Developing a National Program: Brazil Case Study

1. Developing a National Program: Brazil Case Study Vera Luiza da Costa e Silva, MD, MBA, PhD Tobacco Control and Consumer Health Risk Assessment Unit Pan American Health Organization

2. Learning Objectives • Discuss lessons learned in Brazil • Discuss the framework of capacity that needs to exist for tobacco control

3. What Do We Mean by Capacity? Sources: *World Bank. (2003). †Canada International Development Agency. (1996). ‡United Nations Development Programme. (1997).

4. Who Is Involved in Capacity Development? • Individuals and groups • Key skills and knowledge required to perform functions • Organizations • Management systems and business processes • Institutions • Governance • Parliament • The role of private sector and civil society

5. Components of the Capacity Building Process Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

6. People • Tobacco control cell • Focal point/coordination mechanism • Staff members • Committees and task forces • Professional development/regular training Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

7. Place • Where the program is housed • Area of work, organizations involved • Infrastructure, equipment, basic materials • Networking • States, municipalities, provinces • Linking with existing health care framework Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

8. Policy • Existing plans of action • Strategies • Laws, regulations • Cost-effective interventions • Communication and the “seduction” process Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

9. Policy • Existing plans of action • Strategies • Laws, regulations • Cost-effective interventions • Communication and the “seduction” process • Multi-sectoral focus • The tobacco industry Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

10. Partnership • The civil society • The private sector • Ethics and collaboration with the private sector • Stakeholders in general Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

11. Provider (Funds) • Sources of funds • Regular versus extra-budgetary funds • Funding gaps • Resource allocation • Existing fund raising exercise Image source: adapted by CTLT from da Costa e Silva, V.L. (2007).

12. Making Decisions on Capacity Development: Scenario

13. The Capacity Building Process in Brazil • The Unified Health System: SUS • Federal level • State level • Municipal level • Strong participation of the civil society Image source: adapted by CTLT from Ministry of Health Brazil. (2007).

14. Capacity Development: 1985 to 1991 • Initial phase (1985 to 1991) • Sanitary Pneumology Agency (Brasilia) with support from the Department of Chronic Diseases/National Cancer Institute (INCA, Rio de Janeiro) and the National Institute for Lung Disease (CRPHF, Rio de Janeiro) • Development of first national tobacco control plan • Development of a national state and municipal network within the Public Health Care System (SUS) • Creation of National Tobacco Control Day, 1986

15. Capacity Development: 1992 to 1998 • Infrastructure building phase (1992 to 1998) • INCA with support from Pneumology and CRPHF • INCA assumed coordination role for cancer prevention, including tobacco control • Creation of the Committee to negotiate the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) • First national conference: non-governmental organization (NGO) involvement

16. Capacity Development: 1999 to 2005 • Growth phase (1999-2005) • INCA (Rio de Janeiro) and the National Health Surveillance Agency (ANVISA, Rio de Janeiro and Brasilia) • Tobacco products registered • Advances in legislation and regulation • Involvement of other federal agencies • Secretary of Sanitary Surveillance (SVS) • Secretary of Health Assistance (SAS)

17. Capacity Development: 1999 to 2005 • Growth phase (1999 to 2005) • Development of guidelines for cessation within the health care system and creation of the quitline (SUS provision of free cessation services and free Nicotine Replacement Therapy [NRT] and bupropion) • Brazil ratifies the FCTC • Creation of a multi-sectoral government committee (CONICQ) for the implementation of the FCTC • Reduced emphasis and support for state and municipal activities

18. Capacity Development: 2006-Present • Consolidation phase (2006 and beyond) • INCA, ANVISA, SVS, SAS, and other partners at the Ministry of Health • SVS and ANVISA sending resources to states and municipalities • Inter-ministerial agenda for implementation of the FCTC • Building of a tobacco products analysis lab • Work on smoke-free environments • Capacity building for cessation

19. People: Training Image sources (left to right): Brazilian National Cancer Institute, INCA. (2001). (2003). (2007).

20. National Committee for the Control of Tobacco Use Ministry of Health Ministry of External Relations Ministry of Agriculture Ministry for Development, Industry, and Trade Ministry of Finance Ministry of Justice Ministry of Labor and Employment Ministry of Education Ministry for Agrarian Development CONICQ Ministry of Health Ministry of External Relations Ministry of Agriculture Ministry for Development, Industry, and Trade Ministry of Finance Ministry of Environment Ministry of Communication Ministry of Justice Ministry of Labor and Employment Ministry of Education Ministry for Agrarian Development People: National Commissions

21. Place: The Network Image source: da Costa e Silva, V.L.

22. Place: The Network Images source: Ministry of Health Brazil.

23. Policy: International Leadership • Chairmanship of the negotiation process and preparation for the Conference of Parties (COP): WHO FCTC Ambassador Luiz Felipe de Seixas Correa Ambassador Celso Almorim Images source: da Costa e Silva, V.L.

24. Policy: Brazil

25. Policy: Addressing the Supply Side Images source: da Costa e Silva, V.L.

26. Policy: The Regulatory Authority of ANVISA Images source: Ministry of Health Brazil.

27. Policy: Smoke-free Places Initiative Images source: Ministry of Health Brazil.

28. Policy: School-based Program Images source: Brazilian National Cancer Institute, INCA.

29. Policy: Smoking Cessation Initiatives Images source: Brazilian National Cancer Institute, INCA.

30. Policy: World No Tobacco Day Commemoration Images source: da Costa e Silva, V.L.

31. Partnership: NGOs and Health Professional Groups • Currently 200 organizations working on tobacco control

32. Tobacco Control Capacity Development Results: Brazil Source: adapted by CTLT from SRF, MDIC, McKinsey and Company, ETCO.

33. Tobacco Control Capacity Development Results: Brazil • Brazilian adults (> 15 years of age) smoking prevalence (%) • 1989: 32% of total adult population* • 2003: 18.8% of total adult population† Source: *Instituto Brasileiro de Geografia e Estatistica. (1989). †INCA/SVS NCD Survey. (2003).

34. Opportunities • Program is highly regarded both domestically and internationally • Program has 20 years of history • Program was able to block tobacco industry opposition and obtain ratification of WHO FCTC • Municipalities and states do have minimum infrastructure • Growing population awareness and many public health professionals committed to program • Multi-annual planning and integration in health agenda at the federal level

35. Challenges • Improve collaboration with more multi-sectoral activities • Enhance participation of local level in planning • Invest in capacity building, need better methods and strategies; ensure that there is personnel to carry program activities • Improve coordination with other state agencies • Secure funding from federal government for state and local levels

36. Challenges • Develop a capacity to evaluate the program on a regular basis • Improve quitline response: currently the largest number of calls in the world (over two million per year)

37. Summary • Look for partnership and collaboration • Tobacco control must bring partners together and take advantage of current infrastructure Two hands clap and there’s a sound. What is the sound of one hand? —Chinese proverb