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Smiling Brazil
International Perspectives Smiling Brazil Background.—Brazil is the only country with over 200 million inhabitants that has instituted a universal health care system funded by the government. This unified health nico de Sa system (‘‘Sistema U ude’’ [SUS]) covers everyone, with primary health care the basic building block. Within this system, Brazil is addressing health care inequalities. One of the priority areas of the SUS is oral health. This country’s experience and its applicability to other health care systems were explored. Epidemiological Indicators.—Nationwide surveys were conducted in Brazil to provide information for its public health decision-making process. The most relevant to oral health were the National Household Survey (PNAD) and the National Oral Health Survey (SB Brasil). The 2003 PNAD revealed that about 16% of the population had never seen a dentist. SB Brasil was designed to build a database of the main oral health epidemiological indicators. By 2010, the SB Brasil survey indicated that the nation’s epidemiological profile had been altered for some age groups but high rates of oral disease remained for other groups. Decayed, missing, or filled teeth (DMFT) fell among 12-yearold children and adolescents; the number of caries-free persons increased. Socioeconomic inequalities were observed, however. The strategy of gradually expanding and directing public funding to oral health care was determined to be succeeding in reducing these health inequalities. However, income inequality was a significant factor in the occurrence of severe periodontal disease. Elderly populations also tended to be underserved. Development of Dental Professionals.—Over a 10year period, more than $2.6 billion (US dollars) were invested in strategic areas related to health care policy. These included funding scientific studies to inform decisions and the training of oral health team members. The professionals trained were cognizant of their social responsibilities and focused on delivering primary health care. Smiling Brazil, as the national policy of oral health care is known, shaped the job market for dental professionals, increasing the number of dentists in the SUS by 50% and revolutionizing the way Brazil delivers oral health care to its citizens. An estimated 30,000þ oral health care professionals will serve Smiling Brazil by 2020. Integration of Care.—A polyhierarchical system was established to integrate and coordinate the various levels of health care (Fig). Oral health was integrated into the
network, with advances in the institutionalization of the policy and radical improvement in the ‘‘installed capacity’’ of oral health care services at all three levels of care. The role of each level of care and the interactions required among the various sectors were clearly defined through laws and directives. Plans were made and actions taken to overcome regional differences. Once the system was in place, old equipment was replaced and the physical infrastructure of the oral health care network was expanded. New personnel were hired to meet the clients’ needs regardless of the level of care delivered. The oral health care network is now organized on the precepts of family health, with primary care the entry level. About 80% of patients’ problems are expected to be handled through primary care, which includes dental visits and home care visits when needed. Medium-complexity service units, dental specialty centers, and tertiary care complete the care delivery system. Mobile dental units serve hard-to-access or socially excluded regions. The People’s Pharmacy of Brazil dispenses free medications to users of public and private health care services. Regional dental prosthesis laboratories provide dental prostheses and support the network. The diagnostic services issue anatomic pathology reports on which the diagnosis of oral pathology can be based. High-complexity services include hospital care of inpatients with benign maxillofacial tumors, special needs patients who require general anesthesia for treatment, dental care for patients undergoing chemotherapy or radiotherapy, provision of maxillofacial prostheses, and surgery for chronic cases. Smiling Brazil also began the ‘‘GraduaCEO’’ Program, which coordinates oral health services delivered in university clinics with the oral health care network of the SUS. Oral health care teams, which include a dentist, oral health technician, and/or oral health assistant, have increased by 445% in the 10 years of the national health care system’s existence. Before Smiling Brazil, no secondary care network existed and primary care was limited to tooth extraction and simple restorative procedures. The CEOs ensure a full gamut of care is available and have restructured primary care delivery. These medium-complexity care units also offer primary care and serve as referral and counter-referral outpatient clinics for primary and tertiary care delivery.
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Fig.—Polyhierarchical structure of the Brazilian oral health care network, under a unified health system (‘‘Sistema Unico de Sa ude’’ [SUS]). (Courtesy of Pucca GA Jr, Gabriel M, de Araujo ME, et al: Ten years of a national oral health policy in Brazil; Innovation, boldness, and numerous challenges. J Dent Res 94:1333-1337, 2015.)
Future Challenges.—In the future, Smiling Brazil will have to address the ongoing consolidation of the oral health care network, human resources needs, and social and cultural influences. In addition, numerous barriers to accessing care remain to be breached.
Clinical Significance.—Smiling Brazil provides a positive example of what can be accomplished in an integrated system of oral health care delivery. Although much work remains,
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Dental Abstracts
the accomplishments of this system should be instructive to other efforts to establish universal health care.
Pucca GA Jr, Gabriel M, de Araujo ME, et al: Ten years of a national oral health policy in Brazil; Innovation, boldness, and numerous challenges. J Dent Res 94:1333-1337, 2015 Reprints available from sagepub.com/journalsPermissions.nav
network, with advances in the institutionalization of the policy and radical improvement in the ‘‘installed capacity’’ of oral health care services at all three levels of care. The role of each level of care and the interactions required among the various sectors were clearly defined through laws and directives. Plans were made and actions taken to overcome regional differences. Once the system was in place, old equipment was replaced and the physical infrastructure of the oral health care network was expanded. New personnel were hired to meet the clients’ needs regardless of the level of care delivered. The oral health care network is now organized on the precepts of family health, with primary care the entry level. About 80% of patients’ problems are expected to be handled through primary care, which includes dental visits and home care visits when needed. Medium-complexity service units, dental specialty centers, and tertiary care complete the care delivery system. Mobile dental units serve hard-to-access or socially excluded regions. The People’s Pharmacy of Brazil dispenses free medications to users of public and private health care services. Regional dental prosthesis laboratories provide dental prostheses and support the network. The diagnostic services issue anatomic pathology reports on which the diagnosis of oral pathology can be based. High-complexity services include hospital care of inpatients with benign maxillofacial tumors, special needs patients who require general anesthesia for treatment, dental care for patients undergoing chemotherapy or radiotherapy, provision of maxillofacial prostheses, and surgery for chronic cases. Smiling Brazil also began the ‘‘GraduaCEO’’ Program, which coordinates oral health services delivered in university clinics with the oral health care network of the SUS. Oral health care teams, which include a dentist, oral health technician, and/or oral health assistant, have increased by 445% in the 10 years of the national health care system’s existence. Before Smiling Brazil, no secondary care network existed and primary care was limited to tooth extraction and simple restorative procedures. The CEOs ensure a full gamut of care is available and have restructured primary care delivery. These medium-complexity care units also offer primary care and serve as referral and counter-referral outpatient clinics for primary and tertiary care delivery.
Volume 61
Issue 3
2016
129
Fig.—Polyhierarchical structure of the Brazilian oral health care network, under a unified health system (‘‘Sistema Unico de Sa ude’’ [SUS]). (Courtesy of Pucca GA Jr, Gabriel M, de Araujo ME, et al: Ten years of a national oral health policy in Brazil; Innovation, boldness, and numerous challenges. J Dent Res 94:1333-1337, 2015.)
Future Challenges.—In the future, Smiling Brazil will have to address the ongoing consolidation of the oral health care network, human resources needs, and social and cultural influences. In addition, numerous barriers to accessing care remain to be breached.
Clinical Significance.—Smiling Brazil provides a positive example of what can be accomplished in an integrated system of oral health care delivery. Although much work remains,
130
Dental Abstracts
the accomplishments of this system should be instructive to other efforts to establish universal health care.
Pucca GA Jr, Gabriel M, de Araujo ME, et al: Ten years of a national oral health policy in Brazil; Innovation, boldness, and numerous challenges. J Dent Res 94:1333-1337, 2015 Reprints available from sagepub.com/journalsPermissions.nav