Health Promotion

in Brazil

Paulo Marchiori BussPresident of Fiocruz

Conference at the

1st Brazilian Seminar on Health Promotion Effectiveness

Rio de Janeiro, May 10th 2005

THE LAST 35 YEARS OF

HEALTH PROMOTION (1970 – 2005) - I

• 70’s – Health Systems crisis: Ineffectiveness, inequities and credibility crisis vis-a-vis the demographic-epidemiological transition: ageing, change in nosologic patterns, medicalization, technological development and the boom of costs and expenses.

• New concepts of health-disease-care process, more globalizing, linking health and quality of life.

• Lalonde Report (1974) – Health field: Human biology, environment, lifestyle and health service organization.

“Until now, most of society’s efforts to improve health, and the bulk of direct health expenditures, has been focused on the health care organization. Yet, when we identify the main cause of sickness and death, we find that they are rooted in the other three elements of the concept.” (A New Perspective on the Health of Canadians)

THE LAST 35 YEARS OF

HEALTH PROMOTION (1970 – 2005) - II

• Health for All by the Year 2000 (1977) – 30th World Health Assembly

• International Conference on Primary Health Care (1978)Declaration of Alma Ata

Eight essential points to achieve health for all:• education on prevailing health problems, prevention and control• promotion of food supply and proper nutrition• adequate supply of safe water and basic sanitation• maternal and child health care, including family planning.• immunization against the major infectious diseases• prevention and control of locally endemic diseases • appropriate treatment of common diseases and injuries• provision of essential drugs

THE LAST 35 YEARS OF

HEALTH PROMOTION (1970 – 2005) - III

• 1986 – Ottawa Charter for Health Promotion 1st International Conference on Health Promotion (Canada)

• 1988 – Adelaide Recommendations on Healthy Public Policy 2nd International Conference on Health Promotion (Australia)

• 1991 – Sundsvall Statement on Supportive Environments for Health 3rd International Conference on Health Promotion (Sweden)

• 1993 – Caribbean Charter for Health Promotion

1st Caribbean Conference of Health Promotion (Trinidad y Tobago)

• 1997 – The Jakarta Declaration on Health Promotion into the 21st Century

4th International Conference on Health Promotion (Jakarta)

• 2000 – 5th Global Health Promotion Conference (Mexico)

THE LAST 35 YEARS OF

HEALTH PROMOTION (1970 – 2005) - IV

THE UN “PREPARES” THE WORLD FOR THE 21st CENTURY

• 1990 – UN World Summit for Children (New York)

• 1992 – UN Conference on Environment and Development (Rio de Janeiro)

• 1993 – UN World Conference on Human Rights (Vienna)

• 1994 – International Conference on Population and Development (Cairo)

• 1995 – UN 4th World Conference on Women (Beijing)

• 1995 – World Summit for Social Development (Copenhagen)

• 1996 – Second UN Conference on Human Settlements (Habitat II) (Istanbul)

• 1996 – World Food Summit (Roma)

• 2004 – Millenium Development Goals ( U.N. - New York)

HEALTH PROMOTION

HISTORICAL LANDMARKS IN BRAZIL - I

70’s

Criticism on assistance-based model (focused solely on medical care and hospitals)

Social Medicine and the emergence of social sciences in the analysis of problems and health interventions

O Dilema Preventivista (The Preventivist Dilemma) (Sérgio Arouca, 1975)Community Projects and primary care (Montes Claros and Niterói)

ENSP renewal: PESES-PEPPE [Program for Social and Economic Studies & Program for Population Studies and Epidemiological Research].

CEBES [Brazilian Center of Health Studies] (1976)

ABRASCO [Brazilian Association of Graduation in Collective Health] (1979)

HEALTH PROMOTION

HISTORICAL LANDMARKS IN BRAZIL - II

80’s

Fight for Brazil’s redemocratization: 1985, New Republic

Sanitary Reform Movement

1986 – VIII National Health Conference: extensive participation of public health and of community.

Reinforcing principles on health promotion (without this particular label) and the social determination of the health and disease process as well as its intersectoral relations (again, without this label).

1986-1988 – New constitution developed with extensive participation of the

school of thought and political action of the Sanitary Reform Movement.

In 1988, the Federal Constitution was rectified with the health promotion approach.

HEALTH PROMOTION

FEDERAL CONSTITUTION - THE SUS ACT

Ottawa Charter: 1986; VIII National Health Conference: 1986; Federal Constitution: 1988; SUS Acts (8.080 e 8.142): 1990

Article 196: “Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and at the universal and equal access to actions and services for its promotion, protection and recovery”

Act 8.080 (article 2): “Health determinants are, among others, food, basic sanitation, the environment, labor, income, education, transportation, leisure and the access to consumer goods and social services; the health levels of the population reflect the social and economic organization of the country.” (§ 3)

Among the directives are (article 198):Comprehensive health care Community participation

FEDERAL CONSTITUTION - THE SUS ACT

• Universal Access

• Gratuity

• Comprehensiveness: promotion, prevention, care and reabilitation; pharmaceutic assistance

• Descentralization

• Unified direction in each sphere of government

• Social Control

• Public Financing

• Complementary participation of the private iniciative: mix public/private for the delivery of services

• Regulation: ANVISA; ANS

SUS – SOCIAL CONTROL

• National, State and Municipal Health Councils

• Equal Composition: State – Society

• Approval of Health Policies and Plans

• Regular funcioning with varied effectivity

• National Conferences

• National and other levels: every 4 years, also with equal composition

HEALTH PROMOTION

HISTORICAL LANDMARKS IN BRAZIL - III

90’s

• Development of Health Councils at municipal, state and federal levels: formal social control; equal number of members(State and civilian); intersectorial representation

• 1992 – Earth Summit (Rio 92): Agenda 21

• 1995 – National Health and Environment Plan in Sustainable Development, following Pan-American Conference on the subject. Plan was not carried out.

• 1995 – Community Health Aides Program; Family Health Program

• 1998 – Agreement btw ENSP/FIOCRUZ - ABRASCO - CPHA/CIDA

ORGANIZATION OF HEALTH SERVICE

“Family Health” is a strategy for organization and strengthening of basic care as the level of care in

the Unified Health System (SUS)

It aims at strengthening care by expanding access, qualifying and reorienting health

practices based on Health Promotion

STRATEGIC PRINCIPLES

OF FAMILY HEALTH

ENROLLMENT OF CLIENTELEPrecise definition of covered area

TERRITORY DEMARCATIONArea mapping, involving environment and population

HEALTH SITUATION OF THE POPULATIONSurvey of families and individuals, generating data for the

analysis of health situation in the area

LOCAL PLANNINGProgramming activities based on health risk,

prioritizing problem solving

HEALTH PROMOTION

WORK PROCESS CHARACTERISTICS IN FAMILY HEALTH - I

INTERDISCIPLINARITY

Interdisciplinary work, integrating technical and professional areas of different educational orientations

INVOLVEMENT

Participation on the social dynamics of assisted families and of the community itself

CULTURAL COMPETENCE

Valuing different knowledge and practices on a comprehensive and resolutive approach, leading to trust, with ethics, commitment and

respect

HEALTH PROMOTION

WORK PROCESS CHARACTERISTICS IN FAMILY HEALTH - II

COMPREHENSIVINESS

Integral, continuous and organized care to the enrolled clientele, assuring access to complementary resources

SOCIAL PARTICIPATION

Community involvement in the planning, execution and evaluation

INTERSECTORIALITY

Intersectoral work, linking together social projects and related sectors oriented to health promotion

STRENGTHENING LOCAL MANAGEMENT

Supporting strategies to reinforce local management

FAMILY HEALTH

Team composition:•Physician

•Nurse•Nurse auxiliary

•Community health aides•Dentist

•Dental assistant•Dental higienist

HEALTH PROMOTION

Examples of federal programs and actions - I

• Family Health Strategy in Basic Care Reorganization of basic care, entrusting new families to multi-professional

teams and taking comprehensive actions on promotion, prevention and care

• Community Health Agents A part of the Family Health Program; in certain places, they work by

themselves, taking actions on promotion and prevention

• Family Stipend Program and Minimum Income ProgramUse of federal resources to increase family income in order to provide better access to food and to improve families’ health and nutrition conditions, as well as basic education

HEALTH PROMOTION

Examples of federal programs and actions - II

•Breastfeeding

•Friendly Postman Action to encourage and promote breastfeeding. Postmen disseminate information door-to-door.

•Child Friendly Hospital Iniciative Around 230 hospitals throughout the country encouraging and promoting breastfeeding in nursery rooms and among mothers of hospitalized children

•National Policy on Food and Nutrition To include micronutrients: Iron & folic acid in flour; iodine in salt (federal laws)

•Human Milk Bank National Network (IFF/FIOCRUZ) 180 units

HEALTH PROMOTION

Examples of federal programs and actions - III

• Program of Education and Health through Physical Activity and Sport

Action Brazil Centers (“Agita Brasil”)

• National Program of Immunization (PNI)

Vaccines: BCG, Polio, DTP-Hib, MMR, Yellow Fever Vaccine, Influenza

Vaccine (for adults). Future: Rotavirus Vaccine and 7-Pneumococcus

Vaccine

• Program to Humanize Prenatal Care and Childbirth

Improving access to and quality of prenatal care, as well as, assistance to

childbirth and puerperium and newborn, including health promotion

practices; civil registration

HEALTH PROMOTION

Examples of federal programs and actions - IV

•National Program for Cervix Uteri and Breast Cancers Control Education, early diagnosis (Pap smear and breast self-examination) and treatment

•National Program for Smoking Control and Other Cancer Risk Factor Professionals trained in more than 3,000 municipalities in Brazil: schools, corporations and local communities.

Intersectoral actions: Product registry; Sales prohibited for children and adolescents; Publicity restricted in the media;

Regulation of maximum levels of tar, nicotine and CO; Warnings in cigarette packs ;Smoking prohibited in public buildings and aircrafts; Cigarette free schools, work environments and health units

HEALTH PROMOTION

Examples of federal programs and actions - V

• Health Promoting SchoolsWHO/PAHO program: incipient actions throughout the country

• Adolescent Health Program The Adolescent Health Program is aimed at all youths between 10 and 19

years of age and is characterized by its comprehensiveness and focus on prevention and education

• School Health Program Educational videos to be broadcasted on School TV (TV Escola), a TV

channel of the Ministry of Education

• Alcohol Control Advertisement restriction; sales prohibition for under 18

HEALTH PROMOTION

Other actions

• Brazilian Network of Healthy Municipalities

• Healthy communities: Integrated and Sustainable Local Development – DLIS - Manguinhos

• Health-related messages on soap operas

• Social support groups: Alcoholics, obese, smokers, pregnant women, breastfeeders, handicapped

• Traffic Law: extra-sectoral initiative, large impact on morbidity and mortality, safety belt

• Gun Control

HEALTHY PUBLIC POLICIES

PRIORITIES IN RECENT SCENARIOS IN BRAZIL

Morbidity and mortality burdens as well as the present social and economic situation, indicate the best public policies related to health promotion today in Brazil:

• Housing

• Basic Sanitation: water, sewage systems and solid waste • Food safety; food and nutrition policies

• Education: illiteracy; universalization of basic education

• Minimum income through the Family Stipend Program

THANK YOU