Promotion of body practices and physical activities in the Brazilian Unified National Health System: changes in sight, but to which direction?

The National Health Promotion Policy is the major milestone in the promotion of body practices and physical activities in the Brazilian Unified National Health System (SUS). After it, different actions and strategies were created, such as the Health Academy Program, the Expanded Family Health and Basic Healthcare Centers (NASF-AB), and the School Health Program ¹.

Nowadays, the strengthening of neoliberal policies and fiscal austerity measures are aggravating the underfunding of SUS, with a consequent repercussion on body practices and physical activities actions ². Despite this, the creation of a specific organizational structure in the Brazilian Ministry of Health ³ and the release of the Physical Activity Guidelines for the Brazilian Population⁴ show that the topic remains on the agenda.

Moreover, in May 2022, the Brazilian Ministry of Health released the Physical Activity Incentive, a program that aims to implement body practices and physical activities actions in primary health care (PHC) - by hiring physical education professionals, purchasing consumables, and qualifying body practices and physical activities environments - and improve the care of people with chronic non-communicable diseases - by introducing body practices and physical activities in their routine ⁵. This investment includes different values for each type of health unit and physical education professional hired, with two possibilities of workload (Table 1).

Table 1
Type of establishment and values of federal resource transfers.

Type of establishment	Model 1 (no physical education professional)	Model 2 (physical education professional - 20 hours)	Model 3 (physical education professional - 40 hours)
Health center/Health basic unit	BRL 1,000.00	BRL 1,500.00	BRL 2,000.00
Health post	BRL 500.00	BRL 1,000.00	BRL 1,500.00
Mobile river unit	BRL 500.00	BRL 1,000.00	BRL 1,500.00

• Source: Brazilian Ministry of Health 5.

Understanding that the Physical Activity Incentive may significantly change the body practices and physical activities promotion “model” in PHC, this text aims to present initial analyses on the Physical Activity Incentive, considering its acting in the SUS management, as well as in the teaching and research of the authors of this text.

The technical criteria for prioritizing health units that will receive the Physical Activity Incentive are currently unavailable ⁵, but they must aim at equity in the qualification process, so that no unequal access to the resource occur. Health indicators, structuring of the PHC network, size of municipalities, among others, must be part of this prioritization criteria.

In case of qualification, municipal programs of corporal practices and physical activities consolidated in the SUS, municipalities that remained with physical education professionals after the extinction of specific funding for the NASF-AB ⁶ and other initiatives that have these professionals inserted in health units will receive greater amount of resources since they will be able to allocate this professional in qualified health units, except for those who already receive funding resources as similar to the Health Academy Program. However, only one code from the Brazilian Classification of Occupations (CBO), within the eight of the occupational family related to Physical Education, will be eligible to receive the resource: CBO n. 2241-40 - Physical Education Professional in Health. It will possibly promote greater uniformity in the use of the CBO.

Undeniably, the Physical Activity Incentive will be important for municipalities with a management sensitive to the topic and may possibly increase the number of physical education professionals in PHC, however, the magnitude of the power inducing the hiring of physical education professionals need to be analyzed in the medium term. The highest possible value per health unit (BRL 2,000.00) may be far below the real cost of hiring for municipal managements, so if state managements do not co-fund body practices and physical activities actions in PHC ¹ - thus characterizing the tripartite financing of SUS - the greater hiring of physical education professionals and reduction of “care gaps” may be compromised.

In cases where there is a budgetary impact on municipal management, which will need to be supplemented with own resources, which we believe is very frequent, if you have not previously included body practices and physical activities in the municipal plan and/or annual programming, it may be difficult to justify additional expenses. Thus, the Physical Activity Incentive type can be changed monthly and automatically, considering that municipal managements without physical education professionals working in PHC health units can request the Physical Activity Incentive without a proper planning, which hinders the optimization of the body practices and physical activities promotion, as they can not count on these professionals in the initial moments ⁵.

Moreover, the short period to join the program (20 days from the publication of the Ordinance) ⁵ gives little time for municipal managements, in this first cycle of the Physical Activity Incentive, to plan and hire professionals, as well as to introduce body practices and physical activities actions into the routine of health units in order to improve the care process.

On the other hand, the new financial incentive directly linked to health units overcomes the limitation of the Health Academy Program funding, which depends on parliamentary amendments to build new centers. After the release of resources, limitations also emerge in municipal managements until the construction actually starts and be finished ^7,8. However, Health Academy Program - a health promotion program that is not restricted to body practices and physical activities, but develops them as main activities - emerged from the understanding that a physical structure specific to develop activities was important ⁹. It recognizes the importance of building or renovating physical spaces for body practices and physical activities programs as a strategic action to tackle chronic non communicable diseases ¹⁰, however, the use of the Physical Activity Incentive focuses on the possibility of qualifying the environment of health units.

The difference between directly funding health units and the construction of Health Academy Program centers can be justified by the existence of much more health units than centers, although both cases cannot be counted in the constitutional spending on health based on the interpretation of the Brazilian National Congress that the inclusion of body practices and physical activities is a determinant of health ^11,12. However, if no other additional measure regarding funding the Health Academy Program is taken, this program will not be prioritized, even being considered a strategic action of the Prevent Brazil Program ⁶.

In 2022, about BRL 100 million are being provided to the Physical Activity Incentive ¹³, which sum around BRL 16.6 million per month (six months/competencies, from July, since no more applications and qualifications are requested). Thus, in 2022, about 1,380 health units with physical education professionals with a workload of 40 hours would work in comparison with just over 5,500 without physical education professionals, at the highest and lowest value of the Physical Activity Incentive, respectively. For 2023 and beyond, the investment forecast is BRL 170 million/year ¹³.

In a presentation on the Physical Activity Incentive on the day after the publication of the regulation, the Brazilian Ministry of Health claimed that it is complementary to the Health Academy Program but presented data that show more than 1,400 centers built (45.7% of the total) that do not receive resources ¹⁴. Thus, if no other measure is taken in relation to the Health Academy Program - which has been, along with the NASF-AB, the main provider of the body practices and physical activities promotion in SUS - significantly change can happen, as the Physical Activity Incentive will act directly in health units with physical education professionals, who will not necessarily be part of multi-professional teams. Thus, expanding resources for the Health Academy Program is also needed so that municipal managements seek synergy and integration between proposals, avoiding disarticulation and discontinuity of one action or another.

In addition to funding, more physical education professionals in PHC require greater investments in training (undergraduate and continuing education), especially regarding strategies of integration with health units’ teams, in order to ensure multi-professional work and include body practices and physical activities, aiming at comprehensive care so that they are not isolated and decontextualized. Such need exists as the field of Physical Education presents many training and intervention proposals ¹⁵ so that the SUS and PHC are often not part of the curriculum or, when they do, their perspectives on body practices and physical activities - as a response to sedentary lifestyle/physical inactivity - are restricted, contributing to health only as a way to prevent and control diseases, especially chronic diseases. Both perspectives aforementioned are important, but they do not summarize the relationship between body movement and health.

The Physical Activity Incentive, in a certain way, parameterizes a minimum 20-hours workload, which can contribute to a greater link between physical education professionals and users and a greater integration with health units’ teams and other local social facilities. However, both the possible greater number of physical education professionals in PHC and the aforementioned greater possibility of linking will not dispense with intersectoral policies and actions - another topic that needs to be included in training and continuing education actions, since the synergy between policies and actions of different sectors plays is essential to promote body practices and physical activities ⁴.

In conclusion, the Physical Activity Incentive can expand access to body practices and physical activities in PHC but, considering that it is a model that was neither tested nor evaluated in Brazil and that community programs, such as the Health Academy Program, contribute to increase the body practices and physical activities performance during leisure time and positively affect users' health indicators ¹⁶, the changes of this new incentive require future analyses, by monitoring in information systems and population research, among others, in order to identify their potentialities and limitations, especially: (i) differentiation between new physical education professionals and those who already worked in health services; (ii) knowledge and use of health programs and services to perform body practices and physical activities; (iii) contributions of physical education professionals to build the comprehensive care process; and (iv) work relationships that municipal managements formalizes when hiring. Social control, researchers, health professionals, and managers shall monitor the implementation of the Physical Activity Incentive in order to enhance its scope and ensure and expand access to body practices and physical activities.

Referências

• ¹
  Carvalho FFB, Almeida ER, Loch MR, Knuth AG. As práticas corporais e atividades físicas na gestão tripartite do SUS: estrutura organizacional, financiamento e oferta. Ciênc Saúde Colet 2022; 27:2163-74.
• ²
  Vieira LA, Carvalho FFB. As práticas corporais e atividades físicas nos 15 anos da política nacional de promoção da saúde: a defesa da equidade em um contexto de austeridade. Pensar Prat 2021; 24:e68737.
• ³
  Brasil. Decreto nº 9.795, de 17 de maio de 2019. Aprova a Estrutura Regimental e o Quadro Demonstrativo dos Cargos em Comissão e das Funções de Confiança do Ministério da Saúde, remaneja cargos em comissão e funções de confiança, transforma funções de confiança e substitui cargos em comissão do Grupo-Direção e Assessoramento Superiores por Funções Comissionadas do Poder Executivo. Diário Oficial da União 2019; 20 mai.
• ⁴
  Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Guia de atividade física para a população brasileira. Brasília: Ministério da Saúde; 2021.
• ⁵
  Ministério da Saúde. Portaria GM/MS nº 1.105, de 15 de maio de 2022. Altera a Portaria de Consolidação GM/MS nº 6, de 28 de setembro de 2017, para instituir o incentivo financeiro federal de custeio, destinado à implementação de ações de atividade física na atenção primária à saúde. Diário Oficial da União 2022; 17 mai.
• ⁶
  Ministério da Saúde. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da atenção primária à saúde no âmbito do SUS, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União 2019; 13 nov.
• ⁷
  Ferreira RW, Caputo EL, Häfele CA, Jerônimo JS, Florindo AA, Knuth AG, et al. Acesso aos programas públicos de atividade física no Brasil: Pesquisa Nacional de Saúde, 2013. Cad Saúde Pública 2019; 35:e00008618.
• ⁸
  Tusset D, Olkoski M, Merchan-Hamann E, Calmon PCDP, Santos L. Programa Academia da Saúde: um olhar quantitativo das adesões entre 2011 a 2017. Rev Bras Ativ Fís Saúde 2020; 25:e0165.
• ⁹
  Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Programa Academia da Saúde: caderno técnico de apoio a implantação e implementação. Brasília: Ministério da Saúde; 2018.
• ¹⁰
  Secretaria de Vigilância em Saúde, Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil 2021-2030. Brasília: Ministério da Saúde; 2021.
• ¹¹
  Núcleo de Saúde, Consultoria de Orçamento e Fiscalização Financeira, Câmara dos Deputados. Nota Técnica nº 014, de 2012. Análise das principais inovações trazidas pela Lei Complementar nº 141, de 13.01.2012, que regulamentou a Emenda Constitucional nº 29, de 2000. Brasília: Câmara dos Deputados; 2012.
• ¹²
  Brasil. Lei nº 12.864, de 24 de setembro de 2013. Altera o caput do art. 3º da Lei nº 8.080, de 19 de setembro de 1990, incluindo a atividade física como fator determinante e condicionante da saúde. Diário Oficial da União 2013; 25 set.
• ¹³
  Gov.br. Sem sedentarismo. Para incentivar atividade física, Ministério da Saúde promove caminhada no Rio de Janeiro neste domingo. https://www.gov.br/saude/pt-br/assuntos/noticias/2022/maio/para-incentivar-atividade-fisica-ministerio-da-saude-promove-caminhada-no-rio-de-janeiro-neste-domingo-15 (acessado em 17/Mai/2022).
  » https://www.gov.br/saude/pt-br/assuntos/noticias/2022/maio/para-incentivar-atividade-fisica-ministerio-da-saude-promove-caminhada-no-rio-de-janeiro-neste-domingo-15
• ¹⁴
  Departamento de Informática do SUS. Webinário Depros: incentivo financeiro de custeio para ações de atividade física na APS. https://www.youtube.com/watch?v=6JPkvOKm8nA&t=48s (acessado em 18/Mai/2022).
  » https://www.youtube.com/watch?v=6JPkvOKm8nA&t=48s
• ¹⁵
  Nogueira JAD, Bosi MLM. Saúde coletiva e educação física: distanciamentos e interfaces. Ciênc Saúde Colet 2017; 22:1913-22.
• ¹⁶
  Silva AG, Prates EJS, Malta DC. Avaliação de programas comunitários de atividade física no Brasil: uma revisão de escopo. Cad Saúde Pública 2021; 37:e00277820.

Publication Dates

• Publication in this collection
  05 Sept 2022
• Date of issue
  2022

History

• Received
  24 May 2022
• Reviewed
  01 July 2022
• Accepted
  08 July 2022