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. 2020 Nov 4;63(5):237–243. doi: 10.1111/idj.12039

Oral health in the context of primary care in Brazil

Antonio C Nascimento 1,*, Simone T Moysés 2, Renata I Werneck 2, Samuel J Moysés 2
PMCID: PMC9375030  PMID: 24074017

Abstract

This article presents an integrative literature review that analyses the advances and challenges in oral health care of the Brazilian primary health care system, based on a political agenda that envisages re-organising the unified health system (SistemaÚnico de Saúde – SUS). It is presumed that the actions suggested by the Alma-Ata Conference of 1978 are still up-to-date and relevant when adapted to the situation in Brazil. Several studies and policies are reviewed, including works demonstrating the importance of primary care as an organising platform in an integrated health-care network, Brazil’s strategy for reorganising the primary care network known as the Family Health Strategy, and the National Oral Health Policy. This review discusses results obtained over the last twenty years, with special attention paid to changes in oral health-care practices, as well as the funding of action programmes and assistance cover. The conclusion is that oral healthcare in the Brazilian primary health care system has advanced over the past decades; however, serious obstacles have been experienced, especially with regard to the guarantee of universal access to services and funding. The continuous efforts of public managers and society should focus on the goal of achieving universal coverage for all Brazilians.

Key words: Primary health care, health care systems, community health care, family health program, oral health, public health dentistry

INTRODUCTION

After the Alma-Ata Conference1, public managers in several countries were involved in diverse political issues regarding personal will and institutional governance for performing actions convergent to the principles of the primary health care (PHC) approach2. This approach, in many instances, is constrained to offer services of low complexity, which are organised to address some selective needs of poor people with basic problems and precarious resources. Such an understanding does not satisfy the true role of the PHC approach as an integrated health-care network.

The PHC must be structured as the site of initial care (i.e. the preferential entry point for health-care service users) where the majority of problems are solved at the right time and using technology adequate to the specific local situation3., 4.. It also should be organised in such manner that the promotion of health care and the prevention and treatment of diseases are of adequate quality and quantity for the socio-epidemiological profile of the population.

In the specific field of oral health-care policies, the World Health Organisation (WHO) and the FDI World Dental Federation established Global Oral Health Goals for the year 20005; currently, we see that many of those goals have been achieved. Unfortunately, for many people, such targets are nothing but well-intentioned rhetoric that has yet to materialise. Strengthening oral health care in the PHC approach is the first step for transforming these Global Oral Health Goals into a reality by 20206.

This review organises and discusses the pertinent literature on the inclusion of oral health care into the PHC approach, emphasising the Brazilian National Oral Health Policy, namely, the ‘Brazil Smiling’ Programme7.

METHODOLOGY

A narrative and integrative literature review was carried out, guided by the criteria of quality and eligibility, using the RATS (Relevance, Appropriateness, Transparency and Soundness) criteria as often as possible. The electronic scientific databases PubMed/Medline, SciELO (Scientific Electronic Library Online) and Virtual Health Library (VHL/Bireme/WHO-PAHO) were used, and the search was complemented with institutional documents by the Brazilian Ministry of Health. The following searching terms were used (Medical Subject Headings –MeSH): Primary Health Care, Health Care Systems, Community Health Services, Family Health, Oral Health and Public Health Dentistry. The search was restricted to publications between 1990 and 2012 in both English and Portuguese.

RESULTS

Unified health system of Brazil: a brief introduction

The unified health system (SistemaÚnico de Saúde–SUS) was created in 1988 by the Federal Constitution of Brazil to assist the whole Brazilian population, free of charge. This is one of the largest public health-care systems in the world, and the financial responsibilities for managing and operating it are shared between the Federal, State (27 States plus the Federal District) and Municipal (5,566 municipalities) governments8. The universal and equal access to health-care actions and services is organised in a decentralised manner at the local level, with an operational base in the municipalities. This is an important issue in a country of continental dimensions, with a federal system of government and significant economic, social and epidemiological inequalities.

Using their own network or a contracted network of services, the SUS offers a variety of services, from the basic ambulatory outpatient services to more complex procedures, such as organ and tissue transplants, and the integral treatment of diseases, such as cancer and acquired immune deficiency syndrome (AIDS). The SUS is also responsible for promoting immunisation of the entire Brazilian population and for developing programmes of health-care promotion, disease prevention and epidemiological, sanitary and environmental surveillance, as well as the development of research, production and distribution of medication and immunobiological materials, among other services.

In the 24 years following the creation of the SUS, the country has built a solid legal basis upon which the fundamental right to health care is provided to the population. Before this legislation, access to the system was limited to the taxpayers who contributed to the social security system, which excluded the majority of the population, especially the most vulnerable.

Universal coverage offered by a health-care system is now at the core of international debates9, appearing in several countries such as the USA10., 11., 12..The Affordable Care Act establishes a reference plan for the role of state and universal coverage in the organisation of health-care systems in countries such as Brazil, Canada and the UK.

In dentistry, debates on the universalisation and reform of subsystems that offer oral health-care services are heated. Sparer13 highlights the need for the dental community to get involved in debates and become more present in the PHC approach. This reflection is valid, as dentistry in most countries continues to be only marginally included in public policies, prioritising the training of dentists to work in the private sector. The adoption of a new direction towards the public sector was defended by the American Dental Association (ADA)14 when support was given for restructuring public dentistry’s infrastructure in the USA and by the Dunning Symposium15, which discusses the need for a new practice of dentistry that is adequate for the 21st century.

In Brazil, despite the developments, the SUS faces a hegemonic and powerful subsystem of health care that is privately organised, responsible for most of the social budget and available to less than 40% of the population. There are many difficulties in consolidating the SUS, especially in a country in which a large part of the population depends on the public system. Paradoxically, the financial investment is still insufficient and the model of higher education in health care still prioritises individual and curative private practice-based approaches. However, it is important to highlight that since 1988 political and social powers have been acting in Brazil to deal with this issue and to develop measures to consolidate the SUS. For example, the Ministry of Health, together with the states and municipalities, has been running the National Oral Health Policy programme ‘Brazil Smiling’ since 20047., 16..

Primary health care: evidence of effectiveness

In this consideration, we confirmed the scarcity of longitudinal studies that evaluate oral health care in a PHC approach. Such studies are common in the field of general health care.

Experiences in countries with varied levels of development17., 18., 19., 20., 21. have demonstrated that a PHC approach can be adapted and interpreted to fit a specific economic and epidemiological context. Recent research18., 22., 23., 24., 25., 26. has demonstrated that several indicators are positively affected by the strengthening of PHC.

Several studies discussed in this review agree with the aforementioned evidence on general health27., 28., 29., 30.. We have verified that medical services founded in a PHC approach can solve a great deal of the most prevalent health problems. In addition, trends in hospital admission rates for PHC-sensitive conditions are reduced, such that child and general mortality rates are lower and such services are more equitable and accessible, as well as being better accepted culturally by the population.

However, in contrast to the previously presented evidence, Williams et al.31 evaluated the efforts of the National Health Service (NHS) in the UK to improve the cost-effectiveness and access to oral and general health care by transferring more complex services to the PHC system at the beginning of the European economic crisis. They concluded that there is no robust evidence to demonstrate that this initiative will improve the cost-effectiveness of the system.

In the Brazilian case, the incorporation and expansion of the Family Health Strategy (FHS) with oral health teams (OHT) included in the year 2000 is relevant to the inclusion of oral health care in the PHC approach. ‘Smiling Brazil’16 is a strategy that aims to change the Brazilian biomedical practice-based model of dentistry, converging towards the recommendations from Alma-Ata1 and, more recently, from the WHO itself5., 6..

DISCUSSION

Oral health in primary health care in Brazil

Until the 1970s, oral health-care services in Brazil were characterised by limited access and directed to spontaneous demand and individual curative treatments. For decades, through the adaptation of the ‘Incremental Model’32, schoolchildren between 6 years and 12 years of age were prioritised by the national dental service. In most cases, preventative actions were limited to individual topical fluoride applications33. This feature excluded the remaining age groups and placed little emphasis on health-care promotion, diverging from the perspective of an oral health-care system seeking to root itself in the concepts of universality and equality and in the principles of the PHC approach. The situation in Brazil is not unique. By the end of the 1990s, it was estimated that more than four billion people in the world did not have access to a dentist34.

The cooperation between several levels of government, from federal to the municipal, in implementing ‘Smiling Brazil’16 to fulfil the oral health-care needs was demonstrated by the widest ever epidemiological study performed in the country between 2002 and 200335. This study examined approximately 110,000 people at the age-specific indices recommended by the WHO36. At that time, the mean DMFT (Decayed, Filled, and Missing Teeth) at 12 years of age was 2.8, which increased to 6.2 from 15–19 years of age and to 27.8 from 65–74 years of age. These indicators demonstrate the low effectiveness and improper use of resources of the oral health-care system.

Another decisive study ratifying the need for the implementation of ‘Smiling Brazil’ was performed by the Brazilian Institute of Geography and Statistics37, which revealed that by the end of the 1990s, the oral health-care system received a small portion of resources in relation to the total investment in the SUS – only 5.3% of the total health-care expenditure. This situation resulted in nearly 30 million people not having any dental assistance at all; of these about 19 million were aged 19 years or younger. This situation was aggravated in small countryside towns and rural areas.

The ‘Smiling Brazil’ programme advocates the strengthening of the oral health in the PHC approach and developing better-qualified teams with wider access to specialised care. In addition, the municipal governments must provide stimulus for adding fluoride to drinking water supplies. It also attempts to intervene in the process of obtaining a higher education in dentistry such that future professionals join the SUS with knowledge of the real oral health-care needs of the population. Furthermore, ‘Smiling Brazil’ emphasises the integration of dentistry into multidisciplinary teams because there has been an historic exclusion of this field from health-care policies. Such initiatives are supported by the Llodra Calvo et al.38 study, which highlighted the importance of dentistry in multidisciplinary teams that provide primary care.

In the decade since the implementation of the Brazilian oral health policy, important changes in the financial support of the Brazilian PHC approach have been observed (Table 1) in addition to positive impacts on the epidemiological situation and an increase in population coverage by oral health-care teams (Table 2).

Table 1.

Federal government expenditure on healthcare at different levels of complexity or type of services (in US$) in Brazil, 2001 and 2011

2001 2011 Variation %
Primary health care 1,797,772,988.51 7,017,480,842.91 >292
Mean and high complexity (specialised care) 6,792,983,716.48 19,932,351,532.57 >193
Health surveillance 410,680,076.63 1,658,884,099.62 >304
Medication 614,822,796.93 2,444,324,712.64 >298
TOTAL 9,616,259,578.54 31,082,974,137.93 >223
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Source: Ministry of Health. Brazil, 20117., 8., 37..

Table 2.

Comparison of oral health-care expenditure, DMFT (decayed, missing, filled teeth) at 12 years of age and population coverage by oral health teams in Brazil, 2003 and 2010

2003 2010 Variation %
Oral health expenditure (US$) 30,899,396.30 322,648,905.40 >944,2
DMFT at 12 years of age (mean) 2.8 2.07 <25
Inhabitants covered by oral health 26,100,000 135,300,000 >370
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Source: Ministry of Health, Brazil7., 8., 37..

Oral health in primary care in Brazil: history, advances and future challenges

In 1994, when implanting the PHC with FHS, Brazil started to encourage local governments, both financially and technically, to join the new model idealised to allow greater access to health-care services and to reorganise practices in the PHC approach39. It was only in 2000 that the OHTs were included in the strategy, which also included dentists and other dental health-care professionals.

The strategy seeks to reorganise primary healthcare by adjusting the SUS8., 40. guidelines and it is founded on the assumptions of acting in a defined territorial basis, where each multidisciplinary team is responsible for approximately 870 families and/or 3,500 inhabitants. This organisation actively seeks the most vulnerable groups to address the social determinants of poor health and places an emphasis on promotional and preventative activities, without neglecting the clinical time necessary for healing and rehabilitation. Such assumptions will only be achieved by the local planning of health-care teams.

This study demonstrates that the goal of offering health-care services to vulnerable populations has been achieved by covering 72% of the population of the northeast region of the country, which is the poorest, and 36% coverage of those who live in the southeast region, the richest7., 8., 30.. The difference in coverage between the poor and rich, which is favourable to the former, demonstrates that the strategy contributes to tackling the inequalities in access to health – a serious problem in countries such as Brazil.

In 2003 there were 2,800 OHTs working in the FHS. By the end of 2010 there were 28,353 working teams in 4,905 cities, which make up 89% of the municipalities in Brazil. Official data estimate that 135 million people – 71% of the population – are covered by the OHTs40., 41..

An important point in the strategy is the inclusion of community health agents (CHA)40: these are people from the community that form a link between the teams and patients, and especially the most vulnerable patients. Currently, there are 313,246 CHAs who act in 5,418 municipalities and cover more than 124 million people. The CHAs, among other efforts, are instructed to identify, educate and direct individuals and families with oral health problems.

The inclusion of oral health in the FHS seeks to modify the traditional curative–rehabilitative philosophy in the context of health-care services40., 41.; however, such intentions will not be fulfilled if professionals and institutions do not change their paradigms and work processes. It is necessary to offer effective answers to patient needs and to invest in the prevention of oral health-care problems using collective measures and epidemiological knowledge across the entire population residing within the territory of each multidisciplinary team.

Several studies have investigated the effectiveness of oral healthcare in the FHS to change traditional health care delivery models towards a new pattern of patient-driven health care services. A good example is a study performed in northeast Brazil42, which shows the positive impact of this strategy on patient access to oral health-care services. Nevertheless, the same study demonstrated that children up to 12 years of age had greater access compared with other population groups, which suggests the maintenance of practices that prioritise schoolchildren (a remnant of the Incremental Model).

In contrast to the previous study, Nascimento et al43 observed an improvement in access to services for all groups, from children to the elderly, as well as changes in the oral health-care practices after the implementation of the strategy in two important Brazilian cities. Progress was also observed in relation to the humanisation and greater bonding between professionals and families covered. However, the authors detected that serious problems regarding universal access to oral health care persisted both in the PHC approach and in specialised clinics.

In the same line of work, Cruz et al.44 analysed the actions of the oral health-care teams in relation to the SUS guidelines and concluded that they had incorporated the PHC conceptual bases into their work routines, especially those related to the attributes described by Starfield27, including: first preferential contact of the patient with the service network, continuity of care, network coordination, integrality of care,family orientation; cultural competence and, finally, community orientation. It is clear, nonetheless, that there is insufficient access to services for the population, which indicates a need for greater public investment in broadening oral health-care services in the PHC approach.

Another study conducted by Rocha & Goes45 analysed the quality of access to oral health care in areas covered by the FHS and in those areas not covered. The authors did not find a significant difference regarding access by oral health-care-assisted and unassisted populations in the aforementioned strategy. This contradictory finding is worrying and should serve as an alarm because the strategy receives major public investments, and the qualification of access by historically assistance-deprived population groups is the primary goal for oral health care.

Other recent studies in several regions have concluded that oral health care in the strategy7., 8. appears to follow the PHC model of care, with a favourable impact on the quality of population-wide access to the services.

The studies reviewed have encouraged reflection on the lack of uniformity of results with respect to the effectiveness of oral health care in the FHS. Furthermore, it is necessary to recognise the limitations of different studies in relation to the groups studied because they took place in regions with high socioeconomic inequalities and at different consolidation stages of the SUS and the oral health-care assistance network.

While Brazil attempts to reorganise practices in the PHC approach, the WHO is seeking to fight inequality in access to oral health care using the Basic Package of Oral Care (BPOC)46 that proposes three minimal components: (1) prompt care of pain, trauma and oral infections; (2) referral of more complex cases to specialised centres; and (3) affordable fluoride toothpaste and atraumatic restorative treatment. To support public managers and frontline teams, Heldermann & Benzian47 provided operational recommendations for the implementation of the BPOC.

In Brazil, despite the inherent difficulties caused by decreased access to public investments, there is an extensive network of PHC services. In addition, it is desirable to adopt more ambitious measures for a more universal, integral oral health-care plan that is sustained by technologies and where costs supported by the local and central governments; these are viable targets in view of the SUS’s recent history.

There are numerous studies showing a positive correlation between the PHC/FHS and the change in the oral health-care practice model with favourable outcomes in service access, higher resoluteness and patient satisfaction48., 49., 50., 51.. Such evidence must be used critically by the public administrators of oral health care in Brazil and other countries to justify a definitive inflection point for consolidating a new public model of oral health care for the entire population – one that tackles social inequalities. These efforts can play an important role in making the practice of dentistry more concerned with citizenship and social wellbeing and not simply the production of restorative artefacts for dental problems that, in many cases, could have been prevented.

This review aimed to demonstrate that the SUS, in the field of primary care policies in oral health care, presents some characteristics that stand out from health-care systems of other countries52:

  • •

    Multidisciplinary teams are responsible for well-defined geographic territories and population, in which they must identify different biological and social problems and, from those, develop their local plans to tackle these concerns

  • •

    The singular presence of CHAs, which includes people from the community who act as a link between the population and the local team, helps in the identifying the problems and facilitating access, especially in situations identified as higher risk to the individual and/or collective priority

  • •

    Inclusion of OHTs in the FHS, the Brazilian choice for reorganising the PHC approach and strengthening the interdisciplinary practice that has been highly sought after by the dentistry and their representative entities worldwide

  • •

    The inclusion of oral health teams in the FHP is an important achievement, because this program has been the Brazilian choice for reorganising the PHC approach, including multiprofessional teams. The strengthening of interdisciplinary practice has been highly sought after by the dentistry and their representative entities worldwide

  • •

    In line with the principles of the PHC approach, the primary oral health-care team is elected to be the first preferential contact between the patients and health-care services, which optimises financial costs and endeavours to improve patient access.

Amongst the difficulties encountered, the following stand out:

  • •

    The universality of oral health care is not yet a reality for all Brazilians

  • •

    The traditional dental model still persists, giving emphasis to the private dental market; this is a contradictory situation given that 70% of the population in the country consists of SUS users

  • •

    Oral health care in the PHC approach still cannot accommodate and offer integrated care for the oral problems of the population at all levels of complexity

  • •

    Public investment in oral health care, despite receiving an important increase in the past decade, is still insufficient in terms of the needs accumulated over the years and the increasing demand for services by the population.

CONCLUSIONS

This review contributes to the current debates on oral health care in the 21st century by showing that Brazil has experienced important advances in terms of improvements to the PHC approach. However, it is clear that many challenges and inequalities persist in the field of oral health care – a situation that needs to be strongly tackled through a mixed approach, by facing social determinants (upstream) and simultaneously preventing modifiable risk factors at the individual level (downstream).

The increasing municipalisation of health care in Brazil places pressure on local governments to find ways to offer high quality, universal oral health care. To achieve this effect, it is imperative to implement well-conducted studies on the real impact of oral health-care systems that prioritise the principles of the PHC approach, as intended by the SUS, thus allowing for authoritative judgement of this subject.

At present, a major challenge in oral health care for the Brazilian SUS involves the guarantee of integrity of care. The principle of quality oral health care and greater access to all citizens must be strongly pursued in an attempt to overcome merely restorative practices that do not contribute towards improving epidemiological indicators in oral health care.

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