87821 Editor Marí�a Eugenia Bonilla-Chací�n Health, Nutrition and Population PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA Latin America and the Caribbean region World Bank AND THE CARIBBEAN: GOVERNANCE OF FIVE MULTISECTORAL EFFORTS Spanish Fund for Latin America and the Caribbean PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: GOVERNANCE OF FIVE MULTISECTORAL EFFORTS Editor Marí�a Eugenia Bonilla-Chací�n Health, Nutrition and Population Latin America and the Caribbean region World Bank Spanish Fund for Latin America and the Caribbean © 2014 International Bank for Reconstruction and Develop- ment / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work was originally published by The World Bank in Spanish as Prevención de factores de riesgo de la salud en América Latina y el Caribe: Gobernanza de cinco esfuerzos mul- tisectoriales in 2013. 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Cover photo: Marí�a Eugenia Bonilla Cover design: Kilka diseño gráfico Production Coordination: Evelyn Rodriguez Photography: Marí�a Eugenia Bonilla Chací�n, The World Bank, Latin America and the Caribbean Region TABLE OF CONTENT Acknowledgments 7 About the authors 9 Abreviations 13 Introduction 19 References 21 Promoting Healthy Living in Latin America and the Caribbean - Volume I 23 The Health and Economic Burden of NCDs in LAC 23 Risk Factors for NCDs in LAC 24 International Experience in Multisectoral Interventions to Prevent Health Risk Factors: Overcoming Governance Challenges Involved in Their Design and Implementation 25 Main Stakeholders 26 Stakeholder Strategies 27 The Unfinished Agenda 30 References 43 CHAPTER 1. Policies for the Elimination of Trans Fats and the Reduction of Sodium Consumption in Argentina 47 Context 47 Consumption of Trans Fats and Sodium in Argentina 48 Policies: Actions Designed to Eliminate Trans Fats and Decrease the Consumption of Sodium in the Diet 50 Eliminating Trans Fats 52 Reducing Sodium 53 Leading Actors: Positions and Strategies 59 Lessons Learned 63 References 65 CHAPTER 2. Bogotá, Colombia: A City with a Built Environment that Promotes Physical Activity 71 Context 71 Prevalence of Physical Activity in Colombia and Bogotá 72 Determinants of Physical Activity among Adults in Colombia and in Bogotá 72 Bogotá Overview 73 Policies (Programs and Infrastructures): Ciclovía, CicloRutas, TransMilenio, and Outdoor Gyms 74 The Ciclovía Recreativa 74 The CicloRutas Network 76 The TransMilenio System 78 Outdoor Gyms 79 Policy Development and Leading Actors 80 The Ciclovía Recreativa 80 The CicloRutas Network 85 The TransMilenio System 87 Outdoor Gyms 90 Factors that Influenced These Changes in Bogotá 91 Lessons Learned 93 References 95 CHAPTER 3. Mexico’s National Agreement on Food Health: Strategy Against Overweight and Obesity 107 Context 107 The Policy: ANSA, Technical Bases, and General Guideliness 109 National Agreement on Food Health/ Strategy Against Overweight and Obesity 109 Technical Bases of the National Agreement on Food Health 110 General Guidelines for the Sale or Distribution of Food and Beverages in School Consumption Facilities in Basic Education Schools and Single Annex 111 Policy-making Process: Main Stakeholders and the Negotiation Process 111 Main Stakeholders 112 Discussion and Negotiation Processes of the ANSA and the Technical Bases 114 ANSA Follow-up, Transparency, and Evaluation Mechanisms 117 Discussion and Negotiation of the General Guidelines for the Sale or Distribution of Food and Beverages in School Consumption Facilities in Basic Education Schools 118 What has happened after the ANSA? 127 Conclusions and Lessons Learned 130 Strengths 130 Weaknesses 131 Annex 3.1. Some of the actions to prevent and reduce overweight and obesity established in the Strategy Against Overweight and Obesity, by Secretariat 134 Annex 3.2. General work prior to the establishment of the ANSA 135 References 138 CHAPTER 4. Tobacco Control Policies in Uruguay 145 Context 145 Socioeconomic Impact of Tobacco 149 Development and Implementation of Uruguay’s Tobacco Control Policy 150 The Political and Parliamentary Initiative 154 Leading Actors that Supported Tobacco Control 156 The Tobacco Industry 159 Tobacco Farming in Uruguay 159 The Tobacco Industry in Uruguay: Position and Strategies 160 Factors that Favored the Implementation of the Tobacco control Measures 163 Results Beyond Decreasing the Prevalence of Smoking 163 Lessons Learned 165 The Unfinished Agenda in Uruguay’s Tobacco Control 165 Annex 4.1. Characteristics of the smoking population by socioeconomic level 166 References 169 CHAPTER 5. Tobacco Control Policies in Argentina 173 Context 173 Tobacco Consumption in Argentina 174 The economic impact of the tobacco epidemic in Argentina 176 Tobacco production in Argentina 176 Taxes on tobacco 181 International context for tobacco control: the FCTC 183 Development of Tobacco Control strategies in Argentina 183 The National Tobacco Control Program 184 The National Tobacco Control Law 186 Provincial legislation and municipal ordinances 187 Discussions on the ratification of the Framework Convention 188 Other key actors: the Coalition for Ratifying the FCTC in Argentina 190 Lessons learned 193 Conclusions 194 Annex 5.1. Provincial laws for tobacco control, Argentina 195 Annex 5.2. Municipal ordinances, by province, Argentina 201 Referencias 202 ACKNOWLEDGMENTS 7 8 PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts ABOUT THE AUTHORS 9 María Eugenia Bonilla-Chacín is a senior searcher at the Epidemiological Research economist working on the Health, Nu- Institute, National Academy of Medicine trition and Population unit of the Lat- (IIE-ANM), since 2007. Marí�a was a fel- in America and the Caribbean region at low of the multicentric study “Methodol- the World Bank. She has also worked on ogies to Set Research Priorities in Health human development issues in the Africa 2006–2007” and a principal researcher in region of the World Bank. Her areas of in- 2008. She received the National Academy terest are human development policies, of Medicine Award 2009 for the research particularly health policies, and poverty. “Family, Social and Economic Impact of She has led and participated in several Injuries. An Interdisciplinary Approach.” analytical pieces supporting operation- Marí�a was a consultant for various inter- al work and country dialogue. These ef- national organizations (e.g., Inter-Amer- forts have included work on health policy, ican Development Bank, United Nations health financing, governance, and ser- Children’s Fund, Pan American Health vice delivery, work on multisectoral ap- Organization), social security institutions proaches to prevent noncommunicable in Argentina, and the National Ministries diseases, and work on public expenditure of Economics and Health in topics related management in both health and educa- to public health, health economics, and tion sectors. Marí�a Eugenia earned a PhD public policies. She has been a professor in economics (applied microeconomics) in public and private universities. from The Johns Hopkins University. She also has a master’s degree in develop- Adriana Díaz del Castillo Hernández is an ment economics from Vanderbilt Univer- independent researcher and consultant. sity. She earned a bachelor’s degree in She holds a master’s degree in medical international relations at the Universidad anthropology from the University of Am- Central de Venezuela in Caracas, Repúbli- sterdam and a medical degree from the ca Bolivariana de Venezuela. Universidad Nacional de Colombia. She has worked with public and private in- María Eugenia Barbieri has a bachelor’s and stitutions in Colombia and abroad. Her a master’s degree in economics from the field of study involves the interplay be- University of Buenos Aires. She was a re- tween health and society. Specifically, she searcher at the Center for the Study of the is interested in the study of urban infra- State and Society (CEDES), Department of structures as spaces with the potential Economics (2002–07) and has been a re- to construct equality and well-being and shape people’s experiences in cities. She Institute of Sports in Colombia (Colde- has participated in studies and publica- portes Nacional) for the academic work tions about Bogotá’s Cicloví�a and other towards promoting healthy behaviors in programs and infrastructures that pro- Colombia. Her current research interests mote physical activity and quality of life. include physical activity, nutrition and built environment among the populations Ethel Segura Duran is an architect who gradu- of children and adults in Latin Ameri- ated from the Universidad de Los Andes ca. She is currently working in the IPEN in Colombia in 2003. She is specialist in Network (International Physical Activity, planning for regional development. She and Environment Network), the evalua- obtained a master’s degree in governance tion of the effectiveness of the Recreovia in 2011 from the Universidad de los An- Program for the promotion of physical des. She has developed studies in urban activity in community settings, the Chal- management and urban legislation, sup- lenge Score for evaluating the Cicloví�as port systems for spatial decisions at the Recreativas of the Americas and The In- ITC–Netherlands, and in project manage- ternational Study of Childhood Obesity, ment at the School of Business in Los An- Lifestyle and the Environment (ISCOLE). des. She has worked as a functionary at Her work has been published in presti- the planning office for the District of Bo- gious journals including the Lancet, The gotá in the Territorial Plan since 1999 in American Journal of Public Health and urban normative and the interinstitution- Social Science and Medicine. al coordination of digital cartographic in- formation for the evaluation of the plan in Evelyne Rodriguez has a bachelor’s degree in 2003. economics from the Instituto Tecnológi- co de México (ITAM). She has a master’s Olga L. Sarmiento is an Associate Professor of degree in Public Policy from the J. F. Ken- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: the Department of Public Health at the nedy School of Government at Harvard School of Medicine at Universidad de los University. From 1988 to 2005, she held Andes (Bogotá, Colombia). She holds an a number of positions in Mexico´s gov- M.D. from the Universidad Javeriana (Bo- ernment, including director for economic gotá), an M.P.H., and a Ph.D. from the De- and social benefits at the Mexican Social partment of Epidemiology at the School Security Institute; treasurer of Mexico; of Public Health at the University of North general director of planning and budget Carolina at Chapel Hill. Currently she is for agriculture, social development and Governance of Five Multisectoral Efforts the Director of the Group of Epidemiolo- environment at the Ministry of Finance; gy at the Universidad de los Andes. She is and general director for economic studies a board member of the International So- in the deregulation program at the Minis- ciety of Physical Activity and Health and try of Trade. Ms. Rodriguez has played a the Global Advocacy for Physical Activity significant role in the structural reform of (GAPA) council. In 2011 she received the key sectors in the design, implementation Honorary Distinction from The National and evaluation of public expenditure pol- 10 icies, poverty alleviation and rural devel- Working Group for the development of 11 opment programs, including the creation the Guidelines of Article 14 of the WHO and implementation of Progresa-Opor- Framework Convention on Tobacco Con- tunidades. She is the author of numerous trol. Representative of Uruguay in the About the authors articles and coauthored a book with San- Working Group on “Sustainable Measures tiago Levy (IDB), entitled Sin Herencia de to strengthen the implementation of the Pobreza. She currently heads the Depart- Framework Convention on tobacco Con- ment for Research in Health Policies at the trol”. Center for Economic and Social Studies of Mexico’s Children’s Hospital Federico Go- Franco González Mora holds a degree in mez and does consulting for international sociology and master’s degree in De- organizations in different countries. mography and Population Studies. He currently serves as a teacher and re- Amanda Sica holds a Diploma in Social Psy- searcher in the Department of Preventive chologist (ICI - Buenos Aires -Argentina) and Social Medicine, Faculty of Medicine, 1991. Since 1993 she has been the Tech- University of Uruguay, Montevideo. He is nical Deputy of the Technical Training and a consultant at the Educational Research Vocational Area of the Honorary Commis- and Statistics Department of the National sion to Fight Cancer (Montevideo, Uru- Public Education Administration (ANEP). guay). She has developed, coordinated, He is a researcher at the Department of and lectured courses on Tobacco Control Sociology, Faculty of Social Sciences, Uni- in public and private institutions since versity of Uruguay, Montevideo. 1999. She was the Official Delegate to the Intergovernmental Authority on the Winston Abascal is the Director of the Na- WHO Framework Convention on Tobacco tional Program for Tobacco Control at Control (INB4) in 2002. Member of re- the Ministry of Public Health of Uruguay. search groups and official advisory com- Representative of Uruguay to the Inter- mittees on Tobacco Control from 2005 governmental Committee for the Tobac- to date. She was awarded the National co Control of MERCOSUR and Associated Grand Prize of the Academy of Medicine States. Representative of Uruguay to the 2012, as coauthor of the study “Impact Conference of the Parties to the WHO of tobacco control policies in Uruguay, Framework Convention on tobacco Con- 2006-2009”. trol. Ana Lorenzo she is the Assistant to the Direc- tor of the National Program for Tobacco Control of Ministry of Public Health of Uruguay. Alternate Member of the Inter- governmental Commission on Tobacco Control of MERCOSUR and Associated States. Representative of Uruguay in the 12 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts ABREVIATIONS 13 ADL activities of daily living ALAD Latin American Diabetes Association ALIAR Alianza Libre de Humo—Argentina (Smoke-free Partnership—Argentina) ANCT Alianza Nacional para el Control del Tabaco (National Alliance for Tobacco Control), Uruguay ANMAT Administración Nacional de Medicamentos, Alimentos y Tecnología Médica (National Administration of Drugs, Food, and Medical Technology), Argentina ANSA Acuerdo Nacional para la Salud Alimentaria (National Agreement on Food Health), Mexico ASAGA Asociación Argentina de Grasas y Aceites (Argentine Fats and Oils Association) AsAT Asociación Argentina de Tabacología (Argentine Tobacco Association) BAC blood alcohol concentration BAT British American Tobacco BMI body mass index BRT bus rapid transit CAICHA Argentinian Chamber of Sausages and Related Products Industry CAMDI Central American Diabetes Initiative CANACINTRA Cámara Nacional de la Industria de la Transformación (National Chamber for the Transformation Industry), Mexico CASEN Encuesta de Caracterización Socioeconómica Nacional (National Socioeconomic Survey), Chile CATCH The Child and Adolescent Trial for Cardiovascular Health CATU Comisión Antitabáquica del Uruguay (Uruguayan Anti-Tobacco Commission) CCE Consejo Coordinador Empresarial (Business Coordination Council), Mexico CDC Centers for Disease Control and Prevention, U.S. CHD coronary heart disease CHLCC Comisión Honoraria de Lucha contra el Cáncer (Honorary Commission to Fight Cancer), Uruguay CIC Comisión de Investigación Científica (Scientific Research Commission), Buenos Aires, Argentina CIET Smoking Epidemic Research Center CIPA Chamber of Food Products Industrialists CLACCTA Comité Latinoamericano Coordinador para el Control del Tabaquismo (Latin American Coordinating Committee on Tobacco Control) CNCD Chronic noncommunicable diseases COFEMER Comisión Federal de la Mejora Regulatoria (Federal Commission for Regulatory Improvement), Mexico CONACRO Consejo Nacional para la Prevención y Control de las Enfermedades Crónicas no Transmisibles (National Council for the Prevention and Control of Chronic Noncommunicable Diseases), Mexico CONADE Comisión Nacional de Cultura Física y Deporte (National Commission of Physical Culture and Sport), Mexico CONAGO Conferencia Nacional de Gobernadores (National Conference of Governors), Mexico CONAGUA Comisión Nacional del Agua (National Water Commission), Mexico CONAL Comisión Nacional de Alimentos (National Food Commission), Argentina CONCAMIN Confederación de Cámaras Industriales (Confederation of Chambers of Industry), Mexico CONEVAL Consejo Nacional de Evaluación de la Política Social (National Evaluation Board of Social Policy), Mexico ConMEXICO Consejo Mexicano de la Industria de Productos de Consumo (Mexican Council of Consumer Products Industries) PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: CONPES Consejo Nacional de Política Económica y Social (National Council for Economic and Social Policy), Colombia COPAL Coordinadora de las Industrias de Productos Alimenticios (Coordinator of Food Product Industries), Argentina COPD chronic obstructive pulmonary disease CPI Consumer Price Index CSO civil society organization Governance of Five Multisectoral Efforts CVD cardiovascular disease DALYs disability-adjusted life years DBP diastolic blood pressure DEIS Health and Information Statistics Directorate DHS demographic and health survey DIGESA Dirección General de Salud (Directorate General of Health), Uruguay 14 DOT Department of Transportation 15 DOTA Declaration of the Americas on Diabetes EAAB Empresa de Acueducto y Acantarillado de Bogotá (Bogotá Water Supply and Sewage Company) Abreviations ECV Encuesta de Condiciones de Vida (Quality of Life Survey), Colombia EHPM Encuesta de Hogares de Propósitos Múltiples (Multiple Purpose Household Surveys), El Salvador EMNV (Encuesta de Hogares sobre Medición de Nivel de Vida (National Standard of Living Survey), Nicaragua ENCOVI National Quality of Life Survey (Encuesta Nacional de Condiciones de Vida), Guatemala ENFR National Risk Factors Survey ENHA Expanded National Household Survey ENSANUT Encuesta Nacional de Nutrición y Salud (National Health and Nutrition Survey), Mexico EPHF Essential Public Health Functions EPODE Ensemble Prevenons l’Obesite Des Enfants (Together Let’s Prevent Childhood Obesity) ETB Empresa de Telecomunicaciones de Bogotá (Bogotá Telephone Company) FAIPA Federación Argentina de la Industria del Pan y Afines (Argentine Federation of Baked Products Industry) FAO Food and Agriculture Organization FBS food balance sheet FCND Food Consumption and Nutrition Division FCTC Framework Convention on Tobacco Control FDA Food and Drug Administration, United States FENALCO Federación Nacional de Comerciantes (National Federation of Businessmen) FET Fondo Especial del Tabaco (Special Tobacco Fund), Argentina FIC Inter-American Heart Foundation GATS Global Adult Tobacco Survey GDP gross domestic product GIVE Statistics and Health Information Directorate GGCA Globocan Global Cancer Atlas GNP Gross National Product GUIA Guide for Useful Interventions for Physical Activity GYTS Global Youth Tobacco Survey HSS Health and Human Services IADB Inter-American Development Bank ICSID International Centre for Settlement of Investment Disputes IDF International Diabetes Federation IDRD Instituto Distrital de Recreación y Deportes (District Recreation and Sports Institute), Colombia IDS individual survey IDU Instituto de Desarrollo Urbano (Urban Development Insitute), Colombia IFPRI International Food Policy Research Institute IMES Specific Domestic Tax IMESI tobacco excise tax, Uruguay IMSS Mexican Social Security Institute (Instituto Mexicano del Seguro Social) INAL Instituto Nacional de Alimentos (National Food Institute), Argentina INCA National Institute of Cancer INE National Institue for Statistics INEC National Institute of Statistics and Census (Encuesta de Hogares de Propósitos Múltiples) INNSZ Salvador Zubirán National Institute of Medical Sciences and Nutrition INSP Instituto Nacional de Salud Pública (National Institute of Public Health), Mexico INTA National Institute of Livestock Technology INTI Instituto Nacional de Tecnología Industrial (National Institute of PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Industrial Technology), Argentina IP-TFA industrially produced partially hydrogenated fat ISSSTE Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (Institute for Social Security and Social Services for State Workers), Mexico L&M low- and middle-income LAC Latin America and the Caribbean Governance of Five Multisectoral Efforts LMP Land-use management plan LUVEC Liga Uruguaya de Vooulntarios de Educación para la Prevención y Control del Cáncer (Uruguayan League of Education Volunteers for Cancer Prevention and Control) MADD Mothers Against Drunk Driving MERCOSUR Mercado Común del Sur (Common Market of the South) MHAS Mexican Health and Aging Study 16 MoALF Ministry of Agriculture, Livestock, and Fisheries 17 MOH Ministerio de Salud (Ministry of Health) MSP Ministerio de Salud Pública (Ministry of Public Health) Abreviations MxFLS Mexican Family Life Survey NCD noncommunicable disease NCD/D noncommunicable disease and disability NCHS National Center for Health Statistics NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development PA physical activity PAHO Pan American Health Organization PASL Programa de Abasto Social de Leche de LICONSA (Social Milk Supply Program), Mexico PEMEX Mexican Petroleum PHA Public Health Activities PI Physical inactivity PMC Plan Maestro de CicloRutas (CicloRutas Master Plan), Bogotá, Colombia PNCT National Program for Tobacco Control POT Plan de Ordenamiento Territorial PROFECO Federal Consumer Protection Agency PRONASA Programa Nacional de Salud 2007-2012 (National Health Program 2007-2012), Mexico PROPIA Programa de Prevención del Infarto en Argentina (Program to Prevent Heart Attacks in Argentina) PROSESA Programa Sectorial de Salud 2007-2012 (Sectoral Health Program 2007-2012), Mexico PSA public service announcement QALYs Quality Adjusted Life Years R&D research and development RENALOA Red Nacional de Laboratorios Oficiales de Análisis de Alimentos (National Network of Official Laboratories for Food Protection), Argentina RENAPRA Red Nacional de Protección Alimentaria (National Food Protection Network), Argentina SAGARPA Secretaría de Agricultura, Ganadería, Desarrollo Rural, Pesca y Alimentación (Secretariat of Agriculture, Livestock, Rural Development, Fisheries, and Nutrition), Mexico SBP systolic blood pressure SE Secretaría de Economía (Secretariat of Economy), Mexico SEDENA Secretaría de la Defensa Nacional (Secretariat of National Defense), Mexico SEDESOL Secretaría de Desarrollo Social (Secretariat of Social Development), Mexico SEMAR Secretaría de Marina (Secretariat of the Navy), Mexico SEP Secretaría de Educación Pública (Secretariat of Public Education), Mexico SET Supplementary Emergency Tax SFLAC Spanish Fund for Latin America and the Caribbean SHCP Secretaría de Hacienda y Crédito Público (Secretariat of Finance and Public Credit), Mexico SMU Sindicato Médico del Uruguay (Uruguayan Medical Union) SNDIF Sistema Nacional para el Desarrollo Integral de la Familia (National System for Comprehensive Family Development), Mexico SS Secretariat of Health STPS Secretaría del Trabajo y Previsión Social (Secretariat of Labor and Social Welfare), Mexico SUMEFA Uruguayan Society of Family Physicians SUT Uruguayan Tobaccology Society TFC transnational food companies TFR total fertility rate TLS traffic light system PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: TM TransMilenio, Bogotá, Colombia, bus rapid transit system TTC transnational tobacco companies UATA Unión Antitabáquica Argentina (Argentine Anti-Smoking Union) UNICA Argentinian Beef Industry Union UNLP Universidad Nacional de la Plata (National University of La Plata), Argentina Governance of Five Multisectoral Efforts VAT value added tax VIGI+A Health Surveillance and Disease Control WB World Bank WHO World Health Organization 18 INTRODUCTION 19 NCDs represent an important and growing officials develop and implement primary-pre- burden to the health and economies of the Lat- vention policies and programs. Specifically, this in America and the Caribbean (LAC) region. volume is composed of five commissioned case However, some of this burden can be prevent- studies on multisectoral interventions to pro- ed or control through targeted clinical services mote healthy living in the region. These case and multisectoral activities aimed at improving studies examine which stakeholders participat- diet, promoting physical activity, and reducing ed directly or indirectly in the decision-making tobacco use and alcohol abuse. This study fo- process; what positions they held; which incen- cuses on these population-wide, multisectoral tives they faced; which strategies they pursued; interventions to prevent risk factors for NCDs. how did existing institutional arrangements af- This report complements the regional study fect the decision-making process; what lessons entitled “Promoting Healthy Living in Latin can be drawn from these processes; and what America and the Caribbean: Governance of were the successes and setbacks? Multisectoral Activities to Prevent Risk Factors Health policies are shaped not just by public for Noncommunicable Diseases,” which hopes officials, but also by wider and contextual so- to contribute to the design of multisectoral cial and political processes (Roberts and others policies to effectively prevent NCDs in the re- 2008). In population wide interventions, these gion. This study seeks to answer the following processes tend to be complex. In contrast to questions: What is the health and economic secondary prevention and curative interven- burden of NCDs in the region? What are coun- tions that take place within the health system, tries doing to promote healthy living and pre- population-based interventions involve a mul- vent risk factors for NCDs? What are the main titude of actors and opposing forces within and governance challenges countries face in devel- outside government. oping and implementing population-wide NCD This report provides a glimpse into the prevention interventions and which are the types of opposing interests and power games success stories? What else can the region do to involved in proposing, passing, and implement- reduce health risk factors and prevent the on- ing successful or promising population-based set of NCDs? health interventions in LAC. The aim is to pro- This second volume of the regional study vide information on the struggles and challeng- documents governance challenges in the design es involved in the design and implementation and implementation of promising or success- of policies, presenting an array of possible in- ful population-wide interventions intended to struments and models that could be useful and prevent health risk factors in LAC. This second adaptable to specific scenarios. volume focuses on the process whereby public To study how successful or promising pol- signed the Framework Convention on Tobacco icies and programs intended to prevent risk Control, the country has advanced in tobacco factors for NCDs were developed and im- control, and its experience could have import- plemented, this study uses the framework ant lessons for the region. detailed in the work by Roberts and others The selection of the case studies was based (2008), which was used to explain the polit- on an overview of major population-based in- ical economy of tobacco control in low- and terventions in the region. The first four were middle-income countries in Bump and others considered to be some of the most represen- (2009). This framework explains the politics of tative and promising examples of policies and any health reform and, in doing so, shows how programs that promote healthy lifestyles and health policies are shaped by the interaction reduce risk factors for NCDs. Each case study of four factors: players, each player’s relative was included because it examined a program power, the position taken by the players, and or policy targeting a distinct risk factor. In ad- the public perception of the reform. The inter- dition, to ensure as wide as possible a repre- play between the different stakeholders, their sentation, the case studies were drawn from power to shape policies, and the strategies different countries. There was no case study they use inevitably affects the short- and long- commissioned on alcohol control. Although term outcomes of any population-based reform there are some good examples of alcohol con- (Roberts and others 2008). According to this trol policies in LAC, they are limited in their framework, the abovementioned four factors geographical focus or on the array of interven- are not fixed and can be influenced through po- tions or sectors involved. litical strategies that the players adopt. This complementary volume presents, after The first four case studies examined are the the introduction and before the documenta- following: Argentina’s policies to reduce the tion of the five case studies, an overview of the consumption of trans fats and sodium; Bogotá’s first volume of the regional study. Each case (Colombia) built environment that promotes study starts with a description of the context PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: physical activity; Mexico’s National Agree- in which the multisectoral policy under review ments on Food Health (the National Strategy was designed, including the epidemiological to Fight Obesity); and Uruguay’s anti-tobacco situation and the prevalence of relevant health policies. Because Argentina’s and Mexico’ pol- risk factors. The context review is followed by icies are relatively new, information on their a detailed description of the relevant policy effectiveness is limited. They have been in- and by an analysis of the policy design and im- cluded here because they are some of the re- plementation process, the key players in these gion’s most comprehensive policies in the fight processes, and the strategies used by each play- Governance of Five Multisectoral Efforts against NCDs risk factors and because similar er to support or oppose the policy. Each case policies have proven to be highly cost-effective study concludes with an analysis of the factors elsewhere. Uruguay’s and Bogotá’s policies are that made possible the design and implemen- older, and their effectiveness has been better tation of the policies reviewed and the lessons documented. A fifth case—Argentina’s tobac- learned from the design and implementation co control policies—was added to this analy- processes. sis. Despite the fact that Argentina has not yet 20 References Aboriginal Perspectives, Institute on Gov- 21 ernance. Unpublished paper appearing on Bump, J. B., Reich, M. R., Adeyi, O. y Khetrapal, S. www.iog.ca, Ottawa, Canada. 2009. “Towards a Political Economy of To- Roberts, M., Hsiao, W., Berman, P., y Reich, M. bacco Control in Low- and Middle-Income Introduction R. 2008. “Getting Health Reform Right: A Countries”. HNP Working Papers. Washing- Guide to Improving Performance and Equi- ton DC: Banco Mundial. ty.” Oxford:Oxford University Press. Plumptre, T. and Graham, J. 1999. Governance and Good Governance: International and Photography: Marí�a Eugenia Bonilla Chací�n, The World Bank, Latin America and the Caribbean Region EXECUTIVE SUMMARY 23 VOLUME I Promoting Healthy Living in Latin America and the Caribbean - Volume I1 MARÍA EUGENIA BONILLA-CHACÍN The purpose of this report is to contribute to factors, this study incorporates new detailed the design and implementation of policies that analysis of dietary patterns in selected coun- promote healthy living in Latin America and tries in LAC. It also includes new analyses of the Caribbean (LAC), thus effectively prevent- household surveys that explore the potential ing premature mortality from noncommunica- impact of NCDs on labor markets and on house- ble diseases (NCDs) in the region. It examines holds’ health expenditures in the region. Final- the health and economic impact of NCDs in the ly, for the analysis of the governance challenges region and the governance challenges in the involved in the design and implementation of design and implementation of multisectoral selected multisectoral policies in LAC, country policies to prevent these conditions, including case studies were commissioned. These case polices to improve diet, increase physical activ- studies were mainly based on interviews with ity, and reduce tobacco use and alcohol abuse. key stakeholders that participated in these pro- The study focuses on how policy decisions in- cesses. volving multisectoral interventions to prevent health risk factors are taken, which stakehold- The Health and Economic Burden ers directly or indirectly participate in those de- of NCDs in LAC cisions, which incentives they experience, and The Latin American and Caribbean region has what strategies they use in these processes. been experiencing a rapid demographic and The document is based on desk reviews, an epidemiological transition. Not only is the analysis of existing databases, and commis- region’s population aging fast, it is also expe- sioned case studies. In analyzing the health riencing major lifestyle changes, including di- and economic burden of NCDs and their risk etary alterations and more sedentary ways of life. These changes, in turn, have led to shifts economies such as Chile’s or Brazil’s. The com- in LAC’s disease and mortality profiles, which bination of NCDs’ effect on labor participation, have translated into a greater proportion of hours worked, and productivity suggests that NCDs within the overall burden of disease. in these countries these diseases could have a NCDs such as heart disease, stroke, cancer, negative impact of about 0.25 percent of gross and diabetes are the main causes of death and domestic product (GDP), which could increase disability in the region. In addition, NCD death to 0.40 percent once the effect of related dis- rates in LAC (adjusted by age) are higher than ability is included. those prevalent in higher income countries; in Much of this health and economic burden fact, the region has some of the highest diabe- can be avoided, however, since an important tes death rates in the world. And not only are share of NCDs is due to exposure to prevent- death rates higher in LAC than in higher income able risk factors, such as an unhealthy diet, a countries, people in the region are also dying sedentary lifestyle, tobacco use, and alcohol from these conditions at younger ages. NCDs abuse (WHO 2005). Indeed, there are cost-ef- affect everyone in the region, rich and poor, ur- fective, population-based interventions de- ban and rural residents, men and women. signed to reduce exposure to these risk factors NCDs also represent an increasing eco- (WHO 2011a).2 Many of these interventions re- nomic and development threat to households, quire the active participation of several sectors health systems, and economies in the region. outside of the health sector, although the health NCDs require continuous contact with the sector’s involvement is key to ensure that these health system for long periods of time and, if needed interventions actually occur. not controlled, can result in costly hospital- ization. Moreover, out-of-pocket payments for Risk Factors for NCDs in LAC health services, particularly for drugs, can im- An unhealthy diet represents an important poverish households that have members with health risk for the LAC population. Diets in sev- PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: these conditions. Data from Colombia, Jamaica, eral countries in the region are dense in ener- Nicaragua, and Peru show that out-of-pock- gy and high in sodium, refined sugar, and fats. et expenditures in households that include An analysis of household surveys from Boliv- someone with a chronic condition are more ia, Costa Rica, Ecuador, Guatemala, Honduras, than double those of households that do not; Nicaragua, and Panama shows that, on aver- the greatest difference is in expenditures on age, the consumption of added sugar and fat drugs. In Colombia and Nicaragua, households in these countries’ diets is higher than WHO’s with a chronic disease patient are also more recommended levels. Moreover, estimates from likely to have catastrophic health expenditures. Governance of Five Multisectoral Efforts all these countries indicate that caloric intake NCDs also generate a large negative impact in a large share of households is higher than on the labor market, particularly in countries necessary to maintain a healthy weight. Aver- where most workers are in the formal sector. age sodium intake is also higher than recom- Evidence from Brazil, Chile, Colombia, El Salva- mended levels, while the intake of fruits and dor, and Honduras suggests that NCDs have a vegetables is lower. These dietary patterns are greater negative impact (5 percent or higher) likely to increase the risk of developing NCDs. on labor market participation in more formal Energy-dense diets, and diets rich in salt, sug- 24 ars, and fats and poor in fruits and vegetables ca Bolivariana de Venezuela are the countries 25 increase the risk for cardiovascular diseases, in the region with the highest percentage of diabetes mellitus, certain cancers, dental car- adults who are tobacco users (WHO 2011b).3 ies, and osteoporosis (WHO 2003). Alcohol abuse is the leading health risk factor Executive Summary Volume I Energy-dense diets, combined with a seden- in most Latin American and Caribbean coun- tary lifestyle, are responsible for the large per- tries. In fact, in 2010 alcohol use was estimated centage of overweight and obese adults in the to be the leading health risk factor in all LAC region, particularly among women. According subregions, with the exception of the Caribbe- to WHO data, half of adult men and two-thirds an and of countries such as Argentina, Chile, of adult women in the region are overweight and Uruguay, where alcohol ranked among the or obese, greatly exceeding the average rate in first five risk factors (Lim and others 2012). the Organisation for Economic Co-operation WHO ranked Belize, Ecuador, Guatemala, Mex- and Development (OECD) countries. Indeed, ico, Nicaragua, and Paraguay as the region’s due to the disability-adjusted life years (DALYs) countries with the highest alcohol-related lost attributed to high body mass index (BMI), health risk. These countries have the highest the Burden of Disease Study 2010 ranked consumption of alcohol per drinker and the high BMI as the first health risk factor in some largest percentage of drinkers reporting binge Southern Cone countries (Argentina, Chile, and drinking (WHO 2011c). Alcohol abuse not only Uruguay); the second in the Caribbean and in increases the risk of developing some NCDs, but Central America, Colombia, and República Boli- it also increases the risk of injuries, including variana de Venezuela; and the third in the rest those related to traffic accidents and violence. of the region (Lim and others 2012). In several countries, high rates of overweight International Experience in Multisectoral and obesity coexist with high rates of chron- Interventions to Prevent Health Risk ic malnutrition. Three of the four countries in Factors: Overcoming Governance the world with the highest percentage of over- Challenges Involved in Their Design weight mothers and malnourished children and Implementation are in LAC—Bolivia, Guatemala, and Nicaragua (Garret and Ruel 2003). Often, these conditions These changes in lifestyle and in the disease pro- are related; for instance, low birthweight and file in the region present important demands child malnutrition have been associated with on policymakers. Many of the interventions increases in the rates of hypertension, cardio- needed to prevent some of the negative eco- vascular diseases, and diabetes in adults (WHO nomic and health impacts of NCDs go beyond 2005). the health sector and beyond interventions Tobacco use remains among the first five that it traditionally delivers. Thus, health-sec- health risk factors in the region, due to the DA- tor policymakers not only must ensure that the LYs lost attributed to it (Lim and others 2012). prevention, control, and surveillance of these Nearly one in four adult men and one in sev- diseases take place within the sector but also en adult women in the region smoke; smoking must ensure that multisectoral preventive in- prevalence is also high among youth. Argenti- terventions are implemented. Improving diet, na, Bolivia, Chile, Cuba, Uruguay, and Repúbli- increasing physical activity, and reducing to- bacco use and alcohol abuse require the con- and lessons learned from these experiences. certed effort of various stakeholders working Table O.2 maps the main stakeholders, their in multiple sectors (see table O.1). In addition position and strategies, and the results ob- to the public sector’s participation, the private tained for some of the policies reviewed. sector and civil society also must participate. Given the involvement of so many stakehold- Main Stakeholders ers, often holding opposing views, policymak- Many different stakeholders participate in the ers and other health advocates must cope with design and implementation of interventions various challenges in the governance of the de- aimed at improving diet, promoting physical cision-making process of these interventions. activity, and reducing tobacco use and alco- Despite these challenges, there are many hol abuse (table O.1 and table O.2). In policies promising or successful international experi- aimed at improving diet, many government ences, including promising examples in LAC, actors outside the ministries of health or local such as are listed in table O.1. The table’s sec- health authorities have played important roles, ond column classifies the different groups of such as ministries of agriculture, institutes of interventions to improve nutrition, promote industrial technology, and consumer protection physical activity, and reduce tobacco use and agencies (e.g., Food and Drug Administration alcohol abuse, according to their cost-effective- [FDA], United States). The food industry also ness following WHO (2011a). Most interven- has actively participated, sometimes opposing tions included in the table are those that WHO government actions, sometimes working with (2011a) considers as “best buys,” in that they the government to advance public health goals. are “cost-effective, low cost, and can be imple- Restaurant associations and the advertising mented in low resource settings”; the majori- industry also have become involved. In many ty of these aim at controlling tobacco use and policies to promote physical activity, local au- alcohol abuse, but some target improving diet. thorities (e.g., cities, municipalities, and com- PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: Other cost-effective interventions, as well as ef- munities) had leading roles in their design and fective interventions whose cost-effectiveness implementation, particularly local transpor- evidence remains limited, are also listed in the tation, sports and recreation, and urban-plan- table. ning agencies. In tobacco- and alcohol-control In order to learn from these successful or policies, various governmental agencies were promising international examples, it is import- important players, not just those within the ant to understand the processes whereby they health sector, but also agencies in agriculture, were developed and implemented. To that end, commerce, economy, and finance sectors, as it is important to examine the major stake- Governance of Five Multisectoral Efforts well as the legislative branch of government. In holders who influenced and shaped policy de- tobacco- and alcohol-control policies, the role cisions, their positions, incentives faced, and of civil society organizations has been particu- strategies used; the institutional arrangements larly important and effective in advocating for that framed the decision-making process; and supporting control policies. In both alco- public perception of the policies; interaction hol- and tobacco-control policies, particular- between different stakeholders during the de- ly in the case of tobacco control, industry and cision-making and implementation process; 26 producers can become stakeholders who effec- ministries’ views may differ from those held by 27 tively oppose control efforts. agriculture and finance ministries. The devel- The mobilization toward a public health opment and later removal of the Gorbachev-era goal does not necessarily originate with the alcohol control policies in the USSR is a case in Executive Summary Volume I government, but can arise with external in- point of policies that faced strong opposition terest groups that advocate for reform. These within the government. Legislative or regulato- groups can be provider groups, such as doctors ry success often hinges on the effectiveness of or nurses; consumer groups; or groups advo- a government’s strategy to align the interests cating for specific issues, such as preventing of political parties and agencies, civil society underage drinking (the United States), reduc- groups, private businesses, and the public to- ing tobacco use (Uruguay and Argentina), or ward common public health goals. temporarily closing roads to motor vehicles for recreational activities (Bogotá, Colombia). Stakeholder Strategies These groups’ legislative success depends on In the design and implementation of these various factors, including their ability to con- policies, policymakers, politicians, and other vince and mobilize enough political players and health advocates have been able to overcome to develop sound, evidenced-based solutions to the different governance challenges. This has public health challenges. required, among other things, intense dialogue Governments and health advocates face no and negotiation with all parties involved, strong shortage of difficulties in promoting healthy liv- coordination mechanisms, the assessment and ing. On the one hand, companies and business- mobilization of public opinion, the use of in- es tend to resist measures they view as overly formation and research to steer public opinion intrusive or that could lower their profits; on and important stakeholders, strong leadership the other, citizens may oppose the idea because of politicians and policymakers, and taking ad- they may feel that it infringes on their personal vantage of favorable conditions for the design liberties or lifestyle, or that it tells them how and implementation of these policies. to live. Some of these stakeholders can be very As a result of the government’s initiating powerful in terms of the resources they can a dialogue, an industry may develop its own bring to bear in opposing these policies. This guidelines and standards to improve public is particularly so regarding the transnational health. Such was the case in the United King- tobacco, alcohol, and food and beverage indus- dom, when the food manufacturers developed tries. Efforts to improve public health by re- their own nutritional labeling standards (Traf- ducing salt intake, eliminating trans fats from fic Light System [TLS]). processed foods, levying taxes on alcohol, add- Because these voluntary actions can be inef- ing bike lanes, or banning smoking in public fective, policymakers have had to impose regu- places, are far from immune to such opposition. lations to replace them. In Europe, Canada, and Governments also face internal hurdles. the United States, early voluntary nutrition la- Often, policymakers have differing views on beling actions failed to meet government stan- what public goals are valid and on how best dards and expectations, leading governments to pursue them. For instance, in the case of to switch to mandatory guidelines. In New York tobacco control in producer countries, health City, encouraging restaurants to voluntarily provide customers with nutrition information tion for companies to differentiate their brands in plain sight also proved ineffective, and the across products. city mandated regulation. Industry-led initia- Most successful efforts required strong tives to pursue public health goals and prevent coordination among the many participating NCDs also have proven to be less satisfactory stakeholders. Often, this coordination was in the case of food advertising. For example, in- made possible through the leadership of min- dustry guidelines restricting inappropriate ad- istries of health and through institutional ar- vertising, such as promoting unhealthy foods to rangements that favored such coordination. children, proved weak and resulted in low lev- The role of the health sector has been key in els of adherence across the industry. This led many of the examples reviewed. Often it initi- the U. K. government to impose statutory regu- ated the dialogue among relevant actors and lations that restricted advertising for unhealthy ensured coordination among them. Such was foods by limiting the hours during which ads the case in Argentina’s agreements to reduce for foods high in fat, sugar, and salt could be sodium and the revision of the country’s Food aired on television (Hastings and Cairn 2010). Code to reduce trans fats in processed foods. To Sometimes the interplay between the gov- this end, a Ministry of Health (MOH) initiative ernment and the sector it seeks to regulate can created a National Commission to Eliminate be highly confrontational, and governments Trans Fats and Reduce Salt that included sever- should be prepared for this. The regulation of al public and business organizations, scientific the tobacco industry is one such example. Un- associations, and civil society groups. Similarly til recently, the tobacco industry was one of in Uruguay, at the request of the MOH, the Na- the most powerful industries in the consumer tional Alliance for Tobacco Control (ANCT) was market. It is not a coincidence, then, that tobac- established; this coordinating entity comprised co-control policies sometimes took decades to government agencies, parastatal organizations, take effect and, in the success stories reviewed international organizations, academic insti- PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: here, required the commitment of many politi- tutions, and nongovernmental organizations cal players. The steadfastness of policymakers, (NGOs). Finally, in the case of the Cicloví�a in coupled with popular support, becomes even Bogotá, Colombia, the creation early on of the more critical in tobacco-producing countries Cicloví�a multisectoral committee (composed such as Brazil and Argentina. But even those of bicycle activists, the police, the Traffic and countries that have successfully reduced to- Transport Department, and the National Cy- bacco prevalence through strong control pol- cling Federation) bolstered its development. icies still face hurdles, as does Uruguay. In Policymakers and health advocates in gen- 2010, Phillip Morris International brought to eral often gauge and mobilize public opinion in Governance of Five Multisectoral Efforts the International Centre for Settlement of In- support of health promotion policies and en- vestment Disputes (ICSID) an arbitration pro- sure their design and implementation. For in- cedure against the Government of Uruguay for stance, while the regulation to reduce trans fats its tobacco-control policies, specifically for the was being discussed in New York City, the city requirement that 80 percent of the packages government provided constant and persuasive display health warnings and for the prohibi- messages to the public on the links between trans fats and coronary heart disease; this con- 28 certed information campaign contributed to enforces alcohol restrictions, or limits tobacco 29 garner public support for the regulation. The use, the leadership and political commitment policy to promote smoke-free environments in of a few key political figures has been at the Uruguay also was accompanied by strong com- heart of many of the successful cases. For ex- Executive Summary Volume I munication campaigns to ensure public sup- ample, Brazil and Uruguay are countries where port. Similarly, in the city of Diadema, Brazil, a group of committed politicians and policy- through education campaigns and discussions makers, supported by strong advocacy groups, with alcohol retailers, public opinion quickly effectively fought efforts from tobacco lobby- turned favorable to alcohol restriction policies ists and put in place comprehensive and effec- (Pacific Institute for Research and Evaluation tive tobacco-control policies. In Brazil, which is 2004). a major tobacco producer, the leadership and In many of these ventures, research played a commitment of key political players, such as critical role in the adoption of population-wide the director of the National Institute of Can- preventive interventions. Independent re- cer, Marcos Moraes, and the then-Minister of search institutions were fundamental in mov- Health, Jose Serra, were crucial in leading the ing policies forward, and their participation country along the path of tobacco control. In often represented the turning point toward Uruguay, President Tabaré Vasquez played an reform. A solid and convincing research base important role in moving policies forward. In is indispensable for shaping public opinion Bogotá, Colombia, the continuous effort of two and raising support for policies. In the United mayors, Antanas Mockus and Enrique Peñalo- Kingdom, for example, the decision to create za, was behind the consolidation of the city’s a statutory regulation on advertising foods to built environment. The leadership of New York children was influenced by research that found City Mayor Michael Bloomberg also deserves an association between advertising and chil- mention as an important factor behind the dren’s food preferences and by a study showing healthy lifestyle initiatives in that city. that a large percentage of the expenditure on Often, policymakers’ engagement is shaped food advertising during children’s air time was by the advocacy and persuasion of civil society for foods high in fat, sugar, and salt (Hastings, groups. Such was the case for policies involv- Stead, and McDermott 2003). In Brazil, the Na- ing the Minimum Legal Drinking Age (MLDA) tional Cancer Association organized meetings in the United States. One organization in partic- and conferences following the circulation of ular, Mothers Against Drunk Driving (MADD), alarming data on the health consequences of founded by the mother of a victim of a repeat tobacco consumption (Da Costa and Goldfarb drunk driver, was fundamental in convinc- 2003), but that research needs to be communi- ing politicians and policymakers, including cated effectively to policymakers and the pub- then-President Ronald Reagan, to pass a bill lic. Both in the United Kingdom and in Brazil, that awarded highway funds to states with civil society groups played a crucial role in pub- anti-drunk-driving measures in place (Grant licizing that data and raising awareness among 2011). the population. Taking advantage of favorable conditions Whether an initiative is community-based or moments has also been key in the success- or national in scope, whether it tackles obesity, ful enactment and implementation of some of these policies. In the case of tobacco control, motes physical activity in Bogotá, Colombia; the the international context created by the Frame- national agreement for food health in Mexico work Convention on Tobacco Control (FCTC) (Strategy against Overweight and Obesity); and has facilitated the adoption of tobacco-control tobacco-control policies in Uruguay (table O.1). policies worldwide. The signing and ratifica- And there are additional examples: at both the tion of the FCTC in Uruguay gave strong impe- local and national levels, groups of motivated tus to that country’s tobacco-control policies. and deeply committed policymakers and health Similarly, Colombia’s decentralization process advocates have effectively countered opposi- made it possible for elected mayors to inde- tion and been able to put in place effective and pendently pursue policies that changed Bo- long-lasting policies to prevent NCDs. gotá’s built environment. Despite these successful and promising ex- amples, however, there is scant evidence of The Unfinished Agenda ongoing activities to fight NCDs at the popula- Given LAC’s disease profile and the existing evi- tion level in LAC, with the exception of tobacco dence on cost-effective interventions to prevent control. Much remains to be done in the region NCDs at the population level, it is important for to improve diet, promote physical activity, and the region’s countries to strengthen their mul- reduce tobacco use and alcohol abuse. tisectoral efforts to reduce health risk factors, For example, even though Argentina, Brazil, particularly those targeting tobacco use and al- Chile, Costa Rica, and Mexico are pursuing re- cohol abuse. Although there are several cost-ef- ductions in the intake of sodium and trans fats, fective interventions to decrease exposure to these efforts are the exception, rather than the tobacco use and alcohol abuse, there are fewer rule. Moreover, these measures have yet to be measures intended to improve diet and pro- consolidated and evaluated. And the region is mote physical activity, with the exception of only starting to design and implement commu- interventions aimed at decreasing the intake nity-based interventions to prevent and con- PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: of sodium and trans fats. Thus, controlling to- trol overweight and obesity. Although halting bacco use and, particularly, alcohol abuse, the the increasing trend in the percentage of over- main health risk factors in most of the region, weight and obese persons has proven difficult should be the main priority. That said, given the across the globe, there are some policies that importance of overweight and obesity as a risk have proven effective in improving diet and factor, the region’s countries also should ex- promoting physical activity. Since nutrition periment with different programs and policies habits start very early on in life, and since a aimed at stopping the increase in BMI and even growing number of children in the region are overweight, interventions at the school level Governance of Five Multisectoral Efforts to reverse it. The region has seen several examples of suc- would be important to consider and evaluate. cessful or promising interventions to promote An example worthy of closer examination healthy living, such as the agreements between was Mexico’s National Agreement for Food the government and industry to reduce sodi- Health, a promising blueprint for action in the um and the reform of the Food Code to reduce fight against obesity. With high rates of obesity trans fats in processed foods in Argentina; the in the country, the government set up a com- establishment of a built environment that pro- prehensive strategic plan that involved the 30 collaboration of multiple actors, including dif- abuse, but often these are not adequately en- 31 ferent government agencies, the private sector, forced either (WHO 2011b; Monteiro 2007). civil society, and academia. The government For instance, most countries in the region have intended to reduce overweight and obesity by laws on blood-alcohol concentration levels Executive Summary Volume I increasing opportunities for physical activity and restrictions on hours when alcohol can be and improving the population’s diet. According sold, but their enforcement is inconsistent. In to the plan, increased physical activity was to addition, because there are many gaps in these be pursued throughout schools, workplaces, laws, particularly in terms of restricting alcohol neighborhoods, and communities. The plan sales, legislation needs to be strengthened. As also sought to ban trans fats and to implement mentioned earlier, alcohol abuse is the leading programs across different sectors of society to health risk factor in the region, as it increases encourage a greater consumption of fruits, veg- the risk of injuries and of developing NCDs. De- etables, and grains. spite this, information about comprehensive Some of the region’s cities are implement- strategies to control alcohol abuse in the region ing policies aimed at building environments is scanty. In the literature review conducted for that facilitate physical activity. For example, this study, only two good examples were found many cities in the region have Cicloví�as,4 sus- of comprehensive strategies, both at the local tainable public transportation systems, and/or level: initiatives in the cities of Diadema and bike routes. One of the best examples of this ap- Paulina in Brazil. proach is in Bogotá, Colombia. Mostly, though, Because some multisectoral interventions these efforts concentrate in large urban centers to prevent health risk factors are more effec- and in upper-middleincome countries. In the tive at the regional level, it is important that re- case of Cicloví�as, for instance, although a ma- gional and subregional approaches to promote jority of countries have at least one, most are healthy living be developed. This is true for in one or two large urban centers. Only Colom- fiscal policies, particularly tobacco and alcohol bia, Brazil, Mexico, and Peru have several active taxation policies. Further, harmonizing tobacco ones.5 and alcohol pricing (through tax levels) at the In terms of tobacco control, almost all the regional level would reduce the incentive for region’s countries have ratified the FCTC and smuggling. And harmonizing tobacco advertis- have passed laws and regulations according- ing bans and nutrition labels would also make ly. But often these laws are not fully enforced. these policies more effective. There are some Moreover, there is also much improvement to subregional efforts under way in this regard, be done in terms of fiscal policies, since many such as the work by Common Market of the countries still have room to increase taxes on South (MERCOSUR) countries in nutritional la- tobacco products. In 2010, in only 4 out of 32 beling and the work of the intergovernmental countries for which data was available, did tax- Commission for Tobacco Control, which also is es represent more than 70 percent of the price part of MERCOSUR. of the most frequently sold brand of cigarettes Strengthening the countries’ surveillance (WHO 2011b). systems should be part of any strategy to pre- Most countries have in place some cost-ef- vent and control NCDs. There is little informa- fective interventions needed to control alcohol tion on some health risk factors and, when it is available, it is not standardized and thus is dif- interventions targeting these risk factors. Proj- ficult to compare. This is particularly true for ect Guide for Useful Interventions for Physical information on sedentary lifestyle, overweight Activity (GUIA), an initiative funded by the and obesity, abnormal blood-glucose levels, U.S. Centers for Disease Control and Preven- high blood pressure, and high blood-lipid lev- tion (CDC), is attempting to fill this void for els. Some countries do not even have available physical inactivity. Yet, as important as this data on tobacco use and alcohol abuse. Infor- project is in shedding light on current physi- mation on the prevalence of NCDs, although cal activity interventions in the region, it is not available for most countries, is usually based enough. In order for the region’s governments on administrative data, which makes it very dif- to execute meaningful plans to reduce NCDs, ficult to disaggregate by socioeconomic group, it is crucial that they themselves establish an rural or urban residence, or level of education. overview of the current situation, demonstrat- This, in turn, makes it difficult to target inter- ing the strengths and weaknesses of ongoing ventions to groups that need it most. programs and identifying where more action is Little research and evaluation has been con- needed. In addition, international and region- ducted on existing policies and interventions al experiences have shown the importance of in LAC countries. This is particularly import- research, not only for evidence-based policy- ant in the case of policies aimed at improving making, but also to enlist the public’s support diet and promoting physical activity, as there for health promotion policies. is less international evidence on cost-effective PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 32 Table O.1. International Examples of Multisectoral Interventions Designed 33 to Reduce Noncommunicable Disease Risk Factors Risk factor Cost-effectiveness Intervention Examples Sectors involved North Karelia, Finland, Executive Summary Volume I community program subsequently extended nationwide. Salt-reduction strategies Argentina, agreements with the food industry to reduce sodium in processed foods. New York City, ban on trans fats. Best buya Denmark, legislation regulating trans fat levels in processed foods. Agriculture, health, food Replacing trans industry, food retail fats Puerto Rico, ban on industry, advertising Unhealthy diet trans fats. industry, restaurant associations, city Argentina, reform governments, the of the Food Code legislature, others. to regulate amount of trans fats in processed foods. Regulating advertising on marketing of foods United Kingdom, and beverages statutory regulation high in salt, on advertising fat, and sugar, Other cost-effectiveb especially to children Taxes and Poland, elimination subsidies to of butter and lard promote healthy subsidies. diets New York City, bike lanes and bike paths. City governments, urban Effective with Modifying the built planning, transport, insufficient environment to Bogotá, Colombia, Physical inactivity health, civil society evidence on its cost- increase physical sustainable public organizations (CSOs), and effectiveness.c activity transportation, the media. Ciclovía, CicloRutas, and outdoor gyms. Risk factor Cost-effectiveness Intervention Examples Sectors involved United States, “Treatwell 5-a-Day” Work-based program to increase programs fruit and vegetable consumption. United States, Child and Adolescent Trial for Cardiovascular Health (CATCH). Community based School-based Agriculture, health, food Effective with United States, programs to programs industry, food retail insufficient Pathways improve nutrition industry, schools, work evidence on its cost- (randomized control and increase places, food retailers, effectiveness.c study among Native physical activity others. American school children). North Karelia, Finland, decreasing salt and fat consumption Other community- and increasing based programs fruit and vegetable consumption. Europe, EPODE. Fiscal Measures Banning smoking in public places. Several successful Raising awareness examples worldwide. Finance, health, and increasing agriculture, legislature, knowledge Uruguay, tobacco- Tobacco use Best buysa international about dangers of control policy is PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: organizations, tobacco tobacco use. one of LAC’s most industry, farmers, CSOs. successful efforts in Enforcing bans this regard. on tobacco advertising, promotion and sponsorship. Governance of Five Multisectoral Efforts 34 Risk factor Cost-effectiveness Intervention Examples Sectors involved 35 USSR, Gorbachev anti-alcohol legislation. Fiscal Policies Executive Summary Volume I Sweden, state Restrictions on monopoly on alcohol availability and sale (Systembolaget). access to alcohol Various U.S. states’ alcohol licensing systems Best buysa Federal and state Australia, Halls Creek governments, Aboriginal town limit city governments, Alcohol abuse of alcohol sales. health sector, police, Limiting the hours of alcohol sales agriculture, alcoholic- New Zealand, liquor beverage industry, and bans and limitations CSO. on alcohol-sale hours. United States, raising Age restrictions on the Minimum Legal alcohol purchase and sale Drinking Age (MLDA). United States, “Checkpoint Other cost-effective BACd Tennessee” program effortsb to decrease drunk driving. Source: Bonilla-Chací�n, 2014. Note: The table includes most of the programs reviewed for this study. The cost-effectiveness classification in the sec- ond column of the table refers to the intervention in general (in the abstract) as per WHO (2011a). It does not necessarily refers to each particular example provided of each intervention. EPODE = Ensemble Prevenons l’Obesite Des Enfants (Together Let’s Prevent Childhood Obesity); LAC = Latin Amer- ica and the Caribbean. a. “Best buys” are interventions that WHO (2011a) considers as “cost-effective, low cost, and can be implemented in low resource settings.” b. These are other cost-effective interventions that are not among WHO’s “best buys.” c. These are effective interventions for which there is insufficient evidence on their cost-effectiveness. d. Blood alcohol concentration. Table O.2. Design and Implementation of Population-based Preventive Polices, by Risk Factor. Intervention Key stakeholders Positions Strategies Outputs or outcomes An unhealthy diet The government: (1) informational and awareness campaign, which guaranteed The government: consumer demand reducing salt for less salty intake benefits the products; this Salt and saturated population’s health. pressured industry fat reduction to lower sodium strategies in North Local government, The food industry: content. Karelia, Finland. health services, salt is an inexpensive (2) Labeling schools, social way to add taste and regulations, which Output: 20 percent (This community- services, NGOs, to preserve food. required listing decrease in salt based program supermarkets, food sodium levels on intake in 20 years. aimed at industry, community Ministries of prepackaged foods reducing risks for leaders, and media. Agriculture and of Outcome: Decreased cardiovascular Commerce: support Ministries of cardiovascular disease and Ministries of to farmers and Agriculture and of disease rates by included a Agriculture and of businesses affected Commerce financed 73 percent in North component aimed Commerce by the change a collaborative Karelia between at decreasing in consumption project between 1971 and 1995. tobacco use National Nutrition patterns. berry farmers, the and promoting Council berry industry, and vegetable and fruits Dairy farmers: commercial and intake.) reduction of dairy health authorities consumption has to find innovative negative economic ways and new PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: effect. product development to promote berry consumption and help dairy farmers switch to berry production. Governance of Five Multisectoral Efforts 36 Outputs or 37 Intervention Key stakeholders Positions Strategies outcomes MOH: protect the MOH: (i) Coordinated the population against process, (ii) articulated actions harmful effect of with other public agencies, Executive Summary Volume I excessive sodium (iii) negotiated actions with and trans fats. the private sector, and (iv) disseminated information to INAL: as part of consumers. the Ministry, held similar position. INAL: Contributed regulatory, Ministry of Health technological, and monitoring (MOH): INTI: similar knowledge. With INTI, MALF, Output: 8,000 position to the and COPAL, it designed a bakeries National Food Ministry, but with a manual to help small and have signed Institute (INAL) few disagreements. medium enterprises to agreements to eliminate trans fats in their reduce salt in National Institute MoALF: promote production processes. bread. of Industrial value added of Technology (INTI) healthy foods. INTI: In terms of sodium, it In addition, Agreements provides training to bakeries. more than 20 Ministry of with industry to COPAL/ In the case of trans fats, it large companies Agriculture, reduce sodium FAIPA/ASAGA: presents and disseminates have signed Livestock, and in processed representing the evidence on the viability agreements with Fisheries (MALF) foods and to industry wanted of replacing trans fats and the Government to amend the food to avoid sudden sodium in food. reduce sodium in COPAL code to regulate implementation several processed (Coordinator for trans fats in of policies that MoALF: Contributed regulatory foods. Food Product Argentina could be costly and technological knowledge. Industries), which and respond to included FAIPA demands from COPAL/ASAGA: Organized (Argentinean public for healthier meetings with companies Outcomes: Both Federation of foods. In terms to agree on the terms and policies still Baked Products of trans fats, goals to be discussed with the need to be fully Industries) the industry had MOH. Collected and delivered monitored and and ASAGA already started information on sodium content their impact (Argentinean to eliminate them in food. Through ASAGA, it evaluated. Association of and there were contributed technical know- Fats and Oils) technologies how to replace trans fats available. In terms and organized meetings of sodium, it was with companies to agree on considered as an the terms and goals to be inexpensive way discussed with the MOH. It to add flavor and also helped design the manual preserve foods for small and medium size and it has fewer enterprises with INTI and replacements. MALF. Outputs or Intervention Key stakeholders Positions Strategies outcomes Board of Health: (1)first strategy was to convince restaurants to voluntarily The government: reduce trans fats. City New York City reducing trans fat provided training for this. When Board of Health This regulation is Replacing trans intake benefits the this failed, strategy moved to enforced. The city fats in New population’s health. ban trans fats. (2)To address New York State has fines of up York City, United restaurants concerns, the city Restaurant to US$ 2,000 for States NYSRA: changing gave an extension to reach goal Association noncompliance. production of reducing trans fat levels (NYSRA) processes is costly to 0.5 grams per serving. (3) Effective communication campaign linking trans fats to coronary heart disease Physical inactivity NYC DOT: bike lanes promote environmental sustainability, attract businesses and tourism, and increase physical activity. Neighbors for Better Bike Lanes New York City and Seniors for Department of Safety: Both sued Transportation NYC DOT, charging (NYC DOT) that DOT inflated NYC DOT made all information the number of available, showing that the New York City Neighbors for PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: lanes used and increase in bike lanes actually bike lanes, Better Bike Lanes N/A understated reduced the number of United States the number of pedestrian killed in pedestrian- Seniors for Safety accidents. bike accidents. Businesses Businesses: bike The public lanes would inconvenience city drivers, would limit parking for deliveries, and would hinder sales. Governance of Five Multisectoral Efforts The public: A poll showed a higher than 60 percent support for bike lanes 38 Outputs or 39 Intervention Key stakeholders Positions Strategies outcomes Tobacco use The presidency: Enacted Executive Summary Volume I The presidency: several executive decrees Supported tobacco to fast track tobacco control control policies. The presidency MOH: Supported The Alliance: lobbied in tobacco control Parliament for tobacco control; worked towards the ratification Ministry of Health Alliance: Strong of the FCTC; and provided (MOH) and, since advocate of tobacco lawmakers with scientific 2005, the Tobacco control policies evidence on the extent of the Control Program tobacco problem. The tobacco National Alliance industry: tried MOH and National Tobacco for Tobacco to avoid these Control Program, since Control, which policies. 2005: launched broad media includes the campaign to ensure public From 2006 to MOH, and several Trade associations support of the smoke-free 2009 there was parastatals, of bars, environment decree; developed restaurants, a 10 percentage international and launched the country’s casinos, and point decline the organizations, controls and, at the national businesses: prevalence of Tobacco control NGOs, CSOs, and level, coordinated its efforts Originally opposed with the other groups that were daily smokers policies, Uruguay others. the smoke-free among people 15 developing policies; and checks environments to 64 years old policy’s compliance. as they thought in urban centers it would have The tobacco industry: (i) When (95 percent of The tobacco negative economic Uruguay became a smoke-free population) industry. impacts on country in 2006, the industry them. They also claimed the controls limited wanted to ensure “freedom” and smokers’ Trade transparency in the “rights;” (ii) further, when associations of implementation parliament debated the tobacco bars, restaurants, of penalties for law, it lobbied lawmakers to casinos, and non-compliance reject it; (iii) finally, it used businesses. with smoke free litigation at national and environments. international levels. In 2008, it filed judicial and administrative Bus-drivers lawsuits in the country against Bus-drivers union. union: opposed all the regulations. In 2012, the smoke-free it requested arbitration to environment the International Centre for decree. Settlement of Investment Disputes (World Bank). Outputs or Intervention Key stakeholders Positions Strategies outcomes New York Nightlife Association and the Empire State Restaurant and Tavern Association: A study prepared for the associations After the ban The New York City and the tax stated that, following the ban, Board of Health: increase, staffing had been reduced measure would smoking by 16 percent in bars, hotels, educe exposure decreased and nightclubs, and that to second-hand by 11% (from three-fourths of bars and smoke. 21.6% to 19.2%) restaurants had experienced a 30 percent decline in patronage between 2002 The tobacco (Ridgewood Economic and 2003, industry: measure Associates 2004). following the NYC Board of would lead to loss intervention. Health Tobacco of revenues. The tobacco industry: it The decrease industry New financed the restaurant and bar occurred in all York Nightlife New York Nightlife New York City associations’ opposition to the five boroughs Association. Association and Smoke-free Air ban. across all age Empire State Act (the ban was groups, race/ Empire State Restaurant and combined with a The New York City Board ethnicities, Restaurant Tavern Association: tax increase). of Health: sponsored an education levels, and Tavern the ban would evaluation that contradicted and gender. Association harm the city’s the associations’ findings. Almost half of economy by Its study found that, despite all respondents Public decreasing profits the smoking ban, the city had attributed the on the city’s bars experienced increases in jobs, air free act, and and restaurants. liquor licenses, and business the decreased tax payments since the law had exposure to The public: poll taken effect. Moreover, data smoke, as the showed a 59 from the city’s Department primary reason percent approval of Finance found that, from for the decrease rate of the ban April 2003 to January 2004, in smoking among NYC PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: city restaurant revenues had (Frieden and residents. increased by about US$ 1.4 others 2005). million, compared to the same period the year earlier (Elliott 2004). Governance of Five Multisectoral Efforts 40 Outputs or 41 Intervention Key stakeholders Positions Strategies outcomes Alcohol abuse Between 1985 Executive Summary Volume I and 1987, years when the anti-tobacco Ministries of policy was in Finance and of effect, male Trade and the life expectancy Central Planning in Russia Commission: increased from Ministry of Opposed the 61.7 to 64.9, Finance law because it and female life drastically reduced expectancy USSR, 1985 Ministry of Trade revenues from increased from Gorbachev anti- alcohol sales 73 to 74.3. alcohol legislation Central Planning of government In contrast, Commission distilleries and from 1988 to from excise taxes. Health authorities 1994, after the legislation was Health authorities: rescinded, male wanted to reduce life expectancy the burden of decreased to disease created by 57.6 and female alcohol abuse. life expectancy to 71 years (Leon and others 1997). Outputs or Intervention Key stakeholders Positions Strategies outcomes Advocacy groups: wanted to increase the MLDA to reduce traffic accidents produce by drunk driving. Congressional representatives: Two house representatives introduced a bill to increase MLDA to 21; some senators opposed Advocacy groups it, sustaining such as Mothers that it violated Against Drunk the Constitution, U.S. National Driving Advocacy groups: presented a as it ran against Minimum Drinking principles of large body of research showing Different Age Act increased federalism; in their the benefits of increasing Congress the minimum view this should be MLDA, particularly in regard representative legal drinking a responsibility of to the dramatic increase in age (MLDA) to 21 the states. fatal accidents following less Alcohol industry years. restrictive alcohol policies. The alcohol President industry: opposed Public the measure, as it would reduce sales. The president: PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: originally opposed the federal mandate, but eventually supported measures to increase MLDA. The public: strong support for the measure. Governance of Five Multisectoral Efforts Source: Bonilla-Chací�n, 2014 42 References venting Childhood Obesity. Evidence Policy 43 and Practice, edited by E. Waters, B. Swin- Bonilla-Chací�n, Marí�a Eugenia, ed. 2014. Pro- burn, J. Seidell, and R. Uauy. Oxford, UK: Wi- moting Healthy Living in Latin America and ley-Blackwell the Caribbean: Governance of Multisectoral Executive Summary Volume I Hastings, G., M. Stead, and L. McDermott. 2003. Activities to Prevent Risk Factors for Non- Review of Research on the Effects of Food communicable Diseases. Direction in Devel- Promotion to Children. Glasgow, Scotland: opment. Washington, DC: World Bank University of Stratchclyde. Da Costa, L. M., and S. Goldfarb. 2003. “Gov- Leon, D., L. Chenet, V. M. Shkolnikov, S. Zakharov, ernment Leadership in Tobacco Control: J. Shapiro, G. Rakhmanova, S. Vassin, and M. Brazil’s Experience.” In Tobacco Control McKee. 1997. “Huge Variation in Russian Policies: Strategies Successes and Setbacks, Mortality Rates 1984–94: Artefact, Alcohol, edited by J. de Beyer and L. W. Bringden. or What?” Lancet 350: 384–88. Washington, DC: World Bank. Lim, S. S., A. D. Lopez, C. J. L. Murray, M. Ezzati, T. Elliott, A. 2004. “Bars and Restaurants Thrive Vos, A. D. Flaxman, G. Danaei, K. Shibuya, H. Amid Smoking Bans, Study Says.” New York Adair-Rohani, M. Amann, H. Ross Anderson, Times, March 29. K. G. Andrews, M. Aryee, C. Atkinson, L. J. Fletcher, J., D. Frisvold, and N. Tefft. 2010. “The Bacchus, A. Bahalim, et al. 2012. “A Compar- Effect of Soft Drink Taxes on Child and Ad- ative Risk Assessment of Burden of Disease olescent Consumption and Weight out- and Injury Attributable to 67 Risk Factors comes.” Journal of Public Economics 94: and Risk Factor Clusters in 21 Regions, 967–74. 1990–2010: A Systematic Analysis for the Frieden, T. R., F. Mostashari, B. D. Kerker, N. Global Burden of Disease Study 2010.” Lan- Miller, A. Hajat, and M. Frankel. 2005. “Adult cet 380: 2224–60. Tobacco Use Levels after Intensive Tobacco Monteiro, M. 2007. Alcohol and Public Health in Control Measures: New York City, 2002– the Americas. A Case for Action. Washington, 2003.” American Journal of Public Health 95 DC: PAHO. (6): 1016–23. Pacific Institute for Research and Evaluation. Garret, J., and M. Ruel. 2003. “Stunted 2004. “Prevention of Murders in Diadema, Child-Overweight Mother Pairs: An Emerg- Brazil. The Influence of New Alcohol Poli- ing Policy Concern.” FCND Discussion Paper cies.” http://resources.prev.org/resource_ 148, International Food Policy Research In- pub_brazil.pdf. stitute, Washington, DC. Puska, P., E. Vartiainen, T. Laatikaninen, P. Jousi- Grant, D. 2011. “Politics, Policy Analysis, and lahti, and M. Paavola, eds. 2009. The North the Passage of the National Minimum Karelia Project: From North Karelia to National Drinking Age Act of 1984.” Working Paper Action. Helsinki: Helsinki University Print- 1103, Sam Houston State University, De- ing House. partment of Economics and International Ridgewood Economic Associates. 2004. “The Business, Huntsville, AL. Economic Impact of the New York State Hastings, G., and G. Carins. 2010. “Food and Smoking Ban on New York’s Bar.” Prepared Beverage Marketing to Children.” In Pre- for the New York Nightlife Association and the Empire State Restaurant and Tavern As- ———. 2011b. WHO Report on the Global To- sociation, May 12. bacco Epidemic 2011. Geneva: WHO. Sturm, R., L. M. Powell, J. F. Chriqui, and F. J. Cha- ———. 2011c. Global Status Report on Alcohol loupka. 2010. “Soda Taxes, Soft Drink Con- and Health. Geneva: WHO. sumption, and Children’s Body Mass Index.” Health Affairs 29 (5): 1052–58. Notes WHO (World Health Organization). 2003. “Diet, 1. There are also cost-effective clinical interventions to Nutrition and the Prevention of Chronic control some of the biological or intermediate risk fac- tors. However, they are not the focus of this document. Diseases: Report of a Joint FAO/WHO Ex- 2. Data comes from WHO’s Global Health Observatory pert Consultation.” Technical Report Series Data Repository on Tobacco 19, WHO, Geneva. 3. Control, at http://apps.who.int/gho/data/node.main. ———. 2005. “Preventing Chronic Diseases. A Tobacco. Vital Investment.” WHO Report, Geneva. 4. A cicloví�a is a program that temporarily closes streets to motor vehicles and offers safe and free spaces for ———. 2011a. Global Status Report on Non- recreation and physical activity. communicable Diseases 2010. Geneva: WHO. 5. For additional information on Cicloví�as, visit http:// www.cicloviasrecreativas.org/en/map. PREVENTION OF RISK FACTORS FOR HEALTH IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 44 45 46 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts Latin America and the Caribbean Region Photography: Marí�a Eugenia Bonilla Chací�n, The World Bank, CHAPTER 1. 47 Policies for the Elimination of Trans Fats and the Reduction of Sodium Consumption in Argentina MARÍA EUGENIA BARBIERI, FOR THE NATIONAL MINISTRY OF HEALTH OF ARGENTINA This case study describes how Argentina has trol of Noncommunicable Diseases, in order advanced in designing and implementing pol- to (a) monitor and analyze the determinants icies to eliminate trans fats and reducing the of chronic NCDs in order to guide the policies consumption of sodium in its population. Its that control them; (b) reduce the level of expo- content is based on published materials on the sure to common chronic NCD risk factors; and subject and interviews with key stakeholders (c) strengthen the care for people with chronic of both initiatives. NCDs by means of standards and cost-effective guides (WHO, 2008).1 Based on these guide- Context lines, as well as with the Pan American Health According to World Health Organization (WHO) Organization’s (PAHO) Regional Strategy for estimates, NCDs represent 80% of total deaths the Prevention and Control of Noncommuni- and 76% of DALYs in Argentina (WHO, 2009). cable Chronic Diseases, Argentina created a Moreover, according to data from the Director- similar national strategy through Ministerial ate of Health Statistics and Information (DEIS Resolution 1083/09. from its Spanish acronym), the leading cause of In the context of this strategy, various ac- death in 2010 was cardiovascular disease, fol- tions are being carried out to reduce the prev- lowed by cancer (DEIS, 2011). alence of risk factors and mortality and to In 2008, WHO developed the Action Plan for improve access and quality of care. Actions de- the Global Strategy for the Prevention and Con- signed to promote a healthy diet also has been implemented, given that nutrition has been avoid between 30,000–130,000 cases of isch- established as a key determinant of chronic emic heart disease each year in Mexico, Central NCDs that can be modified. Indeed, increasing America, and South America and a reduction of evidence shows that changes in eating hab- 4% would prevent twice that number (Mozaf- its can have both positive and negative effects farian, 2008). on a person’s health throughout his or her life Regarding sodium consumption, studies course. Moreover, changes in the diet can have have demonstrated a causal relationship be- long-term effects, such as the likelihood of de- tween salt intake and cardiovascular disease veloping cancer, diabetes, or cardiovascular and stroke, as well as a greater risk of hyper- diseases (WHO, 2003). tension (OMS, 2007). Evidence also has shown Argentina has launched two activities deal- that small reductions in salt intake during four ing with nutrition problems: the first, “Argen- or more weeks significantly lower blood pres- tina 2014 Free from Trans Fats, a program sure, in both persons with normal blood pres- designed to gradually replace trans fats in the sure and in those with high blood pressure (He, diet; and “Less Salt, More Life, which aims to 2004). In Argentina, it is estimated that low- reduce sodium consumption.” Both strategies er sodium in processed foods could decrease are coupled by campaigns promoting fruit and the incidence of coronary disease by 10%, vegetable consumption and physical activity. myocardial infarctions by 7.3%, strokes by 11.8%, death from coronary disease by 6.5%, Consumption of Trans Fats and deaths from all causes by 2.5%. More- and Sodium in Argentina over, reducing sodium in food would decrease spending in health, by preventing those health Diets worldwide are currently undergoing a problems linked to its consumption (Ministerio “nutritional transition,” characterized by high de Salud de la Nación, 2010). consumption of saturated fats, sugars, and The National Risk Factors Surveys (ENFR, salt (such as milk, meats, refined grains, and for its Spanish acronym), conducted in Ar- processed foods) and reduced intake of com- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: gentina in 2005 and 2009, sheds light on salt plex carbohydrates, fibers, leafy greens, other consumption in the country’s population. At vegetables, and legumes. Such dietary habits the national level in 2009, 25.3% of the pop- contribute to hypertension, higher cholesterol, ulation always added salt to food after it was diabetes, overweight, and obesity (WHO, 2008, cooked, representing an increase compared to 2003; OPS, 2007). the 23.1% figure recorded in 2005. An analy- In terms of trans fats, evidence shows that sis by age group (conducted in 2009) showed their consumption increases the risk of cor- a higher prevalence of salt consumption among Governance of Five Multisectoral Efforts onary disease and diabetes (Hu, 2001, 1997; 18–24-year-olds, with 32.9% of this age group Brunner, 2007). That said, evidence also shows adding it to their foods, and lower percentages that there are proven ways to eliminate their for age groups older than 50—14.7% for the use in prepared food, which would be a cost-ef- 50–64 age group and 18.4% for those 65 and fective way to prevent cardiovascular diseases older (Table 1.1) (Ministerio de Salud de la Na- (OPS, 2008). It is estimated that a reduction ción, 2011, 2006). of 2% in the consumption of trans fats would 48 Table 1.1. Prevalence of salt consumption (always or almost always) by age group, 49 Argentina, 2005 and 2009 (in percentages). Year Grupos de edad (en años) 18–24 25–34 35–49 50–64 65 and older Average Chapter 1 2005 33.5 29.1 22,3 17.0 12.5 23.1 2009 32.9 31.1 26,7 19.5 14.8 25.3 Variation -1.8 6.9 19,7 14.7 18.4 9.5 Source: Author, based on data from the National Risk Factors Survey, 2005 and 2009. The 2009 and 2005 ENFRs also help to an- 64 years old showed the highest percentage of alyze the variables associated with the con- obesity (27.3%); the ENFRs also highlighted sumption of trans fats and sodium, because the increase in obesity among those 18–24 they gather information on cholesterol, blood years old since the 2005 survey. pressure, diabetes, and bodyweight in adults In 2009, 34.8% of the population reported (Table 1.2). Nationwide in 2009, 29.1% of the having high blood pressure, a slightly higher population reported having high cholesterol,1 percentage than that seen in 2005 (34.5%).3 an increase of 4.3% over 2005. Those older Those 65 years and older had the highest prev- than 65 reported the highest levels (39.7%), alence at 63%, an increase of 7.1% over the followed by 50–64-year-olds (39%); 18–24- 2005 figure (58.8%). In fact, the prevalence of year olds accounted for only 13% of the cases, high blood pressure was directly related to age. and those 25–34 years old, for 16.4%. All age The percentage of population that reported groups showed increases, especially those 35– having diabetes or high blood glucose in 2009 49 years old. was 9.6%, a value higher than that recorded in The ENFRs collected bodyweight infor- 2005 (8.4%).4 Prevalence was higher in old- mation through respondents’ self-reporting.2 er groups, with 19.0% among those over 65, According to the surveys, 18% of Argentina’s compared to 3.6% among those 18–24. An im- population was obese in 2009. This represents portant decrease in the prevalence of diabetes a 23.3% increase over the 14.6% figure record- among those under 34 was also observed be- ed in 2005. In regard to age groups, those 50– tween 2005 and 2009. Table 1.2. Prevalence of high cholesterol, obesity, hypertension, and diabetes, Argentina, 2005 and 2009 (in percentages). Variable Year/ Age groups (in years) variation 18–24 25–34 35–49 50–64 65 and Average older High 2005 11.9 15.3 22.0 37.3 38.0 27.9 cholesterol 2009 13.0 16.4 24.1 39.0 39.7 29.1 Variation 9.2 7.2 9.5 4.6 4.5 4.3 Obesity 2005 3.9 10.4 16.9 22.8 17.7 14.6 2009 6.6 12.8 21.1 27,3 20.1 18.0 Variation 69.2 23.1 24.9 19.7 13.6 23.3 Hypertension 2005 13.9 21.3 30.2 47.4 58.8 34.5 2009 14.2 20.2 28.9 47.2 63.0 34.8 Variation 2.2 -5.2 -4.3 -0.4 7.1 0.9 Diabetes 2005 4.7 6.7 7.8 17.2 20.4 8.4 2009 3.6 4.3 7.9 15.1 19.0 9.6 Variation -23.4 -35.8 1.3 -12.2 -6.9 14.3 Source: Author, based on data from the National Risk Factors Survey, 2005 and 2009. Information from the 2005 and 2009 ENFRs up with joint actions designed to reduce trans shows that obesity, diabetes, and high choles- fats and lower sodium consumption in the pop- terol increased, while high blood pressure re- ulation’s diet. However, the approach adopted mained relatively constant, which is consistent for each of these targets was different. In the PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: with an unhealthy diet and an increase in phys- case of sodium, the government sought in- ical inactivity. These risk factors are also more dustry’s self-regulation through the signing of prevalent among populations at highest risk, voluntary agreements, while for trans fats, an with lower incomes, lower levels of education, amendment of the Food Code was agreed upon, and lower prospects of having access to health which became effective in December 2010. care in case of illness (Ferrante, 2011). Approaches differed because the food in- dustry was already working to replace the trans Policies: Actions Designed to Governance of Five Multisectoral Efforts fats, given that the technical feasibility, foreign Eliminate Trans Fats and Decrease the experience, research/development, and exist- Consumption of Sodium in the Diet ing substitutes were already available to do so. In fact, 70% of the sector’s companies are al- Argentina, through its Ministry of Health and ready pursuing retrofitting. In regards to sodi- pursuing an inter-sectoral approach, called um, the situation is more complex, because this on different sectors involved in the regulation, ingredient is found in many processed foods, production, and distribution of food to come there is less awareness of its effects (such as 50 there is with trans fats), its substitution is inate Trans Fats and Reduce Salt, which was 51 more difficult, and more technical know-how is created at the Ministry of Health’s initiative; the needed to find alternatives and parameters for Commission is made up of several public orga- acceptable sodium levels in food. nizations, chambers of commerce, scientific as- Chapter 1 The strategies are carried out within the sociations, and civil society groups (Box 1.1). framework of the National Commission to Elim- Box 1.1 Participating Institutions in the National Commission to Eliminate Trans Fats and Reduce Salt • Ministry of Health • Ministry of Agriculture, Livestock, and Fisheries • Ministry of Social Development • Ministry of Science and Technology • Ministry of Economy • National Institute of Industrial Technology (INTI) • National Food Institute (INAL) • Argentinian Federation of Baked Products Industry (FAIPA) • Coordinator of Food Products Industries (COPAL) • Argentinian Association of Fats and Oils (ASAGA) • Chambers of commerce • Workers’ cooperatives • Universities and scientific societies • Consumer associations Source: Argentina’s Ministry of Health Although addressing the problem of trans framework, WHO’s Global Strategy on Diet, fats and sodium in Argentinians’ diet began in Physical Activity, and Health (2008) came un- full force in 2008, the Ministry of Health had der discussion, particularly those issues deal- launched some efforts in 2004, as requested by ing with food content and the necessary actions the Program for the Prevention of Heart Attacks to move the initiative forward. Some projects in Argentina (PROPIA) at the National Univer- were also financed with funds from the Health sity of La Plata (UNLP). The program’s purpose Surveillance and Disease Control (VIGI+A) Pro- is to reduce the number of deaths and patients gram, such as the one designed to reduce salt in due to atherosclerosis (heart attacks) through artisanal breads, which fell under the respon- actions focused on a healthy diet, physical ac- sibility of the National Institute of Industrial tivity, and anti-smoking campaigns. Within this Technology (INTI).5 Eliminating Trans Fats 2. Regulation-Legislation Commission, co- ordinated by the National Food Institute Overwhelming evidence about the effects of (INAL);6 trans fats on health led to a recommendation 3. Communication-Consumer Commission, to eliminate their consumption (WHO 2004). coordinated by the former Secretariat of Then, in 2007, the Pan American Health Orga- Agriculture, Livestock, Fishing, and Food nization (PAHO) created the Trans Fats-Free (currently Ministry of Agriculture, Live- Americas working group to evaluate trans fats’ stock, and Fishing). effect on nutrition and health and discuss prac- In August 2008, the Regulation-Legislation tical steps to gradually eliminate them from Commission began its work to amend the Food food. In 2008, the group issued the Declaration Code, prepare a manual with recommendations of Rio de Janeiro, Trans Fat-Free Americas in for small and medium enterprises, and devel- which it suggested the following (OPS, 2008): op consumer guides on healthy eating habits. 1. Replacing trans fats in processed foods The commission was made up of several pub- and using a concentration of no more than lic agencies and representatives from the food 2% total fat in oils and margarines, and no industry. INAL, the former Secretariat of Agri- more than 5% in processed foods. culture, Livestock, Fisheries, and Food (current 2. Compulsory nutritional labeling of pro- Ministry of Agriculture, Livestock, and Fish- cessed foods, including a statement of the eries), the Ministry of Health, and INTI were content of trans fatty acids. among the participating public agencies. Indus- 3. Developing education programs on differ- try representatives included the Coordinator of ent types of fats and the way to read labels, Food Products Industries (COPAL), a business and on applying the information in every- association for chambers of commerce, food day life. and beverage companies, and the Argentinian 4. Forming national working groups with the Association of Fats and Oils (ASAGA), an entity participation of industry, the scientific com- formed by technicians and companies involved munity, and public health authorities. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: in the production and processing of fats, oils, In 2008, the Ministry of Health adopted a and byproducts which was already working on leading role in the implementation of measures ways to substitute other products for trans fats. to eliminate trans fat convening a national Amendments to Argentina’s Food Code re- meeting to begin applying the Rio recommen- lied on other countries’ experiences. For ex- dations. Participants included representatives ample, in 2006, Denmark limited trans fats to from State agencies, academia, and industry, 2% of the total content of fats in all marketed who endorsed the formation of various work- foods and, that same year, Canada recommend- Governance of Five Multisectoral Efforts ing commissions (Secretarí�a de Polí�ticas, Regu- ed that trans fats should not exceed 2% of to- lación e Institutos y Secretarí�a de Agricultura, tal fat content in vegetable oils and spreadable Ganaderí�a y Pesca, 2010). They include the: margarines, nor 5% of other foods (OPS, 2008) 1. Academic-Scientific Commission, coordi- The joint effort between public agencies and nated by UNLP; the food-industry representatives made it pos- sible to reach an agreement to reduce trans fats and prepare an amendment to the Food Code, 52 after approval by the National Food Commis- 2006, the presence of trans fats must be stated 53 sion (CONAL), which was reflected in Article on product labels. No. 155 tris, chapter III, of the Argentine Food At the end of the adjustment period in 2014, Code, which established that (Código Alimen- it is expected that the monitoring of the mea- Chapter 1 tario Argentino, 1969): sure’s compliance and its effects will begin. To “The content of industrially-produced trans this end, the Ministry of Health and INAL are fatty acids in food should not exceed: 2% of working to strengthen the food control system total fats in vegetable oils and margarines for in the areas of monitoring, audit and lab. direct consumption and 5% of total fats in the rest of foods. These limits do not apply to fats Reducing Sodium from ruminants, including milk fat. ” WHO’s 2004 Global Strategy on Diet, Physical The article was incorporated by resolution Activity, and Health also recommended limiting No. 137/10 and No. 941/10 of the Secretariat sodium consumption from any origin. For its of Policies, Regulation, and Institutes (Ministry part, PAHO issued the Political Declaration for of Health) and the former Secretariat of Ag- the Reduction of Cardiovascular Diseases in the riculture, Livestock, and Fisheries, and Food Americas, which set the population’s reduction (current Ministry of Agriculture, Livestock, and of salt intake in food to a goal of under 5 grams Fisheries), in December 2010. The resolution per person per day by 2020; Argentina agreed also sets a two-year timetable for modifying to these parameters (OPS, 2009). vegetable oils and margarines for direct con- In 2010, the Ministry of Health addressed sumption and up to four years for other foods this topic, establishing the initiative “Less Salt, from December 2010), when the resolution en- More Life,” which aims to lower salt consump- tered into effect (OPS, 2008). tion as a way to reduce cardiovascular, cerebro- While the terms for replacing trans fats run vascular, and kidney diseases. The strategy is their course, work is under way in two areas: based on three components: i) disseminating information to small and me- 1. Public awareness on the need to lower salt dium industries, which will face greater dif- intake. ficulties in meeting the standard, as they lack 2. Progressive reduction of salt in processed the financial and technical resources to begin foods through agreements with the food in- retrofitting; and ii) launching campaigns to dustry. educate consumers about healthy diets. With 3. Reduction of salt content in artisanal bread. respect to the first, a guide was prepared on Reducing Sodium in Processed Foods recommendations and strategies to replace The joint effort between public and private enti- trans fats for healthier alternatives (Ministe- ties involved in food production is a key element rio de Salud de la Nación, 2011). With regard of any strategy designed to reduce sodium con- to consumers, materials were developed to re- sumption, since it is estimated that more than port on health effects and how to read food la- 60% of salt intake comes from processed foods bels so as to identify the presence of trans fats.7 (Ministerio de Salud de la Nación, 2011). Giv- It should be noted that, based on MERCOSUR en this, the Ministry of Health and the Ministry resolution GMC No. 46/03, adopted in August of Agriculture, Livestock, and Fisheries agreed with COPAL and the food industry companies and chambers of commerce on pursuing a pro- The established goals set progressive sodi- gressive and voluntary reduction of sodium um reductions from 5% to 15% over the max- content in food. To this end, four food groups imum values measured or over higher levels were selected: meat products and byproducts; than the established average. In terms of the farinaceous foods (cookies, baked goods, and category “soups, dressings, and canned foods,” snacks); dairy products; and soups, dressings, agreements were only reached for soups; in and canned foods. These products were se- terms of dairy products, agreements only were lected on the basis of three criteria: their high reached for cheese. These objectives should consumption by the population, their high so- be met within two years, and it is expected dium content, and the ease of reducing sodium that with this voluntary, progressive strategy, in them. Nonetheless, setting goals for each of WHO’s goal of 5 grams of average salt con- these four groups has been difficult, given the sumption per person per day will be achieved wide range of products involved in each catego- by 2020 (Mozaffarian, 2008; OMS, 2007, 2004; ry. As a result, specific goals were set based on He, 2004; Ministerio de Salud de la Nación, technological feasibility, consumer acceptance, 2010, 2011, 2006; Ferrante, 2009; OPS, 2008; impact on health, and weight of the products in Secretarí�a de Polí�ticas, Regulación e Institutos the market. The Ministry of Health; the Ministry y Secretarí�a de Agricultura, Ganaderí�a y Pesca, of Agriculture, Livestock, and Fisheries; INTI; 2010; Código Alimentario Argentino, 1969). INAL; COPAL; and the chambers of commerce Table 1.3 shows the goals agreed upon for each participated in this task within the framework product. of the National Commission to Eliminate Trans Fats and Reduce Salt. Table 1.3. Selected foods and goals for voluntary, progressive sodium reduction, Argentina. Meat products and byproducts Included products Sodium reduction goal PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Cold cuts, cooked sausages, sausage, and uncooked meats At a minimum a 8% reduction of maximum sodium content in Cooked salted meats, including sausage, salami, 100 gr of product (1,300 mg), reaching a value of 1,196 mg mortadela, cooked ham, cooked cold meats, and black blood sausage Dry sausages, including salami, pork sausages, At a minimum a 5% reduction of maximum sodium content in and “sorpresata.” 100 gr of product (2,000 mg), reaching a value of 1,900 mg Governance of Five Multisectoral Efforts At a minimum 5% reduction of maximum sodium content in Fresh sausages 100 gr of product (1,000 mg), reaching a value of 950 mg At a minimum a 15% reduction of maximum sodium content Fresh meats: hamburgers in 100 gr of product (1,000 mg), reaching a value of 850 mg Breaded chicken, including nuggets, tidbits, At a minimum an 8% reduction of maximum sodium content chicken breasts, drumsticks and thighs, in 100 gr of product (800 mg), reaching a value of 736 mg medallions, “chickenitos” and “formitas” 54 Farinaceous (starchy) products 55 Included products Sodium reduction goal Crackers with bran At a minimum, 5% sodium content in foods over 600 mg/100g Chapter 1 Crackers without bran At a minimum, 5% sodium content in foods over 990 Crackers (snacks) mg/100g Sodium content of all marketed products must not exceed Snacks 950 mg/100g At a minimum, 5% sodium content in foods over 310 Sweet dry cookies mg/100g At a minimum, 5% sodium content in foods over 320 Sweet cookies with filling mg/100g Bread products with bran At a minimum, 5% sodium content in foods over 450 Bread products without bran mg/100g Frozen bread products Dairy products (cheese) Included products Sodium reductiongGoal At the very least, 5% sodium content in cream cheeses over Cream cheese 558 mg Na/100 g At the very least, 5% sodium content of Cuartirolo cheese Quartirolo cheese over 496 mg Na/100 g At the very least, 5% sodium content of Dambo cheese over Dambo cheese 542 mg Na/100 g At the very least, 5% sodium content of Mozzarella cheese Mozzarella cheese over 510 mg Na/100 g At the very least, 5% sodium content of PorSalut cheese over Port Salut cheese 536 mg Na/100 g At the very least, 5% sodium content of Tybo cheese over 625 Tybo cheese mg Na/100 g Soups Included products Sodium reduction goal At the very least, 5% sodium content of any product with a Paste (cubes/tablets) and granulated broth value greater than 374 mg/100g At the very least, 5% sodium content of any product with a Clear soups value greater than 346 mg/100g At the very least, 5% sodium content of any product with a Cream soups value greater than 306 mg/100g At the very least, 5% sodium content of any product with a Instant soups value greater than 352 mg/100g Source: Argentina’s Ministry of Health. Available at: http://msal.gov.ar/ent/MenosSalMasVida/PDF/Tabla%20de%20 Alimentos%20seleccionados%20en%20los%20que%20se%20reducira%20sodio.pdf (Acceso el 18 de marzo de 2013) As of this writing, 35 companies and cham- committed itself to developing a logo that the bers of commerce have adhered to the agree- companies can use in their documents or insti- ment, listing products on which they commit to tutional communication activities and to dis- work (Box 1.2). The Ministry of Health also has seminating the list of participating companies. Box 1.2. Chambers of commerce and companies that signed on to the agreements of voluntary sodium reduction in processed foods • Arcor S.A.I.C. • Bark S.A. • Bimbo de Argentina S.A. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: • Cafés La Virginia S.A. • Cámara Argentina de la Industria de Chacinados y Afines (CAICHA) • Cámara de Industriales de Productos Alimenticios (CIPA) • Centro de la Industria Lechera • Coordinadora de la Industria de Productos Alimenticios (COPAL) • Compañía de Alimentos Fargo S.A. • Frigorífico Ridhans S.A. Governance of Five Multisectoral Efforts • Kraft Foods Argentina • Mastellone Hermanos S.A. • Molinos Cañuelas S.A.C.I.F.I.A. • Molinos Río de La Plata S.A. • Nestlé Argentina S.A. • Quickfood S.A. • Sancor Cooperativa Unidas Limitadas 56 57 • Unión Industria Cárnica Argentina (UNICA) • Unilever Argentina • Vaes S.R.L. Chapter 1 • Piamontesa S.A. • Frigorífico Paladini S.A. • Whim Burger • Imax • Pepsico • Ottonello • Galletitas Tía Maruca • Veneziana • Dulcor • La Paulina • Manfrey • Milkaut • Asociación de Pequeñas y Medianas Empresas Lácteas • Verónica • Williner Source: Argentina’s Ministry of Health There are plans to expand the list of prod- end, INAL and the Ministry of Health are work- ucts covered under the agreement, although ing to strengthen the laboratory network’s they have not yet been selected. It is also ex- technical capacities, equipment, and harmoni- pected that new companies will join the initia- zation and articulation. tive. If companies do not comply with the agree- To monitor the agreement, a two-pronged ment, they will have six months to do so, national strategy is being developed. The first with help from facilitators. If no resolution is component involves a multi-sectorial control reached, the parties may voluntarily opt out of commission made up of INAL; the Ministry of the agreement with no ill effect. Agriculture, Livestock, and Fisheries; INTI; the A study conducted by the Ministry of Health, Ministry of Health; and COPAL, that will collect assuming a 3-gram reduction of salt in the diet, and analyze indirect indicators, such as compa- estimated that the intervention would yield a nies adhering to the agreement, a results-based net savings of US$ 3,765 million and a gain of decrease of sodium, and sworn statements by 656,657 quality adjusted life years (QALYs) in the companies. The second component, which the high effect scenario and of 401,659 QALYs will operate under INAL, involves a monitoring in a low effect scenario. In addition there would strategy that will function through a laboratory be reductions in the incidence of heart disease network that will evaluate the products. To this (24.1%), acute myocardial infarction (21.6%), and stroke, and in mortality from coronary did, and that most do not weigh the amount heart disease (19.9%) and from all causes they use. Based on these results, an awareness (6.4%) (Ferrante, 2012). Another recently pub- raising effort was undertaken with the bakery lished study, also conducted by the Ministry, sector, which consisted in meetings with bak- finds that the “Less Salt, More Life” initiative eries to inform them about the importance of could have significant improvements on car- lowering the salt content and disseminating diovascular diseases in the coming 10 years. It this information to local mass0media outlets is estimated that 19,000 deaths from all causes, (newspapers, radio and television stations). 13,000 deaths due to acute myocardial infarc- Subsequent evaluations showed that this tion, and 10,000 deaths due to stroke could be awareness campaign had reduced the salt con- prevented (Konfino, 2013). tent in bread (DEISA, 2011). The Strategy for Reducing Sodium in Baked Later (in 2006), with financing from the Sci- Products entific Research Commission (CIC for its Span- Bread consumption is an important source of ish acronym) of the Province of Buenos Aires, salt intake in Argentina. It is estimated that, a nutritional and sensory optimization project on average, 190 grams of bread are consumed was conducted on bakery products. The results by every person a day, with a salt content of formed the basis of the report presented to 2%, contributing 4 grams of the 12 grams that CI Health-Centre for Chronic Disease Control, an Argentinian is estimated to consume daily which in 2007 financed the “Impact of Salt (25%) (Ferrante, 2012). Considering WHO’s Reduction in Processed Foods in Argentina” proposed goal of limiting sodium consumption project. Results from this project led to the con- to 5 grams a day, measures clearly must be in- clusion that consumers would not notice a re- troduced to lower salt in bakery products. duction of the salt content between 15% (from In 2004, INTI, through the Center of Grains 1.8% to 1.5%) to 30% (from 2% to 1.4%), but and Oleaginous Products, and the Argentinian that this change could significantly benefit the Federation of Baked Products Industry (FAIPA), public’s health (Ferrante, 2011; Apro, 2007). PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: with the support of the Ministry of Health’s In 2007, FAIPA and the Ministry of Health VIGI+A Program, launched a project to reduce formalized their collaboration by entering into sodium in baked products. The main aim was an agreement that aimed to promote healthy to evaluate the use of salt in artisanal bakeries, habits in the population and develop bakery as well as to develop and transfer necessary products whose consumption has a positive technology and provide training and informa- impact on health and the quality of life. The tion to bakeries to help them prepare breads agreement specifies communication strategies and other bakery products with less salt. and consumer education, as well as technology Governance of Five Multisectoral Efforts Initially, a survey was conducted in the transfers and training for the bakery sector for 9-de-Julio area bakeries in the province of Bue- preparing breads and breaded products with nos Aires, based on a pilot survey and a phys- lower sodium content. The agreement also icochemical analysis of bread samples. Results aims to improve the nutritional value of breads showed that when comparing the data from the and replace trans fats.8 interviews with those from the analyses, bak- Although a management change at the Min- ers reported using less salt than they actually istry of Health in 2008 halted the activities 58 shared with FAIPA, these were renewed in population’s health, spearheaded the discus- 59 2009, with a project in the province of La Pam- sions on measures to be undertaken to elimi- pa, that conducted a broader epidemiological nate them. Although initial efforts in this regard study with regard to the use and intake of salt, had started in 2004, it was not until 2008 that Chapter 1 trans fats, and fiber through breaded products, this initiative gained strength. This was due in order to confirm their impact on health. Pre- to the fact that, early on, there were discus- liminary results are expected in 2014, at which sions within the Ministry regarding whether time the study will be extended to the rest of its role was to regulate or negotiate with the the provinces (Apro, 2009). companies. It was thought the Ministry could Since 2010, the Ministry of Health, INTI, and only make recommendations to the population FAIPA renewed their collaboration to produce about which foods were healthier, without be- artisanal bread with lower or no salt. The initia- coming involved in making such foods avail- tive involves providing technical assistance and able. technology transfer to bakeries, distribution of The Ministry of Health began implementing salt measuring cups (since it was observed that the strategy by bringing together various actors bakers did not measure the salt they used), and (from both the public and the private sectors), massive information dissemination on salt con- which took on various roles. INAL, for example, sumption. one of the institutes of the National Adminis- That same year, the national contest “Less tration of Drugs, Food, and Medical Technology Salt, More Life” was launched, intended to re- (ANMAT) and a decentralized entity within the duce salt content in breads produced in artis- Ministry of Health, participated in the discus- anal bakeries; FAIPA and INTI supported the sion of the measures because of its knowledge effort, and PAHO sponsored it. To participate, about regulations, technology, food labeling, enrolled businesses had to prepare bread no and analytical verification. It also helped raise more than 1.5% salt, as well as unsalted bread. the issue at the provincial and municipal lev- Once enrolled, a bakery received a measuring els through the areas in which it operates, such cup, a poster letting consumers know that it as the National Food Protection Network (RE- was participating in the contest, and a poster NAPRA) and the Network of Food Protection showing how to prepare bread with less salt. Official Laboratories (RENALOA). When the registration period ended, the Minis- RENAPRA consists of about 1,000 agents try of Health held a lottery among participating who work in food regulatory entities (provin- bakeries to present 10 awards (consisting of cial and municipal) across the country with the supplies) throughout the country. aim of sharing information and experiences to identify best practices, build consensus on food Leading Actors: Positions and Strategies control, and provide training opportunities. Issues on which to focus are proposed each Eliminating Trans Fats: Leading Actors, month within the network, and one of them Strategies and Positions was trans fats, in order to place the issue on the agenda of other jurisdictions. For its part, The Ministry of Health, persuaded by the evi- RENALOA promotes the exchange of informa- dence on the harm that trans fats have on the tion to improve the quality of work in the food analysis laboratories, and provides training institutional agreement between the INTI and programs to member laboratories; in this case, the Ministry be developed, spelling out what the goal was to focus on food control issues to INTI was expected to do and validating INTI’s achieve consensus among the provinces and role with the companies—to which they also municipalities. provide advice—ensuring that the needs of the INAL had already been invited by PAHO to public sector hold sway. It demanded continui- participate in the “Trans Fat-Free Americas” ty of the policies, discussions regarding control group in 2007, and then, at the Ministry of measures, and a significant education strategy Health’s request, it assumed the coordination negotiated with the Ministry of Education. Fi- of the working group that addressed the reg- nally, it called attention to the low participation ulatory topic that led to modifying the Food of small and medium enterprises in the discus- Code. Further, it worked with the Ministry of sion of the measures. Agriculture, Livestock, and Fisheries in com- The Ministry of Health also invited the pri- munication activities, and with that Ministry vate sector to participate in the debate. Al- and INTI to prepare a manual on how to rede- though COPAL was invited to participate in the sign the production processes at small and me- trans-fats process, the leading role was shifted dium enterprises. to ASAGUA. The latter had been working on The Ministry of Agriculture, Livestock, and substituting fats in food and finding affordable Fisheries participated in the initiative as part of technologies to do so, in light of the interna- its goal to bring the importance of healthy diets tional standards that were being developed in to the fore, and to generate guidelines to that this regard. ASAGA met with companies to de- effect. This Ministry worked hand in hand with termine the feasibility of adopting necessary the Ministry of Health in this process, providing technological innovation and to set acceptable evidence on the technological feasibility of re- timetables for companies to make the change. placing trans fats. In addition, it played a lead- In light of the difficulty faced by small and me- ership role in discussions on dietary standards, dium companies in adapting to the change, PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: in that it participates in CONAL, the Codex Ali- ASAGUA worked with other public sector par- mentarius Commission, and in the definition of ticipants in the initiative on developing rec- dietary standards in MERCOSUR. The Ministry ommended guidelines aimed at this industry also worked in crafting the manual to facilitate sector. the process in small and medium enterprises. Discussions regarding trans fats faced some INTI collaborated with the Ministry of initial resistance. Companies worried about Health by participating in negotiations with costs. Early on, substitution alternatives were companies by helping to prepare the manual to costly, with fats being the most expensive in- Governance of Five Multisectoral Efforts assist in the retrofitting of small and medium gredient in the products. As the companies that enterprises with regard to trans fats, as well provide fats were able to lower their prices, as by providing evidence on the technological substitution became more feasible, although feasibility of replacing fats. Although INTI basi- user companies also were required to adapt cally aligned itself with the Ministry of Health’s their production processes, which required objectives, it also disagreed in how the strategy both time and investments. Given this con- was being conducted. First, it requested that an text, the possibility of discussing realistic time- 60 frames and goals with the Ministry was greatly keting. There also was disagreement regarding 61 valued. the benefit of reducing salt: some argued that In addition, concerns were raised regard- this would increase the incidence of goiter (as ing the ability of small and medium compa- the consumption of iodized salt would dimin- Chapter 1 nies to meet deadlines for substituting trans ish) and some viewed salt in food as a vehicle fats in food, as well as the way in which com- for incorporating other nutrients in the diet. pliance would be evaluated. The first issue The strategy involved reaching agreements was addressed through guidelines with rec- with industry for reducing the salt content in ommendations on alternatives for replacing food, and it had broad participation of many trans fats. The guidelines were developed by public- and private-sector actors who worked ASAGA, in collaboration with INAL, INTI, the hand in hand with the Ministry of Health in var- Ministry of Agriculture, Livestock, and Fisher- ious ways. ies, the Ministry of Health, and COPAL. Despite INAL supported the initiative through the the availability of these guidelines, however, participation of its technicians in discussion it remains difficult to have small and medium sessions with chambers of commerce and companies participate in the discussions. companies regarding reduction measures and Companies also worried about the variabili- timeframes for each food group under consid- ty of the analytical methods and capabilities of eration. the laboratories that would control the com- INTI focused on presenting and disseminat- pliance with trans fats standards. To address ing evidence on the technological feasibility of this concern, ASAGA worked on defining a reducing sodium in food, training bakers on common analytical method that all the labora- how to produce bread with lower salt content, tories would use. To this end, it requested the and participating in negotiation meetings with cooperation of INTI, the National Institute of companies. The Institute also brought to the Agricultural Technology (INTA, for its Spanish table its joint work with FAIPA to lower the salt acronym), and INAL. As previously mentioned, content in artisanal bread. the Ministry of Health is also engaged in defin- While INTI endorsed the Ministry of Health’s ing an evaluation methodology. objectives, it disagreed with some aspects of the initiative. It called for stricter goals in terms Sodium Reduction: Leading Actors, of reducing sodium in food and greater control Strategies and Positions on how companies may use the agreements to position their products in the marketplace. As The Ministry of Health, as it did with trans fats, with trans fats, INTI urged continuity in the pol- took the leadership role in implementing the icies, discussions on enforcement methods, the strategy. Since 2004, the Ministry had been implementation of a vigorous education strate- working on this issue, starting with reduc- gy supported by the Ministry of Education, and ing salt content in artisanal breads. It was not greater involvement of small and medium com- until 2008, however, that the strategy gained panies in discussions regarding the measures. strength; up to that point, it was thought that The Ministry of Agriculture, Livestock, and the Ministry of Health could only make dietary Fisheries contributed technical and food reg- recommendations, not become involved in mar- ulation capabilities to the process. Its actions focused on collaborating in the negotiations to discuss the measures and of the respectful between the public and private sectors and environment and clear rules that prevailed on disseminating results and materials that throughout the process. The companies also emerged in the process through means such understood that consumers increasingly de- as newsletters, a dedicated webpage (www. manded healthy food—given the awareness alimentosargentinos.gob.ar), various publica- about the effects of diet on health—which made tions, reports, fairs, and events of the agricul- the discussion of adopting new techniques and ture and food sector. Communication activities retrofitting production processes essential. carried out by this Ministry are extremely Although the companies accepted the in- useful, because they are instrumental in posi- vitation to participate, some were reluctant tioning these provisions within the food and at the beginning. They were concerned that food-and-agriculture industries, especially in reducing sodium would change the flavor of small and medium companies that are diffi- their products and they would lose their cus- cult to reach and who need greater assistance tomers, especially if their competitors did not throughout the retrofitting process. The Minis- accept to participate in the agreements. They try also provides counseling to small and medi- also worried about the alternatives available to um companies. preserve food. That said, the strategy of hold- Other participants invited to the discussions ing discussions by product groups and of nego- included the food production companies, which tiating different goals facilitated the dialogue. brought on board to discuss and reach consen- Larger companies were concerned that be- sus on the measures to be implemented. To this cause small and medium firms were unable to end, the Ministry of Health established contact make the necessary retrofitting investments with COPAL, a business association of more and did not feel pressured to do so because the than 35 food and beverage companies, which likelihood of being inspected was low, unfair represents all the food-and-beverage produc- competition would be generated, with one sec- tion sectors. COPAL coordinated the participa- tor being forced to invest while the other was PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: tion of companies and chambers of commerce not. They acknowledged, however, that medi- in the process to reduce salt, and organized um and small companies needed support in the meetings to define goals and terms prior to the retrofitting process, but stated that this would discussions with the Ministry of Health. It also be difficult to arrange because smaller enter- provided information on the sodium content in prises are not grouped under an umbrella enti- foods. ty that can help them, live day to day, and do not The incentive that led companies to coop- have the time or technical/economic resourc- erate was that they were aware of an interna- es to discuss processes and goals. Given this Governance of Five Multisectoral Efforts tional trend to deal with this issue, and given scenario, they proposed that the state should the likelihood that regulations could be rapid- play a leading role in providing information ly introduced without adequate time to adapt, and helping to implement policies and mea- also encouraged them to join the discussions sures, but this would mean that the Ministry of and reach consensus on the measures. In fact, Health would have to undertake an enormous COPAL (as did ASAGA with trans fats) took ad- task, without having enough resources to iden- vantage of the Ministry of Health’s willingness 62 tify and summon the many small and medium have signed on to the cooperation agreement. 63 food-sector firms. It has been noted that bakeries are reluctant to Finally some companies questioned raised provide information on how they develop their doubts about how compliance with the agreed products. But reducing sodium in bread does Chapter 1 goals would be monitored. The methods to not involve higher costs nor the adoption of measure sodium concentrations have a wide new technology for the bakeries, while clients, margin of error, and thus require large samples overall, seem gratified by the bakers’ efforts to to verify that goals have been met; in addition, improve their clients’ health. evaluation techniques are not always uniform. FAIPA is strongly committed the initiative, To this end, COPAL is working on a proposal to and it has now incorporated the issue on its ac- measure sodium whereby, in addition to the tivity agenda. That said, it called for greater ef- laboratory evaluation of products, companies forts to disseminate and publicize information would provide information about their prod- on the actions being undertaken, stressed the ucts and processes and documentation on how importance of working to reduce salt in baked they operate to demonstrate that work is being goods, and ensuring the continuity of actions. carried out according to the agreement. In the It also highlighted the need to have additional same line, the Ministry of Health plans to meet resources for disseminating messages through with scientific associations, so they can help the mass media and to travel to the provinces define the monitoring methods. and municipalities to attract more bakeries to Regarding salt in artisanal breads, the Min- the effort. istry of Health worked with FAIPA, the umbrel- la entity that encompasses 30,000 bakeries in Lessons Learned Argentina. One of FAIPA’s tenets is a commit- The main lesson to be drawn from Argentina’s ment to health and good dietary habits, which experience is the need to work with various is why it is involved in various activities such as public entities involved in activities concern- fortifying flour with folic acid and eliminating ing regulations and food technology, as this potassium bromate in breads. As part of this knowledge is beyond the scope of the Minis- commitment, since 2004 FAIPA has worked to try of Health. This was essential for negotiat- reduce sodium in collaboration with INTI and ing goals and terms with the industry, which the Ministry of Health. Its strategies have been is well organized and has the economic and based on promoting chats in those provinces technical resources to position itself in discus- and municipalities that show an interest in the sions and defend its interests. The Ministry of strategy, distributing sodium-reduction post- Health’s willingness to engage in dialogue and ers and salt measuring cups to prepare bread, negotiations with industry is another import- launching information campaigns, designing ant lesson; the Ministry’s attitude dispelled the instruction materials for preparing breads, companies’ initial fears about sudden chang- participating in all the events to which they are es and short or no adaptation timetables, and invited to demonstrate experience, and train- helped persuade them to work together to de- ing bakers. fine the measures that benefit public health. The bakeries’ participation in the initiative Such negotiations were possible because is voluntary, and today, some 8,000 of them there is an international effort in this regard, and consumers are increasingly calling for technical difficulties involved make it essential healthy food. Moreover, the inclusion of dif- to develop regulations in the long term. The ferent actors opened the way for constituting voluntary sodium-reduction agreement is a po- a multi-sectorial working team that ultimately litically opportune effort for including the issue produced the amendments to the Food Code in the public agenda, but it has no enforcement and the voluntary agreements, thus laying the mechanisms or penalties that can be applied foundation for future measures to promote when food producers do not comply. healthy diets. Moreover, the Ministry of Health is con- The process has revealed some weakness- cerned that as the compliance date nears, com- es, however, such as insufficient resources to panies will ask for extensions, citing technical carry out mass information campaigns and to and legal issues. And whereas this would not strengthen strategies designed to have more be a problem with the elimination of trans bakeries adopt “Less salt, more life” practices. fats—since most of the industry has begun ret- In addition, small and medium enterprises only rofitting its processes—it could pose a problem participated to a limited degree in the discus- with regard to sodium. Questions also might be sions, largely because they are scattered around raised about the capacity of the public sector the country and do not fall under an umbrella to monitor and evaluate compliance, especially organization that could represent them and fa- with respect to the availability and the ability cilitate the negotiations. Further, it is unlikely of the laboratories to perform their tasks. The that their owners or employees would have the limited baseline information available also rep- time and resources to discuss these issues, and resents a problem, as does the fact that mul- the Ministry of Health does not have the time or tinational companies’ global policies may not budget to bring all of them into the discussions. be consistent with the voluntary agreements With regard to the monitoring and evalua- signed in Argentina. Finally, other actors have tion of the new trans fats regulations and the pointed out that the strategies launched by the agreements to reduce salt in food, a standard- Ministry of Health could be halted, due to a PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: ized methodology for the testing laboratories change in management within the Ministry, as remains to be defined. Even though business has already occurred. associations have already advanced in this re- Box 1.3 summarizes the strengths, opportu- gard by forming their own working groups, the nities, weaknesses, and threats affecting the so- state agencies need to become more proactive dium-reduction and elimination-of-trans-fats in these essential activities. measures in Argentina. And, while voluntary agreements have been reached on the sodium-reduction issue, the Governance of Five Multisectoral Efforts Box 1.3. Strengths, Opportunities, Weaknesses, and Threats affecting the Trans-Fats-Elimination and Sodium-Reduction Measures Strengths • Intersectoral dialogue and negotiation. 64 65 • Role of the Ministry of Health. - Leadership and coordination with other public entities. - Dialogue and negotiations with the private sector. Chapter 1 • Consumers view the public-private joint effort on behalf of the public’s health as a positive development, which helps improve the companies’ image. Opportunities • An international climate inclined to work on promoting healthy diets. • Increasing consumer demand for healthy food. • The creation of an intersectoral working group that led to modifying the Food Code. Weaknesses • Insufficient resources for launching mass campaigns to disseminate information and for strengthening strategies to bring more bakeries, as well as small and medium enterprises, on board. • Small and medium enterprises are missing in the discussion about measures. • Monitoring and evaluation: need for laboratory standardization to perform the tests. • Sodium: the voluntary agreements do not have enforcement power. Threats • Companies may request extensions to achieve the goals (particularly with regard to redu- cing sodium). • Monitoring and evaluation: - Questions about the capacity and availability of laboratories. - Limited baseline information. • Transnational companies that set their policies at the global level can hinder the agreed upon agreements. • Lack of policy continuity over time due to management changes. Referencias Apro, N. y V. Ferreira. Estrategia de reducción de sodio y grasas trans en panificados. INTI. Apro, N., V. Aguilar, R. Blasco, V. Ferreira, G. Gil Noticiero Tecnológico Semanal Nº 177. Oc- et al. Desarrollo de productos de panadería tober 2009. con bajo y sin contenido de sal. 6º Jornadas Brunner, E. et al. Dietary advice for reducing de Desarrollo e Innovación Tecnológica cardiovascular risk. The Cochrane Collabo- 2007. Available at: http://www-biblio.inti. ration. London. 2007. gov.ar/trabinti/AL-254.pdf (last accessed: Código Alimentario Argentino, Capí�tulo III. 29 Marcgh 2013). 1969. Available at: http://www.anmat. gov.ar/alimentos/codigoa/Capitulo_III.pdf Hu, F., J. A. Manson y W. Willett. Types of dietary (last accessed: 22 March 2013). fat and risk of coronary heart disease. The DESA; ISETA; INTI. Programa de Subsidios Journal of American College of Nutrition. para proyectos de investigación, desarrollo 2001; 20:5-19. Available at: http://www. y transferencias. Optimización nutricional y jacn.org/content/20/1/5.full.pdf+html sensorial de productos de panadería.  2011. (last accessed: 22 March 2013). Internal document. Konfino, J., T. Mekonnen, P. Coxson, D. Ferrante, K. Ferrante, D., B. Linetzky, J. Konfino, A. King, M. Bibbins-Domingo K. Projected Impact of a So- Virgolini et al. Encuesta Nacional de Facto- dium Consumption Reduction Initiative in Ar- res de Riesgo 2009: Evolución de la Epidemia gentina: An Analysis from the CVD Policy Model de Enfermedades Crónicas No Transmisibles – Argentina. PLoS ONE. 2013; 8(9): e73824. en Argentina. Estudio de Corte Transversal. Ministerio de Salud de la Nación. Costo-efectividad Rev Argent Salud Pública. 2011; 2(6): 34- de intervenciones de prevención cardiovascular 41. Available at: http://msal.gov.ar/rasp/ en Argentina I: reducción de sodio en alimentos rasp/articulos/volumen6/encuesta-nacio- procesados. Boletí�n de Vigilancia de Enferme- nal.pdf (last accessed: 22 March 2013). dades No Transmisibles y Factores de Riesgo Ferrante, D., N. Apro, V. Ferreira, M. Virgolini, V. Nº 2. 2010. Available at: http://msal.gov.ar/ Aguilar et al. Feasibility of salt reduction in ENT/VIG/Publicaciones/Boletines_ENT/PDF/ processed foods in Argentina. Rev Panam Sa- Boletin%20Epidemiologico%202.pdf (last ac- lud Pública. 2011; 29 (2):69–75. Available cessed: 22 March 2013). at: http://www.scielosp.org/pdf/rpsp/ ———. Dirección de estadí�sticas e información de v29n2/a01v29n2.pdf (last accessed: 22 salud (DEIS). Estadísticas vitales-2010. Serie 5, March 2013). Nº 54. Argentina. 2011. Available at: http:// Ferrante, D., J. Konfino, R. Mejí�a, P. Coxson, A. www.deis.gov.ar/Publicaciones/Archivos/Se- Moran, L. Goldman et al. Relación costo- rie5Nro54.pdf (last accessed: 22 March 2013). utilidad de la disminución del consumo de sal ———.Guía de recomendaciones para la pequeña y PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: y su efecto en la incidencia de enfermedades mediana industria. 2011. Available at: http:// cardiovasculares en Argentina. Rev Panam www.msal.gov.ar/argentina-saludable/ Salud Publica. 2012;32(4):274–80. pdf/Guia%20de%20Recomendaciones%20 He, F. y G. MacGregor. Effect of longer-term PyMEs%20marzo%202011.pdf (last accessed: modest salt reduction on blood pressure. 22 March 2013). Cochrane Database Syst Rev. 2004; (3): ———. Primera Encuesta Nacional de Factores de CD004937. Riesgo. 2006. Available at: http://www.msal. Hu, F., M. Stampfer, J.A. Manson, E. Rimm, G. Governance of Five Multisectoral Efforts gov.ar/ent/images/stories/vigilancia/pdf/en- Colditz et al. Dietary fat intake and the cuesta_factores_riesgo_2005_completa.pdf (last risk of coronary heart disease in wom- accessed: 5 de abril de 2013). en. The New England Journal of Medi- ———.–Sal +Vida: Disminuí el consumo de sal para cine. 1997; 337: 1491-1499. Available at: tener una vida más saludable. Hoja informati- http://www.nejm.org/doi/full/10.1056/ va. 2011. Available at: http://msal.gov.ar/ent/ NEJM199711203372102 (last accessed: 22 MenosSalMasVida/PDF/Iniciativa.pdf (last ac- March 2013). cessed: 22 March 2013). 66 ———.Segunda Encuesta Nacional de Factores de mentaria de toda la población. 2009. Available 67 Riesgo para enfermedades no transmisibles. at: http://msal.gov.ar/ent/MenosSalMasVida/ 2011. Available at: http://msal.gov.ar/ENT/ PDF/Reduccion_sal_OPS.pdf (last accessed: 22 VIG/Areas_Tematicas/Factores_de_Riesgo/ March 2013). Chapter 1 PDF/Segunda_Encuesta_Nacional_De_Factores_ ———. Las Américas Libres de Grasas Trans. De_Riesgo_2011.pdf (last accessed: 22 March Declaración de Rí�o de Janeiro 2008. Available 2013). at: http://www.paho.org/spanish/ad/dpc/nc/ Mozaffarian, D. Relación entre el consumo de ácidos transfat-declaracion-rio.pdf (last accessed: 22 grasos trans y la cardiopatía isquémica en las March 2013). Américas. En Aceites Saludables y la eliminación Secretarí�a de Polí�ticas, Regulación e Institutos y de ácidos graos trans de origen industrial en las Secretarí�a de Agricultura Ganaderí�a y Pesca. Américas. Iniciativa para la prevención de en- Resolución Conjunta 137/2010 y 941/2010. In- fermedades crónicas. OPS. 2008. Available at: corporación del Artí�culo 155 tris al Código Ali- http://www.msal.gov.ar/argentina-saludable/ mentario Argentino. Available at: http://www. pdf/aceites-saludables.pdf (last accessed: 22 de anmat.gov.ar/webanmat/Legislacion/Alimen- marzo de 2013). tos/Resolucion_Conjunta_137-2010_941-2010. OMS. Estrategia mundial sobre régimen alimen- pdf (last accessed: 22 March 2013). tario, actividad física y salud. 2004. Available WHO. Diet, Nutrition and the Prevention of Chron- at: http://www.who.int/dietphysicalactivity/ ic Diseases. Technical Report Series 916. 2003. strategy/eb11344/strategy_spanish_web.pdf Available at: http://whqlibdoc.who.int/trs/ (last accessed: 22 March 2013). who_trs_916.pdf (last accessed: 22 March ———. Reducción del consumo de sal en la po- 2013). blación. Informe de un foro y una reunión técnica ———. Health statistics and health information de la OMS. 2007. Available at: http://www.who. systems. 2009. Available at: http://www.who. int/dietphysicalactivity/salt-report-SP.pdf (last int/healthinfo/global_burden_disease/esti - accessed: 22 March 2013). mates_country/en/index.html (last accessed: OPS. Estrategia Regional y Plan de Acción para un 22 March 2013). Enfoque Integrado sobre la Prevención y el Con- ———. Preventing Chronic Diseases: a vital invest- trol de las Enfermedades Crónicas. 2007. Avail- ment. 2005. Available at: http://www.who.int/ able at: http://www.paho.org/spanish/ad/ chp/chronic_disease_report/contents/en/in - dpc/nc/reg-strat-cncds.pdf (last accessed: 22 dex.html (last accessed: 22 March 2013). March 2013). ———. Promoting fruit and vegetable consumption ———. Aceites saludables y la eliminación de ácidos around the world. Global Strategy on Diet, grasos trans de origen industrial en las Américas. Physical Activity and Health. Available at: Iniciativa para la prevención de enfermedades http://www.who.int/dietphysicalactivi - crónicas. 2008. Available at: http://www.msal. ty/fruit/en/index.html (last accessed: 22 gov.ar/argentina-saludable/pdf/aceites-salud- March 2013). ables.pdf (last accessed: 22 March 2013). ———. The Global Burden of Disease. 2004 Update. ———. Declaración Política: Prevención de las En- 2008. Available at: http://www.who.int/ fermedades Cardiovasculares en las Américas healthinfo/global_burden_disease/GBD_ mediante la reducción de la ingesta de sal ali- report_2004update_full.pdf (last accessed: al had indicated at least once that the respondent had high blood pressure. 22 March 2013). 4 Diabetes levels were based on self-reporting by the ———. 2008-2013 Action Plan for the Glob- respondents, for whom a physician, nurse, or other al Strategy for the Prevention and Control of health professional had indicated the person had dia- Noncommunicable Diseases. 2008. Available betes or “high blood sugar.” 5 The National Institute of Industrial Technology (INTI) at: http://whqlibdoc.who.int/publica- is a decentralized national government agency that op- tions/2009/9789241597418_eng.pdf (last erates under the jurisdiction of the Ministry of Indus- accessed: 22 March 2013). try. Its mission is to generate and transfer industrial technology. 6 The National Food Institute is in charge of register- Notes ing and controlling—within the scope of the National 1 High cholesterol levels are based on self-reporting by Drugs, Food, and Medical Technology Administration respondents who had ever had their cholesterol mea- (ANMAT)—prepared foods, their inputs, use of domes- sured, regardless of whether a physician, nurse, or tic products, and materials that come in contact with other health professional had said the respondent had food. high cholesterol. 7 The campaign poster is available at: http://www. 2 Body mass index (BMI) categories were defined as fol- msal.gov.ar/argentina-saludable/media/Afiche%20 lows: normal weight, 18.5 to 24.9 kg/m2; overweight, grasas%20trans.pdf 25 to 29.9 kg/m2; and obesity, 30 or more kg/m2. 8 For additional information, visit http://www.faipa. 3 The prevalence of hypertension was based on self-re- org.ar/Legales/convenio_min_de_salud.htm porting; a physician, nurse, or other health profession- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 68 69 70 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts Colombia Photography: Olga Sarmiento ,Universidad de los Andes, CHAPTER 2. 71 Bogotá, Colombia: A City with a Built Environment that Promotes Physical Activity OLGA LUCÍA SARMIENTO, ADRIANA DÍAZ DEL CASTILLO H., AND ETHEL SEGURA DURÁN This study describes a program and three ur- mortality due to diabetes has tripled in the last ban infrastructures that could promote phys- 25 years (Ministerio de la Protección Social and ical activity in Bogotá, Colombia: the Cicloví�a, Universidad de Antioquia, 2010). In addition, the CicloRutas, the TransMilenio, and outdoor NCDs account for 76% of the burden of disease gyms. The main objective is to report on the based on disability-adjusted life years (DALYs) processes that led to their design and imple- (Acosta Ramí�rez et al., 2008). mentation and on the key actors that played a Undoubtedly, promoting physical activity is role to provide useful information that could critical for preventing NCDs. Evidence clearly lead to the development of similar policies, shows that physical inactivity increases the risk programs, and infrastructure projects in other for the leading NCDs worldwide. In 2008, 5.3 cities. million of the 57 million deaths were attributed to physical inactivity (Lee et al., 2012). Physical Context inactivity is estimated to cause roughly 10% of Medium-income countries, such as Colombia, colon cancer cases, 10% of breast cancer cases, are experiencing rapid economic, demographic, 7% of type II diabetes mellitus cases, and 6% and nutritional transitions associated with the of coronary disease cases (Lee et al., 2012). increased prevalence of chronic, noncommuni- Similarly, in Bogotá it was estimated that 7.6% cable diseases (NCDs) (Abegunde et al., 2007; of total mortality and 20.1% of mortality from Jacoby E.. et al. 2003). In Colombia, mortality NCDs from CNCDs was attributed to physical from cardiovascular diseases has doubled and inactivity (Lobelo et al., 2006). Prevalence of Physical Activity in of transportation (Instituto Colombiano de Colombia and Bogotá Bienestar Familiar, 2010). As is the case in most countries in the Americas, Determinants of Physical Activity among a significant percentage of Colombian adults Adults in Colombia and in Bogotá lead sedentary lifestyles (Instituto Colombia- no de Bienestar Familiar, 2010, 2006; World The socio-ecological model suggests that phys- Health Organization, 2009). Among adult Co- ical activity is related to individual, social, en- lombians, only 53.5% meet the recommended vironmental, and political determinants (Sallis physical activity levels,1 and 46.5% are inactive. JF et al., 2008). These factors, in turn, vary de- Among adults who engage in physical activity, pending on which physical activity category 19.9% meet physical activity recommenda- is being studied (i.e., during leisure time, as tions during their leisure time, 33.8% walk as a a means of transportation, as work, or in the means of transportation, and only 5.6% bicycle home). as a means of transportation. However, between In Colombia, those meeting physical activity 2005 and 2010, compliance with physical activ- recommendations during leisure time are more ity recommendations increased significantly. likely to be male, young adults, with higher ed- Trends observed between 2005 and 2010 ucational levels, living in high socio-economic show a significant increase in the prevalence neighborhoods, and less likely to be overweight of overall compliance with physical activity (Instituto Colombiano de Bienestar Familiar, recommendations, from 50.1% to 53.5%. This 2010). The built-environment factors associ- increase comes at the expense of walking as a ated with meeting physical activity recommen- means of transportation, however, and in the dations during leisure time include access to category of “physical activity during leisure parks, a sense of security, participation in the time” the prevalence of compliance with phys- Cicloví�a, and access to TransMilenio (TM) (Go- ical activity recommendations is actually low- mez et al., 2010a; Sarmiento et al., 2010a). er. In Colombia physical activity as a means of Studies have shown that walking as a means PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: transportation predominates over physical ac- of transportation is associated with socio-de- tivity during leisure time, and walking predom- mographic factors, such as lower socioeco- inates over bicycling (Instituto Colombiano de nomic status, being age 50 and older, being Bienestar Familiar, 2010). An effective and sus- employed or looking for a job, and not owning tainable promotion of physical activity must a motor vehicle. Environmental factors asso- encompass all dimensions of physical activity. ciated with walking as a means of transporta- Bogotá’s compliance with the physical ac- tion include such urban attributes as higher Governance of Five Multisectoral Efforts tivity recommendations (57.8%) is higher than connectivity and road density (kms of road/ compliance at the national level. In the city, area in km2). The use of bicycles as a means of 18.3% of adults meet physical activity recom- transportation has been associated with being mendations during their leisure time, while male, having lower education, and living in a 40.5% walk at least 150 minutes per week as low socioeconomic neighborhood. Environ- a means of transportation and 4.3% reports cy- mental factors associated to cycling for trans- cling at least 150 minutes per week as a means 72 port include higher street density (Cervero et to 0.58 for the national figure) (Alcaldí�a Mayor 73 al., 2009). de Bogotá et al, 2007). Transportation and Green Areas in Bogotá Bogotá Overview Overall, Bogotá’s residents have the following Chapter 2 Bogotá is the country’s capital and administra- transportation options: public transportation,6 tive center. It is one of the five most populated TransMilenio (TM), taxis, private vehicles, mo- cities of Latin America and the Caribbean, with torbikes, bicycles, or walking. According to pre- more than 7.5 million inhabitants (16% of the liminary data from the 2011 transport survey, Colombian population) and a population den- 46% of trips are on foot (versus 15% reported sity of 4,100 people per km2 (Departamento in 2009) and 50% involve motorized modalities Administrativo Nacional de Estadí�stica, 2005; (public transportation, TM, taxis, private vehi- Economist Intelligence Unit, 2010)2. The city cles, other). Public transport and TM account sits on a plateau 2,630 meters above sea lev- for 57% of total motorized trips. Private vehi- el (Alcaldí�a Mayor de Bogotá 2009); it has no cles account for only 11% of total trips (21% of seasonal changes and an average temperature motorized trips) and bicycles account for 3%. of 14ºC. Most non-motorized and public transport trips Socioeconomic Information are made by residents of middle- and low-in- Bogotá is the eighth largest economy of Lat- come strata (Secretarí�a Distrital de Movilidad, in America, accounting for 26% of Colombia’s 2011).7 Gross Domestic Product (GDP) (Cámara de As of this writing, Bogotá has 4.35 m2 of Comercio de Bogotá, 2011b). As do other Latin green area per inhabitant, which includes a net- American cities, Bogotá faces challenges relat- work of parks stratified according to size, cov- ed to social inequality, as well as socio-political erage, and structure. Green areas help maintain conditions due to the armed conflict. 3 the environmental balance and are a natural Since colonial times, Bogotá’s neighbor- heritage that guarantees—partly—free space hoods have been segregated in terms of space set aside for recreation (Alcaldí�a Mayor de Bo- and access to services (Gómescásseres, 2003a; gotá, 2004). When residential areas are built, Programa de las Naciones Unidas para el De- 17% of the land must be set aside as green ar- sarrollo, 2007). The city is divided into 20 eas, representing a public and obligatory trans- administrative districts and it is stratified so- fer as part of urbanization. The green areas set cioeconomically based on the characteristics aside in major housing developments now have of the home and its surrounding areas.4 In June sports equipment in accordance of where they 2011, 36.4% of households in Bogotá were clas- fall within the park stratification system. Lo- sified as level 3 (medium-low), 36.3% as level 2 cal parks are classified according to their size (low), 11.3% as level 4 (medium), 9% as level 1 and use (Instituto Distrital de Recreación y De- (low-low), 5.5% as level 5 (medium-high) and porte, 2011b) (Table 2.1). 6 (high), and 1.3% as “without stratum” (Al- In general, and for all types of parks in Bo- caldí�a Mayor de Bogotá and Departamento Ad- gotá, users are 52.2% male and 47.8% female. ministrativo de Planeación Distrital, 2011). In Adults between 18 and 59 years old are more 2007, the Gini coefficient5 was 0.59 (compared likely to use them. Among users, 37% have incomes close to the minimum wage (approx- imately US$ 320 in 2013). Approximately 60% 55% of users feel safe in the parks during the of users reported being satisfied with the parks day (Instituto Distrital de Recreación y De- overall condition. According to a 2005 study, porte, 2011b). Table 2.1. Classification and Number of Parks in Bogotá Classification Description Number Regional Large natural spaces with high environmental value 4 Metropolitan Open areas larger than 10 hectares, destined for recreation, 15 sightseeing, and environmental uses. Zonal Open areas between 1 and 10 hectares that serve a group of 64 neighborhoods for active recreation; they may include such equipment such as gyms, swimming pools, sports fields or courts, and skating rinks. Local Open areas for community recreational activities and meetings 3,168 Pocket-size Open areas under 1,000 m .2 1,768 Source: Instituto Distrital de Recreación y Deporte: http:/www.culturarecreacionydeporte.gov.co/portal/node/228 (last accessed on 20 March 2013). Policies (Programs and Infrastructures): Photo 2.1. Bogotá’s Ciclovía (Boyacá Avenue). Ciclovía, CicloRutas, TransMilenio, and Outdoor Gyms The Ciclovía Recreativa The Cicloví�a Recreativa is a program that tem- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: porarily closes streets to vehicular traffic and opens them for allowing citizens to have a safe and free space to engage in recreation and sports (OPS, 2009). Photo: Diana Fernández Bogotá’s Cicloví�a operates every Sunday and Governance of Five Multisectoral Efforts holiday of the year, from 7 a.m. to 2 p. m. (72 events per year). Since 1999, it includes other events such as the “Nighttime Cicloví�a,” which is held on the second Thursday of December, from 6 p.m. to 12 a.m. (Sarmiento et al., 2010b). Table 2.2 describes Cicloví�a’s complementary activities. 74 Figure 2.2. Complementary Activities of Bogotá’s Ciclovía 75 Activity/program Description Recreovía (physical Parks or plazas in public spaces along the route offer one-hour physical activity activity sites) classes taught by instructors. There are currently 19 Recreovía areas operating during Chapter 2 weekends; 17 on Tuesdays, Thursdays, and/or Wednesdays and 11 twice a week during the evening. Service stations Vendors along the route offer food and beverages, and there are bicycle-repair stations. The Secretariat of Social Integration selects vendors. Children’s activities Recreational activities and sports. RAFI locations These sites promote physical activity and healthy nutrition; they provide weight and height measurements to calculate BMIs. The District Recreation and Sports Institute IDRD operates RAFI locations. Bogotá’s Cicloví�a network encompasses The Ciclovía and Physical Activity 121 interconnected kilometers. An estimated Bogotá’s Cicloví�a is recognized for its potential 600,000 to 1.4 million persons use the Cicloví�a public health benefits, which include promot- in each Sunday event (8%–19% of the city’s ing physical activity and other benefits such as population).8 Among similar Cicloví�a programs building social capital, fostering the economic worldwide, Bogotá’s is the longest and has the recovery of communities, and reducing envi- highest number of users. Most Cicloví�a users ronmental pollution by decreasing the number are male, around 60% are adults 19–45 years of motor vehicles and noise levels (Hoehner et old, and approximately 90% live in low and me- al., 2008; Sarmiento et al., 2010a; Sarmiento dium socioeconomic neighborhoods (Universi- and Behrentz, 2008). dad Nacional, 2005; Torres, 2013). Programs such as Bogotá’s Cicloví�a, which Cicloví�a’s annual cost is US$ 1.7 million (in- run for seven hours at least once a week and cluding materials, personnel, operations, and that have many participants, help the popula- logistics), most of which comes from public re- tion meeting with international weekly stan- sources (Dí�az del Castillo et al., 2011). dards for physical activity levels . Based on The Cicloví�a is managed by the District Rec- Bogotá’s population size, number of users, reation and Sports Institute (IDRD for its Span- and average minutes spent in the program, it ish acronym). Its operation, maintenance, and is estimated that Bogotá’s Cicloví�a provides the evaluation require multisectoral work, howev- population with 13.64% of the recommended er. Nine sectors were identified as being part of weekly minutes of physical activity (Sarmiento the program: recreation, culture, and sports; O.L. et al. 2010b). An estimated 40.5% of users transportation and urban planning; govern- report using the Cicloví�a for at least three hours mental administration; security; marketing (Universidad Nacional, 2005). Cicloví�a users and services; academia and research; health; say their activities include cycling (46.2%), education; and the environmental sector (Dí�az walking (47.9%), and other activities (5.9%) del Castillo et al., 2011). (Montes et al. 2012). It also was estimated that of the total num- ber of adults who reported participating in the Cicloví�a in the previous month, 20% said they pating regularly in the Cicloví�a were most like- meet with physical activity recommendations ly to engage in physical activity during their by spending at least 30 minutes of physical ac- leisure time (Gomez et al., 2004). The average tivity during their leisure time at least five days number of minutes of physical activity carried a week (Sarmiento et al., 2010b). Most Cicloví�a out during leisure time and by cycling by Ci- users (59.5%) meet physical activity recom- cloví�a users is greater than that of the overall mendations (Torres et al., 2013). Another study adult population of Bogotá (Figure 2.1). also showed that women who reported partici- Figure 2.1. Average number of weekly physical activity minutes for users of Bogotá’s Ciclo- vía, CicloRuta, TransMilenio, and parks. 500 450 400 350 Minutes 300 250 200 150 100 50 0 Ciclovía Ciclorutas Trans Milenio Park users Bogotá Walking for transportation Bicycling for transportation Moderate-activity during leisure time PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: The program is cost-benefit (Montes et al., The CicloRutas Network 2012). An evaluation of the program’s cost Bogotá’s CicloRutas network is an urban in- benefits, considering its potential health ben- frastructure that has permanent, dedicated efits through engaging the adult population in bicycle lanes. These lanes may be located on physical activity, estimated that for each dollar sidewalks or clearly separated from the road- invested in the program, US$ 3 to US$ 4 could way (Alcaldí�a Mayor de Bogotá 2000). Governance of Five Multisectoral Efforts be saved in direct expenses in health care relat- ed with physical activity (Montes et al. 2012). This implies an annual gain of between US$ 13 million and US$ 30 million, depending on the number of adult users. 76 Photo 2.2. CicloRuta in Bogotá (El Tintal Library). 77 Chapter 2 Photo: Ethel Segura According to data from the Urban Develop- prevalent among low and medium socioeco- ment Institute (IDU from its Spanish acronym), nomic residents: 97% of bicycle trips are made there were 344 kms of CicloRutas in 2010, rep- by residents of stratum 1–3 and the trips re- resenting the most extensive such network in ported by the poorer population are the lon- Latin America (Instituto de Desarrollo Urbano, gest. It should be noted that only 10% of those 2011a). The network has 1,640 bicycle racks using bicycles for transportation own a car and that are free, under surveillance, and located in only 2.2% own a motorcycle (Massink et al., different parts of the city (at IPES or meeting 2011). points, and at TransMilenio stations). These According to 2009 data, annual costs for the racks location was intended to foster multi- CicloRutas’, including construction and main- modal transportation between bicycle and tenance costs, were around US$ 3 million, for mass-transport ridership. However, only 40% a total investment of US$ 50 million (Instituto of CicloRutas users report having seen bicycle de Desarrollo Urbano, 2009). The CicloRutas racks, and of these, only 19% use them (Segu- network is managed primarily by the IDU, al- ra, 2011). There also are more than 90 points though their operation, maintenance, and eval- of interruption in the network, which hinders uation require multisectoral work. The sectors connections and the transfer to mass transport involved are urban planning; transportation; (Segura, 2011). public services; recreation, culture, and sports; Based on the 2004–2008 administrative and academia.9 data, 83,436 people use the CicloRutas daily The CicloRutas and Physical Activity (approximately 1% of the city’s residents) (In- In high-income countries, CicloRutas and simi- stituto de Desarrollo Urbano, 2008); most are lar infrastructures are associated with the pro- young men (Alcaldí�a Mayor de Bogotá and In- motion of physical activity (Pucher et al., 2010). stituto de Desarrollo Urbano, 1999). The use of In Bogotá, studies of CicloRuta users show that bicycles as a means of transportation is more 70% bicycle more than five days a week, 73% bicycle because it offers a rapid means of trans- to being physically active (Ricaurte, 2010). The portation, and 13% use it for health reasons. reported benefit is less than that reported for Nearly one-fourth report that the CicloRutas Cicloví�as because the investment in infrastruc- infrastructure is an incentive to use bicycles ture is not compensated by a large number of as a means of transport (Segura, 2011). The users. average number of minutes spent carrying out physical activity during leisure time and cy- The TransMilenio System cling by CicloRuta users is greater than that of TransMilenio (TM) is a mass transport system Bogotá’s adult population (Figure 2.1). of the bus rapid transit (BRT) type. Buses travel A 2010 cost-benefit analysis showed that on dedicated lanes and operate in ways similar for each US$ 1 invested in the CicloRutas, US$ to rail-based systems, as TM has exclusive sta- 2.8 could be saved through health gains related tions for its users (Peñalosa ,2002). Picture 2.3: TransMilenio buses in Bogotá (Portal de las Américas). PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Photo: Ethel Segura Construction of the TM system began under 2011a). The average number of TM passengers the 1998–2001 administration. According to during rush hours is 192,936 (TransMilenio, data from 2011, it encompasses 84 km of main 2011a). According to a 2010 survey, 82% of TM routes and 895 km of lanes (Cámara de Comer- users reside in strata 2 and 3, and 93% do not Governance of Five Multisectoral Efforts cio de Bogotá and Universidad de Los Andes, own a vehicle (a profile similar to those using 2011; TransMilenio, 2011a). The network has public transportation). The price of a ticket, 102 routes along the city’s main roadways, 82 as of December 2011, was $ 1,700 pesos (US$ feeder routes, 1,290 buses, and 114 stations 0.93) during peak hours Monday through Sat- (TransMilenio, 2011b). The system carries urday, and $ 1,400 pesos (US$ 0.77) during about 463 million passengers a year (2010 off-peak periods, on Sundays and holidays. data), and the figure has steadily increased The price covers travel throughout the net- by 5% a year in the past years (TransMilenio, work (two daily trips for 20 days during peak 78 hours represent 12% of the minimum wage in costs were estimated at US$ 3.32 billion, which 79 2013).10 included vehicles and fare collections (Cain et TM operates through a public-private part- al., 2006). nership. The state provides the infrastructure TransMilenio and Physical Activity Chapter 2 (network trunks, stations, platforms, work- The link between TM and physical activity is shops, and complementary infrastructure) that users must walk (or ride a bicycle) to reach through the IDU, while seven private firms the stations, which are approximately 500 me- selected through public bidding (which are ters apart, and they must also walk within the paid per kilometer covered)11 operate the sys- system.14 Thus, TM increases the likelihood tem, and two private firms obtain concessions that a person will walk for transportation. It is to operate the collection system12 (Cain et al., estimated that adults living in a neighborhood 2006; TransMilenio, 2011b). A public company, with one or two TM stations are more likely to TransMilenio S.A., plans, manages, and controls walk for transportation, and so meet physical the system. The system is financed through 3% activity recommendations more than those of ticket fares and secondary activities, such as who live in neighborhoods without TM stations advertising at the stations (Hidalgo, in Leal and (Cervero et al., 2009). On average, the number Bertini, 2003). of minutes that TM users spend walking both Regarding costs, Caí�n et al. (2006) estimat- as a means of transportation and for leisure ac- ed that Phase I infrastructure amounted to tivities is greater than that of Bogotá’s overall US$ 240 million (US$ 5.9 million per km2), fi- adult population (Figure 2.1). nanced from the gasoline tax (46%), national budget (20%), a World Bank loan (6%), and Outdoor Gyms local funds (28%). Costs for Phase II were esti- Outdoor gyms consist of urban parks equipped mated at US$ 545 million (US$ 13.3 million per with user-friendly and low-maintenance equip- km2).13 Financing sources for this second phase ment for engaging in PA free of charge (Secre- included the national government (66%) and tarí�a de Cultura, 2011). gasoline tax (34%). In the TM master plan, total Photo 2.4. Outdoor gym in Bogotá (El Virrey Park) Photo: Ethel Segura Outdoor gyms were installed in six parks lo- tive among a diverse population that includes cated in four of the city’s districts (2011 data). a significant number of Latinos (Cohen et al., Three were metropolitan parks, two were 2012). In Bogotá, studies of adults and seniors zonal, and one was local. Some zonal parks in routinely show that the density of parks and Engativá district have a few pieces of installed their frequent use help residents meet recom- equipment. Each park has exercise equipment mendations of physical activity during leisure on which several people can simultaneously time (Gomez et al., 2010a, 2010b). The aver- do warm-ups, muscular toning, stretching, and age number of minutes spent walking, both as cardiovascular exercises (the amount of equip- a means of transportation and during leisure ment depends on the park’s size/conditions). time by users of parks is greater than that of The aim is to use each piece of equipment for Bogotá’s overall adult population (Figure 2.1). 10 minutes and, for parks with 11 pieces of equipment, do the entire cycle in 1 hour and 50 Policy Development and Leading Actors minutes (Instituto Distrital de Recreación y De- porte, 2011a). The Ciclovía Recreativa15 In general, these gyms function through an Beginning of the Ciclovía (1974–1984) agreement between the district and private Most sources consulted for this study agree enterprise. Private health sector firms (Col- that the first Cicloví�a event took place in 1974 sanitas, a pre-paid health insurance company, (Alcaldí�a Mayor de Bogotá D.C. and Instituto and Novartis Laboratories), recreation and Distrital de Cultura y Turismo, 2007; Dí�az del sports-sector firms (Athletic Colombia S.A., a Castillo et al., 2011; Gómescásseres, 2003a). company selling sports equipment), and two This was mainly a private, independent event, private cooperatives from the education sec- involving a group of students who took over tor donated some of the equipment, financed some of the city’s main streets with their bicy- its installation, and, in some cases, maintain it. cles. The transportation department gave its The rest of the pieces were installed and are informal support by facilitating the closure of PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: managed by the IDRD; in the case of Engativá, main streets. Various activists who had been they are managed locally. organizing annual bicycle rides (starting in Bo- The cost of the equipment at each site, land gotá) to promote bicycle use for recreation and adaptation, and installation of 11 pieces fluc- well-being also participated in the event. tuated between US$ 25,000 and US$28,000 Two years after (in 1976), the department ($ 45 million $ 50 million Colombian pesos); of traffic and transportation conducted an ur- the costs vary according to the parks’ condi- ban development study which recommended tions and the number of pieces of equipment. Governance of Five Multisectoral Efforts creating a temporary Cicloví�a (Gómescásseres, Parks and Physical Activity 2003a). This idea then led to Decree 577 Many studies have linked the presence of green (during the Luis Prieto Ocampo administra- areas—including parks—with physical activity tion) which formally defined the Cicloví�a and (Diez Roux et al., 2007; Duncan and Mummery, designed four circuits on the main streets of 2005; Gomez et al., 2010a, 2010b). Moreover, both low- and high-income neighborhoods (Al- it was found that outdoor gyms in Los Angeles caldí�a Mayor de Bogotá, 1976; Alcaldí�a Mayor County (California, U.S.A.) could be cost-effec- 80 de Bogotá D.C. et al., 2007). During these years, tempt to meet the public’s recreational needs 81 the Cicloví�a continued to be an isolated event, and may have contributed to raise bicycles however. According to those interviewed, this historically low status (Ciclismo al Dí�a, 2012; was because it lacked a defined organization, Colombia es pasión, 2006; Gómescásseres, Chapter 2 no entity was responsible for operating and 2003b). promoting the program, and it was no lon- While it is possible that activists’ efforts ger a priority for the government in power at may have helped to formalize the program, this the time (Alcaldí�a Mayor de Bogotá D.C. et al., cannot be confirmed in official documents. Ac- 2007). Activist groups continued to organize cording to former Mayor Ramí�rez Ocampo, his events on their own, and sought official sup- interest was also sparked by his visits to New port to achieve formal status. According to York, where he observed that some streets bor- a member of the group, they did not receive dering Central Park were closed for bicycles. support because the two administrations that Thus, it cannot be precisely established how followed had other priorities (such as con- the idea was conceived, and it is common to as- structing infrastructure, such as bridges, for sign many “parents” to Bogotá’s Cicloví�a. automobile traffic). Nonetheless, the popula- In the next two years, the Cicloví�a contin- tion’s initial acceptance of the Cicloví�a concept ued to function weekly, managed by the traffic revealed the need for public recreation spaces, department, whose principal role was to close which was later confirmed by its participation the streets. A Cicloví�a multisectoral committee in other events, such as the National Bicycle was established that included bicycle activists, Day in 1981 (Alcaldí�a Mayor de Bogotá D.C. et the police, the Traffic and Transport Depart- al., 2007). ment, the Secretariat of Education, Coldeportes In 1982, Mayor Augusto Ramí�rez Ocampo (the Colombian Institute for Recreation and was elected to office (Dávila et al., 2001). The Sports), and the National Cycling Federation Mayor, based on documents of the time, be- (Alcaldí�a Mayor de Bogotá D.C. et al., 2007; Gó- lieved that returning public space to citizens mescásseres, 2003a). By 1984, the Cicloví�a was and creating opportunities for recreation for 84 km long (personal communication, IDRD the most vulnerable, could help combat in- 2009). equality (Ramí�rez, 1983; Ramí�rez, 2005). That Key Actors year, the Cicloví�a was formally inaugurated Based on the previous description, the follow- (Alcaldí�a Mayor de Bogotá D.C. et al., 2007; Gó- ing actors played key roles during this phase: mescásseres, 2003a) and received broad media • Civil society groups promoting bicycle use coverage encouraged by the participation of and a formal Cicloví�a, which also participat- public figures. At that time, cycling had become ed in the multisectoral committee; popular in Colombia, fanned by the achieve- • Citizens who participated enthusiastically ments of Colombian cyclists in international in the first events; competitions. Citizens became fans, the media • The police, who facilitated the events, the and private enterprises participated actively in Traffic and Transport Department, which promoting it, and the State invested in creating conducted the Cicloví�as study, the Secre- roads where cyclists could train. Some observ- tariat of Education, Coldeportes, and the ers consider this phenomenon to be a first at- National Cycling Federation (which were all represented in the multisectoral com- although without a clear organizational mittee); structure or much support from city admin- • The administration, which initially passed istrations. the decree along with the transit depart- Institutionalization (1995–2007) ment, district planning, and public works. A new period in the program began with an- Later, the mayor decided to formally inau- other change in the city administration, in gurate the program. 1995. Between 1995 and 2003, Bogotá had Change in Priorities (1985–1994) three different administrations (1995–1997, With the change in administration in 1984, 2001–2003, and 1998–2000) which shared a priorities also changed. The program’s or- vision regarding what the city should be for its ganizational structure stopped functioning, citizens, and the relationship between Bogotá the traffic department was in charge of street and its residents, emphasizing the promotion closings (although this was not done regularly of new cultural practices and the transforma- everywhere), and the police provided securi- tion of the urban infrastructure (Pizano, 2003). ty. For some observers, limiting the traffic de- Given this vision, the city experienced eight partment’s function to street closings without years in which urban transformations and the a larger vision of what the program could be culture of citizenship were priorities for the and without offering new services, brought the government, and the Cicloví�a became a space program to a standstill. It could be said that a in which some of these ideas could play out (Al- program such as the Cicloví�a was not a prior- caldí�a Mayor de Bogotá D.C. et al., 2007; Monte- ity for the department in charge of traffic and zuma, 2003; Pizano, 2003).16 transport. According to Gomescásseres (2003), This new vision for the city fostered a shift during this time, the route was progressively in the program towards an emphasis on rec- shortened, interconnections ceased, and much reation, the promotion of well-being, physical of the program (80%) ran mainly in high-in- activity, and the proper use of free time, which come areas. Thus, the Cicloví�a began to lose led to the transfer of the management of the PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: its appeal and was used by a smaller percent Cicloví�a from the transportation sector to the of the public. According to some interviewees, recreation and sports sector, under the IDRD. the program was sustained mainly because It is impossible to precisely establish whether citizens continued to use the Cicloví�a and as- this change came from city hall or from IDRD sumed responsibility for closing the streets, officials; whatever the source, this change re- even those not officially sanctioned. By 1995, invigorated the program. Cicloví�a was given a the Cicloví�a had only 51 km (personal commu- defined organizational and operational struc- nication, IDRD 2009). ture and offered new services to meet users’ Governance of Five Multisectoral Efforts Key Actors needs. The changes included: i) assigning new The following key actors played a role during personnel to manage the routes (Cicloví�a care- this phase: takers); ii) entering into agreements with the • The citizens, who continued to use the pro- police and Secretariat of Education whereby gram and closed the streets; police officers and students would serve with- • The traffic department and the police, who in the Cicloví�a logistics team (Law 191/1995 facilitated the program’s continuation, and Resolution 4210/1996 set forth that 82 10% of those doing military service with the • The citizens, who embraced the changes 83 police should do so in the Cicloví�a and that and continued using the program, which at- secondary-school students could fulfill their tracted large, weekly crowds; compulsory social service in the program; iii) • The recreation and sports sector, led by Chapter 2 increasing the system’s length (81 km in 1996 IDRD, which managed and transformed the to 121 Km in 2000), reconnecting the north- program; south circuit to cover 70% of districts (Alcaldí�a • City governments, which included the pro- Mayor de Bogotá D.C. et al. 2007), and installing gram and their new vision in their develop- permanent signals; iv) launching new activities ment plans and priorities; (such as the Recreoví�a); v) designing a logo and • The security and education sectors, which brand for the program that would help consol- established informal agreements to sup- idate it and gain the public’s ownership of the port the program; program;17 vi) extending the duration of events • The urban planning and transportation by two hours; and v) obtaining a small percent- sectors, which maintained the reads in age of private financing. According to the IDRD, good conditions and implemented the new about 1.2 million persons participated in 1997, transportation system; and by 2000, the Cicloví�a had 121 km. • City council members and congressional As mentioned above, several urban trans- representatives. formations occurred during this period. Unfor- Maintenance (2008 to the present) tunately and paradoxically, the new TM system Although in the last five years the Cicloví�a has negatively affected the program because due not undergone major transformations, changes to the development of TM infrastructure, the have been made that include the organization Cicloví�a temporarily lost several important of street vendors, an increase in the number corridors, and with them, kilometers and con- of Recreoví�a sites, offer of new services (such nectivity (it went from 121 active kms to 97 as RAFI points), and the need to adapt to the during the Phase III construction). By 2013, infrastructure works under way in the city however, Cicloví�a’s access to one of these cor- since 1998. Currently, the operation, mainte- ridors was re-established, and with it, the orig- nance, and evaluation of the program involve inal 121 km. various sectors. They include the recreation, In 2007, two city councilmembers and two culture, and sports sector (manages and leads congressional representatives presented a the program through IDRD); the urban trans- draft agreement to the Council of Bogotá and a portation and planning sector (conducts re- draft legislation to the Congress, declaring the search on mobility and is responsible for the Cicloví�a a national cultural heritage. The legis- road network and for resolving connectivity lation sought to promote and protect the pro- problems in the Cicloví�a while causing the gram, and guarantee the resources to maintain least impact on vehicular traffic); the govern- its quality and coverage (Rodrí�guez et al., 2007; ment (in charge of all city policies and oversees Silva, 2007). IDRD); the health sector (provides care in case Key Actors of emergencies through a communication sys- The following actors played a role during this tem of the district’s Center for the Regulation phase: of Emergencies); the education sector (pro- vides human resources through the participa- a transportation law that included an article tion of secondary-school students who carry that proposed changing the Cicloví�a schedule out their compulsory social service in the pro- (from the current 7 a.m. to 2 p.m. to 5 a.m. to gram); the security sector (provides human noon); it was argued that the Cicloví�a nega- resources through the participation of police tively affected motor vehicle traffic, especial- cadets); the environment sector (its objectives ly private vehicles. However, the community and interests alight with benefits provided by reacted forcefully: a group of activists mobi- the Cicloví�a); the marketing and services sec- lized—through social networks, the Internet, tor (disseminates information to the means communications media, and petitions—to pro- of communication, provides logistical support test the reform, and the mayor and other civil for the implementation of each event; and ac- servants also expressed their opposition to the ademia (which evaluates the program) (Meisel change (Comité Cí�vico Pro Defensa de la Ci- et al., 2013). cloví�a, 2008; Peñalosa, 2008; Revista Cambio, It should be mentioned that the health sec- 2008). Although the proposal was not passed, tor’s role has been insignificant in developing for other reasons, the public reaction showed and consolidating the Cicloví�a, because, from the users’ rallying power. And, while some the beginning, the focus was on recreation and private-vehicle owners complain about road sports (and, in a way, social inclusion) and not restrictions on Sundays (and during the night- on promoting healthy life-styles.18 The recent time Cicloví�a), these concerns are only made in recognition of the Cicloví�a’s benefit to public private or refer to isolated events. health has come mainly from academia and The business sector’s opposition main- multilateral organizations, and has manifest- ly dealt with the plans to expand the Cicloví�a ed itself when Cicloví�a was included in spe- network of routes in the 1990s. The opposition cific recommendations of the National Public mostly came from a commercial sector (shoe Health Plan (Decree 3039/2007) and the Law stores located along the main routes where the on Obesity (1355/2009) as a strategy to pre- expansion was planned, represented by the Na- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: vent risk factors for chronic, non-communica- tional Federation of Business Owners [Fenal- ble diseases. co]), which argued that the program threatened Other Key Actors: Opponents and Barriers their businesses. The Administration in power Throughout its history, Cicloví�a’s has had its at the time dealt with this opposition by sub- opponents and barriers, mainly transporta- mitting evidence of the impact of the program tion priorities, private automobile owners, and on the businesses through market studies car- businesses. ried out with the support of the Chamber of Regarding transportation, as mentioned Commerce of Bogotá. Other strategies included Governance of Five Multisectoral Efforts earlier, the reduced kilometers and connec- workshops held with those potentially affect- tions due to the TM construction had a tem- ed, the promotion of business alternatives that porary paradoxical effect that resulted from would be welcomed by Cicloví�a users (for ex- sustainable transport policies, compatible with ample, bicycle repair shops and food vendors), the principles supporting the Cicloví�a. and the establishment of alternate parking lots. Regarding motor vehicles, in 2007–2008, a Most of those interviewed said that a decisive congressperson presented an amendment to factor in the debate was the mayor’s decision to 84 continue the expansion plans, arguing that the • JICA, which recommended an intermodal 85 public benefit overrides the private concerns, articulation for the city’s transportation despite the complaints from the business com- systems. munity (El Tiempo, 1996b). Development (1998–2004) Chapter 2 When the city government changed in 1998, The CicloRutas Network the CicloRuta began to be viewed less as an ini- Beginnings (1995–1997) tiative that yielded environmental and recre- In part, the history of the design and imple- ational benefits and more as an opportunity for mentation of Bogotá’s CicloRutas can be traced alternative transportation. As a result, among to the development plan, “Charting a City,” ad- the list of priorities in Mayor Peñalosa’s devel- opted during Mayor Mockus’s administration opment plan “For the Bogotá We All Want” was (1995–1998) (Alcaldí�a Mayor de Bogotá and the construction of 80 km of CicloRutas that Departamento Administrativo de Planeación would connect to the main road network and Distrital, 1995). Since public space was one of the city’s main parks (Concejo de Bogotá et al., its priorities, the plan included a permanent 1999). This idea was linked to the goal of “es- “cicloví�a road network” that would provide a tablishing transportation systems that would recreation environment and would also inte- reduce trip times and provide a decent, com- grate the water system with the metropolitan fortable, and efficient service that respected green-area system (Instituto de Desarrollo Ur- the urban setting and the environment” (Con- bano, 2011a). The first corridor in the Fucha cejo de Bogotá, 1998). River canal was constructed in 1997 (Instituto That same year, a study for the CicloRutas de Desarrollo Urbano, 2003). Master Plan (PMC from the Spanish acronym) A year earlier (1996), the Japanese Interna- was conducted as a way to promote bicycle tional Cooperation Agency (JICA) conducted a transportation; IDU contracted the study out study of the Santa Fe de Bogotá urban trans- to a private consortium. The plan set forth the portation master plan, and recommended di- necessary conceptual foundations, studies, ac- versifying the city’s transportation modes and tions, mechanisms, and policies for implement- creating its intermodal articulation (Instituto ing and maintaining a 300.9-km CicloRutas de Desarrollo Urbano, 2003; Nair and Kumar, network. Although the PMC focused on trans- 2005). Although not all the recommendations portation, it considered the role of bicycling in were adopted, some were included subse- promoting health, recreation, and sports (Al- quently as a background to the CicloRutas mas- caldí�a Mayor de Bogotá et al., 1999). Based on ter plan three years later (Alcaldí�a Mayor de the PMC, the alternative transport project—Ci- Bogotá et al. ,1999). cloRuta—was incorporated into the Land-Use Key Actors Management Plan as a component in the over- The following actors played a role during this all transportation system (Alcaldí�a Mayor de phase: Bogotá, 2000; Cámara de Comercio de Bogotá, • The Mayor’s Office, which included the Ci- 2009). However, one of the PMC’s limitations is cloRutas in its development plan; that it has not been regulated through an ad- • The planning sector, which carried out the ministrative decree. first works through the IDU; During that same administration (1998– de Bogotá, 2005). More recently, however, the 2001), further studies were carried out and CicloRutas have been included in the Law on 232.1 CicloRutas kms were constructed. The Obesity (1355/2009) as a strategy to prevent construction was facilitated by the renovation non-communicable diseases. of roads and infrastructure undertaken for the During the past two administrations (Garzón TM system. Over the next three years, another 2004–2007 and Moreno 2008–2010), the de- 45 km were added: 33.6 km were the responsi- velopment plans included the construction of bility of the IDU and 11.4 km were linked to the 76 km of CicloRutas (Alcaldí�a Mayor de Bogotá recovery of water facilities by the Water Sup- et al., 2004; Concejo de Bogotá, 2008). Howev- ply and Sewerage System Company of Bogotá er, since these administrations did not make (EAAB for its Spanish acronym) (Segura, 2011). the works a priority (as did Mayor Peñalosa’s The IDRD also participated, constructing 20.54 administration), they were limited to building km. In 2002, the first maintenance phase was CicloRutas in the intervened roads to comply undertaken and in the following year, the with the provisions in the Land Use Plan, ac- World Bank granted a loan for investments in cording to which all road construction must in- road connections, promotion, and optimization volve the road’s profile and, based on its type, of the network (Instituto de Desarrollo Urba- must include the construction of one CicloRuta no, 2003). in the principal road network and one in the Key Actors secondary road network (Decree 430/2004, The following actors played a role during this Article 174). phase: The CicloRutas network includes an inter- • Mayors’ offices, which included the Ciclo- sectoral component. Although responsibility Rutas in their city models; for its maintenance rests primarily with the • The urban planning sector, through the IDU, public utility companies are also involved, IDU, charged with executing the works and such as the EAAB, and the telephone company which arranged for the study that led to the (ETB from its Spanish acronym), Codensa (the PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: PMC (conducted by a private company); electric company), as well as the Transporta- • The water supply and sewerage company; tion Secretariat (Instituto de Desarrollo Urba- • The Culture, Recreation, and Sports Insti- no, 2003). In 2006, an agreement was signed tute (IDRD). with the National Police to guarantee security Maintenance (2004 to the present) along the network and conduct educational Between 2005 and 2006, CicloRutas were in- activities with users (Instituto de Desarrollo cluded in the Transportation Master Plan as Urbano, 2009). University students and activ- non-motorized transportation strategies, and ists also organize caravans going to universi- Governance of Five Multisectoral Efforts in the Public Spaces Master Plan as components ties and workplaces using the CicloRutas, as of the cross-sectional public space sub-system. a way to provide greater security and present Although both master plans mention the poten- the bicycle as a transport alternative for high- tial health benefits of the CicloRutas network, er-income groups (Segura, 2011; Universidad those were not the main objectives nor do they de Los Andes, 2011). They also participate in involve the health sector in their design, imple- political advocacy processes in support of bicy- mentation, and promotion19 (Alcaldí�a Mayor cle use. 86 Key Actors and the insecurity caused by thefts (Cámara de 87 The following actors played a role during this Comercio de Bogotá, 2009). Even now, the Ci- phase: cloRutas are still not attractive or a real option • Transport and urban planning sectors, to some population groups (women, high-in- Chapter 2 which included the CicloRutas in their mas- come persons, children, and the elderly). ter plans and participated in their execu- Another barrier is the lack of institution- tion and maintenance; al coordination. The district does not have a • Public utility companies (EEAB, ETB, and lead entity in charge of promoting/facilitating Codensa); bicycle use as a means of transportation. Nor • The National Police; is there a clear policy on bicycle use that inte- • Bicycle activists. grates existing regulations; the PMC has not Other Key Actors: Opponents, Strategies, been included in any administrative act to sup- and Barriers port it within the city (rather, it serves only as During the construction of the first CicloRutas, a frame of reference) and it has not been inte- some community organizations opposed it and grated effectively to the Land Use Plan. More- publicized their complaints in the media. For over, existing regulations do not consistently example, some residents of the area around the support bicycle use (for example, motor vehi- Fucha River complained that the construction cles continue to be given precedence over cy- negatively affected the environment. The city clists) (Cámara de Comercio de Bogotá, 2009). tried to negotiate with them, by offering such concessions as the inclusion of a linear park The TransMilenio System that offered additional benefits. This was done Beginnings (1995–2000) so that, as with the Cicloví�a, the CicloRutas Starting in the second half of the 20th centu- would remain a priority (El Tiempo, 1996a). ry, discussions were held about constructing a When compared with the size of both the in- metro system to solve the city’s transportation vestment and the infrastructure, the number of problems (Cain et al., 2006; Hidalgo, 2004; Leal CicloRutas’ users is low. According to the Segu- et al., 2003; Lleras, 2003). With most local and ra study (2011) and data from Bogotá’s Cham- national authorities favoring this alternative, ber of Commerce, some of the reasons that roughly 10 attempts to construct such a sys- explain the low usage are the network’s con- tem were undertaken between 1947 and 1997 nectivity problems, its lack of articulation with (Lleras 2003). According to some authors, the other transport modalities, the lack of securi- attempts failed due to the high estimated costs, ty, and insufficient bicycle racks. The fact that the lack of organizational capacity, and the op- owning an automobile conveys higher status position from public transport operators (Leal than riding a bicycle is a barrier for new users et al., 2003; Lleras, 2003). to begin to participate20 (Cámara de Comercio In that context, the steps that led to the BRT de Bogotá, 2009). system began in 1995, when the development Further, the construction of the CicloRutas plan “Charting a City” included integrating a was not coupled with promotion and cultural potential metro with other projects, such as campaigns about respecting cyclists or suffi- the metrobus and trunk-route system (Alcaldí�a cient measures to reduce the rate of accidents Mayor de Bogotá et al., 1995)21. The next ad- relationship based on concession contracts) ministration (1998–2001) also proposed inte- and also changed the transportation economic grating a metro system with a bus network that model, which was framed as a subsidy to the operated along dedicated lines. To this end, it infrastructure. Under the new scheme, trans- considered the creation of the TransMilenio portation companies had to be licensed; in S.A. company (Concejo de Bogotá, 1998).22 Ac- addition, fare collection was separated from cording to Caí�n et al. (2006) and Gilbert (Cain operation (Sandoval, 2010). In April 2000, four et al., 2006; Gilbert, 2008), the metro option companies established by local operators with at that time was indefinitely postponed when ties to international investors were granted the it was clear that the costs exceeded the coun- concession to operate 470 new buses (Cain et try’s finances and that a metro system would al., 2006; Leal et al., 2003). In December 2000, fall short of the city’s high demand. The authors TM’s Phase I officially began operations (Insti- note that, despite the national authorities’ re- tuto de Desarrollo Urbano, 2011b). That same luctance, these reasons led he local authorities year, a Conpes23 document set the guidelines to prioritize the project that ultimately led to for the Urban Public Service of the Passenger the TM, based on more than 20 years of experi- Mass Transport System of Bogotá, as proof of ence in Curitiba, Brazil. the political will at the national level (Departa- In this way, as occurred with the creation mento Nacional de Planeación, 2000) of the CicloRutas, the decision to establish the Key Actors TM system came out of a top-down approach in The following actors played a role during this which the administration gave top priority to phase: improving the transportation system. It project • City administrations, which included trunk was financed through a percent of the gasoline road networks in their development plans, tax, the district budget, a World Bank loan, and integrating them to their priorities and vi- national budget resources (Hidalgo et al., 2007; sion, and finally made the decision to im- Leal et al., 2003). TransMilenio S.A. was creat- plement a BRT. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: ed in 1999. The project’s planning, design, and • Transportation companies. construction involved the participation of local • Urban planning and transport sectors. and foreign companies (Cain et al., 2006) and • Private concessionaires. feasibility studies took about 18 months (Leal Development (2001 to the present) et al., 2003). In 2002, four main routes were completed un- At the onset, public transportation oper- der Phase I. One year later, the system carried ators—who historically had exerted political about 792,000 passengers each day (Hidalgo, and economic power in the city—objected to 2004). The three Phase-II main routes were de- Governance of Five Multisectoral Efforts the plan. According to several authors, the situ- livered and fully operational in December 2005 ation was resolved when the city invited these (Instituto de Desarrollo Urbano, 2011b). operators to bid on contracts to operate the Initially, the plan set out to establish a net- system (Gilbert, 2008; Hidalgo et al., 2007; Leal work of 388 km, covering 85% of the city’s et al., 2003), which averted further protests or demand, to be built in eight stages and fin- strikes. This shifted the relationship between ished by 2016. Over time, the timetable and the city and the transport operators (the new the projected phases have changed several 88 times. Construction of the first part of Phase Other Key Actors: Opponents, Strategies, 89 III was delayed several times and suffered cost and Barriers overruns; it also was the focus of a corruption From the onset, the city’s transportation oper- scandal in the city (El Tiempo, 2011b; Revista ators opposed the new transportation system Chapter 2 Semana, 2012; Revista Semana, 2010th). The for the changes it would bring to them (Gilbert, appropriate design for one of the corridors 2008; Hidalgo et al., 2007; Hidalgo, 2004; San- (Avenida Carrera 7) has been the topic of sev- tos 1999). And, although the city sought to in- eral debates since 2007, involving experts, pol- clude them in the bidding processes, according iticians, the media and the public (El Tiempo, to Gilbert, this strategy favored large companies 2007; Revista Semana 2007; Revista Semana, at the expense of the bus owners, which the ex- 2010b). As of this writing, additional resources perts and media criticized. Observers note that are needed to finance the remaining stages and, in the next phases the process was more dem- once again, the debate on the relative benefits ocratic, but the concentration of investment in of a metro or a tram system versus those of the a few companies has been denounced (Gilbert TM have resurfaced (Cain et al., 2006; Correa, 2006). 2012; Hidalgo, 2004; Leal et al., 2003; Metro en The TM has sparked objections and oppo- Bogotá, 2012). nents. During the construction of Phase II in The health sector, once again, did not have 2004, and again during the 2007 and 2011 a role in the planning, design, implementation, mayoral campaigns, critics voiced their oppo- or maintenance of the TM. Rather, its role has sition in the media and in public debates (El been limited to acting as a first responder in Tiempo, 2007; Revista Semana, 2010a; Revista emergencies that may arise in the system. Only Semana, 2010b; Revista Semana, 2007). Citi- academia has explored TM’s potential to gener- zens complained of the congestion generated ate public health benefits (Cervero et al. 2009). by the works and the construction delays, of Key Actors the rapid deterioration of the concrete slabs The following key actors played a role during used in the system’s corridors (which led to this phase: large investments in maintenance and caused • City administrations, which continued delays in travel times), of overcrowded buses building the system and participating in the and stations, of poor safety, and of costly fares debates about the design and changes to (17% higher than that of common public trans- the initial plans. portation)24 (Cain et al., 2006; Gilbert, 2008; Hi- • The urban planning and transportation sec- dalgo, et al. 2007). The same complaints were tors. made by those who think their properties have • Private concessionaires. been negatively affected by the construction • The media. of the system (El Tiempo, 2006). The associ- • Citizens. ations of architects and urban planners have • Transportation, urban planning, and aca- also expressed dissatisfaction with the effect demic experts. of incomplete works on the city’s aesthetics (for example, the persistence of walls of demol- ished properties) (El Tiempo, 2011a). More- over, as mentioned earlier, the benefits of the TM over other mass transportation systems are equipment). This adaptation was subject to still being debated (Dinero, 2012; Revista Sem- feasibility studies, previous supply, and in ac- ana, 2011). cordance with master plans. This new perspec- tive played out within a change in mindset at Outdoor Gyms the IDRD compared to that of previous admin- Beginnings (2009) istrations; it was now thought that the design Outdoor gyms were installed in Bogotá in of infrastructure should be based on the needs 2009, when a private initiative promoted what of specific communities, not necessarily stan- had already been done in Spain, Portugal, and dardized throughout the city. the United States. The timing coincided with Key Actors studies conducted by the IDRD’s technical unit, The following actors played a role during this which sought to promote the installation of new phase: equipment in public spaces and the renewal of • Citizens. equipment installed in the parks, to respond • The private sector. to the needs of the different communities and • The culture, recreation, and sports sector— age groups. The initiative was presented to the IDRD. IDRD, and the private company installed equip- Continuation (2010 to the present) ment for four months in El Tunal Park as a sam- In the following months, the IDRD encouraged ple of what could be offered. The equipment private-sector companies to fund new equip- was extremely well received by the communi- ment and its installation in the parks. This was ty, and when the company removed the equip- based on the idea that it could benefit Bogotá’s ment eight months later, citizens launched a residents in terms of physical activity, health, mail-in protest campaign, demanding that the and well-being, and at the same time benefit the equipment be restored. The IDRD, prompted by private sector by having it display a gesture of the community’s demand, acquired equipment social responsibility (Instituto Distrital de Rec- designed to its specifications, and installed reación y Deporte, 2011a). This outreach to the PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: it using private-sector resources within the private sector involved two models. The first framework of the 2008 Agreement 78 (Con- was a modification of IDRD’s “Adopt a Park” cejo de Bogotá D.C., 2002). This agreement es- program. This initiative seeks a partnership be- tablished a tax exemption for companies that tween the community, private enterprises, and invest in the management, upkeep, or improve- the district to restore and maintain the city’s ment of district parks by signing contracts with parks through interinstitutional agreements the IDRD. that last one to three years (Instituto Distrital de Recreación y Deporte, 2010). This initiative Governance of Five Multisectoral Efforts This change, whereby the IDRD installed the equipment, also implied a different approach. allowed a company to adopt a park by provid- The promotion company had initially offered ing exercise equipment for outdoor gyms. The outdoor equipment for senior citizens, while second model involves donating equipment the IDRD adapted them so they could be used (without any maintenance commitment) with- by different age groups and in various local in the framework of the 2008 Agreement 78 of conditions and parks sizes (for example, some 2002, described previously. of the smaller parks cannot hold 11 pieces of 90 Outdoor equipment was installed in the next • Private enterprise dealing with health and 91 two years, donated by the international corpo- education. ration of prepaid health care Colsanitas, Novar- • The culture, recreation, and sports sector— tis Laboratories, Athletic Colombia S.A., and the IDRD. Chapter 2 IDRD. The pieces of equipment were installed • Citizens. in in high-, medium-, and low-income neighbor- Other Key Actors: Opponents, Strategies, hoods in parks of various sizes, including parks and barriers in the metropolitan area, which serve a great Neither the literature review nor the inter- many residents. The first equipment was im- views were able to identify opponents to this ported, but installed by Colombian companies. initiative. In fact, residents (both in media cov- Later, Colombian firms began to manufacture erage and in interviews) express enthusiastic the equipment, based on IDRD designs (Agen- support for the infrastructure. According to the da CM&, 2011). In 2011, new gym installations interviewees, the greatest difficulty is raising involved the participation of two cooperatives funds for new equipment, and an important from the education sector and Engativá’s may- obstacle is guaranteeing that it is not vandal- or’s office. ized. To prevent vandalism, the equipment The equipment installation and upkeep fos- has been produced with specific designs and ters the community’s participation. The IDRD placed in areas, such as larger parks, which can holds workshops with resident associations guarantee surveillance and the community’s from neighborhoods to be affected, in order to participation. On the other hand, it is paradox- identify their needs and preferences and raise ical that the technical requirements to install awareness about the project. Feasibility stud- the equipment require hardening the areas (of ies also take into account the findings of earlier the parks), which reduces the amount of green studies (such as those conducted by the Na- space. One strategy seeks a design that uses tional University or the Cultural Observatory) more environmentally friendly materials. that present the public’s most pressing needs. Interviewees expressed that it was crucial for Factors that Influenced These Changes communities to take ownership of the equip- in Bogotá ment and help with its care. For example, a The program’s implementation and the infra- neighborhood association near one park has structures’ construction or installations that assumed monitoring the infrastructure to pre- are reported on in this study were influenced vent vandalism. by the international, national, and local factors As of this writing, the outdoor gyms func- that are discussed below. tion through intersectoral work that includes Urbanization and rapid growth: In the sec- public-private partnerships that function with- ond half of the 20th century, Latin America in the previously detailed framework; the rec- experienced a rapid and massive urbanization reation, culture and sports, and the health and process (Varela C 1998). Such vast changes education sectors; and the public. pose major challenges for the cities, such as Key Actors the need to ensure access to basic services to The following key actors played a role during this a growing population; a rise in unemployment, phase: poverty, and inequality; and a reduced stan- liberal economic model. The country also lived dard of living (United Nations, 2008). Urban through an escalation of violence, drug traffick- living also leads to a more sedentary lifestyle ing, urban terrorism, and the forced displace- and to a diet rich in processed and high-calorie ment of people to the main cities (Bushnell, foods (PAHO, 2007). In Bogotá, annual growth 2007; Dávila and Gilbert, 2001; Mosquera, between the 1950s and the 1990s was 6.5% 2010). (Varela. 1998), and in only nine years (1964– Among other changes, the 1991 Constitu- 1973), the city’s population doubled (Instituto tion consolidated a decentralization process de Estudios Urbanos, 2011). that had been under way for several years and The population increase was coupled with created a special scheme for Bogotá, granting an unplanned urban sprawl that affected pub- it greater political and administrative auton- lic spaces, the equitable access to recreation omy and establishing fixed terms for mayors and community activities, and the urban in- (Bushnell, 2007; Dávila et al., 2001; Mockus et frastructure serving the growing population, al., 1997). Changes also included the consid- problems that were compounded by inequality eration of recreation, sports, and leisure time and poverty, among others (Dí�az del Castillo et as rights of all citizens, and required that their al., 2011; Ramí�rez A 2005). infrastructure be democratic, charging the Cities in the global economy: The 1990s State with their promotion and supervision brought major changes at the global, nation- (República de Colombia, 1991). al, and local levels. Globalization caused cities Further, a new statute made Bogotá a decen- to gain importance as centers of production, tralized district, with greater potential for effi- and had to compete for foreign investment, ciency, an administrative organization, greater and adapt to the investors’ standards (Bush- autonomy for its leaders, new opportunities for nell, 2007; Dí�az del Castillo et al., 2011). This citizen participation, new duties and responsi- included transforming the urban environment bilities for city districts, and a larger budget25,26 and providing services, as well as addressing (Dávila et al. 2001; Mockus et al. 1997; Pizano PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: growing concerns about the environmental 2003). Prior to these changes, the city’s polit- impact of production and economic activities. ical-administrative circumstances were less Thus, the concepts of sustainable cities, stra- favorable. For example, the country’s mayors tegic planning, quality of urban life, and envi- were not elected by popular vote until 1988, ronmentalism gathered importance (Carrión, terms of office were irregular and short, and 2001). In Bogotá, the consolidation of the Ci- mayors had low credibility. Moreover, the city’s cloví�a, the implementation of the CicloRutas budget did not cover the needs associated with and the TM system, and the increase in the the rapid growth (Bushnell, 2007; Dávila et al., Governance of Five Multisectoral Efforts number of parks, were part of—and also were 2001). The new scheme gave Bogotá greater influenced by—this new way of viewing the autonomy for promoting the comprehensive city. development of its area and for improving its Political and administrative changes in Co- residents’ quality of life. (República de Colom- lombia and Bogotá: In Colombia, the 1990s bia, 1993). also ushered in significant reforms, including City administrations that shared a vision the adoption of a new constitution and a neo- for the city and its citizens: As previously men- 92 tioned, several independent administrations such, these are clear examples of the need for 93 (1995–1997, 2001–2003, and 1998–2000) the health sector to build on the experiences shared a vision for the city and the citizenry or programs of other sectors, mainly those of that focused on urban transformations and recreation, culture, sports, transportation, and Chapter 2 citizenship culture (Pizano, 2003). In addition, urban planning. several factors came together to facilitate the Including the health sector in urban planning: process, such as the fact that the first Mockus It is recommended that the health sector’s per- Administration did not execute the total budget, spective be included in the planning and evalu- providing the next administration with enough ation stages of urban planning processes.27 resources to carry out its plans. Further, in Including health indicators: It is important 1997, Mayor Peñalosa was elected along with a to include indicators of public-health benefit city council that supported his proposals. Thus, in the design, evaluation, and monitoring of the Development Plan “For the Bogotá We All urban development programs. To this end, it is Want” (1998–2000) was included in the coun- recommended that the transportation and ur- cil’s Agreement 06 of 1998. ban-planning sectors consider the effects that Such shared priorities made it possible for their interventions may have on physical activ- the city to carry on several changes. These in- ity and that they work with the health sector cluded the recovery and appropriation of public to evaluate them. Specifically, the inclusion of space, the creation of a new public transporta- indicators that measure the level of physical tion system, and the promotion of alternative activity reported by users of the Cicloví�a pro- means of transportation (Montezuma, 2003; gram, CicloRutas, TM, and outdoor gyms in the Parra et al., 2007). Beginning in 2004, however, transportation and leisure time dimensions is the administrations in power had other prior- recommended. ities (Alcaldí�a Mayor de Bogotá and Departa- Using existing infrastructure: The Cicloví�a mento Administrativo de Planeación Distrital, and its parallel programs (Recreoví�a), along 2004), and the urban transformation process with the outdoor gyms, demonstrate that it lost steam. is possible to maximize resource utilization if existing urban infrastructure is used to pro- Lessons Learned mote physical activity and if public-private This section describes the lessons learned and partnerships are fostered. The fact that these puts forth recommendations about these pro- program’s and infrastructure’s benefits go be- grams and infrastructures, so they can be du- yond physical activity, makes it easier to foster plicated in other contexts, cities, or countries a collaborative environment involving other and can serve to promote physical activity. sectors, such as recreation, social integration, Multisectoral work: The Cicloví�a, CicloRutas, transportation, culture, and tourism. TransMilenio, and outdoor gyms are all exam- The public space’s potential: The cases re- ples of multisectoral work, although they may viewed here are examples of how strategies de- entail differing levels of formal agreements and signed to improve public spaces and to foster numbers of participants. In all four cases, the their ownership by citizens can be used to en- health sector played a secondary—nearly in- hance health by encouraging physical activity. visible—role in promoting physical activity. As However, such efforts must be accompanied by comprehensive interventions that guarantee The community, in turn, has supported the safety, equity, and real opportunities for differ- Cicloví�a and the outdoor gyms simply by using ent age groups (children, adolescents, adults them, frequently and in great numbers. This and seniors) and for those with disabilities. ongoing, strong support makes it very diffi- Guaranteeing sustainability: The CicloRutas cult for government officials to go against the and TM illustrate how this type of initiative re- popular tide and risk political consequences. A quire that they be sustained through several community that takes ownership of programs city administrations, to ensure that they do not and infrastructures is willing to fight for them cease to evolve. Cities must consider these ini- against initiatives that may erode them. Both tiatives in the short-, medium-, and long-term, governmental actors and interest groups were but administrations also must stay flexible (and are) necessary, but neither is sufficient by enough to be able to incorporate new technolo- itself. gy and state-of-the-art changes. The implemen- Promoting different dimensions of physi- tation of new coordinated and comprehensive cal activity: Bogotá experience also illustrates infrastructure will lead to greater efficiency that the promotion of physical activity must than isolated interventions. involve several of its dimensions, such as en- Institutional strengthening: These cases also gaging in physical activity during leisure time illustrate the need to strengthen and coordi- and bicycling or walking for transportation. nate institutions in order to achieve common These strategies still need to be strengthened objectives. As competencies, resources, and and promoted more widely. Moreover, there is management are strengthened, there will be a need to undertake comprehensive interven- greater coordination among them for imple- tions that address issues such as safety, the menting multisectoral projects. high status that society accords to private ve- Political will and citizen participation: Re- hicles, inequality, and a lack of easy connection garding the Cicloví�a, CicloRutas, and TM, histo- with other means of transportation. In a city ry has shown how the leadership, commitment, such as Bogotá, where currently only 11% of PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: and political will of city leaders who shared a trips are made in private vehicles, it is critical vision for the city were key at the beginning of to improve the social marketing strategies and the process and ultimately led to their imple- to make infrastructure more efficient, so that mentation. Plans were executed because they trips now made by walking, cycling, and public were an important part of their agendas and transportation are not replaced by the use of priorities, responded to specific needs in the private vehicles. city (such as transportation, inequity, recre- Factors that facilitated or hindered the de- ation, and availability of resources) and were sign and implementation of the Ciclovía as a Governance of Five Multisectoral Efforts consistent with city models pursued through way to promote physical activity: The factors several administrations. In terms of the Ci- that facilitated the design and implementa- cloví�a, although some interested civil groups tion of the Cicloví�a include i) a multisectoral launched some initiatives at the beginning of approach with clear leadership promoting it, the process, it was the changes in administra- which in this case has been the recreation and tion that made it possible for the program to sports sector (IDRD); ii) political will; iii) citi- grow and be sustained. zens’ participation; and iv) social marketing of 94 the program. Factors that impeded it include prior unsuccessful experiences in establish- 95 i) changes in the government’s priorities that ing dedicated public transportation corridors. did not ensure its continuity; ii) private auto- The factors that hindered TM’s design and im- mobiles; iii) transportation priorities ; and iv) plementation include i) low user satisfaction Chapter 2 nearby businesses. (given overcrowding in buses and stations and Factors that facilitated or hindered the design poor safety); ii) the cost of the fare exceeds that and implementation of CicloRutas as a way to of regular public transportation; and iii) prob- promote physical activity: The factors that pro- lems in execution and operations (construction moted the design and implementation of the delays, corruption scandals, cost overruns in CicloRutas include i) a vision for Bogotá that the corridor construction, and deterioration of focused on sustainable transportation models; the pavement). ii) a development plan that considered them a Factors that facilitated or hindered the design priority and allocated sufficient resources to and implementation of outdoor gyms as a way them; and iii) changes to the road network that to promote physical activity: The factors that fa- fostered the interchange between transporta- cilitated the design and implementation of the tion modes, specifically, incorporating the full TM include i) partnerships between the public road profile in the building of new roads and and private sectors to the benefit of both; and TM infrastructure, including sidewalks, parti- ii) widespread public use and ownership of the tions, and CicloRutas (with tree planting and program. The factors that hindered the design laying underground networks). The factors and implementation of outdoor gyms include i) that hindered it include i) inconsistent inter- inadequate financing to install new equipment ventions that lead to interrupted circuits and and ii) risk of vandalism. discourage their use; ii) a lack of visible lead- ership directly responsible for coordinating the References design, implementation, and monitoring of the Abadí�a-Barrero, C., G. Cortés, D. Fino Sandoval, infrastructure; iii) inconsistent transportation C. Garcí�a Alvarez, D. Goretty Oviedo, M. Pini- priorities (with greater weight given to auto- lla Alfonso, et al. Perspectivas inter-situa- mobiles than to bicycles); iv) poor road safe- das sobre el capitalismo en la salud: desde ty and crime; v) the bicycle’s low status as a Colombia y sobre Colombia. Palimpsesto. transportation alternative; and iv) inadequate 2007;6:178-190. Available at: http://sed- financing for maintenance. local.sedbogota.edu.co/cdlusme/images/ Factors that facilitated or hindered the de- stories/saludalcolegio/perspectivas.pdf sign and implementation of the TM as a way (last accessed on: 27 March 2013). to promote physical activity: The factors that Abegunde, D., C. Mathers, T. Adam, M. Ortegon and promoted the design and implementation K. Strong. The burden and costs of chronic of the TM include i) a change in the access to diseases in low-income and middle-income the system that meant that users need to walk countries. Lancet 2007;370:1929-1938. about 500 m to reach it, which entails roughly Available at: http://www.who.int/choice/ 15 minutes per trip, thus complying with phys- publications/p_2007_Chronic_disease_bur- ical activity recommendations; ii) the political den_Lancet.pdf (last accessed on: 27 March will at the national and local levels; and iii) 2013). Acevedo, J., J. Bocarejo, J. Echeverry, G. Lleras, diabogota.gov.co/sisjur/normas/Norma1. G. Ospina and Á� . Rodrí�guez. “El transporte jsp?i=2393#1 (last accessed on: 27 March como soporte al desarrollo de Colombia. 2013). Una visión al 2040.” Bogotá: Universidad de ––––––. Departamento Administrativo de los Andes. 2009. Planeación Distrital 2004. Bogotá Sin In- Acosta Ramí�rez, N., R. Peñaloza and J. Rodrí�- diferencia. Un compromiso social contra guez Garcí�a. Carga de enfermedad Colombia la pobreza y la exclusión. Plan de Desa- 2005: resultados alcanzados. Documen- rrollo económico, social y de obras públi- to técnico ASS/1502-08. 2008. Available cas. Bogotá, Distrito Capital. 2004-2008. at: http://www.cendex.org.co/GPES/in- Available at: http://www.cideu.org/site/ formes/PresentacionCarga_Informe.pdf go.php?id=499 (last accessed on: 27 March (last accessed on: 27 March 2013). 2013). Agenda CM& 2011. Los bioparques se toman a ––––––. Departamento Administrativo de Pla- Bogotá. Available at: http://www.youtube. neación Distrital. Bogotá Ciudad de Es- com/watch?v=fVrfCYMDcSg (last accessed tadí�sticas. Población, viviendas y hogares a on: 27 March 2013). junio 30 de 2011, en relación con la estrati- Alcaldí�a Mayor de Bogotá. “Decreto 566 de ficación socioeconómica vigente en el 2011. 1976.” Colombia. Boletí�n No. 31. Bogotá, 2011. ––––––. 2005. Plan Maestro de Movilidad ––––––. Instituto de Desarrollo Urbano. “Plan [Mobility Master Plan]. Available at: Maestro de Ciclo-Rutas.” 1999. http://www.transitobogota.gov.co/ad - ––––––. Secretarí�a Distrital de Hacienda, Direc- min/contenido/documentos/ResuPlan - ción de estadí�sticas y estudios fiscales. “Co- Maes_11_13_35.pdf eficiente de GINI según localidad año 2007. ––––––. Bogotá, una ciudad andina. 2009. 2007.” Available at: http://www.bogota.gov.co/ Alcaldí�a Mayor de Bogotá, Distrito Capital, Ins- portel/libreria/php/01.270701.html (last tituto Distrital de Cultura y Turismo. “La ci- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: accessed on: 27 March 2013). cloví�a: laboratorio para el futuro.”: Alcaldí�a ––––––. Plan de Ordenamiento Territorial POT. Mayor de Bogotá D.C. 2007. 2011. Available at: http://www.alcaldi- Bushnell, D.., “Una nación a pesar de sí� misma.” abogota.gov.co/sisjur/normas/Norma1. Bogotá, Colombia: Editorial Planeta. 2007. jsp?i=5002 (last accessed on: 27 March Cain, A., G. Darido, M. Baltes, P. Rodrí�guez and 2013). J. Barrios. “Applicability of Bogotá’s Trans- ––––––. Decreto 619. 2000. “[Adopción del] milenio BRT System to the United States.” Plan de Ordenamiento Territorial para San- Washington: Federal Transit Administra- Governance of Five Multisectoral Efforts ta Fe de Bogotá, Distrito Capital.” tion. 2006. ––––––. “Decreto 190 de 2004.” Colombia. 2004. Cámara de Comercio de Bogotá. “Indicadores ––––––. Departamento Administrativo de Pla- de calidad de vida en Bogotá.” Observatorio neación Distrital 1995. Formar Ciudad. Social de Bogotá 2007;20:2-15. Plan de desarrollo económico, social y de ––––––. 2009. Movilidad en bicicleta en Bogotá. obras públicas para Santa Fe de Bogotá D.C. Available at: http://camara.ccb.org.co/ 1995-1998. Available at: http://www.alcal- documentos/5054_informe_movilidad_en_ 96 bicicleta_en_bogota.pdf (last accessed on: Comité Cí�vico Pro Defensa de la Cicloví�a 2008. 97 27 March 2013). Defendamos nuestra cicloví�a. Available at: ––––––. “Encuesta de percepción sobre las http://www.defendamoslaciclovia.blog - condiciones y calidad del servicio de Trans- spot.com/ (last accessed on: 27 March Chapter 2 porte Público Colectivo y TransMilenio.” 2013). Bogotá. 2011a. Concejo de Bogotá 1998. Acuerdo 6 de 1998. ––––––. Observatorio de la región Bogotá-Cun- Por el cual se adopta el Plan de Desarrollo dinamarca. “Comportamiento de la econo- Económico, Social y de Obras Públicas para mí�a de la Región en el primer semestre de Santa Fe de Bogotá, D.C., 1998-2001 - Por la 2011.” Bogotá. 2011b. Bogotá que queremos. Available at: http:// ––––––. Universidad de Los Andes. Observato- www.alcaldiabogota.gov.co/sisjur/nor - rio de movilidad. “Comportamiento de los mas/Norma1.jsp?i=535 (last accessed on: indicadores de movilidad de la ciudad a di- 27 March 2013). ciembre de 2010.” Bogotá. 2011. ––––––. 2008. Acuerdo 308 de 2008. Por Carrión, F., “Las nuevas tendencias de urba- el cual se adopta el plan de desarrollo nización en América Latina. In: La ciudad económico, social, ambiental y de obras construida. Urbanismo en América Latina.” públicas para Bogotá, D.C., 2008-2012 Carrión Fernando, ed. Quito: FLACSO, pp. Bogotá positiva: para vivir mejor. Available 7-23. 2001. at: http://www.alcaldiabogota.gov.co/sis- Cervero, R., O. Sarmiento, E. Jacoby, L. Gómez jur/normas/Norma1.jsp?i=30681 (last ac- and A. Neiman. “Influences of Built Envi- cessed on: 27 March 2013). ronments on Walking and Cycling: Lessons ––––––. 2002. Acuerdo 78 de 2002. Por el cual from Bogotá.” International Journal of Sus- se dictan normas para la administración y tainable Transportation 3:203-226. sostenibilidad del sistema de parques Dis- Cicilismo al dí�a 2012. Ciclismo colombiano - tritales. Available at: http://www.alcaldi- Las Vueltas a Colombia. 2009. Available abogota.gov.co/sisjur/normas/Norma1. at: http://ciclismo.al-dia.info/index.php? jsp?i=6824 (last accessed on: 27 March option=com_content&task=view&id= 2013). 13&Itemid=29 (last accessed on: 27 March Correa, L.. ¿Por qué el tranví�a no es una op- 2013). ción?. 2012. Available at: http://www. Cohen, D., T. Marsh, S. Williamson, D. Golinelli elespectador.com/impreso/bogota/articu- and T. McKenzie. “Impact and cost-effec- lo-320302-el-tranvia-no-una-opcion (last tiveness of family Fitness Zones: A natural accessed on: 27 March 2013). experiment in urban public parks.” Health Dávila, J. and A. Gilbert. “Los alcaldes mayores Place. 2012; 18:39-45. y la gestión de Bogotá, 1961-2000.” Territo- Colombia es pasión 2006. Ciclismo en Colom- rios 2001;5:15-34. bia. Historia. Available at: http://www. Departamento Administrativo Nacional de colombiaespasion.com/ciclismo/VBeCon- Estadí�stica 2005. Censo General 2005 tent/newsdetail.asp?id=4134&idcompa - República de Colombia [General Census ny=24 2005 Republic of Colombia]. Available at: http://www.dane.gov.co/censo/files/pre- sultados.pdf (last accessed on: 27 March ––––––. 2011b. Revelan sobrecostos en Trans- 2013). Milenio de Soacha, la 26 y la 10a. Available Departamento Nacional de Planeación. Docu- at: http://www.eltiempo.com/archivo/ mento Conpes 3093. “Sistema de servicio documento/CMS-9965966 (last accessed público urbano de transporte masivo de on: 27 March 2013). pasajeros de Bogotá.” Bogotá. 2000. ––––––. 2007. Arrancó campaña por alcaldí�a Dí�az del Castillo, A., O. Sarmiento, R. Reis and R. de Bogotá con polémica por TransMilenio Brownson. “Translating evidence to policy: en la carrera séptima. Available at: http:// Urban interventions and physical activity www.eltiempo.com/archivo/documento/ promotion in Bogotá, Colombia and Curiti- CMS-3412063 (last accessed on: 27 March ba, Brazil.” Translational Behavioral Medi- 2013). cine 2011; 1:350-360. ––––––. 2006. Enterrados por Transmilenio. Diez Roux, A., K. Evenson, A. McGinn, D. Brown, Available at: http://www.eltiempo.com/ L. Moore, S. Brines, et al. “Availability of rec- archivo/documento/MAM-1680090 (last reational resources and physical activity in accessed on: 27 March 2013). adults.” American Journal of Public Health ––––––. 2011a. Así� van las troncales de Trans- 2007; 97:493-499. Milenio en la calle 26 y la carrera 10a. Dinero 2012. Metro de Bogotá irá hasta Suba. Available at: http://www.eltiempo.com/ Available at: http://www.dinero.com/ac- colombia/bogota/ARTICULO-WEB-NEW_ tualidad/economia/articulo/metro-bogo- NOTA_INTERIOR-10843124.html (last ac- ta-ira-hasta-suba/140556 (last accessed cessed on: 27 March 2013). on: 27 March 2013). Gilbert, A.. “Bus Rapid Transit: Is Transmilenio Duncan, M. and K. Mummery. “Psychosocial a Miracle Cure?” Transport Reviews 2008; and environmental factors associated with 28:439-467. physical activity among city dwellers in re- Gómescásseres, T.. “Deporte, juego y paseo gional.” Queensland. Preventive Medicine. dominical: la recreación en espacios públi- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: 2005; 40:372. cos urbanos, el caso de la Cicloví�a de Bo- Economist Intelligence Unit 2010. Latin Amer- gotá.” Universidad Nacional de Colombia. ican Green City Index. Available at: http:// 2003a. www.siemens.com/entry/cc/features/ ––––––. “Deporte, juego y paseo dominical: la greencityindex_international/all/en/pdf/ recreación en espacios públicos urbanos, el report_latam_en.pdf (last accessed on: 27 caso de la Cicloví�a de Bogotá.” Thesis for a March 2013). sociology degree. Universidad Nacional de El Tiempo 1996a. Cicloví�as siguen siendo prio- Colombia. 2003b. Governance of Five Multisectoral Efforts ridad. Available at: http://www.eltiempo. Gómez, L., J. Mateus and G. Cabrera. “Lei- com/archivo/documento/MAM-440249 sure-time physical activity among women (last accessed on: 27 March 2013). in a neighbourhood in Bogotá, Colombia: ––––––. 1996b. No a la cicloví�a, dice el Res- prevalence and socio-demographic cor- trepo. Available at: http://www.eltiempo. relates.” Cadernos de Saude Pública 2004; com/archivo/documento/MAM-521461 20:1103-1109. (last accessed on: 27 March 2013). 98 Gómez, L., D. Parra, D. Buchner, R. Brownson, O. Instituto de Desarrollo Urbano. “Programas 99 Sarmiento, J. Pinzón, et al. 2010a. “Built en- desarrollados en función de la promoción y vironment attributes and walking patterns uso de las CicloRutas.” 2009. among the elderly population in Bogotá.” ––––––. Ciclorrutas. Sistema de transporte al- Chapter 2 American Journal of Preventive Medicine ternativo. 2003. Available at: http://www. 38:592-599. itdp.org/documents/Seminar/3%20An - Gómez, L., O. Sarmiento, D. Parra, T. Schmid, M. dres%20Trujillo.pdf (last accessed on: 27 Pratt, E. Jacoby, et al. 2010b. “Character- March 2013). istics of the built environment associated ––––––. “Ciclo-rutas.” Gestión de ciclo-rutas. with leisure-time physical activity among 2008. adults in Bogota, Colombia: a multilev- ––––––. CicloRutas. 2011a. Available at: http:// el study.” Journal of Physical Activitytand www.idu.gov.co/web/guest/espacio_ciclo- Health 7 Suppl 2: S196-S203. rutas (last accessed on: 27 March 2013). Heath, G. W., D. C. Parra, O. Sarmiento L., L. B. ––––––. Infraestructura Transmilenio. 2011b. Andersen, O. Neville, S. Goenka, F. Montes,R. Available at: http://www.idu.gov.co/web/ Brownson. “Evidence-Based Physical Activ- guest/construcciones_transmilenio (last ity Intervention: Lessons from Around the accessed on: 27 March 2013). Globe.” Lancet 2012 Jul 21;380(9838):272- Instituto de Estudios Urbanos. Evolución ur- 81. bana de Bogotá. 2011. Available at: http:// Hidalgo, D.. “TransMilenio Bus Rapid Transit institutodeestudiosurbanos.info/enda - System Expansion 2002-2005 – Bogotá, tos/0100/0140/01411.htm (last accessed Colombia”. on: 27 March 2013). Hidalgo, D., P. Custodio y P. Graftieaux. “A Criti- Instituto Distrital de Recreación y Deporte. cal Look at Major Bus Improvements in Lat- Adopta un parque. 2010. Available at: in America and Asia: Case studies of hitches, http://www.idrd.gov.co/htms/seccion- hic-ups and areas for improvement; syn- adopta-un-parque_128.html (last accessed thesis of lessons learned” Washington: The on: 27 March 2013). World Bank. 2007. ––––––. Clasificación de parques distritales. Hoehner, C., J. Soares, D. Perez, I. Ribeiro, C. 2011b. Available at: http://www.idrd.gov. Joshu, M. Pratt, et al. “Physical activity in- co/htms/seccion-definicin-y-clasifica - terventions in Latin America: a systematic cin-de-parques-distritales_32.html (last ac- review.” American Journal of Preventive cessed on: 27 March 2013). Medicine. 2008;34:224-233. ––––––. Gimnasios al aire libre en Bogotá. Instituto Colombiano de Bienestar Familiar. 2011a. Available at: http://www.idrd.gov. “Encuesta Nacional de Salud Nutricional en co/htms/seccion-gimnasios-al-aire-li - Colombia, 2010.” Bogotá. 2010. bre-en-bogot_1181.html (last accessed on: ––––––. “Encuesta Nacional de Salud Nutricio- 27 March 2013). nal de Colombia, 2005.” Bogotá: Panameri- Jacoby, Enrique, Fiona Bull and A. Neiman. cana Formas e Impresos. 2006. “Rapid changes in lifestyle make increased physical activity a priority for the Ameri- cas.” Revista Panamericana de Salud Públi- bogota.com/movilidad-bogota/carrera-7/ ca 2003; 14:226-228. se-abre-la-discusion-sobre-la-posibilidad- Leal, M. and R. Bertini. Bus Rapid Transit: An de-tener-tranvia-por-la-7a (last access on: alternative for developing countries. Paper 27 March 2013). presented at Institute of Transportation Ministerio de la Protección Social. Universidad Engineers, Annual Meeting. 2003. Available de Antioquia FNdSP. “Análisis de la situa- at: web.pdx.edu/~bertini/papers/brt.pdf ción de salud en Colombia 2002-2007.” Bo- (last accessed on: 27 March 2013). gotá. 2010. Lee, I-M, E.J. Shiroma, F. Lobelo, P. Puska, S. Mockus, Antanas, J. Castro, J. Ruiz, J. Silva and N. Blair, P.T. Katzmarzyk; Lancet Physical N. Córdoba. “Descentralización. Moderni- Activity Series Working Group. “Effect of zación de la gestión en Santa Fe de Bogotá.” physical inactivity on major non-commu- Bogotá: Fundación Corona. Fedesarrollo. nicable diseases worldwide: an analysis of 1997. burden of disease and life expectancy.” Lan- Montes, Felipe, O. Sarmiento, R. Zarama, M. cet. 2012 Jul 21; 380(9838):219-29. Pratt, G. Wang, E. Jacoby et al. “Do Health Lleras, G.. “Bus Rapid Transit: Impact on Trav- Benefits Outweigh the Costs of Mass Recre- el Behavior in Bogotá.” Master’s thesis for ational Programs: An Economic Analysis of a degree in urban planning and transporta- Four Cicloví�a Programs.” Journal of Urban tion at the Massachusets Institute of Tech- Health: Bulletin of the New York Academy nology. 2003. of Medicine En prensa. Lobelo, F., R. Pate, D. Parra, J. Duperly and M. Montezuma, R..”The transformation of Bogotá, Pratt. “Carga de Mortalidad Asociada a la Colombia 1995 - 2000. Investing in citizen- Inactividad Fí�sica en Bogotá.” Revista de Sa- ship and urban mobility.” Global Urban De- lud Pública 2006; 8:28-41. velopment 2005;1:1-10. Massink, Roel, M. Zuidgeest, J. Rijnsburger, O. ––––––. “La transformación de Bogotá. Redefi- Sarmiento and M. van Maarseveen. : “The nición ciudadana y espacial 1995-2000.” PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Climate Value of Cycling.” Natural Resourc- Quito Programa de Gestión Urbana – UN/ es Forum 2011; 35:100-111. HABITAT: Fundación Ciudad Humana. Jose D. Meisel, Olga L. Sarmiento, Felipe Mon- 2003. tes, Edwin O. Martinez, Pablo D. Lemoine, Mosquera J. “Bogotá y sus cambios ¿Por qué Juan A. Valdivia, Ross C. Brownson, Rober- cambiamos?.” 2010. to Zarama. “Network Analysis of Bogotá’s Nair, P. and D. Kumar. “Transformation in Road Cicloví�a Recreativa, a Self-Organized Mul- in Road Transport System in Bogota: An tisectorial Community Program to Pro- overview.” The ICFAI Journal of Infrastruc- Governance of Five Multisectoral Efforts mote Physical Activity in a Middle-Income ture 2005; 20-28. Country.” American Journal of Health Pro- Organización Panamericana de la Salud. “La Ví�a motion In-Press.2013 doi: http://dx.doi. RecreActiva de Guadalajara.” Facultades de org/10.4278/ajhp.120912-QUAN-443 Medicina e Ingenierí�a de la Universidad de Metro en Bogotá. Se abre la discusión sobre la los Andes BC. Centros para el Control y la posibilidad de tener un tranví�a por la 7a. Prevención de Enfermedades. Manual para 2012. Available at: http://www.metroen- 100 implementar y promocionar la Cicloví�a República de Colombia 1991. Constitución 101 Recreativa. 2009. Polí�tica de Colombia. 1991. Available at: Pan American Health Organization. Regional http://wsp.presidencia.gov.co/Normativa/ strategy and plan of action on an integrated Documents/ConstitucionPoliticaColom - Chapter 2 approach to the prevention and control of bia_20100810.pdf (last accessed on: 5 Jan- chronic diseases. 2007. Available at: http:// uary 2011). www.paho.org/english/ad/dpc/nc/reg- República de Colombia. Decreto ley 1421 de strat-cncds.pdf (last accessed on: 27 March 1993. Por el cual se dicta el régimen espe- 2013). cial para el Distrito Capital de Santa Fe de Parra, D., L. Gómez, M. Pratt, O. Sarmiento, J. Bogotá. 1993. Mosquera and E. Triche. “Policy and built Revista Cambio. Posibilidad de cambio de environment changes in Bogotá and their horario de la cicloví�a ha puesto en alerta a importance in health promotion.” Indoor sus usuarios. Revista Cambio 2008;775. Built Environment. 2007;16:344-348. Revista Semana. Enero, mes clave en procesos Peñalosa, E.. La cicloví�a es un patrimonio cul- del `carrusel de la contratación´. 2012. tural de los bogotanos. 2008. Available Available at: http://www.semana.com/ at: http://www.caracol.com.co/oir.aspx- nacion/enero-mes-clave-procesos-del-car- ?id=578955 (last accessed on: 27 March rusel-contratacion/170159-3.aspx (last ac- 2013). cess on: 27 March 2013). ––––––. “The role of transport in urban devel- ––––––. Lí�os en TransMilenio III. 2010a. Avail- opment policy.” In: Sustainable transport: a able at: http://www.semana.com/enfo- sourcebook for policy-makers in develop- que/lios-transmilenio-iii/134065-3.aspx ment cities, GTZ, ed. pp. 1-22. 2002. (last accessed on: 27 March 2013). Pizano, L.. “Bogotá y el cambio. Percepciones ––––––. Procuradurí�a recomienda suspen- sobre la ciudad y la ciudadaní�a.” Bogotá: der la licitación de obras de TrasnMile- Universidad Nacional de Colombia. Univer- nio por la Séptima. 2010b. Available sidad de los Andes. 2003. at: http://www.semana.com/nacion/ Programa de las Naciones Unidas para el De- p roc u ra du r i a - re c om i e n da - su sp e n d - sarrollo. “Bogotá con desarrollo humano. er-licitacion-obras-transmilenio-septi - Ahí� está el detalle. Informe de desarrollo ma/143525-3.aspx (last access on: 27 humano para Bogotá. Entre todos, para to- March 2013). dos.” Bogotá. 2007. ––––––. TransMilenio destrozarí�a la séptima. Pucher, J., J. Dill and S. Handy. “Infrastructure, 2007. Available at: http://www.semana. programs, and policies to increase bicy- com/enfoque-principal/transmilenio-de- cling: an international review.” Preventive strozaria-septima/100700-3.aspx (last ac- Medicine. 2010; 50:S106-S125. cessed on: 27 March 2013). Ramí�rez A. 2005. “Todos los ombligos son re- ––––––. El metro de Bogotá se construye: dondos.” Santos. 2011. Available at: http://www. Ramí�rez A. 1983. “La ciudad para el ciudada- semana.com/nacion/metro-bogota-con - no.” In: Cicloví�as, Bogotá para el ciudadano. struye-santos/164964-3.aspx (lst accessed Bogotá: Benjamí�n Villegas. on: 27 March 2013). Ricaurte, A.. “Cost benefit analysis of the Ci- Journal of Physical Activity and Health cloRuta in Bogotá: A health and a willing- 2006, 3:20-29. ness to pay approach.” Tesis de grado para Schmid, T., M. Pratt y E. Howze. “Policy as in- optar por el tí�tulo de magí�ster en economí�a. tervention: Environmental and policy 2010. Facultad de Economí�a, Universidad approaches.” American Journal of Public de los Andes. Health 1995, 85:1207. Rodrí�guez, J., G. Jiménez and L. Pizano. Proyecto Secretarí�a de Cultura RyD. Bogotá cuenta con de acuerdo 437 de 2007, Concejo de Bogotá seis Parques Biosaludables para todo el D.C. 2007. Available at: http://www.alcal- público. 2011. Available at: http://www. diabogota.gov.co/sisjur/normas/Norma1. culturarecreacionydeporte.gov.co/portal/ jsp?i=26754 (last accessed on: 27 March node/2059 (last accessed on: 27 March 2013). 2013). Sallis, J., N. Owen, E. B. Fisher. “Ecological mod- Secretarí�a Distrital de Movilidad. SDM entrega els of health behavior.” En: Health Behavior resultados preliminares de la encuesta de and Health Education: Theory, Research, movilidad 2011. 2011. Available at: http:// and Practice, 4th edition, K. Glanz, B. K. www.movilidadbogota.gov.co/?pag=954 Rimer, & K. Viswanath, eds. San Francisco: (last accessed on: 27 March 2013). Jossey-Bass, pp. 465-486. 2008. Secretarí�a Distrital de Planeación. Subsecre- Sandoval, Edgar. “¿A dónde van los recursos de tarí�a de Planeación Socioeconómica. De- TrasnMilenio?” En: Hace 10 años. La histo- partamento Administrativo Nacional de ria de la ciudad que cambió. Bogotá: Subdi- Estadí�stica. “Encuesta Calidad de Vida rección imprenta digital. 2010. 2007. Para Bogotá ECVB-2007.” 2007. Santos, A.. Paros de paros. 1999. Available at: Segura, E.. “Movilidad y Espacio Público en http://www.semana.com/opinion/paros- el planeamiento urbano para promover paros/39870-3.aspx (last accessed on: 27 ciudades más saludables: el caso de las March de 2013). CicloRutas y TransMilenio en Bogotá D.C. - PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Sarmiento, O. and E. Behrentz. “La cicloví�a, un Colombia.” Thesis for a the degree of Master espacio sin ruido.” Nota Uniandina. 2008. in Government. Bogotá: Escuela de Gobier- Sarmiento, O., T. Schmid, D. Parra, A. Dí�az del no. Universidad de Los Andes. 2011. Castillo, L. Gómez, M. Pratt, et al. “Quality Silva, V., Proyecto del Ley 071 de 2007 por of Life, Physical Activity and Built Envi- medio de la cual se declara el Programa ronment Characteristics Among Colombi- de cicloví�a y recreoví�a de Bogotá, como an Adults.” Journal of Physical Activity & patrimonio cultural vivo de la Nación y se Health 7:S181-S195. 2010a. dictan otras disposiciones. 2007. Available Governance of Five Multisectoral Efforts Sarmiento, O., A. Torres, E. Jacoby, M. Pratt, T. at: ftp://ftp.camara.gov.co/secretaria/de- Schmid and G. Stierling. “The Cicloví�a-rec- bate2/P.L.071-2007C%20(CICLOV%C3%- reativa: a mass recreational program with 8DA%20Y%20RECREOVIA).doc (last public health potential.” Journal of Physical accessed on: 27 March 2013). Activity and Health 7:S163-S180. 2010b. Torres, A., O. Sarmiento, C, Stauber , R. Zarama, Schmid, T., M. Pratt and L. Witmer. “A frame- “Ciclovia and Cicloruta programs: promis- work for physical activity policy research.” ing interventions to promote physical activ- 102 ity and social capital in Bogotá.” American www.who.int/dietphysicalactivity/goals/ 103 Journal of Public Health, Vol. 103, No. 2, en/ (last accessed on: 27 March 2013). February 2013: e23-e30. ––––––. “Global health risks: mortality and bur- TransMilenio. Sistema TransMilenio. Ci- den of disease attributable to selected ma- Chapter 2 fras. 2011a. Available at: http://www. jor risks.” Ginebra: WHO. 2009. transmilenio.gov.co/WebSite/Contenido. aspx?ID=TransmilenioSA_TransmilenioEn- Notes Cifras_EstadisticasGenerales (last accessed 1 The recommendation is to carry out 150 minutes of on: 27 March 2013). moderate physical activity per week, or 75 minutes of vigorous activity per week (US Department of Health ––––––. Sistema TransMilenio. Componen- and Human Services, 2008). tes. 2011b. Available at: http://www. 2 Bogota’s urban area acccounts for 33% of the city’s to- transmilenio.gov.co/WebSite/Contenido. tal area and concentrates 90% of the population. The aspx?ID_REDIRECT=TransmilenioSA_Quie- program and infrastructures described in this docu- ment are targeted at the urban population. nesSomos_SistemaDeTransporte_Compo- 3 Bogotá received approximately 12% (2 million) of the nentes (last accessed on: 27 March 2013). displaced population from 2000–2006 (Cámara de United Nations. Habitat: United Nations Con- Comercio de Bogotá, 2007). ference on Human Settlements.Vancouver. 4 These characteristics include the location of the home’s entry within the block; condition of street 2008. Available at: http://www.unostamps. pavement; street access; size of the façade; whether nl/subject_habitat_conference_i.htm (last the home has sidewalks and porches; and construction accessed on: 27 March 2013). materials used in the façades, garages, and roofs. 5 The GINI coefficient is a measure of inequality that Universidad de Los Andes. A los Andes en bici... ranges between 0 (total equality) and 1 (total inequal- 2011. Available at: http://www.uniandes. ity). edu.co/component/content/article/276- 6 Public transportation, which has been available in a-los-andes-en-bici (last accessed on: 27 some form since the 1950s, is privately operated and run by private companies that are responsible for March 2013). certain routes, which are assigned through licenses. Universidad Nacional. “Resultados del estudio Traditionally, these companies have had significant de Cicloví�a y Recreoví�a.” Estudio Universi- political and economic power in the city. Bus owners are usually small operators or independent drivers af- dad Nacional. Convenio inter administra- filiated to these companies. Owners’ profits depend on tivo N0311 entre el IDRD y la facultad de the number of passengers they carry, which has led to what is known as the “penny war.” Most of the system ciencias de la Universidad Nacional. 2005. functions without established stops and the level of US Department of Health and Human Services. user satisfaction was 29% in 2010 (Caí�n et al., 2006; “Physical Activity Guidelines for Ameri- Gilbert, 2008; Lleras, 2003; Cámara de Comercio de Bogotá 2011a). cans.” 2008. 7 It should be noted that through District Decree 1098, Varela, C.. “La ciudad latinoamericana en nues- issued in 2000, Bogotá established a “car-free day,” tros dí�as.” Revista austral de ciencias socia- which is celebrated on the first thursday of February les 19-27. 1998. each year. The day starts at 6:30 a.m. and ends at 7:30 p.m. In 2003, Bogotá participated in the international ––––––. WHO Report. “Preventing Chronic Dis- campaign of “car-free day,” along with 3,000 other cit- eases. A Vital Investment.” Ginebra: WHO. ies (Decree No. 297, issued in 2003). 2005b. 8 The 2005 National University study estimated that 41% of users spend more than three hours in the Ci- ––––––. Global Strategy on Diet, Physical Activ- cloví�a; 33% walk or run, 49% bicycle, and 38% skate ity and Health.2005a. Available at: http:// or use some other type of wheels (Universidad Nacio- lishes that the district entities in charge of the envi- nal, 2005). ronment, health, and transportation must establish 9 Academia’s participation involves conducting evalua- cooperation mechanisms to carry out public health tions. campaigns. 10 The 2013 legal minimum monthly wage was $ 589,500 20 Bogotá’s vehicle fleet in Bogotá has steadily increased pesos (US$ 323), with $70,500 (US$ 38.64) of trans- in recent years, despite measures to discourage vehicle portation aid; the latter pays for about 42 TM trips use (Acevedo et al. 2009). during peak hours. 21 These proposals sought to improve previous failed at- 11 Operators are responsible for procuring and running tempts with the trunk road of Avenida Caracas. the vehicles, hiring personnel, and managing mainte- 22 These proposals were part of the transportation and nance yards and parking (TransMilenio, 2011a). public space priorities of the administration, which in- 12 Private concessionaires are in charge of logistics for cluded promoting non-motorized transport, providing operating the system, supplying the equipment, selling disincentives for using private vehicles, and recovering tickets, processing information , and maintaining the public space. (Montezuma, 2005). The construction of collection equipment (TransMilenio, 2011a). TM stimulated the renovation of the urban infrastruc- ture within its area and around its stations (Caí�n et al 13 The increased cost was due to greater investment in 2006). infrastructure and to modifications in the surrounding public space (Caí�n et al., 2006) 23 Conpes: from the Spanish acronym Concejo Nacion- al de Polí�tica Económica y Social (National Council of 14 Although the idea of having users walk to the TM sta- Economic and Social Policy) tions was included in its design, it was not conceived from a health perspective or to promote physical activ- 24 Even though the 2012–2015 administration lowered ity, but rather as a cultural change.. the non-peak fare, it is still higher than that of the com- mon public transportation. 15 This section is an adaptation of Dí�az del Castillo et al, 2011. 25 Although Bogotá has the highest taxes in the country, these revenues are distributed nationally; thus, not all 16 For example, the Cicloví�a involved the citizens’ use of of these taxes contribute to the city’s budget. public space, and to equally weight the needs of pe- destrians and those of motor vehicles, which was con- 26 Several of these processes occurred during the admin- sistent with promoting bicycling as alternative means istration of Jaime Castro (1992–1994), and some au- of transportation; it also provided a setting where the thors note that these decisions opened the way for the culture of citizenship could be promoted. changes that followed (Pizano, 2003 and Dávila and Gilbert) 2001. 17 Even today, those interviewed remember the slogan “Bogotá does not have an ocean, but it has the Cicloví�a,” 27 The infrastructure described in this document can which they view as a very successful marketing strate- also have negative health externalities in terms of en- vironmental pollution and a lack of traffic safety. Thus, PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: gy. it is necessary to take account of these aspects in ur- 18 The health sector’s role is circumscribed to providing ban planning processes, with the participation of the emergency care to Cicloví�a users who may need it. health sector. 19 The health sector is mentioned only in the paragraph 29 of the Transportation Master Plan, where it estab- Governance of Five Multisectoral Efforts 104 105 106 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts Latin America and the Caribbean Region Photography: Marí�a Eugenia Bonilla Chací�n, The World Bank, CHAPTER 3. 107 Mexico’s National Agreement on Food Health: Strategy Against Overweight and Obesity EVELYNE RODRÍGUEZ The objective of this study is to document study: first, an attempt was made to reflect the the design and negotiation process of Mexico’s opinions of the different actors who participat- National Agreement on Food Health: Strategy ed in the process and that were interviewed, Against Overweight and Obesity (known as these opinions were not totally in agreement. ANSA for its Spanish acronym). Furthermore, The interviews were not recorded, thus any er- it seeks lessons from the process that could ror in the transcription or interpretation of the be useful to Mexico and other countries in the observations is the responsibility of the author. development and implementation of similar policies. In addition to the ANSA, there are two Context documents that are part of the same effort and In January 2010, the Government of Mexico whose content, preparation, and negotiation launched the National Agreement on Food are also discussed here: the Technical Bas- Health: Strategy Against Overweight and Obe- es of the National Agreement on Food Health sity (ANSA), the first national multisectoral (hereinafter Technical Bases) and the General strategy developed to tackle these two prob- Guidelines for the Sale or Distribution of Food lems. One of the main public health challenges and Beverages in School Consumption Facili- is the high prevalence of overweight and obesi- ties in Basic Education Schools (hereinafter the ty among Mexico’s population. According to the Guidelines), issued by the Secretaries of Pub- National Public Health Institute (INSP), obesity lic Health and Education, a document derived is the main modifiable risk factor in chronic from the actions agreed upon in the ANSA for non-communicable diseases (CNCD) such as the Secretariat of Public Education. Some ex- diabetes mellitus and cardiovascular diseases, ceptions should be pointed out regarding this which are among the leading causes of mortali- ty in the country. The prevalence of overweight ii. 34.4% of school-age minors (5 to 11 years and obesity in Mexico has significantly in- old) of both sexes are overweight or obese: creased in the last three decades. In the case of 19.5% of boys are overweight and 17.4% obesity, such rapid increase is among the most are obese, while for girls the percentages documented worldwide. are 20.2% and 11.8%, respectively. In 2008, it was estimated that the costs at- iii. 35% of adolescents (12 to 19 years old) tributable to obesity in Mexico were equiva- are overweight or obese: 19.6% of men lent to 13% of total health expenditures (0.3% are overweight and 14.5% obese, while of gross domestic product [GDP]). It was also for women the percentages are 23.7% and pointed out that if no cost-effective interven- 12.1%, respectively. tions are implemented to prevent and control iv. 71.3% of adults (over 20 years of age) are obesity and its comorbidities (hypertension, overweight or obese: in men, the percentag- type-2 diabetes mellitus, cardiovascular dis- es are 42.6% overweight and 26.8% obese, eases, breast cancer and colorectal cancer), di- while for women the figures are 35.5% and rect costs could double and indirect costs could 37.5%, respectively. triple in just one decade (INSP 2012). Figure 3.1 also shows that the combined The most recent information on the preva- prevalence rates of overweight and obesity in- lence of overweight and obesity in Mexico cor- creased from 2006 to 2012 for children under responds to the National Health and Nutrition five, although not for school-age children (5 to Survey 2012 (ENSANUT 2012),1 which points 11 years old). These prevalence rates also in- out that: creased for both men and women 12 years old i. 9.7% of children under 5 of both sexes are and older. overweight or obese and 23.8% are at risk of overweight. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 108 Figure 3.1. Prevalence rates of overweight and obesity in different age groups, 1988-2012 109 % 80 Chapter 3 69.8 71.3 70 60 1998 50 1999 40 34.8 34.4 33.2 34.9 2006 30 26.9 2012 20 9.7 10 7.8 8.8 8.3 0 Preschoolers School-age children Adolescents Adultzs (under 5 years old) (5 to 11 years) (12 to 19 years) Source: Rodrí�guez and Pasillas (2013), based on INSP, 2012; INSP, 2006; and ENSANUT 2012. Note 1: The 2006 datum on adults was obtained through the calculation of a weighted average of the prevalence rates of adult women and men, since the INSP 2006 shows only the prevalence rates by gender, but not the total. Note 2: The National Nutrition Survey of 1988 and 1999 collected only information on childbearing-age women: 12 to 49 years old. The Policy: ANSA, Technical Bases, a. Reverse, among children 2 to 5 years old, and General Guidelines the growth of the prevalence of overweight and obesity to less than in 2006. b. Stop, among the population 5 to 19 years National Agreement on Food Health/ old, the advance in the prevalence of over- Strategy Against Overweight and weight and obesity. Obesity c. Slow the growth of the prevalence of over- Within this context, the Secretariat of Health weight and obesity among the adult popu- (SS) signed the National Agreement on Food lation. Health: Strategy Against Overweight and Obe- To this end, the ANSA established the fol- sity (henceforth ANSA or Agreement). The lowing 10 priority objectives: ANSA is the first national multisectoral strategy 1. Promote physical activity among the po- with multidisciplinary actions that takes into pulation in school, workplace, community, account different environmental and personal and recreational environments with the determinants, aimed at reversing the obesity collaboration of public, private, and social epidemic and its associated chronic diseases. sectors. The Agreement was signed by public sector 2. Increase the availability, access, and con- agencies and entities and industrial represen- sumption of safe drinking water. tatives with the following goals for 2012: 3. Decrease the consumption of sugars and fats in drinks. 4. Increase daily intake of fruits and vegeta- cies; national business organizations (food and bles, legumes, whole grain cereals, and fi- non-alcoholic beverages, agricultural products, ber in the diet by making these foods more industrialization, marketing, food sale and con- available, more accessible, and by promo- sumption); national academic institutions (re- ting their consumption. lated to nutrition, physical activity, and social 5. Improve the population’s decision-making and economic aspects on the subject); the na- capacity about proper diet through nutri- tional municipal representation in health, and tion labeling that is useful and easily un- social organizations (national representatives derstood, and through the promotion of of the health professions, unions, and civil soci- literacy in nutrition and health. ety), and iii) describes the role of the industry, 6. Promote and protect exclusive breast-fe- the municipalities, civil society, academia, and eding until six months of age and appro- professional and union organizations. With re- priate complementary feeding beyond 6 spect to the involvement of the food industry, months old. the Agreement indicates that the latter pro- 7. Decrease the consumption of sugar and vides coordination mechanisms to advance in- other caloric sweeteners added to foods, by, novation of products, better information to the among other measures, increasing the avai- consumer on the nutrient composition of food, lability and accessibility of food with redu- and voluntary measures to regulate advertising ced or no added caloric sweeteners. aimed at children, without establishing specific 8. Provide guidance to the population on re- commitments. The Agreement also points out commended portion sizes in home food that the involvement of the food industry is preparation and make processed foods crucial in decreasing the consumption of sugar that allow for this accessible and available, and fat in non-alcoholic beverages, sugar added including smaller portions sizes in restau- in food, the size of portions, and the consump- rants and food outlets. tion of saturated fats as well as to eliminate the 9. Reduce daily intake of saturated fats in the production of trans fats and limit the amount of PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: diet and minimize trans fats from industrial sodium added to food. Annex 3.1 describes the sources. aforementioned actions by agency in the ANSA. 10. Reduce daily sodium intake by lowering the amount of added sodium and increasing Technical Bases of the National the availability and accessibility of pro- Agreement on Food Health ducts with low or no sodium. The Technical Bases of the ANSA, is a document The general Agreement signed in Janu- that, among others, i) describes the conceptual ary 2010 is a document that, among other Governance of Five Multisectoral Efforts framework; ii) provides an extensive diagnosis things, i) summarizes the financial and social of the problems, including some international costs of overweight and obesity; the causes experiences on how to deal with them; iii) in- of overweight and obesity, and the goals for troduces the basic strategy, stating the vision, 2012 agreed upon with federal agencies, the the goals for 2012 and its objectives in a much industry, and social organizations; ii) defines more precise manner than the General Agree- a National Forum for the Prevention of Over- weight and Obesity made up of public agen- 110 ment, and iv) develops the proposed policies can also provide a context of the efforts and the 111 and actions to combat overweight and obesity. discussions on overweight and obesity at the end of 2008. General Guidelines for the Sale or In 2008, through the Department of Disease Distribution of Food and Beverages in Chapter 3 Prevention and Health Promotion, the SS began School Consumption Facilities in Basic work to support and design the ANSA. First, it Education Schools and Single Annex carried out an estimation of the financial costs of chronic diseases through the Economic Anal- The General Guidelines, which became effective ysis Unit of the SS and secondly, it requested on January 1, 2011 with a gradual implementa- the support of the INSP to outline the general tion mechanism, aim at ensuring that the foods characteristics of what could become a nation- that are prepared and sold at schools contrib- al strategy, identifying actions and objectives ute to a healthy diet. These Guidelines were based on the risks of obesity, and proposing issued as a secretarial agreement between the viable recommendations. To this end, the INSP Secretariat of Health (SS) and the Secretariat of group, led by the Research Center on Nutrition Public Education (SEP), in compliance with the and Health, and based on the ENSANUT results: commitments made by the SEP in the ANSA, i) made the diagnosis of the evolution of over- and are a compulsory official regulation for weight and obesity in Mexico, identified risk all public and private basic education schools factors and the burden of disease; ii) reviewed that, among others, i) establishes the nutri- the Mexican experience regarding prevention ent criteria that regulate the type of food and and care of obesity and chronic noncommuni- beverages recommended for consumption and cable diseases, such as the one carried out by sale in the schools as well as those that should PrevenIMSS, as well as foreign experiences; iii) not be distributed (both for industrialized and compiled the international recommendations non-industrialized food prepared by the school (among them the WHO recommendations) and cafeterias), and ii) creates a School Food Fa- those of the different Mexican medical societ- cility Committee to monitor the preparation, ies, such as the Mexican Diabetes Association, management, consumption, and sale of food and iv) examined and generated evidence sup- and beverages within the schools. For a critical porting the recommendations through the re- analysis of the Guidelines, see Flores Huerta et view or updating of the specialized literature, al. (2011), and for a description of the ratio- meta-analysis and systematic revisions of liter- nale, see Hernández and Martí�nez (2011). ature such as that of the Global Fund for Can- cer Research (Global Fund for Cancer Research, Policy-making Process: Main 2007). Stakeholders and the Negotiation The INSP together with the SS prepared the Process document “Bases for a State Policy to Prevent This section describes some efforts and actions Obesity,” and outlined proposals for general related to the ANSA that were carried out prior actions to prevent overweight and obesity. A to its signing. In addition, Annex 3.2 includes preliminary and confidential version of this other previous actions that were not part of the document and the proposed actions by agency strategy to materialize the Agreement, but that were reviewed in December 2008 in a work- shop of experts organized by the SS through • Secretariat of Agriculture, Livestock, Ru- the Disease Prevention and Health Promo- ral Development, Fisheries, and Nutrition tion Department and the INSP (Secretariat of (SAGARPA) Health 2010). • Secretariat of National Defense (SEDENA) • Secretariat of Social Development Main Stakeholders (SEDESOL) As can be inferred from the description of the • Secretariat of the Economy (SE) ANSA objectives, the Agreement proposed • Office of the Consumer Federal Public Pros- objectives whose compliance could not be ecutor (PROFECO) achieved only by actions that fall under the • Secretariat of Public Education (SEP) responsibility of the Secretariat of Health nor • National Commission of Physical Culture even of the agencies and entities of the Federal and Sports (CONADE) Government. This is the case because the ob- • Secretariat of Finance and Public Credit jectives involved behavior changes at the per- (SHCP) sonal level and changes in the supply of food • Secretariat of the Navy (SEMAR) both at the industrial and restaurant levels. • Secretariat of Labor and Social Welfare As was previously described, the Agreement (STPS) establishes the targets and general goals and • National Water Commission (CONAGUA) describes the actions without specifying any • National System for Comprehensive Family specific action for the industrial sector. In turn, Development (SNDIF) the Technical Bases detail the annual activities • Mexican Social Security Institute (IMSS) and goals by agency and entity per year but • Institute for Social Security and Services for only through 2012. The Agreement was signed State Workers (ISSSTE) in January 2010 by 14 agencies and entities of • Mexican Petroleum (PEMEX) the federal public sector and 4 organizations • Center for Research in Nutrition and Health representing the food industry. The Technical National Institute of Public Health (INSP), PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Bases established 117 activities with 249 ac- as representative of the academic institu- tions, designating responsibilities per Secre- tions tariat and entity, which were only agreed to by • Business Coordination Council (CCE) the representatives of the Federal Government. • Confederation of Industrial Chambers Subsequently, in August 2010, the Agreement (CONCAMIN) was published along with the general Guide- • National Chamber of Transformation In- lines for the Sale or Distribution of Food and dustries (CANACINTRA) • Mexican Council of Consumer Products In- Governance of Five Multisectoral Efforts Beverages in School Consumption Facilities in Basic Education Schools, issued by the secre- dustries (ConMEXICO) taries of Public Education and Health. Even though several agencies and social or- The ANSA was subscribed by the incum- ganizations signed the Agreement, the main bents of the following agencies and public en- stakeholders and their roles are detailed in tities: table 3.1. With respect to the public sector, the • Secretariat of Health (SS) leading role in the design and negotiation of the ANSA was the Secretariat of Health, with 112 significant technical support from the National different industries, mostly food and bever- 113 Institute of Public Health (INSP), an agency of ages (among them Coca Cola, Pepsico, Nestle, the SS.2 The Coordination of the Social Cabinet Bimbo, Danone, Alpura, Barcel and Kelloggs). under the Presidency played an important role Among its functions is representing the indus- Chapter 3 in convening the other federal agencies for the try before State agencies. Although other social discussion and signing of the Agreement. In re- organizations participated (CONCAMIN, CO- gard to the Guidelines, the principal negotiators PARMEX, CCE, CNA), ConMEXICO represented were the SEP, the SS and the Secretariat of the the views of the entire industry. Economy both the central unit (and regulatory During negotiations of the Agreement, the entity) as its agency COFEMER, with respect to Technical Bases, or the Guidelines there was the approval of the regulations; SAGARPA also not involvement of organizations representing participated in these negotiations. consumers or parents. Neither was the Con- The leading role on the part of the industry gress or individual lawmakers involved, al- was taken by the Mexican Council of Consumer though at the time of the Agreement there were Products Industries (ConMEXICO). ConMEXI- several reform initiatives related to obesity in CO is the organization representing the indus- Congress. Furthermore, the media did not play try which groups 43 major companies from a relevant role. Table 3.1. Main Stakeholders and their Responsibilities Institution departments or units Roles and responsibilities Secretariat of Health • Secretary Design the proposed Agreement; conduct its negotiations within the executive branch and with • Undersecretariat for Prevention and Health industry. • General Directorate of Health Promotion Responsible for monitoring. • Strategy and Development Directorate of Healthy Environments • Coordination of Advisers of the Secretary • Coordinating Unit for Vinculation and Social Participation Secretariat of Public Education Negotiation of the Guidelines with the Secretariat of Health. • The Secretary Responsible for implementation. • Secretariat for Basic Education Program School-Health • General Directorate of Development • Management and Educational Innovation Institution departments or units Roles and responsibilities National Institute of Public Health Design of specific recommendations to the Agreement. • Center for Research in Nutrition and Health Generation of technical evidence for the design and negotiation of the Agreement. Participation in negotiating tables with industry; providing technical support to the Secretariat of Health. Secretariat of the Economy Participated in the negotiation of the Guidelines with industry, along with the secretariats of Health and of • Undersecretariat of Industry and Trade Public Education. Federal Commission for Regulatory Responsible for approving federal regulations that impact the private sector. It approved the Guidelines. • Improvement (COFEMER) Presidency of the Republic Called on federal government secretariats and agencies to discuss the Agreement. • Social Cabinet Mexican Council of Consumer Products Industries Leader of the industry’s position in the negotiation of (ConMEXICO) the ANSA and the Guidelines. CONCAMIN, COPARMEX, CCE, CNA Negotiation of the Guidelines Discussion and Negotiation Processes four major discussion and negotiation process- of the ANSA and the Technical Bases es were identified. Discussion within the SS In 2008 the SS, through the Disease Prevention Within the SS, two approaches were suggest- and Health Promotion Under Secretariat, be- ed to deal with the overweight and obesity gan work to support and design the ANSA. In epidemic. The first one refers to the 5-Steps December of that year, it held an experts’ work- Strategy that emphasizes individual responsi- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: shop to review the document “Bases for a State bility. The Steps are: 1) Become active, 2) Drink Policy for the Prevention of Obesity.” In March water, 3) Eat fruits and vegetables, 4) Control 2009, the SS had a proposal of the Agreement, yourself, and 5) Share with friends and family. which integrated the content of what would This strategy was promoted and supported by become the Agreement and the Technical the Coordination of Advisers of the SS Secre- Bases. Furthermore, in January 2009, the SS tary and had been launched in January 2009 by announced the 5-Step Strategy as a “basic in- the Health Secretary, who announced that “The strument that... makes it possible to reverse the Governance of Five Multisectoral Efforts 5-Step Program has been conceived as that ba- trends of the epidemiological problem.” The sic instrument that will allow us to conquer ANSA was signed in January 2010, the Tech- health, be the originator not only of individu- nical Bases in February, and the Guidelines in al but also of family and social well-being and, August of that same year. The signing of these thus, reverse the trends of the epidemiological documents implied discussions and negoti- problem and direct the country to the adoption ations both within the Federal Executive, and of a healthy lifestyle”; the promotion of this with the industry and the states, during which strategy remained among the activities of the 114 ANSA under the responsibility of the SS. The head of the secretariat. The rest of the secre- 115 second approach was supported by the Disease tariats saw obesity as the responsibility of the Prevention and Health Promotion Under Secre- SS which was reflected in much less ambitious tariat, which promoted the General Agreement, goals than those originally proposed by the SS. Chapter 3 under the premise that in addition to individu- It should be noted that the cost of implemen- al responsibility, we live and we socialize in an tation of these actions was not estimated nor obesogenic environment, with obesity being were additional budgetary resources allocated a multifactorial problem whose attention sur- to them. passes the sphere of action of the health sector.3 These processes led to the agreement of 117 These two approaches affected the SS in its activities with 249 actions to be carried out by discussions and negotiations with other agen- different agencies and entities: 12 activities cies and with the industry. They also affected refer to regulatory changes, with different de- ANSA institutionally, by making CONACRO the grees of specificity; 5 activities, to substantive entity responsible for monitoring the Agree- changes in programs; and the rest have to do ment, instead of establishing the National with the promotion of actions for the gener- Forum for the Prevention of Overweight and al population or for workers of each agency Obesity made up of the different actors (public, which do not represent significant changes in private, academic, and social sectors) as agreed the task of the agencies. and explicitly defined in the ANSA. There were proposals originally present- Negotiation of the ANSA and the Technical ed by the SS which did not lead to consensus Bases within the Executive at Federal Level with the corresponding agencies, among them Based on the “Bases for a State Policy for the were: the updating of nutritional labeling Prevention of Obesity” document, the SS sub- standards (SE), fiscal incentives and taxes on mitted a proposal to the social cabinet to have beverages (SHCP), changes in the supply of an agreement on obesity and the actions pro- products through the Diconsa stores network posed by agency, which was approved generally (SEDESOL-Diconsa), change from whole milk in March 2009. The agreement originally pro- to skim milk in Liconsa (Sedesol-Liconsa), posed was much more ambitious than the one changes in the food supplements of Opportu- which was finally signed. The SS with support nities (Sedesol-Oportunidades), construction from the social cabinet convened the differ- standards for public spaces (Sedesol), and pro- ent responsible agencies at the level of Under motion of sale of skim dairy products (SAGA- Secretaries to discuss the proposed actions. RPA). For example, the SS proposed the estab- The principal secretariats convened were: La- lishment of a tax and fiscal incentive scheme bor and Social Welfare (STPS), Public Educa- but SHCP’s commitment was stated as “Analyze tion (SEP), Economy (SE), Finance and Public financial instruments to promote healthy food Credit (SHCP), Social Development (SEDESOL) consumption.” and Agriculture, Livestock, Rural Development, The SS brought up the issue persistently to Fisheries, and Nutrition (SAGARPA). From this the National Health Council, made up of the 32 initial meeting, as reported by the SS, only the secretaries of health of the states and chaired SEP showed real interest and participation in by the Secretary of Health of the Federal Gov- the Agreement, including at the level of the ernment. Negotiation of the ANSA by the SS non-alcoholic beverages, especially the ad- with the Industry vertising aimed at children. The final outcome of the negotiation was the • Continue to promote physical activity, agreement with the industry of only the gen- sports, and healthy lifestyles among the eral objectives of the ANSA and the formation Mexican population, including the work- of working groups to address the issues where place, among other actions (ConMEXICO, the role of the industry was key: sodium, fats, 2010; Zabludovsky, 20104). sugars, advertising, and communication. There The process was exhausting for both parties are differences of opinion between the SS and (including the INSP researchers). This situa- the industry with respect to additional agree- tion was exacerbated in the negotiation of the ments. According to Hernández (2012), the SS Guidelines described in the following section. agreed on with the industry the additional fol- Following are some characteristics of this pro- lowing actions: cess: • Gradual reduction of sugar, sodium, and 1. The SS convened and negotiated the ANSA saturated fat in industrialized foods. with the industry through its corporate • Reduction of the size of portions offered in structures. The SS did not convene the SE industrialized food and in restaurants. to this negotiation (Federal Government • Signing of international commitments to agency responsible for relations with the limit advertising to minors. industry), a factor that would turn out to be • Joint effort to develop a labeling that helps fundamental in the later negotiation of the consumers to select the best option with re- Guidelines. gard to their food and health. 2. Work groups were formed with concrete • Elimination of trans fats of industrial origin. objectives and terms, which were suspen- • Code of Self-regulation of Food and Non-al- ded due to the sanitary alert caused by the coholic Beverages Advertising Aimed at H1N1 influenza. According to the SS, among Child Audiences (Code PABI). the rules established to work with the in- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: However, the food industry states that it rec- dustry were: proposals had to be suppor- ognizes the problem and assumes its shared re- ted, representatives at the meetings could sponsibility only on four lines of action: not be changed, attendees had to have the • Continue with the innovation and develop- endorsement of the organizations and once ment process of new products, and explore an agreement had been reached it was no the possibilities of reformulating existing longer open to discussion. product lines to offer more and better op- 3. The negotiation tables discussed the 10 tions to consumers. objectives of the ANSA and a wording that Governance of Five Multisectoral Efforts • Provide consumers more and clearer in- consensually seemed appropriate to the formation on the nutrient composition of industry. There were objectives in which food and non-alcoholic beverages at their agreement was rapidly arrived at, for exam- disposal. ple, promotion of water consumption and • Adopt, as it already has been doing with physical activity. Agreement was more the PABI Code, voluntary measures in the complicated in those that were related to marketing and advertising of food and the consumption of sugar, saturated fatty 116 acids, and sodium, in which the industry re- 8. In accordance with the SS, the industry had 117 quested more evidence. a delaying strategy and through different 4. During the negotiation, the INSP acted as pressure groups (lobbying) tried to impede the technical adviser of the SS, contributing and delay the signature of the ANSA. Chapter 3 the supporting evidence for the proposals State and Municipal Authorities of the SS and taking a place at the negotia- After its announcement at the federal level, the ting tables. The process was also exhausting ANSA was presented at the National Confer- for the INSP researchers, who went from a ence of Governors (CONAGO), where the Decla- scheme of “researchers” to that of “almost ration for Food Health was approved on March negotiators”, among others, attending the 23, 2010, to be added to the National Strategy meetings and preparing responses to the Against Overweight and Obesity.5 Such Dec- objections that were on the tables; althou- laration recognizes that “overweight, obesity, gh always in the presence of an official from and their complications constitute a priority the SS. public health problem that requires the imple- 5. On the part of the industry, their participa- mentation of a multisectoral national policy, as tion was largely of people associated with well as the collaboration and consensus of the the regulatory areas and relations with three levels of government and state their will government, and only occasionally were to strengthen its content, so that in its respec- there technical staff and nutritionists. This tive scopes of action, assist in the execution and implied that the discussion did not focus achievement of the ANSA targets and goals.” on technical issues (not even as regards to The Agreement was also taken before the lipids, as pointed out by one of the inter- Mexican Network of Healthy Municipalities, viewees). which adhered to the ANSA with the Signature 6. One of the arguments of the industry was of the Declaration of the Mexican Network of that most of the evidence for establishing Municipalities for Health and the State Net- the contribution to overweight and obesity works of Municipalities for Health, April 7, in the development of chronic diseases and 2010 (Censia 2010). their potential burden, as well as on the cost-effectiveness or impact of the actions ANSA Follow-up, Transparency, and to prevent and to serve these programs, co- Evaluation Mechanisms rresponded to the international sphere and, In February 2010, less than one month after the in some cases, the proof was not conclusive signing of the ANSA, it was established that the (Sassi et al., 2009). agency that would evaluate and follow-up the 7. Due to the complexity of the negotiation commitments established in the Agreement and in order to have the Agreement signed would be the National Council for the Preven- in the terms originally proposed, on several tion and Control of Chronic Non-communica- occasions the SS tried to replace the dialo- ble Diseases (CONACRO), a council created in gue of ConMEXICO with that of the princi- that same month through an agreement of the pal companies, which was not an effective SS and made up of only agencies of the Federal strategy. Government. The formation of this Council is not what follow-up, according to one of the interviewees, was expected in the ANSA or in the Technical “with little high-level institutional support.” Bases, this follow-up and evaluation is one of On the other hand, even though evaluation the weakest aspects of the Agreement. The was included as a component in the ANSA, a Technical Bases stated as the main recommen- monitoring and evaluation scheme was not dation of the experts, the creation of a coordi- foreseen either for the ANSA nor for the specif- nation mechanism in the form of a “National ic actions (including the Guidelines discussed Board for the Prevention of Obesity”, appointed below); nor was an indicator system devel- directly by the President of the Republic and oped beyond the physical goals. Thus, to date formed by experts in the field and representa- an external evaluation has not taken place and tives of the different sectors involved, (p. 61). neither is public information available on the The ANSA established the creation of the Na- achievement of the goals. This is a major weak- tional Forum for the Prevention of Overweight ness of the Agreement. and Obesity made up by public agencies, ma- jor national business associations (food and Discussion and Negotiation of the non-alcoholic beverages, agricultural produc- General Guidelines for the Sale or tion, industrialization, marketing, sale and food Distribution of Food and Beverages in consumption), national academic institutions School Consumption Facilities in Basic (related to nutrition, physical activity, and so- cial and economic aspects on the issue), na- Education Schools tional municipal representation in health, and Following the signing of the Agreement, work social organizations (national representatives began to draft the Guidelines, which were de- of the health professions, unions, and civil so- rived from the commitments of the SEP in the ciety organized for the issue). This Forum was ANSA. After periodic meetings with the SS and not created. the SEP, the INSP developed a proposal with Thus, an institutional entity with the pres- gradual implementation mechanisms. The PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: ence of the principal governmental, industrial SEP and the SS convened a meeting to discuss and academic actors was not established to this proposal with state education and health monitor the ANSA and allow an opportunity authorities. These two secretariats also sent, for discussion and work on an issue that will prior to their negotiation and agreement with certainly require numerous negotiations in the the industry and to its publication, their pro- future. In reality, CONACRO has not performed posed Guidelines to the Federal Commission well in the monitoring of the ANSA. for Regulatory Improvement (COFEMER). The fact that CONACRO has been assigned COFEMER is an agency of the SE whose man- Governance of Five Multisectoral Efforts the responsibility of following up the ANSA date is to analyze and dictate the regulations is partly the result of the existence of two ap- that the Federal Government agencies wish to proaches within the SS throughout this pro- issue to guarantee that its impact in terms of cess. CONACRO came into being in the context social benefits are greater than its costs. To this of the 5-Step Strategy and not of the ANSA. end, before issuing its resolution, it must sub- Upon publication of the ANSA, the General mit the draft regulations to a public consulta- Directorate of Health Promotion assumed its tion process and establish a period to receive 118 comments from the interested parties and also had left the environment and the relations 119 publicize its decision. fractured. In the Guidelines, the SEP played an The negotiation and agreement with state active role at the level of its incumbent with re- education and health authorities were neces- gard to the school environment. Chapter 3 sary given their decentralized nature in Mex- This process promoted a better relationship ico. With respect to the food and beverages between the SS and the SEP, the establishment industry, the proposal included some restric- of a work institutional framework between tions to the sale of processed products at basic the two, as well as greater prioritization of the education schools. Among others, it included a health issue for the SEP vis-à-vis the constant ban on the sale of sugared beverages and the demands from different institutions to incor- development of new presentations that com- porate subjects into the curriculum or in the plied with the standards which included reg- school area. The intersectoral relationship be- ulations on energy density. The negotiations tween the SEP and the SS is not new, but during with the state authorities and with the indus- the administration of President Calderón, and try occurred simultaneously. In the case of the in particular in this process, was strengthened negotiation with the state authorities, the pre- and institutionalized— identified as one of the sentation and discussion of the Guidelines was strengths. In 2008 the SS and the SEP had pub- carried out jointly by the SEP and the SS, with lished the Specific Action Program 2007-2012 the state secretaries of health and education, School and Health (see Secretariat of Health conveying both the impact of overweight and 2009). The Guidelines were included within obesity on health and the effects of malnutri- the Action Program in the school context pub- tion on learning disabilities. Local industries lished in 2011.6 also advocated their arguments with regard to In order to provide a context of the impor- the ANSA with their state authorities. tance of school stores, it is worth mentioning In turn, the Guidelines negotiation process that students spend on food and beverages at with the food industry was particularly com- schools a total of 40,788 million pesos, of which plex and exhausting. The public sector was 20,378 million correspond to sales of indus- represented by the SS, SEP, and INSP (as tech- trialized products. In public primary schools, nical support). Subsequently, and at the re- 31% of the students consume food brought quest of the industry once it became familiar from home, another 31% buys it at school, and with the Guidelines, the Presidency and the SE 36% brings food from home and also buys it at also participated in the negotiation, and the SS school (SEP, 2010). contracted ITAM for the financial aspects, later Following are some of the characteristics incorporating researchers from other institu- and elements of the Guidelines negotiation pro- tions, such as the Ibero-American University cess with the industry. Some of them are also and the INNSZ for the technical aspects. On the applicable to the ANSA negotiation process: part of the industry, mainly the same structures 1. Discussions of the Guidelines held by SS of corporate representation participated as for and SEP with the industry were largely the ANSA and ConMEXICO also played a lead- with their corporate structures. ership role. The SS and the industry had just 2. The process was complex and exhausting finished the ANSA negotiation process which for both parties. Establishing restrictions to the sale of processed products was ne- servations. The industry requested the in- cessarily going to imply a complex process, tervention of the SE from the Presidency, as but may be it was much more so due to the it perceived that a decision had deliberately absence of a previous negotiation strategy been made to present them a fait accompli. that: i) incorporated from the beginning It was at that time that, through instruc- and at all the meetings all the key actors; tions from the Presidency, the principal ne- ii) ensured a vision and single position of gotiation forum took place in the facilities the Federal Government; iii) included an of the SE. The way the involvement of the assessment of the economic impact of the SE came to be—at the request of the indus- measures and of alternative measures; iv) try and instructions from the Presidency established clear monitoring, enforcement, and not from a previous invitation of the and evaluation mechanisms; and v) esta- SS—generated the perception in the SS and blished an institutional negotiation fra- the SEP of the SE as “supporter of the in- mework for the Guidelines but also of the dustry”; however, this perception was not discussions, follow-up and evaluation that shared by the SE. allowed continuity of the work beyond the 6. The main concerns of the industry with res- publication of the regulation, not only until pect to the non-technical parts of the origi- 2012 but also into the next administration nal proposal, for the most part presented and in the medium term. This complicated to COFEMER in the drafting process of the the negotiation but also debilitated the pos- Guidelines, were the following: sibility of continuing the work with the in- a. That the economic impact of the mea- dustry once the Guidelines were signed. sures had been left out. 3. As mentioned earlier, after the ANSA was b. That the Guidelines did not include the signed, the National Forum for the Preven- subjects of implementation nor estab- tion of Overweight and Obesity was not lished a clear mechanism to ensure the created. Thus, there was no institutional evaluation, monitoring, and enforce- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: entity for the discussion of the Guidelines. ability of the measures, nor the entity 4. At the beginning of the negotiation, the that would be responsible for this. Federal Government did not have a single c. That the proposal included restrictions position before industry nor pre-establi- only to the sale of processed food within shed negotiation mechanisms and limits schools but not of the unprocessed food for its different secretariats for dialogue prepared and sold in the school coop- with the industry on these subjects. Nei- eratives. Nor did it incorporate restric- ther were there clear instructions within tions to the sale of food product in the Governance of Five Multisectoral Efforts the Executive during the process; one of the surrounding areas of the schools. The interviewees pointed out that “there were foregoing, coupled with the absence of moments during the negotiation in which enforcement mechanisms of the Guide- government officials felt alone.” lines at the level of the cooperatives 5. When the Guidelines were initially pre- and of the schools, in the opinion of the sented to the industry, they were given a industry, would nullify the impact of one-week time frame to submit their ob- restricting and limiting the sale of pro- 120 cessed food products and presentations what colloquially was referred to as the 121 in schools. “potato-traffic” (referring to the intro- In Mexico, school cooperatives are duction into the school of French fries, responsible for the preparation and sale or of products in which the sale or the Chapter 3 of food in the schools, both processed type of products was limited within the products as well as others that are pre- school facilities). pared and sold in situ. These coopera- d. According to the industry, sales within tives are businesses owned by parents the school environment are not signif- and teachers, and represent an import- icant. Thus, more than the economic ant source of income for the schools and impact of the proposal on the specific for those who operate them. According school market was the reputation-type to the SEP, the annual amount of food problem that could lead to the stigmati- sales in public schools amounts to ap- zation of industrial products. The indus- proximately 60,000 million pesos. The try was not willing to accept that food majority of the children buy something be labeled as good or bad, if it meets the at school daily, on average spending prevailing standards and insisted that some 12 pesos daily. The gains of the there are not good or bad products, but cooperatives are an important resource good or bad habits. for the schools, which is partly ear- e. The lack of foresight, valuation, or in- marked to school maintenance, since corporation of alternative or additional schools do not have budgetary resourc- actions, such as extending school sched- es allocated for current expenditures. ules to expand physical activity in the According to the industry, 80% of what schools, which for the most part is lim- is sold at schools is prepared by the co- ited to one hour per week; establish box operatives and only 20% is of an indus- lunches for all schoolchildren and close trial nature; the industrialized products the school cooperatives, or ensure com- sold by the cooperatives, for the most plete availability of drinking water, nor part are not supplied directly from the was there discussion of actions to pro- companies but from grocery stores. mote the change of habits. The industry Furthermore, around the schools perceived a heavy emphasis on environ- all types of products are also sold (in- mental issues (changes of relative pric- cluding just outside school doors with es, taxes, availability of products, etc.) informal sellers not subject to any kind rather than in change of habits. of regulation). Given the full availabil- f. The foregoing gave the perception to ity of all kinds of products, not only in the food industry that in the overweight grocery stores but literally just outside and obesity problem “only the industry school doors, and that there are no re- was expected to pay”, that the vision strictions to the products that school- was short-term, and that a comprehen- children can introduce or consume at sive plan was lacking. school, the industry was concerned of 7. As a negotiation mechanism, the industry having something established similar to requested the creation of an institutional committee to bring together all the pla- ted by one of the interviewees, “demonstra- yers “pact type”7 for the negotiation and te that they were not going to bankrupt the subsequent follow-up. An institutional en- industry.” According to the INSP, its support tity that invited all the stakeholders, with was very important because the proposals an independent secretariat, with a shared were supported by evidence and interna- diagnosis and negotiation and evaluation tional recommendations, particularly those mechanisms, that would also test pilot of WHO were very useful since it could be programs. The Director of ConMEXICO is a argued that Mexico as a member had the reputed negotiator in Mexico, thus this re- moral obligation to apply them. The INSP quest derived from trying to generate ins- also pointed out that the industry approved titutional conditions for the negotiation of the participation of researchers that did not the Guidelines and for later discussions, ba- work in public institutions. sed on his experience.8 12. On the negotiating tables, as well as in the 8. ConMEXICO offered a nutritional labeling case of the ANSA, the industry was largely as a voluntary standard and the integra- represented by those responsible for the tion of a trust fund to finance actions in the regulatory areas and liaison with the go- schools. vernment and only sporadically experts on 9. In this context, the main task of the SE was nutrition. Thus, more than to argue on the to incorporate the financial cost of the pro- technical specifications proposals of the posed measures in the discussion, and to products, the main concerns of the industry look for implementation mechanisms that were those described in point 6. Regarding were more adequate in terms of the econo- the technical aspects, according to the SS mic impact of the measures. the main arguments of the industry were 10. Thus, although the proposal originally did that there was no relevant information for not consider the economic and implemen- Mexico, without making specific proposals, tation issues, these were being addressed which was perceived as a delaying tactic. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: throughout the negotiation at the request Although, in the opinion of the INSP, the ar- of the industry and the SE. Such situation guments of the industry did indeed proved made the process more complex, because relevant with respect to food technology. part of the argument was being developed 13. Furthermore, neither consumers nor the in response to the industry. parents or lawmakers participated in the 11. The SS and the SEP (as with the ANSA) were discussions. In the case of Mexico, neither technically supported by the INSP and re- parents’ nor consumer associations are searchers from other institutions (such as very active entities. Governance of Five Multisectoral Efforts the INNSZ, the Ibero-American University 14. In the decision-making process of the and the medical societies). Furthermore, to Guidelines, COFEMER received 864 ob- respond to the arguments of the industry servations from business organizations, on the economic impact of the Guidelines, companies, associations, individuals and which were considered disproportionate, others,9 each one receiving direct respon- the ITAM was contracted to evaluate the ses from the SEP and the SS. The private economic impact of the proposals to, as sta- sector also submitted observations both 122 from its organizations and food industry order to promote healthy habits among 123 and beverage companies, and from private the students; the absence of drinking wa- associations, companies, and primary sec- ter at schools, as well as adequate facilities tor producers, in particular from milk and for hygienic food preparation and areas to Chapter 3 sugarcane producers. Following is a des- carry out physical activity; that children cription of the main categories of observa- have too many opportunities to consume tions and some of the associated arguments food; the lack of capacity at the school level (SEP 2010). to identify the quality of food as proposed • Economic: Among others, the change in in the Guidelines; proposals to involve nu- presentations and portions would imply tritionists in the implementation of the adaptation costs in packaging and in the food standards at schools and for teachers production chain; there would be a loss in to supervise what the children bring for sales at schools and in general (both be- lunch, and elimination of the certification cause of the reduction in demand in schools of schools. Furthermore, there were con- and due to the stigmatization of the prod- cerns over the sale of products banned in ucts), which would affect employment and areas close to the schools and the fear that small and medium enterprises (SMEs). implementation of the guidelines and its The foregoing would affect the value of the enforcement could generate bureaucracy, brands and competition. They also ques- corruption, and complex procedures for the tioned the restrictions to consumer choic- concession of school stores.13 es, the informal trade around the schools 15. Some of the answers of the SEP and the SS and the lack of availability of drinking wa- to the arguments of the industry are as fo- ter. The industries that commented were llows (SEP, 2010). particularly those related to the production • Financial costs for the industry upon effec- and sale of beverages, sugar, and milk.10 tiveness of the Guidelines: The industry is • Legal: The observations focused on ques- prepared to carry out these modifications tioning the legal basis of the draft provi- since it is characterized by carrying out sions, particularly because the general frequent packing modifications and pre- Agreement was not of a legal or regulatory sentation portions. Some of the products nature and, accordingly, could not be the with characteristics adequate for school legal support for the Guidelines; they also facilities are already available in others dis- stated that they violated individual guaran- tribution channels. No price increases of tees.11 the products are expected due to the low • Health and nutrition: There were observa- share school sales represent to the indus- tions with respect to the definition of food tries, or effects on the employment level of and beverages and to the proposal to certify the industry, or a high impact in the SMEs; schools as free from sweetened beverages neither are reductions in the sale of the and food.12 industry’s products to the schools. In ad- • Educational issues: The observations re- dition, the opinion of the Federal Commis- ferred to the need to train parents and sion on Competition (CFC) was requested teachers and modifying the curriculum in and it pointed out that the measures are not discriminatory nor create exclusive ad- nicipalities. The actions underway by the vantages. In one of the answers it pointed SEP include promoting the consumption of out how the Bimbo group announced that drinking water in the program of studies it was reducing trans fats, fats, sugars, and and, through the National Institute of Edu- salt in its products, as well as producing cational Physical Infrastructure, developing smaller portions. With regard to consump- the technical standard for the installation tion of non-caloric sweeteners, the CFC ex- of drinking water fountains in schools and pressed that the scientific evidence on the promotion of the availability of simple po- subject is not conclusive, thus consumption table water in the schools that do not have of these products will be allowed only in drinking water fountains. The construction high schools. project of drinking water fountains “will • Reputacional effect: The observation is be gradual in order to manage to serve the only partially probable, since it has been largest possible number of schools in the observed that children exert an important medium term” (p. 641). influence on the consumption decisions • Informal trade outside the schools: Opera- of their families. However, there will not tion conditions of the schools restrict stu- be a change in the total demand for food dents to go to external sale points during and beverages, but rather a modification the school day. Joint efforts with the author- in their composition, giving special impor- ities are expected to remove the informal tance to products low in calories and fats. trade from the proximity of the schools. The drafting of the Guidelines was modi- • Costs to the sugar industry: The Guidelines fied to avoid negative qualifications of the do not completely eliminate the content of products. With respect to possible damage sugars and other caloric sweeteners. Since to the value of the brands, it was argued schools only represent 3% of the food and that companies have faced similar regula- beverage industry the effect would be mar- tions in other countries, such as the case of ginal and would help reduce the deficit in PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: beverages, Coca Cola being today the most the national production. valuable brand in the world of the beverag- • Supervision and surveillance: The Guidelines es and food industry. do not refer to supervision by the authori- • Availability of drinking water: The indus- ties but rather by the School Consumption try includes in its products portfolio bot- Committee. The Guidelines do not intend tled drinking water, a product that does to explicitly detail the supervision proce- not have any restriction in the Guidelines, dure, but rather to regulate the operation of thus it can be easily distributed in the co- school consumption facilities. Governance of Five Multisectoral Efforts operatives and meet the hydration needs • Physical activity promotion: The PACE in- of the students, regardless of the avail- cludes the promotion of physical activi- ability of drinking water in the schools. In ty. The draft Guidelines included that the addition, it is mentioned that solving this teaching staff would be in charge of ex- problem is not the exclusive competence of plaining to the students the importance of the SEP, since the provision of services to physical activity and sports. Furthermore the schools is the responsibility of the mu- the SS promotes, among others, “5 Steps for 124 Your Health”, while the SEP and the CON- ceiving sugar as detrimental (SEP, 2010). The 125 ADE have made commitments to facilitate institutional entity to negotiate and follow-up, physical activity in the school environment. which the ANSA sought to establish as request- The Guidelines are not an isolated measure. ed by the industry, was not created. Chapter 3 • Benefits of the Guidelines: The financial im- After the approval of COFEMER, in August pact was analyzed longitudinally in a period 2010 the SS and the SEP published the General of 100 years. A savings potential of approx- Guidelines in the Official Journal of the Federa- imately 30,000 million pesos of 2008 was tion through a secretarial agreement between estimated, both by direct savings derived the two secretariats. from the reduction in the medical care ex- As can be observed from the brief descrip- penditure and by indirect savings derived tion of the negotiation of the Guidelines, the de- from the gain in productivity by years of cision-making process of COFEMER compelled avoided death and additional healthy years making explicit the assumptions of costs, ben- of life. efits, and complementary measures, both by Based on the arguments of the parties, COFE- the industry and the authorities. It would be MER issued its decision contained in 180 pages important to perform an ex-post evaluation of which may be consulted at: www.apps.cofe- the development/evolution of these variables. mer.gob.mx/COFEMERAPPS/scd_expedien- Program of Action in the School Context te_3.asp?id=01/ 0596/10061. The Guidelines were subsequently included Finally, the intensity of the negotiation of within the Program of Action in the School the Guidelines resulted in a loss to follow-up of Context (PACE) published in 2011 by the SEP, the general Agreement. together with the SS, consisting of three com- As a result of the negotiation process, the ponents: original proposal underwent modifications and a. Health promotion and education whose ob- some elements–such as limiting the sale of food jective is the development of competencies based on an energy density criterion–were re- so that children learn to make decisions on placed with others. With respect to caloric bev- what food and beverages to consume, and erages, the proposal completely restricted the the physical activity they perform, through sale of all caloric beverages (including nectars) the modification of textbooks, teacher but the final Guidelines only restricts the sale of training, and guidance to parents. beverages in primary schools, but allow them in b. Actions to promote greater physical activ- their “light” version in secondary schools. Mod- ity as far as possible in schools, for exam- ifications were also made to the draft to avoid ple through guidance to physical education stigmatizing, give a negative qualification, or teachers and physical activities during highlighting certain products, establishing only school recesses. “what it is recommended due to its composi- c. Access and availability of healthy food and tion and because it encourages or favors that beverages in the terms established in the the consumer develop habits for a good diet.” Guidelines. Furthermore, the certification of schools free of According to the SEP in the period 2007- sweetened beverages and food was eliminated 2012, a “golden stage” came into being in rela- from the Guidelines, since it would lead to con- tions between the SEP and the SS: they came to an agreement regarding the priorities (on what tion School Councils (formed by parents, can really be done in the schools) and in being teachers, former students and members of more mindful regarding the goals, taking into the community) to monitor and ensure that account the restrictions of the education sector. the schools’ stores operate in accordance Also, the SS agreed that it could not go alone with the provisions. Include specifically at to the schools without the previous agreement least one nutrient and one health objective of the SEP and that it needed the support and with regard to the development of healthy negotiation of the SEP. Thus, both institutions eating habits, to be consistent with the edu- agreed on joint work plans and for the first cational mission of the school. time jointly convened the decentralized ser- Weaknesses vices and held national intersectoral meetings. • The target population does not participate One of the “apex moments” of the relation was actively in achieving a healthy diet. during the H1N1 influenza emergency, where • The consumption establishments by the the role of the schools was essential. simple fact of selling healthy products (ei- As corollary, it is observed that despite this ther food or beverages, processed or nat- strengthened relationship between the SEP ural), will not develop healthy habits. The and the SS, specific resources for the “School- students, depending on their resources and Health Program” were not allocated, there is hunger, may acquire or buy one or more no specific responsible area within the SEP for portions. this program nor were resources allocated to • The actions are not integrated in an ecologi- ensure the availability of drinking water in all cal model following the factors that encour- the schools. age that the students of a primary school Technical Analysis of the Guidelines ingest a larger number of calories than they The technical analysis of the Guidelines spend. carried out by Flores Huerta et al. (2011), • It does not include—because it is not the points out among its strengths and weak- issue although it is mentioned—actions to PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: nesses the following: promote the development of physical activ- Strengths ity habits, exercise, and recreational activi- • Recognition of school as obesogenic envi- ties for the children. ronment that the authorities may change • No consideration is given to the times or for a healthy one with political will, through the spaces to eat, or the importance of mak- the educational community. ing the meals an opportunity to share and • Having adopted as a regular strategy that enjoy the food. the school store purchase/sell food and • The consumption facilities are uniform, Governance of Five Multisectoral Efforts beverages, processed or natural, that ful- without considering if the site where the fill with the technically correct established school is located offers utilities such as requirements. These products will reach water, electricity, and drainage, or if there extracurricular areas in the entire national is space for an installation of this nature. territory. There is the possibility of establishing min- • Incorporate the participation of the school imums for categories of facilities according community, through the Social Participa- to the services that are available, the size, 126 and site of the locality and of the location of would allow making an evaluation into the fu- 127 the school. ture. The two studies that have been done on • It mentions that the facility can sell water, the Guidelines are based solely on the opinion but nothing is said about the school having of different actors on the processes. Chapter 3 drinking water fountains for the children. Compliance of the activities and actions of • There is no mention of an implementation the secretariats: Without a public evaluation program or a consolidation model and mid- scheme of the ANSA it is difficult to know its and long-term evaluations. degree of implementation and its impact. Re- • There is not mention of how the purchase/ cently the organization El Poder del Consumidor sale of unhealthy food sold in the surround- (The Power of the Consumer), based on infor- ing areas of the school competing with the mation obtained from the secretariats through mission of a healthy diet of the school will the Federal Institute of Access to Information be regulated. (IFAI), announced that most of the commit- ments assumed by the various governmental What has happened after the ANSA? secretariats have not been fulfilled (El Poder There is no public and consolidated informa- del Consumidor, 2012). Also Boatman et al. tion on the follow-up of the ANSA, the Technical (2012) point out that the ANSA has been only Bases, and the Guidelines. Below is a descrip- partially fulfilled since, for example, the Front/ tion of what could be compiled from different Top Labeling standard has not been met. sources with regard to what has happened af- Changes in programs: The major changes in ter these documents were signed: governmental programs are the improvement Achievement of goals on the prevalence of in the quality of school breakfasts and the sub- overweight and obesity by age groups: With the stitution of whole milk to semi-skimmed milk available information in the ENSANUT 2012, in Liconsa: we still do not know whether these goals were • School breakfasts. The quality of its con- met. However, as already pointed out, to date tent has improved. In a 2-year period, the the public results report increases from 2006 use of reduced-fat milk went from 41.4% to 2012 in the prevalence rates of obesity and to 89.7%; the combination of two or more overweight in children under 5, in adolescents whole grain cereals from 44% to 96.6%; aged 12 to 19, and in adults 20 years old and vegetable or fruit from 13.8% to 58.6%; above. Furthermore, due to the absence of an two or more legumes from 89.7% to 100%, evaluation framework of the ANSA, it cannot be and without sugar, from 17.2% to 48,24% known whether the results are attributable to (Hernández, 2012). the ANSA. • Liconsa. Initiated the substitution of whole Monitoring and evaluation: There is no pub- milk to semi-skimmed. lic information available regarding compliance Advertising aimed at children, applying the on the part of the secretariats or the impact of PABI code: The PABI Code (Art. 16) establishes the measures, or their effectiveness, based on that the Council of Self-regulation and Adver- changes in behavior and risk factors and cov- tising Ethics, CONAR will make a four-month erage. Neither was a basal survey of anthro- evaluation of food and non-alcoholic bever- pometric measures been made in schools that ages advertisements aimed at children. These reports should be sent to the Disease Preven- trient labeling system (“Check and select, keys tion and Health Promotion Under Secretariat nutrition”) (For a critique of this system, see of the SS and to PROFECO. According to Barros Barquera et al., (2012)). (2012), from December 2008 to 2011, com- Application of the Guidelines: According to pliance of on air advertising went from 8% to Ciscomani (2012), the application of the nutri- 91%. Mexican child sees an average of 4 hours ents criteria corresponding to stage 1 (school daily of television and in that period would be cycle 2010-2011) and Stage II (2011-2012) exposed to approximately 15 spots of food and was carried out. In the 2012-2013 school cycle beverages. These reports, however, do not ap- application of the criteria established for Stage pear in the CONAR Webpage and could not be III was initiated. With the support of the INSP, found in open sources. the lists of products that meet the nutrient Evaluation of the 5-Steps Strategy: An ex- criteria established in the Guidelines for each ternal evaluation of results and impact has not stage were prepared. been made (Barquera et al., 2012). Evaluation of the Guidelines: As indicat- Other actions: No national education cam- ed before, a system of indicators, monitoring, paign to improve eating habits has been under- or evaluation for the Guidelines was not de- taken. The health strategy does not emphasize signed. Neither was a baseline established in the importance of primary care, nor where in- the schools. According to the SEP, an evalua- formation and counseling can be obtained on tion would be made on the implementation changes in lifestyles and chronic disease pre- of the Guidelines in 2012 on: the operation of vention, although there are national prevention the control agencies; implementation; partici- programs, such as PrevenIMSS, PrevenISSSTE, pation of parents and teachers; attachment to and Línea de Vida (Lifeline). On the other hand, the availability and dietary intake and, in gen- the dairy product market has not turned to eral, operation of the strategy. Such evaluation low-fat products. would be carried out by the INSP. Although it Actions of the industry – products in the is commendable to perform an external evalua- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: schools: The industry generated specific pre- tion, it is considered that the fact that it be car- sentations for schools, which are also sold in ried out by the same institution that designed grocery stores. It is worth stating that the in- the Guidelines may present conflict of interest dustry publicized these products with legends problems and of credibility of the evaluation. that stated “they fulfill with school food guide- Ciscomani (2012) states that, in order to assess lines established by the SEP and the SS.” In the the progress in the application of the Guide- opinion of the SE, the share of these products lines, two studies were carried out that point in the market is very small, which could lead to out the following strengths and challenges: Governance of Five Multisectoral Efforts their disappearance. Strengths Other actions of the industry: In accordance • It was possible to raise awareness of the ac- with ConMEXICO, the industry has increased tors of the school community on the prob- the variety and presentations of their prod- lem of obesity and overweight, which they ucts, and plans to modify the labels so that they identify as the main reason for the develop- contain clearer information. In January 2012, it ment of the Guidelines. initiated the implementation of a voluntary nu- 128 • The school community is aware of the crite- • Among the main obstacles to the imple- 129 ria that the schools should follow to imple- mentation of the Guidelines, the informants ment the Guidelines. considered those having to do more with • A high proportion of actors (80 to 95%) re- the home environment than with the school, Chapter 3 gard the inclusion of fruits and vegetables such as the lack of interest on the part of the as the basis of a healthy lunch. parents and unhealthy family habits in case • Between 40 and 60% of the actors know of primary schools. In secondary schools, that pure water should be included as part the opinion was that children prefer to eat of a healthy lunch. junk food. • 90% of the actors perceived changes in the These studies, however, are based only on supply of food and around 50% in beverage the opinion of different actors on the process- sales. es. One of the interviewees also pointed out • 65.1% of food providers of primary schools that there could be important implementation and 76.5% in secondary schools report problems of the Guidelines, stating that, al- having carried out changes in their practic- though at most schools there are no carbonat- es to improve the diet of the students and ed beverages for sale, there are indeed juices achieve compliance of the Guidelines. in large containers. This said, they do observe • More than 60% of the schools have drink- “less fried food, use of cream and butter.” ing water sources. Written materials generated from the Guide- • Great progress is also reported in the sur- lines: The following materials were published vey of Guidelines Stage II with respect to and distributed, among others: i) Manual for the ENSE 2012, since the availability of the preparation and hygiene of food and bev- vegetables, fruits and non-fried processed erages in cafeterias of basic education schools; food has increased considerably, while the ii) Guidelines for the regulation of the sale of availability of fried food, sweetened bever- food and beverages at basic education schools. ages, milk, and fruit juices decreased. The Guide for administrators and educators; and lunches that students bring from home con- iii) Preparation of school lunches and an ap- sist mainly of non-fried food and drinking propriate diet. Manual for mothers and parents water instead of beverages in the case of and the entire family.14 primary schools. Challenges • Increase the involvement of parents in the actions being carried out in the schools to implement the Guidelines and encourage physical activity. • There is still high consumption of sweet- ened beverages and refreshments vis-à-vis consumption of potable simple water, espe- cially in secondary schools, as well as sweet appetizers in secondary schools and salted appetizers in primary schools. Conclusions and Lessons Learned Following are some of the principal strengths and weaknesses of the ANSA, the Three basic documents resulted from this pro- Technical Bases, and the Guidelines. The ob- cess: The ANSA, The technical Bases, and the jective of this section is to identify lessons and Guidelines. Of the three, the Guidelines are the areas of opportunity moving forward for Mex- most visible and legally solid document, and ico that could also be useful to other countries also the one containing the most substantive considering implementing similar initiatives. and lasting actions derived from the ANSA. Barquera et al. (2012) and Rivera et al. (2012) The ANSA and the Technical Bases are gener- also provide observations in this regard. al policy documents that establish, for the first time, actions and multisectoral goals for the Strengths prevention of these problems. The activities and actions included in these two instruments First strategy/multisectoral initiative for the correspond only to the federal administration prevention of obesity. The promotion of health- and the goals were established only through ier nutrition and greater physical activity nec- 2012. The greatest changes are concentrated essarily require intersectoral work and the in the SEP and the SS, and on the quality im- participation of industry and society. provement of school breakfasts. There were Positioning of the obesity issue. The Agree- not budgeted or earmarked budgetary re- ment generated visibility and awareness of the sources for the actions contained in the ANSA issue within the Federal Executive, and made it and the Technical Bases whose compliance possible to position the subject on the agenda. implied additional resources. As stated by one It also generated sensitivity in the industry and of the interviewees from the SS, the “ANSA re- greater awareness that this would be a recur- mained in the minimum acceptable, [while] the rent subject and of growing importance in the Guidelines did indeed remained at the level of future. European countries.” The three documents suf- Generation of a good base document that fer from the absence of indicators systems, of a gave leadership to the Secretariat of Health PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: monitoring and evaluation scheme, and of en- on an issue whose main actions are not under forceability mechanisms. its scope of action. Obesity is a multifactorial The main challenge is continuity of this problem and its prevention and care requires Agreement as a multisectoral policy and as the actions that transcend the functions and re- platform to invite the different actors, moni- sponsibilities of the SS. tor, and evaluate what has already been agreed Diagnosis and estimations of the costs of upon and discuss and agree on new actions— overweight and obesity. The ANSA was based Governance of Five Multisectoral Efforts or, at least, an entity with this same orienta- on a good diagnosis of the problem, a review of tion. It should be noted that the administrative the literature and of the experiences and most changes that have occurred in the SS based on relevant recommendations at the national and the signing of the ANSA, as well as the change international levels. in federal administration, also point in this di- Involvement of technical experts. The in- rection. volvement of the INSP and other institutions and experts in the analysis, scientific evaluation of the proposals, and preparation of the recom- 130 mendations. Although the INSP played a key Weaknesses 131 role providing technical support, as an entity of Design. The ANSA is a general policy paper with the Federal Government it was sometimes per- general goals and targets for the reduction of ceived as a pro-government entity, not neces- overweight and obesity only up to 2012. The Chapter 3 sarily objective. This perception changed with actions committed in the Agreement and its the incorporation of researchers from other Technical Bases are not sufficient to meet the institutions. 10 objectives of the Agreement, nor include Formation of working groups made up of commitments on the part of the industry; there different agencies of the civil service and the are not adequate mechanisms foreseen to con- private sector, those responsible for the food tinue with the negotiation of new actions that production chain, under the leadership of the SS. facilitate meeting these objectives. Awareness and greater responsibility on the Temporary nature of the Agreement. The part of the industry, upon foreseeing that this Agreement established goals only to 2012, but will be an issue of growing importance. Although not at the mid- and long-term. It was designed as the initiative of the ANSA mobilized the com- a short-term instrument and it was not planned panies, the fact that an institutional follow-up as a mechanism after the administration of entity was not created—with the involvement President Calderón. This imposes important le- of the different actors—it lost momentum and gal challenges on its continuation, since it would a window of opportunity was perhaps wasted. imply the renegotiation and establishment of Strengthening of SEP-SS relations. The lead- actions and goals with other terms. ership of the SEP and its partnership with the Institutional follow-up and discussion entity. SS regarding the actions in the school environ- Although the text of the ANSA included the cre- ment resulted in a more robust and institution- ation of a forum with the participation of the al relationship between the two secretariats, main actors (including government, industry and in giving greater prioritization to the issue and academia, among others), such entity was of health in the school environment. Thus, for not established. Thus, there were no estab- example, according to the SEP, health was in- lished entities nor institutional mechanisms cluded for the first time as a thematic guide in of this nature with support at the highest level, teacher training. Also the joint convening and that allow and encourage the parties to moni- negotiation with the state education authori- tor what was agreed upon, and to continue with ties should be highlighted. the discussions and agreements on a problem Public consultation process. The public con- that without a doubt will need coordinated ef- sultation process on the Guidelines, that by law forts and discussions and additional actions in COFEMER had to carry out, facilitated the sub- the short, medium and long term, from the gov- mission of objections, observations or propos- ernment, the industry, and civil society, at the als to this document by all interested parties, community level, family, and individual. The compelling authorities to answer promptly creation of a forum of this type would also al- each of them. The design of the process tries to low a more orderly discussion of the initiatives ensure that the social benefits of the regulation of the Legislative branch to combat overweight are greater than their costs. and obesity. The CONACRO, assigned with the monitor- and the impact of the interventions, as point- ing responsibility and made up of only feder- ed out by González Pier (2012), COFEMER, al entities, has not been effective in concrete and Fundación Chespirito (2012) and Flores actions. The responsibility for operational fol- Huerta et al. (2011). The lesson would be the low-up fell on the General Directorate of Health importance of including, from the design, the Promotion, with little high-level institutional accountability schemes, monitoring and evalu- support. ation—including external evaluation. This situation also generated little visibili- Compulsory nature and enforceability. There ty of the ANSA after it was signed and did not are not enforceability mechanisms of the actions allow maintaining the negotiation momentum that imply consequences in case of non-imple- with the industry. These elements hinder the mentation or noncompliance. The foregoing, continuity of the ANSA and/or of specific ef- coupled with the absence of follow-up and ac- forts. Maintaining a multisectoral policy of this countability mechanisms that allow to know magnitude requires sustained efforts in the whether the commitments are being met (and long run, institutional support with specific re- lack of budgetary allocation), decreases the in- sources, and a group devoted to this and with centives for compliance of the same. solid top-level support. Measurement of the budgetary cost and allo- Staff turnover (common in Mexico during cation of the priorities and actions of the Agree- changes of administration or of incumbents in ment in the public budgets of the secretariats. the secretariats) make it necessary to establish The implementation cost was not calculated formal entities that meet periodically thus in- nor was there a budgetary allocation in the re- creasing the probability of continuity. One of sponsible secretariats to ensure that resources the interviewees pointed out that “ANSA has were available and earmarked to carry out the not been very visible and is easy to let it die.” proposed actions. Thus, a lesson of this process is the importance Lack of internal alignment of the Secretariat of creating and strengthening institutional of Health with respect to the strategy to combat PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: mechanisms and entities to perform monitor- overweight and obesity throughout the process. ing and long-term negotiation, with the partici- This debilitated the negotiation process, the pation of the main stakeholders. design, and the follow-up mechanisms. Monitoring and evaluation. No accountabil- Negotiation strategy. There was no negoti- ity schemes, monitoring or evaluation of the ation strategy previously established with all ANSA, the Technical Bases or the Guidelines the relevant institutional actors to establish a were established to make it possible to know common front by the Federal Executive, in par- whether the actions are being fulfilled or if ticular with the industry. Neither was there a Governance of Five Multisectoral Efforts there have been implementation problems, or strategy or mechanisms to continue to negoti- to ascribe results in the desired direction to the ate in the future in what undoubtedly will be a proposed actions. This can hinder the negotia- long and constant process. However, in actions tion in the future with other secretariats of the as those included in the ANSA, it is complex for Federal Government and even with the indus- authorities to strike an adequate balance be- try. On this matter, it is this matter it is funda- tween unilateral decisions by the authority and mental to be transparent regarding the costs negotiating. 132 The negotiation left the parties exhausted • Availability of drinking water at schools. 133 and fractured relations. After the launch of the There is no availability of free drinking wa- ANSA and the issuance of the Guidelines, work ter at all schools, either in drinking water with the industry declined in intensity and lev- fountains or demijohns and no resources Chapter 3 el. With the turnover of civil servants with the were earmarked to ensure its availability. new government, there will surely be opportu- The SEP considers that there is availability nities to resume or reestablish the joint efforts, of drinking water in the schools whenever provided this is one of the priorities of the SS. there is water for sale even when there are However, it is probable that the momentum no drinking water fountains or demijohns. with the industry, continuity, and part of the • Impact of the possible loss of profits of school learning may have been partly lost. One of the cooperatives. The profits of school coopera- lessons of the ANSA is the importance of safe- tives are an important resource for schools guarding the negotiation processes in light of to cover their maintenance costs because complex negotiations and regulations that are there are no earmarked budgetary resourc- difficult to implement and enforce. es for the schools’ current expenditure. Re- School setting. With respect to the weak- sources for the education sector were not nesses/challenges of the actions in school quantified, projected, or subsequently as- settings related to overweight and obesity, in- signed in the Strategy to cover the potential cluding those of the Guidelines: loss of resources from school cooperatives • Actual class hours and possibilities of physical with the entry into force of the Guidelines. activity at school. The actual class hours and If the Guidelines turn into lower sales in the accordingly of learning opportunities in the cooperatives (or the cooperatives perceive classroom are only four. In addition, the ma- it could happen), this could lead to noncom- jority of the schools do not have adequate pliance of the Guidelines on the part of the spaces for physical activity. Only 40 percent cooperatives and/or a negative impact on of the public schools have a physical educa- maintenance and current expenditure of tion teacher.15 At primary schools there is, the schools and, accordingly, the quality of on average, a 40-minute weekly physical ed- education offered. Thus, the incentives are ucation class, of which only 9 minutes are of not aligned at the school level. moderate or intense activity.16 • The sale of food and beverages in the sur- • Resources for compliance of the actions. The rounding areas of the schools and the prob- School and Health Program does not have abilities that students may introduce any assigned resources, thus resources from product to the same. In the surrounding ar- other programs and actions must be reas- eas of the schools (as close as outside the signed to comply with the actions of this front door), there are frequently informal Program in terms of educational materials merchants who sell all sorts of products and training, among others. Thus, in the and are not subject to any regulation. future, the importance of this program will depend on the prioritization of the official on duty and of the strength of the relation- ship between the SS and the SEP. Annex 3.1. Some of the actions to Secretariat of Labor and Social Welfare: prevent and reduce overweight and • Promote physical activity and appropriate eating habits in the workplace obesity established in the Strategy • Monitor compliance of the standards relat- Against Overweight and Obesity, by ed to the availability of free drinking water Secretariat • Advocate breastfeeding and review legisla- Health sector: tion to promote it among working mothers • Promote sectoral programs Secretariat of Social Development: • Update standards and regulations on food • Rescue parks and public spaces to carry out and advertising physical activity • Support breastfeeding and nutrient literacy • Promote participation in physical activity • Promote the incorporation of potable sim- among youth in the Opportunities Program ple water into school breakfasts and pan- • Promote the availability of reduced-fat milk tries • Carry out educational activities on nutri- • Train state and municipal DIF on healthy tional counseling school food options Secretariat of Economy: • Promote physical activity in all settings • Create support frameworks for the distri- • Train health professionals in counseling on bution chains and access to fruits, vegeta- appropriate eating habits bles, legumes, and whole grains Secretariat of Public Education: • Update the standards and support the SS to • Promote physical activity among school- issue a NMX on “educational labeling” children for at least 30 minutes daily • Disseminate information on healthy prod- • Encourage gender equality in sports ucts markets to the industry • Promote, through the program of studies, Secretariat of Agriculture, Livestock, Rural consumption of drinking water and nutri- Development, Fishing, and Food: ent literacy • Promote alternative uses of sugarcane PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: • Guarantee the installation of drinking wa- • Improve the supply of skimmed dairy prod- ter fountains in public schools ucts • Promote and facilitate the availability of • Attend structural support problems for ag- water and non-alcoholic beverages with ricultural, livestock, and fishery foods low caloric content in collaboration with • Strengthen the 5 a Day program to support the food industry consumption of fruits and vegetables • Develop guidelines for school food suppli- Treasury and Public Credit Secretariat: • Analyze treasury instruments to promote Governance of Five Multisectoral Efforts ers to decrease sugar consumption • Promote a Secretarial Agreement for the healthy food consumption sale of food and beverages in school stores National Water Commission: or cooperatives of basic education schools • Encourage the supply of simple potable wa- for a healthy school diet ter in vulnerable areas Source: ANSA, p. 27. 134 Annex 3.2. General work prior to the lifestyle (Secretarí�a de Salud, 2007; Coneval, 135 establishment of the ANSA 2010). In 2007, the SS initiated the construction In 2004, Mexico signed the Global Strategy on and operation of the Medical Specialties Units Healthy Diet, Physical Activity, and Health for Chapter 3 (UNEMEs), in order to provide specialized ser- the prevention of chronic diseases of the World vices in a single unit for specific conditions (e.g. Health Organization (WHO). This strategy con- facilities that provide comprehensive services), tains recommendations on food and diet (both among them overweight, cardiovascular risk, for demand and supply) as well as on physical and diabetes mellitus (UNEME SoRID).18 activity. The WHO technical report on nutrition, At the beginning of 2008, the health secre- diet, and chronic disease prevention contains a tary convened an expert committee to develop complete analysis of the available scientific in- the “Recommendations on the Consumption of formation. Beverages for the Mexican Population,” aimed In 2006, at the beginning of the administra- at consumers, health professionals, and the gov- tion of President Felipe Calderón (2006-2012), ernmental sector. Up to that time the nutritional the Secretariat of Health prepared an intersec- guides had focused on food, however, the inges- toral strategy for chronic diseases. The Sectoral tion of energy from beverages (mainly sweet- Health Program 2007-2012 (PROSESA) estab- ened beverages, juices, whole milk and alcohol lished as one of the lines of action for disease among male adults) represents 21% of total prevention and control, to promote a compre- consumption of energy among Mexican ado- hensive policy for the prevention and control of lescents and adults (the highest in the world). overweight, obesity, Diabetes Mellitus and car- This document provided a diagnosis and rec- dio and brain vascular illnesses (Line of action ommended water consumption in the first 2.12 of the strategy 2), without setting specific place, followed by beverages without or with goals with regard to overweight and obesity.17 low caloric content and skim milk over those of In turn, the National Health Program 2007- greater caloric content or sweetened, including 2012 (PRONASA) recognized overweight and artificial sweeteners. The experts also included obesity as one of the principal risk factors faced recommendations on quantities for each cate- by the Mexican population and the health sys- gory of beverages and illustrated patterns of tem, associated to several of the leading causes healthy consumption for adults of both sexes. of death in the country. Thus, both documents Among the directives proposed by this Commit- recognize the transition of diseases and the tee are: the availability of drinking water and generation of these by aging and exposure to restriction of sweetened beverages in schools; risks related to unhealthy life styles, and point the use of skim milk in school breakfasts; regu- out as the leading causes of death both for men lation of the sale of beverages in cafeterias and and women to non-communicable illnesses vending machines in facilities of the health sec- such as Diabetes Mellitus and cerebrovascular tor; promote the sale of milk and yogurt with ischemic heart diseases, that share factors such low fat content or fat-free instead of whole milk; as a poor diet, overweight, high cholesterol lev- as well as recommendations on subsidies and els, hypertension, smoking, and a sedentary taxes to change the relative prices of the prod- ucts and of advertising and labeling. In February 2008, the SS announced that, Ethics (CONAR), made up of members of the because of their high caloric content, school food and non-alcoholic beverages industry. breakfasts would be replaced throughout the On the other hand, starting in October-No- country, except in the 125 municipalities with vember 2008 the Social Milk Supply Program greater marginalization, as part of the reorien- (PASL) of LICONSA modified the milk formula tation of the Comprehensive Strategy of Food and fat content by 33%, to contribute to the Assistance (EIASA) of the National System for prevention of the overweight problems in the the Comprehensive Development of the Family population (Coneval, 2010). (SNDIF) to respond to the rapid epidemiologi- Also in 2008, the SS gathered a group of ex- cal and food transition. The main changes in the perts to work in the Comprehensive Nutrition program would be the substitution of whole Strategy of the beneficiary population of the milk with reduced-fat or skim milk, and of Opportunities Human Development Program cookies and peanut brittle, with food prepared (EsIAN), which to date has not been imple- with whole grains and fruits (Figueroa, 2008). mented. Opportunities is a money transfers Toward the end of 2008, the new EIASA Guide- program for poor families provided members lines were published, modifying the content of the household visit the health clinic for pre- of cold breakfasts, hot breakfasts, and school ventive actions and attend school. It is the larg- foods to, among others: i) consider the dietary est program against poverty in Mexico, both in culture of the region to take advantage of the coverage and in fiscal resources. products of the area; ii) offer in hot and cold Obesity was also subject to recommenda- breakfasts reduced-fat milk instead of whole tions by different entities from the SS. The cow milk; iii) increase the size of the part of National Evaluation Board of Social Policy whole grains in cold breakfasts (from 30 to 60 (CONEVAL),20 in its Social Development Policy grams) and offer the alternative of other seeds, Evaluation Report 2008, recommended “devel- and iv) eliminate consumption of sweet bread oping an effective policy to contain, decrease, and dessert (Coneval, 2010; SNDIF, 2008). and prevent obesity in the country, with special PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Furthermore, in September 2008, at the attention to children.” As part of the analysis, initiative of the industry and the SSA, the it was observed that although the overweight Self-regulation Code of Food and Non-alcohol- and obesity problem is recognized in the na- ic Beverages Advertising Targeting Children tional planning documents linked to the health (PABI Code) was signed, which became effec- sector, goals have yet to be considered aimed at tive on January 1, 2009. According to its text, their care and the reduction of its prevalence this Code “is consonant with the principles that (Coneval, 2010). guide the private sector with regard to health In January 2009, the Health Secretary an- Governance of Five Multisectoral Efforts protection and is framed in the recommenda- nounced the launching of the 5 Steps Program tions of the World Health Organization estab- as a “basic instrument that will allow us to lished in the Global Strategy on Diet, Physical conquer health, to be directly responsible of Activity, and Health.”19 Monitoring and imple- individual, family, and social well-being, thus, mentation of this Code is the responsibility of making it possible to reverse the trends of the the Council of Self-regulation and Advertising epidemiological problem and guide the coun- try to the adoption of a healthy lifestyle.” To 136 this end, the SS signed an agreement with the weight and obesity, due to beverage consump- 137 French Program EPODE that, according to the tion and unhealthy eating habits, the lack of SS, has been the most successful in Europe in physical activity, and risky behavior and condi- the prevention of child obesity.21 In announcing tions.” The general objective of this program is Chapter 3 this Program, the Secretary stated that “[ … ] to “Carry out intersectoral, preventive, compre- we have been working this in a multi-secretari- hensive, and effective interventions, with basic at manner in the Social Cabinet, where the SEP, education children, adolescents and young … the Labor Secretariat, … SEMARNAT, … the adults of secondary and high school, to make it Agriculture Secretariat meet to see what each possible for them to develop the ability to have secretariat could do in this global program to greater control over the causal determinants contain obesity and overweight and we have of their health, improve it, and thus increase been advised and we are implementing part of learning achievement.” One of its specific ob- this strategy, an European strategy called EP- jectives is to: “Promote knowledge of healthy ODE …. whose results are impressive, the dif- beverages, appropriate eating habits, and phys- ference between the cities where the strategy ical activity practices that generate habits and was adopted and those that did not, it is radical changes in children and youth and thus stop with regard to decreasing overweight and obe- the increase of obesity and chronic degenera- sity and this truly has an incidence and a very tive diseases.” The Program adopts strategies positive effect with regard to the global aspects and specific lines of action, with annual goals of the quality of life of the people, as to the fi- until 2012. (It should be pointed out that prior nancing quality of the health system.”22 to this program, the collaboration between the Furthermore, in 2008 the SS and the SEP SEP and the SS occurred in the context of the published the Specific Program of Action 2007- Education and Health Intersectoral Program.) 2012 School and Health.23 This program con- Finally, it should be noted that the INSP, siders schoolchildren from the basic level up to which at the request of the Secretariat provided the higher level and seeks to affect the health support in outlining what would be the nation- determinants to impact efficiently on some of al strategy to combat overweight and obesity, the health problems that were considered a had previously worked on the issue (as an in- priority in Health Sectoral Program 2007-2012 stitution and individually various members (maternal mortality, infant mortality, cervical of the Nutrition in Health Research Center) cancer, auditory disability, dengue, family plan- and used part of that material in the prepara- ning, vaccine-preventable diseases, diabetes tion of its recommendations for the design of mellitus, overweight and obesity, addictions, the strategy. Examples of these works are: the injuries due to road accidents, breast can- workshop the INSP organized in 2005 with the cer, HIV/AIDS, and mental health disorders); Institute of Medicine of the United States to de- through the implementation of the actions in- velop a binational strategy for the prevention cluded in the guaranteed Package of preven- and control of obesity in Mexican children in tion and promotion services for better health. the United States;24 the study carried out in Included within the challenges of this Program, Mexico City in 2005-2006, to quantify physi- are: “From an early age stop the chronic disease cal activity in schoolchildren and describe the epidemics and injuries, brought about by over- school setting with regard to recreation and physical education classes;25 characterization Calderón, during the event: Acuerdo Na- of the school environment in public prima- cional para la Salud Alimentaria, Estrategia ry schools in Mexico City and 12 cities of the contra el Sobrepeso y la Obesidad. Explana- country, to establish the obesogenic context; da Francisco I. Madero of the Official Res- consultation and the meeting of experts in idence Los Pinos. Mexico City. January 25, 2008 to generate recommendations for nutri- 2010. Available at: http:/www.youtube. ent guides at public primary schools;26 the pilot com/watch?v=o8SI3Gu1Tg (last accessed: to evaluate the effect of changes in the environ- 20 May 2013). ment and school policies and greater physical Agreement establishing the general guidelines activity of the students in Mexico City schools,27 for the sale or distribution of food and bev- and the execution of the National Health Sur- erages in school consumption facilities in vey of Schoolchildren 2008, whose objective basic education schools and Single Annex. was to describe the health status, education, National Agreement on Food Health. Strat- and living conditions of schoolchildren from egy to Combat Overweight and Obesity. public primary and secondary schools and to Program of Action in the School Context. identify the main risk factors to health.28 Also, Available in: http:/www.sep.gob.mx/work/ the INSP participated in the work of the Expert models/sep1/Resource/635/1/images/ Committee convened by the SS that prepared acuerdo_lin.pdf (last access: May 20, 2013). the “Recommendations on the consumption of Barquera, S., I. Campos, J. Rivera, and Á� . Velasco. beverages for the Mexican population” in 2008. “Obesidad en México: polí�ticas y programas This document would also serve as the ba- para su prevención y control.” In: Obesity sis to subsequently design the Guidelines in in Mexico: Recommendations for a State schools, in particular the identification of “the Policy. UNAM. Dirección General de Publi- school environment as one of the probable caciones y Fomento Editorial UNAM. 2012. causes for such high prevalence of overweight Barros, H., J. Luis. Self-regulation and Adver- and obesity in which consumption of food and tising Ethics Council. PowerPoint presen- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: beverages with high energy density is promot- tation at the Forum on Analysis of Public ed and the opportunities to carry out physical Policy for Obesity Control. Mexico. October activity is restricted, resulting in an energy im- 23, 2012. balance.”29 It should be pointed out that, as it Censia. 2010. National Agreement on food will be seen below, the role of the INSP tran- Health: Strategy to Combat Overweight and scends this stage, by remaining as the main Obesity PowerPoint Presentation. Available technical support of the SS throughout the at: http:/www.censia.salud.gob.mx/des- discussion and negotiation process, not only cargas/infancia/2010/2.9._Estrategia_Sa- Governance of Five Multisectoral Efforts generating documents but participating in the lud_Al im.pdf negotiations. Ciscomani. “Polí�tica para el control de la obe- sidad en el Sistema Educativo Nacional.” References PowerPoint Presentation at the Forum on Acuerdo Nacional para la Salud Alimentaria, Analysis of Public Policy for Obesity Con- Estrategia contra el Sobrepeso y la Obe- trol. Mexico. October 23, 2012. sidad. Intervention of President Felipe 138 COFEMER. Manual de la Manifestación de Im- Flores Huerta, S., M. Klünder Klünder and P. 139 pacto Regulatorio. DOF July 26, 2012. Medina Bravo. Análisis crítico del ACUERDO Comisión Federal de Mejora Regulatoria (COFE- mediante el cual se establecen los lineamien- MER) and Fundación Chespirito IAP. “El tos generales para el expendio o distribución Chapter 3 problema de la Obesidad en México: diag- de alimentos y bebidas en los establecimien- nóstico y acciones regulatorias para enfren- tos de consumo escolar de los planteles de tarlo.” Regulatory Research Documents No. educación básica. Medical Bulletin of the 2012-02. PowerPoint Presentation at the Children’s Hospital of Mexico. (online). Forum on Analysis of Public Policy for Obe- 2011; 68(1): 69-78. ISSN 1665-1146. [quot- sity Control. Mexico. October 23, 2012. ed 2013-02-20] Available at: http://www. Conference at the induction of CONACRO. scielo.org.mx/scielo.php?script=sci_art - Meeting at the National Health Council. text&pid=S1665-11462011000100010&l- Mexico. Available at: http://www.salud. ng=es&nrm=iso (last access: May 20, 2013). gob.mx/unidades/dgcs/sala_noticias/dis- Global Strategy on Healthy Diet, Physical Ac- cursos/2010_05_12-prevencion.htm (last tivity, and Health for the Prevention of access: May 20, 2013). Chronic Diseases. Implementation Plan in ConMEXICO. Press release of the ANSA. Avail- Latin America and the Caribbean 2006- able at: http://conmexico.com.mx/sitio/ 2007. PAHO. Available at: http://www. wp-content/uploads/2010/06/Comunica- paho.org/spanish/ad/dpc/nc/dpas-plan- do-Acuerdo-Nacional-250110.pdf (last ac- imp-alc.pdf (last access: May 20, 2013). cess: May 20, 2013). Global Fund for Cancer Research/United States El Poder del Consumidor. El fin del Acuerdo na- Cancer Research Institute. Food, Nutrition, cional por la Salud Alimentaria (ANSA) y la Physical Activity, and Cancer Prevention: A Necesidad de una ley y Política integral de World Perspective. Washington, D.C.: AICR, combate a la obesidad. August, 2012. Avail- 2007. able at: http://issuu.com/cencos/docs/ González Pier, E. “La obesidad como falla de doc_ansa (last access: May 20, 2013). mercado. Análisis de la polí�tica pública Evaluación de consistencia y resultados 2007 para el Control de la Obesidad.” PowerPoint de la Estrategia Integral de Asistencia So- Presentation at the Forum on Analysis of cial Alimentaria. Sistema Nacional para el Public Policy for Obesity Control. Mexico. Desarrollo Integral de la Familia. Tecnológi- October 23, 2012. co de Monterrey. Coneval. 2008. Available Hernández Á� vila, Ma. and O. Georgina at: http://www.coneval.gob.mx/Informes/ Martí�nez Montanez. Lineamientos gene- Evaluacion/Consistencia/2007_2008/SA- rales para el expendio o distribución de LUD/Programa%20de%20Asistencia%20 alimentos y bebidas en los establecimien- Alimentaria%20a%20Familias%20en%20 tos de consumo escolar en los planteles de Desamparo%20%28EIASA%2924mar.pdf educación básica. Medical Bulletin of the (last access: October 1, 2013). Children’s Hospital of Mexico.(online). Five Steps Strategy. Available at: http://5pasos. 2011;68(1):1-6. ISSN 1665-1146. [quot- mx/ (last access: October 1, 2013). ed 2013-02-20]. Available at: http://www. scielo.org.mx/scielo.php?script=sci_art - text&pid=S1665-11462011000100001&l- sarrollo social en México: evaluación de ng=pt&nrm=iso (last access: May 20, 2013). ocho fondos de política pública. Mexico, Hernández Á� vila, Ma. National Agreement on D.F. CONEVAL. 2010. Available at: http:// Food Health. Strategy to Combat Over- www.coneval.gob.mx/rw/resource/con - weight and Obesity. PowerPoint Presen- eval/info_public/PDF_PUBLICACIONES/ tation at the Forum on Analysis of Public Ramo_33_PDF_02032011.pdf (last access: Policy for Obesity Control. Mexico. October October 1, 2013) 23, 2012. National Public Health Institute (INSP), Re- Jennings-Aburto, N., F. Nava, A. Bonvecchio, M. search Center on Nutrition and Health. Safdie, I. González-Casanova, T. Gust and J. 2012. National Health and Nutrition Survey Rivera. “Physical Activity during the School 2012: Evidence for the public health policy. Day in Public Primary Schools in Mexico Obesity in adults: the challenges downhill. City.” Salud Pública Mexicana. 2009; 51:141- Available at: http://ensanut.insp.mx/doc- 147. tos/analiticos/ObesidadAdultos.pdf (last Latinovic, L. Acuerdo nacional vs. Obesidad. access: May 20, 2013). PowerPoint Presentation of the Secretar- National Survey of Health and Nutrition 2012. iat of Health at the Forum on Urban Con- Nutritional status, anemia, food security sumption. First Week of the Consumer in of the Mexican population. Secretariat of Puebla. Mexico. March 17, 2010. Available Health, National Public Health Institute. at: http://www.slideshare.net/semanadel- Available at: http://ensanut.insp.mx/doc- consumidor/acuerdo-nacional-vs-obesi - tos/ENSANUT2012_Nutricion.pdf (last ac- dad (last access: May 20, 2013). cess: May 20, 2013). Office of the Presidency of the Republic of Mex- National Survey of Health and Nutrition 2012. ico. Agreement creating the National Board National Results. Available at: http://ensa- for the Prevention and Control of Non-com- nut.insp.mx/doctos/FactSheet_Resultados- municable Chronic Diseases. Official Journal Nacionales14Nov.pdf (last access: May 20, PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: of the Federation. February 11, 2010. Avail- 2013). able at: http://dof.gob.mx/nota_detalle. Rivera, J., O. Muñoz-Hernández, M. Rosas- php?codigo=5131456&fecha=11/02/2010 Peralta, C. Aguilar-Salinas, B. Popkin and (last access: May 20, 2013). W. Willett. Consumo de bebidas para una Programa Emergente 2011–2012. Prevention vida saludable: recomendaciones para la po- and control of overweight and obesity. March blación mexicana. Salud Pública Mexicana. 2011. Available at: http://www.salud.gob. 2008;50:173-195. Available at: http:// mx/unidades/cdi/pot/fxi/CENAPRECE/ www.medigraphic.com/pdfs/bmhim/ Governance of Five Multisectoral Efforts PROG2011_2012.pdf (last access: May 20, hi-2008/hi083g.pdf (last access: May 20, 2013). 2013). Programa Estrategia cinco pasos. Available at: Rivera, J., Á� . Velasco, M. Hernández, C. Aguilar, http://5pasos.mx/ (last access: May 20, F. Vadillo and C. Murayama. “Obesidad en 2013). México: recomendaciones para una polí�tica National Evaluation Board of the Social De- de estado.” Trabajo de Postura. In: Obesi- velopment Policy. El Ramo 33 en el de- dad en México: Recomendaciones para una 140 Política de Estado. UNAM. Dirección Gene- Estrategia_Salud_Alim.pdf (last access: May 141 ral de Publicaciones y Fomento Editorial. 20, 2013). 2012. ———. Specific Program of Action 2007-2012 Sassi, F., M. Cecchini, J. Lauer and D. Chisholm. School and Health. Mexico. 2009. Available Chapter 3 Improving Lifestyles, Tackling Obesi- at: http://www.promocion.salud.gob.mx/ ty: The Health and Economic Impact dgps/descargas1/programas/programa_ of Prevention Strategies. OECD Health escuela_salud.pdf (last access: May 20, Working Papers. 2009:48. OECD Pub- 2013). lishing. Available at: http://dx.doi. Secretariat of Public Education. “Response to org/10.1787/220087432153 (last access: specific observations from individuals to May 20, 2013). the provisional draft of General Guidelines Secretariat of health. National Health Program for the sale or distribution of food and bev- 2007-2012. Por un México sano: constru- erages in school consumption facilities of yendo alianzas para una mejor salud. 2007. basic education schools.” August 13, 2010. ———. “Bases para una polí�tica de Estado para Secretariat of Public Education and Secretar- la prevención de la obesidad.” 2009. iat of Health. 2011. National Agreement ———. Acuerdo Nacional para la Salud Ali- on Food Health-Strategy to Combat Over- mentaria-Estrategia contra el sobrepeso y la weight and Obesity: Program of Action in obesidad. 2010. Available at: http://promo- the School Context. Available at: http:// cion.salud.gob.mx/dgps/descargas1/pro- www.sep.gob.mx/work/models/sep1/Re- gramas/Acuerdo%20Original%20con%20 source/635/1/images/prog_accion.pdf creditos%2015%20feb%2010.pdf (last ac- Secretariats of Public Health and Education. cess: May 20, 2013). AGREEMENT establishing the general Secretariat of Health. Bases técnicas del Acuer- guidelines for the sale or distribution of do Nacional para la Salud Alimentaria-Es- food and beverages in school consump- trategia contra el sobrepeso y la obesidad. tion facilities of basic education schools. 2010. Available at: http://portal.salud.gob. Published in the official Journal of the mx/sites/salud/descargas/pdf/ANSA_bas- Federation. August 23, 2010. Available at: es_tecnicas.pdf (last access: May 20, 2013). http://dof.gob.mx/nota_detalle.php?codi- ———. 2009. Press conference of the Secretary go=5156173&fecha=23/08/2010 (last ac- of Health, José Á� ngel Córdova Villalobos, on cess: May 20, 2013). the start-up of 5 Steps Program, to live bet- United Nations Food and Agriculture Organi- ter. January 2009. Available at: http://www. zation (FAO), 2012. Panorama of Nutrition salud.gob.mx/unidades/dgcs/sala_noti - and Food Security in Latin America and the cias/entrevistas/2009_01_12_mejor.htm Caribbean 2012. Available at: http://www. (last access: May 20, 2013) fao.org/alc/file/media/pubs/2012/pan- ———. PowerPoint Presentation of the Nation- orama.pdf (last access: October 1, 2013). al Agreement for Food Health. Strategy to Combat Overweight and Obesity. May 19, Notes 2010. Available at: http://www.censia.sa- 1 Since at November 2012 the data of the ENSANUT 2012 lud.gob.mx/descargas/infancia/2010/2.9._ had not yet been published, the information included in this study was obtained from documents with gen- schools; availability of drinking water; adaptation cost eral results, as well as from some presentations made (portion sizes); informal trade; contradictory to other by the National Public Health Institute (INSP) in the policies; costs of the sugar industry; effect on the bev- meeting on overweight and obesity results of the EN- erage industry; and, effect on the dairy industry. SANUT held on November 21, 2012. 11 The categories in which the observations related to 2 Researchers from the Ibero-American University and the legal basis were classified were aimed at: that the the Salvador Zubirán National Nutrition Institute emission of the Guidelines breaks with Article 3 point (INNSZ) as well as from the academic and medical so- ii of the Agreement of Regulatory Quality; the lack of cieties also participated. basis for the issuance of the general Guidelines and vi- 3 Author’s summary of the presentation of the technical olation to individual guarantees; and, to add legal pre- Bases of the Agreement. cepts to the foundation of the draft provisions. 4 Source: http://www.avs.org.mx/sitio/?p=469 12 The categories in which the health- and nutrition-re- lated observations were classified were those that 5 Source: http://www.conago.org.mx/Comisiones/Det- question the certification of schools free from sweet- alle.aspx?Comision=Salud ened beverages and food; they question the definition 6 Available at: http://www.sep.gob.mx/work/models/ of food; they refer to interference with the Federal Law sep1/Resource/635/1/images/prog_accion.pdf. of Protection to the Consumer; they refer to sanctions; 7 The Pact is a reference to the Economic Growth Pacts those related to Mexican official standards; those re- used during the administrations of Presidents de la lated to supervision and surveillance; to the omission Madrid (1982-1988) and Salinas (1988-1994), in of the food list; to conflicts with the national agreement which the authorities met periodically with the repre- on food health; to the health promotion and education sentatives of the economic and social sectors and joint- components and the promotion of physical activation; ly agreed on the economic measures. to legal instruments of an international nature; and, 8 The director of ConMEXICO was responsible for the ne- the good drinking Pitcher. gotiation of the Free Trade Agreement between Mexico 13 The categories in which the observations related to and the European Union and, in his private practice, he the educational issues were classified were: the need has advised governments, multilaterals and companies to train parents and teachers so that they promote on trade and competitiveness. healthy habits in the students; the need for modifica- 9 Of the 864 observations received between June 10 tions to the curriculum through July 22 came from: 92 companies; 74 associa- 14 Available at: http://www.sep.gob.mx/es/sep1/salud_ tions and business chambers; 54 social or public insti- alimentaria#.UfaudawzJBk tutions; 27 teachers and school directors; 9 students; 15 Source: http://journalmex.wordpress.com/2011/05 79 parents and family members; 200 professionals and /18/solo-40-de-escuelas-publicas-tienen-un-mae - researchers, and 329 to other citizens. Of the total, in stro-de-educacion-fisica/ accordance with the SEP, 195 were against, 662 in favor, PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: 16 Source: http://www.avs.org.mx/sitio/?page_id=63 and 8 with no preference. Source: SEP (2010), a 778- page document of the SEP with the responses to each 17 In contrast, both the PRONASA and the PROSESA have comment. Another source to read the observations as as one of their goals for 2012 to reduce by 20% the well as the final decision with the comments made by prevalence of malnutrition in children under 5 that COFEMER is: www.apps.cofemer.gob.mx/COFEMER- present underweight for their height in the 100 munic- APPS/scd_expediente_3.asp?id=01/0596/100610. ipalities with the lower human development index. 10 The categories in which the observations related to 18 Source: Presentation of PowerPoint of the SS: UN- the economic impact of the measures were classified EMES-Medical Specialties Units. Available in: http:// were: packaging adaptation costs; effect on price for portal.salud.gob.mx/descargas/pdf/unemes07.pdf. In Governance of Five Multisectoral Efforts packaging cost; increase in child expenditures; effects that year the SS announced the construction of 50 UN- on employment; restrictions in the freedom of choice EMEs SoRID throughout the country. of consumers; negative impact on SMES (small and 19 The PABI Code is available at: http://www.promocion. medium enterprises); effect on loss of sales at schools; salud.gob.mx/dgps/descargas1/programas/codigo_ impact on total demand; effects on the production pabi.pdf chain; cost for lost sales at schools; effect on the total 20 The National Evaluation Board of Social Development demand, by brand; effect on the value of the brands; in- Policy (CONEVAL) is a decentralized public agency of fluence on children on consumption decisions; effects the Federal Civil Service, with autonomy and technical on competition; elasticity of demand; adaptation costs capability to generate objective information on the sit- (reformulation); penetration of industrialized food at uation of the social policy and the measurement of pov- 142 erty in Mexico that allows improving decision-making 25 Jennings-Aburto N et al, 2009. 143 on the matter. Source: http://web.coneval.gob.mx/ 26 Recommendations for nutritional guides in public quienessomos/Paginas/Quienes-Somos.aspx. primary schools – Characterization of the school envi- 21 Mexico was the first country of the Americas to sign it. ronment in primary schools of states of the Mexican See Press Conference of the Secretary of Health, Janu- republic and recommendations for a “healthy school ary 2009. http://www.salud.gob.mx/unidades/dgcs/ lunch.” INSP, 2010. Chapter 3 sala_noticias/entrevistas/2009_01_12_mejor.htm. For 27 Aburto, N. J., J. E. Fulton, M. Safdie, T. Duque, A. Bonvec- more information on EPODE, go to: http://www.ep- chio, and J. A. Rivera. Effect of a School-Based Interven- ode-european-network.com/en/background/een-ob- tion on Physical Activity: Cluster-Randomized Trial. jectives.html. Med. Sci. Sports Exerc., Vol. 43, No. 10, pp. 1898–1906, 22 Source: Press conference of the Secretary of Health, 2011. January 2009. http://www.salud.gob.mx/unidades/ 28 The methodology and the results are in the National dgcs/sala_noticias/entrevistas/2009_01_12_mejor. Health Survey in Schoolchildren, April 2010, prelimi- htm nary version. Ed. Teresa Shamah. 23 See Ministry of Health. Specific Program of Action 29 Source: Recommendations for nutritional guides 2007-2012 School and Health. Mexico: Secretariat of in public primary schools – Characterization of the Health; 2009. Available at: http://www.promocion.sa- school environment in primary schools of states of the lud.gob.mx/dgps/descargas1/programas/programa_ Mexican republic and recommendations for a “healthy escuela_salud.pdf. school lunch.” INSP. 24 See: Obesity prevention in children and adolescents of Mexican origin: Workshop on collaboration United States-Mexico 2007. 144 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts República Oriental del Uruguay. Photography: Cortesí�a del Fondo Nacional de Recursos, CHAPTER 4. 145 Tobacco Control Policies in Uruguay AMANDA SICA, FRANCO GONZÁLEZ MORA, WINSTON ABASCAL, AND ANA LORENZO, FOR THE MINISTRY OF PUBLIC HEALTH OF URUGUAY This study documents advances in the de- Of these, 14.5% (some 13 deaths each day) are sign and implementation of Uruguay’s tobacco attributed to tobacco consumption, and they control policies in the last decade. The policies are distributed as follows:1 4.9% to cancer, mainly aimed at complying with the country’s 28.7% to respiratory diseases, 28.0% to car- commitments from its ratification of WHO’s diovascular diseases, and the remaining 8.0% Framework Convention on Tobacco Control to second-hand smoke (Sandoya, 2011). (FCTC). Initially, an interdisciplinary and in- According to the 2006 Global Cancer Atlas ter-institutional team worked to implement (Globocan), Uruguay was the Latin American tobacco-free environments. Nearly at the same country with the highest mortality from lung time, work began on designing interventions cancer that year. The report highlights that lung for complying with the rest of the Convention’s cancer is “the leading cause of death from can- provisions. Within three years, the treaty’s cer in Uruguayan men,” and that 90% of lung most important articles had been implement- cancer is attributable to tobacco. The incidence ed. The implementation of Uruguay’s tobacco of lung cancer mortality for women at that time control policies, especially during the last de- was on the rise, due to an increase in tobacco cade, has brought about a significant decrease consumption among women in the previous in tobacco-consumption indicators, both in decades, the mortality rate from lung cancer adults and in young persons, with a greater in women, adjusted by age, rose more than 3% impact seen in women and among those with each year. higher education levels. According to The Tobacco Atlas (4th edition, 2011), Uruguay ranks as the leading country in Context Latin America for deaths due to tobacco among In Uruguay, noncommunicable diseases ac- men (within the 20.0% to 24.9% range). count for more than 60% of deaths each year. Prevalence of Tobacco Consumption in the sample and methodological designs, adjust- Overall Population ments were made to ensure that the geograph- In order to obtain comparable measurements ic area and the population age group under of the prevalence of tobacco consumption over study would coincide across all surveys (Table time, based on micro-data from some surveys 4.4), figure 4.1 shows trends in prevalence of conducted between 1998 and 2011, and to de- current smokers in five urban areas. termine which similarities they shared in their Table 4.1. Selected surveys for comparing the prevalence of tobacco consumption and consumption of other drugs over time, Uruguay, various years. a Description Year Age group Second National Survey on Drug Consumptionb (JND) 1998 15 to 64 Third National Survey on Drug Consumptionc (JND) 2001 15 to 64 Fourth National Survey on Drug Consumptiond (JND) 2006 15 to 64 Global Adult Tobacco Survey (GATS-MSP-INE) 2009 15 to 64 Continuous Household Surveye (INE) 2011 15 to 64 a The five surveys were conducted in locations with 5,000 or more residents. b Segunda Encuesta Nacional de Prevalencia de Consumo de Drogas c Tercera Encuesta Nacional de Prevalencia de Consumo de Drogas d Cuarta Encuesta Nacional de Prevalencia de Consumo de Drogas e Encuesta Continua de Hogares Figure 4.1. Variation in the prevalence of current smokers (daily and occasional), according to five urban surveys, Uruguay, 1998–2011. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: 34,0 % 34,0 % 34,2 % 28,9 % 28,0 % JND 1998 JND 2001 JND 2006 GATS 2009 ECH-INE 2011 Governance of Five Multisectoral Efforts Source: Author, based on data from the National Institute for Statistics (INE, for its Spanish acronym), the Global Adult Tobacco Survey (GATS), and the National Board of Drugs (JND, for its Spanish acronym). 146 Figure 4.2. Prevalence of daily smokers, according to four urban surveys, 147 Uruguay, 2001–2011. 33,5 % 30,7 % Chapter 4 23,5 % 22,8 % JND 2001 JND 2006 GATS 2009 ECH 2011 Source: Author, based on data from the Expanded National Household Survey (Encuesta Nacional de Hogares Ampliada [ENHA]). As shown in Figure 4.2, although the preva- 2009, 25% of persons 15 years old and older lence figures for daily smokers were similar be- nationwide smoke every day or occasionally tween 2001 and 2006, in 2009 they plummeted (20.4% and 4.5%, respectively; 30.7% males compared to 2006—10 percentage points, with and 19.8% females). a variation nearing 30% (see Table 4.1 for de- The average number of cigarettes consumed tails on the comparability of this information). by daily smokers was 15 cigarettes per day, Given the clear progress Uruguay had made greater in men than in women. On average, in tobacco control, the country was invited to young smokers (20–34 years old) began smok- participate in the Global Adult Tobacco Survey ing at age 16; only 11.2% of this age group be- (GATS), to measure and study the impact of gan smoking at age 20 or older. For additional the country’s policies. The survey, conducted details on the socioeconomic characteristics of in 2009, is the most important assessment on the smoking population, see Annex 4.1. tobacco consumption carried out in the coun- Regarding exposure to second-hand smoke, try, not only because of the number of cases, GATS found that 40.8% of persons 15–24 but because it was the first nationwide survey years old are exposed to second-hand smoke (for example, up to that time, no tobacco-con- at home, a figure 11% greater than that of per- sumption studies had been conducted in rural sons of any age group exposed to second-hand areas). According to the survey’s results, in smoke (Figure 4.3). Figure 4.3. Percentage of persons exposed to second-hand smoke, by age group, Uruguay, 2009. 40,8 34.7 29,6 28,2 15,5 16,7 14,0 11,6 15-25 25-44 45-64 65 y más Global No smokers Source: Author, based on data from the 2009 Global Adult Tobacco Survey (GATS). Prevalence of Tobacco Consumption among to evaluate the second-hand smoke exposure Physicians of children and women in their homes. Among Results from two nationwide surveys aimed at the leading findings is the fact that two or more practicing physicians nationwide, coordinated smokers lived in 26% of households, of whom by the Medical Union of Uruguay (2001 and 86% smoked in the home and 91% smoked in 2007), and from another survey conducted in front of children (Wipfli et al., 2008). Accord- 2011 by the Research Center for the Smoking ing to another study conducted that year, 24% Epidemic, highlight one of the main concerns: PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: had been exposed to second-hand smoke at raising awareness among health professionals home and 36.2% at work in the seven days pri- regarding their tobacco consumption. or to the survey (Ministerio de Salud Pública, The leading results from the above-men- 2006). GATS data show that in 2009, 29% of in- tioned surveys show a trend toward decreasing terviewees had been exposed to second-hand tobacco consumption among health profes- smoke at home in the week prior to the survey, sionals in Uruguay—while in 2001 the preva- and 16.5% had been exposed at work in the 30 lence was 27%, in 2007 in decreased to 17%, days prior to the survey. Governance of Five Multisectoral Efforts and in 2011 it dropped further to 9.8% (CIET, According to the 2006 Expanded National 2011). Household Survey (ENHA, for its Spanish ac- Exposure to Second-hand Smoke According ronym), even when there is no information on to the 2006 Expanded National Household second-hand smoke exposure in the home, it Survey (ENHA) is possible to identify households that include In 2006, Uruguay was one of 31 countries that smokers and that also include minors under 15 participated in an international study designed years old. For the country as a whole, 39.2% of 148 households fit that category. When household The relative weight that minors in house- 149 income level (per-capita income quintiles) is holds with smokers bear depending on the taken into consideration, marked differenc- income level, also is clear in observing family es are seen between households in the first life-cycle stages, which can be considered as Chapter 4 quintile (highest income level) and those in a wake-up call when planning and designing the fifth quintile (lowest income level). While prevention campaigns intended to decrease nearly 70% of lowest-income-level households exposure to second-hand smoke in the home include smokers and minors, only 13% of high- (Table 4.2). est-income-level households do. Table 4.2. Percentage of households with smokers, by family life-cycle stage, and by income quintiles 1 and 5, Uruguay, 2006. Households with smokers (%) Stage (age of the children) (according to ENHA 2006) Quintile 1 Quintile 5 Family initiation (under 6 years old) 10.3 4.2 Expansion (under 12 years old) 20.8 5.7 Consolidation (12–18 years old) 44.4 14.7 Departure (18 and older) 12.8 24,8 Empty nest (couple without children, woman older than 45 years) 3.5 12.3 Source: Author, based on data from the Expanded National Household Survey (ENHA). Socioeconomic Impact of Tobacco annual revenue collected from IMESI, plus that of the value added tax (VAT), reached US$ 190 According to results from the 2009 GATS, Uru- million. The tax contribution of the tobacco guayan smokers spent an average of 20% of industry as a whole barely exceeds a one-half that year’s minimum wage to purchase ciga- percentage point of the total gross domestic rettes. The impact of spending on tobacco on product (GDP). household budgets varies greatly if the wide The costs to the country from tobacco con- differences in income across the country are sumption far exceed what is collected in taxes. taken into consideration, with the impact being Considering that health costs represent, over- much greater among society’s poorer sectors. all, between 7% and 11% of GDP in the MER- And yet, the lower the cost of loose tobacco COSUR countries, in 2003 it was estimated that used to manufacture cigarettes, the more to- the health costs linked to smoking would rep- bacco consumption is promoted and the great- resent about one percentage point of GDP in er its access (mainly among the young). any given year. In Uruguay, this rate amounts to In terms of tax revenues, funds collected some US$ 150 million per year in direct costs through the specific domestic tax (IMESI, for (Ramos, 2006), to which indirect costs from its Spanish acronym) in 2005 reached nearly US$ 70 million, while by the end of 2009, the higher work absenteeism and social-security consumption and delay its initiation among costs due to disability should be added. children and adolescents. In 1994, the first course on smoking for Development and Implementation of post-graduates, “Tobacco and Health,” was in- Uruguay’s Anti-tobacco Policy troduced, and the School of Medicine of the University of the Republic was declared a The Pioneers “Smoke-free Building.” That same year, the Hon- In the 1950s, when the first international stud- orary Commission for the Fight against Cancer ies demonstrating the damage caused by tobac- (CHLCC, for its Spanish acronym), working co consumption began to appear, pioneers such from the university’s area of social education, as Doctor José Saralegui (first) and Professor began to disseminate information to the pop- Helmut Kasdorf (subsequently) began to work ulation and to work with different institutions on tobacco control. In the 1950s Dr. Saralegui to implement 100% smoke-free environments. conducted surveys on the smoking prevalence In addition, the area of professional technical among secondary school students and civil training carried out research on youth, and in servants. Then, in the 1970s, experiencing an 1999 began to conduct a series of courses and advanced epidemiological transition, Uruguay academic seminars aimed at health profession- had one of the highest mortality rates from als. At the same time, the Honorary Commission cancer in the world. Helmut Kasdorf, work- for Cardiovascular Health worked on popula- ing through nongovernmental organizations tion-based education and coordinated the first (NGOs) such as the Uruguayan League of Vol- “Quit and Win” contests. The aforementioned unteers for the Education, Prevention, and Con- institutions began to coordinate tasks with the trol of Cancer (LUVEC) and then through the support of the Pan American Health Organiza- Anti-smoking Commission of Uruguay (CATU), tion (PAHO). began to provide information to authorities in In 2000, at the request of the Ministry of order to limit where smoking would be allowed Public Health’s General Directorate of Health and to control tobacco advertising. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: (DIGESA, for its Spanish acronym), a nongov- Alliances and the First Anti-tobacco ernmental organization was created—the Na- Measures and Policies tional Alliance for Tobacco Control (ANCT, for its The first polyclinic to treat smoking began to Spanish acronym), which was made up of gov- operate in 1988 at Medical Clinic “A” of the Uni- ernmental, parastatal, international, academ- versity of the Republic’ School of Medicine, led ic, and nongovernmental organizations. The by Professor Milton Portos in the Hospital de institutions conforming the Alliance were: the Clí�nicas. With the support of the Pan Ameri- Pan American Health Organization (Uruguay Governance of Five Multisectoral Efforts can Health Organization (PAHO) and the Latin Country Office), the Ministry of Public Health, American Coordinating Committee on Smoking the Montevideo City Hall, the Honorary Com- Control (CLACCTA, for its Spanish acronym), mission for the Fight against Cancer, the Hon- educational activities aimed at primary- and orary Commission for Cardiovascular Health, secondary-education teachers were organized the Medical Union of Uruguay, the Medical Fed- as a way to reduce the prevalence of tobacco eration Outside of Montevideo, the University of the Republic (School of Medicine-Hospital de 150 Clí�nicas-Clí�nica Médica A), Uruguayan Passive Strengthening and Consolidation of Anti-to- 151 Smokers (an nongovernmental organization), bacco Activities and the Uruguayan Society of Family Physi- Initially, the process began by providing infor- cians (SUMEFA, for its Spanish acronym). mation on the extent of the tobacco problem at Chapter 4 The creation of the Alliance made it possible every level (population, professional, business, for these institutions to coordinate their work political, and the mass media); this effort was to reduce the morbidity and mortality due to followed by advocacy work for signing onto tobacco-related diseases, to unify criteria, and and subsequent ratification of the Framework to optimize human and material resources. Convention in Parliament. During this phase, The various governmental and nongovern- the Alliance, in addition to its population-based mental organizations worked together on sus- campaigns, also conducted workshops with tained lobbying activities, and, as a result, the journalists, health-service administrators, discussion about tobacco consumption from and those responsible for human resources in a public health perspective was for the first government agencies. Furthermore, activities time positioned in the news media and in the designed to provide scientifically sound infor- political arena. This, in turn, gave visibility to mation on the smoking epidemic to policymak- the Uruguay’s growing movement on tobacco, ers and political-party representatives proved and led to a greater awareness about the extent to be an important strategy in raising these of the problem both among health-policy deci- group’s awareness about the problem. sion-makers and the population as a whole. In Many of the institutions that formed part 2002, the Senate’s Public Health Commission of the Alliance, command the highest political for the first time met with members of the re- and academic respect in the health field. It was cently created ANCT, who formally present- within the Alliance that the working strategies ed the Alliance as an organization and stated were developed, with each institution provid- their concern over the smoking epidemic in the ing human and material resources, from their country. positions of greatest strength. The richness and The different institutions that made up the diversity of its members made it possible for the ANCT also lobbied individually, which launched Alliance to broaden the exchange and address a collective demand from governmental and all the intervention levels. The work was chart- civil-society institutions to ratify the Frame- ed during weekly or biweekly meetings where work Convention on Tobacco Control (FCTC); full consensus was sought—each delegate was the Convention was ratified in 2004. Uruguay free to propose any idea, which was then fully was one of first 40 countries to ratify the FCTC discussed. Once agreement was reached, tasks and the first one to do so in South America. The were assigned, thus transforming ideas into ac- Alliance played a significant role in ratifying tion. The work within the Alliance was key for the Convention, and the country’s legislative preserving the balance of power, as well as for advances earned Uruguay recognition from engaging the commitment of the participants PAHO/WHO during the 2005 World No Tobac- and the absence of vying for a limelight among co Day. The Alliance’s early work sparked a shift most of the delegates. in society’s conceptualization of the “smoking” The inter- and multidisciplinary approach problem. offered by the Alliance, as well as its indepen- dence from party politics, was critical in con- ical area, activity, and category of violation. fronting a problem that requires that social, Based on these data, the Ministry then imposes economic, health, and other factors be ad- the appropriate fines, after prior consultation dressed in order to arrive at the most effective with the PNCT and the Advisory Commission. scenario for raising the population’s awareness At the regional and international levels the of the issue. The Alliance spearheaded this PNCT is the focal point representing the coun- process, strengthening and broadening its ca- try in MERCOSUR’s Intergovernmental Com- pacity for action and impact. The broad range mission for Tobacco Control and at WHO and of organizations that came under its umbrel- FCTC Secretariat meetings. It is important to la—state, parastatal, and civil society—many point out that, at the regional level, the PNCT of which had excellent reputations and social has advised and provided information to var- recognition, facilitated the securing of funds, ious Latin American countries as they devel- public visibility, and the positioning the issue op their tobacco control policies and work on in society. their implementation processes. In 2004 the Ministry of Public Health creat- Upon ratification of the FCTC and the cre- ed the National Advisory Commission for To- ation of the National Program for Tobacco Con- bacco Control, a governmental entity under the trol, Uruguay implemented a vigorous tobacco Ministry and made up of governmental, public control policy that translated into a compre- nongovernmental institutions, and represen- hensive package of measures, whose linchpin tatives of medical associations, to advise the was the implementation of 100% smoke-free Ministry in all tobacco control matters. Since environments. This measure does away with then, the Commission has contributed informa- the sense that smoking is “normal,” discourag- tion that has served as the basis for resolutions es ever starting to smoke (and decreases smok- and legislative and regulatory projects that the ing), and fosters smoking cessation attempts. Ministry launched during the period. All the measures were supported by informa- In 2005, the National Program for Tobacco tion campaigns before, during, and after the PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Control (PNCT, for its Spanish acronym) cre- law became effective. ated within the Ministry of Public Health was In May 2005, coinciding with “World No intended to be the focal point for national-lev- Tobacco Day,” the Executive Branch approved el tobacco control policies. The PNCT has been several decrees, such as provisions to raise to- responsible for planning, developing, and im- bacco taxes; the use of graphics in the health plementing all tobacco control policies that warnings that already took up half of both main the country has carried out since then, and has sides of cigarette packets; a ban on misleading generated ideas and launched the most import- terms such as “light”, “ultra-light,” or “smooth” Governance of Five Multisectoral Efforts ant activities in tobacco control. cigarettes; and a ban on advertising, promo- The PNCT is charged with ensuring compli- tion, and sponsorship of tobacco products as- ance with the regulation; to this end, a cadre sociated with sports activities. Significantly, the of specially trained inspectors are deployed Executive Branch pursued fast-track regulation throughout the country to carry out this task. regarding tobacco consumption, marketing, Results are entered into a database that gathers and advertising: approval of decrees. the information and classifies it by geograph- 152 One of the greatest hurdles in preparing to ties would be imposed on drivers who smoked 153 implement smoke-free environments was per- in the vehicles. suading the associations of bars, restaurants, Two intense campaigns dealing with the and casinos, as well as businesses in general, new anti-tobacco measures were launched: one Chapter 4 to support the measures. Reaching consensus prior to the date in which the measure would with these players was fundamental in facili- go into effect, on 1 March 2006, and the oth- tating the implementation of the measures de- er subsequently, beginning in April 2006. The signed to achieve smoke-free spaces. From the first campaign, called “One Million Thanks,” onset, it was made clear that establishing 100% involved collecting signatures thanking smok- smoke-free environments was a high-level po- ers for quitting smoking in enclosed spaces litical decision. As a result, the measure itself beginning on the enforcement date, 1 March. never was in question, discussions only dealt The campaign set a goal of one million signa- with what would be the best way to carry it out tures to be collected, but the campaign actually for all those involved. collected 1.3 million signatures in 45 days. The Businessmen had been given distorted in- objective was achieved and, in addition, the formation concerning the economic conse- campaign accomplished a very important mo- quences that they would sustain—information bilization function with the entire population provided by the tobacco industry. Mutual trust and the communications media, demonstrating had to be built by providing these groups with the high degree of involvement with and accep- scientific proof so they could begin to accept tance of smoke-free environments. The second the change. A significant event occurred when campaign, called “Tobacco-Smoke-Free Uru- the owners of the major commercial areas con- guay,” began in April 2006, immediately after ducted their own surveys among their clients the smoke-free-environments measure went to ascertain their opinion on the smoke-free into effect. The campaign relied on information environments and whether the measure would about the benefits of smoke-free air: it raised affect their patronage of those commercial cen- awareness about the rights of nonsmokers and ters. The results demonstrated that more than offered treatment to smokers who wanted to 80% of respondents supported the measure, quit. Both campaigns stressed the positive and including smokers. Finally, business associa- never stigmatized smokers, so that the cam- tions which strongly supported the implemen- paigns would be viewed as including smokers tation of anti-tobacco measures, became one of and nonsmokers alike. the strongest allies in the process. As stated earlier, on 1 March 2006 the ban In addition, much work was done with on smoking in all enclosed public spaces and transportation business owners and union work areas, as well as in outdoor areas of any members; the latter vigorously resisted the health or educational center, went into effect. proposed changes. Dialogue centered on as- Ministry of Public Health teams also began to pects dealing with occupational health, and an inspect compliance at this time. agreement was reached to provide treatment At that stage of the implementation process, through the public health system to all smokers the political context was favorable to the mea- who requested it. It was made clear that penal- sures: on the one hand, the party in power had guaranteed parliamentary backing because it held the majority in both chambers; on the oth- and the requirement to provide diagnosis and er, one of the lawmakers that spearheaded the treatment for tobacco addiction at the primary process in parliament (a physician completely care level throughout the health services; these committed to the issue) belonged to the lead- decrees and new measures together rendered ing opposition party.2 Finally, the remainder of this legislation into a comprehensive package the political spectrum included representatives of convergent measures that mutually rein- who supported these measures. force each other. Also in 2007, the debate on a comprehen- In 2010, an increase in tobacco taxes in- sive draft legislation on tobacco control began creased the price of tobacco products. Inflation in parliament, culminating with the approval and variations in the population’s purchasing of Law 18,256 on 6 March 2008. This law in- power make it necessary to periodically adjust corporated decrees already in effect and added the price of these products. Figure 4.4 shows measures such as the ban on advertising, pro- how the price of tobacco products diverges motion, and sponsorship of tobacco products from the consumer price index (CPI). Figure 4.4. Evolution of the price of cigarettes, Uruguay, 2004–2010. 260 240 220 200 180 160 140 120 100 dec-04 apr-05 agu-05 dec-05 apr-06 agu-06 dec-06 apr-07 agu-07 dec-07 apr-08 agu-08 dec-08 apr-09 agu-09 dec-09 apr-10 agu-10 dec-10 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Price of cigarettes Base index of Dec. 2004=100 Source: National Institute of Statistics (Instituto Nacional de Estadí�stica [INE]). Governance of Five Multisectoral Efforts The Political and Parliamentary Initiative that they would have these materials in hand during the debate. This effort covered every During the approval process for Law 18,256, representative, regardless of political affilia- various government and civil-society institu- tion. tions carried out significant advocacy work Uruguay has had parliamentarians who with parliamentarians. Lawmakers were pro- were physicians, which was important for the vided with information and scientific evidence advocacy work. Having the support of part- about the issues that would be discussed, so 154 ners in parliament who could understand the motion, and treatment of disease. On the oth- 155 importance of tobacco control from a health er, the Executive Branch’s draft legislation and standpoint was extremely useful at the time the another one submitted by a member of parlia- law was passed. Four years had elapsed since ment from the opposition dealt with issues that Chapter 4 the ratification of the Framework Convention targeted the establishment of 100% smoke- when the draft legislation began the decisive free environments; the setting of violations, debate in parliament. The ratification gave mo- fines, and education standards; and raising mentum to the discussions and legitimized the awareness about tobacco, smoking prevention, tobacco control movement. and treatment of tobacco dependence. As can In 2005, at the time a new administration be seen, the first group of bills did not include assumed power in the country, the National the establishment of smoke-free environments, Program for Tobacco Control was established and the second group did not include a ban on within the Ministry of Public Health. The gov- advertising. ernment, which had sent the draft legislation The work conducted at the commission lev- to parliament, held the majority in both par- el was enhanced by the contribution of organi- liamentary chambers. Even so, opposition par- zations that were invited to put forward their ties participated in drafting the legislation, and views on the issue. The intervention of the Min- their agreement with wording resulted in the istry of Public Health’s National Program for support of a vast majority of politicians for the Tobacco Control, was particularly important, initiative. Another important factor was the as was the participation of many scientific and fact that the country’s president was an oncol- nongovernmental organizations. All these in- ogist with firm convictions on health, which led stitutions attempted to explain the importance him to involve his party in the Framework Con- of tobacco control and urged parliamentarians vention’s proclamations, which later were used that measures be consolidated to achieve this for approving the law. in Uruguay. For the most part, Program repre- The Parliamentary Debate sentatives were active participants in the dis- In the years prior to the approval of the legisla- cussions and figured prominently in the media. tion’s final wording, four draft bills dealing with The tobacco industry also had an opportu- tobacco control were submitted. Upon reach- nity to meet with parliamentarians and present ing consensus, these were consolidated into a its viewpoint on the matter, frequently attend- single piece of legislation that incorporated the ing sessions of parliament’s commissions on best of each bill; this allowed the discussion health and requesting meetings with individ- about smoking in Uruguay to occur within the ual lawmakers. During those meetings they framework of State policy. expressed concern over the impact that an ad- The draft bills can be grouped in two broad vertising ban would have on the local industry, categories. On the one hand, there were those over the labor sources for personnel actively bills submitted by lawmakers from with the working in the industry, and over the difficul- main opposition parties,3 which included basic ties they saw in implementing 100% smoke- elements of the Framework Convention, among free environments. them the banning of advertising, standards Tobacco-industry workers, grouped under dealing with smuggling, education, health pro- the Tobacco Trade Union, expressed their mis- givings about the potential loss of jobs as a re- Ley.asp?Ley=18256&Anchor [last accessed on sult of the implementation of the regulations, 26 March 2013). as well as about the effect that tobacco smug- gling would have on them. The discussion then Leading Actors that Supported Tobacco aimed at unifying the four draft bills and, with Control the agreement of their sponsors, a single draft The main actors in Uruguay’s fight against to- legislation emerged, which was brought to a bacco consumption between 2000 and 2004 vote at the plenary session in each parliamen- were the institutions within the National Al- tary chamber. liance for Tobacco Control (ANCT) that were Discussions in the House of Representatives previously mentioned. and in the Senate considered various opinions The Alliance’s objectives were to unify cri- regarding the smoking ban in enclosed spaces, teria, work within a network, promote partic- in that this measure could damage the tourism ipation and dialogue with the different social industry, which is extremely important in the actors and their organizations, and pursue ad- country. Questions also were raised regarding vocacy work with policymakers, the communi- the State’s authority to intervene in public life cations media, and the overall population. With by regulating the behavior of individuals in the creation of the Ministry of Public Health’s public spaces. The tobacco industry, which was National Program for Tobacco Control in 2005, familiar with this line of reasoning, used the the Alliance launched a broad coordination and mass media to claim that freedom of choice cooperation effort aimed at developing an im- was being curtailed by restricting smoking ar- plementation plan for the tobacco control poli- eas. cies related to the FCTC. The Alliance operated A group of parliamentarians also was made until 2006. The following paragraphs briefly aware of the complaint of some media outlets describe the role each institution within the Al- and publicity agencies, which claimed that liance played and the power sources for each. their profits from creating and selling public- Pan American Health Organization (PAHO): PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: ity products would be harmed, and proposed through its country office in Uruguay, the Or- that advertising at points of sale be allowed. ganization provided critical financial and tech- In short, the total ban on advertising became a nical support. It also supported the Alliance’s broad prohibition, in that it had the support of representatives attendance at world congress- most of the votes in parliament. es and preparatory meetings of the FCTC in After parliamentary deliberations, agree- Geneva. The contributions of Dr. Julio González ment was reached on the law’s wording, Molina were decisive for obtaining support which included a comprehensive package of Governance of Five Multisectoral Efforts from international organizations. measures that echoed the main provisions of Ministry of Public Health: the Ministry par- WHO’s Framework Convention. This text was ticipated in the Alliance from its beginning, ini- voted on by lawmakers from every political tially through its delegates, and then through party, and became Law 18,256, approved on the National Program for Tobacco Control and March 2008. (The text can be seen at: http:// through an advisory commission made up of www.parlamento.gub.uy/Leyes/AccesoTexto- different institutions. The Ministry served as 156 the headquarters for the Alliance and, based on Montevideo’s Municipality: The Montevideo 157 the agreements reached in that venue, became City Hall has a Health Division that manag- the spokesperson for conveying the demands es neighborhood polyclinics at the prima- of the institutions in favor of tobacco control ry-health-care level, where services are free. Chapter 4 before executive branch agencies and legisla- Income for the Mayor’s Office comes from var- tive-branch representatives. ious taxes. During the implementation of activ- In its legal capacity of policing the popula- ities against tobacco consumption, the Office, tion’s health, the Ministry created the Tobacco with the support of institutions such as the Control Advisory Commission, whose function School of Medicine and the Honorary Commis- is to advise it on all matters of tobacco con- sion to Fight Cancer, carried out an anti-tobac- trol. The Commission is made up of delegates co advocacy campaign within its walls, going on from the Ministry of Public Health, the National to become one of the first institutions that at- Board on Drugs, the Montevideo City Hall, the tained a 100% smoke-free environment, even School of Medicine, the Honorary Commission before the national regulations took effect. Si- to Fight against Cancer, the Honorary Commis- multaneously, within the Health Division, pro- sion for Cardiovascular Health, the Medical fessional staff received training to help fellow Union of Uruguay, and the Medical Federation officers quit smoking, and health team profes- outside of Montevideo. Civil-society’s role in sionals were trained on how to offer treatment this Commission deserves special mention: it in neighborhood polyclinics. functions as an external control for policymak- The Honorary Commission to Fight Cancer: ers, in that it has a freedom to act that allows This Commission, which was established by it to be critical or even differ from the govern- law in 1989, was declared of national interest ment’s positions. in the fight against cancer. From a legal stand- The National Program for Tobacco Con- point it is a parastatal statutory body that is trol: the Program was created by the Ministry not part of the Ministry of Public Health, al- of Public Health in 2004 and, since then, has though it must report to it on its activities; its functioned as the national focal point for the main source of income comes from tobacco development and implementation of tobacco and alcohol taxes. The Commission’s board of control policies. The Program drew up and ar- directors includes representatives of highly re- ticulated the strategies for preventing the on- spected academic and political institutions that set of smoking and for dealing with diseases work to fight cancer, can set educational poli- related to tobacco dependence. It also worked cies in both the public and professional arenas, on the rehabilitation and treatment of tobacco and have significant revenues under their con- dependence, in line with provisions within the trol. From the onset, the Commission worked Framework Convention. In 2009, the Program in public education and in providing technical coordinated the group working to develop the and professional training through promotion National Guidelines for Dealing with Smok- and education campaigns designed to increase ing, which are aimed at all health workers and the number of smoke-free environments. It whose recommendations are compulsory, in was the first institution to offer post-graduate accordance with existing legislation. courses to health professionals on such topics as the promotion, prevention, diagnosis, treat- ment, and control of tobacco, and also carried cus involves working with primary education out research on smoking among young people. professionals. It has developed brochures and The Commission’s materials have become ex- guidelines on the risk for cardiovascular dis- tremely important, not merely those that have ease, and was responsible for coordinating and been used in campaigns against cancer, but carrying out the anti-smoking contest “Quit also a series of useful tools that have educa- and Win” (Deje y Gane). tional applications in this regard. In fact, WHO The Medical Union of Uruguay: This associ- has used posters designed by the Commission, ation is a collective of working physicians and and this institution has received recognition on medical students in their last year of school. Its more than one occasion for the development of objectives include the defense of the moral and these tools. material interests of its members and, more Honorary Commission for Cardiovascular broadly, of all physicians in Uruguay; support- Health: This Commission was created by law in ing the deepening of professional culture; the 1994, at the time that all activities intended to enhancement of physicians’ technical profile control risk factors for cardiovascular disease and continuing education; and the improve- were declared of national interest. From a le- ment of all of the country’s health structures. gal standpoint, the Commission is a parastatal The Union is financed through member contri- entity that is not part of the Ministry of Public butions, and wields the influence that comes Health, but must report to it on its activities; from the participation of Uruguay’s entire most of the entity’s revenue comes from tobac- medical corps. In terms of health matters that co and alcohol taxes. The Commission’s board call for broad political consideration, its judg- of directors includes delegates from the Exec- ment holds sway, because its opinions generate utive Branch, particularly from the Ministry of much interest from the mass media. The Union Public Health; representatives from academia, concentrates on lobbying by interviewing as well as from professional and trade associ- senators, house representatives, and various ations that are involved in cardiology; and oth- governmental authorities and policymakers, PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: er civil-society organizations. The Commission relying on the weight that its union members also includes a delegate from the Social Securi- confer on its knowledge about tobacco control. ty Office (Banco de Previsión Social), the social Medical Federation Outside of Montevideo: security institution that provides coverage for The Federation is a union that brings togeth- social risks such as accidents and illness. er all physicians who work outside the city of Among its objectives, the Commission pro- Montevideo. It provides health care to more motes, coordinates, and develops plans and than 680,000 members through a health ser- programs for the prevention, early diagnosis, vice network of 23 institutions distributed Governance of Five Multisectoral Efforts treatment, and rehabilitation of those affected throughout the country. Its objectives include by cardiovascular diseases. It also fosters basic promoting the full development of physicians’ epidemiological and operational research, and practice in the country’s interior, and ensuring promotes the exchange with specialized cen- that the population receives health services ters and international organizations in order to provided through a structured health care sys- train and upgrade the skills of the staff assigned tem managed by its affiliated physicians. to the programs. The Commission’s primary fo- 158 In addition to the health promotion and dis- vera and Artigas; tobacco is farmed as mono- 159 ease work carried by its member health care culture, and cultivation is entirely linked to the centers, the Federation took it upon itself to Monte Paz S.A. company. include, within its continuing medical educa- A leading consequence of the Monte Paz Chapter 4 tion, training for the health team on tobacco hegemony is that it has altered the forms of consumption control, thereby educating spe- production and the relationship with tobacco cialists who later became responsible for spe- farmers. The company completely controls the cialized-treatment polyclinics throughout the harvesting and planting of the raw material, by country’s departments. providing financing and supplying production University of the Republic: This public and inputs, controlling the harvesting process and free university provides training for technical quality, and purchasing the farmers’ entire to- health care personnel through its school of bacco crop. This has led to a co-dependency be- medicine and manages and operates the Hos- tween the producers and the company, which pital de Clí�nicas, Uruguay’s only university guarantees investment and income for the fam- hospital. The university’s size and structure ilies devoted to tobacco production. ranks it as the country’s main academic center. Although the company ultimately sets the It accounts for about 90% of Uruguay’s enroll- price, each crop is subject to climatic condi- ment in tertiary education. The university is fi- tions and their effect on the quality of the raw nanced with funds from the national treasury. material. This dependency and loyalty that the Its school of medicine and, more specifically, farmers have with Monte Paz, gives them eco- its internal medicine unit (Medical Clinic A) at nomic security, in that the company finances the Hospital de Clí�nicas, offered undergraduate the inputs and purchases the total production. education, treatment to smokers, and research. In this regard the farmers’ commercial rela- In 2009, a curriculum change led to the inclu- tionship with the tobacco company may be, in sion of the topic of smoking in the introductory some cases, more attractive than the retrofit- study course. ting and assistance plans that the Uruguayan Uruguayan Passive Smokers: This NGO government can offer. fought for the rights of nonsmokers. It dissem- That said, the economic benefit for farm- inated standards to civil-service employees as ers may be relative. Their earnings from each they were developed, and denounced violators. harvest (about US$ 3,000 each year) often rep- resents the family’s only income for the year, The Tobacco Industry but when translated into monthly income, it is significantly lower than the national mini- Tobacco Farming in Uruguay mum wage (roughly US$ 350 in January 2012). It should be noted that tobacco producers ac- Tobacco farming accounts for only a small por- count for 10% of the raw material used by tion of the country’s agricultural production; Monte Paz, which shows the scant importance moreover, its importance has been decreasing that this industry has on the country’s employ- in recent years. Tobacco production is concen- ment indicators. trated to the country’s north (along the border Current estimates put the number of fam- with Brazil), mainly in the departments of Ri- ilies devoted to tobacco farming at approxi- mately 150. In general, these families are of tobacco farming, the tobacco manufacturing medium-low socioeconomic status, and they and marketing sector also represents a small rarely supplement their income by working in part of the overall industrial sector, account- the region’s main harvests. ing for 2.3% of the gross national production. Although for several years there has been BAT is only involved in the marketing of ciga- consensus regarding the advisability of retro- rettes, not in production, since all the products fitting or diversifying these producers, the pro- it sells are imported. And Philip Morris closed ductive and commercial nature in which they its cigarette manufacturing plant in Uruguay are locked limits such a possibility, at least in in October 2011, citing economic disadvantag- the short term. As of today the retrofitting has es as a result of the health measures aimed at not happened, even in a scenario that could be diminishing tobacco consumption in Uruguay; seen as favorable for such an initiative, given the company continues to sell its products in the implementation of tobacco control mea- the country, however, which it imports already sures that has occurred in recent years. manufactured. The tobacco industry as a whole The area devoted to tobacco farming bare- employs only 3 out of every 1,000 workers in ly represents 0.04% of Uruguay’s total farming the Uruguayan manufacturing sector (Ramos, area (2003 data). As a result, most of the to- 2006). bacco used in the national cigarette production The Tobacco Industry’s Reaction to the is imported and does not come from domestic Tobacco Control Measures cultivation. This means that the tobacco farm- When the anti-smoking measures were im- ing sector is of little economic consequence plemented in Uruguay, the country’s tobac- to the country. in terms of the value of tobac- co industry reacted by attempting to avoid or co production, it depends on the price set by minimize their impact. As Uruguay became a Monte Paz, the main national tobacco company, smoke-free country, the tobacco industry at- once the quality of the raw material has been tempted to seed dissent among the public by certified. According to the last agricultural cen- raising such isues as smokers’ “freedom” and PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: sus, the value of the harvested ton is estimated “rights.” Tobacco companies published arti- at US$ 1,000. cles in the local press, citing the example of countries such as Chile, the Netherlands, and The Tobacco Industry in Uruguay: Spain, where there were designated smoking Position and Strategies areas within enclosed spaces and expressing the opinion that “all unnecessary bans would For many years there have been only three squander freedom.” “Why don’t we preserve companies engaged in the manufacturing and that freedom in Uruguay?,” they asked. Governance of Five Multisectoral Efforts marketing of tobacco in Uruguay: Monte Paz, On the other hand, the Ministry of Public S.A., the only national company, and two mul- Health and various organizations working on tinationals, British American Tobacco (BAT) tobacco control countered with the following and Philip Morris (Abal Hermanos). Since the arguments: 1980s, Monte Paz, S.A., has had the largest mar- • Smoking is an addictive disease and, as a ket share in terms of the production, industri- result, the smoker consumes the product alization, and sale of tobacco products. As with 160 because it is addicted to the that substance promotions (such as giving out free cigarette 161 and is not free to choose. samples to young people), carrying out public- • Smoking is not prohibited; it is regulated ity without the counter-publicity required by for public health reasons. Smokers cannot the regulation (for example, by using promot- Chapter 4 smoke in enclosed spaces, because having ers at points of sale), using the brand’s colors 100% smoke-free spaces is the only effec- in different objects or businesses, and, more tive way of protecting people from the risks directly, by carrying out specifically prohibited caused by exposure to said smoke. publicity. Health Warnings, which Were Poorly Re- Advocacy and Litigation Efforts of Tobacco ceived by Tobacco Companies Companies to Forestall the New Measures The implementation of health warnings also Somewhat later, when the various drafts were was opposed by the tobacco industry. Tobacco presented for the approval of a tobacco control companies used a variety of strategies: law in parliament, the tobacco industry contin- • They argued that printing the images in the ued to lobby lawmakers. Their main arguments boxes on time and as required posed tech- during parliamentary discussions were: 1) the nical difficulties, and they asked for long measures infringed on individual rights, ii) the extensions. However, by the time the reg- smoking ban in enclosed spaces could harm the ulation came into force the graphics were tourism industry, and iii) the measures would already in the market. have repercussions on the ability of the national • They tried to influence public opinion tobacco industry to compete with the interna- through the press, by stating that the type tional industry—the national industry argued of images used stigmatized smokers and that a total advertising ban would hurt it specif- denigrated manufacturers. At no point, ically, in that multinational tobacco companies however, did they deny that that tobacco would be able to advertise in other countries. consumption produced the effects depicted Finally, the tobacco industry used litigation in the graphics, nor did they claim that the as a tool to oppose the implementation of the graphics presented false information. tobacco control policies, both at the national • They tried to weaken the message by pre- and international levels. At the national level, paring alternative images and offering them since 2008, all the companies that comprise as substitutes for the graphics approved by Uruguay’s tobacco industry have countered all the Ministry of Public Health. They never tobacco control regulations by filing judicial denied the effectiveness of the health warn- and administrative lawsuits. Abal Hermanos, ings in diminishing tobacco consumption. representing Philip Morris in Uruguay, as well Reaction of Tobacco Companies to the Ad- as British American Tobacco (BAT) and Mon- vertising Ban te Paz, filed lawsuits against different smok- The tobacco industry also resisted the ban on ing-control regulations. publicity, promotion, and sponsorship of tobac- As their first legal action against the tobac- co products, as did some other groups (for ex- co control policies, BAT and Abal Hermanos ample, advertising agencies and kiosks where filed appeals in contentious administrative cigarettes were sold). The industry attempted proceedings aimed at immediately obstructing to avoid the prohibition by conducting banned the implementation of Ordinance 514/2008. The companies argued that the ordinance was they questioned the decrees’ constitutionality, unlawful because the measure, in mandating stating that they infringed on rights and that that graphics cover 50% of cigarette packages the executive branch was usurping powers and requiring a single presentation for each that rested with the legislative branch, that it brand, restricted these companies’ basic rights, expropriated the brand name and limited its such as their right to use their brands and de- use—by decree—when it stipulated the size of signs, the right to work, and the right of trade the pictograms, and that these graphics were and of industry, thereby causing serious eco- demeaning and exceeded the State’s aims. In nomic harm to tobacco companies and to their response to the tobacco industry’s position, the workers. Contentious Administrative Tribunal, as had Both the courts of first instance and the ap- the Supreme Court before it, acknowledged the pellate courts that heard the cases recognized Ministry of Public Health’s regulatory authori- the Ministry of Public Health’s powers to reg- ty in health matters, and also made reference ulate health policy, and found that none of the to the country’s commitment to comply with regulations were excessive and that they were WHO’s Framework Convention on Tobacco justified. Abal Hermanos filed a lawsuit with Control, which was approved and ratified by the Supreme Court, claiming that articles 9 and law, and the State’s duty to protect the popula- 24 of Law 18,256 were unconstitutional. The tion’s health to avoid the thousands of deaths company argued that these articles violated due to smoking each year. the principles of legality and of separation of The Tobacco Companies Appeal the Imple- powers, because the power to limit rights can- mentation of Tobacco Control Measures to not be delegated to the executive branch, as it International Bodies rests with the legislative branch, for reasons of In 2010, Philip Morris Brands Sarl (Switzer- broad interest. In addition, the brand was being land), Philip Morris Products, and Abal Her- indirectly expropriated without compensation, manos brought an arbitration request to the given the size of the pictograms; moreover, the International Centre for Settlement of Invest- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: rights pertaining to work, production, industry, ment Disputes (ICSID). Switzerland and Uru- branding, and commerce also would be limited. guay have an investment protection Agreement In November 2010 the Supreme Court issued and both are members of the ICSID. its opinion: it rejected the claim for unconstitu- Philip Morris based its request on the Uru- tionality and expressly recognized the powers guayan government’s alleged breach of the of the executive branch and of the Ministry of Investment Promotion and Protection Treaty Public Health to regulate matters of health; it signed between it and Switzerland in 1991, by also stated that many laws, such as this one, re- having passed Ordinance 514 (2008), which Governance of Five Multisectoral Efforts quire complementary executive branch regula- provides for the single presentation of each to- tions for their practical enforcement. bacco product trade name, and Decree 287/09 All the tobacco companies questioned the (2009), which establishes the size of the pic- legality of Decree 284/08, Ordinance 514/08, tograms (80% of both main faces of cigarette 287/09, ordinances 466/09 and 374/011 in packages). the contentious administrative tribunal, using The companies argued that their free-trade the same arguments that they had used when and industry rights had been violated; that the 162 pictograms degraded their brand name, and • The creation of the National Program for 163 that Uruguay would be expropriating their Tobacco Control within the Ministry of Pub- brand by requiring that the pictograms cover lic Health. 80% of the surface of each main sides of the • The existence of the Honorary Commission Chapter 4 package, thereby violating Philip Morris’ au- to Fight Against Cancer and the Honorary tonomy in the use of its brand name. Commission for Cardiovascular Health, Uruguay, in turn, claimed its sovereign right which are fully consolidated, autonomous, to establish public health policies designed to and deeply committed to health promotion protect its population against the unavoidable and disease prevention. threat to health caused by tobacco consump- • The diplomatic commitment Uruguay en- tion. Furthermore, the country held that the tered into by signing an international agree- right to health, by being intimately linked to the ment, such as the Framework Convention right to life, should be regarded as a fundamen- on Tobacco Control. tal human right and, therefore, measures must • The characteristics of the country’s political be established to regulate the marketing of a regime: a unitary and presidential form of product harmful to health. government, and a long tradition of broad Early in the arbitration process brought participation of all political parties in the forth by Philip Morris to the ICSID, and pri- generation of agreements that lead to State or to the analysis of the underlying issue, the policies. Uruguayan State in 2011 presented a “jurisdic- • A political context that favored change and tional objection” waiver, arguing that accord- the establishment of new State policies. ing to a previous claim submitted by Uruguay, • The strong commitment of the then-pres- the legal requirements that the 1991 treaty ident of the country, a medical oncologist, requires had not been complied with, thereby who assumed office in March 2005. nullifying the arbitration request. • The active participation of lawmakers from the opposition parties throughout the pro- Factors that Favored the Implementation cess. of the Tobacco control Measures • The existence of a critical mass of trained health professionals committed to tobacco The success of the measures designed to de- control. crease smoking in Uruguay, whose origins can • A population extremely well informed on be traced to the 1990s, was due to the conver- the harm from tobacco consumption. gence of various factors that created a favorable environment for implementing such policies. Results Beyond Decreasing the Among the most important are the following: • The country’s epidemiological profile, Prevalence of Smoking whereby noncommunicable diseases are Public Opinion the main cause of morbidity and mortality. The results of various public opinion studies • The establishment of the National Alliance on tobacco consumption in Uruguay, as well as for Tobacco Control, made up of govern- on research on the tobacco control measures, mental and civil-society organizations. are presented below. The information collect- ed provides an overview on how the collective 63% of smokers approved of it and 86% of consciousness regarding tobacco, its risks, and nonsmokers did. With regard to the decree the policies implemented evolved. It also shows possibly affecting the frequency with which how a culture shift came about in terms of the people went out, 70% of respondents stated population’s beliefs and attitudes regarding to- that they would go out as frequently as before bacco consumption. and 10% stated they go out more frequently According to National Board of Drugs (JND) than before; among smokers, the figures were data, in 2002, 11% of the surveyed population 63% and 12%, respectively. referred to cigarettes as drugs, but only 3% In analyzing the data from the Global Youth considered tobacco among dangerous drugs. Tobacco Survey for that same year, 88.2% of re- By 2006, six months after the smoke-free en- spondents acknowledged the negative effects vironment regulation went into effect, the Pan of cigarettes and 83.4% of those surveyed fa- American Health Organization (PAHO) con- vored the smoking ban in public places. ducted an opinion study to assess the popula- Regarding whether environmental tobacco tion’s knowledge and attitudes regarding the smoke is detrimental to health, slightly more measure. Results from that study showed that than 70% of all young people surveyed4 agreed, 98% of the population was aware of the regula- compared with 60.2% of young smokers. Final- tion and 80% supported it. Widespread accep- ly, there is parity in whether quitting smoking tance held true across all sociocultural strata, helps to lose weight: 52.6% of respondents and and was consistent among men and women 52.2% of smokers consider that it does. and within and outside Montevideo; even two- Environmental Pollution thirds of smokers approved of the measure. In 2002 a study was conducted in seven Latin In terms of exposure to second-hand smoke, American countries to measure nicotine levels 92% of the surveyed population considered in the air from tobacco use in enclosed places. that exposure to second-hand smoke is very In Uruguay, high pollution levels were found in dangerous (57%) or dangerous (35%). Inter- 95% of sites surveyed. The study was repeated PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: estingly, 87% of the smokers also consider that in 2007, regulations requiring 100% smoke- this exposure is very dangerous (46%) or dan- free environments had been implemented; gerous (41%). results show a 91% reduction in air pollution Similarly, 95% of respondents felt that all levels (2002: 0.75 µg/m3 – 2007: 0.07 µg/m3). workers have the right to work in a smoke- A series of studies was also conducted to free environment and 92% defended the right evaluate pollution levels by measuring the of children to breathe smoke-free air at home. concentration of particles smaller than 2.5µ in Among smokers, the figures were 92% and the air of enclosed places used by the public.5 Governance of Five Multisectoral Efforts 87%, respectively. In 2005, an average concentration of 210 mi- Regarding the policies implemented since crograms/m3 in Uruguay, rising to 314 in bars 2005, 58% of the population considered that and restaurants, even though international the decree is fully complied with and 30% felt standards establish a maximum level of 50 mi- that it was partially complied with; among crograms/m3 for health risk. Results for 2007 smokers, the figures were 61% and 27%, re- found that the average concentration had de- spectively. In terms of supporting the decree, 164 creased to 18 micrograms/m3, representing a among them and potentiating each measure’s 165 90% reduction in pollution in en closed spaces. impact. The importance of establishing clear and transparent monitoring procedures also Lessons Learned was demonstrated, along with effective con- Chapter 4 The joint work between the government and trols for measuring compliance with the regu- civil society was key in the effort to control to- lations and the application of severe economic bacco consumption in Uruguay; as important sanctions to violators. Regulations that were was the participation of an inter-institutional not monitored turned into mere wishful think- and multidisciplinary group that brought var- ing. ious skills to bear upon the process, committed The development of “national clinical guide- its human and financial resources, and worked lines” also was found to be useful in the fight towards arriving at consensus. Maintaining against smoking. These guidelines covered all communication with the population also was health workers—not just medical staff—and essential: keeping the population informed and they were mandatory in light of the regulation making it aware of the damage from tobacco in force. Even in the health sector it is import- use, while insisting on the benefits of not con- ant to offer universal and free access to treat- suming tobacco through positive messages that ment for tobacco dependence, both in public did not stigmatize smokers, brought about a and private primary health care services. greater public acceptance of all the measures. Finally, considering the impact of the mea- The use of large pictograms with powerful sures on the prevalence of tobacco consumption images and direct and clear messages, also once the implementation process concluded, proved to be effective. In selecting the imag- two population groups stood out: the group at es, it is important to rely on qualitative studies low socioeconomic and educational status, and aimed at the target population. For example, adolescents. The first, because it was more re- images showing persons were more effective sistant to lowering prevalence compared to the than those that are merely symbolic. population as a whole; the second, because it is Selecting an overarching element—in this precisely in this age group where the epidemic case, “smoke-free environments”—was not is replicated, as each year a fresh generation of only effective, but enabled other intervention adolescents acquires new roles and, therefore, levels to be incorporated. In fact, establish- is at risk of beginning to consume tobacco. ing these healthy environments as the pol- icy’s main thread turned out to be one of the The Unfinished Agenda in Uruguay’s most important successes: it “denormalized” Tobacco Control smoking, fostered the desire to quit smok- Even though compliance with the measures ing, decreased consumption among those that designed to decrease tobacco consumption has continued to smoke, helped those who were been highly satisfactory, the monitoring and abstaining continue to not smoke, and repre- control mechanisms needed to sustain them sented a significant change in social behavior. and increase their compliance nationwide need The simultaneous application of a compre- to be strengthened. Recently, health authorities hensive group of measures contributed to the submitted to parliament draft legislation in- success of the project, by generating synergism tended to eliminate the last remaining publici- The increase in prices of tobacco products ty for cigarettes—advertising at points of sale. must accompany economic variables such as Enacting this law will be an uphill battle, how- purchasing power (given increases in people’s ever. income level) and inflation. Therefore, the in- The Uruguayan State has the responsibil- creases should be regular and frequent. ity to ensure the sustainability of health pro- motion and tobacco-consumption-prevention Annex 4.1. Characteristics campaigns. Each year, new waves of young of the smoking population people enter the market for cigarettes, which by socioeconomic level makes it necessary to launch initiatives de- An index was developed for analyzing signed to evaluate the reach and quality of care, GATS-survey data that allowed the population and the results of treatment units for smoking under study to be classified according to socio- cessation. economic status, even though the Global Adult Finally, work remains to be done in con- Tobacco Survey (GATS) questionnaire did not ducting research, particularly to determine the include questions about personal or household morbidity and mortality burden attributed to income.6 Through this index it has been possi- smoking, as well as the years of healthy life lost ble to demonstrate the complex relationship due to disability. Such studies must be comple- between a person’s socioeconomic status and mented with research on the economic burden tobacco consumption. In fact, a higher prev- that these smoking consequences place on the alence of tobacco consumption is seen in the health and social-security systems. group at the lowest socioeconomic level. Figure A.4.1. Tobacco consumption by socioeconomic-level index (INSE, for its Spanish acronym), Uruguay, 2009. 35,0 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: 25,0 24,7 22,1 19,6 Total High Medium high Medium low Low INSE Governance of Five Multisectoral Efforts Source: Global Adult Tobacco Survey (GATS), 2009. Sociodemographic Characteristics of the in the evolution of smoking prevalence be- Smoking Population tween 2006 and the 2009 GATS survey, other As a way to characterize the smoking popula- data sources that have researched the subject tion and be able to identify relevant aspects may be analyzed. One of them is the Expand- 166 ed National Household Survey (ENHA, for its smoked among the unemployed population 167 Spanish acronym) conducted by Uruguay’s (those looking for a job). National Statistics Institute in 2006. This re- On the other hand, the fact that between the search, which covered a three-month period, first survey and the second there was an in- Chapter 4 collected information on approximately 23,000 crease in the relative weight of smokers among households and 70,000 persons throughout the the total number of the unemployed deserves country. Although it is impossible to compare, mention. without qualification, the point estimate of the The unemployed population is far from prevalence of tobacco consumption—given the homogeneous: it is integrated by men, wom- methodological differences between these sur- en, and persons of different ages, educational veys—important measures confirmed in both levels, and socioeconomic status. Women, the surveys can be observed. Understanding the young, and those with low educational and in- characteristics of the smoking population was come levels tend to be over-represented among essential in order to efficiently and effectively the unemployed. According to data from Uru- target campaigns and interventions. guay’s National Institute of Statistics (INE, for Prevalence of Tobacco Consumption its Spanish acronym), the country’s unem- by Employment Status ployment rate has been decreasing in recent Both ENHA 2006 and GATS 2009 show similar years, and there also have been changes in the findings: the inactive population (understood socio-demographic composition of the unem- as the unemployed who are not seeking em- ployed population. Both of these factors should ployment) had the lowest percentage of cur- be considered in observing data from these rent smokers, while a considerable percentage surveys (Table A.4.1). Table A.4.1. Employment status in current smokers, Uruguay, 2006 and 2009. Current smokers (%) Employment status ENHA, 2006 GATS, 2009 Employed 30.9 29.0 Unemployed 34.4 55.5 Inactive 14.2 14.3 Source: Author, based on data from the Expanded National Household Survey, 2006, and the Global Adult Tobacco Survey, 2009. The same trend holds in analyzing data by sex, although women’s figures are always lower. Table A.4.2. Employment status among current smokers, by sex, Uruguay, 2006 and 2009. Current smokers Employment status ENHA, 2006 GATS, 2009 Men Women Men Women Employed 35.5 24.9 33.8 23.2 Unemployed 36.2 33.2 65.4 43.5 Inactive 18.1 12.5 15.4 13.8 Source: Author, based on data from the Expanded National Household Survey, 2006, and the Global Adult Tobacco Survey, 2009. Prevalence of Tobacco Consumption Ac- Comparing the data from ENHA 2006 and cording to Educational Level GATS 2009 makes it possible to state that, Both surveys show some relationship between between 2006 and 2009: i) the prevalence of years of schooling and the prevalence of to- smokers increased in both men and women bacco consumption, with lower percentages of who had only primary education; ii) the prev- smokers among those with tertiary education; alence decreased among women with tertiary the prevalence is greater among persons with education and increased among men with that only basic or less educational attainment. The level of education; and iii) decreased among relationship is less clear when analyzing at the both men and women with intermediate edu- data by sex, with women with only primary ed- cational levels (Table A.4.3). ucational levels showing the lowest percentage after women with tertiary education. Table A.4.3. Evolution of the percentage of current smokers (persons 25 years old and older), by educational level, Uruguay, 2006 and 2009. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Current smokers Educational level ENHA 2006 GATS 2009 Men Women Total Men Women Total Primary 33.0 15.4 23.3 34.3 17.4 25.5 Basic cycle 36.4 24.6 30.3 29.6 26.7 28.2 Secondary 29.2 22.0 25.5 26.3 20.9 23.3 Governance of Five Multisectoral Efforts Tertiary 18.3 17.9 18.0 29.2 16.5 21.3 Source: Author, based on data from the Expanded National Household Survey, 2006, and the Global Adult Tobacco Survey, 2009. 168 References Junta Nacional de Drogas. 2001. Informe III 169 Encuesta Nacional de prevalencia sobre con- Boado M, Bianco E. Tabaquismo en los médi- sumo de drogas. Montevideo, Uruguay. cos uruguayos. Revista Uruguaya de Cardio- Junta Nacional de Drogas. 2010. Informe IV En- logía, 2011. Chapter 4 cuesta Nacional sobre consumo de drogas en Centro de Investigación para la Epidemia del estudiantes de enseñanza media. Montevi- Tabaquismo. 2008. Informe Primera En- deo, Uruguay. cuesta Nacional de Tabaquismo. Montevi- Junta Nacional de Drogas. 2003. Primera En- deo, Uruguay. cuesta Nacional sobre Consumo de Drogas Organización Panamericana de la Salud. 2006. en Estudiantes de Enseñanza Media. Monte- Informe “Estudio de conocimientos y acti- video, Uruguay. tudes hacia el Decreto 268/005”. OPS. Ministerio de Salud Pública, Dirección General Instituto Nacional de Estadí�stica. 2006. Mi- de la Salud, División Epidemiologí�a. 2006. cro-datos de la Encuesta Nacional de Ho- Primera Encuesta Nacional de Factores de gares Ampliada. Montevideo, Uruguay. Riesgo de Enfermedades Crónicas no Trans- Available from www.ine.gub.uy [last ac- misibles. Montevideo, Uruguay. cessed 1 April 2013]. Organización Mundial de la Salud. 2008. Instituto Nacional de Estadí�stica, la Encuesta MPOWER. Availablr from: http://www. Mundial de Tabaquismo y la Junta Nacional who.int/tobacco/mpower/package/es/ de Drogas. Encuesta Nacional de Hogares [last accessed 1 April 2013]. Ampliada 2006 y la Encuesta Mundial de Pan American Health Organization. “Global Tabaquismo en Adultos Centro de Investi- Adults Tobacco Survey, GATS”. PAHO, 2011. gación para la Epidemia del Tabaquismo. Ramos, A. 2006. “Economí�a del control del taba- Junta Nacional de Drogas. 2002. Informe de co en los paí�ses del MERCOSUR y Estados investigación Tabaquismo, consumo en el asociados.” Organización Panamericana de ámbito de la enseñanza media. Montevideo, la Salud. Washington, DC. Uruguay. Sandoya, E., Bianco. E. 2011. “Mortalidad por Junta Nacional de Drogas. 2006. Informe de la tabaquismo y por humo de segunda mano IV Encuesta Nacional en hogares sobre Con- en Uruguay”. Revista Uruguaya de Cardio- sumo de Drogas. Montevideo, Uruguay. logía. 26:201-206, 2011. Junta Nacional de Drogas. 2006. Informe II En- Sebrié E., Sandoya E., Hyland A., Bianco E., cuesta Mundial de tabaquismo en jóvenes. Glantz, S.A. Cummings, M. K. 2011. Hospital Montevideo, Uruguay. admissions for acute myocardial infarction Junta Nacional de Drogas. 2006. Informe II En- before and after implementation of a com- cuesta Nacional sobre consumo de drogas en prehensive smoke-free policy in Uruguay. estudiantes de enseñanza media. Montevi- Available from: http://tobaccocontrol.bmj. deo, Uruguay. com/content/14/5/e2.full.pdf [last ac- Junta Nacional de Drogas. 1998. Informe II En- cessed 1 April 2013]. cuesta Nacional sobre consumo de drogas. Sindicato Médico del Uruguay. 2008. Tabaquis- Montevideo, Uruguay. mo en Uruguay. Informe de la Comisión de Tabaquismo del Sindicato Médico del Uru- distribuidos/caratulas/senado/S20072155. guay. htm&TIPO=CAR Vassallo, J.A. 1989. “Cáncer en el Uruguay.” Reg- 11 December 2007 istro Nacional del Cáncer, Uruguay. http://www0.parlamento.gub.uy/indexdb/ Wipfli H., Avila-Tang E., et al. 2008. “Second- Distribuidos/ListarDistribuido.asp?URL=/ hand Smoke Exposure among Women and distribuidos/caratulas/senado/S20072192. Children: Evidence from 31 Countries”. htm&TIPO=CAR American Journal of Public Health. 2008;98 House of Representatives 6 July 2004 Parliament Transcripts http://www0.parlamento.gub.uy/distribuidos/ Senate AccesoDistribuidos.asp?Url=/distribuidos/ 28 May 2002. contenido/camara/d20040706-0218-2518. http://www0.parlamento.gub.uy/distribuidos/ htm AccesoDistribuidos.asp?Url=/distribuidos/ 10 August 2005 contenido/senado/s20021535.htm http://www0.parlamento.gub.uy/indexdb/ 13 November 2003 Distribuidos/ListarDistribuido.asp?URL http://www0.parlamento.gub.uy/indexdb/ =/distribuidos/caratulas/camara/ Distribuidos/ListarDistribuido.asp?URL=/ D20050810-0218-0225.htm&TIPO=CON distribuidos/caratulas/senado/S20032546. 21 December 2005 htm&TIPO=CAR http://www0.parlamento.gub.uy/distribuidos/ 14 June 2005 AccesoDistribuidos.asp?Url=/distribuidos/ http://www0.parlamento.gub.uy/indexdb/ contenido/camara/d20051221-0218-0416. Distribuidos/ListarDistribuido.asp?URL=/ htm distribuidos/caratulas/senado/S20050187. 19 April 2006 htm&TIPO=CAR http://www0.parlamento.gub.uy/distribuidos/ 26 July 2005 AccesoDistribuidos.asp?Url=/distribuidos/ PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: http://www0.parlamento.gub.uy/distribuidos/ contenido/camara/d20060419-0218-0491. AccesoDistribuidos.asp?Url=/distribuidos/ htm contenido/senado/s20050282.htm 13 September 2006 16 October 2007 http://www0.parlamento.gub.uy/distribuidos/ http://www0.parlamento.gub.uy/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ contenido/camara/d20060913-0218-0753. caratulas/senado/s20072033.htm htm 3 October 2006 Governance of Five Multisectoral Efforts 13 November 2007 http://www0.parlamento.gub.uy/indexdb/ http://www0.parlamento.gub.uy/indexdb/ Distribuidos/ListarDistribuido.asp?URL=/ Distribuidos/ListarDistribuido.asp?URL distribuidos/caratulas/senado/S20072114. =/distribuidos/caratulas/camara/ htm&TIPO=CAR D20061003-0218-0778.htm&TIPO=CON 27 November 2007 4 October 2006 http://www0.parlamento.gub.uy/indexdb/ http://www0.parlamento.gub.uy/distribuidos/ Distribuidos/ListarDistribuido.asp?URL=/ AccesoDistribuidos.asp?Url=/distribuidos/ 170 contenido/camara/d20061004-0218-0782. contenido/camara/d20100824-0218-0206. 171 htm htm 10 October 2006 1 September 2010 http://www0.parlamento.gub.uy/distribuidos/ http://www0.parlamento.gub.uy/distribuidos/ Chapter 4 AccesoDistribuidos.asp?Url=/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ contenido/camara/d20061010-0218-0816. contenido/camara/d20100901-0218-0208. htm htm 6 March 2007 http://www0.parlamento.gub.uy/distribuidos/ Notes AccesoDistribuidos.asp?Url=/distribuidos/ 1 In the distribution by type of disease, deaths due to contenido/camara/d20070306-0218-0910. tobacco consumption account for 100%. htm 2 Members of the National Party, the main opposition party, had approximately 40% representation in Par- 19 February 2008 liament. http://www0.parlamento.gub.uy/distribuidos/ 3 The National Party and the Colorado Party AccesoDistribuidos.asp?Url=/distribuidos/ 4 Youth 13–15 years old who attend middle school. contenido/camara/d20080219-0218-1419. 5 A 32-country comparison of tobacco smoke derived htm particle levels in indoor public places. A Hyland, MJ Travers, C Dressler e al. Tobacco Control 2008;17:159- 7 May 2008 165 http://www0.parlamento.gub.uy/distribuidos/ 6 The technical team responsible for the research vali- AccesoDistribuidos.asp?Url=/distribuidos/ dated the index. contenido/camara/d20080507-0218-1529. htm 12 November 2008 http://www0.parlamento.gub.uy/indexdb/ Distribuidos/ListarDistribuido.as- p?URL=/distribuidos/caratulas/camara/ D20081112-0218-1857.htm&TIPO=CON 27 July 2010 http://www0.parlamento.gub.uy/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ contenido/camara/d20100727-0218-0148. htm 10 August 2010 http://www0.parlamento.gub.uy/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ contenido/camara/d20100810-0218-0182. htm 24 August 2010 http://www0.parlamento.gub.uy/distribuidos/ AccesoDistribuidos.asp?Url=/distribuidos/ 172 PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Gobernanza de Cinco Esfuerzos Multisectoriales República de Argentina. Photography: Cortesí�a del Ministerio de Salud de la Nación, CHAPTER 5. 173 Tobacco Control Policies in Argentina MARÍA EUGENIA BARBIERI, FOR ARGENTINA’S MINISTRY OF HEALTH This case study documents Argentina’s ad- Context vancements in the design and implementation In Argentina, noncommunicable diseases of tobacco control policies since the Nation- (NCDs) account for 80% of deaths and 76% al Program for Tobacco Control (PNCT, for its of the Disability-Adjusted Life Years (DALYs) Spanish acronym) was launched in 2003. Ar- (OMS, 2009). Tobacco consumption is respon- gentina’s experience shows how a country sible for 40,591 deaths a year, representing can make progress in implementing control 13.6% of all deaths in persons older than 35. measures, despite resistance and even when It is estimated that 111 persons die each day the country has yet to ratify the Framework from tobacco consumption. Cancer accounts Convention on Tobacco Control (FCTC). Three for 31% of deaths, followed by cardiovascu- elements lie at the heart of these advances. On lar diseases (30%) and respiratory diseases the one hand, the Ministry of Health engaged in (27%). Of the total deaths attributed to tobacco a strategy that sought to work toward mobiliz- use, men account for 71% and women, for 29% ing, raising awareness among, and empower- (Pichon-Riviere et al., 2013). ing other actors, both within the Ministry and According to disease-burden figures, an in other State sectors. On the other, a myriad estimated 824,804 DALYs are lost each year of civil-society organizations coordinated their due to tobacco use, with 35.5% representing work to continuously advocate for and inform premature mortality and 64.5% to lives lived on the importance of this issue. Finally, an ap- with varying degrees of disability. While men proach of working with subnational-level to sustain the greatest burden (67% of years of enact laws and ordinances that set forth recom- healthy life lost), the rising trend in tobacco mended measures for tobacco control played a consumption among women, especially young- significant role. er ones, may shift this trend (Rossi et al., 2004). In addition, an estimated 926,878 quality-ad- justed life years (QALYs) are lost each year. This Nonetheless, the Program has made some total is the sum of years lost due to premature gains, such as the approval of tobacco control death (73%) and years of productive life lost legislation at the provincial and municipal lev- due to disability (27%). The greater proportion els, and more recently, the enactment of Na- of years of life lost due to premature death are tional Law No. 26,687. Useful information also due to lung cancer (23%), chronic obstructive has been generated for decision-makers (such pulmonary disease (21%), ischemic heart dis- as epidemiological studies and research on the ease, and stroke (13%) (Pichon-Riviere et al., impact of interventions), and work has been 2013). undertaken on regulating access to cigarettes, Deaths from tobacco consumption could be promoting healthy lifestyles, creating smoke- prevented, however, provided that highly ef- free environments, and developing services to fective interventions be widely implemented. help those who want to stop smoking. Indeed, there is strong evidence of the signifi- cant impact that strategies such as raising to- Tobacco Consumption in Argentina bacco taxes, disseminating information about In the last 14 years, tobacco consumption in the risks of smoking, banning smoking in pub- Argentina has decreased: for example, in 1999, lic places and work sites, outlawing tobacco the Secretariat of Planning for the Prevention advertising, and providing access to resources of Drug Abuse and the Fight against Drug Traf- to reduce or eliminate tobacco consumption ficking (SEDRONAR, for its Spanish acronym) (OMS, 2011; Chaloupka et al., 2001). estimated that 39.8% of the population 16–64 Up to 2003, Argentina’s tobacco control had years old smoked. According to the National been weak, but this changed that year when Surveys of Risk Factors (ENFR, for its Spanish the National Tobacco Control Program was acronym) conducted in 2005 and 2009, the launched. The Program rests on a comprehen- prevalence of tobacco consumption2 declined sive policy that reflects Argentina’s situation, from 29.7% in the first year to 27.1% in in the dealing with the leading principles that deter- second year, for a reduction of 8.8% in the in- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: mine the country’s high level of tobacco con- tervening four years (Table 5.1). When persons sumption: easy access to products, widespread over 65 were excluded, the prevalence was positive images associated with smoking, high 30.1% in 2009, compared to 33.4% in 2005. In exposure to second-hand smoke, and the health 2009, persons 25–34 years old had the high- services’ limited capacity to treat smokers. est prevalence of tobacco consumption, while Although the Program was launched, sever- in 2005, 18–24-year-olds showed the highest al tobacco control laws were rejected (Sebrie et rate. Although smoking decreased in those un- al., 2005; Committee on economic, social and Governance of Five Multisectoral Efforts der 49, there was an obvious increase among cultural rights, 2011). Moreover, even though those over 50. The over-50 age group had the the President signed the WHO Framework Con- highest number of persons who quit using to- vention on Tobacco Control (FCTC) in 2003, the bacco in both 2005 and 2009 (about 26%) Convention has yet to be ratified even after 31 (Ministry of Health, 2011, 2006). bills to this end had been introduced in the Na- tional Congress (17 in the Senate and 14 in the Chamber of Representatives).1 174 Table 5.1. Prevalence of tobacco consumption, by age group, Argentina, 2005 and 2009. 175 Year Age groups 18 to 24 25 to 34 35 to 49 50 to 64 65 and older Total Chapter 5 2005 36.1 34.6 35.8 26.8 8.9 29,7 2009 28.8 33.3 30.3 27.9 10.2 27.1 Var. % -20.2 -3.8 -15.4 4.1 14,6 -8.8 Source: Author, based on data from the 2005 and 2009 National Risk Factor Surveys. The 2012 Global Adult Tobacco Survey (20.2% in girls compared to 23.7% in boys) (GATS) shows that the prevalence of smoking (Ministry of Health, 2013). among persons older than 18 decreased to Another survey, conducted in 2002 by the 21.4%, equivalent to 700,000 fewer smokers Ministry of Health in five large urban centers than in 2009 and almost one million fewer (Buenos Aires, Rosario, Córdoba, Mendoza, and smokers than in 1999. In considering the pop- Tucumán) among school adolescents 12–18 ulation older than 16, 22.3% of that age group years old, found that 3 out of every 10 were stated that they consumed tobacco in 2012, smokers at the time of the survey; the preva- with higher rates in males than in women lence among girls was greater than among boys, (29.6% and 15.7%, respectively). Among ciga- and almost half who reported having tried cig- rette smokers, most smoked daily (17.1%). The arettes said they first smoked when they were age group 25–34 years old was the age group 12 or 13 (Ministry of Health, 2002). with the highest rate of cigarette consumption Argentina also has history of high levels of (28.2%) (Ministry of Health, 2013). exposure to second-hand smoke. A 2002-2003 Although consumption is declining among study of public areas in several Latin Amer- those over 18, tobacco consumption among ican cities found that Argentina (along with adolescents is of great concern, because this Uruguay) had the highest levels of exposure group is considered a key market niche for the (Navas-Acien et al., 2002-2003). According to tobacco industry (Committee on economic, so- the ENFR 2009 survey, second-hand smoke cial and cultural rights, 2011). According to the exposure declined to 40.4%, from the 52.0% results of the last Global Youth Tobacco Survey recorded in the ENFR 2005 survey. In 2009, (GYTS) conducted in Argentina in 2012, 22.0% the sites with greater exposure were bars and of adolescents between 13 and 15 years old restaurants (46%), workplaces (28.9%), and smoke, and 43.7% said they had tried smoking homes (25.6%), levels that make it even more it at least once. Of current smokers, 47.3% said imperative to enact legislation to create 100% they bought their cigarettes at a kiosk, store, or smoke-free environments. In fact, the survey street vendor, and 81.5% were not denied the showed that in jurisdictions that have such product because of their age. Further, it was laws, exposure was lower. The 2012 Global observed that—unlike in adults—the highest Adult Tobacco Survey (GATS) shows a slight- prevalence among adolescents is among girls ly higher percentage of exposure (46.8%), although this figure should be considered cau- tiously, considering that it is an indicator that 2000, there were 39,131 deaths attributed to has methodological differences. Exposure in tobacco in persons older than 35 years, rep- 2012 was greatest in nightclubs (86.2%), fol- resenting an annual cost from loss of future lowed by universities (40.9%), public buildings income (due to premature death) of US$ 469 (24.5%), restaurants (23.2%), and educational million, implying an expenditure of US$ 14 facilities (23.1%). Moreover, 31.6% reports be- pesos per inhabitant, or 0.17% of that year’s ing exposed at work and 33.0%, being exposed gross domestic product (GDP). By 2003, costs at home (Ministry of Health, 2013). According had increased to US$ 184 million, representing to results from the 2012 Global Youth Tobacco 0.14% of that year’s GDP (Conte Grand et al., Survey (GYTS), 43.7% of adolescents (13–15 2003). years old) was exposed to second-hand smoke A recent study estimated that providing at home, with levels of exposure decreasing care for diseases directly attributed to smoking compared to the 2007 survey (54.7%) (Minis- represent a cost equivalent to 1% of Argenti- try of Health, 2013). na’s GDP and 12% of the overall amount spent on health each year. The leading determinants The economic impact of the tobacco for this high cost were: heart disease, cancer, epidemic in Argentina and chronic obstructive pulmonary disease (Pi- chon-Riviere et al, 2013). Tobacco consumption imposes a significant economic burden on the countries due to the Tobacco production in Argentina cost of caring for the sick and the loss of pro- ductivity due to disease and premature death. In 2010, global tobacco production was 7.1 It is estimated that in high-income countries, million tons: 80% is produced in China, India, the annual cost of health care attributed to Brazil, the US, Turkey, Zimbabwe, and Malawi smoking can range from a 6% to a 15% of total (Ministry of Agriculture, Livestock, and Fishing, expenditures in health (OPS, 2000). 2011). Argentina accounted for 2% of the glob- In Argentina, it was estimated that the cost al production and represented 4% of the inter- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: of care for tobacco-related diseases in 2003 national trade (Corradini et al., 2004). was approximately US$ 1.5 million, which The country’s tobacco production is mainly represents 15% of total health expenditures, concentrated in the northwest and northeast, greatly exceeding all tobacco taxes for that year, accounting for 90% of the cultivated areas in which amounted to US$ 848 million (Bruni, the provinces of Jujuy, Salta, and Misiones. Ac- 2005)3, a daily expenditure of some US$ 4 mil- cording to the 2009/2010 harvest data, the lion to treat pathologies linked to tobacco con- roughly 133,000 tons produced were distrib- Governance of Five Multisectoral Efforts sumption. Moreover, figures for 2006 show uted as follows: Jujuy, 37.2%; Salta, 34.5%; that the cost of care soared to US$ 2.3 million, Misiones, 22.1%; Tucumán, 4.2%; Corrientes, again exceeding the US$ 1.4 million collected in 0.9%; Catamarca, 0.6%; and Chaco, 0.4%. In taxes that year (Ministry of Health, 2008). monetary terms, the 2009/2010 harvest ex- Other estimates seek to quantify the cost of ceeded US$ 386.6 million, including the Special mortality attributed to tobacco in adults older Tobacco Fund (FET) (see Box 1.1), 7.3% more than 35 based on the loss of productivity. In than the surpassing the 2008/2009 harvest by 7.3% and nearly doubling the 2004/2005 har- 176 vest; almost 80% of the harvest was concen- 5.2). Information on the size of tobacco planta- 177 trated in Jujuy and Salta. tions shows that 95% of producers own under In Argentina’s tobacco-growing sector there five hectares and 50% of the cultivated surface, are 17,243 farmers who employ 49,517 per- while 1% of producers have 28% of the surface Chapter 5 sons; 15% of the farmers in Jujuy and Salta planted with tobacco and account for 37% of account for 70% of the country’s tobacco pro- the production (Corradini et al., 2005). duction and almost half the planted area (Table Table 5.2. Tobacco growing sector—production, labor, and producers, Argentina, 2009-2010 harvest. Area Value in Labor force Tobacco millions of employed in sector Production Province (en hectares) US$ (storage the tobacco producers (Kg) price + FETa) sector Planted Harvested Jujuy 19,625 19,625 49,461,487 153.8 11,220 915 Salta 22,061 21,434 45,864,600 149.2 12,517 1,691 Misiones 28,581 19,192 29,412,975 79.6 21,134 11,310 Tucumán 4,239 4,021 5,631,765 0.4 2,548 1,582 Corrientes 2,552 2,331 1,167,698 1.7 1,268 1,414 Catamarca 661 487 778,249 0.4 498 147 Chaco 575 575 543,214 1.4 332 184 Total 78,294 67,665 132.859,988 386.6 49,517 17,243 Source: Author’s calculations based on data from the Ministry of Agriculture, Livestock, and Fishing. Note: FET = Special Tobacco Fund. Argentina exports almost 80% of its tobacco to the 2009 figures. In 2011, the situation was (Ministry of Agriculture, Livestock, and Fishing, reversed, with the value of exports increasing 2011). In 2010, exports totaled US$ 306 million by 28.2% and the volume by 21.6%, totaling and amounted to 67 million kg, for a decrease of US$ 392.9 million and 82 million kg. 18.6% in value and 25.5% in volume compared Figure 5.1. Trends in tobacco exports in millions of US$ and in millions of kg. Argentina, 2006–2011 392,9 120,0 376,4 450,0 352,8 400,0 306,5 275,0 100,. 350,0 252,1 80,. 300,0 250,0 60,0 200,0 40,0 150,0 100,0 103,3 103,0 106,4 20,0 90,6 67,4 82,0 50,0 0,0 0,0 2006 2007 2008 2009 2010 2011 In millions of Kg In millions of US$ Source: Author based on data from the Ministry of Agriculture, Livestock, and Fishing. Cigarette sales depend on such variables sumption again rose in 2006. This was because as price, the population’s income, information the price of cigarettes dropped an average 8% on risks, or a ban on smoking in public plac- that year (or 16.9% in real terms) and the pop- es. Over the last 20 years, consumption in the ulation’s real income rose (Bruni, 2005). Final- country has dropped (Figure 5.2), but there ly, consumption dropped again, beginning in have been many fluctuations during this peri- 2008. It should be noted that the increase that od. For example, in 2001, consumption soared occurred in 2006 reinforced the need to levy during the economic crisis, then ended in 2003 taxes to increase the price of cigarettes and, when the National Tobacco Control Program thus, decrease sales. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: was introduced. After two years of decline, con- Governance of Five Multisectoral Efforts 178 Figure 5.2. Trends in cigarette sales and per capita consumption, Argentina, 1990–2010. 179 61 2.500 59 Chapter 5 2.000 Per cápita consumption 57 55 Millions of packs 1.500 53 1.000 51 49 500 47 45 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Per cápita consumption Total packs (in millions) Source: Author, based on data from the Ministry of Agriculture, Livestock, and Fishing. Argentina’s tobacco industry (cigarette In terms of employment, the cultivation of production and sales) is highly concentrated tobacco in its entirety (primary and second- and privately owned. There are only two com- ary activities) employed 170,754 workers, or panies—Nobleza Piccardo (linked to British 1% of the employed population at the national American Tobacco) and Massalin Particulares level. Regarding cultivation, it accounts for an (a Philip Morris subsidiary)—representing estimated 1.9% of employment in the seven 37.2% and 62.8%, respectively, of the invoiced tobacco growing provinces: 5.1% in Misiones, segment of the market (González Rozada, 4.3% in Jujuy, and 2.5% in Salta (see Figure 5.3) 2006). It is estimated that in 2009, tobacco (Ministry of Agriculture, Livestock, and Fishing, cultivation contributed 0.2% to the that year’s 2011). GNP (Ministry of Agriculture, Livestock, and Fishing, 2011).4 Figure 5.3. Importance of tobacco cultivation employment over total employment in the Ar- gentinian provinces of Misiones, Jujuy, Salta, Tucumán, Catamarca, Corrientes, and Chaco, 2010. 6 5,1 5 4,3 4 3 2,5 % 2 1 0,4 0,4 0,3 0,1 0 Misiones Juluy Salta Tucuman Catamarca Corrientes Chaco % en el empleo total Source: Author, based on data from the Ministry of Agriculture, Livestock, and Fisheries. These data show the importance of the to- are made to negotiate tobacco control policies, bacco sector in Argentina’s economy, partic- because it can effectively oppose the develop- ularly in some provinces. This weight makes ment of such measures. gives it a privileged position when attempts Box 5.1. Argentina’s Special Tobacco Fund (FET, for its Spanish acronym). Tobacco cultivation began to be promoted in Argentina in 1967, when the Tobacco Technologi- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: cal Fund was created, originally as a temporary and emergency measure. The 1978 Decree No. 19,800 established the Special Tobacco Fund (FET), which made the tobacco promotion policy permanent. PET is financed through a tobacco excise tax, representing approximately 7% of the retail price of each cigarette pack. According to the law, 80% of the tax collected is for price supports to tobacco producers, which represents a subsidy; the remaining 20% goes to retrofitting, and diversification plans in the tobacco-growing provinces. However, Argentina began to reduce the subsidy in 1997, when it Governance of Five Multisectoral Efforts signed the Agricultural Agreement of the World Trade Organization (WTO); this agreement man- dated that the internal assistance must be reduced by 13% within 10 years, beginning in 1995. At present, Argentina cannot provide more than US$ 75 million a year in direct subsidies to tobac- co-growing activities. The funds collected are allocated to the tobacco growing provinces based on the value of tobacco production. The Fund’s revenues increased 214% between 2006 and 2011, amounting to US$ 276 million in that last year. Most of the resources go to Jujuy and Salta, which receive more than 60%. 180 181 The Ministry of Agriculture, Livestock, and Fishing enforces the FET. Its functions are to peg the price of the varieties of tobacco and transfer the collection of the FET to the provinces, which are in charge paying the surcharge directly to producers. It also uses the remaining balances to finance the sector’s retrofitting plans. These plans include credit to tobacco producers, tech- Chapter 5 nological inputs, market studies, maintenance of payment systems, purchase of capital goods, technical assistance, training courses and institution building. On many occasions between 1984 and 2004, the Executive Branch tried to reduce the transfers to the FET. For example, Decree 455 of 1999 provided for a 12% reduction, and the 2001 budget stipulated a 50% reduction; however, none went into effect. On the contrary, in 2008, Law 26,467 established measures to compensate the agro-industrial chain, the regional economies that depend on tobacco production, and the fiscal collection for the potential damage caused by the tobacco control measures, increasing the amount of the FET. The law was submitted along with another regulation on health measures (file 0039-EP-2008, presented to the Chamber of Re- presentatives) signed by the President and the Ministry of Health. The latter was not approved, however. Source: Alonso and González Rozada, 2010; Ministry of Agriculture, Livestock, and Fishing, 2011; Law 26.467, 2008; Argentina, Executive Branch. Draft bill 0039-PE-2008 Taxes on tobacco 67.9% of the cigarette price to consumers rep- resents various taxes and specifically assigned The tax structure on cigarettes affects their contributions (González Rozada, 2006). Table sales price to consumers. It is estimated that 5.3 shows the various taxes and rates. Table 5.3. Tobacco taxes, rates, and fund allocation. Tax Rate Allocation Internal 60% Nation-Provinces VATa 21% Nation-Provinces Supplementary emergency 7% Social Welfare Fund (National) FET 7.35% + $0.2112 per 20-cigarette pack Primary sector Gross income 1.5%–3.5% Provinces Source: Ministry of Agriculture, Livestock, and Fishing.21 a Value-added tax Internal taxes are a single-phase tax to the fi- cy Tax. The VAT was established by Law No. nal manufacturer. They are established by Law 23,349 and applies to all phases of production No. 24,674 and have a 60% rate on the final and distribution. On cigarettes, it levies a 21% price of cigarettes, excluding the value-added rate on factory prices, plus the distribution tax (VAT) and the Supplementary Emergen- margin. The Supplementary Emergency Tax was es- goal and the amount collected. If the collected tablished by Law No. 24,625 to finance social taxes exceed the goal, the excess is transferred programs (especially health programs) within to the next fiscal period. This agreement also the Rural Change Program and the Social-Live- establishes that the Ministry of Economy does stock Program. The rate of this tax is 7% and it not create or modify any tax, contribution, is applied to the retail price, including the rest fund, or surcharge on tobacco (González Roza- of the taxes involved in the final price. da, 2012). The FET is an earmarked contribution es- The tobacco industry also contributes to tablished by Law No. 19,800, and is designed to revenues with other taxes, such as export rights meet the economic and social needs of the to- that amount to 10% for non-finished products bacco areas by imposing a rate of 7.35% on the (de-stemmed tobacco, tobacco leaves) and 5% final price prior to the VAT, internal taxes, and for value-added products (cigarettes, cigarri- supplementary emergency tax, plus $0.2112 llos), and the taxes on the companies’ profits. per 20-cigarette pack. The tax on gross income Table 5.4 shows the revenue from taxes on is earmarked for provincial financing, and is tobacco from 2006 to 2010, which amounted paid by the company, retail distributor, and re- to almost 28.500 million pesos, for an annual tail vendor. The rate ranges from 1.5% to 3.5%, average of 5.700 million pesos, or US$ 1.652 depending on the jurisdiction where the sales million. Internal taxes have the greatest partic- occurs. ipation on the total revenues (66%). With re- The tobacco sector and the Executive gard to the revenue goals, the tobacco sector’s Branch, through the Ministry of Economy, agree agreement with the Ministry of Economy set on semi-annual collection goals, which are met the amount at approximately 26,400 million through the revenues from internal taxes, the pesos (from 2006 to 2010), which was exceed- VAT, supplementary emergency taxes, and FET. ed by 900 million pesos, for a total of 27,296 In recent years, the collection goals increased, million pesos. due to large price increases, from 4.0 billion pe- Regarding earmarked distributions, the cen- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: sos to 7.6 billion pesos between 2006 and 2010 tral government is the main beneficiary, taking (González Rozada, 2012). 50% of total revenues, while the remaining If the State’s revenues from cigarette taxes half is distributed among the provinces (39%) do not reach the goal, the tobacco companies and tobacco producers (11%), through FET re- pay the State for the difference between the sources. Table 5.4. Fiscal resources generated by the tobacco sector (in millions of pesos and millions of US$, Argentina, 2006–2010. Governance of Five Multisectoral Efforts Tax 2006 2007 2008 2009 2010 Internal 2,717 3,021 3,641 4,323 5,081 VAT 380 423 509 605 711 Supplementary emergency 398 447 555 658 786 FET 363 413 486 763 1,016 182 Tax 2006 2007 2008 2009 2010 183 Total tax agreement 3,858 4,304 5,191 6,349 7,594 Profits 20 51 49 58 69 Chapter 5 Export rights 77 84 109 139 118 Total National 3,955 4,439 5,349 6,546 7,781 Gross income 55 61 74 87 103 Total collection 4,010 4,500 5,423 6,633 7,884 In US$ 1,305 1,445 1,715 1,779 2,015 Earmarked distribution 2006 2007 2008 2009 2010 Central government 2,054 2,303 2,793 3,324 3,875 Provincial governments 1,593 1,784 2,144 2,546 2,993 Producers/FET 363 413 486 763 1,026 Total 4,010 4,500 5,423 6,633 7,884 Source: Ministry of Agriculture, Livestock, and Fishing, 2011. International context for tobacco control: able alternative for tobacco growers. The FCTC the FCTC also lists actions related to environmental pro- tection, technical and scientific cooperation, WHO’s Framework Convention on Tobacco and the exchange of information. Control (FCTC), adopted on 21 May 2003 by the By January 2012, 174 countries—represent- World Health Assembly, is the first internation- ing nearly 85% of the world’s population—had al legal instrument to respond to the smoking ratified the FCTC, committing themselves to epidemic, becoming an effective and cost-effec- adopt and implement the Convention’s mea- tive solution to reduce the disease, death, and sures. Argentina has yet to ratify the Conven- economic damage from tobacco consumption. tion. The FCTC recommends actions to reduce the demand and the supply of tobacco. The Development of smoking-control provisions designed to tackle demand are orga- strategies in Argentina nized along two broad lines: i) price and fiscal measures, and ii) non-price measures, such as The nature of Argentina’s tobacco control pol- protection against second-hand smoke; educa- icies is complex, in that the sector carries an tion, communication, training and awareness important social and economic weight, partic- programs, restrictions on tobacco ads, spon- ularly in producer provinces. sorship and promotion, and new labeling of A study published by Sebrié, Barnoya, tobacco products. Those related to supply in- Pérez-Stable, and Glantz (2005) found, after clude i) strengthening laws to control the ille- reviewing tobacco industry internal docu- gal trade of tobacco products, ii) banning sales ments, newspapers, local magazines, and draft to minors, and iii) supporting economically vi- legislation, and after interviewing key actors (lawmakers, Ministry of Health personnel, and activities would be funded by the Ministry of tobacco-control spokespersons), that very sim- Health (Ministry of Health, 2006). ilar strategies were used in Argentina to try to The program’s strategy rests on a compre- stop legislation that included tobacco-control hensive approach to tackle the leading deter- measures as were used in the United States minants of tobacco consumption—easy access and other countries. For example, they creat- to tobacco products, widespread positive im- ed a weak voluntary self-regulating code that ages associated with smoking, high exposure eliminated television ads since 2003, proposed to second-hand smoke, and limited capacity of less stringent draft legislations that neutralized the health services to help individuals to stop or diverted attention from the good initiatives, smoking. The interventions that are put in place promoting instead programs such as “Courtesy act on those determinants and are coordinated of Choice” in order to avoid the 100% smoke- in order to address all three dimensions of the free environments and smoking prevention tobacco problem: primary prevention, cessa- programs for young people, in order to avoid tion, and protection of passive smokers. These stricter measures. Reports on the negative eco- interventions include: i) regulating access to nomic effects of such policies also were dis- tobacco, ii) promoting a lifestyle without tobac- seminated (Chalopka, 2001). co, iii) promoting and regulating smoke-free Until 2002, smoking-control policies in Ar- environments, and iv) developing services and gentina were limited. In 2003, however, with incentives to help smokers stop. (National To- the Ministry of Health’s launching of the Na- bacco Control Program, 2012). Since 2011, the tional Tobacco Control Program, this trend was program also is responsible for implementing reversed, as comprehensive policy was devel- the National Legislation, which requires the es- oped that included strategic actions to address tablishment of a national registry for recording the main issues related to tobacco consump- demands and violators of the law. tion. The Program is described below, along The purpose of regulating access is to pre- with progress attained in the laws it promoted. vent individuals from ever starting to smoke PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: and to reduce consumption through economic The National Tobacco Control Program barriers and measures that control the way to- In 2003, the Ministry of Health began to work bacco products are distributed. Specifically, it actively to launch some of the measures in the would increase the price of and tax on tobac- FCTC, thanks to a clear political decision by the co products, regulate the minimum size of the then minister, who wanted to address the prob- units sold, prevent the sale of loose cigarettes, lem. Thus, with the 2003 Ministerial Resolution ban sales by and to people under 18, and stop the sale through vending machines or other Governance of Five Multisectoral Efforts 236 and funding from the VIGI+A Program,5 the National Smoking Prevention and Control Pro- means that give children easy access. gram was introduced to sensitize and empower The last three aspects were incorporated the population, promote the FCTC’s ratification, into National Law No. 26,867, although the law and approve national laws. Later, through the did not address the issue of prices and taxes. To 2006 Ministerial Resolution 1124, it became address pricing and taxation, the Ministry has the National Tobacco Control Program whose supported economic studies that estimate the price elasticity of cigarette consumption and 184 the effects on tax revenues. For example, a 2004 The Ministry of Health has also worked 185 study conducted with PAHO support showed extensively to promote 100% smoke-free en- that long-term cigarette price-demand elastic- vironments as a way to protect persons from ity in Argentina was -0,265, which implies that second-hand smoke. In this regard, it has pro- Chapter 5 a 10% increase in the sales price would reduce moted the establishment of smoke-free envi- consumption by 2.65%. This result is similar to ronments in public and private institutions, the one found in high-income countries (-0.25 collective-use spaces, transportation, and to -0.50). As for the effects on fiscal revenues, it homes, and has set standards that ban smok- found that taxes could increase up to 102% and ing in work environments and enclosed public in so doing, improve tax revenues (González areas. Rozada, 2006). The Ministry also promoted To this end, it has i) created a National Regis- studies to follow up on draft legislation. try of Smoke-Free Companies and Institutions The promotion of a tobacco-free lifestyle that in 2012 listed 1,252 subscribers, includ- disseminates messages that discourage tobac- ing private enterprises, municipalities, public co consumption and prevent persons from ever agencies, schools, hospitals, and national uni- starting to consume tobacco. Specifically, the versities;6 ii) trained multipliers and prepared goal is to set standards that restrict, as much good practices guides, manuals, and training as possible, advertising, promotion, or spon- or communications materials to encourage sorship of tobacco products; avoid misinforma- more institutions to establish smoke-fee envi- tion aimed at consumers (such as using terms ronments; iii) provided technical assistance to as “light” or “smooth” cigarettes); provide mes- provinces and municipalities on how to intro- sages with strong health warnings on cigarette duce legislation on smoke-free environments; packs; disseminate messages to counter tobac- iv) disseminated information; and iv) conduct- co ads; recast smoking as an addiction; and in- ed studies and evaluations on the creation of corporate smoking prevention and control of smoke-free environments, the public’s accep- exposure to second-hand smoke into the edu- tance of them, and their benefits to health. cational system. The National Program has cooperated with On the one hand, some of these issues were the Argentinian Network of Healthy Municipal- addressed in the National Law, such as banning ities to promote smoke-free municipalities. To misleading words such as “light” or “smooth,” this end, it has provided training and techni- and placing graphic health warnings on ciga- cal and economic assistance so municipalities rette packs. On the other, the Ministry of Health can meet the requirements to be considered is still working on other measures, such as the 100% smoke-free.7 It also distributed materi- evaluation of different national, provincial, and als at various events and devoted a section of municipal laws to totally ban tobacco ads, pro- its website to the creation of smoke-free mu- motion, and sponsorship. Further, it continues nicipalities.8 to prepare and disseminate communication The Essential Public Health Functions and teaching materials, conducts studies on to- (EPHF) project also has provided funds. This bacco marketing and ads, and organizes school initiative involves a consensual planning pro- competitions on the issue. cess between the central and the provincial governments as a way to continue making progress through administrative commitments guide and evaluate decision-making; (2) a net- and incentives known as “public health activ- work of civil-society organizations, the scien- ities” (PHA), which are based on the provinc- tific community, the media, and provincial and es’ specific needs and the national programs’ municipal health agencies working to support goals. This approach represents a results-based and expand program activities; and (c) public financial transfer from the central government awareness and empowerment. to the provinces, based on their reaching the goals set in the health indicators. The National Tobacco Control Law Public Health Activity 45 serves to certify Enacting legislation is a basic step, which, smoke-free environments. Under it, projects combined with other simultaneous measures, have been financed to bring more public institu- lead to compliance with the Program’s four in- tions into the National Registry of Smoke-Free tervention areas. It was only until June 2011, Institutions, particularly health and education however, and after various attempts, that the facilities. This has been a crucial move; in the National Congress approved Law No. 26,687, early stages, participating institutions came which regulates the advertising, promotion, mainly from the private sector, and this effort and consumption of tobacco products. The highlighted the need to provide assistance to law’s key aspects include:9 public institutions to bolster their efforts to im- • Promoting 100% smoke-free environments plement these measures. by banning smoking in all public or private Finally, the National Program promotes enclosed spaces, including casinos, bingos, smoking cessation, through efforts such as: i) bars, restaurants, theaters, museums, li- establishing a free telephone service to help braries, public transportation, covered sta- smokers quit ; ii) launching “Quit and Win” diums, and workplaces. contests; iii) setting up a Web page to support • Banning advertising, promotion, and spon- smokers who want to quit; iv) disseminating sorship of cigarettes or tobacco products in national guidelines on treatment of tobacco the media and on public thoroughfares. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: addiction, which have been endorsed by more • Including graphic health warnings and ban- than 35 national scientific institutions, aca- ning the use of misleading terms such as “li- demia, and professionals; v) training health ght,” “smooth,” “low tar content.” teams on how to treat tobacco addiction; and • Banning cigarette sales to minors, whether vi) disseminating information to the general loose or in packs, in educational, health, or public. recreational establishments. These activities involve strategies that sus- According to a Ministry of Health study, the tain the program, such as: (1) social, multisec- Governance of Five Multisectoral Efforts full implementation and compliance with the toral, and intergovernmental participation; measures set forth in National Law 26,687 (2) mass communication; (3) education and could prevent 7,500 deaths due to coronary training; (4) promotion of local projects; (5) heart disease, 16,900 acute myocardial infarc- the conduct of studies and research; and (6) tions, and 4,400 strokes between 2012 and surveillance. In broad terms, these strategies 2020. Annual percent reduction would be 3% have generated three basic inputs for carrying for coronary heart disease, 3% for acute myo- out the program’s activities: (1) information to cardial infarctions and 1% for stroke. While 186 this positive effect would reach all of society, tablishments to define their smoking areas (for 187 the group that would derive the most benefit example, Santa Cruz lets industrial, commer- would be males under 55 years old, who are cial, or service establishments choose whether the age group that have the highest tendency or not to apply the smoking ban). Chapter 5 for suffering from cardiovascular disease and Fourteen provinces enacted articles about suffer the greatest mortality from those diseas- advertising, promotion, and sponsorship of es (Konfino et al., 2012). tobacco products. Most prohibit direct or indirect ads and sponsorship during sports Provincial legislation and municipal or cultural events; they also forbid the use of ordinances clothing that advertise the tobacco companies The enactment of the National Law was a ma- at those events. Legislation in some provinces, jor step in advancing smoking-control policies, such as Rí�o Negro, Santa Cruz, Catamarca, and although many initiatives already had been Chubut, allow certain types of ads, provided introduced at the subnational level. For ex- they state that consuming tobacco harms ample, some provinces have had laws in place since the 1990s (Chubut in 1992 and Formo- health. sa in 1994, reviewed in 2011 after adhering to In addition, some municipalities have en- the National Law). Beginning in 2005, several acted smoke-free regulations, applied in 47 provinces began approving smoking control municipal ordinances (see Annex 5.2). Some laws with technical support from the Ministry initiatives have been successful, such as that of of Health. Córdoba, Santa Fe, Tucumán, the City Bahí�a Blanca, in the province of Buenos Aires. of Buenos Aires, Rí�o Negro, Chaco, Corrientes, That city launched a mass media campaign to Tierra del Fuego, San Juan, and San Luis were announce that an ordinance was passed that the pioneering provinces. Altogether, 21 prov- would create 100% smoke-free environments inces out of 24 have tobacco control laws. and guarantee their compliance. Although the The laws vary (see Annex 5.1). Overall, they regulation was to be introduced gradually for promote smoke-free environments, but some different types of establishments, it would ulti- also ban advertising, promotion, and sponsor- mately include all eating establishments, malls, ship of tobacco products, or sales to minors. In bars, pubs, discotheques, and gambling rooms. terms of smoke-free environments, some prov- For each stage, the issuance and its associat- inces have enacted strict laws, such as Córdoba, ed actions would be announced in the media. Santa Fe, Tucumán, Neuquén, and the City of Before the end of the implementation process, Buenos Aires (based on Law No. 3718 passed the establishments were visited, materials on 2010). Some jurisdictions make exempt some smoke-free environments were distributed, locations, however, such as gambling rooms along with “no smoking allowed” posters, and and casinos; entertainment sites that do not awareness-raising sessions were held with admit anyone under 18; mental health cen- those in charge to encourage their cooperation. ters; prisons; reserved smoking areas in bars, Bahí�a Blanca is one of the Argentine jurisdic- restaurants, or coffeehouses; and smokers’ tions with the highest level of compliance with clubs. To a lesser extent, some laws allow es- the 100% smoke-free standard (ALIAR, 2011). In some provinces that lack smoking laws, (86.3% to 37.5%) after the law was introduced some municipalities have introduced ordinanc- (Schoi et al., 2010). Further, a study shows that es, such as the capital city of Salta and Tala (Sal- in Santa Fe province, there was a 28.3% reduc- ta), San Salvador de Jujuy (Jujuy), and Jardí�n tion in hospitalizations for acute coronary syn- América (Misiones). drome after the smoke-free environment law As a result of these actions, many provinc- was implemented (Ministry of Health, 2009). It es have consolidated their smoking control was also shown that 100% smoke-free laws in programs, promoting their application and the City of Buenos Aires, Córdoba, Santa Fe, and compliance. For example, the city of Neuquén Tucumán have not negatively affected sales in experienced a significant reduction in both ex- bars and restaurants; in fact, in the City of Bue- posure to second-hand smoke and respiratory nos Aires there may have been an increase in symptoms (from 57.5% to 28.8%) and irritation such sales (González Rozada et al., 2008). Box 5.2. When to apply national legislation and when to apply provincial laws, and municipal ordinances A basic legal principle holds that the standards from higher-level jurisdictions prevail over those from lower levels. If there were any incompatibility, the national standard prevails over the pro- vincial law, or the provincial one prevails over the municipal one. Nevertheless, if the standards protect a human right, as with tobacco controls that protect health, according to the international treaties, the more protective measure is the one that holds sway. As a result, it is understood that the National Tobacco Control Law No. 26,687 sets the standard, which means that in all provinces or municipalities without laws establishing 100% or a lesser degree smoke-free environments, the National Law must be applied. In provinces or municipali- ties that already have enacted laws, the highest standard regarding public health will prevail, be it national, provincial, or municipal. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Source: Smoke-free Partnership-Argentina (ALIAR, for its Spanish acronym). Discussions on the ratification of the tion, employment, and collection of the FET, Framework Convention which is considered as the small producers’ main support. These conclusions are based on Governance of Five Multisectoral Efforts Some studies suggest that the failure to rati- interviews with key sector actors; and analysis fy the FCTC was due to the tobacco industry’s of newspaper coverage, tobacco industry doc- lobbying strategies, pursued by tobacco pro- uments, and legislation and other documents ducers, aimed at lawmakers and Ministry of presented to the National Congress (Mejia et Economy officials (Mejia et al., 2008; Barnova al., 2008). and Glantz, 2002). The industry’s arguments The arguments of those potentially affected focused on the potential damage that ratifying can be inferred from legislation presented to the Convention would have on tobacco produc- 188 the National Congress. The Chamber of Rep- sumption, employment, tax collection, and 189 resentatives also submitted resolutions that exports) of tobacco cultivation in several prov- asked for more information about the FCTC’s inces, claiming that all these factors would be effects on tobacco production. In 2005 in par- affected if the FCTC were ratified (Ministry of Chapter 5 ticular (file: 3843-D-05), the Executive Branch Agriculture, Livestock, and Fishing, 2011). was asked to analyze whether ratifying the The arguments outlined above make it pos- FCTC would adversely affect Argentina’s to- sible to infer that the legislators’ decision to not bacco producers or workers, and whether the ratify the FCTC was due to industry objections Government had plans to provide support and about the loss of the FET, viewed as the small financial aid to pursue alternative activities for producers’ main means of support, and the tobacco growers (request report to the Execu- economic damage that reduced consumption tive Branch, 2005a). In the same year, another would have on tobacco producers. However, project (file: 4805-D-05) requested that the some studies show that these arguments can- Executive Branch report on the number em- not be fully sustained (ALIAR, 2010). ployed by the industry, the revenue obtained by According to a study conducted by the Tor- the national treasury from cigarette taxes, and cuato Di Tella University, FET funds do not nec- whether any measures existed to offset the ef- essarily benefit small producers; rather, they fects that the FCTC could have on both (request are distributed based on the value of the pro- report to the Executive Branch, 2005b). duction each province generates. For example, In 2005, the Chamber of Senators presented Salta and Jujuy, which are the major producers, nine initiatives requesting non-adherence to receive two-thirds of the funds. But in these the FCTC (seven of the resolutions) or asking provinces, a few large producers account for for additional information on the above-men- most of the tobacco farming, so the FET ben- tioned effects. For example, Draft Resolution efits them, not the small farmers (Alonso et 2868/05, submitted by 10 legislators, asked al., 2010). According to the most recent Minis- lawmakers to reject the FCTC, because it would try of Agriculture data, in 2011, 65.4% of FET affect tobacco production, eradicate tobacco resources were allocated to Salta (35%) and farming, and negatively affect the FET (Draft Jujuy (30.4%). These provinces account for Resolution, 2003). 15.1% of total tobacco producers, with an aver- The Ministry of Agriculture recently pub- age of 17.2 hectares planted per producer (13.0 lished a document (“Regional Impact of the in Salta and 21.4 in Jujuy), which is the highest FCTC: Quantification of the Economic and Social in the country (Table 5.5). Impact in the Tobacco Producing Provinces”) that shows the economic and social relevance (in terms of production level, value chain, con- Table 5.5. Distribution of Special Tobacco Fund (FET) monies (in millions of US$ and as a %), Argentina, 2011. Execution of FET funds Producers Planted area Province In millions of US$ % Total % In hectares Per producer Salta 96.6 35.0 1,691 9.8 22,061 13.0 Jujuy 83.9 30.4 915 5.3 19,625 21.4 Misiones 67.9 24.6 11,310 65.6 28,581 2.5 Tucumán 12.4 4.5 1,582 9.2 4,239 2.7 Corrientes 9.9 3.6 1,414 8.2 2,552 1.8 Chaco 3.9 1.4 184 1.1 575 3.1 Catamarca 1.2 0.4 147 0.9 661 4.5 Total 275.9 100 17,243 100 78,294 5 Source: Ministry of Agriculture, Livestock, and Fishing. The Di Tella University study also estimates growers have increased (Alonso et al., 2010). the effects that the control measures would These resources also could be used for retrofit- have over the FET collections. According to ting programs, as proposed by the Framework projections, were a comprehensive policy to Convention’s in Article 17, which urges coun- be implemented, FET collections would drop tries to foster economically viable alternatives by 50% between 2005 and 2025. However, the for workers, farmers and, ultimately, small to- amount in US dollars collected in 2025 would bacco vendors. exceed that collected in 2005 by 23%. Further, Interestingly, although ratification could these estimates suggest that it would be suf- mean a reduced domestic consumption, this ficient to increase the price of a pack of ciga- would not directly affect the producers’ in- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: rettes by only US$ 0.30 in the next 15 years, in come, because 80% of their tobacco harvest is order to prevent FET revenues from dropping exported. Moreover, the impact would not be (Alonso et al., 2010). immediate, since any change in consumption Ratifying the FCTC would not bring about occurs in the medium- and long-term, giving the end of the FET, either; in fact, the Fund producers time to adopt economically viable has been limited since Argentina signed the alternatives. World Trade Organization’s (WTO) Agricul- Governance of Five Multisectoral Efforts tural Agreement. According to this agreement, Other key actors: the Coalition the country cannot earmark more than US$ 75 for Ratifying the FCTC in Argentina million annually in direct subsidies to tobac- Civil-society organization has played an im- co-growers. For this reason, direct subsidies portant role in advancing toward tobacco-con- (amounts paid producers for surcharges) de- trol. On the whole, these organizations play five creased in recent years and resources allocat- roles: advocacy, coalition building, information ed toward modernizing programs for tobacco dissemination, compliance monitoring, and 190 service delivery (Mercet Champagne, et al., counteract the tobacco industry’s lobbying (see 191 2010). In Argentina, civil society has matured Box 5.3). and worked effectively and collaboratively to Chapter 5 Box 5.3. Leading civil-society groups in Argentina. • Coalition for the Ratification of the FCTC by Argentina • Argentinian Anti-Smoking Union (UATA, for its Spanish acronym) • Argentinian Tobacco Association (AsAT, for its Spanish acronym) • Smoke-Free Partnership–Argentina (ALIAR, for its Spanish acronym) • Inter-American Heart Foundation Argentina (FIC-Argentina, for its Spanish acronym) Source: Mercet Champagne et al., 2010. The Smoke-Free Partnership-Argentina Association (AsAT), a scientific entity created (ALIAR) is one of the most prominent entities. in 2006, is composed of health professionals Created in 2007 as a coalition of more than and others dealing with smoking from differ- 100 groups working to enact tobacco control ent perspectives (journalists, educators, public legislation and, especially, establishing 100% opinion makers, etc.). The Association is orga- smoke-free environments countrywide. In ad- nized into commissions on education, the print dition to medical organizations, it also includes media, youth, Web pages, bulletins, policies, human rights and environmental groups, as and interinstitutional relations. well as associations of health professionals The Inter-American Heart Foundation-Ar- and the catering sector, and communications gentina (FIC Argentina) also has played a part. organizations. It has contributed scientific ev- Created in 2009, the Foundation is associated idence about the economic and health impacts with the Inter-American Heart Foundation, a of smoke-free environments, and has evaluated group that works in most of the Region’s coun- compliance with the standards by monitoring tries. It works from a comprehensive view of air quality and public opinion, positioning itself public health and tackles projects through an as a reliable source of information. interdisciplinary perspective (medicine, law, Other organizations also have made signif- economy, and social work). It focuses on pro- icant contributions to the development of ac- moting legislation and public policies, and it tivities for smoking control. For example, the also develops educational and training activi- Argentine Anti-Smoking Union (UATA), created ties targeted at the community at large and at in 1987 and with more than 300 members, ad- specific audiences such as the health sector, the vocates for new generations of non-smokers. It media, and civil-society organizations. It also is works through discourse and the dissemina- involved in numerous research projects. tion of information to promote tobacco-control In December 2009, the Coalition for the Rat- activities and coordinates educational activ- ification of the FCTC was formed, representing ities and programs. The Argentinian Tobacco a milestone in civil-society organization. The coalition harnesses the efforts of nearly 70 Given industry’s historically close ties with NGOs and scientific associations that promote lawmakers and the executive branch, the group tobacco control, it works closely with the Min- also discussed the likelihood that the FCTC istry of Health’s National Tobacco Program and would not be ratified. It considered, instead, in developing a strategy to get the FCTC rati- negotiating national legislation that included fied. three health protection measures that were Discussions about the National Law also within the FCTC: i) creating 100% smoke- The Coalition pursued a strategy based on free environments; ii) banning advertising, advocacy, mass-media campaigns, training promotion, and sponsorship of and by tobacco of journalists, public events, public demon- products; and iii) having graphic health warn- strations at the National Congress to demand ings on cigarette packs. ratification, and disseminating materials to By addressing the legislation from a health lawmakers on why the issues linked to smok- perspective, and making it clear that the tobac- ing are critical. These strategies bore fruit co subsidy would not be eliminated, the cooper- when Daniel Filmus, senator for the City of ation between the tobacco industry (cigarette Buenos Aires, included the tobacco issue in production and sale) and the producers was his agenda and brought together civil groups, ruptured. And so, in June 2010, Senator Filmus representatives of the National Program, phy- submitted new draft legislation for a tobac- sicians, economists, lawyers, and the tobacco co-control law, which received support from companies in two hearings. In one, people af- the National Program. This regulation rested fected by tobacco consumption also participat- on two previous draft legislations submitted by ed, describing the health problems they suffer the Ministry of Health in 2006 and 2008. due to their addiction to tobacco. On 16 Feb- Along with the 2010 proposed law, four more ruary 2010, the senator proposed legislation pieces of draft legislation were submitted, three to ratify WHO’s Framework Convention on To- from lawmakers representing tobacco provinc- bacco Control (file 3430/09). Tobacco indus- es (Salta, Tucumán, and Jujuy), which included PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: try lobbyists once again stopped the bill from several concessions such as separate smoking being approved, however. They also presented areas, ventilation requirements for enclosed the same arguments that misrepresented the spaces (in bars and restaurants), minor warn- FCTC, claiming that it would affect the regional ings on cigarette packs (with no graphics), and economies, eliminate the FET, and ban tobacco only partial prohibitions on advertising. production. Negotiations continued between smok- After this setback, the Coalition warned ing-control advocates and those who backed against such delays and about some lawmakers’ the weaker laws. Again, Coalition representa- Governance of Five Multisectoral Efforts plans to propose weak tobacco control laws. It tives worked with the senator’s advisors, insist- also requested interviews with the country’s ing that smoke-free environments and graphic president, minister of health, and heads of par- warnings on the packages were non-negotiable. liamentary blocs to enlist their support and They ultimately yielded on the issue of adver- commitment to the ratification of the FCTC and tisements, however, which led to the following the approval of a strong national law on tobac- exceptions to Article 6 of the law: co control. 192 Exceptions to the ban on advertising or pro- developing smoking–control policies in Argen- 193 motion carried out: tina, especially after long years of advocating a. within points of sale or retailing of tobacco such a measure. Even though the FCTC has yet products, in accordance with the provisions to be ratified and even without a national leg- Chapter 5 of the regulation of the present law; islation (as of 2011), activities have been im- b. in commercial publications targeted sole- plemented that decreased smoking prevalence ly to people or institutions involved in the by 18% between 1999 and 2012—the equiva- growing, manufacture, import, export, dis- lent of some one million fewer smokers. This tribution, deposit, and sale of tobacco pro- decrease is also seen in the adolescent popu- ducts; lation, according to the Global Youth Tobacco c. through direct communications to persons Survey. The implementation of various smoke- over 18 years old, if and when prior con- free provisions has decreased the exposure sent has been obtained and his/her age has to second-hand smoke, especially in bars and been confirmed. restaurants. In addition, a national surveillance This is precisely one of law’s weakest fea- system has been developed within the Ministry tures, because it leaves the law open to inter- of Health, which has made it possible to imple- pretation, especially regarding inset “c,” on the ment the Global Youth Tobacco Survey; Argen- direct communication with those older than 18. tina is one of four Latin American countries This provision does not align with the FCTC’s that has done so. Finally, these gains should be recommendations, nor does the lack of regu- viewed as important, even without the ratifica- lation on tobacco taxes and prices. Moreover, tion of the FCTC, and should give an idea of the the law does not ensure that smoking-cessa- additional benefits that the country’s public tion programs or adequate treatment for to- health would gain if this international conven- bacco dependency will be in place, nor does it tion were to be ratified. prevent the tobacco industry from interfering with tobacco control policies. Finally, it does Lessons learned not include sustainable alternatives for tobacco The main lesson to be drawn from Argentina’s farming and environmental protection. experience is that progress can be made in ad- Moreover, the FCTC considers that it is vancing tobacco-control policies even in light critical to enlist international cooperation on of difficulties, such as the meager support from technology transfer, knowledge, financial as- other departments and the importance that the sistance, technical assistance, research, mon- tobacco sector has in the country, especially in itoring, and information exchange. It also some provinces. Working at subnational gov- emphasizes the cooperation among national ernmental levels (a bottom-up strategy), ob- organizations, and regional and international taining the cooperation and support of other intergovernmental groups in the effort to con- organizations, and launching public awareness trol illegal tobacco sales, advertising, and the campaigns for 10 years made it possible to ob- promotion of smoking across national borders. tain significant gains, despite the roadblocks. It The adoption of the National Law is not a also shows that, even without the FCTC mea- substitute for ratifying the FCTC. That said, sures being adopted, laws were enacted to cre- however, the law does represent a huge step in ate 100% smoke-free environments in many sation services have been strengthened, a locales. national tobacco law has been adopted, and While there are some issues still pend- sensitization and awareness-raising activities ing, efforts to date have led to the creation of on the issue have been carried out. multisectoral and multidisciplinary networks Civil society organizations, with support (such as the Coalition for the Ratification of from the Ministry of Health, also have played a the FCTC), empowered actors who can create significant role in the fight against tobacco for greater demands for action, and signed provin- many years. Their work has included advocacy, cial, municipal, and national laws. coalition building, information dissemination, surveillance, and service delivery. In particu- Conclusions lar, they have played a key role in getting the Tobacco consumption in Argentina is respon- National Law approved, working through a sible for 40,000 deaths a year and the loss of coalition of associations that have fought for 824,804 DALYs. Although overall smoking de- implementing measures to combat the tobacco clined the last 14 years, tobacco use among epidemic. adolescents is a matter for serious concern. In Argentina’s experience is an example of how addition, a study estimated that diseases as- controls can be introduced, even in the face of sociated with tobacco consumption represent resistance and even though the FCTC had not 15% of national health expenditures, far great- been ratified. Key to the success was the Min- er than the tobacco taxes collected in the year istry of Health’s strategy to mobilize, sensitize, of the study. and empower other actors; reaching out to Tobacco-control policies in Argentina have other players through such entities as MER- been historically weak. This began to change COSUR’s Intergovernmental Commission; and in 2003, however, when the National Tobacco coordinating the work of organizations that Control Program was created, in order to de- have long advocated for, cooperated in, and velop a comprehensive policy that seeks to have informed about the importance of addressing PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: an effect on the leading consumption determi- this issue. The strategy has also been key at the nants: easy access, widespread positive images provincial and local levels, generating various associated with tobacco consumption, high ex- laws and ordinances that set forth tobacco con- posure to second-hand smoke, and the health trol measures. services’ low capacity to treat smoking-related Challenges remain, however, such as rati- disorders or to promote smoking-cessation fying the FCTC, banning all forms of tobacco programs. advertising and sponsorship, designing a tax policy that increases the price of tobacco prod- Governance of Five Multisectoral Efforts Since the Program was introduced, much progress has been made in tobacco control. ucts to decrease consumption and dissuade There have been 100% smoke-free environ- youths from starting in the most effective way ments created, studies have been conducted possible. That said, the actions undertaken that have contributed valuable information for over the past 10 years have opened the way for the Program’s management, tobacco-control a more optimistic scenario in which to discuss legislation has been enacted in most provinc- tobacco-control future measures. es and in several municipalities, smoking-ces- 194 Annex 5.1. Provincial laws for tobacco control, Argentina.a 195 Tobacco advertising, Province Law No. Year Smoke-free environments promotion, and sponsorship Chapter 5 Bans smoking in public and private Banning of ads and enclosed spaces but allows reserving government sponsorship certain areas for smoking, such 1,799 of the CBA events that Ciudad de as party rooms, dance venues, modified by 2005 and encourage tobacco Buenos Aires restaurants, bars or cafeterias, Law 3718 2010 consumption or that (CABA)b and shopping malls/galleries. of 2010 associate smoking With the approval of Law Nº 3718, with improved sports CBA establishes 100% smoke-free performance. environments. Bans smoking in public-sector premises, factories, health and Banning of ads that education institutions (public and associate smoking with private), recreation and entertainment sports performance, their Córdobab 9,113 2005 areas for children, public posting in public agencies, transportation, theaters, cinemas, recreational spaces, concert halls, enclosed sports student media, and free stadiums, and restaurants. There are distribution of samples. no exceptions. No person may smoke or hold lighted tobacco products in enclosed interior areas of any workplace, public or private. Banning all direct and indirect ads, sponsorship of This includes public buildings, sports and cultural events, Santa Feb 12,432 2005 whether or not they offer services to and participants wearing the public, and all public or private clothing that advertises agencies, whatever their purpose companies associated with (health, educational, commercial, tobacco. cultural, services, etc.). Means of public transportation are also included. There are no exceptions. Smoking is banned in health and education facilities (public and private), public agencies, enclosed or semi-enclosed entertainment Adjusted to the terms of Tucumán 7,575 2005 settings, public transportation, and National Law 23,344 all enclosed public or private settings (e.g., museums, banks, cinemas, bars, theaters, stores, etc.). There are no exceptions. Tobacco advertising, Province Law No. Year Smoke-free environments promotion, and sponsorship Banning of ads and promotion in the media, public thoroughfares, and Smoking is banned in all enclosed in all public spaces. Ads spaces in public agencies, workplaces are exempted within points 13,894 in general, public transportation, and of sale and in publications 2008 and private spaces with access to the related to the sector. Province of 2012 modified by public. Buenos Airesb Law 14,381 Patronage and sponsorship of 2012 Exempted are smokers’ clubs and of sports, recreational, cigar stores, outpatient mental health and cultural events are centers and detention centers. prohibited, as is the wearing of clothing with tobacco ads in these events. Smoking is banned in all public or private enclosed environments with access to the public. It also includes common areas in enclosed settings: hallways, stairs, restrooms, and foyers. Entre Ríos 9,862 2008 — Exempt from this prohibition are mental health centers with inpatient facilities, prisons and penitentiaries, casinos and gambling sites, party rooms (when exclusively used for private events), and tobacco tasting points of sale. Subject to National Law 23,344. Ads are banned PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: that associate smoking with Smoking is banned in all public sector sports performance. Law 7,525 areas, in enclosed places in private of 2003, areas with access to the public (e.g. Ads are banned in public La Riojab modified by 2010 health care centers, theaters, cinemas, agencies as are tobacco Law 8,870 etc.), and in public transportation. promotion and ads in of 2010 There are no exceptions. amusement parks, plazas, parks, fairs, exhibits and/ or sports events open to persons under 18 years old. Governance of Five Multisectoral Efforts 196 Tobacco advertising, 197 Province Law No. Year Smoke-free environments promotion, and sponsorship Smoking is banned in any enclosed space (public or private) that has Chapter 5 access to the public. Exempted are mental health centers Mendozab 7,790 2007 and detention centers, party rooms — when used for private functions, gambling/game rooms under the provincial gambling and casinos authority, and private gambling rooms and casinos. Smoking is banned in all enclosed areas of public administration buildings and vehicles, any enclosed Neuquénb 2,572 2007 establishment (commercial, industrial — or service sector) used by the public, and in all public transportation. There are no exceptions. Smoking is banned in public sector All ads that associate agencies (whether or not they smoking with improved Law 3,986 provide services), in private entities sports performance are of 2005, with customer services, in places 2005 and banned. All tobacco ads or Río Negro modified by where food is handled and sold, in 2011 promotions in any media Law 4,714 public transportation, in areas where must state that tobacco of 2011 flammable substances are handled, in consumption is detrimental television programs, and in eateries or to health and is addictive. entertainment centers. Smoking is banned in public sector offices, public transportation, public and private entertainment sites, All ads related to tobacco Chacob 3,515 2005 consumption must comply Industrial, commercial, and service with National Law 23,344. establishments that people visit may opt to permit or ban smoking, stating this clearly at the buildings’ entrances. Smoking is banned in public sector offices and premises, medical care centers, exhibition rooms, convention sites, museums, banks, educational establishments, waiting rooms, and Corrientes 5,537 2004 — public transport. However, authorities (of public and private offices) may establish areas where people can smoke. Tobacco advertising, Province Law No. Year Smoke-free environments promotion, and sponsorship Smoking is banned in all areas of public sector agencies whether or not they offer services to the public, and in means of transport. Tierra del 175 2004 — Fuego Each agency may designate an area where smokers can smoke, but must place a sign stating that cigarette smoking is detrimental to health. Smoking is banned in public sector 1,103 establishments, those offering patient care, public transportation, enclosed (in 2011 it and semi-enclosed entertainment approved places, and places that sell fuel. Adjusts provisions of 1994 and Formosab Law 1,574 Article 2 of National Law 2011 to adhere When technical conditions regarding 23,344 to National the safety, health, and respect for Law non-smokers allow, it a smokers’ area 26,687) may be designated, with highly visible signs. Smoking is banned in public administration and public corporation offices and premises, in public transportation, in enclosed premises for public use, and signs must be San Juan 7,595 2005 displayed warning that “In this place, — smoking is prohibited according to Law No. 7595.” The Executive Branch may stipulate exceptions. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Smoking is banned in all enclosed areas of public sector agencies (although smoking areas may be Direct and indirect ads designated), in public transportation, that target people under recreational areas (e.g. cinemas, 18 are banned, along with theaters, stadiums), educational sponsorship of sports and and health establishments (public cultural events by tobacco and private), television programs, companies; clothing worn Santa Cruzb 2,964 2007 and workplaces with flammable by participants may not Governance of Five Multisectoral Efforts substances. contain tobacco ads. Mental health centers, prisons and All tobacco ads, promotion, correctional detention centers are and sponsorship not exempt. Industrial, commercial and prohibited by the Law, must service facilities may opt to allow or contain health warnings. ban smoking, but must state this at their entrances. 198 Tobacco advertising, 199 Province Law No. Year Smoke-free environments promotion, and sponsorship Smoking is banned in public buildings, private agencies that provide services, Banning of all ads that Chapter 5 health and education centers, public associate smoking transportation, restaurants, bars, with improved sports cafeterias, bus terminals, shopping performance. malls, theaters, cinemas, cultural centers, among others. Any tobacco ad or Catamarcab 5,223 2007 promotion must state that Exempted are places of general tobacco is detrimental public use, and dance venues where to health and causes those under 18 are not allowed in. addiction. Restaurants and bars may set aside a maximum of 30% of the area for smokers. Smoking is banned in public and private enclosed spaces where there is public access. Mental health and detention centers, Santiago del 6,962 2009 smokers’ clubs, party rooms for — Esterob private functions, and entertainment sites authorized by the province which do not allow entrance to people under 18 are exempted. These areas must have ventilation systems. Smoking is banned in public sector establishments, educational and IX-0326 in health facilities, private places of a 2004 and public nature (e.g. malls and stores, subsequent 2004 and restaurants, bars, discotheques, San Luisb approval 2010 supermarkets, and libraries, among in 2010 of others), and in public transportation. Law No. III-073 Penitentiary centers, prisons, and police detention sites are exempted. Tobacco advertising, Province Law No. Year Smoke-free environments promotion, and sponsorship Smoking is banned in workplaces, clubs, auditoriums, malls, places that handle food, public transportation, elevators, telephone booths, ATMs, enclosed urban spaces, areas where flammable substances are handled, and social welfare or recreation La Pampab 2,563 2010 centers frequented by people under 18. Areas designated for smokers at workplaces, mental health centers and detention centers where smoking areas can be designated, and smokers’ clubs are exempted. Smoking is banned in public sector All tobacco promotions establishments, educational and must prominently state that Chubut 3,775 1992 health facilities, public transport, “Smoking is Detrimental to and in the presence of children and Health.”. pregnant women. Source: Author, based on information in provincial legislation. a Health warnings are not included. b Sales to persons younger than 18 years old is forbidden. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 200 Annex 5.2. Municipal ordinances, by province, Argentina. 201 Province Ordinances Buenos Aires (13) Coronel Suárez–Bahía Blanca–Berazategui - Coronel Pringles–Coronel Rosales– Monte Hermoso–Olavarría–Saavedra–Alsina - Florencio Varela–Necochea–Pillar–Mar Chapter 5 del Plata Corrientes (2) Corrientes (capital)–Curuzúu Cuata Chaco (1) Barranqueras Chubut (3) Esquel–Trelew–Puerto Madryn Entre Ríos (5) La Paz - Santa Rosa de Villaguay–Gualeguaychú–Urdinarrain–Chajari Jujuy (1) San Salvador de Jujuy La Pampa (1) Santa Rosa Mendoza (2) Mendoza (capital)–Lavalle Misiones (1) Jardín América Neuquén (1) Neuquén (capital) Río Negro (4) Cipoletti–El Bolsón–Gral. Roca–Viedma Salta (2) Salta–Tala San Juan (5) Angaco–San Juan Capital–Caucete–Calingasta–Rivadavia San Luis (3) Juana Koslay–Mercedes –Villa Merlo Santa Cruz (1) Río Gallegos Tierra del Fuego (2) Rio Grand–Ushuaia Source: Ministry of Health. References lelo al Informe Periódico del Gobierno de Argentina. 47° Perí�odo de Sesión. Noviem- ALIAR. Por qué Argentina necesita el Convenio bre 2011. Available at: http://www2.ohchr. Marco para el Control del Tabaco. Documen- org/english/bodies/cescr/docs/ngos/ to informativo. Available at: http://www. ONeill_FIC_Fundeps_Argentina47_sp.pdf aliarargentina.org/images/stories/Docu- (last accessed on: 8 April 2013). mentos/fact_sheet_por_que_arg_necesita_ Conte Grand, M., P. Perel, R. Pitarque y G. Sán- el_cmct.pdf (last accessed on 8 April 2013). chez. Estimación del Costo Económico en ALIAR. Ambientes 100% libres de humo de ta- Argentina de la Mortalidad Atribuible al baco: herramientas para la implementación Tabaco en Adultos. Ministerio de Salud. Ar- y la evaluación. 2011. Available at: http:// gentina. 2000. www.aliarargentina.org/images/stories/ Conte Grand, M.. Estimación Actualizada del Documentos/manual_aliar_final.pdf (last Costo Económico en Argentina de la Mor- accessed on 8 April 2013). talidad Atribuible al Tabaco en Adultos. Alonso, Cristian y Martí�n González Rozada. Al- Documento de trabajo N° 253. Universidad gunas consideraciones para el tratamiento del CEMA. 2003. Available at: http://www. del Convenio Marco de Control de tabaco. ucema.edu.ar/publicaciones/download/ 2010. documentos/305.pdf (last accessed on: 8 Alonso, Cristian y Martí�n González Rozada. April 2013). Algunas consideraciones para el trata- Corradini, E., H. Zilocchi, R. Cuesta, R. Segesso, miento del Convenio Marco de Control de M. Jiménez y J. Musco. Caracterización del tabaco. 2010. Available at: http://www. sector productor tabacalero en la Repúbli- utdt .edu/ver_contenido.php?id_con - ca Argentina. Serie Documentos de Inves- tenido=5595&id_item_menu=11594 (last tigación. Universidad Católica Argentina. accessed on: 8 April 2013). Segunda versión. 2004. Available at: http:// Argentina. Poder Ejecutivo. Proyecto de Ley ex- www.msal.gov.ar/tabaco/images/stories/ pediente 0039-PE-2008. PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: institucional/pdf/catacterizacion-sec - Barnoya J., S. Glantz. Tobacco industry success tor-tabacalero-2vsCorradini.pdf (last ac- in preventing regulation of secondhand cessed on: 8 April 2013). smoke in Latin America: the ‘‘Latin Project’’. ———. Caracterización del sector productor Tobacco Control 2002;11:305–14. tabacalero en la República Argentina. Serie Bruni, José. Costos directos de la atención Documentos de Investigación. Universidad médica de las enfermedades atribuibles al Católica Argentina. Tercera versión. 2005. consumo de tabaco en Argentina. Ministe- Available at: http://64.76.123.202/site/ Governance of Five Multisectoral Efforts rio de Salud de la Nación. 2005. Available agricultura/tabaco/03=informes/02-pub- at: http://msal.gov.ar/htm/site_tabaco11/ l i c a c i o n e s / _ a rc h ivo s / 0 0 0 0 0 2 - E s t u - pdf/costos_directos_at_medica.pdf (last dios/000002-Caracterizaci%C3%B3n%20 accessed on: 8 April 2013). del%20Sector%20Tabacalero%20Argen- Comité de Derechos Económicos, Sociales y tino/000001-Informe%203%C2%BA%20 Culturales. Control de Tabaco en Argentina: Versi%C3%B3n%20-%20Junio%202005. Avances y Tareas Pendientes. Informe Para- pdf (last accessed on: 8 April 2013). 202 Chaloupka, F., P. Jha, M. Corrao, V. da Costa e Sil- Ley 26.467: Modificaciones a la Ley Nº 24.674 203 va, H. Ross, C. Czart y D. Yach. The Evidence de Impuestos Internos y a la Ley Nacional Base for Reducing Mortality from Smoking del Tabaco Nº 19.800. Establézcanse medi- in Low and Middle Income Countries. CMH das económicas para desalentar el consumo Chapter 5 Working Paper Series. Paper No. WG5: 7. de productos elaborados con tabaco. 2008. 2001. Available at:http://library.cph.chula. Mejia, R., V. Schoj, J. Bernoya, L. Flores, E. ac.th/Ebooks/HealthCareFinancing/WG5/ Pérez-Stable. Tabacco Industry Strategies Paper%20no.WG5_7.pdf (last accessed on: to Obstruct the FCTC in Argentina. CVD 8 April 2013). Prev Control. 3(4):173:179. 2008. Available González Rozada, M.. Economí�a del Control del at: http://www.ncbi.nlm.nih.gov/pmc/ar- Tabaco en los paí�ses del Mercosur y Esta- ticles/PMC2630219/ (last accessed on: 8 dos Asociados. Argentina 1996-2004. OPS. April 2013). 2006. Available at: http://www.paho.org/ Mercet Champagne, B., E. Sebrié y V. Schoj. Spanish/AD/SDE/RA/Tab_Mercosur_ARG. The role of organized civil society in ta- pdf (last accessed on: 8 April 2013). bacco control in Latin America and The ———.Estudio sobre el comercio ilegal de pro- Caribbean. Salud Pública de México 2010; ductos del tabaco en Argentina. 2008.— 10; 52 supl 2: S330-S339. Available at: ——.Una polí�tica fiscal saludable. Foro http://bvs.insp.mx/rsp/articulos/articu- Económico. 2010. Available at: http:// lo_e4.php?id=002536 (last accessed on: 8 focoeconomico.org/2010/10/13/una-po- de abril de 2013). litica-fiscal-saludable/ (last accessed on: 8 Ministerio de Agricultura, Ganaderí�a y Pes- April 2013). ca. Impacto Regional del Convenio Marco González Rozada, M., M. Molinari, y M. Virgo- para el Control de Tabaco. Cuantificación lini. The economic impact of smoke-free del impacto económico y social en las pro- laws on the sales in bars and restaurants vincias productoras de tabaco. 2011. Avail- in Argentina. Universidad Torcuato Di Tel- able at: http://www.minagri.gov.ar/site/ la y Minsiterio de Salud de la Nación. 2008. agricultura/tabaco/03=informes/02-pub- Available at: http://www.utdt.edu/down- licaciones/_archivos/000004-Publicacio- load.php?fname=_126633053664344100. nes_y_Estudios_Especiales/000013-Impac- pdf (last accessed on: 8 April 2013) to%20Regional%20del%20Convenio%20 Jha, P., F. Chaloupka, J. Moore, V. Gajalakshmi, P. Marco%20para%20el%20Control%20 Gupta, R. Peck et al. “Tobacco Addiction”. In de%20Tabaco%20-Version%20en%20 Disease Control Priorities, Second Edition. Espa%C3%B1ol.pdf ?PHPSES- Capí�tulo 46. Pp. 869–885. 2006. Available SID=c54d5256425db5f41be9f201c5dcf2f5 at: http://www.dcp2.org/pubs/DCP (last (last accessed on: 8 April 2013). accessed on: 8 April 2013). ———. Ejecución mensual del presupuesto del Konfino J., D. Ferrante, R. Mejí�a, P. Coxson, A. Mo- FET - Ejercicio 2011. ran, L. Goldman, E. Perez-Stable. Impact on ———.Volumen de Paquetes de Cigarrillos Cardiovascular Disease Events of the imple- Vendidos por Rango de Precio. 2004-2012. mentation of Argentina’s National Tobacco Control Law. Tobacco Control 2012;0:1–8. Ministerio de Salud de la Nación. Encuesta nal_De_Factores_De_Riesgo_2011.pdf (last Nacional de Tabaquismo en adolescentes, accessed on: 8 April 2013). 2002. ———.Encuesta Mundial de Tabaquismo en ———.Primera Encuesta Nacional de Facto- Adultos. Argentina 2012. 2013 res de Riesgo. 2006. Available at: http:// ———.Encuesta Mundial de Tabaquismo en msal.gov.ar/ENT/VIG/Publicaciones/En- Jóvenes. Argentina 2012. Resumen ejecuti- cuestas_Poblacionales/PDF/Encuesta%20 vo. 2013. Nacional%20De%20Factores%20De%20 Navas-Acien, A. A. Peruga, P. Breysse, A. Zavale- Riesgo%202005%20-%20Version%20 ta, A. Blanco-Marquizo, R. Pitarque et al. Completa.pdf (lst accessed on: 8 April Secondhand tobacco smoke in public places 2013). in Latin America, 2002-2003. JAMA. 2004; ———.Resolución Ministerial 1124 del 4 de 291(22): 2741-45. Available at: http:// agosto de 2006. Available at: http://www. jama.ama-assn.org/content/291/22/2741. msal.gov.ar/tabaco/images/stories/insti- full.pdf+html (last accessed on: 8 April tucional/pdf/resolucion-1124.pdf (last ac- 2013). cessed on: 8 April 2013). OMS. Convenio Marco de la OMS para el ———.Programa Nacional de Control del Tab- Control del Tabaco. 2003. Available at: aco. Informe de gestión 2003–2007. 2008. http://whqlibdoc.who.int/publications/ ———.Encuesta Mundial de Tabaquismo en 2003/9243591010.pdf (last accessed on: 8 Adolescentes en Argentina. Resultados April 2013). 2007 y comparación con encuestas previ- ———. The Global Burden of Disease. 2004 Up- as. Mayo 2009. Available at: http://www. date. 2008. Available at: http://www.who. msal.gov.ar/tabaco/images/stories/in - int/healthinfo/global_burden_disease/ fo-equipos-de-salud/pdf/encuesta_mundi- GBD_report_2004update_full.pdf (last ac- al_tabaquismo_adolescentes_2007.pdf (last cessed on: 8 April 2013). accessed on: 8 April 2013). ———. Global status report on noncommu- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: ———.Reducción de los ingresos hospitalarios nicable diseases 2010. 2011. Available at: por sí�ndromes coronarios agudos luego de http://whqlibdoc.who.int/publications/ la implementación exitosa de la legislación 2011/9789240686458_eng.pdf (last ac- 100% libre de humo. Boletí�n de Vigilan- cessed on: 8 April 2013). cia de Enfermedades No Transmisibles y ———. Health statistics and health informa- Factores de Riesgo N° 1. 2009. Available tion systems. Available at: http://www. at: http://msal.gov.ar/ENT/VIG/Publica- who.int/healthinfo/global_burden_dis - ciones/Boletines_ENT/PDF/Boletin%20 ease/estimates_country/en/index.html Governance of Five Multisectoral Efforts Epidemiologico%201.pdf (last accessed on: (last accessed on: 8 April 2013). 8 April 2013). ———. Tobacco Free Initiative (TFI). MPOW- ———.Segunda Encuesta Nacional de Factores ER. Available at: http://www.who.int/to- de Riesgo para enfermedades no transmi- bacco/mpower/publications/en/index. sibles. 2011. Available at: http://msal.gov. html (last accessed on: 8 April 2013). ar/ENT/VIG/Areas_Tematicas/Factores_ OPS. La epidemia de tabaquismo. Los gobier- de_Riesgo/PDF/Segunda_Encuesta_Nacio- nos y los aspectos económicos del control 204 del tabaco. Publicación cientí�fica N° 577. Programa Nacional de Control del Tabaco: 205 2000. Available at: http://www.paho.org/ http://www.msal.gov.ar/tabaco/ (last ac- spanish/dbi/PC577/PC577_prelim.pdf cessed on: 8 April 2013). (last accessed on: 8 April 2013). Rossi, S., M. E. Roger, J. Leguiza y A. Irurzun. Chapter 5 Pichon-Riviere, A., A. Alcaraz, A. Bardach, F. Au- Carga Global de enfermedad atribuible al gustovski, J. Caporale, F. Caccavo. Carga de tabaquismo en Argentina. 2005. Programa Enfermedad atribuible al Tabaquismo en Vigia, Ministerio de Salud de la Nación. Argentina. Documento Técnico IECS N° 7. Sebrie, E., J. Barnoya, E. Perez-Stable, y G. Stan- Mayo 2013. ton. Tobacco industry successfully prevent- Proyecto de Ley: Ratificación del Convenio ed tobacco control legislation in Argentina. Marco para el Control de Tabaco aproba- Tobacco Control. 14;2. 2005. Available at: do por la 56 Asamblea Mundial de la Salud http://www.fac.org.ar/fcardio/gral/Ar - (OMS), aprobado el 21 de mayo de 2003. gentina.pdf (last accessed on: 8 April 2013). Nº de Expediente 1198-D-2011. Trámite Schoj, V., M. Alderete, E. Ruiz, S. Hasdeu, B. parlamentario Nº 016. 2001. Available Linetzky y D. Ferrante. Impacto de legis- at: http://www1.hcdn.gov.ar/proyxml/ lación 100% libre de humo en la salud de expediente.asp?fundamentos=si&numex- los trabajadores gastronómicos de la ciu- p=1198-D-2011 (last accessed on: 8 April dad de Neuquén, Argentina. Tobacco Con- 2013). trol. 2010; Apr; 19 (2):134-7. Available Pedido de informe al Poder Ejecutivo sobre at: http://www.ficargentina.org/images/ los efectos perjudiciales para productores stories/Documentos/Impacto_salud_ tabacaleros y trabajadores del sector, del Neuquen_ALH.pdf (last accessed on: 8 April Convenio Marco de la OMS para el control 2013) del tabaco. Expediente Nº 3843-D-05. Fe- cha de publicación 29/06/2005. Notes Pedido de informes al Poder Ejecutivo sobre el 1 Draft legislation: Ratification of the Framework Con- empleo e ingresos que genera la industria vention on Tobacco Control approved by the 56th world Health Assembly, approved on 21 May 2003. Dock- tabacalera en la República Argentina. Expe- et No. 1198-D-2011. Parliamentary procedure No. diente Nº 4805-D-05. Fecha de publicación: 016.2001. 24/08/2005. 2 Prevalence is defined as those who have consumed Proyecto de Resolución Rechazando el Con- more than 100 cigarettes in their lifetimes and cu- rrently smoke venio Marco de la OMS para el control del 3 The study assessed the direct cost of caring for di- tabaco, suscripto en Ginebra, Confedera- seases attributed to tobacco. Among the mortality ción Suiza, el 21 de mayo de 2003. Expe- considered were deaths from lung cancer, chronic obs- tructive pulmonary disease, acute myocardial infarc- diente Nº2868/05. Available at: http:// tion, and stroke (CVA), which represented almost 70% www.senado.gov.ar/web/proyectos/ver- of all the deaths attributed to smoking.. Expe.php?origen=S&tipo=PR&numex- 4 In 2002, three multinationals (Japan Tobacco, Philip p=2868/05&nro_comision=&tConsulta=3 Morris, and British American Tobacco) controlled the tobacco market; their combined income was over US$ (last accessed on: 8 April 2013). 121 billion. This amount is greater than the combined GDPs of Albania, Bahrein, Belize, Bolivia, Botswana, Cambodia, Cameroon, Estonia, Georgia, Ghana, Hon- duras, Jamaica, Jordan, Macedonia, Malawi, Malta, ducts are to be sold in the premises (kiosks or internal Moldavia, Mongolia, Namibia, Nepal, Paraguay, Sene- bars); and (6) there are to be no ash-trays, except at gal, Tajikistan, Togo, Uganda, Zambia, and Zimbabwe. the institution’s entrances so that smokers can discard (Source: PAHO. Tobacco increases the poverty of coun- cigarette butts. Accreditation is valid for two years. tries. Fact sheet. 2004. Available at: http://www.paho. 7 Municipalities must meet the following requirements: org/English/AD/SDE/RA/TOB_FactSheet2.pdf) have an ordinance creating 100% smoke-free pu- 5 The VIGI+A Program was a Ministry of Health pro- blic space; make all its buildings and facilities 100% gram designed to strengthen surveillance and disease smoke-free; ban the sale of tobacco in its buildings control, as well as promote health; it had World Bank and facilities; require that all its events be smoke-free; financing. exercise leadership in tobacco control; and periodica- 6 To be incorporated in the registry, an institution must lly carry out media campaigns to promote tobacco-free meet the following requirements: (1) all of its enclosed environments and lifestyles. spaces must be smoke-free, and smoking is banned not 8 Available at: http://www.msal.gov.ar/tabaco/index. only in enclosed spaces, but also in open areas near php/informacion-para-profesionales/ambientes-li- the buildings’ air vents; (2) all the institution’s vehicles bres-de humo/municipios must be smoke-free; (3) all institution events must be 9 Law 26,687 may be viewed at: http://www.infoleg.gov. smoke-free; (4) all institutional levels (employees, ma- ar/infolegInternet/anexos/180000-184999/183207/ nagers, owners) and visitors (suppliers, clients, etc.) norma.htm. must comply with the regulation; (5) no tobacco pro- PREVENTION OF HEALTH RISK FACTORS IN LATIN AMERICA AND THE CARIBBEAN: Governance of Five Multisectoral Efforts 206 The World Bank 1818 H Street, NW, Washington, DC 20433, USA. www.worldbank.org