Policy for Health Promotion (PNPS), the national and international commitments made by the Brazilian Government led to the need of reviewing and updating the policy, which occurred from 2013 to 2014, culminating in the publication of the updated version of the PNPS in the end of 2014, and the printed version was published in 2015.²⁹29. Brasil. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2014 nov 13;Seção 1:68. Figure 3 presents detailed information on the communication, active aging and the revision of PNPS.

Regarding Pillar III - Comprehensive Care - these are the main initiatives and actions carried out in recent years:

These actions of Pillar III strengthen SUS response capacity and expand the set of interventions that can offer a comprehensive approach to health, for prevention and control of NCDs. Figure 4 provides more details on them.

In addition to the Ministry of Health, several other ministries lead the intersectoral actions listed on NCDs Plan. This collective mobilization is a key to fighting this group of diseases, and the Plan itself emphasizes the importance of crossed-actions and the need to broaden the dialogue on this issue in the different sectors of the Federal Government. The table in Figure 5 details the actions identified by participants in an inter-ministerial meeting, according to the corresponding entity.

Discussion

The NCDs have been top priority in the Brazilian government's agenda. The implementation of the actions mentioned in the Plan for NCDs 2011-2022⁹9. Malta DC, Silva JB. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil após três anos de implantação, 2011-2013. Epidemiol Serv Saude. 2014 jul-set;23(3):389-95. has counted with the participation of several areas of the Ministry of Health and other sectors, in cooperation with the Global⁵5. World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013 [cited 2014 Oct 20]. Available from: Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... and Regional⁶6. Organização Pan Americana de Saúde. Plano Estratégico da Organização Pan Americana de Saúde, 2014-2019. Washington: Organização Pan Americana de Saúde; 2014. Plans for Tackling NCDs. Among the monitoring actions, the progress in NCDs and their risk factors surveillance, and the strategic importance of the National Health Survey - PNS -⁵5. World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013 [cited 2014 Oct 20]. Available from: Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... are noteworthy.

It is important to highlight the actions of Pillars II and III, for health promotion, disease prevention, strengthening of primary health care, coordination of services and emergency networks in order to expand NCDs approach to address the various levels of care, and seek the longitudinal monitoring of patients with these diseases, and under the responsibility of health services and professionals.

The actions to implement the NCDs Plan developed by the Ministry of Health between 2011 and 2015, according to this analysis, have shown promising results and advances. Data of VIGITEL 2014, PNS and SIM point out that most of the targets are in a good rhythm to be completed by 2022, for instance: reduction of premature mortality (30-69 years) due to NCDs; reduction in tobacco consumption and regular consumption of soft drinks; higher consumption of fruits and vegetables, more physical activity practice and higher mammography coverage. However, the targets not met refer to Pap smear tests, which presented stability, and obesity, which increased among adults, but has not been measured again in children and adolescents.⁹9. Malta DC, Silva JB. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil após três anos de implantação, 2011-2013. Epidemiol Serv Saude. 2014 jul-set;23(3):389-95.^,1010. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2014: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2015.

It is necessary to keep the focus, even on the right track targets, expanding the actions implemented and reviewing strategies in the case of targets that have not yet presented any progress.The actions of the Plan are aligned with the National Policy on Health Promotion,²⁹29. Brasil. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2014 nov 13;Seção 1:68. the Primary Health Care Policy³⁷37. Brasil. Ministério da Saúde. Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da República Federativa do Brasil, Brasília (DF), 2011 out 24; Seção 1:48. and other policies of the Ministry of Health, as the National Health Plan38 and the Strategic Plan of the Ministry of Health,³⁹39. Ministério da Saúde (BR). Secretaria-Executiva. Departamento de Monitoramento e Avaliação do SUS. Planejamento estratégico do Ministério da Saúde 2011- 2015: resultados e perspectivas. Brasília: Ministério da Saúde; 2013. through the Strategic Goal 6 (OE 6), which gives priority to comprehensive care for NCDs and to the elderly.³⁹39. Ministério da Saúde (BR). Secretaria-Executiva. Departamento de Monitoramento e Avaliação do SUS. Planejamento estratégico do Ministério da Saúde 2011- 2015: resultados e perspectivas. Brasília: Ministério da Saúde; 2013. All the Secretariats of the Ministry, other areas and regulatory agencies of Health have worked together, with specific tasks and integrated monitoring and are accompanied by the monitoring system of the Executive Secretariat (e-Car). The State and Municipal Health Departments launched state and capital cities plans specific to tackling NCDs. In 2012, the Secretariat of Health Surveillance/Ministry of Health held financial transfers for the implementation of state and capital cities plans.⁴⁰40. Brasil. Ministério da Saúde. Portaria nº 23, de 9 de agosto de 2012. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2012 ago 10; Seção 1:43.

It is important to progress in the actions of integration and articulation of sectors in order to mobilize and make the NCDs a cross-sectional topic for organizing services, and the Health sector, in general. The challenges and limitations related to intersectoral activities that seek to fulfill the Strategic Action Plan for Tackling Chronic Non-communicable Diseases in Brazil, 2011-2022, will be minimized with the joint involvement of civil society, health authorities, universities, Health Councils, NGOs and SUS users. The participation of the civil society is vital so this agenda can become a priority. The monitoring of the goals should be broad and transparent, and accompanied by a large discussion involving the data released by the PNS¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014 [citado 2014 dez 22]. Disponível em: Disponível em: http://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
http://ftp.ibge.gov.br/PNS/2013/pns2013.... ^,1212. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde [Internet]. Brasília: Ministério da Saúde; 2014 [citado 2015 dez 1]. Disponível em: http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/leia-mais-o-ministerio/673-secretaria-svs/vigilancia-de-a-a-z/doencas-cronicas-nao-transmissiveis/l2-doencas-cronicas-nao-transmissiveis/14127-pesquisa-nacional-de-saude-pns
http://portalsaude.saude.gov.br/index.ph... on health status and risk behavior and protection, in order to implement policies for the reduction of these diseases and the consequent improvement of the population's life quality.⁸8. Malta DC, Silva JB. O Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiol Serv Saude. 2013 jan-mar;22(1):151-64.^,99. Malta DC, Silva JB. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil após três anos de implantação, 2011-2013. Epidemiol Serv Saude. 2014 jul-set;23(3):389-95.

NCDs have gained priority and assumed leadership in global agendas. However, many challenges remain for the development of effective policies. We can highlight the need for further advances in regulatory and legal measures, especially related to alcohol and food, bearing in mind the successful example of such measures to reduce tobacco use.

Partnerships between different sectors are also essential in supporting NCDs prevention actions, not only in attracting financial resources and capacity strengthen, but also in researches and defending prevention and control actions for non-communicable diseases. In the approach of NCDs, besides the necessary organization of Public Health to ensure surveillance, health promotion, prevention and assistance to the patient, it is essential to articulate intersectoral actions and, especially, to engage in reducing inequalities and disparities in health. Finally, the alignment and coordination of public policies for dealing with chronic non-communicable diseases, settled in integrated and cooperative actions is of highly importance^.4141. Malta DC, Gosch CS, Buss GP, Rocha DG, Rezende R, Freitas PC, et al. Doenças crônicas não transmissíveis e o suporte das ações intersetoriais no seu enfrentamento. Cienc Saude Coletiva. 2014 nov;19(11):4341-50.^,4242. Shankardass K, Solar O, Murphy K, Greaves L, O'Campo P. A scoping review of intersectoral action for health equity involving governments. Int J Public Health. 2012 Feb;57(1):25-33.

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