Public Health Policies Interface with private sector

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• Public Health Policies - Interface with private
  sector
• The Brazilian Experience
• Dr. José Gomes TemporãoMinister of Health of
  BrazilOctober 1st, 2008

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UNIFIED HEALTH SYSTEM (SUS) Brazilian Public
Health Service

• Brazil has a public health service that offers
  integrated, universal and equal access to medical
  treatment. The Brazilian National Health System
  (SUS) is celebrating its 20th anniversary.
• More than 80 of the Brazilian population depends
  exclusively on SUS (150 million people) for its
  health needs
• Every year
• 2.3 billion clinical procedures
• 300 million medical consultations
• 11.3 million hospitalizations
• 15,000 organ transplants
• The structure of SUS was inspired by universal
  health systems of other countries, such as the UK
  and Canada. The guiding principles of SUS are
  universal and equal access, comprehensive health
  care and control by society. The supply of
  services is decentralized, but policies are
  implemented in a unified way.

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Management Priority

• To enforce the public health policies, within
  SUS, that aim to broaden citizens quality of life
  and wellbeing.
• Within this strategic priority, the Brazilian
  government has developed a number of actions
  promoting health for its population with strong
  support from society. Those that have a greater
  interface with the private sector are
• The fight against smoking
• Controlling the consumption of alcoholic
  beverages
• Healthy nourishment (reduction of salt, sugar and
  trans fat content)

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Main Challenges

• Behavioral changes create greater awareness
  regarding health risks
• Modify every day habits that are deeply ingrained
  in the population
• Deal with industry and media interests
• Face powerful lobbies in Congress
• POLEMIC Individual freedom of choice X the
  Governments role in defending the collective
  health and protect the lives of its citizens.
• Although some of the Ministry of Healths
  foreseen actions affect the funds allocated for
  publicity and even the number of jobs, there is a
  consensus that the initiatives are essential in
  order to deal with serious public health issues

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Tobacco

• Tobacco is the second cause of death in the
  world
• It causes 4.9 million deaths a year
• Second-hand smoke also kills non smokers
• 50,000 annually in USA.
• 79,000 annually in 25 countries in the European
  Union
• Brazil
• Smoking is the primary risk factor for the
  main causes of death cardiovascular diseases and
  cancer
• 200,000 annual deaths
• Second hand smoke kills 2,700 non smokers
  annually
• Smoking prevalence concentrates in more
  vulnerable groups low income and educational
  level groups
• Brazil is the second largest tobacco producer in
  the world

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Tobacco epidemicA result of an aggressive and
globalized business

• Almost 1.3 billion people currently smoke
  worldwide
• 84 of all smokers live in developing countries
• Result from agressive globalized tobacco
  marketing strategies advertising promotion,
  sponsorship, prices and lobby to undermine
  tobacco control

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WHO Framework Conventionon Tobacco Control a
global answer
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Main actions

• Worldwide consensus to control tobacco through
• Strategies
• Prevention of smoking
• Increase quitting of smoking
• Protection (from second hand smoke exposure)
• Regulate tobacco products
• Measures
• Reduce demand
• Reduce supply

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• Measures to reduce demand
• Tax and price measures
• Measures to protect from second hand smoke
• Tobacco products regulation ( emission and
  contents)
• Package and labelling of tobacco products
• Education, communication and training to raise
  awareness on dangers of tobacco
• Advertising, promotion and sponsorship
• Measures related to tobacco dependence treatment
  and quitting of smoking
• Measure to reduce supply
• Tobacco illicit trade (smuggling and
  counterfeiting)
• Sale to minors
• Support viable economic alternatives for
  tobacco crops

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It is possible to change this scenario

• Since 1987 the Brazilian government has
  pioneered a national tobacco control program,
  that is internationally recognized
• National awareness campaigns
• School based program
• Treatment for quitting smoking is provided for
  free in the Public Health System.
• Nationwide Toll- Free Helpline for Quitting
  Smoking

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It is possible to change this scenario

• Strong legislation
• Smoke free legislation (allows smoking designated
  areas) (since 1996)
• Tobacco advertising is restricted to internal
  part of point of sale (since 2000)
• Sponsorship of cultural and sport events by
  tobacco products is prohibited (since 2000)
• The use of misleading descriptions (light,
  mild) are prohibited (since 2001)
• Strong health warnings with photos are put in
  tobacco products packaging together with a toll
  free help line for quitting smoking (since
  2001)

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Brazil Tobacco health warnings with photos
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Tobacco control in Brazil State Policy

• These measures have allowed Brazil to achieve
  important results
• Smoking has decreased from 34 in 1989, to 16.7
  in 2006.
• The lung cancer death rate among men started to
  decrease.

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Alcohol consumption

• Federal Law toreduce alcohol-related
• traffic accidents

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Costs of alcohol consumption to theUnified
Health System (SUS)

• US 39.3 million spent in treatment
• US 2.9 billion/year in emergency and in-patient
  admissions due to traffic accidents
• US 13.6 billion in economic and social loss

Sources Ipea, 2004 Ministry of Helath, 2007
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Drink and driving new legislation(Federal law
came into force on June 20, 2008

• Aimed at reducing one of Brazils most
  important health issues - high levels of car
  crashes related to alcohol consumption - Federal
  Government has resolved to restrict severely
  drunk-driving legislation.
• The current Brazilian law is now one of the most
  rigorous in the world and has reduced tolerance
  of drunk-driving behaviour among drivers almost
  to zero.
• Current blood alcohol concentration (BAC) 0.2
  g/l
• Penalties Fine of US 523.00 retention of the
  vehicle and suspension of drivers licence for
  one year. Driver can be arrested if BAC is above
  0.6 g/l.

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Results of new drunk-driving legislation

• In Brazil, positive results were obtained in the
  weeks following the introduction of stricter
  legislation
• Reduction of 15 in acute and emergency
  admissions by SAMU within Brazilian capitals.
  In 7 cities this percentage has reached more
  than 20
• 1,772 less traffic accidents in the first
  month of the new law.
• After 2 months, there was a reduction of
  13.6 in the traffic accidents with injuries
  within federal highways and Brazilian
  government has saved almost US 28 million
• Hospitals presented data that confirmed
  reduction in numbers of domestic violence

Sources Ministry of Health, 2008 PRF, 2008
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Results - 2

• Raised a healthy discussion in the Brazilian
  society
• Widely positive support of Brazilian public
  opinion
• Public opinion in Brazil has forced a positive
  approach from the alcohol industry regarding the
  new law, thereby strengthening government
  marketing initiatives focusing on responsible
  drinking.
• Changing behavior among youths, aiming at
  developing ways of driving without drinking
  (designated driver AMIGO DA VEZ).
• Negative reaction was received from bars and
  restaurant owners associations on account of
  their economic losses. On the other hand, the
  transportation sector (especially taxi drivers)
  have seen an increase in services.

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Restriction on alcohol marketing

• The Brazilian Ministry of Health presented to
  President Luiz Inácio Lula da Silva draft
  legislation to update current definitions
  concerning alcohol marketing in Brazil. The
  legislation aims to regulate media promotion of
  alcoholic beverages with alcohol concentration
  equal to 0.5 degrees Gay-Lussac or above
  (according to the currentl definitions
  restrictions are applied just to beverages
  above13 degrees Gay-Lussac).
• According to the World Health Organization
  (2004)¹, France, Denmark and Switzerland ban any
  alcohol marketing on television. Italy, Portugal,
  and Chile, have restrictions to alcohol marketing
  on television¹, as the Brazilian Government is
  proposing.

¹ World Health Organization (2004). Global Status
Report Alcohol Policy. Geneva
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Restriction on alcohol marketing 2

• Self-regulation is being acknowledged by the
  alcohol beverage industry, marketing
  professionals and media owners as the best way to
  regulate alcohol marketing. Guidelines provided
  by the Brazilian private institution (CONAR) are
  sometimes disrespected by marketing agencies,
  especially in beer ads.
• Media campaigns against the Government initiative
  state that government is to abolish freedom of
  speech and to impose a censorship.
• World Health Organization (2007)¹ recommends that
  unless processes related to alcohol advertising
  standards come under a legal framework, and are
  monitored and reviewed by a government agency,
  governments may find that allowing
  self-regulation by industry results in loss of
  policy control of a product that seriously
  affects public health.

¹ World Health Organization (2004). Global Status
Report Alcohol Policy. Geneva
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Promoting Healthy Eating
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Epidemiological and Nutritional Profile

• 43 of the population in Brazilian capitals are
  overweight
• 13 of the population in Brazilian capitals are
  obese
• 20 of the Brazilian population suffer from
  hypertention
• Up to 260 thousand deaths could be avoided every
  year if the population had adequate nutrition.

The WHO recommendation is that the government,
society and industry work together putting an
emphasis on the production sectors
responsibility towards the populations healthy
nutrition.
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Food Consumption in Brazil

• Family Budget Survey (2002-2003)
• High consumption of vegetable oils and fats (30)
• High consumption of salt ( 11 g/day without
  considering eating out)
• High consumption of soft drinks and cookies (400
  increase between 10 and 19 year olds)
• 30 of nourishment occurs outside the home
  (fast-foods)

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Food Consumption of those who Benefit From the
Bolsa Familia Program
National survey on the profile of the families
that benefit from the Bolsa Família Program and
ways in which they have access to food, its
repercussions as well as the food and nutritional
safety

• Conclusions
• The changes that have taken place in the
  nourishment of the families who participate in
  the Bolsa Familia program (greater vulnerability)
  follow a tendency shown in the Family Budget
  Survey with more impact on the consumption of
  certain foods
• Increase in the consumption of cookies (63)
• Increase in the consumption of oils, fats, sugars
  and industrialized foods
• Increase, although in smaller proportion, in the
  consumption of vegetables and greens

Source IBASE/DOCUMENTO SÍNTESE PBF (2008)
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Change in percentage of chosen foods between
1975 and 2003
Source POFs OF IBGE - USP
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Food Labeling Rules

• Required Nutritional Labeling in all foods
• Agreed upon sanitary regulations in Mercosul
  requires that the caloric, protein, carbohydrate,
  total fats, saturated fats, trans fats and sodium
  be shown.
• Optional declaration of Trans Fats
• The product labels can declare No Trans Fats as
  long as the product has a maximum of 0.2g trans
  fats per portion and a maximum of 2g of
  saturated fat per portion.
• Present Situation
• A survey done by the Nutrition Department of the
  University of Brasilia, in 2008, in the Brazilian
  market, showed that 43 of the margerines,
  creamed cookies, cake mixes and cream crackers
  had a higher amount of trans fat than was shown
  on the label.

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Publicity Measures

• Public Consultation of regulations for
  advertising processed foods
• Publicized on the Agência Nacional de Vigilância
  Sanitária (National Health Surveillance Agency)
  site for a period of 90 days.
• Received more than 250 contributions from civil
  society as well as industrial associations
• Forums, public hearings, seminars and debates in
  courses on governments role in regulating
  publicity.
• Proposed Measures
• Identification of foods with high levels of
  sugar, salt, saturated and trans fats
• Messages that circulate after publicizing
  propaganda
• Restrictions of schedules ( 600am to 900pm)
• Criteria for gifts and comercial promotions

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Monitoring Foods

• The National Institute for Health Quality Control
  - INCQS is monitoring the nutritional profile of
  23 types of industrialized foods
• Cold cuts, dairy, finger foods - chips, cookies,
  drinks, flours and ready made meals
• In 2009, the central public health laboratories
  for the 27 federal units will be trained to carry
  out the monitoring.

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Americas Work Group

• Meeting for the Pan-American Health
  Organization in Rio de Janeiro that took place
  in June of this year
• Approval of the Rio de Janeiro Declaration to
  Eliminate Trans Fats
• OPAS representatives, for public health and food
  industry for Brazil, Chile, Argentina and Costa
  Rica unanimously approved a historical
  declaration that aims at eliminating trans fats.
• Recommendation to substitute trans fats from
  industrialized foods where its presence is not
  permitted to be higher than 2 of the total fats,
  oils and margerines and not higher that 5 of the
  total fats in the processed foods.

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Industry Partnership

• In November, 2007, a Cooperation Agreement was
  signed between the Ministry of Healthand the
  ABIA (Brazilian Food Industry Association.)
• Its objective is the reduction of fat, salt and
  sugar content in industrialized foods.
• The first forum for the construction of a working
  agenda with objectives and deadlines took place
  in June of this year.
• The joint effort should promote changes in food
  composition within a time scale of threeto five
  years.

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Brazilian economyoverview a newdevelopment
cycle
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Sustainable growth

• A sustainable growth process is under way.
• A new cycle of economic growth with
• Higher rates of growth
• GDP growth 24 consecutive quarters
• Consumption growth 17 consecutive quarters
• Investment growth 16 consecutive quarters
• Based on foreign trade and increase of domestic
  demand
• Fiscal Commitment
• Inflation under control - Expectation for 2008
  4.7
• Employment creation Annual average (2004-2007)
  1.41 million

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GDP growth(Annual rate )
/ Government projections (PPA 2008-2011) Source
IBGE. Prepared by MF/SPE.
34
International reserves(US billion)
Source BCB. Preparedby MF/SPE.
35
Volume of total bank credit(US billions)
Source BCB. Elaboratedby MF/SPE
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Mass consumption and new middle class
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Mass market

• Enhancement of the Population is Consumption
  Capacity
• Expansion of employment and income
• Minimum wage
• Credit revolution
• Expansion of social programs
• Inflation under control
• Emerging New Middle Class

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Social mobility of the Brazilian
populationNowadays, Class C (middle class)
represents the base of the social pyramid in
Brazil, accounting for 86.2 million people.
Between 2006 and 2007, this social segment
increased its share from 36 to 46 mainly
because of upaward mobility from the lower-level
classes (Classes D/E).
New social stratification pyramid
/ Social classification includes income, wealth
and education class A/B R2,217 class C
R1,062 class D/E R850. Source IPSOS Research
(O Estado de São Paulo, page B16, 30/03/2008).
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Health Economic-Industrial Complex

• If, on one hand, Brazilian Health Systems
  concern with public health leads government to
  stand up against some private interests, on the
  other hand, it opens the market to new
  investments in order to boost national health
  industry.

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National Situation

• 80 of population depend on SUS
• 20 of population have health insurance and
  medical service plans
• 7.000 hospitals
• 70,000 health establishments
• 29,000 Family Health Care teams
• Public Health System
• 2.3 billion clinical procedures
• 300 million medical consultation
• 11.3 million hospitalizations
• 15,000 organ transplants

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Health as Development

• Health as a given right of each citizen and a
  preeminent area of development The public health
  sector must be seen not as a cost, but as
  generating wellbeing and social and economic
  progress.
• Situation in Brazil
• About 8 GDP
• 10 of qualified work of the country
• 9.0 million direct and indirect jobs
• Platform for new technological paradigms (fine
  chemicals, biotechnology, eletronics,
  nanotechnology, materials, etc)
• Articulation of economic logic with health logic
• Development of production base combined with
  health needs

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Health Economic-Industrial Complex (HEIC)
43
Pharmaceutical Market in Brazil (HEIC) 2007
Without duties
Source Febrafarma, 2008.
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Brazilian Pharmaceutical IndustryTop 10 firms
2006
45
Equipments and Materials IndustryNational
Situation

• Market dynamism in the recent period
• Market around US 5 billion
• Prevalence of small and medium sized companies
• Main Challenge products of higher value and
  technology
• Outstanding role of the State in the sales of
  the sector (50)

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Trade Balance of Equipmentsand Materials
(updated by USA inflation)
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
47
PNI BudgetImmunobiological Acquisition
Source Ministry of Health, CGPNI
48
Trade Balance of Reagentsfor Diagnosis
 (updated by USA inflation)
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
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Services SectorNational Situation

• Reduction of the infant mortality in 50 (last
  20 years since SUS was created)
• Life expectancy increased to 73 years
• Public Budget US 70 billion (national level -
  2008-12)
• Improvement in income distribution
• Perspective of explosion of demand and a strong
  pressure on the productive basea challenge and
  an opportunity

50
Evolution of Brazilian Health TradeBalance a
general overview (updated by USA inflation)
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
51
HEIC 2007 Industries Participationin Deficit
Trade
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
52
HEIC 2007 Evolution ofTrade Balance Brazil
USA (updated by USA inflation)
53
HEIC 2007 Trade BalanceUSA Participation (US)
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
54
HEIC 2007 Trade Balance USA(1996-2007 values
in US, updated by USA inflation)
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
55
HEIC 2007 Segments USA Trade Balance
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
56
HEIC 2007 Segments USA Import
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
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HEIC 2007 Segments USA Export
Source Elaborated by Gadelha, 2008 (Coord.) -
GIS/ ENSP VPPIS/FIOCRUZ from Alice Web Data
(SECEX/ MDIC).
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Health and Development in BrazilPolitical Context

• Health in the industrial and innovation policy
• Industrial and Trade Policy (2003)
• BNDES Program Profarma II
• Plan for Science, Technology Innovation (2007)
  priority for the health complex
• Innovation and Production in Health agenda
• The New Health Strategic Plan (Mais Saúde)
• Central role of the Health Industrial Complex
• Politics of Productive Development main policy
  orientation to development

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Health and NationalDevelopment Intervention
(PAC-Health)
Source Gadelha, 2007
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Health as a Window of Opportunity

• Dimension of the national market
• Existence in Brazil of a productive tradition
  (the most developed in Latin America)
• Universal health system high public demand
• Scientific structure and human resources
• A well structured sanitary regulatory system
  organized on a national basis
• Macroeconomic stability (investment grade)
• Projected Industrial GDP growth (yearly) 5
  (2008/11)
• Reduction of income inequalities (high market
  impact)
• Priority of HEIC within national policy

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Final ConsiderationsHealth, Innovation and
Development

• Present confluence of health, innovation and
  industrial policies
• Main criteria to attract investments
• RD activities in Brazil
• Partnership with local private and public
  producers
• Contribution to the trade balance
• Benefits to Health Policy in terms of access and
  product quality (cooperation in the regulatory
  system sanitary, intellectual property, public
  procurement, etc.)

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