| Biomedical hegemonic care model |
a. Care model, historically focused on high and medium complexity |
With a health care system that is both complex and incomplete, Juiz de Fora historically concentrated a lot of high and medium complexity health services. Therefore, it has a very good technological structure, it has access to high and medium complexity services, almost in their totality. - P01 |
| [...]we have quite a satisfactory offer of services in Juiz de Fora, we have a tertiary care system, (...) the quality of hospital care in Juiz de Fora is very good. - P03 |
| b. Health financing in the municipality is compromised by medium and high complexity |
In Juiz de Fora, high and medium complexity take more than 85%, almost 90% of the health resources [...] This draining of resources from primary care to medium and high complexity hampers any expansion of the service, especially of services that will be expensive for the town, which will require construction, remodeling, equipment, will demand the hiring of personnel, demand inputs, all with precarious financing. - P01 |
| So, how can we expect and hope that PHC can resolve 85% of the health problems of the population if it has just a little more than 12% of the resources invested? So, we have to consider that there is a contradiction and a problem in this reality. But we are aware that the resources that are available for health care today are minimal. - P11 |
| c. Most of the PHC units have inadequate structures |
There must be a structure in the first place. It is not easy to organize a structure for dental services like this, in a municipality the size of this, because not all the PHC units have a dentist’s office. - P07 |
| We will have challenges ahead, challenges to our structures. At least part of them were not planned for FHS, nor for oral health. Even for structural interventions, the resources are meager. - P11 |
| Care model proposed by management focused on the dental clinic |
a. Oral healthcare model in PHC, organized by regional centers |
Dentistry is one of the weakest areas of PHC in my understanding é [...] We do not have a dentist in every UBS, more than half do not have a dentist. - P01 |
| In management, our concept was regionalization. [...] So, we decided to also regionalize UPS for Dentistry, [...] planning large Regional Dental Units where we had a DSC connected to the unit. [...] Today, in the city we have 4 ROUs that work very well and manage to provide access to the population [...] where we have state of the art infrastructure, [...] where we can put this principle of integrality into operation. - P05 |
| Healthcare at the DSC is global, because the users have everything there. You can do everything, get an x-ray, root canal treatment. The only thing you cannot do there are prosthetics. Unfortunately. - P10 |
| b. Oral health management is verticalized and inarticulate |
So, I think that this fragmentation is something from the oral health department dividing PHC from oral healthcare being in one sector, while the DSCs and the hospital technology are in another sector, it ends up making it difficult to manage. - P07 |
| There is no desire to adopt those policies from that department [OHD]. There is a very clear discourse that we [OHD] are different [...] the National Oral Health Policy is not up to you [...]. I cannot see any desire for a collective construction of the policies. - P11 |
| c. The proposal of insertion of the OHT in the FHS that management defends does not seek the restructuring of the care model |
[In 2020] the Oral Health Department of Juiz de Fora began this movement of getting dentists [into the FHS] [...]. That situation lasted many years, it only ended with the approval of this Bill [...] in 2016 by the Municipal Council. - P05 |
| Obviously, there should be a study to make the areas of greater social vulnerability viable [...] putting more FHS in distant neighborhoods, and here in downtown, you can work with RDUs, which already exist even with primary care. - P05 |
| [In 2018] We put together a financial impact study, to hire this dentist and assistants [...]. - P05 |
| We always proposed the implementation of the OHT. We used to make the projects to present to the administrative managers [...] 10 teams, in the end we got down to 5 [...]. - P06 |
| We have it in our Municipal Health Plan, established [...] 2021 two more, totaling 6 OHTs until the end of 2021. - P05 |
| Different conceptions of the oral healthcare model |
a. The Municipal Health Council’s conception of a care model is counter-hegemonic |
Family health care is not done with just doctors. It is done with doctors, nurses, social workers, dentists, primary care, so you can have prevention. - P08 |
| We never agreed to this process of regionalization [RDUs]. [...] It goes against what the system establishes [...]. I had serious arguments concerning this issue of the regionalization process, I didn´t agree, I even created a certain animosity towards people. - P08 |
| Look, we’ve noticed that since my first term as manager in the Council in 2001. [...] Ready to implement, we tried to adapt the legislation so that the dentists could do 40-hour shifts. Only now, in 2016, the legislation is ready. - P02 |
| b. The expectation by the Municipal Health Council for the insertion of oral health care in the FHS does not find the support of the population or the dentists |
But there is no pressure by the users, the people. [...] They do not mobilize for Dentistry. - P01 |
| There is still no evidence of a demand for oral health care. Did you search for oral health events at the ombudsman? You do not have to, because there is none. A large part of the population does not search for oral health, it seems as if there is no need for oral health expressed by the population. - P11 |
| So, it is not a common demand in the local and regional councils, in the municipal council it appears in these conditions by means of a representative of social control who has a high level of education and knowledge of the cause. - P11 |
| I do not notice a desire on the part of many dentists to implement oral health care into family health care, the dentists do not want this change. - P11 |
| There is also a lack of social cohesion. [...] That shows fragility. [...] of how much the discussion around oral health is still incipient in terms of its importance for the population. - P09 |
| c. Model for oral health care meets the professional profile and the expectations of the dentists |
The training of the dentist is pretty much aimed at specialization. [...] they want to become specialists, and few have the availability for public service. - P03 |
| There is the professional valuation [...] there is studying, there are careers, and there is [...] a certain accommodation, it is easier to leave things as they are [...]. So, maybe because of all that we do not have a strong mobilization to achieve the implementation of oral health in the FHS. - P03 |
| The view that I have today is that the fellow municipal dentists approve of the model that is being proposed and offered. - P11 |
| Missing the window of opportunity provided by the PNSB |
a. Choices by the management in terms of applying the resources from the PNSB |
[In 2004] financing was not sufficient, we [...] demonstrated that the expenses were valid…but with the passing of time, with the reduction of financing by the Federal government, nowadays the financing do not meet the expenses with the professionals. So Dental equipment was something very expensive, [...] with the 2004 health policy, the price went down a lot. We managed to buy a lot of equipment... - P03 |
| We still have a long way to go, [...] because it was with the management of oral health care [in 2006] [...] when the government created the Smiley Brazil Program, and that brought an opportunity for funding for Dentistry that we did not have before [...] so we had a lot of difficulties with materials, a lot of difficulty with infrastructure, and after Smiley Brazil things began to change, and we received funding for the implementation of the DSCs. - P05 |
| b. Constitutional Amendment 95: from chronic under-funding to the de-funding of health care |
This town suffers, as do all the others, with a severe problem of under-funding of SUS. - P01 |
| The federal resources to fund OHTs in the FHS is a small amount [...] not enough to implement all that is needed. - P07 |
| The most important barrier, perhaps, has to do with the decline in funding in recent years. - P03 |
| So, I do not see much hope, that this possibility, that it happens now. Even more so with Constitutional Amendment 95, which froze public expansion for the next 19 years. - P01 |
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Source: Authors.