From the mid-twentieth century, several changes took place in global demographic, nutritional and epidemiological patterns.¹1. Santosa A, Wall S, Fottrell E, Högberg U, Byass P. The development and experience of epidemiological transition theory over four decades: a systematic review. Glob Health Action. 2014 may;15(7): 23574. The processes of social and economic development, improvements in environmental conditions and public health, and advances in medicine and health care contributed to the sharp drop in the fertility rate, to a marked reduction in infant and childhood mortality, and to the increase in life expectancy.²2. GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396(10258): 1160-203. With the ageing of the global population and changes in the morbidity and mortality profile, noncommunicable diseases (NCDs) have become the most relevant health problem in most countries.³3. Saha A, Alleyne G. Recognizing noncommunicable diseases as a global health security threat. Bull World Health Organ. 2018 Nov 1; 96(11): 792-793.

In view of the acknowledgment that the risk of developing a NCD can be significantly reduced through the adoption of public policies that support better living and health conditions, some strategies were established in order to increase people's quality of life and, thereby, improve the health of populations.⁴4. Atallah N, Adjibade M, Lelong H, Hercberg S, Galan P, Assmann KE, et al. How Healthy Lifestyle Factors at Midlife Relate to Healthy Aging. Nutrients. 2018; 10(7): 854. As part of the Sustainable Development Goals (SDGs), most public health actions have focused on health promotion, encouraging healthy behaviors and the reduction of risk factors.⁵5. Fortune K, Becerra-Posada F, Buss P, Galvão LAC, Contreras A, Murphy M, et al. Health promotion and the agenda for sustainable development, WHO Region of the Americas. Bull World Health Organ. 2018; 96(9): 621-26. Delaying the onset of complications and disabilities through early detection and providing quality care to alleviate the severity of chronic problems have also been considered fundamental strategies.⁶6. Fisher M, Freeman T, Mackean T, Friel S, Baum F. Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare. Int J Health Policy Manag. 2022; 11(5); 690-700. doi: 10.34172/IJHPM.2020.232
https://doi.org/10.34172/IJHPM.2020.232...

In Brazil, NCDs have accounted for a high number of deaths before the age of 70 and loss of quality of life with ageing, generating disabilities and a high degree of limitation in work and leisure activities. National studies based on data from 1990 to 2017 indicate that NCDs are responsible for more than 70% of deaths and a large proportion of unhealthy life years.⁷7. Azeredo Passos VM de, Champs APS, Teixeira R, Lima-Costa MFF, Kirkwood R, Veras R, et al. The burden of disease among Brazilian older adults and the challenge for health policies: results of the Global Burden of Disease Study 2017. Popul Health Metr. 2020; 18(Suppl 1): 14.^,88. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MS, et al. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metr. 2020 Sep 30; 18(Suppl 1): 16. The expansion of primary care throughout the national territory and the National Policy for Health Promotion (PNPS), introduced in the mid-2000s, were milestones in the implementation of actions related to the control of arterial hypertension and diabetes, and to the prevention of NCDs, by means of strategies aimed at promoting physical activity, healthy eating habits, weight control, and at preventing smoking and alcohol abuse.⁹9. Buss PM, Hartz ZMA, Pinto LF, Rocha CMF. Health promotion and quality of life: a historical perspective of the last two 40 years (1980-2020). Cien Saude Colet. 2020; 25(12): 4723-35.

In this context, it is relevant and opportune to discuss the implementation of NCDs surveillance in Brazil and at subnational levels.

Surveillance of non-communicable diseases in Brazil

Aiming to monitor the magnitude and spatio-temporal distribution of NCDs, associated risk factors and the health care provided to the chronically ill, in order to support management, NCDs surveillance is carried out by means of secondary data from health information systems and primary data collected in health surveys.¹⁰10. Malta DC, Silva MMAD, Moura L, Morais OL Neto. The implantation of the Surveillance System for Non-communicable Diseases in Brazil, 2003 to 2015: successes and challenges. Rev Bras Epidemiol. 2017 Oct-Dec; 20(4): 661-675.

Among such information systems, the following stand out: the Hospital Information System of the Brazilian National Health System (SIH-SUS), which contains data on diagnoses and hospital admission expenses,¹¹11. Santos MAS, Oliveira MM, Andrade SSCA, Nunes ML, Malta DC, Moura L. Tendências da morbidade hospitalar por doenças crônicas não transmissíveis no Brasil, 2002 a 2012. Epidem. Serv. Saude, 2015; 24(3), 389-398. and the Mortality Information System (SIM), which collects information on deaths in all Brazilian municipalities and allows monitoring premature mortality due to NCDs.¹²12. Cardoso LSM, Teixeira RA, Ribeiro ALP, Malta DC. Premature mortality due to non-communicable diseases in Brazilian municipalities estimated for the three-year periods of 2010 to 2012 and 2015 to 2017. Rev Bras Epidemiol. 2021; 24(suppl 1): e210005. A survey carried out by the Health Surveillance Secretariat of the Ministry of Health (SVS/MS), in 2018,¹³13. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Panorama da vigilância das doenças crônicas no Brasil, 2018. Boletim Epidemiológico. 2019 Dez; 50(40). aimed to identify the existing structure, as well as the development of NCDs epidemiological surveillance actions in state and municipal health secretariats in the state capitals (SES and SMS Capitals), found that the main sources of information for NCDs surveillance were SIM and SIH, in line with a previous study.¹⁴14. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. A vigilância, o controle e a prevenção das doenças crônicas não transmissíveis: DCNTs no contexto do Sistema Único de Saúde brasileiro. Brasília: Ministério da Saúde; 2005. Both systems are essential for the surveillance of NCDs, as they provide an overview of the epidemiological situation of deaths and hospitalizations in the Brazilian population. Although there are differences in coverage and quality of information, the analysis of data arising from these systems can support interventions at different levels of geographic disaggregation (federal, state and municipal).¹⁵15. Ministério da Saúde (BR). A experiência brasileira em sistemas de informação em saúde. Brasília: Ministério da Saúde, 2009.

However, in order to strengthen the surveillance of NCDs, besides the need to invest in improving the coverage and quality of secondary data related to hospital mortality and morbidity, it is necessary to encourage the conduction of frequent and regular health surveys that enable monitoring the prevalence of NCDs, the adoption of healthy behaviors and the reduction of habits that are harmful to health, as well as the adequacy of health care from the perspective of the user.¹⁶16. Szwarcwald CL, Malta DC, Pereira CA, Vieira ML, Conde WL, Souza Júnior PR, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação [National Health Survey in Brazil: design and methodology of application]. Cien Saude Colet. 2014 Feb; 19(2): 333-42.

Brazilian national health surveys

Among the surveys conducted by the Ministry of Health in terms of the surveillance of NCDs, which support the monitoring of the 2011-2022 Strategic Action Plan for Addressing Chronic Noncommunicable Diseases (NCDs) in Brazil, and the responses to the Regional¹⁷17. Organización Panamericana de la Salud. Enfermedades no transmisibles en las Américas: construyamos un futuro más saludable. Washington, DC: OPS; 2011. and Global¹⁸18. World Health Organization (WHO). Global action plan for the prevention and control of noncommunicable diseases 2013-2020.Geneva: WHO; 2013. Plans, as well as the SDGs,¹⁹19. Organização das Nações Unidas. Objetivos de Desenvolvimento Sustentável [Internet]. 2021. Brasília: Organização das Nações Unidas. [acesso em 19 out 2021]. Disponível em: https://brasil.un.org/pt-br/sdgs
https://brasil.un.org/pt-br/sdgs... the following stand out: the Chronic Disease Risk and Protective Factors Surveillance Telephone Survey (VIGITEL), the National Adolescent School-based Health Survey (PeNSE) and the National Health Survey (PNS).

VIGITEL, the most sustainable health survey in the country, presents the evolution of important life habits of Brazilian adults living in the capitals and was essential in monitoring the goals set by managers from different areas of the Ministry of Health and other entities of the federation over the past two decades.²⁰20. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2020. PeNSe, carried out in partnership with the Brazilian Institute of Geography and Statistics (IBGE), investigates the risk and protection factors for NCDs in schoolchildren aged 13 to 17 years and makes it possible for the education and health sectors to articulate actions directed to this group.²¹22 21. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016.

The PNS, the subject of this special edition of the journal Epidemiologia e Serviços de Saúde (RESS), is the largest health survey ever carried out in Brazil and provides a portrait of the living and health conditions of the country residents.²²23 22. Instituto Brasileiro de Geografia e Estatística - IBGE. Pesquisa Nacional de Saúde 2019: Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020. Its design, specifically elaborated to provide estimates of health indicators and to enable analyses at various geographic levels and according to socioeconomic and demographic characteristics of individuals, makes it possible to establish health priorities that are relevant for management.²³24 23. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude. 2020 Oct 5; 29(5): e2020315. Information from the two editions of the PNS, carried out in 2013 and 2019, provide an overview of the main NCDs and their associated risk factors in Brazil and bring important elements to support the surveillance of NCDs.

The PNS data are available to the public, and prior authorization to use the information is not required. The health indicators, selected by the Ministry of Health as being the most important for management, are available on the IBGE website (https://bit.ly/38DaRNd), for Brazil, large regions, Units of the Federation, state capitals, rural/urban area of residence and according to the sociodemographic characteristics of Brazilians.²⁴25 24. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde [Internet]. 2021. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística. [acesso em 27 out 2021]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas/soc... Additionally, in order to expand access to information and health indicators, Fundação Oswaldo Cruz (Fiocruz), through the Institute of Scientific and Technological Communication and Information in Health and in partnership with SVS/MS, created a panel with data from the two editions of the PNS, available at https://www.pns.icict.fiocruz.br.²⁵26 25. Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. Pesquisa Nacional de Saúde [Internet]. 2021. Rio de Janeiro: Fundação Oswaldo Cruz. [acesso em 16 de outubro de 2021]. Disponível em: https://www.pns.icict.fiocruz.br/painel-de-indicadores-mobile-desktop/
https://www.pns.icict.fiocruz.br/painel-... It is possible to access and download the estimates of several indicators, view them in tables, graphs or maps, for all the socioeconomic and geographic disaggregation established for both of the PNS.

It is understood that it would be of great importance for this strategy to be extended to other surveys conducted by the Ministry of Health, in order to facilitate and expand the use of information available to health managers and staff so that they can be used in a timely manner in the (re)direction of actions to tackle NCDs.

A challenge that still needs to be faced in Brazil is obtaining reliable information about NCDs and their risk factors within the scope of the SUS Information Systems, and which can be accessible to health managers and workers. In these terms, the e-SUS strategy²⁵26 25. Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. Pesquisa Nacional de Saúde [Internet]. 2021. Rio de Janeiro: Fundação Oswaldo Cruz. [acesso em 16 de outubro de 2021]. Disponível em: https://www.pns.icict.fiocruz.br/painel-de-indicadores-mobile-desktop/
https://www.pns.icict.fiocruz.br/painel-... is a possibility, as it encompasses data from the Primary Care Registry, whose function, in turn, is to aggregate socioeconomic and health characteristics of the population of a given territory, including aspects of interest for the surveillance of NCDs,²⁶27 26. Ministério da Saúde (BR). e-SUS Atenção Primária à Saúde (e-SUS APS). Brasília: Ministério da Saúde, 2021. mainly at levels of disaggregation that will not be represented in national surveys. However, it is known that there are difficulties, especially for SES and SMS NCDs surveillance workers, in using information solely from this system, since part of its access is controlled and restricted.²⁶27 26. Ministério da Saúde (BR). e-SUS Atenção Primária à Saúde (e-SUS APS). Brasília: Ministério da Saúde, 2021. In fact, a survey carried out by the SVS/MS pointed to low use of the e-SUS to carry out surveillance of NCDs.¹³13. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Panorama da vigilância das doenças crônicas no Brasil, 2018. Boletim Epidemiológico. 2019 Dez; 50(40).

However, it is not just information gaps that interfere with NCDs surveillance at subnational levels. In 2018, more than 20% of SES or SMS Capitals did not have the NCDs surveillance area incorporated into their institutional organizational charts; the average number of professionals involved in the composition of surveillance was six for SES and three for SMS Capitals.¹³13. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Panorama da vigilância das doenças crônicas no Brasil, 2018. Boletim Epidemiológico. 2019 Dez; 50(40). The situation of smaller municipalities must probably be even more precarious.

Conducting large health surveys, such as those briefly presented here, is a difficult task. It takes time to plan, besides the engagement of various areas of the Ministry of Health for its execution and funding, collaboration of researchers and articulation between bodies and academic institutions. Given that NCDs continue to be the main causes of premature mortality in the country, ensuring the sustainability and periodicity of research that encourage discussion and review of policies to control NCDs should be a priority for SUS. Additionally, to activate and improve the surveillance of NCDs at different geographic levels, it is necessary for the Ministry of Health to guide its SES and SMS Capital counterparts on the use of available information, so that the instrumentalization of management is based on scientific evidence.

References

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