January 2013 Number 181 75189
www.worldbank.org/enbreve
A regular series of notes highlighting recent lessons emerging from the operational and analytical
program of the World Bank‘s Latin America and Caribbean Region (LAC).
Governance of Multi-sectoral Interventions to
Promote Healthy Living in Latin America and
the Caribbean1
by María E. Bonilla-Chacín Fondo Español para Latinoamérica y el Caribe
2. Much of this health and economic burden can be avoided, since
an important share of NCDs is due to exposure to preventable
risk factors such as unhealthy diets, physical inactivity, tobacco
use, and alcohol abuse.2 Diets in most LAC countries are high in
calories, sugars, fats and sodium, and low in fruits and vegetables.
These diets, combined with sedentary lifestyles, are responsible
for the large percentage of overweight and obese adults. Due to
the disability-adjusted life years lost, attributed to overweight and
obesity, the 2010 Burden of Disease Study ranked high body mass
index as the first risk factor for health in southern LAC (Argentina,
Chile and Uruguay), the second in the Caribbean and in Central
LAC (Mesoamerica, Colombia and Venezuela), and the third in the
rest of the region.3 The study also ranked tobacco use among
Ciclovía Bogotá , photo taken by Diana Fernández. the first five risk factors in LAC and alcohol abuse as the main risk
factor in all sub-regions, with the exception of the Caribbean and
southern LAC, where alcohol was ranked among the first five.
Health and Economic Burden of
Non-Communicable Diseases in LAC Multisectoral Interventions to Prevent
Health Risk Factors and Pending Agenda
1. The Latin America and Caribbean region has been experiencing
a rapid demographic and epidemiological transition which has
for LAC
important health and economic consequences. Not only is the
population aging rapidly, but it is also experiencing major changes in 3. Many interventions to prevent some of the NCD economic and
lifestyle. This has altered the disease and mortality profile, reflected health impacts go beyond the health sector and the activities it
in the increasing weight of non-communicable diseases (NCDs), traditionally delivers. In this context, strengthening multi-sectoral
such as heart disease, stroke, cancer and diabetes. These conditions efforts to improve diets, promote physical activity, and particularly,
also represent an increasing economic and development threat to to reduce tobacco use and alcohol abuse, are priorities. There are
households, health systems, and economies. several cost-effective interventions that have been proven to lower
1. This En Breve was prepared by María E. Bonilla-Chacín based on the regional study on Promoting Healthy Living in Latin America and the Caribbean:
Governance of Multi-sectoral Activities to Prevent Health Risk Factors. This study was made possible thanks to the financial support of the Spanish Fund for
Latin America and the Caribbean.
2. World Health Organization. 2005. WHO Report. Preventing Chronic Diseases. A Vital Investment. Genève: WHO.
3. Lim, Stephen. S., A. D. Lopez, C. J. L. Murray, M. Ezzati, T. Vos, A.D. Flaxman, G. Danaei, K. Shibuya, H. Adair-Rohani, M. Amann, H Ross Anderson, K.G. Andrews,
M. Aryee, C. Atkinson, L. J Bacchus, A. Bahalim, et al. 2012. A comparative risk assessment of the disease and injury burden attributed to 67 risk factors and risk
factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60.
1
6. In addition, policies to control tobacco use and alcohol abuse
Table 1:
are often not fully enforced, and there is room for improving fiscal
Examples of successful or promising multi-sectoral interventions to prevent risk factors in OECD and LAC countries –targeted risk
policies 4,5, In the case of alcohol abuse, the laws have many gaps,
factors, evidence of cost-effectiveness (C/E) according to WHO, and sectors involved
particularly those that restrict alcohol sales. Although alcohol
abuse is the main health risk factor in most of the region, there Risk
is little information about comprehensive strategies to control it. WHO – C/E Intervention International Examples Sectors Involved
Factor
However, two promising strategies were implemented in Brazil, in
Salt reduction strategies North Karelia, Finland community program to Agriculture, health,
the cities of Diadema and Paulina.6,7 reduce CVD. food production,
Argentina agreements with the industry to food retai, food
International and Regional Experiences reduce sodium in processed foods. advertising,
restaurants, city
with Multi-sectoral Interventions to Replacing trans fat New York City ban on trans fats in restaurants.
governments,
Best Buys
Denmark legislation.
Prevent Health Risk Factors – Lessons for Argentina reform of the Food Code to regulate legislature.
Unhealthy diets
Mexico City, photo by M. Bonilla-Chacín. LAC amount of trans fats in processed foods.
Nutrition labeling UK traffic light system.
US 1994 Nutrition and Education Bill.
exposure to tobacco use and alcohol abuse (Table 1). There are 7. Improving diets, increasing physical activity, and reducing NYC regulates calorie content in restaurants.
fewer well known cost-effective interventions to improve diets tobacco use and alcohol abuse require the concerted efforts Social media campaigns Wheeling, US, 1% or less campaign.
and promote physical activity, except for those to decrease the of different stakeholders in various sectors; for this reason, the EPODE Project.
intake of sodium and trans fats. Thus, controlling tobacco use and decision-making process associated with these interventions Regulating Advertising on marketing UK statutory regulation on advertising.
interventions
and low cost
alcohol abuse should be the main priorities, followed by reducing presents challenges to policymakers and other health advocates. of foods and beverage high in salt,
Other C/E
the intake of sodium and trans fats. But, given the importance International experience shows that to overcome them, some of fats and sugar, especially to children
of overweight and obesity as risk factors, countries should adopt the following strategies will be required. Taxes and subsidies to promote US Taxes on sodas.
policies to improve diets in general and physical activity. healthy diets Poland Elimination of butter and lard subsidies.
8. To consolidate the various stakeholders’ interests towards the
Social media campaigns US VERB campaign. City governments,
Best
Buy
Physical Inactivity
4. There are several examples of successful or promising same public health goal, policymakers must engage in dialogue Brazil Agita Sao Paulo. urban planning,
interventions to promote healthy living in the region. These and negotiations with all interested parties. To succeed, in this transport, health,
Modifying the built environment to Bogotá, Colombia.
Effective but
civil society
not enough
include the following: (a) In Argentina, agreements between the course authorities need to understand the incentives for each
evidence
increase physical activity organizations
on C/E
government and industry to reduce sodium in processed foods stakeholder. There are promising examples of agreements
(CSO), media.
and the reform of the Food Code to reduce trans fats in processed between governments and industry to improve public health; one
foods, (b) in Bogota, a built environment that promotes physical of those examples can be found in LAC, the agreements reached
activity; (c) in Mexico, the National Agreements for Food Health between the food industry and the Government of Argentina to Work-based programs US Treatwell 5-a-day. Agriculture, health,
Effective but not enough
nutrition and physical
programs to improve
(the National Anti-Obesity Strategy), and (d) in Uruguay, tobacco reduce sodium in processed foods. food industry, food
Community-based
School-based programs US Child and Adolescent Trial Cardiovascular
evidence on cost
control policies (Table 1). Also, almost all countries signed the retail industry,
effectiveness
Health (CATCH).
schools, work
activity
Framework Convention for Tobacco Control (FCTC) and have 9. Often, when a government initiates the dialogue, companies US Pathways.
places, food
passed laws and regulations accordingly. Similarly, most LAC develop their own guidelines and standards that improve their Other community based program North Karelia – Finland. retailers, others.
countries have in place some of the cost-effective interventions products’ impact on public health. In the UK, food companies Mexico National Accords for Food Health
- Technical Guidelines for the sale and
needed to control alcohol abuse. Moreover, at the local and developed their own standards for nutrition labels (Traffic Lights distribution of food and beverage in basic
national levels groups of deeply committed policymakers and System) which have been effective.8 education establishments
health advocates have created effective and long-lasting policies Fiscal Measures There are several successful world examples. Finance, health,
Tobacco use
to prevent NCDs. 10. However, voluntary actions are often ineffective and Banning smoking in public places. In LAC, Uruguay tobacco control policy is legislature,
Best Buys
policymakers have replaced them with regulations. For example, Raising awareness and increasing among the most successful ones. international
5. Despite these examples, there is relatively little evidence in Europe, Canada, and the US, early voluntary nutrition labeling knowledge about dangers of tobacco organizations,
use. tobacco industry,
of ongoing activities to fight NCDs at population level in LAC, actions failed to meet government standards and expectations CSO.
particularly with respect to policies to improve diets. It has been which led governments to use mandatory guidelines. In New York
Fiscal Policies USSR, Gorbachev anti-alcohol legislation. Federal and state
difficult worldwide to reverse the obesity trend; however, some City, authorities encouraged restaurants to voluntarily provide governments,
Restrictions on availability and access Sweden Systembolaget.
policies have helped improve diets and promote physical activity. easily-seen nutrition information to customers, but, as this did not City government,
Alcohol abuse
Best Buys
to alcohol US licensing system
Regarding physical activity, some LAC cities are launching policies occur, the City passed a regulation.9,10 health sector,
Limiting the hours of alcohol sales Austraila, Halls Creek. police, CSO.
to build environments that facilitate it; but such efforts often occur Brazil, Diadema.
only in large urban centers and upper-middle-income countries.
Age restrictions on alcohol purchase US Minimum Legal Drinking Age.
and sales.
4. World Health Organization 2011. Global Status Report on Alcohol and Health. Geneva: WHO. BAC US Checkpoint Tennessee.
5. World Health Organization 2011. WHO Report on the Global Tobacco Epidemic 2011. Geneva: WHO.
6. Pacific Institute for Research and Evaluation 2004. Prevention of Murders in Diadema, Brazil. The Influence of New alcohol Policies. Source: Bonilla-Chacin, M.E. (in process) Promoting Healthy Living in Latin America and the Caribbean: Governance of Multi-sectoral Activities to Prevent
http://resources.prev.org/resource_pub_brazil.pdf Health Risk Factors. Washington DC: The World Bank.
7. Monteira, Maristela. Alcohol and Public Health in the Americas. PAHO . A case for Action. Washington DC, 2007. Note: The second column of the table (WHO-C/E) indicates whether WHO considers the intervention a “best buy�?; those interventions “known to be effective,
8. Van Camp D.J., N.H. Hooker, D.M. Souza-Monteiro 2010. Adoption of voluntary front of package nutrition schemes in UK food innovations. British Food feasible, and affordable in any resource setting�? (World Health Organization. 2011. Global Status Report on Non-communicable Diseases 2010. Geneva: WHO).
Journal, Vol. 112, 6, 580-591. It also includes other cost-effective interventions and those that are effective but do not have enough evidence on their cost-effectiveness (C/E).
2 3
11. In some cases, the dynamic between the governments and public support. Similarly, in the city of Diadema, Brazil, through
the sector they want to regulate can be highly confrontational; education campaigns and discussions with alcohol retailers, public
thus, governments must be prepared for this. Regulations in the opinion quickly supported policies to restrict alcohol sales.
tobacco industry provide a clear example. Even where countries
successfully reduce tobacco use through strong control policies, 14. In many instances, research has played a critical role in
they still face hurdles, as occurred in Uruguay: In 2010, Phillip Morris having widespread preventive interventions adopted. Thus, the
International appealed to the International Centre for Settlement importance of solid, independent, and convincing research cannot
of Investment Disputes (ICSID) for an arbitration procedure against be overstated, as it is critical in shaping public opinion and raising
the Government of Uruguay for some of its tobacco control support for policies. For example, in the UK, the decision to create
policies.11 a statutory regulation on food advertisements aimed at children
was influenced by research that found an association between
12. Most successful efforts require strong coordination among advertising and children’s food preferences, and a study showing
the many stakeholders involved; often, it occurs through the that a large percent of the expenditures on food ads directed at
leadership of ministries of health and institutional arrangements children was for products that were high in fat, sugar and salt.13
that favor it. The role of the health sector has been key in many Because research findings must be communicated to policymakers
successful experiences. Often, it launched the dialogue among and the public, civil society groups have played a crucial role in
various actors and ensured their coordination. This occurred in publicizing the data and raising public awareness.
Argentina, with the agreements to reduce sodium and the revision
of the Food Code to reduce trans fats in processed foods: Under a 15. Many of the successes have been due to the leadership
MoH initiative, a National Commission to Eliminate Trans Fats and and political commitment of some key political figures. For
Reduce Salt was created that involves several public and business example, (a) in Uruguay, a group of committed politicians and
organizations, scientific associations, and civil society groups. Also, policymakers, including President Tabaré Vázquez, supported by
in Uruguay, through a MoH request, the National Alliance for strong advocacy groups, fought tobacco lobbying efforts and
Tobacco Control, a coordination agency was created that consists passed comprehensive, effective tobacco control policies; and
of government agencies, parastatals, international organizations, (b) in Bogotá, the continuous efforts of two mayors, Antanas
academic institutions, and NGOs. Mockus and Enrique Peñaloza, helped consolidate the city’s built
environment in ways that would promote physical activity.
13. In general, policymakers and health advocates often gauge
and mobilize public opinion to support these health promotion 16. Also, taking advantage of favorable conditions or times has
policies and ensure their design and implementation. For example, been key to enacting some of the policies. With respect to tobacco,
while the regulation to reduce trans fats was being discussed the Framework Convention for Tobacco Control has generated
in New York City, authorities routinely publicized their concerns an international awareness that helped tobacco control policies
about the links between trans fats and coronary heart disease, to be adopted globally. Similarly, the decentralization process in
which contributed to public consensus in favor of the regulation.12 Colombia made it possible for elected mayors to independently
In Uruguay, the policy to promote smoke-free environments was pursue policies that changed the cities’ built environment in ways
accompanied by strong communication campaigns to ensure that promoted physical activity.
9. New York City Board of Health 2007. http://www.cspinet.org/new/pdf/nyc_frieden.pdf
10. Mello MM 2009. New York City’s War on Fat. The New England Journal of Medicine. 360; 91. Boston: The Massachusetts Medical Society.
11. Weiler T. Phyllip Morris vs. Urugay. An Analysis of Tobacco Control Measures in the Context of International Investment Law. Report #1 for Physicians for a
Smoke Free Canada. 28 July 2010.
12. Mello MM. 2009.
13. Hastings G and Carins G. 2010 Food and beverage marketing to children. In Preventing Childhood Obesity. Waters, E., B. Swinburn, J. Seidell, R. Uauy.
Editors. Preventing Childhood Obesity: Evidence Policy and Practice. Wiley-Blackwell. BMJI Books.
Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive
Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not
guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not
imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.
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