Abstract

This article discusses the structuring of health care networks in the Unified Health Care System, detailing the main priority thematic networks. It is argued that the transversal insertion of oral health in priority networks makes the specific demands of the area invisible. It is argued that the oral health care network has all the elements to constitute a priority network, with points of care, logistical and diagnostic support. It is concluded that it is necessary to place dental management beyond the primary health care division in order to develop a specific network, and strengthen the municipal and state dental management instances.

Key words:
Oral health; Oral health services; Health policy; Health care

The legal mark of Oral Healthcare Networks (OHNs) in Brazil was Decree 4.279/10, which established the guidelines for the reorganization of the health system. This Decree defined OHNs as: organizational arrangements of actions and health services, of different technological densities, which, integrated through technical, logistic, and management support systems, seek to guarantee the integrality of care. The new arrangements emerge as a strategy to overcome the fragmentation of health care and coordination in the Health Regions, as well as to improve the political-institutional functioning of the Brazilian Unified Health System (SUS), in an attempt to improve the integrality of care, both effectively and efficiently. The OHNs emerge in to rearrange the services in order to face certain challenges in the healthcare system, including the triple load of the disease, a strong predominance related to chronic conditions, and a healthcare system that is fragmented, episodic, reactive, and geared mainly toward acute events²2 Mendes EV. As redes de atenção à saúde. Cien Saude Colet 2010; 15(5):2297-2305..

In subsequent decrees, the Ministry of Health designed proposals for the reorganization of the network into five priority networks: 1) the Maternity Child (Stork) Network³3 Brasil. Portaria nº 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS) a Rede Cegonha. Diário Oficial da União 2011; 24 jun.; 2) the Urgency and Emergency Care Network (UECN)⁴4 Brasil. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção à urgências e institui a rede de atenção às urgências no Sistema único de saúde (SUS). Diário Oficial da União 2011, 7 jun.; 3) the Psychosocial Care Network (PCN)⁵5 Brasil. Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras rogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2011; 23 dez.; 4) the Disability Care Network (DCN) (Living without Limits)⁶6 Brasil. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2012; 24 abr.; and lastly, the Chronic Disease Healthcare Network⁷7 Brasil. Portaria nº 438, de 1º de abril de 2014. Redefine a Rede de Atenção à Saúde das Pessoas com Doenças Crônicas no âmbito do Sistema Único de Saúde (SUS) e estabelece diretrizes para a organização das suas linhas de cuidado. Diário Oficial da União 2014; 1 abr..

It is important to highlight the invisibility of the OHNs within the priorities of the Ministry of Health, even though the design of the National Oral Health Policy (Brasil Sorridente) points out the legitimacy of this network. Currently, there are 25,334 modality I oral health teams, and 1,942 type II oral health teams, together with 1,126 Dental Specialty Centers (DSC), 615 of which are linked to the DCN (Living without Limits)⁹9 Brasil. Cidades Atendidas com Centros de Especialidades Odontológicas 2022 [Internet]. [acessado 2022 ago 2]. Disponível em: https://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
https://aps.saude.gov.br/ape/brasilsorri... , and 3,244 Regional Laboratories for Dental Prostheses (RLDP)¹⁰10 Brasil. Cidades Atendidas com Laboratórios de Prótese 2022 [Internet]. [acessado 2022 ago 2]. Disponível em: https://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
https://aps.saude.gov.br/ape/brasilsorri... , which enable access to oral health for thousands of Brazilians.

The invisibility of OHN, in the official documents of the Thematic Networks of the Healthcare and Service Networks¹¹11 Brasil. Portaria de Consolidação nº 3. Consolidação das normas sobre as redes do Sistema Único de Saúde. Capítulo I - Das Redes de Atenção à Saúde, Capítulo II - Das Redes de Serviço de Saúde. Diário Oficial da União 2018; 7 fev., has led some state and municipal managers, especially non-dentists, to understand that oral health is a transversal network¹²12 Secretaria de Saúde do Estado do Ceará. Relatório do Plano Regional de Saúde. Ceará; 2019, that is, transversally, in the discussions of other priority networks. This question arises because the dental services “appear timidly” in care lines, even with specific financing in other priority networks, as can be seen in the DCN and the UENC. The DSCs receive an additional resource to structure the specialized dental care network for people with disabilities⁶6 Brasil. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2012; 24 abr., guaranteeing specialized dentists, 40 hours weekly, in the authorized centers within the DCN. In the UENC, dental care is provided only in the Emergency Care Units (ECUs), level III, implemented due to the reported population of between 200,000 and 300,000 inhabitants. The ECUs, level I and II, do not include dental urgencies. It is a fact that oral health is transversal to the health of pregnant women, of people with mental suffering or disorders, of drug and alcohol users, and of people with chronic diseases, given that oral health weakens specific discussions in the area, and reinforces the non-institutionalization of the OHN. Furthermore, much like oral health is transversal to other networks, they should also be transversal among themselves. In other words, it is important to work on the mental health of pregnant women, the chronic diseases in patients with mental disorders, and the urgency and emergency care in people with disabilities.

In this context, do OHNs really exist? Yes, in the most recent manual, produced by the National Dental Chief Office¹³13 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. A saúde bucal no Sistema Único de Saúde (SUS). Brasília: MS; 2018., in scientific articles¹⁴14 Godoi H, Mello ALSFD, Caetano JC. Rede de atenção à saúde bucal: organização em municípios de grande porte de Santa Catarina, Brasil. Cad Saude Publica 2014, 30(2):318-332.

15 Basso MB, Nunes NB, Corrêa LBC, Vieira CN, Vilarinho JLPDS, Pucca GA. A construção da rede de atenção à saúde bucal no Distrito Federal, Brasil. Cien Saúde Colet 2019; 24(6):2155-2165.^-1616 Cayetano MH, Almeida Carrer FC, Gabriel M, Martins FC, Pucca Jr GA. Política Nacional de Saúde Bucal Brasileira (Brasil Sorridente): um resgate da história, aprendizados e futuro. Universit Odontol 2019; 38(80):6-9., containing theoretical models that clearly design all of the themes of care provided by the OHN, as proposed by Cayetano, Carrer, Gabriel, and Martins (2019)¹⁶16 Cayetano MH, Almeida Carrer FC, Gabriel M, Martins FC, Pucca Jr GA. Política Nacional de Saúde Bucal Brasileira (Brasil Sorridente): um resgate da história, aprendizados e futuro. Universit Odontol 2019; 38(80):6-9.. These authors drafted a theoretical design that contemplates: 1) the population of the territories; 2) primary care, with the oral health teams coordinating the care provided; 3) the support system, consisting of the mobile dental units, histopathological laboratories, those of prostheses, and teledental services/DSC gauge; 4) the logistics systems, such as electronic and integrated medical records, a regulated access system, and a health transport system; 5) specialized outpatient care, performed by the DCNs, which aid the population in the dental specialties of endodontics, periodontics, oral diagnoses, maxillofacial surgery; help patients with special needs, and offer specific implant dentistry and orthodontics services; 6) hospital care, which occurs through the structuring of maxillofacial trauma and hospital dentistry, as well as through the growing demand for dental care, with general anesthesia, for patients with special needs. In the end, there are also the High Complexity Oncology Care Centers (CACONS, in Portuguese) and High Complexity Oncology Care Units (UNACONS).

Although the OHN exists as a the theoretical-conceptual model, in the organizational and operational political field, it still seems quite fragmented. The lack of priority, or invisibility, of the OHN at the federal level weakens, in a cascade effect, any attempt to strengthen this network at the state and municipal levels. One argument that reinforces this invisibility is the fact, for example, that the Chief Dental Office within the Health Ministry is inserted within the Family Health Department, which is only one point of the healthcare network. In fact, the current program of financial incentive of primary health care (PHC) - Previne Brasil - instituted by Decree 2979, from November 12, 2019, inserts such points as the ESB, Mobile Dental Units (MDUs), DSCs, and RLDP, in the same funding block, called strategic actions, contributing to consolidate the space of oral health management within the PHC. Our network has expanded, and we no longer offer only primary health care. Another network, such as mental health, until recently, was inserted in the Department of Strategic Programmed Actions. Should this not also be the place for oral health? The federal organization resonates at other managerial levels.

Many state and municipal delegations, when they exist in the respective institutional organograms, end up following the same model of organization of the federal sphere, that is, they end up linked to Primary Care. In fact, there are innumerous weaknesses in the state and municipal delegations of oral health in the country, including the accumulation of functions (care and coordination) and the lack of bonuses for the position, including the inexistence of this function in the respective organograms¹⁷17 Paegle ACRO, Souza EHA, Oliveira PA. Coordenação das Equipes de Saúde Bucal: avaliação para melhoria da qualidade (AMQ). Pesq Bras Odontoped Clin Integr 2012; 12(4):497-503.^,1818 Silvestre, JAC. Coordenação das ações de atenção à saúde bucal na 13ª coordenadoria regional de saúde do estado do Ceará: percepção da gestão municipal [dissertação]. Sobral: Universidade Federal do Ceará; 2012.. The invisible transversality of the OHN leads to a scenario of the non-discussion of specific demands, which are of utmost importance for oral health within state and municipal health plans. The state of Ceará, for example, opted for this perspective, and what was observed during regional health planning meetings is that oral health has once again been relegated to primary health care¹²12 Secretaria de Saúde do Estado do Ceará. Relatório do Plano Regional de Saúde. Ceará; 2019. So many other important demands, such as the expansion of water fluoridation in the state and the regionalization of the hospital dental services were not on the agenda. Our services come and go invisibly in the plans. In a macro context, this situation can be explained by the case of the RLDP, which was reduced to a mere “dental program”¹⁹19 Narvai, P. C. Ocaso do 'Brasil Sorridente' e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus 2020;14(1):175-187. with an expressive reduction in the financing of actions in the folder in 2016, which still remains even today¹⁹19 Narvai, P. C. Ocaso do 'Brasil Sorridente' e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus 2020;14(1):175-187.. The resumption of the RLPD, in a more hopeful political scenario, should clearly present the OHN in the organizational structure of the Ministry of Health, with a redefinition of the specific resource for the area. Bill 8.131/2017²⁰20 Brasil. Câmara dos Deputados. Projeto de Lei nº 8.131/2017, de 2017. Institui a Política Nacional de Saúde Bucal no âmbito do Sistema Único de Saúde (SUS) e altera a Lei nº 8.080, de 19 de setembro de 1990, para incluir a saúde bucal no campo de atuação do SUS [Internet]. [acessado 2022 set 15]. Disponível em: https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra;jsessionid=832C287F31E27AEE2855BC5DC3324826.proposicoesWebExterno1?codteor=1591269&filename=Avulso+-PL+8131/2017.
https://www.camara.leg.br/proposicoesWeb... , which officializes the insertion of Oral Health in SUS is another important element in the consolidation of oral health as a state public policy, with possible effects in increments in the planning and allocation of resources for the area. This Bill²⁰20 Brasil. Câmara dos Deputados. Projeto de Lei nº 8.131/2017, de 2017. Institui a Política Nacional de Saúde Bucal no âmbito do Sistema Único de Saúde (SUS) e altera a Lei nº 8.080, de 19 de setembro de 1990, para incluir a saúde bucal no campo de atuação do SUS [Internet]. [acessado 2022 set 15]. Disponível em: https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra;jsessionid=832C287F31E27AEE2855BC5DC3324826.proposicoesWebExterno1?codteor=1591269&filename=Avulso+-PL+8131/2017.
https://www.camara.leg.br/proposicoesWeb... , since 2018, has been on the table of the Constitutional Commission and needs to be approved. It is hoped that these actions will reverberate at the proper court levels of state and municipal management. While this does not occur, we will continue to fight for a strong dental public health system in the country.

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