Ten Years of a National Oral Health Policy in Brazil

Abstract

Brazil is the only country in the world to propose a universal health care system with the aim of guaranteeing delivery of all levels of health care, free of charge, to a population of over 200 million inhabitants by means of a unified health system (“Sistema Único de Saúde” [SUS]). The national policy of oral health, also known as Smiling Brazil (“Brasil Sorridente”), was implemented in 2004. Oral health was designated as 1 of the 4 priority areas of the SUS, transforming oral health care in Brazil, with the objective that the SUS achieve the integrality of care envisaged at its creation. The aim of this article is to share part of this experience in order to prompt reflection about the inclusion of oral health care in other health care systems around the world. The most significant results of Smiling Brazil can be seen in 3 areas: 1) oral health epidemiological indicators, 2) financial investment and professional development, and 3) the building of an oral health care network throughout the 10 y of the policy. The “Discovery!” article presented here portrays 10 y of evolution; however, it is important to point out that this is a process undergoing construction and that the oral health care network needs to be further expanded, refined, and solidified so that over time and through changes in the political parties in power, Smiling Brazil prevails as a perennial policy and not merely an action by a single government.

Keywords

community dentistry dental public health preventive dentistry epidemiology delivery of health care community health services

Introduction

Brazil is the only country with more than 200 million inhabitants that has a universal health care system funded by federal, state, and municipal budgets (Brasil 1988). In recent decades, the system has evolved from an exclusionary to a universal model, a unified health system (“Sistema Único de Saúde” [SUS]), where everyone is entitled to health care and the government is required to provide it. Primary health care is the backbone of the new system, in keeping with the guidelines set forth by the Primary Healthcare Reform, recommended by the Pan American Health Organization/World Health Organization (WHO) (2007).

In 2011, The Lancet published a special issue reporting on the great strides made by Brazil through the SUS, highlighting the following points: 100% vaccination coverage; universal mother and child health care and universal health care for patients with HIV+ and AIDS; and a consolidated policy of providing high-complexity procedures, such as hemodialysis and transplants, among other services indicative of an effective government policy (Paim et al. 2011). However, the system clearly faces enormous challenges posed by the wide-ranging socioeconomic diversity of the population, whose lower income individuals have limited access to oral health services. This is an ongoing obstacle to overcoming health inequality (Antunes and Narvai 2010).

Evidence shows that Brazil is tackling its health inequalities. In a clear demonstration that the country is overcoming this challenge, it was removed from the WHO’s hunger map in 2014 after 22 million were lifted out of extreme poverty, meaning that the segment of the population living in extreme poverty fell from 25.5% to 3.5% between 1990 and 2012 (Food and Agriculture Organization of the United Nations 2014). These improvements led to Brazil’s meeting one of the United Nation’s Millennium Development Goals for 2015 (United Nations 2000). For Brazil to take these strides, it had to deploy actions across different sectors and take individuals as well as society as a whole into consideration (Baum et al. 2009). Bearing in mind this integral approach, oral health care was incorporated into the public health care system.

During the first years of the SUS, oral health care was incipient and very limited in scope. However, after the 2002 election of Luiz Inácio (“Lula”) da Silva, the national policy of oral health, also known as Smiling Brazil (“Brasil Sorridente”), was launched in 2004. Under its initiative, oral health was designated as 1 of the 4 priority areas of the SUS. This policy changed the concept of oral health care by pursuing the integral care system envisaged for the SUS at its creation (Pucca Jr. et al. 2010). Positive evidence of the accomplishment of this goal can be attested by observing the following: 1) oral health epidemiological indicators, 2) financial investment and professional development, and 3) the building of an oral health care network throughout the 10 y of the policy.

In view of the strides made by Smiling Brazil and the challenges faced by one of the boldest and most innovative public oral health care policies in the world, the aim of this article is to share part of this experience and, in so doing, prompt reflection about the inclusion of oral health care in other health care systems worldwide.

Oral Health Epidemiological Indicators

Brazil tracks its epidemiological indicators through nationwide surveys, aimed at providing information for its public health decision-making process. Two of the most relevant of these are the National Household Survey (“Pesquisa Nacional por Amostra de Domicílios” [PNAD]) and the National Oral Health Survey (“Pesquisa Nacional de Saúde Bucal,” also known as SB Brasil) (Ministério da Saúde 2010), addressing oral health more specifically. The 2003 PNAD survey revealed that 27.9 million (approximately 16% of the national population) had still never been to a dentist (Instituto Brasileiro de Geografia e Estatística 2003). This situation raised the following question: Can integral health care be ensured without including oral health care? The answer was a resounding “no” and drew attention to the urgent need to review the prevailing public health policies.

The goal of the SB Brasil survey was to build a permanent database of the main oral health epidemiological indicators, given that oral health surveillance is one of the principal pillars of the Smiling Brazil policy. This survey has provided primary data to numerous studies, supporting a broader discussion and smarter decision making. In 2013, a special issue of Revista de Saúde Pública (2013) came out with a presentation of data from the 2010 SB Brasil survey. The issue featured comprehensive epidemiological analyses of the oral health status of the age groups established by the WHO (1997). Presented below are some of the major conclusions of these studies to provide the reader with an overview of the epidemiological status of oral health of the Brazilian population.

In 2010, the survey assessed the preliminary impact of the Brazilian oral health policy and identified a positive shift in the nation’s epidemiological profile for some age brackets but indicated the persistence of high prevalence rates of oral diseases for other index ages in the Brazilian population. Brazil had now joined the group of countries whose 12-y-old children had a low prevalence of caries, according to WHO criteria, after having reduced the rate of decayed, missing, or filled teeth (DMFT) from 2.8 in 2003 to 2.1 in 2010. Roncalli et al. (2015) also noted a significant DMFT decline among adolescents and a rise in the number of caries-free individuals. The authors, however, stressed the need to correct lingering socioeconomic inequalities (Roncalli et al. 2015). An important advance was observed among adults, who had significant ongoing unmet needs, with greater access to oral health care services, mostly by low-income individuals; however, the epidemiological indicators of the adult and elderly age brackets remain markedly higher than those recommended by the WHO (adult DMFT = 16.75; elderly DMFT = 27.53) (Pinto Rda et al. 2012). In addition to conducting curative and individual actions, Smiling Brazil gave priority to community actions and in particular water fluoridation. According to data from the Ministry of Health, 128,199,809 people (63.7% of the population) had access to fluoridated water in 2013, supplied through a total of 6,647 public supply systems located in 3,109 municipalities (J. Grigoletto, written communication, 2015). Further investigation is warranted to definitively establish the impact of the policy on inequality and on the development of oral health indicators at both the national and regional levels. Nonetheless, the available studies have shown that the strategy of gradually expanding and directing public funding to oral health care in order to build an oral health care network may be succeeding in reducing health inequalities (Antunes and Narvai 2010).

Vettore et al. (2013) found that 15.3% of the Brazilian adult population had “moderate to severe” periodontal disease and that 5.8% had a “severe” form of disease. Moreover, the study correlated periodontal disease and social inequality in that it revealed that income inequality played a significant role in the occurrence of “severe” periodontal disease. Compared with the 2003 epidemiological survey, the authors found a 6.3% increase in the prevalence of “moderate to severe” periodontal disease and suggested that this rise may be related, at least in part, to a decline in tooth loss over the past few years.

Peres et al. (2013) reported that there was a significant decline in tooth loss among adolescents and adults compared with the 2003 data but that this decline was not observed among the elderly. Another study points out that 88.5% of the elderly population in 2010 had between 0 and 20 teeth and that, among these, 69.2% had prosthodontic needs (Ferreira Cde et al. 2013). The studies also point to the existence of persisting regional and social inequalities in Brazil.

These studies, and many other publications, provide evidence on the oral health status of Brazilians and reflect the effort being made by researchers to provide information to support the planning of oral health actions. The outlook that they provide is one in which huge efforts are still required to change the epidemiological profile of the population and ensure oral health for all Brazilians. Nevertheless, improvements in oral health indicators between 2003 and 2010 can already be seen.

Financial Investment and the Development of Dental Professionals

Over US$2.6 billion was invested in oral health in Brazil over a 10-y period. This investment was made in several areas considered strategic to strengthening the health care policy, including the funding of scientific studies providing information for decisions and the training of oral health team members (dentists, oral health technicians, and oral health assistants).

According to data from the Ministry of Health, the Pro-Health (“Pró-Saude”) Program was one such training effort. It invested US$50,960,480.72 in both public and private universities between 2012 and 2014 (E. Monteiro, written communication, 2015). The investment went to funding curricular changes outlined by the federal government to train professionals engaged in the public sector, who were aware of their social responsibilities and focused on delivering primary health care, the point of entry to the system. The underlying goal of these initiatives was to build a financially sustainable and truly effective oral health care network.

As a parallel development, Smiling Brazil was pivotal in shaping the job market for health professionals in Brazil by boosting the number of dentists in the SUS by 50% and leading to about one quarter of all dentists nationwide having ties to Brazil’s public health services (43,205 dentists in 2003 v. 65,560 today) (Ministério da Saúde 2010). These professionals are distributed among the 3 levels of health care, forming a complex care network. In recent years, this has revolutionized the way that the government delivers oral health care to its citizens. As a result of this investment, estimates project that over 30,000 oral health care professionals (including dentists, oral health technicians, and oral health assistants) will be serving Smiling Brazil by 2020.

We know that returns on investment in education must be expected only in the midterm and long term. Therefore, further research is required in order to follow this ongoing process of change in the profile of graduates as a result of the new policies.

A Health Care Network: Integrating Care

Regarding the model in which dentistry is incorporated under the current public health system, it is important to understand that Brazil evolved from a precarious and unilateral system—that is, where dentistry in the public sector was practiced solely by individual dentists without coordinated team work and following a mutilating and iatrogenic pattern—to the structuring of an oral health care network system (Frazão and Narvai 2009). In line with the experience of other countries, a polyhierarchical system was established to integrate and coordinate all levels of health care (Shortell et al. 1993). Oral health was efficiently integrated into this network, and the main advances have been on 2 levels: 1) the institutionalization of the policy, and 2) the radical improvement in the “installed capacity” of oral health care services across all 3 levels of health care.

With respect to institutionalization of the policy, it should be mentioned that Brazil had tentative oral health public policies prior to Smiling Brazil, but they were largely ineffective, primarily because they were not backed by the necessary political will and were underfunded. After 2004, however, the role of each level of care and the interaction required among different sectors were clearly defined by way of laws and directives. The need for planning and performing actions to overcome regional differences also became apparent, and this was pursued accordingly.

After overcoming the barrier of institutionalizing the Brazilian oral health policy, a concerted effort was made to replace scrapped equipment and expand the physical infrastructure of the oral health care network that was being constructed by improving the “installed capacity” of this network and hiring new personnel to meet the users’ needs across all levels of care. Brazil now boasts an organized oral health care network based on the precepts of family health. An outline of this network is shown in the Figure, and its components will be explained below.

Primary care is the backbone of the SUS line of care and is the entry level after which patients are referred to the other levels of care. This is why primary care is at the center of the Figure. It is expected that patients will have 80% of their problems solved by primary care after entering the SUS. Dental care visits take place in the primary health care unit and as home care visits, when needed. The remaining cases are referred to medium-complexity service units, to the dental specialty centers (“Centros de Especialidades Odontológicas” [CEOs]), and to tertiary care.

Mobile dental units (“Unidades Odontológicas Móveis”) are deployed to serve hard-to-reach and socially excluded regions. Another key element supporting the network has been the implementation of the People’s Pharmacy of Brazil (“Farmácia Popular do Brasil”), which dispenses free medications to users of both public and private health care services.

The regional dental prosthesis laboratories (“Laboratórios Regionais de Prótese Dentária” [LRPDs]) provide support to the network and have delivered 2.1 million dental prostheses in 10 y to meet the demands of Brazil’s adult and elderly population. Currently, 1,954 cities have LRPDs rendering services to the SUS. Another fundamental network component is the diagnostic service, which issues anatomic pathology reports for the diagnosis of oral pathologies.

Once the structured primary care and medium-complexity services were in place, the high-complexity services had to be organized. High-complexity services encompass hospital care of inpatients with benign maxillofacial tumors, special-needs patients requiring treatment under general anesthetics, dental care for patients in chemotherapy or radiotherapy, provision of maxillofacial prostheses, and chronic patients admitted for surgical procedures.

More recently, Smiling Brazil achieved another major milestone: the launch and financing of the “Gradua-CEO” Program, a partnership between the Ministries of Health and of Education. The program coordinates oral health services provided in university clinics as part of the oral health care network of the SUS.

The account presented here reports on 10 y of evolution; however, this is an ongoing process, and the oral health care network needs to be further expanded, refined, and consolidated so that Smiling Brazil may prevail as a perennial policy and not merely an action performed by a single government. Much is yet to be done to ensure that it will stand the test of time and withstand the changes brought in by the political parties in power.

The number of oral health teams (dentist, oral health technician, and/or oral health assistant) working in primary health care increased by 445% over a period of 10 y. These oral health teams work together with family health teams (physician, nurse, nursing assistant, and community health worker) and are distributed nationwide. In 2003, there were 4,261 oral health teams in 3,184 cities. Today, there are 23,940 such teams in 4,978 cities. As a result, there is at least 1 oral health team in 89.5% of Brazil’s cities today. Oral health teams are organized to maintain a balance between individual clinical care sessions and community actions, such as health education, supervised brushing, topical application of fluoride, and atraumatic restorative treatment (Ministério da Saúde 2006).

Prior to the implementation of Smiling Brazil, the country had no secondary care network. Primary care actions were limited to tooth extraction and simple restorative procedures, and there were no regular preventive procedures in schools. Smiling Brazil created the CEOs to ensure a full line of care and to restructure primary care. All centers provide at least minor oral surgery, diagnostics for oral cancer and other soft tissue diseases, periodontics, special-needs patient care, and endodontics and commonly provide orthodontic and dental implant therapy.

Up until January 2015, the Ministry of Health had registered 1,030 CEOs. CEOs are medium-complexity care units but also offer primary care, serving as referral and counterreferral outpatient clinics for both primary and tertiary care.

In 2014, after 10 y of Smiling Brazil, the Ministry of Health appraised primary health care and CEO services in a complex assessment process called the Access and Quality Improvement Program (“Programa de Melhoria do Acesso e da Qualidade” [PMAQ]). The services were assessed for structure, professional satisfaction, management of health care services, and user satisfaction. According to the National Coordination of Oral Health of the Ministry of Health, the preliminary results of the PMAQ revealed that the oral health teams of the family health strategy were adhering closely to the priority goals of Smiling Brazil: 80.5% of the oral health teams performed oral cancer prevention and detection, 78.4% monitored pregnant women from their catchment area, 80.8% provided care for children aged ≤5 y, and 78.4% made home visits (National Coordination of Oral Health of Brazil [COSAB], written communication, 2015).

Final Considerations

Brazil is a vast developing country with a population of over 200 million people. In 1990, it had the courage to set up a universal health care system. In 2004, it created and implemented Smiling Brazil on a nationwide level.

We have made great strides in 10 y. The policy has proven sustainable, has taken root, and is expanding within the SUS. Nevertheless, numerous challenges lie ahead. To summarize these fronts and set out a plan for the future, 3 key pillars are highlighted:

Continuous consolidation of the oral health care network: The complex interrelationships between access, scale, scope, quality, cost, and effectiveness need to be addressed. Patients still have difficulty with scheduling appointments for some specialties in the CEOs, and barriers remain to building a unified and integrated system to offset the influence of private providers and their interests in the health care market.

Human resources: University training is still dictated by the requirements of private dental clinics, where practice is centered on diseases, where care is fragmented, and where routines and norms are based on the perceptions of dental professionals as opposed to the needs of patients. Another serious problem is the poor distribution of dental professionals in the country.

Social and cultural aspects: Oral health is clearly not yet perceived as an entitlement by society, and the lower social stratum whose oral needs are most repressed still lacks the political clout to ensure representation, as is also the case in other nations.

Lastly, the literature indicates numerous barriers limiting access to oral health care services worldwide and challenges for implementing effective public policies in this area (Al-Haboubi et al. 2013). We believe, however, that smiling Brazil is an extraordinary experience that can be emulated and adapted to the conditions of other countries and other health care systems, evidently taking into account internal political and budgetary considerations. Our main recommendation is that any similar initiative must prioritize the structuring of a coordinated oral health network (as outlined in the Figure) as a strategy to achieve institutionalization in addition to providing integral oral health care as opposed to conducting fragmented and potentially unsustainable actions.

Author Contributions

G.A. Pucca Jr, M. Gabriel, M.E. de Araujo, F.C.S. de Almeida, contributed to conception, design, and data analysis, drafted the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Footnotes

Acknowledgements

The National Coordination of Oral Health and the Department of Community Dentistry of the University of São Paulo thank the editorial board of the JDR for its invitation to publish this material in its “Discovery!” section. The authors also extend thanks to their colleagues, Jacques E. Nör, William Giannobile, and Marcelo José Strazzeri Bönecker, for their encouragement and support in the effort of publicizing Brazil’s oral health care experience, the Smiling Brazil policy.

The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

References

Al-Haboubi

Klass

Jones

Bernabé

Gallagher

. 2013. Inequalities in the use of dental services among adults in inner South East London. Eur J Oral Sci. 121(3 Pt 1):176–181.

Antunes

Narvai

. 2010. Dental health policies in Brazil and their impact on health inequalities. Rev Saude Publica. 44(2):360–365.

Baum

Bégin

Houweling

Taylor

. 2009. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health. 99(11):1967–1974.

Brasil. 1988. Constituição da República Federativa do Brasil. Brasília: Senado.

Ferreira Cde

Antunes

Andrade

. 2013. Factors associated with the use of dental services by elderly Brazilians. Rev Saude Publica. 47(Suppl 3):90–97.

Food and Agriculture Organization of the United Nations. 2014. The state of food insecurity in the world 2014: strengthening the enabling environment for food security and nutrition [relatório]. Rome: Food and Agriculture Organization.

Frazão

Narvai

. 2009. Oral health in the Brazilian national health system: twenty years of fighting for a public policy. Saude em Debate. 33.81:64–71.

Instituto Brasileiro de Geografia e Estatística. 2003. Pesquisa nacional por amostragem de domicílios. [accessed 2015 Jul 17]. http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2003/saude/saude2003.pdf.

Ministério da Saúde. 2006. Caderno de atenção básica no. 17: saúde bucal. [accessed 2015 Jul 17]. http://bvsms.saude.gov.br/bvs/publicacoes/abcad17.pdf.

10.

Ministério da Saúde. 2010. Projeto SB Brasil 2010. Condições de saúde bucal da população brasileira: resultados principais. Brasília: Coordenação Nacional de Saúde Bucal, Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde.

11.

Paim

Travassos

Almeida

Bahia

Macinko

. 2011. The Brazilian health system: history, advances, and challenges. Lancet. 377(9779):1778–1797.

12.

Pan American Health Organization/World Health Organization. 2007. Renewing primary health care in the Americas: a position paper of the Pan American Health Organization/World Health Organization. [accessed 2015 Jul 17]. http://apps.who.int/medicinedocs/documents/s19055en/s19055en.pdf.

13.

Peres

Barbato

Reis

Freitas

Antunes

. 2013. Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey. Rev Saude Publica. 47(Suppl 3):78–89.

14.

Pinto

Rda S

Matos

de Loyola Filho

. 2012. Characteristics associated with the use of dental services by the adult Brazilian population. Cien Saude Colet. 17(2):531–544.

15.

Pucca

Jr. Lucena

Cawahisa

. 2010. Financing national policy on oral health in Brazil in the context of the unified health system. Braz Oral Res. 24(Suppl 1):26–32.

16.

Revista de Saúde Pública. 2013. São Paulo: Faculdade de Saúde Pública. [accessed 2015 Jul 17]. http://www.scielo.br/scielo.php?script=sci_issuetoc&pid=0034-891020130009&lng=pt&nrm=iso.

17.

Roncalli

Sheiham

Tsakos

Watt

. 2015. Socially unequal improvements in dental caries levels in Brazilian adolescents between 2003 and 2010. Community Dent Oral Epidemiol. 43(4):317–324.

18.

Shortell

Gillies

Anderson

Mitchell

Morgan

. 1993. Creating organized delivery systems: the barriers and facilitators. Hosp Health Serv Adm. 38(4):447–466.

19.

United Nations. 2000. Resolution A/55/2: Millennium Declaration. [accessed 2015 Jul 17]. http://www.un.org/millennium/declaration/ares552e.htm.

20.

Vettore

Marques

Peres

. 2013. Social inequalities and periodontal disease: multilevel approach in SB Brasil 2010 survey. Rev Saude Publica. 47(Suppl 3):29–39.

21.

World Health Organization. 1997. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization.