Abstract

This study analyzed the implementation of Brazil’s National Oral Health Policy during the period 2018-2021, covering institutional actions, implementation of public dental services, results achieved, and federal funding. We conducted a retrospective descriptive study using documentary analysis and secondary data obtained from institutional websites, government information systems, and reports published by dental organizations. The findings show a significant reduction in funding between 2020 and 2021 and declining performance against indicators since 2018, such as coverage of first dental appointments and group supervised tooth brushing, which stood at 1.8% and 0.02%, respectively, in 2021. Federal funding dropped in 2018 and 2019 (8.45%), followed by an increase in 2020 (59.53%) and decrease in 2021 (-5.18%). The study period was marked by economic and political crises aggravated by the COVID-19 pandemic. This context influenced the functioning of health services in Brazil. There was a sharp reduction in performance against oral health indicators, while performance in primary health care and specialized care services remained stable.

Key words:
Health policy; Monitoring; Oral health; Dental care

Introduction

Created in 2003, the National Oral Health Policy (PNSB) ushered in a new approach to oral health in Brazil. Otherwise known as “Brasil Sorridente” or “Smiling Brazil”, the main focus of the policy was the expansion of oral health teams (OHt) in primary health care (PHC) services and the organization of specialized care (SC) through the creation of specialist dental centers (CEOs) and regional dental prosthesis laboratories (LRPDs) in 2004. Other priorities included health promotion, such as group procedures and water fluoridation, and oral health surveillance, through periodic epidemiological surveys and the creation of collaborating centers with universities, whose main role was the assessment of CEOs and fluoridation monitoring¹1 Brasil. Diretrizes da Política Nacional de Saúde Bucal. Brasília: MS; 2004.^,22 Chaves SCL, Almeida AMFL, Rossi TRA, Santana SF, Barros SG, Santos CML. Política de Saúde Bucal no Brasil 2003-2014: cenário, propostas, ações e resultados. Cien Saude Colet 2017; 22(6):1791-1803..

Oral health service provision and coverage increased between 2003 and 2006 and remained stable during the periods 2007-2010 and 2011-2014, followed by a more restrictive political environment after the impeachment of president Dilma Rousseff in 2016²2 Chaves SCL, Almeida AMFL, Rossi TRA, Santana SF, Barros SG, Santos CML. Política de Saúde Bucal no Brasil 2003-2014: cenário, propostas, ações e resultados. Cien Saude Colet 2017; 22(6):1791-1803.^,33 Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saude Debate 2018; 42(n. esp. 2):76-91.. Between 2016 and 2018, during the Temer administration, political and economic instability and fiscal austerity measures, notably the approval of Constitutional Amendment 95/2016 freezing public spending until 2036, had a direct impact on the funding of the country’s public health system, o Sistema Único de Saúde (SUS) or Unified Health System, and, consequently, oral health care services⁴4 Rossi TRA, Sobrinho JEL, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436.^,55 Narvai PC. Ocaso do 'Brasil Sorridente' e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus Actas Saude Colet 2020; 14(1):175-187.. In addition, in 2017 the Ministry of Health published a new version of the National Primary Health Care Policy (PNAB), which, among other things, relaxed the rules governing the deployment of PHC teams⁶6 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2017.. During this period, there were also successive changes in the Ministry of Health’s General Office for the Coordination of Oral Health Care (CGSB) and performance against PHC and SC indicators declined²2 Chaves SCL, Almeida AMFL, Rossi TRA, Santana SF, Barros SG, Santos CML. Política de Saúde Bucal no Brasil 2003-2014: cenário, propostas, ações e resultados. Cien Saude Colet 2017; 22(6):1791-1803.^,33 Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saude Debate 2018; 42(n. esp. 2):76-91..

At the beginning of the Bolsonaro administration in 2019, the first health minister, Luiz Henrique Mandetta, defended a “strong and supportive private system” during his swearing-in ceremony speech⁷7 Bravo MIS, Pelaez EJ. A saúde nos governos Temer e Bolsonaro: lutas e resistências. SER Soc 2020; 22(46):191-209.. In the same year, the Ministry of Health launched the Programa Previne Brasil (“Prevent Brazil Program”), setting new criteria for federal government funding of PHC based on the number of registered service users and performance⁸8 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2019.. Under these news rules, CEOs, OHts, and LRPDs remained in the strategic actions budget category. In line with electoral campaign proposals, which made reference only to maternal and child oral health, the only monitored oral health care indicator was the proportion of pregnant women receiving dental care delivered by OHts⁸8 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2019.. Basing funding on the number of registered service users poses a barrier to 100% population coverage and the fundamental principle of universality of the SUS⁹9 Massuda A. Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Cien Saude Colet 2020; 25(4):1181-1188.. These changes were influenced by the movement towards universal health coverage supported by the World Bank, which focuses on core primary services and private or public health insurance coverage to the detriment of public universal healthcare systems¹⁰10 Giovanella L, Mendoza-Ruiz A, Pilar ACA, Rosa MC, Martins GB, Santos IS, Silva DB, Vieira JML, Castro VCG, Silva PO, Machado CV. Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias. Cien Saude Colet 2018; 23(6):1763-1776..

The monitoring of the implementation of these changes to PHC and health funding was set to begin in 2020, a year marked by the coronavirus pandemic¹¹11 Organização Mundial da Saúde (OMS). Organização Panamericana da Saúde (OPAS). Folha informativa-COVID-19. Principais informações [Internet]. 2020 [acessado 2022 jan 13]. Disponível em: https://www.paho.org/pt/covid19.
https://www.paho.org/pt/covid19... . In March 2020, the Ministry of Health announced that there was widespread community transmission across the country¹²12 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Saúde credencia 1,8 mil Equipes de Saúde Bucal com horário diferenciado [Internet]. 2020 [acessado 2022 jan 13]. Disponível em: http://aps.saude.gov.br/noticia/10157.
http://aps.saude.gov.br/noticia/10157... and the CGSB issued a technical note recommending the suspension of scheduled dental appointments, maintaining only emergency services¹³13 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Guia de Orientações para a atenção odontológica no contexto da Covid-19. Brasília: MS; 2020.. Preliminary analyses show that there was a significant reduction in SUS dental procedures during this period¹⁴14 Lucena EHG, Freire AR, Freire DEWG, Araújo ECF, Lira GNW, Brito ACM, Padilha WWN, Cavalcanti YW. Offerand Use of Oral Health in Primary Care Before and After the Beginning of the COVID-19 Pandemic in Brazil. Pesq Bras Odontopediatr Clín Integr 2020; 20(Supl. 1):e0139.^,1515 Chisini LA, Costa FS, Sartori LRM, Corrêa MB, D'Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil's Public Dental System. Braz Oral Res 2021; 35:e082.. The reorganization of health services in response to the pandemic, focusing on hospital treatment to the detriment of PHC, also contributed to this reduction¹⁵15 Chisini LA, Costa FS, Sartori LRM, Corrêa MB, D'Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil's Public Dental System. Braz Oral Res 2021; 35:e082.^,1616 Massuda A, Tasca R. A resposta dos sistemas de saúde à covid-19: breve análise sobre o SUS. In: Santos AO, Lopes LT, organizadores. Principais elementos. Brasília: CONASS; 2021. p. 78-95.. The health crisis continued throughout 2021, which saw the start of the COVID-19 vaccination campaign¹⁷17 UNA-SUS. Vacinação contra a covid-19 já teve início em quase todo o país [Internet]. [acessado 2022 jan 13]. Disponível em: https://www.unasus.gov.br/noticia/vacinacao-contra-a-covid-19-ja-teve-inicio-em-quase-todo-o-pais.
https://www.unasus.gov.br/noticia/vacina... . With the onset of the pandemic, the requirement to comply with the new funding rules established by the Programa Previne Brasil was pushed back¹⁸18 Brasil. Portaria nº 59, de 26 de outubro de 2020. Prorroga o prazo da etapa de transição da capitação ponderada do Programa Previne Brasil. Diário Oficial da União; 2020.^,1919 Brasil. Portaria nº 166, de 27 de janeiro de 2021. Dispõe, excepcionalmente, sobre a transferência dos incentivos financeiros federais de custeio da Atenção Primária à Saúde, no âmbito do Programa Previne Brasil, para o ano de 2021. Diário Oficial da União; 2021., meaning that federal funding was transferred in full in 2020 and 2021, irrespective of the number of registered service users and performance¹⁸18 Brasil. Portaria nº 59, de 26 de outubro de 2020. Prorroga o prazo da etapa de transição da capitação ponderada do Programa Previne Brasil. Diário Oficial da União; 2020.^,1919 Brasil. Portaria nº 166, de 27 de janeiro de 2021. Dispõe, excepcionalmente, sobre a transferência dos incentivos financeiros federais de custeio da Atenção Primária à Saúde, no âmbito do Programa Previne Brasil, para o ano de 2021. Diário Oficial da União; 2021..

The monitoring and analysis of the changes to the PNSB is performed by the Observatory for Health Policy Analysis, run by the Federal University of Bahia’s Public Health Institute, using figures dating back to 2003. Monitoring considers four core components: institutional actions, implementation of public dental services, results achieved, and federal funding. The present study brings the systematic monitoring of oral health policy in Brazil up to date, focusing on the period 2018-2021.

Method

We conducted a retrospective descriptive study to assess institutional actions, implementation of public dental services, results achieved, and federal funding using documents and content available on Ministry of Health websites and secondary data derived from information systems. Chart 1 describes the components analyzed and corresponding data sources.

The indicator “first diagnostic dental appointment coverage” was chosen as it represents the proportion of the Brazilian population who used primary dental care services, while the indicator “group supervised toothbrushing” represents group infection/caries prevention actions and provides an estimate of the proportion of the population who had access to toothbrushing with guidance/supervision from a dental professional, which is an indicator of changes in the care model^20.21.

The SC indicators a) and b) (Chart 1) refer to outpatient care delivered only by CEOs, representing procedures typically carried out by specialized services, which are referral points for primary dental care services. Indicator c) refers to outpatient care provided by dental prosthesis services (LRPDs).

To analyze funding, annual total funding data were inflation-adjusted to December 2021 using the National Consumer Price Index (IPCA) to allow for comparisons. The amounts were adjusted using the Central Bank official calculator (https://www3.bcb.gov.br/CALCIDADAO).

Due to funding changes, with federal transfers starting to be made in two block (capital investment and costs)⁶6 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2017., primary dental care funding data for 2018 and 2019 were obtained from the National Health Foundation website. Data on transfers made to SC services were not available. For 2020 and 2021, PHC and SC funding data were obtained from the primary care information portal e-Gestor AB, as the amounts on the FNS database refer only to capital investment in PHC.

Data from the years preceding 2018 are also presented for comparison purposes and to identify possible trends. The data were collected in February 2022 by a single researcher using Tab for Windows® (TABWIN) and exported to Microsoft Excel® (2007). The timeseries data were analyzed by service level (PHC and SC), showing the results achieved for each indicator (Tables 1 and 2).

Results and discussion

Changes to the PNSB during the Temer and Bolsonaro administrations

During the period 2018-2021, the number of dental surgeons (DS) registered in the Federal Council of Dentistry (CFO) increased by 20.1%, while the number of places on dentistry degree courses increased by 54.8% in private universities and 21.1% in public universities. Private universities therefore accounted for the largest share of the increase in places (Chart 2). This increase was influenced by the expansion of oral health services under the PNSB, beginning in 2004. Programs such as the student loan program, FIES, and “University for All Program” (PROUNI) contributed to the expansion of the private higher education sector, where the logic of capital and education as a commodity predominates²²22 Mattei TS, Bidarra ZS. O papel do FIES e do PROUNI na privatização, mercantilização e financeirização da educação superior brasileira. Barbaroi 2022; 1(61):53-84..

The number of OHts in the Family Health Strategy (FHS) increased by 13.4%, while the number in PHC decreased by 11.3%, along with a reduction in OHt population coverage (-6.57%). The number of CEOs rose by 3.2% between 2018 and 2021. However, the number of CEOs decreased slightly during the Bolsonaro administration due to the closure of some facilities and population coverage remains very low. The number of LRPDs increased by 65.3% over the period (Chart 2).

During the Temer administration, the CGSB was headed by Lívia Maria Almeida Coelho de Souza. The office remained without a coordinator during the first four months of the Bolsonaro administration, eventually being headed by the dental surgeon Rogéria Cristina Calastro de Azevedo (for 12 months), followed by the events manager Vivaldo Pinheiro Guimarães Júnior (one month), the dental surgeon Caroline José Martins dos Santos (15 months), and the dental surgeon Wellington Carvalho, who took up the post in December 2021²³23 Observatório de Análise Política em Saúde. Análise de Políticas de Saúde Bucal no Brasil: A Participação Social na Política Nacional de Saúde Bucal: monitoramento das entidades odontológicas e da Associação Brasileira de Saúde Coletiva (Abrasco) no ano de 2020 [Internet]. Salvador: OAPS; 2020 [acessado 2022 jan 13]. Disponível em: https://observatorio.analisepoliticaemsaude.org/matrizes.. Dental organizations protested against the appointment of Guimarães Júnior because he was not a dental surgeon and had no experience of dentistry²³23 Observatório de Análise Política em Saúde. Análise de Políticas de Saúde Bucal no Brasil: A Participação Social na Política Nacional de Saúde Bucal: monitoramento das entidades odontológicas e da Associação Brasileira de Saúde Coletiva (Abrasco) no ano de 2020 [Internet]. Salvador: OAPS; 2020 [acessado 2022 jan 13]. Disponível em: https://observatorio.analisepoliticaemsaude.org/matrizes.. Reports in the national media suggested that the appointment was political and blatantly failed to consider technical criteria²⁴24 Jornal O Globo. Após repercussão negativa, governo exonera indicado do centrão para coordenação de Saúde Bucal [Internet]. 2020 [acessado 2022 jan 13]. Disponível em: https://glo.bo/3eSygd5.
https://glo.bo/3eSygd5... . It is worth mentioning that the CGSB was led by the same person during the period 2003-2015. The successive changes in leadership made since October 2015 generated instability in the national coordination of oral health policy, resulting in interruptions in both funding and the implementation of certain components, such as the dental extension program GraduaCEO, launched in 2014²⁵25 Lima AMFS. A Política Nacional de Saúde Bucal no Brasil: análise sócio-histórica de 2003 a 2018 [tese]. Salvador: Universidade Federal da Bahia; 2022.. The Dilma administration did not give the same priority to oral health as Lula’s government and the issue dropped off the agenda during Temer’s term, which was marked by fiscal austerity and the promotion of privatizations in the health sector²⁵25 Lima AMFS. A Política Nacional de Saúde Bucal no Brasil: análise sócio-histórica de 2003 a 2018 [tese]. Salvador: Universidade Federal da Bahia; 2022.. As Narvai⁵5 Narvai PC. Ocaso do 'Brasil Sorridente' e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus Actas Saude Colet 2020; 14(1):175-187. underlines, despite the maintenance of oral health services, the political rupture that resulted in the ousting of President Dilma Rousseff in 2015 completely undermined the PNSB created in 2003.

The Temer administration based its counter-reform measures on a number of documents - including “Agenda Brasil” (08/2015), “A Bridge to the Future” (10/2015), and “A Travessia social” or “The Social Crossing” (04/2016) - all of which defended the commodification of health care, emphasizing popular health insurance plans⁷7 Bravo MIS, Pelaez EJ. A saúde nos governos Temer e Bolsonaro: lutas e resistências. SER Soc 2020; 22(46):191-209.. In his swearing in ceremony speech, the then Minister of Health Ricardo Barros mentioned that it was necessary to “reduce” the SUS and rethink universal access to health care, claiming that country did not have the financial capacity to support a public health system and defending popular health insurance plans⁷7 Bravo MIS, Pelaez EJ. A saúde nos governos Temer e Bolsonaro: lutas e resistências. SER Soc 2020; 22(46):191-209.. In 2017, the new version of the PNAB was published without the approval of the National Health Council. A series of criticisms were levelled at the text by specialists, health managers and workers, public health organizations, and social movements who defended the country’s health reform²⁶26 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220.. The literature highlights that the changes undermine the FHS model and threaten many of the achievements made in PHC in Brazil over the last two decades²⁶26 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220.. In the same year, the Temer administration published the report “Brazil Health Coalition: an agenda to transform the health system”, which proposed the construction of a new health system for the country, with strong private sector involvement dating back to 2014⁷7 Bravo MIS, Pelaez EJ. A saúde nos governos Temer e Bolsonaro: lutas e resistências. SER Soc 2020; 22(46):191-209..

At the end of the Temer administration, the main institutional actions related to oral health were the changes to the funding of CEOs and LRPDs, which were incorporated into PHC funding, the launch of the national oral health survey, Projeto Saúde Bucal Brasil 2020, and the publication of the book “Oral health in the SUS”, which updated Caderno 17 da Atenção Básica Saúde Bucal (Primary oral health care guidance manual: 17)²⁷27 Brasil. Ministério da Saúde (MS). A saúde bucal no Sistema Único de Saúde. Brasília: MS; 2018.. This book was produced during the Dilma administration, but publication was interrupted by the crisis in the federal government and instability in the CGSB between 2015 and 2016 and resumed by Lívia Souza in 2017²⁵25 Lima AMFS. A Política Nacional de Saúde Bucal no Brasil: análise sócio-histórica de 2003 a 2018 [tese]. Salvador: Universidade Federal da Bahia; 2022.. Payment of oral health services was suspended and some services were disaccredited, justified by lack of information on the Primary Health Care Information System (SISAB) and/or irregularities in relation to the PNAB (2017) (Chart 2).

One of the first measures taken by the Bolsonaro administration in 2019 was the creation of the Programa Previne Brasil, which changed funding criteria and PHC evaluation systems and abolished national programs for improving access and quality geared towards primary care and CEOs (PMAQ-AB and PMAQ-CEO), created in 2011. Although the effects of abolishing the PMAQs need to be better understood, studies highlight the results achieved by the programs and draw attention to the adverse effects of discontinuing these initiatives²⁸28 Cavalcanti P, Fernandez M. Programa de Melhoria do Acesso e da Qualidade da Atenção Básica: uma análise das principais mudanças normativas. Physis 2020; 30(3):e300323.^,2929 Rodrigues AWD, Mello ECA, Candeia RMS, Silva G, Gomes LB, Sampaio J. Pagamento por desempenho às Equipes da Atenção Básica: análise a partir dos ciclos do PMAQ-AB. Saude Debate 2021; 45(131):1060-1074..

Fund-to-fund transfers to municipal governments started to be made on a capitation basis, based on the number of service users registered in the FHS and other primary care services or on performance⁸8 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2019.^,1919 Brasil. Portaria nº 166, de 27 de janeiro de 2021. Dispõe, excepcionalmente, sobre a transferência dos incentivos financeiros federais de custeio da Atenção Primária à Saúde, no âmbito do Programa Previne Brasil, para o ano de 2021. Diário Oficial da União; 2021.. With the onset of the pandemic, most of these changes only came into force in the second semester of 2021¹⁸18 Brasil. Portaria nº 59, de 26 de outubro de 2020. Prorroga o prazo da etapa de transição da capitação ponderada do Programa Previne Brasil. Diário Oficial da União; 2020.. According to the creators of Previne Brasil, the program would increase funding, improve access, and promote equity in health resource allocation, arguing that more resources would be transferred to health teams working with socially and economically vulnerable groups and poorer municipalities in remote areas³⁰30 Harzheim E. "Previne Brasil": bases da reforma da Atenção Primária à Saúde. Cien Saude Colet 2020; 25(4):1189-1196.. However, emphasis is placed on PHC and a shift towards increasingly limited primary care services, guided by the “universal health coverage” approach proposed by the World Bank, which seeks to prioritize the poorest in the face of scarce resources⁸8 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde. Diário Oficial da União; 2019..

The debate within the field of public health is ongoing. Studies highlight the prevalence of the concept of “SUS for the poor”, going against the principle of universality, with increasing involvement of the private sector to the detriment of health care reform or even flexible health reform, in which the SUS has been implemented with concessions to the original proposal and constantly underfunded and “downgraded”⁷7 Bravo MIS, Pelaez EJ. A saúde nos governos Temer e Bolsonaro: lutas e resistências. SER Soc 2020; 22(46):191-209.^,99 Massuda A. Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Cien Saude Colet 2020; 25(4):1181-1188.^,2626 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220..

With the onset of the COVID-19 pandemic in 2020, it was initially recommended to suspend oral health services. However, the Ministry of Health continued to transfer resources to enable the delivery of urgent and emergency services by the SUS¹²12 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Saúde credencia 1,8 mil Equipes de Saúde Bucal com horário diferenciado [Internet]. 2020 [acessado 2022 jan 13]. Disponível em: http://aps.saude.gov.br/noticia/10157.
http://aps.saude.gov.br/noticia/10157... . Guidance and technical notes on the provision of oral health services in the context of COVID-19 were issued and funding was provided for adaptations and modifications to health facilities¹³13 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Guia de Orientações para a atenção odontológica no contexto da Covid-19. Brasília: MS; 2020..

In 2021, changes were also made to the registration of PHC teams in the National Registry of Health Care Facilities (CNES), with the creation of the National Team Identifier (INE). Thereafter, PHC funding began to be allocated on a team/facility basis. The normative instrument that created the INE claims that INE-based transfers provide health managers with greater access to information³¹31 Brasil. Portaria nº 47, de 19 de dezembro de 2019. Dispõe sobre os códigos referentes à Identificação Nacional de Equipe (INE) e ao Cadastro Nacional de Estabelecimentos de Saúde (CNES) das equipes ou serviços de Atenção Primária à Saúde para fins da transferência dos incentivos de custeio federal, acompanhamento, monitoramento e avaliação. Diário Oficial da União; 2019.. However, these changes need to be subjected to monitoring and evaluation.

Finally, at national level, President Bolsonaro vetoed Bill 34/2013, which would have made dental care mandatory for hospitalized patients. Dental organizations, including the CFO, Interstate Dental Federation, and National Dental Federation, issued statements opposing the veto³²32 Observatório de Análise Política em Saúde (OAPS). Análise de Políticas de Saúde Bucal no Brasil: Atores governamentais, não governamentais e participação social na Política Nacional de Saúde Bucal em 2019 [Internet]. Salvador: OAPS; 2019 [acessado 2022 jan13]. Disponível em: https://observatorio.analisepoliticaemsaude.org/matrizes..

Maintenance of implementation and decline in performance

There was an 18.44% rise in the number of OHts during the period 2018-2021. An additional 1,615 teams were created in 2020, an increase of 5.57% in relation to 2019. This increase is partially explained by the accreditation of 1,800 part-time OHts (20/30 hours per week) in 272 municipalities³³33 Brasil. Portaria nº 2.918, de 21 de outubro de 2020. Credencia municípios a receberem incentivos financeiros referentes às Equipes de Saúde Bucal com carga horária diferenciada. Diário Oficial da União; 2020.. Population coverage of oral health care services in the FHS reached 46% in 2021. The population coverage of primary dental care increased from 52.71% in 2018 to 56.11% in 2020, remaining stable in 2021 (56.61%) (Table 1). The number of CEOs remained stable at around 1,100 facilities between 2014 and 2017, followed by an increase of 3.1% between 2018 and 2021. The number of LRPDs rose by 22.1% during the period 2018-2021 (Table 2).

The Ministry of Health claimed that the introduction of flexible working hours for PHC teams gave municipalities greater autonomy in service organization and improved efficiency and performance. However, health experts, managers, and health councils warn of the underlying market and privatization intentions of Previne Brasil, posing a serious threat to achievements in community-based family health care³⁴34 Seta MH, Ocké-Reis CO, Ramos ALP. Programa Previne Brasil: o ápice das ameaças à Atenção Primária à Saúde? Cien Saude Colet 2021; 26(Supl. 2):3781-3786..

Monitoring of OHts in the FHS revealed that 6.7% of Brazil’s municipalities had reduced the number of teams 21 months after the publication of the new PNAB (2017). Reductions were highest in the South and Northeast and in large cities with higher levels of social inequality³⁵35 Lucena EHG, Lucen CDRX, Alemán JAS, Pucca Júnior GA, Pereira AC, Cavalcanti YW. Monitoramento das equipes de saúde bucal após a Política Nacional de Atenção Básica 2017. Rev Saude Publica 2020; 54:99.. These reductions may lead to a subsequent reduction in access to oral health services, especially among those who most need care³⁵35 Lucena EHG, Lucen CDRX, Alemán JAS, Pucca Júnior GA, Pereira AC, Cavalcanti YW. Monitoramento das equipes de saúde bucal após a Política Nacional de Atenção Básica 2017. Rev Saude Publica 2020; 54:99.. Other studies have shown inequalities in oral health care provision across Brazil, with populations in more socially and economically disadvantaged municipalities being more exposed to excessive tooth extraction due to the lack of integrated oral health programs³⁶36 Stein C, Santos KW, Condesa AM, Celeste RK, Hilgert JB, Hugo FN. Presença de Centros de Especialidades Odontológicas e sua relação com a realização de exodontias na rede de atenção de saúde bucal no Brasil. Cad Saude Publica 2020; 36(1):e00054819..

Despite an increase in service availability and the stability of OHt population coverage throughout the period, performance against PHC indicators has declined since 2015 (Table 1). The findings reveal poor access to individual dental care, health promotion and infection/caries prevention, and comprehensive health care under the SUS. In addition, there was a decline in performance against most public dental service indicators between 2011 and 2019³3 Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saude Debate 2018; 42(n. esp. 2):76-91.^,3737 Chaves SCL, Rossi TRA, Lima AMFS. Dental service coverage and oral health promotion community actions in primary care in Brazil between 2003 and 2019. Health Policy OPEN 2020; 1:100022..

The COVID-19 pandemic has had a significant negative impact on dental care, especially when it comes to the public system. There was a sharp decline in performance against PHC indicators between 2019 and 2020, the first year of the pandemic. This may be largely due to the suspension of scheduled dental appointments and disruption of group oral health initiatives, with services being reduced to urgent care from the middle of March by the National Health Surveillance Agency (ANVISA)³⁸38 Brasil. Agência Nacional de Vigilância Sanitária (ANVISA). Nota técnica GVIMS/GGTES/ANVISA nº 04/2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2) - atualizada 08 maio de 2020. Brasília: ANVISA; 2021. and Ministry of Health³⁹39 Brasil. Nota Técnica nº 9/2020-CGSB/DESF/SAPS/MS. Atendimento Odontológico no SUS. Diário Oficial da União; 2020.. The CFO requested the Ministry of Health to suspend scheduled appointments in both public and private services and to implement more rigorous biosecurity measures in the private system⁴⁰40 Santos LPS, Lima AMFS, Santana SF, Chaves SCL, Vilela DMOC, Vieira LCL, Oliveira Neto J, Santos CTB. Pandemia do novo Coronavírus e o funcionamento dos serviços odontológicos no Brasil: um seguimento de quatro meses. Res Soc Dev 2021; 10(12):e200101220266.. Various different situations were witnessed. There are reports of municipalities in which health managers pressured for a return to scheduled appointments in public services, despite lack of evidence⁴¹41 Carletto AF, Santos FF. A atuação do dentista de família na pandemia do Covid-19: o cenário do Rio de Janeiro. Physis 2020; 30(03):e300310.. Others delayed the return of OHts, claiming poor working conditions and lack of resources for compliance with biosafety measures, including the high cost of PPE⁴⁰40 Santos LPS, Lima AMFS, Santana SF, Chaves SCL, Vilela DMOC, Vieira LCL, Oliveira Neto J, Santos CTB. Pandemia do novo Coronavírus e o funcionamento dos serviços odontológicos no Brasil: um seguimento de quatro meses. Res Soc Dev 2021; 10(12):e200101220266..

The effects of the pandemic on access to primary dental care services may lead to an increase in a historically suppressed demand for dental treatment, a decline in oral health status, deterioration in oral diseases, especially dental caries and early-stage periodontal problems, and delays in the diagnosis of mouth cancer, with a consequent increase in mortality. It is worth highlighting that the deterioration of caries, the leading oral health problem in Brazil, is considered a key causal factor for pain and tooth loss⁴²42 Carneiro CDA, Peixoto SS. Impacts of COVID-19 on the productions of oral health teams in primary health care. Res Soc Dev 2021; 10(12):e598101220826., making the strengthening and expansion of prevention and care actions all the more necessary.

In addition to a reduction in the number of first scheduled dental appointments due to the suspension of services, the findings also show a significant reduction in urgent dental care during the first four months of the pandemic, suggesting that urgent cases were not received by the public health system¹⁴14 Lucena EHG, Freire AR, Freire DEWG, Araújo ECF, Lira GNW, Brito ACM, Padilha WWN, Cavalcanti YW. Offerand Use of Oral Health in Primary Care Before and After the Beginning of the COVID-19 Pandemic in Brazil. Pesq Bras Odontopediatr Clín Integr 2020; 20(Supl. 1):e0139.. This reduction may also have been influenced by the different forms of organization of urgent care, lack of PPE, and changes in patient behavior, with less individuals seeking dental services¹⁴14 Lucena EHG, Freire AR, Freire DEWG, Araújo ECF, Lira GNW, Brito ACM, Padilha WWN, Cavalcanti YW. Offerand Use of Oral Health in Primary Care Before and After the Beginning of the COVID-19 Pandemic in Brazil. Pesq Bras Odontopediatr Clín Integr 2020; 20(Supl. 1):e0139..

There was an 80% reduction in coverage of group supervised toothbrushing in 2020 and 2021 in relation to previous years. These findings reveal an acceleration in the pace of reduction of health promotion and infection/caries prevention actions, which had shown a downward trend over the last 10 years (Table 1). These actions were strongly affected in the first two years of the pandemic, mainly due to social distancing measures, including the interruption of collective oral health initiatives and suspension of face-to-face teaching at schools, most of which implemented in the middle of March⁴³43 Silva LLS, Lima AFR, Polli DA, Razia PFS, Pavão LFA, Cavalcanti MAFH, Toscano CM. Medidas de distanciamento social para o enfrentamento da COVID-19 no Brasil: caracterização e análise epidemiológica por estado. Cad Saude Publica 2020; 36(9):e00185020..

Teaching remained online until May 2021 in most public schools in Brazil and all state schools provided hybrid teaching, with a mix of face-to-face and online classes, or 100% face-to-face classes up to November 2021⁴⁴44 Organização das Nações Unidas para a Educação, a Ciência e a Cultura (UNESCO). Situação da educação no Brasil (por região/estado - nov. 2021) [Internet]. [acessado 2022 jan 13]. Disponível em: https://pt.unesco.org/fieldoffice/brasilia/covid-19-education-Brasil.
https://pt.unesco.org/fieldoffice/brasil... .

Despite these limitations, some teams managed to develop health educations actions, albeit on a smaller scale, via the School Health Program using digital tools⁴⁵45 Fettermann FA, Silveira MGS, Escobar TA, Valença JAP, Sganzerla FL, Pessano RFR, Mansilha LVQ, Cunha FIJ, Nunes CS. School health program and the alignment of actions in the prevention of coronavirus. Res Soc Dev 2021; 10(5):e37810514686..

It is important to highlight however that digital inequalities, such as lack of equipment or skills, poor internet access, or connectivity problems, exacerbate inequality in education and access to health promotion and disease prevention⁴⁶46 Moreira MES, Cruz ILS, Sales MEN, Moreira NIT, Freire HC, Martins GA, Avelino GHF, Almeida Jr S, Popolim RS. Metodologias e tecnologias para educação em tempos de pandemia COVID-19. Braz J Health Rev 2020; 3(3):6281-6290..

There was an increase in the number of root canal treatments and dental prostheses produced in 2018 (6.5% and 13.8%, respectively). These indicators of SC also showed an increase in 2019, together with periodontal treatments (8.4%, 14.3%, and 1.2%, respectively). The increases in 2019 (Table 2) may be related to an external evaluation carried out under the PMAQ-CEO in the same year. In many municipalities the evaluation resulted in the overhaul of health services, hiring of health workers, adoption of self-evaluation instruments, and increases in team productivity⁴⁷47 Filgueiras LV, Cabreira FS, Hugo FN, Celeste RC. Influência da autoavaliação para melhoria do acesso e da qualidade no quantitativo de procedimentos dos Centros de Especialidades Odontológicas. Cien Saude Colet 2022; 27(1):253-261..

In 2020, percentage reductions were higher than in the last 18 years (2003 to 2020) for both SC and PHC indicators. The number of root canal treatments, periodontal treatments, and dental prostheses produced dropped by 53.8%, 38.1%, and 38.9%, respectively, in relation to 2019. Dental care delivered in CEOs consists of scheduled specialist appointments referred by PHC services and was therefore impacted by the suspension of scheduled appointments³⁹39 Brasil. Nota Técnica nº 9/2020-CGSB/DESF/SAPS/MS. Atendimento Odontológico no SUS. Diário Oficial da União; 2020.. Progress on vaccine rollout, the return of services, and maintenance of funding and investment in service modifications and adaptations to comply with biosecurity standards are factors that contributed to an increase in these procedures in 2021.

The services provided by LRPDs were either reduced or suspended during the first year of the pandemic. This is because, while prosthetic repairs are considered to be urgent, procedures are primarily scheduled, and patients requiring this type of service are predominantly older persons and therefore a risk group³⁹39 Brasil. Nota Técnica nº 9/2020-CGSB/DESF/SAPS/MS. Atendimento Odontológico no SUS. Diário Oficial da União; 2020..

The service that saw the largest reduction in number of procedures among the SC indicators in the first year of the pandemic was root canal treatment. Urgent dental consultations did not decrease in the same proportion as urgent procedures. One factor that may explain this is that dentists use pharmacological approaches to manage pain to avoid surgical procedures and aerosol production⁴⁸48 Cunha AR, Velasco SRM, Hugo FN, Antunes JLF. The impact of the COVID-19 pandemic on the provision of dental procedures performed by the Brazilian Unified Health System: a syndemic perspective. Rev Bras Epidemiol 2021; 24:e210028.. This may also partially explain the reduction in the number of root canal treatments.

Federal funding of the policy: changes and setbacks

The inflation-adjusted amount of federal funding transferred to state and municipal governments showed an overall increase between 2003 and 2012, oscillating thereafter betweenperiods of increasing and decreasing funding up to 2017 and followed by a fall in 2018 and 2019. The amount grew once again in 2020, followed by another fall in 2021. It is worth noting that the amount allocated in 2012 was the highest since the origin of the PNSB (Table 3).

The proportion of funding allocated to PHC between 2020 and 2021 increased by 3.2%, while the share allocated to SC fell by 3.2%. The share of funding allocated to PHC was constantly higher since 2003. Data on federal transfers to CEOs and LRPDs in 2018 and 2019 were not available (Table 3).

Other studies show that nominal funding and spending on infrastructure and human resources increased between 2003 and 2020. Fund-to-fund transfers also showed an upward trend between 2003 and 2010, remaining stable thereafter between 2011 and 2018³3 Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saude Debate 2018; 42(n. esp. 2):76-91.^,44 Rossi TRA, Sobrinho JEL, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436.. Narvai⁵5 Narvai PC. Ocaso do 'Brasil Sorridente' e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus Actas Saude Colet 2020; 14(1):175-187. underlines that there was a significant reduction in federal funding, with the amount in 2018 being 58.3% lower than the annual average over the period 1995-2002. It is worth noting that, up to 2017, funding for the PNSB was divided into three blocks administered by the FNS (PHC, Medium and High Complexity, and Management) and subdivided into specific budget categories⁴4 Rossi TRA, Sobrinho JEL, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436.. Another block (Investment) was destined to the implementation of services and acquisition of dental equipment and tangible assets⁴4 Rossi TRA, Sobrinho JEL, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436.. In 2018, federal transfers started to be made in two blocks (capital and operating expenses)⁴4 Rossi TRA, Sobrinho JEL, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436., which may partially explain the lack of data on SC funding in 2018 and 2019 in the FNS database.

The inflation-adjusted data show that funding fell in real terms between 2012 and 2020, despite an increase in the Brazilian population from 193,946,886 to 211,755,692 in the same period.

PHC and SC funding data for 2020, when the new funding model came into force⁴⁹49 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2019. and data started to be made available on the primary care information portal e-Gestor AB, are not available in the FNS database. Criticisms of Previne Brasil focus on the emphasis given to metric-based management mechanisms associated with an “operational SUS”⁴⁹49 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2019..

The overall amount of federal transfers fell between 2020 and 2021, resulting in a reduction in funding of state and municipal governments, evidencing the bureaucratized defunding of the SUS⁵⁰50 Mendes A, Melo AM, Carnut LC. Análise crítica sobre a implantação do novo modelo de alocação dos recursos federais para atenção primária à saúde: operacionalismo e improvisos. Cad Saude Publica 2022; 38(2):e00164621.. It is important to highlight that a previous study analyzing municipal government spending on PHC also collected data on federal funding sources without considering municipal and/or state resources, understanding that the federal government plays a pivotal role in state and municipal health funding⁵¹51 Cabreira FS, Ritter F, Aguiar VR, Celeste RK. Despesas municipais em atenção primária à saúde no Rio Grande do Sul, Brasil: um estudo ecológico. Cad Saude Publica 2018; 34(12):e00150117..

In this regard, state and particularly municipal governments encounter difficulties in funding oral health using their own resources due to a fall in municipal tax revenues and competing demands from other sectoral and intersectoral policies. Municipal governments have been the most affected by the public funding crisis since the 1990s. Both state and municipal governments therefore need complementary funding for PHC⁵²52 Marques RM, Mendes A. Atenção Básica e Programa de Saúde da Família (PSF): novos rumos para a política de saúde e seu financiamento? Cien Saude Colet 2003; 8(2):403-415.. However, the amounts transferred by the federal government do not cover the real costs of services and municipalities therefore end up partially funding federal policies⁵²52 Marques RM, Mendes A. Atenção Básica e Programa de Saúde da Família (PSF): novos rumos para a política de saúde e seu financiamento? Cien Saude Colet 2003; 8(2):403-415..

Final considerations

Our findings show that limited progress has been made in implementing oral health policy in Brazil, revealing a significant decline in performance against indicators between 2018 and 2021, a period marked by the pandemic, political and economic crisis, and a political shift towards privatization in the current government that runs counter to the guiding principles of the SUS.

The main limitation of this study is the use of secondary data, which are subject to lack of uniformity and underreporting. During the study period, changes and updates were made to data presentation and Ministry of Health information systems, resulting in data inconsistency. On the other hand, monitoring of the PNSB has contributed to the analysis of changes, ruptures, continuity, and new state responses to the population’s oral health needs. Analysis contributes to manager decision-making processes, control, public participation, and the formulation or revamping of proposals in scenarios that are more favorable to the development and consolidation of the SUS. While the evidence reveals a gap between reality and expectations, the results achieved by the policy reinforce the need to join and align social forces to defend universal access to good quality public oral health care.

References

Publication Dates

History