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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.23 no.6 Rio de Janeiro jun. 2018

http://dx.doi.org/10.1590/1413-81232018236.04782018 

ARTICLE

Brazil’s Unified Health System and the National Health Promotion Policy: prospects, results, progress and challenges in times of crisis

Deborah Carvalho Malta1 

Ademar Arthur Chioro dos Reis2 

Patrícia Constante Jaime3 

Otaliba Libanio de Morais Neto4 

Marta Maria Alves da Silva5 

Marco Akerman3 

1Escola de Enfermagem, Universidade Federal de Minas Gerais. Av. Prof. Alfredo Balena 190, Santa Efigênia. 30130-100 Belo Horizonte MG Brasil. dcmalta@uol.com.br

2Departamento de Medicina Preventiva, Escola Paulista de Medicina, Universidade Federal de São Paulo. São Paulo SP Brasil.

3Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde, Faculdade de Saúde Pública, USP. São Paulo SP Brasil.

4Departamento de Saúde Coletiva, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás. Goiânia GO Brasil.

5Hospital das Clínicas, Universidade Federal de Goiás. Goiânia GO Brasil.

Abstract

This article examines progress made towards the implementation of the core priorities laid out in the National Health Promotion Policy (PNPS, acronym in Portuguese) and current challenges, highlighting aspects that are essential to ensuring the sustainability of this policy in times of crisis. It consists of a narrative review drawing on published research and official government documents. The PNPS was approved in 2006 and revised in 2014 and emphasizes the importance of social determinants of health and the adoption of an intersectoral approach to health promotion based on shared responsibility networks aimed at improving quality of life. Progress has been made across all core priorities: tackling the use of tobacco and its derivatives; tackling alcohol and other drug abuse; promoting safe and sustainable mobility; adequate and healthy food; physical activity; promoting a culture of peace and human rights; and promoting sustainable development. However, this progress is seriously threatened by the grave political, economic and institutional crisis that plagues the country, notably budget cuts and a spending cap that limits public spending for the next 20 years imposed by Constitutional Amendment Nº 95, painting a future full of uncertainties.

Key words: Health promotion; Health policy; Intersectorality; Regulation; Smoking

Introduction

Health promotion consists of a set of strategies and measures designed to support healthy living, meet society’s health needs and improve quality of life1. The Ottawa Charter for Health Promotion, signed in 1986 by 35 countries, states that health promotion should tackle health inequities, promote opportunities for making healthy choices, and enable people to take control of those things which determine their health and quality of life1.

Although the guiding principles of health promotion are set out in both the 1988 Constitution and Basic Health Law (Lei Orgânica de Saúde), which came into force in 1990, the National Health Promotion Policy (PNPS, acronym in Portuguese) only became reality almost two decades later in 2006. This policy was later reviewed by the Tripartite Intermanagement Committee (CIT) and National Health Council and changes were approved in 20142 that recognize the importance of social determinants of health and the adoption of an intersectoral approach to health promotion based on shared responsibility networks aimed at improving quality of life2-4.

Thirty years after the creation of Brazil’s Unified Health System (Sistema Único de Saúde - SUS), it is important to conduct a critical review of the implementation of the PNPS. Accordingly, this article examine progress made towards the implementation of the core priorities laid out in the policy and current challenges, highlighting aspects that are essential to ensuring the sustainability of the PNPS in time of crisis.

Methods

A narrative review of the implementation of the core priorities of the PNPS was conducted drawing on relevant literature, regulatory instruments issued by the federal government between 2005 and 2017, reports and publications published by the Ministry of Health, and books and other publications on the PNPS found on institutional websites. We consulted the data bases of the Latin American and Caribbean Center on Health Sciences Information, better known as BIREME, and the Virtual Health Library using the following describers: “national health promotion policy”, “Brazil”, and “health promotion”.

The analysis focused on the following core themes set out in the PNPS: a) tackling the use of tobacco and its derivatives; b) tackling alcohol and other drug abuse; c) promoting safe and sustainable mobility; d) adequate and healthy food; e) Physical activity; f) Promoting a culture of peace and human rights; and g) Promoting sustainable development.

The results refer to PNPS priorities identified in the review and the methodology of the studies is briefly outlined in the description of the results.

Results

Tackling tobacco use

A study of Brazil’s overall disease burden showed that tobacco use moved from second to forth in the ranking of the leading global risks for burden of disease between 1990 and 20155. This can be explained by a notable decline in the prevalence of smoking in Brazil, which fell from 36.4% in 1989 to 15% in 20136. Annual national telephone surveys conducted between 2006 and 2016 as part of the Noncommunicable Disease Monitoring System (VIGITEL, acronym in Portuguese) showed that the prevalence of smoking in state capitals decreased from 16% in 2006 to 10.2% in 2016 and that prevalence was highest among men (Table 1). This reduction was shown to be statistically significant, demonstrating the effectiveness of the country’s tobacco control efforts7,8.

Table 1 Trends in smoking by sex in Brazil’s 27 state capitals between 2006 and 2016. 

Sex 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 p-value Annual reduction
Male 19.3 19.6 18 17.5 16.8 16.5 15.5 14.4 12.8 12.8 12.7 < 0.001 -0.757
Female 12.4 12.3 12 11.5 11.7 10.7 9.2 8.6 9 8.3 8 < 0.001 -0.503
Both 15.6 15.7 14.8 14.3 14.1 13.4 12.1 11.3 10.8 10.4 10.2 < 0.001 -0.62

Source: VIGITEL – Surveillance of Risk Factors and Protection against Noncommunicable Diseases System, Ministry of Health, 2016.

A notable measure was the prohibition of tobacco advertising in the 1990s, which has been intensified during the last decade. Decree Nº 5.659 issued in 2006 ratified the Framework Convention on Tobacco Control, while Law No 12.546, which came into force in 2011, prohibited smoking in closed public areas, increased taxes on cigarettes to 85%, defined a minimum selling price, and aimed to curb cigarette smuggling. Presidential Decree Nº 8.262 issued in 2014 increased the size of warning labels on cigarette packets, regulated smoke-free areas, and provided that states and local governments shall be responsible for health enforcement and surveillance and imposing penalties for infringement. It is also important to mention that the government improved access to medications and treatment for smoking cessation in SUS services6,8.

These results serve as encouragement for the country to continue investing in health promotion policies directed at smoking prevention. A 30% reduction in smoking prevalence is one of the targets of the Strategic Action Plan for Tackling Noncommunicable Diseases in Brazil: 2011-20229, the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2015-202510, and the Sustainable Development Goals outlined in Agenda 203011. Brazil is considered a primary reference point around the globe for its success and has received a number of awards from the World Health Organization (WHO), Bloomberg Foundation, and Pan American Health Organization (PAHO)6.

The measures implemented by the country are in tune with good practices recommended by the WHO12. It is important to highlight, however, that further steps need to be taken, such as generic packaging, inspection of smoke-free areas and retail outlets, and tackling the illicit cigarette trade. The Supreme Federal Court (SFC) is currently considering Direct Action of Unconstitutionality No4874, brought by the tobacco industry in 2012, questioning the regulatory role of the National Health Surveillance Agency (ANVISA, acronym in Portuguese) in the restriction of the use of chemical additives in tobacco products. The approval of this action by the SFC would have serious consequences for regulatory policy and represent a significant setback for the control of tobacco.

Tackling alcohol abuse

The WHO’s global strategy to reduce harmful use of alcohol published in 2010 details a number of strategies to reduce alcohol consumption, especially among young people. One of the principal initiatives developed by the Ministry of Health to tackle alcohol abuse was the creation of the Alcohol and Drugs Psychosocial Support Centers (CAPS-Ad, acronym Portuguese) in 2010, marking a shift in approach to treating and tackling alcohol dependence in accordance with WHO guidelines12.

The Ministry of Health took the lead in approving laws that tighten the rules for drinking and driving, such as Law N° 11.705/2008, known as the Lei Seca (dry law), and Law N° 12.760/2012, known as the Nova Lei Seca (new dry law), which strengthen the role played by traffic enforcement agents in enforcing life protection and road traffic accident prevention measures related to alcohol. VIGITEL data demonstrate the effectiveness of these types of regulatory measures in changing drink driving behaviors, revealing a statistically significant fall in the consumption of alcohol and drink driving in the years following their implementation13 (Figure 1).

Source: VIGITEL – Surveillance of Risk Factors and Protection against Noncommunicable Diseases System, Ministry of Health, 2016. Malta et al.13. Current data.

Figure 1 Temporal trends* in alcohol abuse in the adult population by sex. VIGITEL, 2007 to 2016.*Trends 2007 to 2016 - Men p = 0.0024; Women p = 0.0057; Men/women p= 0.0013. 

However, these measures are still rather tentative, bearing in mind the measures advocated by the WHO: a) banning of or imposing wide-ranging restrictions on alcohol advertising, b) restrictions on alcohol sales (limits on opening times for retail alcohol sales)12. Other shortcomings include poor enforcement of Law Nº 13.106/15, which criminalizes the sale of alcohol to children and adolescents. The WHO also recommends the adoption of measures to regulate sponsorship activities that promote alcoholic beverages and ban promotions in connection with activities targeting young people12. Another problem is the outdated Law Nº 9.294/1996, which imposes restrictions on the marketing of beverages containing an alcohol content of over 13 degrees Gay Lussac14, thus excluding beers and ice beverages. Changing this law is essential and demands extensive mobilization of civil society considering the commercial interests involved15,16.

Safe and sustainable mobility

The PNPS provides for the promotion of safe, healthy and sustainable environments and surroundings aimed at improving human mobility and quality of life, through participatory integrated planning involving the establishment of partnerships and definition of the functions, responsibilities, and specificities of sector. One notable initiative is the Road Safety in 10 Countries Project coordinated by the WHO and other international organizations, dubbed in Brazil Projeto Vida no Trânsito (life in traffic project – PVT, acronym in Portuguese)17,18. The PVT was implemented in five municipalities (Belo Horizonte, Curitiba, Teresina, Palmas, and Campo Grande)17,18. Give the project’s success, in 2002 the initiative was expanded to all state capitals and cities with over one million inhabitants17,18.

The PVT prioritizes two accident risk factors: drink driving; and excess speed/inappropriate speed for the road conditions. Intervention priorities are defined jointly between different sectors and actions are implemented according to the responsibilities and specificities of each partner institution, which include the Military Police, municipal transport agencies, state and federal highway police forces, and State Transport Department17,18. A study conducted by John Hopkins University of the impact of the PVT in Belo Horizonte, Curitiba, Teresina, Palmas, and Campo Grande in partnership with the Federal University of Rio Grande do Sul, Federal University of Minas Gerais, and Pontifical Catholic University of Paraná used interrupted time series analysis and the Holt-Winters method to analyze rate of mortality due to land transport accidents (LTA), where the control group was all causes of death except external causes. The findings showed that there was a relative reduction in the rate of mortality due to land transport accidents in all the capitals studied except Campo Grande17 (Table 2).

Table 2 Rate of mortality due to land transport accidents and control group, forecast and observed after the implementation of the PVT. Uninterrupted time series analysis. 2004 to 2012. 

Capital/Rate of mortality Observed accumulated rate of mortality Foreseen accumulated rate of mortality Relatve percentage reduction in rates

% (CI95%) p- value
Palmas
Rate of mortality due to LTA 47.67 55.61 -14.3 (-142.8; 114.2) p = 0.25
Rate of mortality - Control group 456.66 430.7 6.0 (-41.4; 53.4) p = 0.20
Difference* -20.3 P = 0.002
Teresina
Rate of mortality due to LTA 48.54 49.38 -1.75(-59.4; 56.0) p = 0.806
Rate of mortality - Control group 898.34 802.06 12.0 (9.9; 14.1) p < 0.001
Difference* -13.7 p = 0.005
Belo Horizonte
Rate of mortality due to LTA 22.1 27.47 -19.5 (-22.7; -16.4) p < 0.001
Rate of mortality - Control group 970.69 936.53 3.6 (-7.9; 15.2) p = 0.06
Difference* -23.2 p < 0.001
Curitiba
Rate of mortality due to LTA 22.96 25.69 -10.6 (-43.7; 22.4) p = 0.05
Rate of mortality - Control group 941.69 900.45 4.6 (-6.5; 15.7) p = 0.17
Difference* -15.2 p = 0.009
Campo Grande
Rate of mortality due to LTA 42.93 43.08 -0.3 (-63.1; -62.5) p = 0.96
Rate of mortality - Control group 946.97 955.29 -0.9 (-24.1; 22.3) p = 0.76

Difference* 0.5 p = 0.06

Source: Mortality Information System (SIM, acronym in Portuguese).

*Difference in relative reduction (Impact of the PVT after implementation in municipalities).

Another important initiative was the United Nations/WHO Second Global High-Level Conference on Road Safety held in Brazil in November 2015. Attended by numerous countries and around 2,000 people, the conference culminated in the “Brasilia Declaration”, which was centered on safe and sustainable human mobility19.

Promoting a culture of peaces and human rights

Health promotion and violence prevention actions have focused on the organization of surveillance of these previously invisible events and local level actions through structuring the country’s health promotion and violence prevention centers. Actions were directed at education, training and capacity building, supporting the implementation of regulatory instruments governing the institutionalization of care, prevention, and protection programs, advocacy, and support for setting up an effective legal framework.

The following advances were made in the establishment of an effective intersectoral legal framework: the Maria da Penha Law (Law Nº 11.340, 7/8/2006); the National Policy for Combating Human Trafficking (Decree Nº 5.948, 26/10/2006); and intersectoral and sectoral plans, such as the National Plan for Combating Sexual Violence against Children and Adolescents (2007) and the VIVA Youth Plan, the latter of which deals with black homicide victimization. These advances are a reflection of intersectoral coordination, which is one of the pillars of the PNPS3.

Violence and Accident Surveillance (Vigilância de Violências e Acidentes - VIVA) in the SUS aims to analyze trends in accidents and violence, particularly domestic violence which has traditionally been underreported. VIVA, created in 2006, helps to bring to light previously invisible domestic and sexual violence and capture self-inflicted violence, like attempted suicide, and other forms of violence, such as child labor, psychological/moral violence, neglect and abandonment, human trafficking, violence caused by legal intervention20, and homophobic violence20. In 2011, violent events began to be registered in the Notifiable Disease Information System in accordance with Ministerial Order 104/201121.

Figure 2 shows that the number of mandatory notifications of violence increased between 2011 and 2015, from 107,530 to 242,347, and that 70% of cases involved violence against women. This increase shows that reporting and surveillance of violent events improved over the period. Furthermore, the data provides important inputs to help promote the integration of victim protection actions between the health sector and victim care and protection networks20.

Source: Accident and Violence Surveillance (VIVA). Ministry of Health.

Figure 2 Number of notifications of interpersonal and self-inflicted violence (total and by men and women). Brazil, 2011 to 2015. 

One of the challenges faced by the PNPS is the alignment of the policy with the “Curitiba Charter”22. One of the legacies of the 22nd IUHPE World Conference on Health Promotion held in May 2016, the charter reaffirms the need for health promotion to tackle the social and environmental determinants of health, firmly placing equity at the center of the health promotion agenda as an essential element for the promotion of human rights and a culture of peace and nonviolence.

Another major challenge is the risk of setbacks for human rights policies and regulatory framework. Examples include pressure from commercial interests and the arms lobby for changes to the Disarmament Statute (Law Nº 10.826, 22/12/2003), which has played a major role in reducing homicide in 2004, demonstrating that it is possible to prevent violence and that this sort of measure cannot be abandoned. A study conducted by Souza et al.23 showed that the voluntary hand over of firearms in 2004 led to a drop of around 3,200 homicides in 2004. Additional threats that need to be addressed include calls for a reduction of the minimum age of criminal responsibility and changes to the Child and Adolescent Statute, and proposals to tighten abortion laws, which currently allow abortion in specific cases.

Adequate and healthy food

The right to adequate food is a fundamental human right and a determinant of health. Various food and nutrition security actions were developed by the Ministry of Health between 2003 and 2015, including: intersectoral and intrasectoral collaboration to promote the care and autonomy of individuals and communities2,24; implementation of family health support centers; systemic monitoring of compliance with the health-related requirements of the family benefit program Bolsa Família; implementation of the National Food and Nutrition Surveillance System (SISVAN, acronym in Portuguese); promotion of breastfeeding; actions to promote healthy eating developed under the School Health Program, created by Presidential Decree in 2007 and implemented across around 87% of Brazil’s municipalities in 2015; and actions developed under the Strategic Action Plan for Tackling Noncommunicable diseases in Brazil 2011-2022 to encourage the consumption of fruit and vegetables, reduce salt intake, and curb the growth in obesity9.

The Food Guide for the Brazilian Population version 2006 and the revised 2014 edition mark a new paradigm for understanding eating habits within the context of the food system and the nutritional transition currently occurring in the country, becoming a reference point for various countries25. The guide contains a comprehensive set of recommendations regarding foods and eating habits aimed at supporting health promotion and well-being25,26.

Another important initiative was the Salt Intake Reduction Plan, which coordinated actions together with the food industry aimed at reducing sodium levels in processed foods. Implemented gradually, voluntarily and based on biannual goals, the plan focuses on the development of new technologies and formulations and changing consumer palates27,28. The terms of commitment were monitored in 2011, 2013-2014, and 2017. Nilson et al.28 analyzed the results of the monitoring, obtaining the levels of sodium of industrialized foods directly from the mandatory information that must appear on product labels taken from the food company websites and packaging. Table 3 shows the average sodium levels of the 16 food subcategories evaluated by the study. Levels showed a continual decline over the period for all products except corn-based savory snacks. Statistically significant reductions in the level of sodium against the baseline were found in 65% of the subcategories28.

Table 3 Voluntary agreement with the food industry and monitorin of sodium levels on selected subcategories of food products compared to baseline 2011 and dm monitoring cycles 2013 – 2014 and 2017, Brazil. 

Category n Sodium 2011 (mg/100g) n Sodium 2013-2014 (mg/100g) n Sodium 2017 (mg/100g) p* Reduction




Average Average Average 2011-2017
Sliced bread 117 426.5 87 380.3 82 365.0 < 0.001 14,3
Bread buns 9 436.1 8 388.5 11 374.4 0.359 14,2
Cake mixture 125 372.3 201 309.6 135 291.6 < 0.001 21,8
Instant pasta 90 1,960.0 97 1,662.3 87 1,598.6 < 0.001 18,5
Potato chips 22 547.6 28 513.3 30 475.4 0.237 13,2
Mayonnaise 31 1063.3 41 891.3 29 852.7 < 0.001 19,8
Dairy products 80 659.5 80 524.4 45 434.5 < 0.001 34,1
Margarine 94 739.9 84 689.8 46 544.3 < 0.001 26,4
Cheese 26 600.2 51 461.2 28 517.2 0.039 13,8
Stock cubes and powder 41 1,035.9 26 985.2 35 952.1 0.003 8
Cookies 17 359.2 45 318.2 52 293.9 0.019 18,4
Cookies with fillings 176 259.5 198 242.6 185 235.5 0.006 9,3
Crackers 39 695.8 94 660.4 84 590.9 0.031 15
Breakfast cereal 27 428.9 21 406.7 15 359.2 0.209 16,3

Source: Nilson et al.28.

Despite progress, significant challenges remain in the fight to curb the growth of obesity in the country, including the need to improve the effectiveness of regulatory measures, approve legislation governing the taxation of ultra-processed foods, create subsidies for healthy food, and restrict or ban food advertising aimed at children12. It is important to mention that such measures face strong opposition from the food industry and the extensive mobilization of civil society is critical to ensure their implementation.

Physical activity

Actions related to this theme gained momentum in 2005 and include the following: a) organization of the surveillance of risk factors and protection against noncommunicable diseases, enabling the monitoring of the practice of physical activity through population surveys such as VIGITEL between 2006 and 20167, the three editions of the National School Health Survey (PENSE, acronym in Portuguese), conducted in 2009, 2012 and 2015, and household surveys, such as the health component of the National Household Sample Survey (2008) and National Health Survey (2013)3.

Other initiatives include the funding of municipal physical activity projects and the Health Gym Program created in 2011 involving the installation of community fitness facilities and community health promotion activities3. Studies conducted by various universities using quantitative and qualitative methodologies show that this program is effective3,29,30, demonstrating that community-based strategies to promote physical activity are effective in increasing the level of physical activity among the population29,30. The coordination of activities with primary health services through family health support centers and the incorporation of health promotion into the daily practices of family health teams has been essential to the success of the program.

Promoting sustainable development

Between 2006 and 2015, numerous intersectoral partnerships were established involving the Ministry of the Environment, Ministry of National Integration, Ministry of Cities, the Executive Office of the President, and state and local government health departments to implement sustainable development plans in areas such as the Mid North Tourist Region (states of Piauí, Maranhão, and Ceará) and the Xingu Sustainable Regional Development Plan, among others. Brazil also hosted Rio+20, whose outcome document recognizes that health is a precondition for sustainable development and played an important role in ensuring that health was incorporated as one of the goals of the United Nation’s 2030 Agenda for Sustainable Development11,31.

Discussion

This article provides an overview of the results of the PNPS, highlighting progress made towards the implementation of the core priorities laid out in the policy and current challenges. Various health promotion projects have been developed at local level together with the implementation of various national programs, such as Vida no Trânsito, the Health Academy Program, Health Promotion and Violence Prevention Centers, and the School Health Program. The review of the PNPS carried out in 2014 was an important milestone for enhancing this policy and stakeholder engagement4. Other important steps forward have been taken, including the incorporation of the PNPS into the budgetary planning process, allocation of funding to projects to promote physical activity, healthy eating, smoking prevention, and violence prevention, as well as human resource development and capacity-building and social mobilization3. The Health Promotion Policy Steering Committee met on a monthly basis between 2005 and 2015, articulating and coordinating intra and intersectoral actions, setting joint agendas, and facilitating the integration of processes3. The continuity of this body is essential for the sustainability of the PNPS.

The guiding principles and core priorities of a policy such as the PNPS and the efforts and funding directed towards its implementation say much about the values that guide the concepts of health, citizenship, sustainable development, and quality of life for a given society. They also reveal the government’s capacity to develop actions and programs in line with the principles laid out in this type of policy.

However, the progress made to date is seriously threatened by the grave political, economic, and institutional crisis that plagues the country, aggravated by the parliamentary coup instigated in 2016, painting a future full of uncertainties marked by a minimal state, budget cuts, fiscal austerity, deregulation, and the discontinuation of measures to promote social inclusion32,33. One can only speculate as to what will become of the SUS and social policies in the coming years. The approval of Constitutional Amendment Nº 95 and the New Fiscal Regime have frozen government spending for the next 20 years32,33. The reduction of federal funding is set to affect local and state government and shrink public health actions and services, including those envisaged under the PNPS and that depend on intersectoral efforts, signalling huge challenges that threaten the very sustainability of the PNPS and the SUS.

Stucker et al.34show that countries that adopt budget cuts gravely jeopardize health. Fiscal austerity only aggravates the crisis, deepening inequalities, which are unfair given the unequal redistribution of burdens. Thus, the above measures adopted by the government are only likely to aggravate the crisis and jeopardize health, resulting in the urgent need for research into the impacts of fiscal austerity on the living conditions and health of the Brazilian population.

Another critical issue is the weakening regulatory role of the government. The country is witnessing the ever-growing power of business in Brazilian politics and the coming together of political forces around conservative agendas. In this respect, various attempts have been made to delegitimize the regulatory role of ANVISA, both by the National Congress, in relation to anorectic drugs, agrochemicals, and cancer drugs for example, and by the tobacco industry, which, through an action in the Supreme Court, is seeking to prevent the enforcement of restrictions on the use of chemical additives in cigarettes. The weakening of the regulatory role of the government will have serious impacts on the SUS and the Brazilian population.

As to the outlook for the PNPS, Agenda 203011, with its 17 Sustainable Development Goals, offers a new perspective on health promotion. The Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development calls for a vigorous integrated response designed around four pillars: “healthy cities”, “good governance”, “health literacy”, and “social mobilization”. This key international agenda should be coordinated at the national, state and local level and calls for the reactivation the PNPS Steering Committee to strengthen intrasectorality and seek new alliances outside the health sector.

Conclusion

Writing “history of the present” or, as Sayuri35 suggests, “writing history hot off the press”, is a challenge subject to limits, since it describes “temporary dwellings” of history. Despite significant progress in the short history of the PNPS, we recognize that 30 years after the creation of the SUS we are still far from overcoming a health care model centered on disease and medical-hospital care. On the whole, the health promotion actions developed over recent years do not constitute a new and necessary way of delivering healthcare and tackling the social determinants of health.

It is essential to resignify the role and importance of the PNPS for the SUS, particularly considering the need to develop strategies to address the challenges imposed by the trends in the country’s epidemiological, demographic, and nutrition profiles.

The reform movement currently underway signals that we are living in difficult times, characterized by the restoration of a conservative order36 that influences all walks of life and has a major impact on policy. Rising unemployment and an increase in precarious work, the breakdown of the welfare state, the dismantling or scrapping of social protection and inclusion policies, relaxation of environmental protection policies and regulations, the rearmament of society, and other conservative reforms currently underway, are indicative of the challenges facing not only the SUS and policies such as the PNPS, but also democracy, social justice, and citizenship. It is necessary to go one step further and combat the predominance of individualism, empowering society to demand that the government fulfils its commitments to ensure the effective implementation of the PNPS.

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Received: December 11, 2017; Revised: January 30, 2018; Accepted: February 27, 2018

Collaborations

DC Malta participated in designing, analyzing and interpreting the data, writing the first version of the article, critically reviewing the relevant intellectual content and approving the version to be published. AA Chioro dos Reis, M Akerman, OL Morais Neto, MMA Silva and PC Jaime participated in the analysis and interpretation of the data, relevant critical review of the intellectual content and approval of the version to be published.

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