1. Addressing the Challenge of NCDs in LAC: Brazil Country Case Study Isabella Danel Christoph Kurowski

2. Brazil Country Case Study  To inform policy dialogue  Lessons learned from developed countries and the potential applicability of the most CE strategies in Brazil  Potential impact of expanding health promotion and improved NCD management on health outcomes  Costs and returns from expanding health promotion and improved NCD management activities  To inform current and future health project (VIGISUS 2 and 3, FHP)  To develop and pilot a model for assessing NCD prevention and control issues in other countries Objectives:

3. Brazil Overview  Largest country in LAC  Population 186 million; 80% urban  Large health disparities  Universal health system since 1990  Decentralized  Family Health Program  % of GDP spent on health: 7.6  Basic health indicators: LE: 69 / aging population TFR: 2.2 IMR: 30 (48 in 1990) HALE at birth: 57/62 (male/female )

4. Burden of Disease by Major Disease Groups, Brazil 1998 Source: BOD study 2002 Thousands of Disability-Adjusted Life Years 24% 21% 55%

5. Burden of Disease, Brazil 1998 Source: BOD study 2002 Thousands of Disability-Adjusted Life Years, Divided into YLLs and YLDs

6. Comparison of Years of Life Lost Among Several Diseases Thousands Years of Life Lost due to Premature Mortality Source: BOD study 2002

7. Avoidable DALYs: Brazil compared to Amer-A* BrazilAmeri-A CausesRate / 1000 ALL270142 Communicable Maternal Perinatal, Nutritional Infectious, parasitic Respiratory infection Maternal Perinatal Nutritional 65 32 8 5 15 5 10 4 1 <1 2 1 Non-communicable Cancer Diabetes Neuro-psychiatric Cardiovascular Chronic respiratory Other 148 15 13 38 31 18 34 118 17 4 42 21 9 25 Injuries Unintentional Intentional 56 45 11 14 9 5 * Very low child and adult mortality: Canada Cuba, USA

8. Prevalence of risk factors in Brazil  Study on nutrition / obesity data is national; all others are smaller studies  Behavioral Risk Factor Survey in most capital cities has been completed – data not yet available  Multiple studies showing wide ranges:  Tobacco – 35-50% for men; 20-33% for women  Inactivity – 45-60% in men; 60-80% in women  Obesity – 10% in adults in ’89 (national survey)  Hypertension – 20-30% in adults; higher among lower SES  Tendencies  Obesity increasing: 6% among adults in ’75; 10% in ’89; also increasing among the poor: 3.6% for lowest female tercile in ’75, 9.7% in ’89  Diabetes increasing: 7.6 / 100,000 for < 15 years old in ’93 (SP); 12.7 in ’98

9. The challenge of NCD’s in Brazil Preliminary results of an economic evaluation

10. Objectives For a subset of largely preventable NCDs, to  estimate the financial costs of treatment and care;  estimate the future burden of disease;  estimate the future financial and economic costs; and  estimate the financial costs of health promotion in comparison with the financial and economic benefits.

11. Model (I) Diabetes mellitus Ischaemic heart disease Ischaemic stroke Chronic obstructive pulmonary disease Cancer (trachea, bronchi, lungs) Physical inactivity Arterial hypertension Smoking

12. Current costs of treating a subset of NCD’s [2002/03] Risk factorSec. DiseaseUSD 2000 [billion] Physical inactivityIHD, CVD*, DM3.4 Arterial hypertension IHD, CVD3.2 Smoking IHD, COPD, “lung” cancer 3.5 Total10.2

13. Future burden of disease 2005/2010 2005201020152020 LE

14. Future burden of disease – selected conditions by risk factor: 2005 to 2010 Risk factorSec. DiseaseBoD 05-10 [DALY, million] Physical inactivityIHD, CVD*, DM4.9 Arterial hypertension IHD, CVD12.6 Smoking IHD, COPD, “lung” cancer 3.7 Total21.2

15. Future costs due to NCD’s 2005/2010 Future costs (status quo persists):  Financial costs: Costs of treating secondary diseases  Economic costs: Financial costs plus productivity losses due to disability and premature mortality

16. Future economic costs due to NCD’s: 2005/2010 Risk factorSec. DiseaseEconomic costs 05- 10 [ USD, 2002, billion] Physical inactivityIHD, CVD*, DM$130.0 Arterial hypertension IHD, CVD$215.2 Smoking IHD, COPD, “lung” cancer $122.0 Total$467.2

17. Model II Physical inactivity Arterial hypertension Smoking Scaling up of AGITA SAO PAULO Treatment of 25% of population c hypertension 10% increase in prices of cigarettes Medical counseling for 25% of smokers

18. Scaling up of AGITA SAO PAULO Intervention: Expansion of program to 25% of population Financial costs of providing intervention 131 million DALY’s averted127,000 Financial costs in care of secondary diseases averted 572 million Losses in productivity averted452 million Benefit cost ratio7.8 Costs in USD 2000

19. Benefit cost ratios Scaling up of AGITA SAO PAULO Treatment of 25% of population c hypertension 10% increase in prices of cigarettes Medical counseling for 25% of smokers 7.8 1.2 2.9 0.1

20. Conclusions  NCDs consume a large share of Total Expenditure on Health  Future economic costs accruing over the period of 2005/2010 equal approximately 70% of GDP in 2002  Effective interventions to prevent NCD’s exist. Some are financially and economically highly attractive.

21. Ministry of Health Response to Health Transition  Fragmented national policies:  National policy to reduce injuries and violence  National anti-tobacco and anti-drug policy  National Food Security policy  National and State Cancer Control policies  National and State Occupational Health policies  Policies not yet operationalized in national / state / municipal health plans  Health Muncipalities project, 2002, UNSP

22. Ministry of Health Structure  Executive Secretariat responsible for establishing health promotion policies and coordinating cross- cutting program  Fragmented national structure:  No one unit responsible for health promotion activities  Four secretariats involved  Greater activity in some states e.g. Sao Paulo

23. Ministry of Health:primary health care  Eight Family Health Program priorities include:  Control of hypertension and diabetes  Health promotion  National plan and guidelines available for hypertension and diabetes detection and control, but not health promotion  Plan has been implemented through training, IEC campaigns, community work  Performance measures on hospitalization and mortality; none for risk factors or HP activities  In process of defining policies to promote healthy lifestyles, health promotion and risk prevention.

24. Interventions in tobacco  National Tobacco Control Program established, 1987  Advisory Board on Tobacco Use Control established, 1987  Warning on cigarettes, 1988; bolder in 2001  Restricted tobacco advertising, 1994  Smoking banned in MOH, 1998  Tobacco considered drug and regulated by ANVISA, 1999  Various media campaigns  Tobacco advertising only at point of sale, 2000  Tobacco use education and control programs in the workplace, schools, and health units

25. Next steps  National health promotion plan -- involvement of multiple sectors; address issues at various levels  Clearly defined priorities and targets  Commitment to financing  Structure that facilitates action  Scale up cost-effective interventions shown to work in Brazil  Piloting interventions found to be cost-effective in other countries based on priorities  HP performance measures include in pactos  Information systems to monitor impact and trends