Financial constraints and incentives for the prevention and control of obesity in the state of Rio de Janeiro, Brazil

Freitas, Matheus Pereira; Burlandy, Luciene; Castro, Luciana Maria Cerqueira; Santos, Cláudia Roberta Bocca; Teléfora, Katiana dos Santos; Cruz, Myrian Coelho Cunha da; Teixeira, Márcia Regina Mazalotti

doi:10.1590/1413-81232024294.01502023EN

Matheus Pereira Freitas

study design

data collection and analysis

writing of the final version of the article

Faculdade de Nutrição, Universidade Federal Fluminense. Rua Mário Santos Braga 30/413, Centro. 24020-140 Niterói RJ Brasil. freitasmatheusp@gmail.com

https://orcid.org/0000-0002-3052-9381

Luciene Burlandy

study design

data collection and analysis

writing of the final version of the article

Departamento de Nutrição Social, Universidade Federal Fluminense. Niterói RJ Brasil.

https://orcid.org/0000-0003-0875-6374

Luciana Maria Cerqueira Castro

study planning

data collection

analysis and review of the final version of the article

Departamento de Nutrição Social, Universidade do Estado do Rio de Janeiro. Rio de Janeiro RJ Brasil.

https://orcid.org/0000-0003-2793-9950

Cláudia Roberta Bocca Santos

study planning

data collection

analysis and review of the final version of the article

Departamento de Nutrição em Saúde Pública, Universidade Federal do Estado do Rio de Janeiro. Rio de Janeiro RJ Brasil.

https://orcid.org/0000-0002-4312-3049

Katiana dos Santos Teléfora

data collection and analysis

review of the article text

Secretaria de Estado de Saúde do Rio de Janeiro. Rio de Janeiro RJ Brasil.

https://orcid.org/0000-0003-0655-7363

Myrian Coelho Cunha da Cruz

data collection and analysis

review of the article text

Fundação Municipal de Saúde de Niterói. Niterói RJ Brasil.

https://orcid.org/0000-0002-6945-4890

Márcia Regina Mazalotti Teixeira

data collection and analysis

review of the article text

Divisão de Vigilância de Doenças e Agravos Não Transmissíveis, Secretaria de Estado de Saúde do Rio de Janeiro.

https://orcid.org/0000-0002-3528-5814

Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Document Title	Factors related to the Institutional structure of SUS	Factors related to Funding	Relationship with actions for Obesity Prevention and Control (OPC)
National Primary Care Policy (PNAB) 2006. Ordinance GM/MS no. 648, from March 28, 2006. Approved PNAB, revised guidelines, and regulations for the organization of the Family Health Program (FHP) and the Community Health Agents Program (CHAP).	Incorporation of the concept of Primary Health Care (PHC); Expansion of the Family Health Strategy (FHS) throughout the country as a replacement for traditional PHC).	Minimum wage for PHC (PAB) fixed + variable as the modality for funding PHC actions; The set value for all municipalities and the variable to boost the implementation and re-organization of the healthcare model: FHS; ACS; Oral Health (OH); Compensation for Regional Specificities; Indigenous Health (IH); and Health in the Prison System.	This does not specifically mention any PCO actions, but the set of action goals in strategic areas establishes control of diabetes and hypertension. It indicates a set of actions with direct and indirect impacts on obesity. It characterizes PHC as a set of individual and collective health actions, which include the promotion and protection of health, prevention of grievances, diagnosis, treatment, rehabilitation and health maintenance. It prioritizes the FHS in its organization, according to precepts set forth by SUS.
Organic Law for Food and Nutritional Safety (Law no. 11346/2006) - creates the National System for Food and Nutritional Safety (SISAN), with the purpose of ensuring the human right to adequate food (DHAA).	Dietary and Nutritional Surveillance (VAN); promotion of health; nutrition, biological, health, nutritional and technological quality of foods; ethnical, racial, and cultural respect.	The states will provide resources in budgets from programs and sanctions of the several sectors that are part of the SAN, which are compatible with the compliance established by DHAA in the SAN plans and in the Administration pact.	This does not mention obesity directly, but deals, in a broader perspective, with the guarantee of access to adequate food as a human right.
National Policy for Food and Nutritional Safety set forth by the Presidential Chief of Staff, from August 25, 2010. Regulates Law no. 11346, from September 15, 2006.	Definition of parameters for the formulation of the National Plan for SAN with intersectoral guidelines, which include SUS.	Details on funding mechanisms in the realm of SISAN.	Recommends intersectoral actions aimed at ensuring the human right to adequate food.
Ordinance MS no. 2488 GM from October 21, 2011. Approved the PNAB 2011, revising guidelines and regulations for the organization of PHC for the FHS and the CHAPs Program.	Solution for critical strangleholds by means of the strategies for the Requalification of the Basic Health Unit (BHU); National Program for Access and Quality Improvement (PMAQ); More Doctors Program (PMM); e-SUS; different kinds of teams; increments in investments and resources.	Change in base calculation for fixed PAB. Provides conditions for the transfer of resources to the implementation of priority programs: FHS; CHAP; NASF; Street Clinics; FHS for riverside communities; Home Care, PSE, Health Gyms. Differentiates per-capita values and benefits poorer municipalities; created the Quality Component, resources dependant on commitments and results generated by PMAQ	This does not specifically mention any OPC actions; however, it does indicate a set of actions which have direct or indirect impacts on the condition, such as the universalization of PSE and its expansion to daycare centers, creation of Centers in Health Gyms, actions of health promotion, prevention of grievances, health surveillance; and educational actions. The PSE and the Health Gyms are potentializing actions to combat being overweight and obesity.
Ordinance no. 2715, from November 17, 2011. Updates the National Policy for Food and Nutrition (Política Nacional de Alimentação e Nutrição - PNAN), created in 1999.	Improvements in the conditions of AN and Health; promotion of nutritional practices which are adequate and healthy, VAN, the prevention and integral care for AN grievances.	Priority in tripartite Funding for PNAN, adequation of equipment and physical structure of healthcare services; VAN and qualification of the workforce.	Indication of strategies, actions, and responsibilities for the fight against being overweight and obesity.
Ordinance no. 424, from March 31, 2013. Redefines the strategies for the organization of the OPC as a line of care of RAS NCD	Definition of guidelines for the organization of the line of care for overweight and obese individuals in the realm of RAS; definition of attributions of the RAS components.	Guaranteed funding is highlighted as a guideline to prevent and control overweightness for RAS and individuals with NCD	Indication of actions to be implemented at each RAS point and criteria to define the flow of care of individuals with overweightness and obesity, to ensure integral healhcare.
Ordinance no. 425, from March 11, 2013. Establishes technical regulations, norms, and criteria for the High Complexity Assistance provided to Individuals with Obesity.	Definition of facilities with High Complexity Assistance for Individuals with Obesity: hospitals with diagnosis and therapeutic specialized support, technical conditions, physical facilities, equipment, and human resources.	Funding increments for the component “ambulatory and pre-operatory services”, for procedures in facilities which are credited as High Complexity Assistance for Individuals with Obesity.	This establishes that High Complexity Assistance for Individuals with Obesity should participate in an articulated and integrated manner, with the Health Care Network for People with Chronic Diseases in the SUS level, and with lines of care defined locally, for treatment of being overweight and obesity.
Intersectoral Strategy for Prevention and Control of Obesity: recommendations for states and municipalities. Brasília: CAISAN, 2014.	Indication of the need to organize RAS at the SUS level to combat being overweight and obesity.	Actions related to guaranteed funding, such as 30% of the PNAE resources for purchases of family agricultural products; Highlights the existing resources and implementation mechanisms..	Axis of action I - Availability and access to adequate and healthy foods; II - Education, communication, and information; III- Promotion of healthy lifestyles; IV - VAN; V- Integral healthcare to individuals with obesity, and VI - Regulation and Quality control of foods.
CE 95, from December 15, 2016. Institutes the New Fiscal Regime and makes other provisions.	Freezing for 20 years of the expenses in the health area, which represents a challenge for the maintenance of the PHC structure.	In a scenario of increasing expenses, the State freezes healthcare expenses.	Considering the under-funding of SUS in general, consequently, the actions related to combatting being overweight will be impacted.
PNAB 2017. Ordinance MS no. 2436, from September 21, 2017. Establishes the revision of guidelines for the organization of basic health at the SUS level.	Reduction of ACS per team; Reduction in minimum workload.	Incorporation of the model of Funding based on performance parameters.	It does not mention specifically any OPC actions, but instead reduction in CHAs and in the workload, which impacts the quality of healthcare for hypertensive and diabetic patients. Actions such as PSE and Health Gyms.
2nd revised National Health Plan for SAN - 2016-2019. Revised. Brasília, September 2018. CAISAN.	Definition of goals related to food and nutritional safety	Problematizes the low use of the resources from the National Plan for SAN; Lists values of the expenses related to the challenges and actions in the Plan.	Definition of indicators and goals for the promotion of adequate and healthy eating.
CE no. 103, from November 12, 2019. Changes the social security system and rules for transition and transitory regulations.	This has no direct connection with the structure, but it represents the deconstruction of constitutional rights established in the 1988 Constitution.	Indicates, together with other policies, a change in the models of funding for public policies.	This has no direct relationship with actions for obesity control.

Document Title	Factors related to the Institutional structure of the SUS	Factors related to Funding	Relationship with actions of Obesity Prevention and Control (OPC)
Presidential Decree no. 6286, from May 12, 2007. Institutes the School Program Health (SHP).	Defines the objective of contributing to the complete education of students in the public Elementary Education system through actions of healthcare prevention and promotion, thus constituting an intersectoral action at the SUS level.	The municipalities which adhere to the program have guaranteed financial resources specifically for the development of actions.	Nutritional evaluation, Promotion of healthy nutrition and physical activities.
Ordinance GM/M no 719, from April 07, 2011. Created the Health Gym Program (Programa Academia da Saúde).	Implementation of centers with infrastructure, equipment, and personnel qualified to guide individuals on bodily practices and physical activities.	Guarantee of resources from the Federal Government for the implementation of actions related to the Program.	Health promotion, disease prevention, care production, and healthy lifestyles through the practice of physical activities and healthy nutrition, integrative and complementary practices.
Ordinances define adherence of towns to the SHP and Growing Healthy (Crescer Saudável) programs - enables one to receive the agreed upon financial resources. Ordinance GM/MS no. 2706, from Oct. 18, 2017: cycle 2017/2018; Ordinance GM/MS no. 2264, from August 30, 2019: cycle 2019/2020; Ordinance GM/MS no. 1320, from June 22, 2021: 2021/2022 cycle.	Definition of criteria related to the calculation of financial incentives passed on to municipalities and the Federal District.	Priority municipalities receive specific resources for the implementation of actions due to the prevalence of obesity in children younger than 10 years of age.	Establishes, at the level of the SHP program, a set of actions to be implemented with the purpose of contributing to combatting childhood obesity.
Ordinance no. 2979, from November 12, 2019. Institutes the Prevent Brasil Program, which establishes a new model to fund the costs of PHC at the SUS level.	Transformation of the funding model based on the number of individuals registered and goals established by the Ministry of Health (MH).	Reduces financial transfers for towns; demands enrollment (informatization), worsening the difficulties for each town; includes programs and actions related to the fight against being overweight and obesity (Health Gyms and SHP) as strategic, with guaranteed funding. Parameters for the transfer of resources: 1. Number of individuals registered at the PHC; 2. Performance based on results achieved in relation to goals; and 3. Incentives for priority actions, and programs.	Indication of the Health Gyms and SHP programs as strategic
Technical note no. n° 3/2020-DESF/SPHC/MS. Expanded Center for Primary Family Healthcare (Núcleo Ampliado de Saúde da Família e Atenção Básica - NASF-AB) and Prevent Brasil Program.	Reinforces the transformation of the multidisciplinary teams, disconnecting them from the NASF-AB teams, providing more autonomy to municipal administrators. Moreover, it reinforces the impact in the certification of new NASF-AB teams. The technical note indicates the structure of the teams for the promotion of articulation between different professionals.	The note reinforces the change in the model of funding, for one with emphasis on the cared-for individual. Establishes that, during the transition of the models, no town shall suffer any losses in terms of transferred resources.	Due to the greater autonomy provided by the Prevent Brasil Program, the state and municipal administrators can direct more financial incentives to PHCactions and services.
Protect Program, Ordinance GM/MS no. 1863, from August 10, 2021. Institutes financial deferral incentives for support costs generated by municipalities with a population size below 30,000 inhabitants in order to implement actions of child obesity prevention and care at the level of the National Strategy for Child Obesity Prevention - Protect (Estratégia Nacional para a Prevenção e Atenção à Obesidade Infantil - Proteja). Ordinance GM/MS no. 2670, from October 13, 2021: Defines and enables participating municipalities to receive federal financial incentives for funding the Proteja Program.	Establishment of federal financial incentives for funding, geared toward towns with less than 30,000 inhabitants in order to implement the actions for child obesity prevention and care at the level of the National Strategy for Child Obesity Prevention - Protect	Establishment of criteria and indicators for the transfer of financial resources to towns.	Financial incentive seeks to: intensify VAN actions of health promotion and prevention and care provided to combat child obesity; promote adequate care that is integral and opportune in identified cases of child obesity; implement actions in schools to make them spaces which promote health, encouraging the consumption of adequate and healthy foods and the regular practice of physical activities; to encourage the implementation of actions of an intersectoral and community nature, which promote healthy environments and support healthy eating, and encourage the practice of physical activities around the cites; to implement actions of communication in order to promote healthy eating and the practice of physical activities; and encourage permanent health education of all professionals involved in child care.

Document Title	Factors related to the Institutional structure of SUS	Factors related to Funding	Relationship with actions of Obesity Prevention and Control (OPC)
Ordinance GM/MS 1357, from June 23, 2006. Ordinance MS 1738, from August 19, 2013. Ordinance 1941, from June 12, 2014. Ordinance 1677, from October 02, 2015. Ordinance 1060, from May 24, 2016. Ordinance 2512, from September 28, 2017. Ordinance 445, from February 23, 2018. Ordinance 2076, from May 8, 2019 Ordinance 802, from April 14, 2020.	Instituted the Food and Nutrition Fund (FAN). Financial resources from the Healthy Food program to boost the organization and structuring of actions of AN by State and Municipal Secretaries.	Financial incentive allocated to municipalities/Federal District with population above 150,000 inhabitants.	Funding of services and expenses related to actions of AN at the RAS, especially at the PHClevel, prioritizing: I - promotion of adequate and healthy food; II - food and nutritional surveillance (VAN); III - prevention of nutritional grievances, especially being overweight and obesity, undernourishment, anemia due to iron deficiency, hypovitaminosis A, and beriberi; IV - qualification of the workforce.
Ordinance 55, from January 6, 2017. Ordinance 3799, from December 26, 2017. Ordinance 3943, from December 28, 2017.	Straightening the actions of AN by providing resources to the State and Municipal Health Secretaries.	Financial incentives for the implementation of AN actions, respectively, for municipalities with populatiosn between 30,000 and 149,999 inhabitants; between 30,000 and 39,870, and between 39,870 and 78,800 inhabitants.	Similar to Ordinance GM/MS 1357, from June 23, 2006, which created FAN.
Ordinance by Ministry of Health (MH) 3992/2017. Changes Consolidation Ordinance 6/GM/MH, from September 28, 2017, to define the funding and transfer of federal resources for public services and actions in health by SUS.	Changes the conditions for the transfer of resources to States and Municipalities; Reallocation of resources related to the funding and investment package.	Criteria to transfer federal resources based on the production of services guided by the historical series of expenses and financial incentives. Transforms five funding packages into only two (funding and investment).	The application of transferred federal resources should meet the purpose of the Work Program of the General Federal Budget as well as the plan for health and the local Annual Health Programing. Therefore, it is necessary to include being overweight and obesity in those instruments.
Ordinance 423, from February 23, 2018. Ordinance 4393, from December 28, 2018. Ordinance 4394, from December 28, 2018. Ordinance 4395, from December 28, 2018.	Strengthening of AN actions through financial resources for State and Municipal Departments of Health.	Incentive for funding and AN actions, respectively, for municipalities with populations between 78,801 and 149,999; between 32,709 and 35,670; between 35,710 and 46,548; between 46,567 and 149,999 inhabitants.	Similar to Ordinance GM/MH 1357, from June 23, 2006, which created the Food and Nutrition Fund.
Ordinance 447, from February 25, 2018. Ordinance 1210, from May 18, 2020.	Financial support to structure VAN by means of acquiring anthropometric equipment, according to Consolidation Ordinance 06/GM/MH, from September 28, 2017.	Municipalities which were contemplated with PHC teams, which adhered to the National Program for Access and Quality Improvement in Primary Healthcare (PMAQ-AB) which has never received funding for the Structuring of VAN and has never received financial incentives for the structuring of the Health Gym Centers.	Financial support provided to municipalities and to the Federal District in the structuring of Food Surveillance in order to achieve a more adequate and humane diagnosis of food and nutrition diagnoses by providing adequate equipment for this purpose.
Ordinance 2068, from August 8, 2019. Ordinance 2088, from August 9, 2019.	Strengthening of AN actions through financial resources for Municipal and State departments of health.	Financial incentives for the implementation of AN actions, based on the PNAN for municipalities with populations between 30,000 and 149,999 (2019) and 30,000 and 32,654 inhabitants (2018).	Similar to Ordinance GM/MH 1357, from June 23, 2006, which created the FAN.
Ordinance 2994, from October 29, 2020.	Established, in an exceptional and temporary nature, federal financial incentives allotted for the care of individuals with obesity, diabetes mellitus, or hypertension at the PHC level, during the emergency in public health caused by the COVID-19 pandemic.	Indication of values to be transferred to municipalities with the aim of strengthening the actions to combat being overweight and obesity, based on the number of FHTs and CHAs.	Funding of actions against being overweight and obesity.
Ordinance 1012, from May 18, 2020.	Funding for FAN.	Ordinances referring to FAN regarding the structuring and implementation of AN actions by State departments and municipalities with 30,000 to 149,999 inhabitants.	Similar to Ordinance GM/MH 1357, from June 23, 2006, which created FAN.
Ordinance GM/MH 3297, from December 4, 2020, as part of the Nursing and Feeding Strategy (Estratégia Amamenta e Alimenta Brasil - EAAB), in PHC.	Financial incentive allocated to the AN fotor promote breastfeeding and healthy complementary nutrition.	Prioritized municipalities which have taken actions and been registered in the AB e-administrator system, the EAAB workshops between January 1, 2015, and August 31, 2020.	AN actions to promote breastfeeding and complementary nutrition are essential for the prevention of being overweight and obesity.
Ordinance 1012, from May 18, 2020.	Strengthening of actions for food and nutrition through financial resources for State and Municipal Departments.	Financial incentives for the structuring and implementation of AN Departments of Health in municipalities with a population between 30,000 and 149,999.	Similar to Ordinance GM/MH 1357, from June 23, 2006, which created FAN.
Ordinance 894, from May 11, 2021.	Financial incentives to support PHC services in the fight against the COVID-19 pandemic.	The calculation for the transfer of funding will be based on a per capita values for municipalities, referring to the estimate conducted in 2019.	Financial incentives for the funding of actions and services at the PHC level to fight against the COVID-19 pandemic and the organization of RAS, and healthcare at PHC.
Ordinance GM/MS n1127, from June 2, 2021.	Funding for FAN.	Ordinances related to FAN for municipalities with populations above 30,000 inhabitants, transferred directly to the State or Municipal Health Fund, in annual transfers.	The financial resources must be used for AN actions, prioritizing the Promotion of Healthy Eating, the prevention of grievances and AN, especially concerning being overweight and obesity.

Document Title	Factors related to the Institutional Structure of SUS	Factors related to Funding	Relationship with actions for Obesity Prevention and Control (OPC)
State Health Plan - 2012-2015. Rio de Janeiro: SES/RJ, 2012.	Structuring, expansion, and qualification of PHC in municipalities.	Planning or budget in terms of the allocation and use of financial resources needed to reach the established goals and objectives.	Implementation of the national guidelines of the Plan of Strategic Actions of the DCNT; SHP; Health Gyms; NASF; Capacitation of CHA, NASF nutritionists and ATAN coordinators.
Strategic action plan to combat non-communicable diseases (NCDs) in the State of Rio de Janeiro (RJS), 2013-2022.	Definition of goals, objectives, and responsibilities related to the strategic action plan to combat NCDs in RJS.	Although it has no direct relationship with elements of Funding, the Plan, by recommending actions and strategies, highlights the need for directing resources for this purpose, and its formulation was set forth under Ordinance SVS/MH 23, from August 9, 2012, through the transfer of federal resources.	Definition of actions related to several axes, including: surveillance, health promotion, and integral care; establishment of an action schedule for the execution of the Plan.
State Health Plan - 2016-2019. Rio de Janeiro: SES/RJ, 2016.	Boosts the expansion and the qualification of PHC in municipalities.	Planning of budget in terms of the allocation and use of financial resources to reach the established objectives and goals.	Care provided to patients with morbid obesity by offering bariatric surgery and repair surgery, through public announcement; Implementation of the State Plan to Combat NCDs
SES Resolution 1846, from May 9, 2019. Approves the Funding for PHC in the state of RJ.	The PHC Funding Program was established in RJS due to the need to support sustainability and boost expansion, and quality in innovative PHC. For that, the program aims to support FHS by maintaining and expanding FHTs.	Direction of financial resources through three components: 1. PHC Sustainability Component; 2. FHS Expansion Component; 3. PHC Performance Component. Moreover, the resolution also defines the classification criteria of each transfer.	Strengthening of the PHC structure in RJS through the transfer of financial resources, which consequently expands the possibility of actions related to the fight against being overweight and obesity in RJS.
Resolution SES 1925 from October 31, 2019. approves the program of the funding of health promotion in RJS. The regulations of the state’s program to fund health promotion are instituted, for the year of 2019.	Support to the structuring of DANT epidemiological surveillance teams, with the purpose of improving quality and outreach in health situation analyses.	The definition of the values, by town, will follow the classification in the last assessment of the Human; Development Index, criteria “Education” - HID-S, conducted by the 2010 IBGE. This criteria was chosen as it is considered to be that with the highest impact on the change in behavior and lifestyles of the population.	COFI-PS has the objective of supporting the Health Promotion (PS) actions conducted by the municipalities, based on DANT epidemiological surveillance teams, with capacity to foment the quality and outreach of the analysis of the health situation regarding the main NCDs and grievances, prioritizing actions to reduce and control risk factors, according to the epidemiological profile of the regions, reaching targets of improvements in the health conditions of the population under its jurisdiction. Surveillance Component I - Health situation analysis, risk, and protective factors, and transfers of resources, based on the recognition of the health situation and causes of mortality in RJS. Inadequate food consumption and offering of executive actions regarding heathy eating practices.
Pluriannual Plan, Rio de Janeiro, 2020. Rio de Janeiro: SES/RJ, 2020.	A program named Food Security was created, which combines several state departments.	The SES creates a budgetary action named: “Food and Nutrition: Surveillance, Promotion, and Organization of Nutritional Care.	The referred action combines the resources of both the federal and state treasuries. Column: This budgetary action joined the actions of the SHP, Health Gyms, and Agreement by LCSO
State Health Plan, 2020-2023. Rio de Janeiro: SES/RJ, 2020.	To support, technically and financially, the nine health regions in order to strengthen municipal PHC management and increase PHC coverage.	Planning of the budget in terms of the allocation and use of financial resources to reach established goals and objectives.	Reduce premature mortality through the four main NCDs, technical support in the nine health regions, structuring of care in Ambulatory and Hospital Services; Operationalizing of the state’s 24h UPA’s; VAN - organization of nutritional care; Care provided to Morbid Obesity; Bariatric and Repair surgeries; Health promotion and bodily practices.
Resolution SES/RJ 2194 from December 8, 2020. Approves the program of the funding of health surveillance actions in RJ.	Recommendation of support for the structuring of terms in health, environmental, and epidemiological surveillance.	Financial transfers based on population size and other criteria; for investment and operational costs; structuring and strengthening of health surveillance actions for the municipalities of RJS.	Support VAN actions, structuring of teams for health, environmental, and epidemiological surveillance; Strengthening the quality and outreach of the DANT situation analysis with priority food actions to reduce and control its risk factors.
Resolution SES/RJ 2199 from December 23, 2020. Approves Funding of Health Promotion in the State of RJ.	Financial support for healthcare, aimed at strengthening the prevention and control of NCDs in SUS health services.	Transfer based on the situation of health in terms of risk and protective factors; Definition of values according to the HDI classification; Transfer for the funding of health actions and NCDs, with focus on prevention and control.	Support provided to Health Promotion Actions in municipalities, based on the structuring of DANT surveillance teams: DANT health situation analysis: prioritizing actions to reduce and control risk factors.
Resolution SES 2348 from July 15, 2021. Updates the program of PHC Funding in RJS (PREFPHC) for the year of 2021.	Such a resolution has the purpose of supporting PHC in municipalities by providing incentives related to the maintenance and expansion of FHS teams and other actions.	Funding incentives for the structuring, expansion and qualification of PHC in municipalities.	Through the strengthening of the PHC, especially the FHS, the actions related to fighting being overweight and obesity are improved.

	Analytical dimensions
Sources and methodology	Economic, political, and funding conjuncture	Programs and actions for obesity prevention and control (OPC)	Factors which complicate and enhance actions
Documents All of the analyzed documents are described in charts 1, 2, 3, and 4. Methodology for documental analysis; Analytical Route: date of publication and historical conjuncture of the production of the document; author, type of document (Law, Ordinance, Norma tive Resolution, Policy, Decree, Technical Note, Program, Plan), obesity prevention and control (OPC) actions and financial incentives established.	The contents related to the economic, political, and funding conjunctures, explored in this study by analyzing government documents, are described in Charts 1, 2, and 3: a) the contents analyzed based on federal policies are described in Chart 1; b) the contents analyzed based on federal programs are described in Chart 2; c) the contents analyzed based on federal normative resolutions for funding are described in Chart 3, and those analyzed based on state-level policies and normative resolutions are described in Chart 4.	The contents related to the OPC programs and actions, examined in this study based on the analysis of government documents, are described in charts 1, 2, and 3. 1) contents analyzed based on national policies are described in Chart 1; 2) contents analyzed based on federal programs are described in Chart 2; (3) contents analyzed based on federal normative resolutions for funding are described in Chart 3, and contents analyzed based on state-level normative resolutions are described in Chart 4. Systematization and analysis of those actions at both Federal and State levels have been presented in greater detail in previous publications that focused on the same theme¹²12 Dias PC, Henriques P, Anjos LA, Burlandy L. Obesidade e políticas públicas: concepções e estratégias adotadas pelo governo brasileiro. Cad Saude Publica 2017; 33(7):e00006016.^,¹⁷17 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 Saude Publica 2020; 36(6):e00116519.^,¹⁸18 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 Saude Publica 2020; 36(3): e00093419 .^,¹⁹19 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. Rev Demetra 2022; 17:e69119..	The factors which complicate or enhance actions, and are present in the documents, deal with the very existence of the funding mechanisms, guaranteeing resources for the implementation, in addition to recommending actions that can be implemented by municipalities, priorities for the policy planning, and instruments of public action related to budgeting. The complications mainly refer to reductions in funding mechanisms.
Interviews and focus groups with municipal managers and professionals from the technical area of Nutrition and Primary Health Care (NPHC) conducted between 2014 and 2018 (PPSUS-ERJ). The number and the profile of the participants of those events have been described in previous publications¹⁷17 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 Saude Publica 2020; 36(6):e00116519.^,¹⁸18 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 Saude Publica 2020; 36(3): e00093419 ..	The participants of interviews and focus groups mentioned the lack of specific resources for OPC, and low autonomy in terms of using allocated federal resources, in this case, from the Food and Nutrition Fund.	The participants in the interviews and focus groups mentioned the programs and actions implemented in municipalities. The analysis of those programs and actions was presented in previous publications¹⁷17 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 Saude Publica 2020; 36(6):e00116519.^,¹⁸18 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 Saude Publica 2020; 36(3): e00093419 .. The main programs which stood out are those implemented at PHC, Health Gym Program, as well as the Health in School Program, the National Program of Feeding in School. The main actions implemented are the execution of individual consultations, group actions, actions in the school space, and incentives for the practice of physical activities.	The participants in the interviews and focus groups mentioned the strategies and challenges for the implementation of programs and actions. This analysis was presented in previous publications^17,18. The main highlighted financial difficulties were low autonomy in the use of allocated federal resources, in this case, from the Food and Nutrition Fund.
Questionnaires with open and close-ended questions with health professionals from municipalities from the state of Rio de Janeiro (RJS) between 2019-2021 (PEO-ERJ). The number and profile of the participants are described in a previous publication¹⁹19 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. Rev Demetra 2022; 17:e69119..	The kind of question most often mentioned by the participants as a factor that complicates the implementation of OPC actions was the lack of financial resources. In fourth place, the participants mentioned insufficient teams.	The participants mentioned programs and actions implemented in the municipalities. The analysis of those programs and actions was presented in a previous publication¹⁹19 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. Rev Demetra 2022; 17:e69119.. The main programs highlighted are those implemented at the PHC level, the Health Gym Program, as well as the National Health in School Program and the Program of Feeding in School. The main implemented actions included the execution of individual consultations, group actions, actions in the school space, and incentives for the practice of physical activities.	Factors indicated by the professionals as challenges to conduct analyses, more related to the issue of funding, referred to the scarcity of financial resources; insufficient staff, and changes in administrative personnel and staff turnover; the distinct employment relationships were also considered.

[1] Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Brasil

Brasil

Financial constraints and incentives for the prevention and control of obesity in the state of Rio de Janeiro, Brazil

Abstract