Dental health policies in Brazil and their impact on health inequalities

This text systematizes available knowledge about the main dental health policies in Brazil in regards to their current degree of implementation and their impact on health inequalities. Although the fl uoridation of publicly distributed water is legally mandated in Brazil, its implementation has been subject to marked regional inequalities. Data are presented about the extent of implementation for the intervention, and studies are reviewed that evaluate the intervention’s impact upon increasing inequality in the experience of dental caries. The provision of public dental services, which expanded considerably after the implementation of the National Unifi ed Health Care System, is also discussed in relation to service provision and its impact on reducing inequality in access to dental treatment. The discussion of the differential effect of these interventions allowed for the proposal of targeted strategies (directing fl uoridation to areas of greater need), aiming to reduce inequalities in the experience of dental caries in Brazil. DESCRIPTORS: Oral Health. Public Health Dentistry. Fluoridation. Health Inequalities. Health Policy. 2 Dental health policies in Brazil Antunes JLF & Narvai PC The monitoring of health inequalities is an important task in public health and part of the fi eld of work commonly identifi ed as “health surveillance”. Extensive literature analytically describes and explores the disparities in morbidity and mortality indicators between socioeconomic, racial and gender strata, across different times and places. Risk or protective factors can occur in unequal patterns across social strata, having deleterious or salutary effects that affect the population in a heterogeneous way and increase inequalities in health. In this sense, it is necessary to evaluate health policies not only for the overall effect they have on the collective health, but also for the result that interventions have upon the preexisting situation of health inequalities. In the last decades, two important interventions in oral health were greatly expanded in all of the country, based upon the constitutional principle of universal health actions and services, including oral health. The fl uoridation of publicly provided water and the dental services available in the public network of the Sistema Único de Saúde (SUS – National Unifi ed Health Care System) surpassed the historical limits for this type of care for children and pregnant women, notably for schoolchildren. The objective of the present study was to systematize the available knowledge regarding the current effi cacy level of these measures and their impact upon health inequalities. This is based on a discussion of data systematized according to the specialized literature and utilizing, as sources, the Ministério da Saúde/ Departamento de Informática do SUS, DATASUS (Ministry of Health’s SUS Health Information Department) and the Fundação Instituto Brasileiro de Geografi a e Estatística (IBGE –Brazilian Institute of Georgaphy and Statistics). FLUORIDATION OF THE PUBLIC WATER

The monitoring of health inequalities is an important task in public health and part of the fi eld of work commonly identifi ed as "health surveillance".Extensive literature analytically describes and explores the disparities in morbidity and mortality indicators between socioeconomic, racial and gender strata, across different times and places.
Risk or protective factors can occur in unequal patterns across social strata, having deleterious or salutary effects that affect the population in a heterogeneous way and increase inequalities in health.In this sense, it is necessary to evaluate health policies not only for the overall effect they have on the collective health, but also for the result that interventions have upon the preexisting situation of health inequalities.
In the last decades, two important interventions in oral health were greatly expanded in all of the country, based upon the constitutional principle of universal health actions and services, including oral health.The fl uoridation of publicly provided water and the dental services available in the public network of the Sistema Único de Saúde (SUS -National Unifi ed Health Care System) surpassed the historical limits for this type of care for children and pregnant women, notably for schoolchildren.
The objective of the present study was to systematize the available knowledge regarding the current effi cacy level of these measures and their impact upon health inequalities.This is based on a discussion of data systematized according to the specialized literature and utilizing, as sources, the Ministério da Saúde/ Departamento de Informática do SUS, DATASUS (Ministry of Health's SUS Health Information Department) and the Fundação Instituto Brasileiro de Geografi a e Estatística (IBGE -Brazilian Institute of Georgaphy and Statistics).

FLUORIDATION OF THE PUBLIC WATER SYSTEM
Fluoride was the fi rst exogenous factor recognized as important for modifying the risk of dental caries, even before the microbiological etiology and the strong association to frequent sugar consumption were proven.In 1986, the World Health Organization and the FDI World Dental Federation promoted an international conference about the appropriate use of fl uoride and concluded that this measure is low cost, can be INTRODUCTION implemented without risk of fl uorosis and is effective for the prevention of caries. 11In 2007, the 60th World Health Assembly reiterated their endorsement of the intervention.a Narvai 12 explains how this knowledge was established, from the initial observations of low prevalence of caries in children with dental fl uorosis, to more recent studies that established the safety and effectiveness of the intervention.
Fluoridation of public water systems was recognized as one of the ten most important public health achievements of the 20th century. 5One of its appealing points is the fact that it does not require intervention by a professional public health agent, nor any initiative to be taken by the recipient populations besides just frequent drinking of publicly provided water or using it in food preparation.Fluoride can also be administered through topical application during a dental consultation or through the routine use of toothpaste.Despite being simple, it is diffi cult for these measures to reach the population in an extensive and regular fashion as fl uoridated water.
In Brazil, the fi rst cities to adopt water fl uoridation did so in the 1950s.Law Number 6,050, b Federal Decree Number 76,872 c and Portaria GM/MS Number 635 d are the legal guidelines in force that establish water fl uoridation as an obligation throughout the country, for the public distribution systems that have water treatment stations.The effects of this legislation were not immediate, though, and the intervention was gradually implemented in the subsequent years, with marked regional inequalities.
In order to evaluate the degree that this intervention has been implemented, a useful source of publicly available information is the National Basic Sanitation Study (Pesquisa Nacional de Saneamento Básico) 10 performed in 2000 by the IBGE Foundation.According to the study, until that year less than half (45%) of the 5,507 Brazilian municipalities had adopted this public health intervention (Table ).The proportion was even lower when the number of districts was analyzed instead of cities: only 37% of the 8,656 Brazilian districts had adopted the intervention.This statistic is less susceptible to the extensive population variation within the municipalities.The scenario suggests that a considerable proportion of municipalities that have implemented fl uoridation were unable to extend it to all inhabitants, possibly excluding the more rural districts and peripheries where the intervention is even more necessary, considering that the preventative power of fl uoridation is relatively larger in places with greater socioeconomic inequality. 8,16ter fl uoridation is recognized as benefi cial.This public health intervention began more than half a century ago and was legally mandated in Brazil for more than 30 years.Despite this, the available data point to an extremely unequal implementation in the country, considering the Federal units and the macro-regions: the intervention advanced more in the states of the South and Southeast, where most of the country's wealth is concentrated, and was insuffi cient in the North and Northeast regions.A public health intervention effective at reducing inequalities is itself subject to profound disparities in implementation, in regards to national public health policy.
Another source of inequality in access to fl uoridated water is the non-universal coverage of the system for publicly distributed water (Table ).As to be expected, this issue also showed greater advancement in the South and Southeast regions.Even though the coverage of the distribution system has expanded in all the regions, the states in the North and Northeast still suffer extensive lack of access to water, with obvious negative health outcomes.
The positive effect of water fl uoridation can be seen in the reduced prevalence of dental caries, as measured in epidemiological studies of dental health conducted at the national level.After the mid-1980s, there was a marked decline in the indicators for caries, and the DMFT index, which describes the number of teeth with history of carries, decreased from 6.7 in 1986 to 2.8 in 2003, among children 12 years of age.Narvai et al 13 studied these indicators and associated their favorable evolution to the expansion of fl uoridated water and to other changes that occurred over the period.
Despite the favorable result, water fl uoridation had an undesired effect in Brazil: the unequal distribution of this preventative measure increased the socioeconomic disparity in prevalence of the disease.Based on the data from the epidemiological study of 2003, Peres et al 15 recalculated the average 2.8 DMFT index for 12 year olds, by stratifying the children for residency in cities with and without fl uoridated water, and found respective values of 2.4 and 3.5.The comparison speaks in favor of the intervention but also shows the social injustice involved in not meeting the legal mandate of fl uoridation for all municipalities.
Peres et al 15 also point to an increased negative correlation between the index of caries and the percentage of households connected to the water system.In cities that participated in the study, the greater the coverage by the water distribution system, the lower the DMFT index at 12 years.In order to guarantee universal access to fl uoride, it is not enough to add it to the water being distributed.It is also necessary to guarantee access to piped water in all households or, at the least, to a community source and, surveillance of the intervention is certainly necessary.
When partially implemented and seen through a socioeconomic point of view, fl uoridation had additional effects on the disparities in the prevalence of caries.In municipalities without fl uoride, there was practically no difference in DMFT between children enrolled in public and private schools, in spite of the presumably higher socioeconomic position of the second group.In municipalities with fl uoride, though, the DMFT index was 43% higher for children in public schools.Increased inequality associated with fl uoride was also observed when contrasting between schools located in urban or rural areas.In comparison to their counterparts in urban areas, students in rural areas had a 16% greater DMFT index in towns without fl uoride; this excess increased to 68% in towns with fl uoride. 15e lack of universal access to fl uoridated water keeps a large contingent of the population from benefi ting from this effective intervention, which is clearly cost-effective. 7Although it is understandable that fl uoridation fi rst occurred in municipalities with larger populations and greater resources to expend in the public interest, the fact that its expansion has been so slow, that in the 21st century more than half of Brazilian municipalities still have not adopted the intervention, necessitates adjustments to the development of this public policy.These adjustments are urgent and necessary principally because interrupting fl uoridation, or not implementing it where it should be done, constitutes an illegal, scientifi cally unsustainable and socially unjust action. 12e

DENTAL CARE IN THE SUS PUBLIC NETWORK
In 1998, the Pesquisa Nacional por Amostra de Domicílios (PNAD -National Household Sample Survey) contained a specifi c section about need, access and use of health services.Based on this data, it was reported that the SUS fi nanced 24.2% of dental care, a proportion in contrast to the much higher percentage of non-dental health care, of which 52.4% was provided by the public sector. 4spite the unfavorable comparison, there was substantial progress incorporating dental health into the offi cial health system in only one decade.The creation of the SUS in the 1998 Constitution is the initial point of reference for the provisioning of regular dental services at a large-scale through the public health system.Universality, integration and equity: the adoption of these constitutional principles by the SUS meant that oral health was recognized as an inseparable part of general health, as an obligation of the state and a right for all.
Nonetheless, expanding public dental services beyond the traditional maternal and child groups has presented great diffi culties for the health system, since the resources destined to this end, although increasing, are insuffi cient to immediately meet all the potential needs of the population.To respond to this challenge, the strategy of prioritizing the fl ow of resources and selecting goals was adopted.The fi rst goal proposed was provisioning services for children, pregnant women and dental urgencies in the basic health units.After the 1998-PNAD, there was an important consolidation of public policy for oral health in the country 14 and new evaluations of these policies could measure if the public sector's participation in the provisioning of dental care in fact increased.In attempting to test this hypothesis, the Figure presents comparative data about the proportional participation of physicians and dentists in the public sector for Brazilian regions in January of 2008.Besides the number of contracted dentists, the Ministry of Health also reports on the amount of resources dedicated to oral health, the amount of procedures performed and the total primary dental consultations in the program.
More than one third (37.1%) of dentists credentialed by the Federal Dentistry Council for professional practice maintain employment registration with the public service.This number is smaller than, although comparable to the proportion of physicians contracted by the SUS in relation to the total number enlisted in the Federal Medical Council: 52.8%.The Figure shows that the proportion of dentists contracted by the SUS was greater in the North and Northeast regions, where percentages similar to those for physicians in the public sector were reached.In the South and Southeast, where more dentists are working (respectively 16% and 59% of the total in the country), their incorporation into the public sector was relatively smaller.
The data refl ects efforts to create greater public provisioning of dental care in the regions in which they are most necessary.This interpretation is compatible with recent studies undertaken in specifi c regional contexts, which conclude that the planning of public dental services were characterized by redistributive and pro-equity trends, with greater provisioning of resources in cities with worse socioeconomic indicators. 3,9e increased contracting of dentists in the public health network even had effects on the dental profession due to the increase in employment opportunities.Even though working in the public sector and working in private dentistry are not confl icting activities (many dentists contracted by the public network do maintain their participation in private practices), it can be said that the increased energy of public services for dental health has lessened the preponderance in Brazil of the hegemonic model of private dental practice.
There are still no national level evaluations regarding the effect of public dental services on the disparities in oral health indicators, and similarly, studies of the regional contexts are scarce.Nonetheless, the strategies of progressive expansion and the channeling of public resources for dental care to programmatic ends can be considered successful in regards to reducing health disparities as shown by the studies already realized.
In regards to the state of São Paulo (Southeastern Brazil), in 1998, racial and gender disparities were identifi ed in the performance of restorative dental treatments.The study of school-age children indicated that blacks and browns had less access to dental care than whites and a lower proportion of their teeth were restored.Nonetheless, this disparity was associated with cities where the incorporation of dentists in the public network was lower, and the disparity was practically nonexistent in those where the public dental care services had progressed more, in terms of the rate of dentists contracted by the SUS. 1 Another study, also analyzing oral health data in the state of São Paulo, made analogous observations in regards to disparities in the provisioning of needed dental restoration for girls and boys. 2 Nonetheless, these studies 1,2 refer to the richest state in the Federation and do not allow for conclusions of a national scope.In a specifi c evaluation of Rio Grande do Norte (Northeastern Brazil), Souza & Roncalli 18 found that only the municipalities with high socioeconomic position displayed advances in incorporation of oral health in the Family Health Strategy.This observation highlights an important point for the organization of health services and how it is necessary that efforts to change assistance models be accompanied by public policies for social development, which go beyond the health sector.

FINAL CONSIDERATIONS
In a well-known study about "sick individuals, sick populations", Rose 17 proposed two complementary preventive strategies: one centered on the protection of more susceptible or vulnerable individuals and another focused on the determinants of a population's morbidity.We present information on public dental services and the fl uoridation of publicly provided water, as respective examples of the fi rst and second intervention modalities.
Due to the impossibility of immediately implementing universal access to public dental services, new priority targets were established for the preferential direction of resources, such as treating children and pregnant women and providing services specializing in dental prosthetics, endodontics and dental radiology.Besides this, priority for urgent care is a consecrated principle in both the public and private sectors.The public dental service also gave priority to health promotion, by means of expanding primary services, health education, preventive actions and epidemiological studies.The expansion of the public dental service followed a strategy of focusing effort and resources towards these programmatic goals.This policy is still in a period of expansion, but there are already favorable indications in regards to its effect in reducing disparities in oral health.
Fluoridation of publicly distributed water is clearly a strategy of intervention on the determinants of dental caries in a population and one of the most important elements in reducing the indicators for the disease in Brazil and abroad.However, its adoption has not reached the desired universal scope of implementation, despite more than fi ve decade of progressive expansion in Brazil.In spite of the anticipated initial diffi culties, this limitation continues to be an important challenge to public health policy during the present period.
When public health interventions are introduced without strategic planning to allow for universal access for the recipients or to direct additional resources to the groups in most need, they end up having an undesirable effect of increasing health disparities.This effect was designated as the "inverse equity hypothesis" 19 to characterize as unjust the fact that groups with higher socioeconomic status absorb earlier and to a greater extent the advantages of benefi cial public policies.Unjust, unnecessary and avoidable inequalities in health are appropriately known as "health inequities". 20rrecting this undesirable condition requires organized societal efforts by means of government action.By emphasizing the problem of how increased inequality in the experience of caries is associated with how water fl uoridation was and is being implemented, this article aimed to contribute to the planning of these public sector initiatives.Though the immediate universalization of this intervention is hardly feasible, the adoption of targeted strategies that preferentially direct the benefi t to areas where it is most needed should be considered, thus effectively contributing to reducing inequalities in the distribution of carries.

Figure .
Figure.Percentage of dentists and physicians contracted by the Sistema Único de Saúde (SUS), in relation to the total qualifi ed for professional duties in the Brazilian regions.January, 2008.Sources: Ministry of Health/DATASUS, Federal Dentistry Council, Federal Medical Council.

Table .
Percentage of municipalities and districts with fl uoridation of publicly provided water in 2000, and coverage of the water distribution system in the regions of Brazil.% of households connected to the water distribution network.Sources: Instituto Brasileiro de Geografi a e Estatística.Pesquisa Nacional de Saneamento Ambiental 2000.[cited 2010 Jan 27] Available from: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/pnsb/default.shtm and Instituto Brasileiro de Geografi a e Estatística.Censo 2000.[cited 2010 Jan 27] Available from: http://www.sidra.ibge.gov.br/cd/default.asp a