0164/2023 - CONSTRANGIMENTOS E INCENTIVOS FINANCEIROS PARA A PREVENÇÃO E CONTROLE DA OBESIDADE NO ESTADO DO RIO DE JANEIRO
CONSTRANGIMENTOS E INCENTIVOS FINANCEIROS PARA A PREVENÇÃO E CONTROLE DA OBESIDADE NO ESTADO DO RIO DE JANEIRO
Autor:
• Matheus Pereira Freitas - Freitas, M.P - <freitasmatheusp@gmail.com>ORCID: https://orcid.org/0000-0002-3052-9381
Coautor(es):
• Luciene Burlandy - Burlandy , L - <burlandy@uol.com.br>ORCID: https://orcid.org/0000-0003-0875-6374
• Luciana Cerqueira Castro - Castro, L.C - <lmccastro54@gmail.com>
ORCID: https://orcid.org/0000-0003-2793-9950
• Cláudia Roberta Bocca Santos - Santos, C.R.B - <claudia.santos@unirio.br>
ORCID: https://orcid.org/0000-0002-4312-3049
• katiana dos Santos Teléfora - Teléfora, K.S - <katianatelefora@gmail.com>
ORCID: https://orcid.org/0000-0003-0655-7363
• Myrian Coelho Cunha da Cruz - Cruz, M.C.C - <myrianccruz@gmail.com>
ORCID: https://orcid.org/0000-0002-6945-4890
• Márcia Regina Mazalotti Teixeira - Teixeira, M.R.M - <marciartx@gmail.com>
ORCID: https://orcid.org/0000-0002-3528-5814
Resumo:
O estudo analisou como as inflexões político-econômicas de financiamento e de estruturação do Sistema Único de Saúde podem ter afetado as condições de implementação de ações de Prevenção e Controle da Obesidade na Atenção Primária à saúde (APS) no Estado do Rio de Janeiro (ERJ) entre 2014 e 2021. Fundamentou-se em referenciais de análise de políticas considerando o contexto de implementação, antecedentes históricos, mecanismos de indução e incentivos governamentais para o desenvolvimento das ações de PCO. Baseou-se em dois projetos realizados nos 92 municípios do ERJ entre 2014 e 2018 (PPSUS-ERJ) e 2019-2021 (PEO-ERJ) pautados em análise documental, entrevistas e grupos focais com profissionais e gestores da APS. Resultados: até 2016 percebe-se os impactos positivos da estruturação da APS e dos mecanismos de indução federais. No entanto, as inflexões na expansão e financiamento da APS contribuíram para o enfraquecimento de unidades, equipes e estratégias, além de uma retração de recursos para as ações estaduais e municipais. Entre 2016-2018 a crise política e financeira do ERJ foi potencializada pelas crises nacionais e os contrapontos positivos desde então foram os mecanismos de indução e recursos federais que permaneceram, além das áreas técnicas da SES-ERJ e do co-financiamento estadual.Palavras-chave:
Políticas Públicas; Obesidade; Atenção Primária à SaúdeAbstract:
Obesity is one of the main global public health problems that can be affected by federal policies and the Rio de Janeiro State Health Department (RJS-HD) has encouraged, mainly since 2012, actions for the Prevention and Control of Obesity (OCP) in the municipalities of the RJS. Ever since, there have been political inflections-promotion, financing and structuring of the Unified Health System (Sistema Único de Saúde, SUS) and the objective of the study was to analyze how these changes, national and state, can affect the conditions of implementation of OCP actions in Primary Health Care (Atenção Primária à Saúde, APS) in the RJS between 2014 and 2021. It was based on policy analysis methods that emphasize the understanding of the implementation contexts and the mechanisms of induction and government incentives for the development of actions and integration of two projects that analyzed the actions of prevention and control of obesity in APS in 92 municipalities of the RJS between 2014 and 2018 (PPSUS-ERJ) and between 2019-2021 (PEO-ERJ). The results indicate that by 2016 the positive impacts of the structuring of the APS and the federal induction mechanisms can be seen in the RJS. However, as inflections in the expansion and financing of the APS contributed to the weakening of units, teams and levels of RJS level, in addition to a retraction of resources for state and municipal actions. Between 2016-2018, the RJS’s crisis and financial policy was enhanced by national crises and the positive counterpoints since then were the induction mechanisms and federal resources that remained, in addition to the technical areas of the HD-RJS and state co-financing resources.Keywords:
Health Policy; Obesity; Primary Health Care;Conteúdo:
Acessar Revista no ScieloOutros idiomas:
CONSTRANGIMENTOS E INCENTIVOS FINANCEIROS PARA A PREVENÇÃO E CONTROLE DA OBESIDADE NO ESTADO DO RIO DE JANEIRO
Resumo (abstract):
Obesity is one of the main global public health problems that can be affected by federal policies and the Rio de Janeiro State Health Department (RJS-HD) has encouraged, mainly since 2012, actions for the Prevention and Control of Obesity (OCP) in the municipalities of the RJS. Ever since, there have been political inflections-promotion, financing and structuring of the Unified Health System (Sistema Único de Saúde, SUS) and the objective of the study was to analyze how these changes, national and state, can affect the conditions of implementation of OCP actions in Primary Health Care (Atenção Primária à Saúde, APS) in the RJS between 2014 and 2021. It was based on policy analysis methods that emphasize the understanding of the implementation contexts and the mechanisms of induction and government incentives for the development of actions and integration of two projects that analyzed the actions of prevention and control of obesity in APS in 92 municipalities of the RJS between 2014 and 2018 (PPSUS-ERJ) and between 2019-2021 (PEO-ERJ). The results indicate that by 2016 the positive impacts of the structuring of the APS and the federal induction mechanisms can be seen in the RJS. However, as inflections in the expansion and financing of the APS contributed to the weakening of units, teams and levels of RJS level, in addition to a retraction of resources for state and municipal actions. Between 2016-2018, the RJS’s crisis and financial policy was enhanced by national crises and the positive counterpoints since then were the induction mechanisms and federal resources that remained, in addition to the technical areas of the HD-RJS and state co-financing resources.Palavras-chave (keywords):
Health Policy; Obesity; Primary Health Care;Ler versão inglês (english version)
Conteúdo (article):
FINANCIAL CONSTRAINTS AND INCENTIVES FOR THE PREVENTION AND CONTROL OF OBESITY IN THE STATE OF RIO DE JANEIROAuthor:
• Matheus Pereira Freitas - Freitas, M.P -
ORCID: https://orcid.org/0000-0002-3052-9381
Co-author(s):
• Luciene Burlandy - Burlandy , L -
ORCID: https://orcid.org/0000-0003-0875-6374
• Luciana Cerqueira Castro - Castro, L.C -
• Cláudia Roberta Bocca Santos - Santos, C.R.B -
ORCID: Claudia Roberta Bocca
• katiana dos Santos Teléfora - Teléfora, K.S -
ORCID: https://orcid.org/0000-0003-0655-7363
• Myrian Coelho Cunha da Cruz - Cruz, M.C.C -
ORCID: https://orcid.org/0000-0002-6945-4890
• Márcia Regina Mazalotti Teixeira - Teixeira, M.R.M -
Resumo:
O estudo analisou como as inflexões político-econômicas de financiamento e de estruturação do Sistema Único de Saúde podem ter afetado as condições de implementação de ações de Prevenção e Controle da Obesidade na Atenção Primária à saúde (APS) no Estado do Rio de Janeiro (RJS) entre 2014 e 2021. Fundamentou-se em referenciais de análise de políticas considerando o contexto de implementação, antecedentes históricos, mecanismos de indução e incentivos governamentais para o desenvolvimento das ações de OPC. Baseou-se em dois projetos realizados nos 92 municípios do RJS entre 2014 e 2018 (PPSUS-RJS) e 2019-2021 (PEO-RJS) pautados em análise documental, entrevistas e grupos focais com profissionais e gestores da APS. Resultados: até 2016 percebe-se os impactos positivos da estruturação da APS e dos mecanismos de indução federais. No entanto, as inflexões na expansão e financiamento da APS contribuíram para o enfraquecimento de unidades, equipes e estratégias, além de uma retração de recursos para as ações estaduais e municipais. Entre 2016-2018 a crise política e financeira do RJS foi potencializada pelas crises nacionais e os contrapontos positivos desde então foram os mecanismos de indução e recursos federais que permaneceram, além das áreas técnicas da SES-RJS e do co-financiamento estadual.
Palavras-chave: Políticas Públicas; Obesidade; Atenção Primária à Saúde
Abstract:
Obesity is one of the main global public health problems that can be affected by federal policies, and the Rio de Janeiro State Health Department (RJS-HD) mostly since 2012, has encouraged actions for Obesity Prevention and Control(OCP) in the municipalities of the state of Rio de Janeiro (RJS). Since then, there have been political inflections-promotion, funding, and structuring of the Unified Health System (SUS). Thus, the present study aimed to analyze how these changes, both at the national and state levels, could affect the conditions of the implementation of OCP actions in Primary Health Care (PHC) in RJS from 2014 to 2021. This study was based on policy analysis methods that emphasize the understanding of the implementation contexts, as well as the induction mechanisms and government incentives for the development of actions and integration of two projects that analyzed the OPC actions in PHC in the 92 municipalities of RJS between 2014 and 2018 (PPSUS-RJS) and between 2019 and 2021 (PEO-RJS). The results indicate that, by 2016, it was possible to observe the positive impacts of the structuring of PHC and the federal induction mechanisms in RJS. However, inflections in the expansion and funding of PHC contributed to the weakening of units, teams, and strategies, and led to retraction of resources for both state and municipal actions. Between 2016-2018, RJS’s political and financial scenario deteriorated due to national crises, and the positive counterpoints since then were the induction mechanisms and federal resources that remained, in addition to the technical areas of the RJS-HD and state co-financing resources.
Keywords: Health Policy; Obesity; Primary Health Care;
Content:
1. INTRODUCTION
Obesity is one of the primary global public health problems. In Brazil, in 2019, 60.3% of all adults were overweight, and 25.9% were obese1. In the capital of the State of Rio de Janeiro (RJS, in Portuguese) these percentages were, respectively, 57.1% and 21.7%2.
Several federal policies can affect this picture3-9 and, as a co-responsible federative entity, the Rio de Janeiro State Health Secretariat (SES/RJ), especially since 2012, has encouraged obesity prevention and control (OPC) actions in municipalities of the RJS10. Since then, decentralization has been driven by strengthening structures and agreement strategies, both between SES/RJ and municipalities, and between municipalities, through its technical areas, such as the Technical Area for Food and Nutrition (ATAN, in Portuguese), with Primary Health Care (PHC) as the main organizer of the Health Care Network (RAS)11. One prior study analyzed the conditions that favored or hindered the implementation of these actions in RJS since 201412. The originality and relevance of the present study lie in understanding how the changes established in the national and state political-economic contexts, as well as in the financing of the Unified Health System (SUS), conditioned this process.
Between 2014 and 2021, there were political and economic inflections and changes in the financing and structuring of SUS that may have affected the implementation of food and nutrition actions, such as: the approval of Constitutional Amendment (CE) 95/201613, which freezes public spending to health; the 2017 National Primary Care Policy (PNAB), which changes PHC funding mechanisms14; and the fiscal crisis of RJS15. Therefore, the present study aimed to analyze how the political, economic, and financing changes of SUS, in the national and state scenarios, may have affected the conditions necessary to implement OPC actions in PHC in RJS between 2014 and 2021, considering related historical antecedents, incentives, and constraints for PHC. It is assumed that, although conditioned by the national context, the specific processes of RJS, especially within the scope of SES, present their own dynamics that can respond to national constraints in varied ways in different situations.
2. METHODS
The present study is based on policy analysis methods that privilege the understanding of implementation contexts, as well as induction mechanisms and government incentives for the development of programs and public actions16. It integrates two research projects that analyzed actions for OPC in PHC in the 92 municipalities of RJS between 2014 and 2018 (PPSUS-RJS) and between 2019-2021 (PEO-RJS). The data are based on the following methods, adopted in the two projects: (1) documental analysis of national policies, having as a framework the 2006 PNAB (Table 1), of federal programs (Table 2), federal funding norms (Table 3), and state policies and regulations (Chart 4); (2) interviews and focus groups with municipal managers (from ATAN and PHC) and with health professionals from PHC and (3) bibliographic research. Based on documents and academic studies, the political, economic, and financial context was analyzed, in addition to the incentives and constraints for the implementation of OPC actions. The main challenges and strategies for the implementation of these actions, from the point of view of managers and professionals, were identified from the interviews and focus groups that, within the scope of the PPSUS-RJS project, have been described in a previous publication17,18 and within the scope of the PEO-RJS project were systematized by Belo et al.19. The document analysis was compared with studies that problematize changes in legislation and policies.
The data set was organized based on the following dimensions of analysis: 1) the national and state political-economic situation and SUS funding, including federal and state strategies for inducing and encouraging actions for OPC; 2) OPC programs and actions at the national and state levels; and 3) the factors that limit and enhance the implementation of these actions in the RJS. These dimensions were defined considering, on the one hand, the elements that make up the objective of the study: 1) political, economic, and financing changes in SUS, in the national and state scenarios; 2) OPC actions in the PHC in RJS between 2014 and 2021; and 3) historical background, incentives, and constraints for PHC. The elements that make up the policy analysis framework adopted in the study16 were also considered, mainly: the context of policy implementation, characterized by political, economic, and institutional factors, and the mechanisms, mainly financial, of inducing actions, which can be used by governments seeking to strengthen a given policy on their agenda. Data analysis and systematization methods were based on inductive coding processes (based on empirical data from documentary sources, interviews, and focus groups) and deductive coding (based on the policy analysis framework adopted)16. Chart 5 presents key themes and empirical elements according to research sources, analysis dimensions, data collection methods, and techniques, including the document analysis script.
The PPSUS project (2014-2018) was financed through Public Notice PPSUS\FAPRJS - E – 26\110.293\2014 and approved by the HUAP Ethics Committee – Opinion CEP 508.687 of 01/09/2014 – CAE 22822413.0.0000.5243 (PPSUS ). The PEO-RJS project was funded by the MS-CNPQ, approved by the HUPE Ethics Committee – opinion CEP 3.288.424 of April 26, 2019 – CAE 10514819.8.0000.5259.
3.1 The national political-economic scenario, SUS funding, and mechanisms to inducie OPC actions
3.1.1 Inflections in the national political and economic situation between 2014 and 2021
The period of national economic expansion (2003 to 2013) was followed by an economic slowdown and political crisis that began concomitantly with the publication of the Overweight and Obesity Care Line (LCSO, in Portuguese) in 201311,19. The Gross Domestic Product (GDP), which was 4.0% per year before 2014, became negative between 2015-2016. After the 2014 elections, an intense political crisis began, whic culminated in the impeachment of President Dilma Roussef in 2016 and the appointment of Michel Temer to the Office of the President21.
These events significantly transformed the national political-economic context, as the Temer government deepened fiscal austerity measures and liberalizing reforms, which affected social security policies and the SUS20,22. CE 95/201613 froze the State\'s public expenditures and investments for 20 years, despite maintaining expenses related to the payment of interest and amortizations on the public debt (Table 1). In a scenario of demographic expansion, impoverishment, and growing demands for social protection resulting from the economic crisis, the government suspended the proposal to consolidate investments in health, education, and social policies, all principles enshrined in the Constitution of 198824. Added to this was the removal of important social goals from the Budgetary Guidelines Law and CE Proposal No. 287/2016, which further restricted social security benefits and provided for the extinction of various labor rights20,23.
An analysis of the Federal Budget between 2014 and 2017 indicated a negative variation of 85.6% in resources for food access and the Promotion of Healthy Eating (PHE) actions related to OPC24. From 2019, with the Bolsonaro government, the backtracking in public investments intensified with the new social security reform (CE 103/201925) and the proposed administrative reform (PEC 32/2020), which eliminates a series of benefits for public civil servants, in turn affecting the rendering of services26.
Austerity policies in times of economic crisis were presented as the only way out of the crisis and economic recovery, and the improvement of financial indicators was linked to the contradictory need to reduce spending on public policies27 which impacted PHC in different ways.
3.1.2 Political-economic inflections, financing. and the institutional structure and national management of PHC
The most significant change in PHC funding occurred with the Standard Operating Procedures (SOP) 96, which established a regular and automatic transfer mechanism to municipalities, dissociated from the production of services. As of 2003, social indicators were incorporated so as to differentiate among transfers to municipalities, complying with the principle of equity. The volume of federal resources for PHC increased by more than 100% between 2002 and 2016. The financial induction strategy was linked to adherence to specific programs by municipalities, in addition to a fixed amount based on their population. PHC financing must be tripartite, according to the 2017 PNAB. However, RJS is one of the few Brazilian states that practices PHC co-financing28.
Between 2013 and 2017, important changes were implemented in PHC that positively impacted the implementation of OPC actions. Since its creation in 2006, between advances and setbacks, the PNAB has boosted the strengthening of the Family Health Strategy (FHS) with the creation of Family Health Support Centers (FHSC), which reached a coverage of 63.7% of the Brazilian population in 201628. It is also important to note that strategies were implemented to improve and expand access, such as the Access and Quality Improvement Program (PMAQ, in Portuguese), which creates a specific financial incentive for performance, the More Doctors Program (PMM, in Portuguese), and the creation of e-SUS, which institutionalized electronic medical records (Chart 2). Between 2003 and 2012, the number of new Family Health Teams (FHTs) expanded as a reflection of the expansion context of both the FHS and the PHC29.
As of 2014, the crisis led to several transformations in policies that weakened the structure of SUS. Despite the historical series of the underfunding of SUS30, in 2015, the federal transfer was half of what would be due. After the enactment of CE 95/2016, the scenario of underfunding became more severe, as the projection of revenue loss for SUS over the following 20 years was calculated at around R$415 billion. At the same time, obesity cases and the demand for PHC resources increased in a context of a heavy decrease in resources31.
Despite the advances that had been taking place in the PHC, the structural problems worsened from 2017 onwards with the beginning of full validity of the primary expenditure ceiling rule of CE 9513 and with the new PNAB14, which establishes specific funding for any other models in the PHC that do not contemplate the formulation of multidisciplinary teams that include community health agents (CHA), breaking with the centrality of the FHS within the framework of SUS32. The year 2017 was critical, as the underfunding of the SUS led to de-funding14,31, and the FHS was weakened. Consequently, PHC problems, such as a high turnover of professionals and the scarcity of financial resources, were not addressed. There was also a dismantling of professional teams with a decrease in the minimum number of CHAs per FHT and a decrease in the minimum weekly workload of the CHA teams in the traditional format established in the 2017 PNAB, with repercussions on the rendering of services and actions14.
In 2017, a modification was also approved in the form of federal funding for SUS on the prerogative of guaranteeing greater autonomy for municipal managers. Federal transfer criteria no longer guaranteed specific resources for PHC and were based on the production of services guided by the historical series of expenditures and financial incentives according to the implementation of health actions and services31 (Chart 1).
In 2019, the criteria for financing PHC with the “Previne Brasil”33 program were again changed, limiting it to the number of registered people and extinguishing the financial incentive for FHSC/FHS (Table 2). Municipalities in both poor areas and areas with large populations must present greater difficulties in enrollment, and there is no indication that this funding model in fact promotes improvements in health outcomes34.
Considering that two-thirds of MS expenditures correspond to transfers to states, municipalities and the Federal District (DF), limitations in SUS funding have repercussions on State and Municipal Health Departments31 and may affect the conditions necessary to implement OPC actions. Nonetheless, federal mechanisms of political and financial induction that drive such actions do stand out.
3.1.3 Food and Nutrition policies and actions at the national level
One of the main policies that contributed to the definition of guidelines to organize OPC actions in SUS was the National Food and Nutrition Policy (PNAN, in Portuguese) of 1999 and 20113,4, in addition to the PNAB itself and the National Policy for Health Promotion (PNPS, in Portuguese)35. Another important policy was the LCSO (2013)11, which guides health regions and municipalities in the elaboration of their own lines of care and guides the planning of actions10. In addition to SUS, another important milestone was the 2014 Intersectoral Strategy for Obesity Prevention and Control (EIOPC), which encourages states and municipalities to develop intersectoral actions7 (Table 1).
In 2006, an important financial induction mechanism was put in place, established by Ordinance No. 1.357/GM/MS, of June 23, 2006, and redefined by Ordinance No. 1.738/GM/MS, of August 19, 2013, which establishes funding incentives to structure and implement food and nutrition actions by state and municipal departments based on PNAN. The Food and Nutrition Fund (FAN) is intended for municipalities with a population of over 150,000 inhabitants and for the Federal District (FD) and is transferred directly to the respective State or Municipal Health Fund. In 2019, this incentive was extended to municipalities with a population of over 30,000 inhabitants. Among the priority actions are PHE, Food and Nutritional Surveillance (VAN, in Portuguese), and the prevention of eating disorders, especially being overweight and obesity, malnutrition, iron deficiency anemia, hypovitaminosis A, and beriberi. ATAN\'s technical managers, in different Brazilian states and municipalities, consider that the FAN enhances the area\'s actions, but they do recognize difficulties in using the resource, such as the small number of nutritionists, the excessive bureaucratic obstacles, in addition to the already mentioned high staff turnover37.
The National Health Plan (PNS) is also a strategic planning tool. However, in the last PNS (2020-2023), the food and nutrition indicators were not related to the objectives of the Multi-Year Plan (MYP), but rather to General Indicators for which targets are not set, but rather reference indexes are established, which may affect the release of specific food and nutrition resources during the period.
Certain programs also contribute to the induction of OPC actions, such as the 2007 School Health Program (SHP) and the 2011 Health Academy Program. Despite the critical inflection in funding established at the time, in 2017, the Crescer Saudável Program (Growing Healthy Program) provided resources for children\'s OPC within the scope of the SHP. In 2020 and 2021, the national funding of OPC actions was linked, temporarily and exceptionally, to facing the COVID-19 pandemic, considering the worsening of symptoms in individuals with obesity, diabetes, and hypertension38. Moreover, in 2021, the National Strategy for the Prevention and Care of Childhood Obesity (Proteja, in Portuguese) was instituted, which also provides for a financial incentive to support municipalities (Table 3).
Sets of actions driven by these funding incentives include: the VAN; PHE actions and physical activity; regulation of advertisements and labels; the need for public safety to perform physical activity; self-care; promotion of breastfeeding and adequate complementary feeding; food and nutrition education; group activities; individual and multidisciplinary care; and culinary practices12,17. Although driven by national policies, the implementation process is challenging.
3.2 Reflections and counterpoints of national dynamics in the State of Rio de Janeiro
In RJS, some sectors of the SES/RJ carry out OPC actions, such as ATAN, linked to the Superintendency of Primary Health Care (SPHC), which seeks to institute and support food and nutrition interventions. In addition, the Division for Surveillance of Noncommunicable Diseases and Injuries (DIVDANT, in Portuguese) and the decentralized structure of PHC to support municipalities stand out, which enhances dialogue with managers and local professionals through regional supporters, the work group of PHC, and the Regional Intermanagers Commission (RIC).
The PHC was boosted by the FHS, and is currently one of the fundamental structures used to provide roots for and reach SUS with a potential impact on obesity control. The institutional structure of PHC in RJS, between January 2014 and February 2017, showed an increase in the number of FHTs from 2,182 to 2,913. However, subsequently, the number tended to decline until the end of 2020, reaching a total of 2,44839.
Despite limitations in federal funding, along with complex and difficult state circumstances, in political and economic terms, since 2019, several specific financial incentives from RJS have been observed, which have boosted PHC and the development of actions related to coping with NCDs with a potential impact on OPC40-43. The MYP and the State Health Plans (SHPs) constitute an important planning instrument in RJS and the SHP 2012-201544, one can observe a major focus on OPC actions, as they affect the development of NCDs, as well as strategies, objectives, and goals related to these diseases. In PES 2016-201945 the same trend was observed, but with the addition of specific goals related to the performance of bariatric surgery procedures. In the current MYP and in the last PES 2020-202346, for the first time, the aim is to elaborate specific lines of care to face not only being overweight and obesity, but also other risk factors related to NCDs. In addition, the same SHP set the goal of institutional support in the nine regions of RJS for the organization of nutritional care, interlinking PHC with other sectors (Chart 4).
In RJS, the policy instrument that more specifically indicates priority actions and guidelines to organize local OPC actions is the Strategic Action Plan for Combating NCDs (2013-2022), which highlights measures related to: the practice of physical activities; the promotion of healthy habits in an intersectoral way; and the implementation of comprehensive care models in the health network, mainly PHC10.
3.2.1 The development of actions to fight being overweight and obesity in the State of Rio de Janeiro and conditioning factors
What stands out here are LCSO construction initiatives in RJS, especially in the North region, in addition to municipal processes in RJ, Niterói, and São Gonçalo17. The main OPC actions indicated by municipal managers of PHC and ATAN, within the scope of the two projects, included: individual consultation and group work, the Health Academy Program, and SHP. In PPSUS, the SHPs also include: bariatric surgery and program actions to combat hypertension and diabetes, and at PEO-RJS, matrix support, shared consultations, and continuing education actions; culinary workshops; specialty clinics and the National School Feeding Program (PNAE, in Portuguese)19.
It was also recognized by managers and professionals that ATAN plays a leading role in OPC actions, but the involvement of different health sectors and other policies is essential.
3.2.2 Challenges and potential for implementing OPC actions according to PHC managers and professionals
Despite the strengthening and enhancement of PHC up to 2016, the managers and professionals interviewed within the scope of the PPSUS claim that the theme of obesity was rarely discussed in the institutional spaces of the SES-RJS (WG of AB and meetings of regional centers of ATAN and RIC), except as a risk factor for NCD. The prioritized themes were those established in the state co-financing instrument, such as actions for the prevention and control of Diabetes and Hypertension, maternal and child care, Infant Mortality and Congenital Syphilis. With the LCSO in 2013, specific discussions on OPC were boosted.
The decentralized support structure of AB and ATAN favored the coordination of actions and the dialogue and support provided to the RJS regional offices. In addition, according to PHC regional supporters, the interaction of different sectors of SES, from local professionals to managers, and the support and discussion of local work, strengthened this decentralized structure.
Several ATAN municipal references cited the lack of specific financial resources necessary to implement OPC actions. However, despite the existence of the FAN resources, it is recurrent that these references report a lack of autonomy in the use and management of this transfer. In addition, between 2006 and 2010 there were financial transfer mechanisms to strengthen specific actions of the PNPS, with emphasis on the Integration of Surveillance, Promotion, and Prevention of NCD actions. During this period, MS made a resource available for the implementation of health promotion projects – according to the axes of the PNPS – which includes the promotion of healthy eating. In RJS, of the 37 participating municipalities: 13 had projects related to the PHE and 19 related to the promotion of physical activity. The remainder was divided into: tobacco control; coping with violence; combating drugs and alcohol and accidents. The resource could be used to hire professionals, but it did not allow for the construction or purchase of permanent materials. In 2011, this resource was transferred to the Health Academies. Projects of this type can help promotion actions to become more concrete and indicate paths toward the integration of the different health sectors that deal with the priorities of the PNPS, such as food and nutrition. The State Plan to Combat NCDs provides for the integration of these sectors and emphasizes the importance of integrated policies to deal with complex problems10.
For the managers and professionals interviewed in the PPSUS, the FHS stands out as essential for the coordination of OPC actions and the organization of levels of care, as these require various types of interventions. They emphasize the matrix work of the FHS and FHSC as the main channels and operators of OPC actions in the territories17.
Despite this, the municipal ATAN coordinators also pointed out several challenges for the consolidation of the RAS in the municipalities of the RJS, mainly related to the historical trajectory of the institutional structure and management, such as: the discontinuity of management; changes of program coordinators together with the change of managers; the lack of knowledge on themes guided by the program coordinators; the lack of a job and salary plan; difficulty in managing FAN resources; the monitoring of the implementation of actions related to the LCSO; insufficiency and high turnover of professionals; and the lack of equipment and physical spaces.
Due to the political, financial, and institutional crisis, several significant changes occurred in the structure of PHC in the RJS from 2016: the disruption of work spaces and processes, followed by difficulties in receiving salaries, which occurred in 2016, in addition to changes in SUS funding mechanisms, with the 2017 PNAB and with the austerity measures that directly affected the major potential of the PHC that had been growing.
Within the scope of the PEO-RJS, professionals claimed the following as the main challenges for the implementation of OPC actions: the scarcity of financial resources to plan and execute actions; the lack of information; the shortage of professionals; violence in territories; the non-existence of FHSC; problems related to professional commitment; and low integration of municipal actions19. Thus, there is a similarity between the challenges reported in the two research periods of 2014-2019 and 2019-2021.
Finally, one project that stands out is the PEO-RJS, which is financed through federal resources and built in partnership with SES-RJS, which can contribute to boosting the implementation of OPC actions through courses offered to managers and professionals in the municipalities.
4. DISCUSSION
There was an abrupt transformation of the political-economic situation during the study period (2014-2021), and the historical series of national economic expansion was interrupted after 2014. From then on, the redirection of economic policies and SUS financing negatively impacted the conditions for implementing actions in the PHC. Although SUS underfunding scenarios are historical, they worsened from 2014 onwards and deepened even further from 2017 onwards. This same trend was recorded for the financing of SAN and PHE actions24.
Between 2014 and 2016, the positive impacts of the institutionalization can be seen in the PHC of RJS, in the decentralized structure of technical support provided to municipalities through regional supporters. In addition, federal triggers, through policies, programs, and the LCSO, have also positively impacted the state process. As of 2016, these gains began to undergo a significant reversal, which was intensified by the political and financial crisis of the RJS government.
The inflections in the expansion of PHC at the federal level, with CE 95/2016 and PNAB 2017, in addition to the cut in resources for PHE and SAN actions as of 2014, contributed to the weakening of units, teams, and strategies in RJS, in addition to a withdrawal of resources for state and municipal actions. Between 2016-2018, the political and financial crisis in RJS was exacerbated by national crises and the underfunding of SUS. Nevertheless, resources from the FAN, the mechanisms for inducing the LCSO and the National Policies, resources for the OPC through specific programs, and the actions of the SES, through ATAN, Health Promotion, and SPHC, as well as state co-financing, continued during this period. It is also necessary to consider the PEO-RJS project itself, which promoted courses for managers and health professionals in the RJS municipalities, promoted the OPC theme, and triggered support from local managers.
Since 2014, the main federal and state induction mechanisms with a positive impact on the conditions for implementing OPC actions included: the LCSO; FAN resources; EIOPC; financial incentives to restructure PHC, including the consolidation of decentralized support structures; the State Plan to combat NCDs, and, on a temporary basis, PNPS resources, in addition to resources from specific programs, state co-financing, and actions by ATAN and SPHC. This set of incentives favors the participation of municipal managers, who are closer to the population\'s reality and play a strategic role in the OPC in the RJS28.
Several challenges for the implementation of OPC actions highlighted by managers and professionals are directly or indirectly related to funding: insufficient resources and teams; low autonomy in the financial management of the FAN; in addition to salary issues, as corroborated by the literature. Fragilities in the institutional and management structure are also highlighted; low VAN coverage and limited support for the FHSC, despite the relevance of its multidisciplinary structure, which enables an expansion in the scope of actions29. Such factors can compromise the care for overweight and obese individuals, as they affect the organization of actions in the territory.
In the scenario of the COVID-19 pandemic, the Ministry of Health\'s initiative to finance care actions for individuals with obesity, diabetes mellitus and systemic arterial hypertension was closely related to the decrease in complications of the disease\'s symptoms in these individuals. In the most recent critical national context, additional funding sources that may favor the OPC are the resources associated with the COVID-19 Pandemic, Proteja, and the different co-financing projects from RJS.
5. CONCLUSIONS
Important inflections were identified in the macro political and economic conditions for the implementation of OPC actions: in 2014, with the political and economic crisis and cuts in resources for food access programs and PHE; in 2016-2017, with the austerity measures and changes in the funding for PHC boosted by the RJS crisis; and in 2019, with “Previne Brasil”, followed by the COVID-19 pandemic.
At the national level, the rerouting of economic policies and SUS funding negatively impacted the conditions for the implementation of PHC actions shortly after the LCSO was issued in 2013. However, the federal mechanisms that induce actions and financial transfers were key to guaranteeing resources and guiding RJS and municipal managers, in addition to triggering agreement and management processes that boosted OPC actions.
In RJS, the transformations that took place were related to the inflections that directly affected the institutional structure of PHC, where strategic OPC actions are located. In this way, despite the progress through federal financial incentives and the orientation of actions, goals, and indicators, due to the political-economic crises, the austerity measures and the difficulties, especially concerning the municipal ATAN in their application of the resources, the conditions for the implementation of OPC shares were affected.
Despite this, important counterpoints to these constraints stand out through the actions of ATAN, APS, DIVIDANT, and resources from state co-financing, in addition to the PEO-RJS project itself.
6. REFERENCES
1. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: atenção primária à saúde e informações antropométricas. Rio de Janeiro; 2019.
2. Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019. Brasília: Ministério da Saúde; 2020.
3. Brasil. Portaria n0 710, de 10 de junho de 1999. Aprova a Política Nacional de Alimentação e Nutrição, cuja íntegra consta do anexo desta Portaria e dela é parte integrante. Ministério da Saúde. Diário Oficial da União 1999; 11 jun.
4. Brasil. Portaria Nº 2.715, de 17 de novembro de 2011. Atualiza a Política Nacional de Alimentação e Nutrição. Ministério da Saúde. Diário Oficial da União 2011; 18 nov.
5. Brasil. Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2012.
6. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde; 2011.
7. Brasil. Ministério da Saúde. Câmara Interministerial de Segurança Alimentar e Nutricional. Estratégia Intersetorial de Prevenção e Controle da Obesidade: recomendações para estados e municípios. Brasília: Câmara Interministerial de Segurança Alimentar e Nutricional; 2014.
8. Brasil. Decreto no 7.272, de 25 de agosto de 2010. Regulamenta a Lei no 11.346, de 15 de setembro de 2006, que cria o Sistema Nacional de Segurança Alimentar e Nutricional – SISAN com vistas a assegurar o direito humano à alimentação adequada, institui a Política Nacional de Segurança Alimentar e Nutricional – PNSAN, estabelece os parâmetros para a elaboração do Plano Nacional de Segurança Alimentar e Nutricional, e dá outras providências. Diário Oficial da União 2010; 26 ago.
9. Brasil. Ministério da Saúde. Câmara Interministerial de Segurança Alimentar e Nutricional. 2º Plano Nacional de SAN - 2016-2019. Revisado. Brasília: Câmara Interministerial de Segurança Alimentar e Nutricional; 2018.
10. Rio de Janeiro. Subsecretaria de Atenção em Saúde, Secretaria de Estado de Saúde do Rio de Janeiro. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis (DCNTs) no Estado do Rio de Janeiro, 2013-2022. Rio de Janeiro: Secretaria de Estado de Saúde do Rio de Janeiro; 2012.
11. Brasil. Ministério da Saúde. Portaria n0 424, de 19 de março de 2013. Redefine as diretrizes para a organização da prevenção e do tratamento do sobrepeso e obesidade como linha de cuidado prioritária da Rede de Atenção à Saúde das Pessoas com Doenças Crônicas. Diário Oficial da União 2013; 20 mar.
12. Dias, PC, Henriques P, Anjos LA, Burlandy L. Obesidade e políticas públicas: concepções e estratégias adotadas pelo governo brasileiro. Cad Saúde Pública 2017; 33(7): 1-12.
13. Brasil. Constituição (1988). Emenda Constitucional nº 95 de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016.
14. Melo EA, Mendonça MHM, Oliveira JR, Carrilho GLA. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde debate. 2018;42(spe1):38-51.
15. O’dwyer G, Graever L, Britto FA, Menezes T, Konder MT. A crise financeira e a saúde: o caso do município do Rio de Janeiro, Brasil. Ciênc. Saúde Coletiva. 2019;24(12):4555-4568
16. Cruz M. Avaliação de Políticas e Programas de Saúde: Contribuições para o Debate In: Mattos R; Baptista T. Caminhos para Análise das Políticas de Saúde. Porto Alegre: Rede Unida; 2015. p285-317.
17. Ramos DB, Burlandy L, Camacho PD, Henriques P, Castro LMC, Teixeira MRM, Bocca CR, Araujo TS, Caldas FA, Souza TR, Souza SR, Cruz MCC. Propostas governamentais brasileiras de ações de prevenção e controle do sobrepeso e obesidade sob perspectiva municipal. Cad Saúde Pública 2020; 36(6):1-18.
18. Burlandy L, Teixeira MRM, Castro LMC, Cruz MCC, Bocca CR, Souza SR, Benchimol LS, Araújo TS, Ramos DBN, Souza TR. Modelos de assistência ao indivíduo com obesidade na atenção básica em saúde no Estado do Rio de Janeiro, Brasil. Cad Saúde Pública 2020; 36(3):1-19.
19. Belo, CEC, Rosa, LCG, Damião, JJ, Lobato, E, Burlandy,L, Castro, LMC. Organização do cuidado às pessoas com sobrepeso e obesidade no Estado do Rio de Janeiro: o olhar de profissionais da Atenção Primária à Saúde. Revista Demetra; 17:e69119, 2022.
20. Souza MB, Hoff TS. Governo Temer e a volta do neoliberalismo no Brasil: possíveis consequências para a habitação popular. Rev Brasileira de Gestão Urb 2019; 11:1-14.
21. Paula LF; Pires M. Crise e perspectivas para a economia brasileira. Estud. av. 2017; 31(89):125-144.
22. Pires W, Pereira E. Austeridade e neoliberalismo no Brasil pós-golpe. Revista Sítio Novo 2020; 4(3): 336-347.
23. Mariano CM. Emenda constitucional 95/2016 e o teto dos gastos públicos: Brasil de volta ao estado de exceção econômico e ao capitalismo do desastre. Rev. Investig. Const 2017; 4(1): 259-281.
24. Souza LE, Barros RD, Barreto ML, Katikireddi SV, Hone TV, Sousa RP, Leyland A, Rasella D, Millett CJ, Pescarini J. The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil. BMJ Global Health 2019; 4:1-7.
25. Brasil. Constituição (1988). Emenda constitucional nº 103, de 12 de novembro de 2019. Diário Oficial da União 2019.
26. Oreiro JL, Helder LF. A PEC 32 da Reforma Administrativa: Uma análise crítica. Brazilian Journal of Political Economy. 2021;41(3):487-506.
27. Menezes AP, Moretti B e Reis AA. O futuro do SUS: impactos das reformas neoliberais na saúde pública – austeridade versus universalidade. Saúde em Debate 2020; 43(spe 5): 58-70.
28. Castro AL, Cristiani V e Lima LD. Financiamento da Atenção Primária à Saúde no Brasil. In: Mendonça MH; Matta GC; Gondim R e Giovanella L (orgs). Atenção Primária à Saúde no Brasil - conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz, 2018.
29. Campos, GW, Pereira Junior, NA Atenção Primária e o Programa Mais Médicos do Sistema Único de Saúde: conquistas e limites. Ciênc. coletiva 2016;21(9): 2655-2663.
30. Mendes A, Carnut L. Capitalismo contemporâneo em crise e sua forma política: o subfinanciamento e o gerencialismo na saúde pública brasileira. Saúde soc. 2018; 27(4):1105-1119.
31. Mendes A, Carnut L, Guerra LD. Reflexões acerca do financiamento federal da Atenção Básica no Sistema Único de Saúde. Saúde debate2018; 42(spe 1):224-243.
32. Abrasco; Cebes; Ensp. Contra a reformulação da PNAB. nota sobre a revisão da PNAB. Acessado em: 04/01/2022 Disponível em https://cebes.org.br/contra-a-reformulacao-da-pnab-nota-sobre-a-revisao-da-politica-nacional-de-atencao-basica/19173.
33. Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde (SUS). Ministério da Saúde. Diário Oficial da União 13 nov 2019.
34. Massuda A. Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Ciênc. & Saúde Coletiva. 2020;25(4):1181-1188.
35. Brasil. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; Secretaria de Vigilância em Saúde 2006.
36. Brandão AL, Reis EC, Cardim CV, Seixas CM, Casemiro JP. Estrutura e adequação dos processos de trabalhos no cuidado à obesidade na Atenção Básica brasileira. Saúde Debate. 2020;44(126):678-69.
37. Reis CS. Avaliação da utilização do rePHEse fundo a fundo para a estruturação e implementação das ações de alimentação e nutrição. Distrito Federal. Dissertação (Pós-Graduação em Nutrição Humana). UNB. 2015.
38. Brasil. Portaria nº 2.994, de 29 de outubro de 2020. Institui, em caráter excepcional e temporário, incentivo financeiro federal para atenção às pessoas com obesidade, diabetes mellitus ou hipertensão arterial sistêmica no âmbito da Atenção Primária à Saúde, no Sistema Único de Saúde, no contexto da Emergência em Saúde Pública de Importância Nacional (ESPIN) decorrente da pandemia do novo coronavírus. Ministério da Saúde. Diário Oficial da União 03 nov 2020.
39. E-Gestor. Cobertura da Atenção Básica [acesso em 20 de dezembro de 2021]. Disponível em: https://egestorab.saude.gov.br
40. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Resolução SES nº 1.846, de 09 de maio de 2019. Aprova o Programa de Financiamento da APS no RJS. SES, RJS, 2019.
41. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Resolução n0 2199 de 31 de outubro de 2019 SES RJ. Estabelece a transferência dos recursos para os Municípios. SES, RJS, 2019.
42. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Resolução n0 2194 de 8 de dezembro de 2020 SES RJ 2194. Aprova o programa de financiamento das ações de vigilância em saúde do RJS. SES, RJS, 2020.
43. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Resolução n0 1925 de 23 de dezembro de 2020 SES RJ. Normas do programa estadual de financiamento da Promoção da Saúde - COFI-PS, para o exercício de 2019. SES, RJS, 2020.
44. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Plano Estadual de Saúde- 2012-2015. Rio de Janeiro: SES/RJ, 2012.
45. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Plano Estadual de Saúde- 2016-2019. Rio de Janeiro: SES/RJ, 2016.
46. Secretaria de Estado da Saúde do Estado do Rio de Janeiro. Plano Estadual de Saúde- 2020-2023. Rio de Janeiro: SES/RJ, 2020.
