Financing national policy on oral health in Brazil in the context of the Unified Health System

This article discusses the model of oral health care implemented in the Unified Health System of Brazil in the last decade. This model was conceived as a sub-sector policy that, over the years, has sought to improve the quality of life of the Brazilian population. Through a chronological line, the study presents the National Policy on Oral Health as a counter-hegemonic patient care model for the dentistry practices existing in the country before this policy was implemented. The reorganization of the levels of oral health care, the creation of reference facilities for secondary and tertiary care, through Centers of Dental Specialties and Regional Dental Prosthesis Laboratories, and the differential funding and decentralized management of financial resources were able to expand the actions of oral health for more than 90 million inhabitants. The evolution shown after the deployment of the National Oral Health Policy, as of 2004, demonstrates the greater integration of oral health care under the Unified Health System and provides feedback information to help this policy to continue to be prioritized by the Federal Government and receive more support from the state and local levels in the coming years. Descriptors: Dental Health Services; Oral Health; Health Policy; Public Health. Introduction The Health System of Brazil (Unified Health System UHS) consists of a set of actions and health services provided by agencies and federal, state and local public institutions, of direct and indirect administrations, and foundations maintained by the Government. It aims to identify and publicize the conditioning factors and health determinants for the formulation of health policy designed to reduce the risk of diseases and other health problems, by reformulating the economic and social policies, establishing conditions that ensure equal and universal access to the actions and services designed for the promotion, protection and recovery of health. The third aim of the UHS was to provide healthcare to the people by carrying out integrated care actions and preventive activities.1,2 However, for years, dental care in the Brazilian public service has been characterized by providing care to restricted population groups, such as students. Moreover, the care was focused on dental caries and periodontal disease. The rest of the population was excluded and dependent on purely curative and mutilating services. This resulted in a low service § Paper presented at the “Promotion of Oral Health in the Public and Private Context” National Symposium, held at the 15th Congress of the Brazilian Association for Oral Health Promotion (ABOPREV), May 27-29, 2010, Brasília, DF, Brazil. Pucca Junior GA, Lucena EHG, Cawahisa PT Braz Oral Res. 2010;24(Spec Iss 1):26-32 27 coverage and poorly solving care, which has become the target of criticism by the actors involved.3 The current stage of construction of the Unified Health System (UHS) has created the possibility of actions that allow attending to the needs of all people (principle of universality), thereby allowing them access to all dental and general health needs (principle of comprehensiveness), and offering more to those who need it the most (principle of equality). According to Narvai,4 to promote transformation, the Public Oral Health sector needed to build an agenda that took into account those relevant actions. The Final Report of the 3rd National Conference on Oral Health (NCOH)5 demonstrated how this agenda should be established. The document was the expression of a process that had the direct participation of about 90,000 people across the country. The final report noted that “the conditions of oral health and the condition of teeth were, undoubtedly, one of the most significant signs of social exclusion. Therefore, the problems in this area required more than assistance-oriented actions undertaken by competent professionals. Intersectoral policies were necessary, as well as the integration of preventive, curative, and rehabilitation actions, and focusing on health promotion, universalization of access, public accountability of all segments of society and, above all, commitment of the State with the involvement of institutions of the three spheres of government”. In that context, the federal government devised and launched the National Policy for Oral Health. This policy had been built for many years in Brazil by various sectors of society, linked to social movements by public health professionals and advanced organizations. For the organization of this model, it was essential to create lines of care by creating flows involving resolutive actions by health teams, focusing on receiving, informing, answering and forwarding.6 Contextualization of the National Oral Health Policy In 2003, the Ministry of Health published the broadest survey on oral health conducted so far – the National Epidemiological Survey on Oral Health – which produced information about the status of oral health in the Brazilian population in order to support the planning and evaluation of actions in this area at different levels of management of the Unified Health System (UHS). In this survey, 108,921 people were examined, including babies (18-36 months old), children (5 years old), adolescents (12 and 15-19 years old), adults (35-44 years old) and the elderly (65-74 years old).7 The group of 12 years of age had, on average, 2.8 teeth with caries experience in the permanent dentition. The group between 15 and 19 years old had, on average, 6.2 teeth with this condition. For these ages, the lowest rates were found in the Southeast and South regions of the country, while the highest averages were found in the Northeast and Midwest. As to adults, the average Index of Decayed, Missing and Filled Permanent Teeth (DMF-T) was 20.1 in the 35-44 years age group, and 27.8 in the 65-74 years age group. In these groups, it was also noted that the regional differences in the components of the DMFT index were repeated: the North and Northeast had higher scores of decayed and missing teeth when compared with the other regions. In children and adolescents, the main problems were untreated caries, while in adults and the elderly, tooth loss arose as a more serious problem. Only 10% of seniors had 20 or more teeth, 75% did not show any functional teeth and 36% did not have dentures.8 Aiming to overcome the inequalities brought about by the traditionally hegemonic logic of care, the abandonment of and lack of commitment to the oral health of the population, the current guidelines of the National Policy for Oral Health (NPOH) were established in 2004 in Brazil. These guidelines aim to ensure the actions of promotion, prevention, rehabilitation and maintenance of oral health of Brazilians. These goals pursue the reorganization of the prevailing practices and the qualification of the actions and services provided, by assembling a series of oral health actions directed at citizens of all ages, by strengthening primary care, and ensuring universal access and the provision of full-fledged oral health care services as structural axes. The National Policy for Oral Health was established and linked to other public health policies, Financing national policy on oral health in Brazil in the context of the Unified Health System Braz Oral Res. 2010;24(Spec Iss 1):26-32 28 with the following main lines: reorganization of Primary Care (especially by means of the Oral Health Teams of the Family Health Strategy); reorganization of Specialized Care (through deployment of Centers of Dental Specialties and Regional Dental Prosthesis Laboratories); addition of fluoride in the public water supply; and oral health surveillance.9,10 The guidelines of the National Oral Health Policy were set to meet the requirements established by the Constitution of Brazil (Chapter II, Section II, Article 196; 1988): “Health is a right for all and a duty of the state, guaranteed by social and economic policies aimed at reducing the risk of disease and other health problems and the universal and egalitarian access to actions and services for its promotion, protection and recovery.” Thus, it became essential to understand health in a comprehensive and universal way, not only with regard to access to services, but also considering social inequalities, seeking policies that could reduce these social inequities.11 The public dental care in Brazil was historically restricted almost entirely to basic services, featuring a low capacity to offer secondary and tertiary care services, thus resulting in inadequate oral health systems of referral and counter-referral in almost all local and regional facilities.12 Reorganization of Primary Oral Health Care The Family Health Strategy (FHS) has become the main developing program of the reorganization of primary health care services. It aimed to reformulate the work process observed in the context of the Unified Health System (UHS). It was also focused on health surveillance through health promotion, prevention and recovery, based on the new concept of the health-disease process, and on the family and organized actions in a defined territory. It became the UHS care model and was designed by the Ministry of Health as an alternative to promote the reform of health actions, considering that the hegemonic model of care entailed a mismatch between the UHS principles and the actual deployment of the health system.13 Understanding oral health as part of this process and its incorporation into the FHS has been deemed as a chance to break the excluding oral health care models based on a curative approach, and on technicality and biologicism. The FHS has as one of its principles the active search for families, and not only articulates the proposed health surveillance based on comprehensiveness. In this new model, families are viewed as the primary social nucleus, serving as an invitation to the exercise of citizenship for those who often find themselves on 


Introduction
The Health System of Brazil (Unified Health System -UHS) consists of a set of actions and health services provided by agencies and federal, state and local public institutions, of direct and indirect administrations, and foundations maintained by the Government. It aims to identify and publicize the conditioning factors and health determinants for the formulation of health policy designed to reduce the risk of diseases and other health problems, by reformulating the economic and social policies, establishing conditions that ensure equal and universal access to the actions and services designed for the promotion, protection and recovery of health. The third aim of the UHS was to provide healthcare to the people by carrying out integrated care actions and preventive activities. 1, 2 However, for years, dental care in the Brazilian public service has been characterized by providing care to restricted population groups, such as students. Moreover, the care was focused on dental caries and periodontal disease. The rest of the population was excluded and dependent on purely curative and mutilating services. This resulted in a low service coverage and poorly solving care, which has become the target of criticism by the actors involved. 3 The current stage of construction of the Unified Health System (UHS) has created the possibility of actions that allow attending to the needs of all people (principle of universality), thereby allowing them access to all dental and general health needs (principle of comprehensiveness), and offering more to those who need it the most (principle of equality). According to Narvai,4 to promote transformation, the Public Oral Health sector needed to build an agenda that took into account those relevant actions.
The Final Report of the 3 rd National Conference on Oral Health (NCOH) 5 demonstrated how this agenda should be established. The document was the expression of a process that had the direct participation of about 90,000 people across the country. The final report noted that "the conditions of oral health and the condition of teeth were, undoubtedly, one of the most significant signs of social exclusion. Therefore, the problems in this area required more than assistance-oriented actions undertaken by competent professionals. Intersectoral policies were necessary, as well as the integration of preventive, curative, and rehabilitation actions, and focusing on health promotion, universalization of access, public accountability of all segments of society and, above all, commitment of the State with the involvement of institutions of the three spheres of government".
In that context, the federal government devised and launched the National Policy for Oral Health. This policy had been built for many years in Brazil by various sectors of society, linked to social movements by public health professionals and advanced organizations. For the organization of this model, it was essential to create lines of care by creating flows involving resolutive actions by health teams, focusing on receiving, informing, answering and forwarding. 6

Contextualization of the National Oral Health Policy
In 2003, the Ministry of Health published the broadest survey on oral health conducted so far -the National Epidemiological Survey on Oral Health -which produced information about the status of oral health in the Brazilian population in order to support the planning and evaluation of actions in this area at different levels of management of the Unified Health System (UHS). In this survey, 108,921 people were examined, including babies (18-36 months old), children (5 years old), adolescents (12 and 15-19 years old), adults (35-44 years old) and the elderly (65-74 years old). 7 The group of 12 years of age had, on average, 2.8 teeth with caries experience in the permanent dentition. The group between 15 and 19 years old had, on average, 6.2 teeth with this condition. For these ages, the lowest rates were found in the Southeast and South regions of the country, while the highest averages were found in the Northeast and Midwest. As to adults, the average Index of Decayed, Missing and Filled Permanent Teeth (DMF-T) was 20.1 in the 35-44 years age group, and 27.8 in the 65-74 years age group. In these groups, it was also noted that the regional differences in the components of the DMFT index were repeated: the North and Northeast had higher scores of decayed and missing teeth when compared with the other regions. In children and adolescents, the main problems were untreated caries, while in adults and the elderly, tooth loss arose as a more serious problem. Only 10% of seniors had 20 or more teeth, 75% did not show any functional teeth and 36% did not have dentures. 8 Aiming to overcome the inequalities brought about by the traditionally hegemonic logic of care, the abandonment of and lack of commitment to the oral health of the population, the current guidelines of the National Policy for Oral Health (NPOH) were established in 2004 in Brazil. These guidelines aim to ensure the actions of promotion, prevention, rehabilitation and maintenance of oral health of Brazilians. These goals pursue the reorganization of the prevailing practices and the qualification of the actions and services provided, by assembling a series of oral health actions directed at citizens of all ages, by strengthening primary care, and ensuring universal access and the provision of full-fledged oral health care services as structural axes.
The National Policy for Oral Health was established and linked to other public health policies, with the following main lines: reorganization of Primary Care (especially by means of the Oral Health Teams of the Family Health Strategy); reorganization of Specialized Care (through deployment of Centers of Dental Specialties and Regional Dental Prosthesis Laboratories); addition of fluoride in the public water supply; and oral health surveillance. 9,10 The guidelines of the National Oral Health Policy were set to meet the requirements established by the Constitution of Brazil (Chapter II, Section II, Article 196; 1988): "Health is a right for all and a duty of the state, guaranteed by social and economic policies aimed at reducing the risk of disease and other health problems and the universal and egalitarian access to actions and services for its promotion, protection and recovery." Thus, it became essential to understand health in a comprehensive and universal way, not only with regard to access to services, but also considering social inequalities, seeking policies that could reduce these social inequities. 11 The public dental care in Brazil was historically restricted almost entirely to basic services, featuring a low capacity to offer secondary and tertiary care services, thus resulting in inadequate oral health systems of referral and counter-referral in almost all local and regional facilities. 12

Reorganization of Primary Oral Health Care
The Family Health Strategy (FHS) has become the main developing program of the reorganization of primary health care services. It aimed to reformulate the work process observed in the context of the Unified Health System (UHS). It was also focused on health surveillance through health promotion, prevention and recovery, based on the new concept of the health-disease process, and on the family and organized actions in a defined territory. It became the UHS care model and was designed by the Ministry of Health as an alternative to promote the reform of health actions, considering that the hegemonic model of care entailed a mismatch between the UHS principles and the actual deployment of the health system. 13 Understanding oral health as part of this process and its incorporation into the FHS has been deemed as a chance to break the excluding oral health care models based on a curative approach, and on technicality and biologicism. The FHS has as one of its principles the active search for families, and not only articulates the proposed health surveillance based on comprehensiveness. In this new model, families are viewed as the primary social nucleus, serving as an invitation to the exercise of citizenship for those who often find themselves on the margins of society. The official incorporation of the dentist in the family health team occurred only in 2000, because the National Household Sample Survey (NHSS) in 1998 found that access to dentists was extremely limited at the time. In October 2009, the Ministry of Health, through Decree no. 2,372, created a plan for the supply of dental equipment for the Oral Health Teams of the Family Health Strategy. Each regular team received a complete dental office. The strategy intended to reorganize primary oral health care, and to render more efficient the basic oral health actions. 15 Besides the main goal of improving the working conditions for dentists, this action had an economic benefit as well, by saving public funds. The equipment being purchased in large quantities through the bidding process by the Ministry of Health was cheaper than if it were to be bought individually for each municipality. The publication of this Ordinance also allowed the municipal managers to invest the entire deployment feature set by the Ministry of Health for each OHT deployed (a lump sum of US$ 3,802.28) in the acquisition of other equipment and instruments necessary to carry out the clinical activities of the OHT.

Constitution of a specialized oral health network
The role of oral health secondary services in Brazil is two-fold: to offer specialty dental treatment, and to offer treatment plans made by dental specialists to referred users, where the treatment is finalized in primary care facilities after cross-referral of the case, i.e. acting as a consulting dental service. 16,17 Data from the last national epidemiological survey on oral health conducted in Brazil 7 and selected   19 showed that the major oral health problems to be faced was dental caries, its consequences (pain and tooth loss), and the lack of access to oral health actions and services. In addition, social inequalities were observed through analysis of the indicators of the health-disease process, involving inequities in the disease and in the service use patterns, to the detriment of those at higher social risk. 20 Reducing socioeconomic disparities and targeting public health measures at the more vulnerable groups remain a challenge for all those involved in formulating and implementing public policies in Brazil. 21 For the implementation of the specialized oral health network in Brazil, the Ministry of Health created the Centers of Dental Specialties (CDS) which, according to Decree no. 599/MO of March 23, 2006, are to be reference facilities to perform specialized procedures that are not offered by the primary care network. These specialized procedures include oral diagnosis, with emphasis on the detection and diagnosis of oral cancer, periodontal procedures, minor oral surgery of hard and soft tissues, endodontic procedures, and providing care for patients with special needs. 22 The number of Centers of Dental Specialties (CDS) increased 708% between October 2004 and December 2009 (Graph 4). The largest number of CDSs is in the Northeast (314) followed by the Southeast (289), South (102), North (53) and Mid-west (50) regions.
Given the demand for prosthetic rehabilitation and the prospect of comprehensive oral health care, the Ministry of Health started to fund the setting up of Regional Dental Prosthesis Laboratories (RDPL). According to Decree no. 599/MO of March 23, 2006, RDPLs are establishments that can perform total and partial dentures, and/or full crown prostheses. 22

Funding oral health research
The National Oral Health Policy has invested, between 2005 and 2008, US$1.1 million in funding for oral health research. The research projects thus financed aimed to expand knowledge about the area, and to contribute to the development of public actions. Consequently, the health conditions of the Brazilian population would be improved, and regional and socioeconomic inequalities overcome.
The Unified Health System (UHS) served as a reference for the research conducted, with the aim of strengthening the interaction between field studies, health services, research laboratories, the public and private sectors, and academic institutions, all in line with the guidelines of the National Oral Health Policy. Studies are underway and results are expected to be released in 2011.  Health -DAB / SAS / MH in establishing guidelines and defining strategies in the area of Oral Health Surveillance, considering the organization and epidemiological characteristics of federal, state and municipal health services. II. To propose criteria for the validation of data from information systems of the UHS, as well as strategies for the institutionalization of Oral Health monitoring and surveillance. III. To propose actions encouraging and promoting the production of knowledge and research on Oral Health. 23 The Ministry of Health is conducting, between the years 2009 and 2010, the National Survey on Oral Health -OH Brazil 2010.This is an important initiative that institutionalizes the Health Surveillance of the National Dental Health Policy component. Its predecessors were the epidemiological sur-veys of 1986, 1996 and 2003. This research has the objectives of determining the oral health condition of the Brazilian population in 2010 and supporting the planning of actions and services at the different levels of management of the Unified Health System, thus contributing to the structuring of a national system of oral health epidemiological surveillance.

Conclusions
With the implementation of the National Oral Health Policy, a set of actions in the individual and collective areas has been developed, involving health promotion, disease prevention, diagnosis, treatment and rehabilitation. These actions are developed through the exercise of democratic and participatory practices, and through the teamwork of the personnel responsible for providing oral health care, taking into account the specific dynamics of the ter- ritory in which they live. Thus, the NOHP is articulated with other public policies, health oriented or otherwise, based on the concept of oral health as an integral and inseparable part of an individual's general health.
The actions undertaken have contributed in innumerous ways to improve access to and the quality of dental care for Brazilians, showing that it is possible to offer quality and comprehensive dental care within the Unified Health System.